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Keywords:

  • stress urinary incontinence;
  • minimally invasive surgery;
  • day-case surgery;
  • pubovaginal sling

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. CONFLICT OF INTEREST
  9. REFERENCES
  10. EDITORIAL COMMENT
  11. Appendix

OBJECTIVE

To prospectively assess the feasibility for discharge 10 h after a porcine dermal pubovaginal sling procedure (PVS), to examine the surgical factors (postoperative complications) affecting discharge, and to measure the short-term cure rate for stress urinary incontinence (SUI).

PATIENTS AND METHODS

Between June 2003 and December 2003, 40 consecutive patients with SUI and scheduled for treatment using a porcine dermal sling were enrolled in this prospective study. Patients were admitted with a planned overnight stay and returned to the ward with no urinary catheter. Outcome measures were bladder emptying efficiency (EE) at 10 h after surgery, time intervals to the first three spontaneous voids, EE of the first three voids, time required to achieve an EE of ≥ 75%, a visual analogue scale pain score, perioperative complications, and short-term cure rate of SUI. Patients were considered suitable for discharge from hospital when the EE was ≥ 75% or when they were self-catheterizing confidently with adequate pain control and no significant complication. All patients were followed for 6 months.

RESULTS

The median EE at 10 h was 61%; 16 patients (40%) achieved efficient emptying and were suitable for discharge 10 h after surgery. The median intervals to the first three spontaneous voids were 7, 10 and 17 h, and the median EEs for the first three voids 46%, 61% and 75%. The median visual analogue scale pain score was 3.5. Patients with intrinsic sphincter deficiency (ISD) were significantly less likely to achieve efficient emptying at 10 h (39% vs 70%). Overall SUI was cured or improved in 90% of patients at the 6-month follow-up.

CONCLUSIONS

In the present study only 40% of patients were suitable for day-case sling surgery. Early bladder emptying inefficiency was the main limiting factor. Exclusion of patients with ISD and possibly decreasing the EE threshold to 50% would improve the discharge rate. The short-term results of this PVS are similar to those obtained with the autologous fascial sling.


Abbreviations
SUI

stress urinary incontinence

ISD

intrinsic sphincter deficiency

PVR

postvoid residual urine volume

KHQ

King's Health Questionnaire

SF-36

The 36-item Short-Form Health Survey

QoL

quality of life

CISC

clean intermittent self-catheterization

EE

bladder emptying efficiency

VAS

visual analogue scale

VV

voided volume

INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. CONFLICT OF INTEREST
  9. REFERENCES
  10. EDITORIAL COMMENT
  11. Appendix

Stress urinary incontinence (SUI) is a common problem [1] and is usually related to increased urethral mobility and/or intrinsic sphincter deficiency (ISD). However, hypermobility and ISD frequently coexist [2]. The degree of urethral mobility and leak-point pressure are generally directly related.

Lack of inpatient beds, and patient and economic demands are driving the concept of minimally invasive, day-case surgery. The apparent cost-effectiveness of day surgery makes this an attractive form of treatment to purchasers of healthcare. Modifications in sling techniques have resulted in broader indications [3], reduced morbidity and a shorter hospital stay [4]. Autologous rectus fascia remains the ‘gold standard’ sling material for the surgical treatment of SUI [5]. However, the Pfannenstiel incision used for harvesting autologous fascia causes considerable postoperative pain and morbidity, thereby prolonging the hospital stay. One solution is to substitute the rectus fascia with a ready-made sling material. However, it is important that treatment safety and efficacy are not compromised. The main disadvantage of using a synthetic substitute is the risk of urogenital tract erosion [6]. Porcine dermal collagen (PelvicolTM, Bard Urology, UK), a biological sling material with virtually no risk of erosion, might be used and implanted as a day-case procedure. Thus the aims of the present study were to assess the suitability for discharge of patients 10 h after the a Pelvicol pubovaginal sling (PVS) procedure, the factors (early complications) affecting time of discharge, and the short-term cure rate.

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. CONFLICT OF INTEREST
  9. REFERENCES
  10. EDITORIAL COMMENT
  11. Appendix

Between June 2003 and December 2003, 40 consecutive patients with SUI were enrolled in this prospective study. Ethical approval for the study was obtained from the local Ethics Committee. Patients were recruited after a decision was made for anti-incontinence surgery. Definitions conform to the standards recommended by ICS [7], except where specifically noted. Our inclusion criteria were that patients had an American Society of Anesthesiologists physical status classification of I or II, urodynamically confirmed SUI, and informed consent. Patients with a history of UTI in the previous 6 weeks, neuropathic bladder, uterovaginal prolapse, detrusor instability and voiding dysfunction (maximum urinary flow rate <15 mL/ s, pressure at maximum flow rate of >40 cmH2O, postvoid residual urine volume, PVR, of >50 mL) were excluded from the study.

All patients were evaluated before surgery by history, physical examination, urine analysis and urodynamic study. All patients had a pelvic examination to assess pelvic floor defects and bladder neck motion. After free uroflowmetry and measuring the PVR, all patients had medium-fill subtracted cystometry using a 6 F double-lumen bladder catheter and a cuffed, air-filled 4 F rectal catheter. Cystometric variables measured included sensation, presence of detrusor stability, compliance and capacity. Urethral sphincter competence was assessed while semi-recumbent or standing, using the Valsalva manoeuvre or cough, at 50 mL intervals from 150 mL of filling, to obtain the abdominal leak-point pressure. Patients also completed the King's Health Questionnaire (KHQ) [8] and the 36-item Short-Form Health Survey (SF-36) quality-of-life (QoL) questionnaire [9]. Explanatory pamphlets were given to each patient, and they were counselled about the possible need for clean intermittent self-catheterization (CISC) after surgery, and briefly taught the technique. Patients were admitted with a planned overnight stay.

All sling operations were scheduled on a morning operating list. Before surgery all patients received thromboprophylaxis with subcutaneous enoxaparin 20 mg and antibiotic prophylaxis with intravenous ceftriaxone 1 g and gentamicin 240 mg. In all procedures patients were under general anaesthesia, with surgery by one urologist (H.D.F.).

The patient was placed in the modified lithotomy position in Allen's stirrups. After antiseptic dressing and draping, a 14 F Foley catheter was inserted. The sling was prepared using a 7 × 2 cm Pelvicol strip secured at each end with a 0 nonabsorbable polypropylene suture. Two small suprapubic stab incisions were made 5 cm apart just above the symphysis pubis. Then, a vertical 2.5 cm anterior vaginal wall incision was made. After paraurethral dissection, a Yachia needle was passed through the suprapubic stab incision and guided digitally behind the pubic ramus into the vaginal incision bilaterally. One end of the polypropylene suture was then passed through the eyelet in the needle, that was then withdrawn upwards. The procedure was repeated on the opposite side and the catheter removed. Cystoscopy was used to exclude any bladder injury. The sling was then placed under the proximal urethra at the urethrovesical junction. The sling sutures were then tied loosely over the rectus sheath on one side after subcutaneous transfer of one polypropylene suture across to the other incision. In patients with ISD the sling was tied with appropriate tension. Skin incisions were closed with absorbable suture and the bladder emptied. Suprapubic and vaginal wounds were infiltrated with local anaesthetic (20 mL of 5 mg/mL levobupivacaine). The patients were returned to the ward with no urinary catheter and a vaginal balloon pack was used for only 3 h after the operation. The operative duration and intraoperative blood loss were recorded, with any complications.

After surgery, NSAIDs such as intravenous parecoxib 40 mg, paracetamol suppository 1 g, diclofenac suppository 100 mg and oral nimesulide 100 mg, were used for pain control; opioid analgesia was avoided. Intravenous fluid was continued with solution-18 at 125 mL/h until the patient was able to drink fluid freely. All patients were instructed to report to a nurse as soon as they had a sensation to void after the pack was removed. They were then encouraged to void, and to use CISC if they failed to void spontaneously. In the absence of a spontaneous void within 6 h after surgery, CISC was used to avoid overdistension of the bladder. The catheterized volume was never >500 mL.

Patients were assessed at 4, 10 and 24 h after surgery for pain intensity using a visual analogue scale (VAS, 0 = no pain, 10 = worst pain). The interval to spontaneous voids, bladder emptying efficiency (EE) and early complications were also recorded. The suitability for discharge was assessed at 10 h after the procedure.

Our day-surgery unit opens at 08.00 hours (surgery at 09.00 h) and closes at 20.00 hours, which gives patients 10 h (allowing 1 h for surgery and recovery) in which to void efficiently in preparation for discharge. After each void, the voided volume (VV) and PVR were measured, the latter using CISC. The EE was calculated as VV/(VV + PVR) × 100. Efficient emptying was defined as an EE of ≥ 75%[3]. Patients were considered suitable for discharge from hospital when emptying efficiently or when they could use CISC confidently with adequate pain control and had no significant complications.

Patients were further evaluated at 6 weeks, 3 and 6 months after surgery in the outpatient clinic. At each visit, patients were assessed by history and physical examination, and a validated questionnaire [10] (Appendix); they also completed the KHQ and SF-36 QoL questionnaires at the 6-month follow-up. Surgery results were classified as ‘cured’ when the patient reported no leakage of urine under any circumstances and no incontinence on a cough-stress test. ‘Improved’ was defined as a reduction of half or more in incontinence and no leakage on cough-stress test. ‘Failure’ was defined as a reduction of less than half in incontinence and or leakage on a cough-stress test [11]. A full urodynamic study was only used if the PVS failed.

The primary outcome measure was the suitability for discharge 10 h after surgery, based on the EE, no significant complication and adequate pain control after surgery. Secondary outcome measures were the time intervals to the first three spontaneous voids, EE of the first three voids, time required to achieve an EE of ≥ 75%, the VAS pain score soon after surgery, perioperative complications and short-term (6-month) SUI cure rate.

Data obtained from case report forms were transferred to a computer spreadsheet and entries then checked for any errors. All data were tested where appropriate for normality. The statistical significance was assessed using Student's t-test, Fisher's exact test or Wilcoxon matched-pairs test where appropriate, with P < 0.05 considered to indicate significant differences.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. CONFLICT OF INTEREST
  9. REFERENCES
  10. EDITORIAL COMMENT
  11. Appendix

Table 1 shows the baseline characteristics of the study population; 13 patients (33%) had ISD. The operation was a primary procedure in 33 (83%) women and secondary in seven (18%). Previous surgery included one periurethral collagen injection, two Kelly plications, two Stamey vesicopexies, one rectus fascia pubovaginal sling and one Burch colposuspension. The median (range) preoperative EE was 100 (94–100)%.

Table 1.  The patients’ characteristics, as the median (range) or n (%)
CharacteristicsValues
  1. HRT, systemic hormone replacement therapy.

Age, years48 (28–66)
Parity 3 (1–7)
Vaginal delivery38 (95)
Caesarian section 2 (5)
Incontinence starting after delivery25 (62.5)
Duration of symptoms, years 5 (1–25)
Preoperative pad use 3 (1–6)
Postmenopausal17 (42.5)
Using HRT 8 (20)
Previous hysterectomy 8 (20)
Previous incontinence surgery 7 (17.5)
Abdominal leak-point pressure, cmH2O85 (29–164)
Patients with ISD13 (32.5)

The variables assessed during and after surgery are shown in Table 2. The median (interquartile range) intervals to the first three spontaneous voids were 7 (6–8), 10 (9–14) and 17 (14–21) h, respectively. The median early EEs for the first three voids were 46  (30–60)%, 61 (45–75)% and 75 (55–85)%, respectively. Although 35 patients (88%) had their first void within 10 h of surgery, only four (10%) achieved efficient emptying at their first void. While 26 patients (65%) had their second void within 10 h after surgery, a further 12 (30%) were able to achieve efficient emptying at their second void. Thus, overall, 16 of 40 (40%) patients achieved efficient emptying and were suitable for discharge 10 h after surgery.

Table 2.  Operative and postoperative variables, as median (interquartile range) or n (%)
VariableValues
  • *

    Excluding six patients discharged on CISC.

Operative duration, min30 (25–35)
VAS pain score in first 10 h after surgery 3.5 (0–5)
EE at 10 h, %61 (40–80)
*Time to EE ≥ 75%, h13 (10–21)
*Number of voids to EE ≥ 75% 3 (2–4)
Number of patients with EE ≥ 75% at 10 h16 (40)

The differences in EE for the first three voids are shown in Fig. 1. The proportion of patients with an EE of ≥ 75% increased significantly from the first void to the second (Fisher's exact test; P = 0.002), but the proportion showed no further significant increase from the second to third void (P = 0.381).

image

Figure 1. Differences in EE (50–74%, green bars; 75–100%, red bars) for the first, second and third voids.

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The cumulative distribution of time to voiding and an EE of ≥ 75% is shown in Fig. 2. Although 20% of the patients had their first void within 5 h, only 2.5% achieved efficient emptying. None of the patients had their second void within 5 h after surgery. Nearly two-thirds of the patients had their second void at 6–10 h and 40% achieved efficient emptying; 70% had efficient emptying within 24 h. The median (range) duration of hospital stay was 1.5 (1–3) days.

image

Figure 2. Cumulative distribution of time to voiding and EE ≥ 75% (light green) for the first (green), second (red) and third (open bars) voids.

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The mean EE 10 h after surgery was significantly higher in those with no ISD than in those with ISD (70% vs 39%, P = 0.001, t-test). Although 15 of 27 (56%) of the patients with no ISD had an EE of ≥ 75% at 10 h after surgery, only one of 13 of those with ISD had (P = 0.014, Fisher's exact test), thus patients with ISD are significantly less likely to have an EE of ≥ 75% at 10 h after surgery. The mean EE 10 h after surgery in patients aged <60 years was greater than in those >60 years old but the difference was not significant (62% vs 40%, P = 0.113, t-test). If efficient emptying was defined as a EE of 50% then 24 (60%) patients were emptying efficiently 10 h after surgery. Overall, 40% of patients had a pain score of 0 (i.e. no pain) 10 h after surgery; one patient had a VAS pain score of 10 at 10 h, but she was mobile, emptying efficiently and was dischargeable; age and pain score did not affect the EE.

There were no major intraoperative complications and no bladder perforations. Two patients had a small amount of vaginal bleeding immediately after removing the vaginal pack (no actions was necessary and both settled on conservative management). One patient had significant nausea and vomiting soon after surgery and another was drowsy even 10 h after surgery. Of the six patients who were discharged on CISC, four achieved an EE of ≥ 75% within 7 days of discharge, and one each within 10 days and 14 days; no patient required urethrolysis.

There was one superficial abdominal wound infection and one abdominal wound haematoma, both resolving with conservative management. Three patients developed symptoms suggestive of UTI within 6 weeks of discharge and all were successfully treated with antibiotics by their family doctor. Two patients complained of intermittent left-sided deep pelvic pain for 3 months, but there was no obvious cause for this and both settled spontaneously with time.

The outcome of the PVS procedure is shown in Table 3. All patients were followed for up to 6 months, and none were lost to follow-up. At the 6-week follow-up, there were no failures; at 3 months, three women reported further improvement of their condition from ‘improved’ to ‘cured’ and four reported deterioration of their SUI from ‘complete cure’ to ‘improved’. Two ‘improved’ women remained the same. One ‘cured’ woman was reclassified as ‘failure’ because of urgency and urge incontinence at the 3-month follow-up, although a urodynamic study showed no SUI or detrusor instability. She was treated with anticholinergic medication and physiotherapy, with some improvement of continence at the 6-month review, but was still considered a failure, as her improvement was less than half.

Table 3.  Outcome of the PVS for SUI, for the 40 patients assessed, as n (%)
Result6 weeks3 months6 months
Cured34 (85)32 (80)30 (75)
Improved 6 (15) 7 (17.5) 6 (15)
Failure 0 1 (2.5) 4 (10)

At the 6-month follow-up, one woman reported further improvement of her condition and she was reclassified as ‘cured’, and one had mild worsening of her continence from ‘cured’ to ‘improved’. Five women remained unchanged, as ‘improved’. Three more women were reclassified as failures after being reported as ‘cured’ at the 6-week and 3-month follow-up. Two had pure SUI and a third had pure detrusor instability on urodynamic study. At the 6-month follow-up, 10 (25%) women reported persistent urgency and two (5%) women developed de novo urgency. QoL measures showed significant improvements in four of the eight domains of the SF-36 and in seven of the eight domains of the KHQ at the 6-month follow-up (Fig. 3).

image

Figure 3. The mean KHQ scores before (green) and 6 months after (red) surgery. *Not significant. The differences in QoL scores were highly significant for all domains (Wilcoxon matched pairs test, P < 0.001) except for general health perception (GH). The domains of the KHQ are: II, incontinence impact; RL, role limitation; PL, physical limitation; SL, social limitation; PR, personal relationships; E, emotions; SL/E, sleep/energy.

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DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. CONFLICT OF INTEREST
  9. REFERENCES
  10. EDITORIAL COMMENT
  11. Appendix

Advances in day-case anaesthesia and development of minimally invasive surgical techniques can be expected to continue. Day-case surgery has presented a new set of challenges and goals for surgeons. The success of day-case surgery depends largely on the nature of the surgery, effective control of postoperative pain and minimization of anaesthetic side-effects, e.g. sedation, nausea and vomiting.

In the present study, 40% of patients emptied efficiently and were suitable for discharge within 10 h of surgery. Only 10% of the patients had efficient emptying in their first void (Fig. 1). This shows that even with a loose sling, most patients have early emptying difficulty. This suggests that either even a loose sling is potentially obstructive or that other factors such as anaesthesia, pain or effects of local dissection influence voiding. With the present study protocol the median pain score was low, so pain was unlikely to be the cause of early emptying difficulty.

The present data also show that, although 68% of the patients had their second void within 6–10 h after surgery, only 20% had their first void within 5 h, and 10% took >10 h for their first void. If the threshold of EE for discharge were reduced to 50%, then 60% of patients could have been discharged. However, we do not know if an EE of ≥ 50% is an acceptable threshold. The implications of these findings for a typical day-surgery unit open from 08.00 to 17.00 hours is that a patient will have only 7 h after surgery in which to void efficiently (allowing 2 h for preparation, surgery and recovery). From the present data, only four patients (10%) would be suitable for discharge at 17.00 hours, and even if we had chosen a 50% EE as the threshold, only 14 (35%) would be suitable for discharge on the same day. In the USA, medical insurance considerations dictate <24 h as a threshold for inpatient ambulatory surgery; applying that threshold to the present patients, then 28 (70%) would have been eligible for discharge.

A standardized method to measure intraoperative sling tension has not yet been developed, although many techniques have been proposed. These techniques are limited because of technical difficulties [12,13] or because of the questionable relevance of procedures such as cough-stress test under regional anaesthesia. Moreover, in a study by Wang and Chen [14], nearly 45% of patients were unable to leak urine during a cough test in the dorsal lithotomy position. As there is no exact method of determining how much tension to put on the sling during surgery, the surgeon must rely chiefly on experience to make the judgement [3,4]. However, we found that patients with ISD were unlikely to achieve early efficient emptying and thus would not be suitable for discharge as day-cases. This is almost certainly because of higher applied sling tension resulting in outlet obstruction.

Difficulty in bladder emptying after anti-incontinence surgery is easily characterized by measuring the EE. The advantage of using EE as the prime measure of emptying difficulty is its simplicity and clinical relevance soon after surgery. In contrast to the PVR, which measures the amount of urine left after a void, the EE takes the pre-void bladder volume into account and is a more objective way to quantify bladder-emptying difficulty.

Although Ulmsten et al.[15,16] reported that most of their patients were discharged one day after an ambulatory procedure for SUI (tension-free vaginal tape), Nilson et al.[17] reported that 80% of the women in their study were discharged on the afternoon of the operation. In another study [18], 17 of 40 (43%) patients were discharged on the same day after a porcine dermal sling procedure. In all three studies there was no information on the time required to first spontaneous void and EE. The difference in the present study for day-case discharge rate reflects our stricter study protocol and discharge criteria.

There is wide variation in the use of catheters and vaginal packs after sling surgery. Although we used a vaginal pack for only 3 h, only two patients reported a small amount of vaginal bleeding soon after surgery and neither required intervention.

Only 10% of the present patients were willing to use CISC within 10 h after surgery and required assistance from a nurse. More extensive preoperative training might improve early ability with CISC and this might in turn improve the suitability for discharge. Furthermore, sedative side-effects of anaesthetic drugs are also an important hindrance to early patient mobility and CISC. Another possible solution would be to discharge patients with a short-term indwelling catheter and bring them to the day-surgery unit after 2–3 days. This would obviously mean another hospital visit and extra cost. Moreover, many of the present women were unwilling to go home with an indwelling catheter on the day of surgery.

Opioid analgesia after surgery might be associated with nausea, vomiting, increased time to tolerate oral fluids, sedation and urinary retention [19,20]. To avoid such possible interference after surgery we used NSAIDS instead of opioids. With our protocol, postoperative pain was never a limiting factor for discharge. Only two patients (5%) were unsuitable for discharge because of anaesthetic problems, and neither of these emptied efficiently.

Using QoL questionnaires and physical examination, overall SUI was cured or improved in 90% of the present patients at the 6-month follow-up. These cure rates are similar to those of other published series. The short-term overall cure rate using the Pelvicol sling is comparable with that of the autologous rectus fascia sling [21].

The present surgery was carried out by one urologist with a special interest in this field, and this might reduce the external validity. This bias would rather reinforce our findings of limitations to the day-case sling surgery approach. This was a prospective observational study; the objective was to provide preliminary estimates of variables and to generate hypotheses for testing in larger multicentre randomized trials where practical. Calculations of sample sizes based on this study can be used for further trials.

The present findings have four implications for clinical practice. First, only 40% of patients are suitable for Pelvicol day-case sling surgery; even patients considered ideal for a minimally invasive day-case sling could expect a significant risk of an overnight stay, which might be an unacceptable proposition because of increased unplanned hospital readmission. Second, early postoperative bladder emptying inefficiency is the main limiting factor; excluding patients with ISD and possibly decreasing the EE threshold to 50% would improve eligibility for discharge. Third, postoperative pain is not a limiting factor for day-case patient discharge. Finally, short-term results with the porcine dermal sling are similar to those with the autologous fascial sling.

ACKNOWLEDGEMENTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. CONFLICT OF INTEREST
  9. REFERENCES
  10. EDITORIAL COMMENT
  11. Appendix

This work was supported by educational grant from the National Institute of Health Sciences (NIHS), Limerick, Ireland and Pfizer Sales Ireland.

CONFLICT OF INTEREST

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. CONFLICT OF INTEREST
  9. REFERENCES
  10. EDITORIAL COMMENT
  11. Appendix

None declared. Source of funding: National Institute of Health Sciences and Pfizer, Ireland.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. CONFLICT OF INTEREST
  9. REFERENCES
  10. EDITORIAL COMMENT
  11. Appendix
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    Clemens JQ, DeLancey JO, Faerber GJ, Westney OL, McGuire EJ. Urinary tract erosions after synthetic pubovaginal slings: diagnosis and management strategy. Urology 2000; 56: 58994
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    Chaikin DC, Blaivas JG, Rosenthal JE, Weiss JP. Results of pubovaginal sling for stress incontinence: a prospective comparison of 4 instruments for outcome analysis. J Urol 1999; 162: 16703
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    Kondo A, Kato K, Gotoh M et al. Quantifying thread tension is of clinical use in Stamey bladder neck suspension: analysis of clinical parameters. J Urol 1989; 141: 3842
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    Yamada T, Kura N, Kawakami S, Watanabe T, Negishi T, Mizuo T. Suburethral sling procedure for urinary stress incontinence. With special reference to determination of tension of suspension from posturethrovesical angle measured by ultrasonography. Nippon Hinyokika Gakkai Zasshi 1990; 81: 13516
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    Wang AC, Chen MC. Randomized comparison of local versus epidural anesthesia for tension-free vaginal tape operation. J Urol 2001; 165: 117780
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    Ulmsten U, Henriksson L, Johnson P, Varhos G. An ambulatory surgical procedure under local anesthesia for treatment of female urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 1996; 7: 815
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    Ulmsten U, Johnson P, Rezapour M. A three-year follow up of tension free vaginal tape for surgical treatment of female stress urinary incontinence. BJOG 1999; 106: 34550
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    Nilsson CG, Kuuva N. The tension-free vaginal tape procedure is successful in the majority of women with indications for surgical treatment of urinary stress incontinence. BJOG 2001; 108: 4149
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    Barrington JW, Edwards G, Arunkalaivanan AS, Swart M. The use of porcine dermal implant in a minimally invasive pubovaginal sling procedure for genuine stress incontinence. BJU Int 2002; 90: 2247
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    Breitfeld C, Peters J, Vockel T, Lorenz C, Eikermann M. Emetic effects of morphine and piritramide. Br J Anaesth 2003; 91: 21823
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    Cepeda MS, Alvarez H, Morales O, Carr DB. Addition of ultralow dose naloxone to postoperative morphine PCA: unchanged analgesia and opioid requirement but decreased incidence of opioid side effects. Pain 2004; 107: 416
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    Cross CA, Cespedes RD, McGuire EJ. Our experience with pubovaginal slings in patients with stress urinary incontinence. J Urol 1998; 159: 11958

EDITORIAL COMMENT

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. CONFLICT OF INTEREST
  9. REFERENCES
  10. EDITORIAL COMMENT
  11. Appendix

The authors concluded that only 40% of patients were suitable for Pelvicol day-case sling surgery. Unfortunately the underlying principle reported here is not new. Sling surgery (even conventional sling surgery) has been used on a day-case basis, and usually is in North America, and the introduction of mid-urethral tapes has meant that a very large proportion of sling surgery is on day-cases. To facilitate this, patients may need to learn CISC or be prepared to go home with an indwelling catheter; sometimes patients are not ready to go home. In this paper the authors identified only 40% of patients who were suitable for day-case sling surgery, but this would not have been the case had the women been taught CISC or sent home with an indwelling catheter. What the authors showed is that voiding function returns gradually during the first few hours after inserting a sling, and that bladder emptying improves quite rapidly.

Linda Cardozo

Appendix

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. CONFLICT OF INTEREST
  9. REFERENCES
  10. EDITORIAL COMMENT
  11. Appendix

Postoperative questionnaire [10]

  • 1
    How much leakage of urine do you have now?
    • A.
      None
    • B.
      Mild
    • C.
      Moderate
    • D.
      Severe
  • 2
    If you do now leak urine, how does it usually occur?
    • A.
      Mostly with coughing, sneezing or physical activity
    • B.
      Usually not with physical activity, but leakage occurs suddenly with an urge to urinate before it can be controlled
    • C.
      Leakage of urine often occurs in both of the situations described above
    • D.
      Not sure when leakage occurs
  • 3
    How much improved is your urinary leakage compared to before sling operation?
    • a.
      100% better
    • b.
      90% better
    • c.
      80% better
    • d.
      70% better
    • e.
      60% better
    • f.
      50% better
    • g.
      40% better
    • h.
      30% better
    • i.
      20% better
    • j.
      10% better
    • k.
      the same
    • l.
      worse than before the surgery
  • 4
    Do you wear any protective pads for urine leakage?
    • A.
      Yes
    • B.
      No
  • 5
    If you are wearing pads, how many do you use in 24 h?
  • 6
    How often do you urinate during the day?
    • A.
      More often than once every hour
    • B.
      Every 1–2 h
    • C.
      Every 3–4 h
    • D.
      Less often than once every 4 h
  • 7
    How many times per night do you wake up from sleep to urinate?
  • 8
    If your incontinence returned after sling operation, how long after surgery was it?
  • 9
    If your incontinence returned after sling operation, how did it happen?
    • A.
      Gradually over months
    • B.
      Suddenly over a few days or week
  • 10
    Do you currently use a catheter to empty your bladder?
    • A.
      Yes
    • B.
      No
  • 11
    Do you get usually the urge to urinate?
    • A.
      Yes
    • B.
      No
  • 12
    Since your surgery, do you have problems with pelvic pain?
    • A.
      Yes
    • B.
      No
  • 13
    If you are having intercourse, is it painful?
    • A.
      Yes
    • B.
      No
    • C.
      Not sexually active
  • 14
    Overall, how satisfied are you with the results of your sling surgery?
    • 0_1_2_3_4_5_6_7_8_9_10

    • Not satisfied

    • Very satisfied

  • 15
    Knowing what you know now, would you have the sling surgery again?
    • A.
      Yes
    • B.
      No
  • 16
    Would you recommend the sling surgery to your friend?
    • A.
      Yes
    • B.
      No
    • C.
      Not sure.