present37

PelvicFloor3DUltrasoundofWomenwithaTVT,TVT-O,orTVT-SforStressUrinaryIncontinenceattheThree-yearFollow-upUltrassonograatridimensionaldoassoalhopélvicoapós3anosdecorreocirúrgicadeincontinênciaurináriadeesforoporslingretropúbico,transobturador,oudeincisoúnicaClaudineiA.
Rodrigues1AnaMariaH.
M.
Bianchi-Ferraro1ElianaVianaMonteiroZucchi1MarairG.
F.
Sartori1ManoelJ.
B.
C.
Giro1ZsuzsannaI.
K.
Jarmy-DiBella11SectorofUrogynecologyandVaginalSurgery,DepartmentofGynecology,UniversidadeFederaldeSoPaulo,SoPaulo,BrazilRevBrasGinecolObstet2017;39:471–479.
AddressforcorrespondenceClaudineiAlvesRodrigues,MD,SetordeUroginecologiaeCirurgiaVaginal,DepartmentodeGinecologia,UniversidadeFederaldeSoPaulo,AlamedaJoaquimEugêniodeLima,913,Apt.
91,SoPaulo,SP,01403-001,Brazil(e-mail:dinhodr@uol.
com.
br).
KeywordsurinaryincontinenceultrasonographypelvicoorAbstractObjectiveUsingthree-dimensionalultrasound(3D-US),weaimedtocomparethetapepositionandtheangleformedbytheslingarmsindifferenttechniquesofmid-urethralslinginsertionforthesurgicaltreatmentofstressurinaryincontinence,threeyearsaftersurgery.
Inaddition,weexaminedthecorrelationsbetweentheUSndingsandtheclinicallatepostoperativeresults.
MethodsAprospectivecross-sectionalcohortstudyof170patientswhounderwentaslingprocedurebetweenMay2009andDecember2011wasperformed.
Thenalsample,withUSimagesofsufcientquality,included26retropubicslings(tension-freevaginaltape,TVT),42transobturatorslings(tension-freevaginaltape-obturator,TVT-O),and37single-incisionslings(tension-freevaginaltape-Secur,TVT-S).
Theimages(atrest,duringtheValsalvamaneuver,andduringpelvicoorcontraction)wereanalyzedofineby2differentobserversblindedagainstthesurgicalandurinarycontinencestatus.
GroupcomparisonswereperformedusingtheStudentt-test,thechi-squaredandtheKruskal-Wallistests,andanalysesofvariancewithTukeymultiplecomparisons.
ResultsDifferencesamongthegroupswerefoundinthemeanangleofthetapearms(TVT119.
94°,TVT-O141.
93°,TVT-S121.
06°;p37-1606125.
ISSN0100-7203.
Copyright2017byThiemeRevinterPublicaesLtda,RiodeJaneiro,BrazilTHIEMEOriginalArticle471IntroductionThecurrentstandardsurgicaltreatmentforstressurinaryincontinence(SUI)involvestension-freemid-urethralsling(MUS)placement,eitherusingtheretropubicortransobtu-ratorapproach,whichhasareportedsuccessrateofupto80%atthelong-termfollow-up.
1Morerecently,single-inci-sionslingsweredevelopedtominimizesomeoftherisksrelatedtoMUSs,suchasinfectionandchronicpain.
However,thistechniquehasnotbeenwell-acceptedbythemedicalcommunityduetothevariabilityininsertiontechniquesandthediversityofmaterialsusedtoensurethexationofthe83.
8%(TVT88.
5%,TVT-O88.
5%andTVT-S78.
4%;p0.
514).
Theslingswerelocatedinthemid-urethrain85.
7%ofthepatients(TVT100%,TVT-O73.
8%,TVT-S89.
2%;p0.
001),withamoredistallocationassociatedwithobesity(distal:66.
7%obese;mid-urethra:34%obese;p0.
003).
Urgency-relatedsymptomswereobservedin23.
8%ofthepatients(TVT30.
8%,TVT-O21.
4%,TVT-S21.
6%;p0.
630).
ConclusionsTheangleformedbythearmsoftheslingtapewasmoreobtuseforthetransobturatorslingscomparedwiththeanglesfortheretropubicorsingle-incisionslings.
Retropubicslingsweremorefrequentlylocatedinthemid-urethracomparedwiththeotherslings,regardlessofobesity.
However,theanalyzedsonographicmeasuresdidnotcorrelatewiththeurinarysymptomsthreeyearsafterthesurgery.
ResumoObjetivoCompararpormeiodeultrassomtridimensional(US-3D)aposioeonguloentreosbraosdafaixa,emdiferentestécnicasdeinserodeslingdeuretramédia,paratratamentodeincontinênciaurináriadeesforo,3anosapósacirurgia,correlacionandoosachadosultrassonográcosaosresultadosclínicospós-operatórios.
MétodosEsteéumestudodecoortetransversalprospectivode170pacientesquesesubmeteramaumprocedimentodeslingentremaiode2009edezembrode2011.
FoipossívelavaliarasimagensdeUSem105pacientes:26comtension-freevaginaltape(TVT),42comtension-freevaginaltape-obturator(TVT-O)e37comtension-freevaginaltape-Secur(TVT-S).
Asimagens(emrepouso,emmanobradeValsalvaeemcontraoperineal)foramanalisadaspordoisobservadoresdiferentes,quedesconheciamotipodeslingutilizadonacirurgia,assimcomoasqueixasdapaciente.
AanáliseestatísticafoirealizadapormeiodostestestdeStudent,qui-quadrado,Kruskal-Wallis,eanálisedevarinciacomcomparaesmúltiplasdeTukey.
ResultadosAsmédiasdosngulosentreosbraosdafaixaforam:TVT119,94°,TVT-O141,93°,TVT-S121,06°(pcomparamosachadosultrassonográcoseosgruposdepacientescomsintomasdeurgência,curasubjetivaeobjetiva.
ConclusoOnguloformadopelosbraosdafaixafoimaisobtusonoTVT-OquandocomparadocomoTVTouoTVT-S.
OsTVTsforamlocalizadosmaisfrequentementenauretramédiaquandocomparadoscomosoutrosdoisgrupos,mesmoempacientesobesas.
Entretanto,asmedidasultrassonográcasnotiveramcorrelaocomossintomasurináriostrêsanosapósacirurgia.
Palavras-ChaveincontinênciaurináriaultrassonograaassoalhopélvicoRevBrasGinecolObstetVol.
39No.
9/2017PelvicFloor3D-USofWomenwithTVT,TVT-O,orTVT-SforUrinaryIncontinenceat3-yearFollow-upRodriguesetal.
472device,whichhasinterferedwithcontinencesuccess.
Thus,traditionalMUSsareconsideredsignicantlysuperiortomini-slingsintermsofcureoutcomes.
2–4AlthoughMUSoperationsareconsideredsafe,complica-tionssuchasurinaryobstructionandpostoperativeurgencymayoccur.
Imagingtechniquescanprovideassistanceinthediagnosisofthesecomplications.
5Ultrasonography(US)isawidespreadtoolusedtoassesstheanatomyandfunctionofthepelvicoorstructures.
Itisanon-invasive,reproducible,andtechnicallysimplemethodtovisualizethelowerurinarytract,particularlytheurethraandthebladder,andanendovaginalortranslabialconvexprobecanbeused.
6Moreover,translabialthree-dimensionalultrasound(3D-US)allowsgoodvisualiza-tionofthesuburethralpolypropyleneslingtapeinorthogonalplanes(axial,coronal,mid-sagittal),andcanbeusedtoexplainthepathogenesisofvoidingdysfunctionfollowingsyntheticslingprocedures.
7Thus,USduringthepostoperativeperiodhasshownanincreasingroleinthemonitoringofsurgicallytreatedpatients,especiallyforcomplicationssuchasurinaryretentionandurinarydisorders.
However,therearefewstudiesthatcorrelatetheinformationobtainedby3D-USandtheprognosticandpredictivemarkersofSUItreatmentwithsyntheticslings.
7Therefore,thepresentstudyutilizedtranslabial3D-US3yearsaftersurgeriesforthecureofSUItoevaluateandcomparethespatialpositionofthepolypropyleneslingtapefor3differentSUIcorrectiontechniques:MUSusingtheretropubicapproach(tension-freevaginaltape,TVT),thetransobturatorapproach(tension-freevaginaltape-obturator,TVT-O),andthesingle-incisionsling(tension-freevaginaltape-Secur,TVT-S).
Inaddition,therelationshipbetweenthe3D-USndingsandtheobjective/subjectivecureratesandurgency-relatedsymptomswasexamined.
OurhypothesiswasthattheangleformedbythearmsofthetapefollowingTVTinsertionisthemostacute,causingmorepost-operativeurgencies,whereastheanglefollowingTVT-Oinsertionismoreobtuseand,consequently,resultsinmorefailuresofSUIcorrection.
Inaddition,weexpectedtheTVT-S,whichisnotcurrentlyonthemarket,toactsimilarlytotheTVT.
Moreover,wehypothesizedthatifthetapeislocatedinthemid-urethra,thebetterthelong-termclinicalpostoperativeresults.
MethodsSubjectsAprospectivecross-sectionalcohortstudyofpatientswhounderwentaslingprocedureattheUrogynecologyandVaginalSurgerySectorofourinstitutionbetweenMay2009andDecember2011wasperformed.
Allpatientswhounderwentthesurgeryduringthestudyperiodwereinvited(viaphone)toparticipate.
Theinclusioncriteriawere:womenover18years-oldwhohadundergoneSUItreatmentwithMUS(usingtheretropubicortransobturatorroutes)orasingle-incisionslingwithoutanyconcomitantpelvicoorsurgicalprocedures.
Inaddition,thepatientshouldhavehadapreoperativediagnosisofSUIwithoutdetrusoroveractivity.
Theexclusioncriteriawereasfollows:incompletemedicalrecordsrelatingtosurgicalhospitaliza-tion,urinaryincontinencepreviouslytreatedbysurgerywithapolypropyleneimplant,orundergoingnewtreat-mentsforurinaryincontinenceduringthefollow-upperiod.
Totalof170patientswereeligibletoparticipateinthestudy(48withTVTs,56withTVT-Os,and66withTVT-Ss).
Amongthese,115acceptedtheinvitation,beingthusselectedandplacedineachgroupaccordingtothesurgeryperformed(TVT:26;TVT-O:46;TVT-S:43).
However,10evaluatedpatientswereexcludedfromtheanalysis(2womenpre-sentedwith2syntheticslingsatUS,and3D-USimagesdidnothaveperfecttechnicalqualityin8cases),resultinginanalsampleof105patients(TVT:26;TVT-O:42;TVT-S:37).
ThepatientselectionprocessisdepictedinFig.
1.
Anurodynamicstudywasperformedbeforethesurgery,andtheresultsoftheValsalvaleakpointpressure(VLPP,meanandstandarddeviation)were67.
6419.
20cmH2O,87.
5732.
14cmH2Oand85.
1427.
05cmH2O,fortheTVT,TVT-OandTVT-Sgroupsrespectively.
Asamplepowercalculationwasperformedusingtheresultsofapreviouspublication,7whichinvolvedtheevalu-ationoftheanglesformedbythearmsofthepolypropylenetapeinsonographicimagesatrestandduringtheValsalvamaneuver.
Atrest,themeanvaluesconsideredinthesamplecalculationwere116°and137°,respectivelyfortheTVTandTVT-Ogroups,andtheoverallstandarddeviationconsideredwas7.
DuringtheValsalvamaneuver,themeanvalueswere130°(TVT)and140°(TVT-O),withastandarddeviationof10.
Consideringthepowerofthesampleof80%,4patientspergroupatrestand17patientspergroupduringtheValsalvamaneuverwouldbenecessary.
Ap-valueCommittee,andthetrialwasappropriatelyregisteredonwww.
clinicaltrials.
gov(NCT02406638).
Allparticipantspro-videdwritteninformedconsent,andtheresearchwasperformedaccordingtotheDeclarationofHelsinki,asrevisedin2008.
ProceduresTheTVTsurgerywasperformedaccordingtotheclassicaltechnique,8usingGynecareTVT(EthiconInc.
,Somerville,NewJersey,US).
TheTVT-Oprocedurewasperformedaccordingtotheinside-outtechniqueproposedbydeLeval,9usingtheGynecareTVTObturatorSystem(EthiconInc.
,Somerville,NewJersey,US).
Thesingle-incisionsling(TVT-Secur,GynecareTVTSecurSystem,EthiconInc.
,Somerville,NewJersey,US)wasinsertedusingthe"U"insertiontech-nique.
10Themanufacturerdiscontinuedthecommercializa-tionoftheTVT-Sin2012.
11Three-dimensionalUSimagingandaclinicalevaluationwereperformedbetweenApril2013andJune2014.
Thephysicalexaminationinvolvedstresstests,includingthe250-mlbladdervolumeandthe20-minutepadtests.
12Inaddition,thequalityoflifewasassessedusingtheKingHealthQuestionnaire(KHQ),whichhadbeenpreviouslyvalidatedforthePortugueselanguage.
13Objectivecurewasdenedastheabsenceofurinaryleakageduringthestresstests.
SubjectiveRevBrasGinecolObstetVol.
39No.
9/2017PelvicFloor3D-USofWomenwithTVT,TVT-O,orTVT-SforUrinaryIncontinenceat3-yearFollow-upRodriguesetal.
473curewasdenedastheabsenceofself-reportedurinaryleakageasindicatedbyaKHQsymptomsscalescoreof0.
Thepresenceofurgency-relatedsymptomswasalsoevaluatedusingtheKHQsymptomsscale.
Three-dimensionalUSwasperformedaftervoiding,withthepatientinthelithotomyposition,withthehipsexedandabducted;itwasperformedatrest,duringtheValsalvamaneuver,andduringperinealcontraction.
The3D-USequip-ment(Voluson730Expert,GeneralElectric[GE]Healthcare,Zipf,Austria)includedaconvexvolumetrictransducercoveredbyaplastictransducer(4–8Mhz)withanacquisitionangleof85°.
Theobtainedimagesofthepelvicoorwerelaterevaluatedusingthe4DView(version14,ext0;GEKretzUltrasound,GEHealthcare,Zipf,Austria)softwareonacomputerwiththeWindowssystem.
Fortheanalysisoftheimages,thesagittalplane(two-dimensional[2D]image)wasselectedwiththesightlinethroughthepubis,theurethra,andthepolypropyleneslingtape.
14Theassessorsoftheultrasounddatawereblindedagainstallclinicaldata.
Themeasurementsoftheurethrallength(UL)andthedistancebetweenthebladderneckandthecentralpointofthetape(BT)wereperformedusinga2D-USimageinthemid-sagittalplane(Fig.
2).
Thetapedisplace-mentinrelationtotheULwasmeasuredasthedifferencebetweentheratiooftheBTandULatrestandduringtheValsalvamaneuverorpelvicoorcontraction.
Foranevaluationoftherelativepositionofthetape,wedividedtheBTbytheUL,andtheresultingnumberwasusedtoclassifythepositionofthetapewithintheurethra.
Thetapewasconsideredtobe:intheproximal-third(closesttothebladderneck)iftheresultwasbetween0and0.
33;inthemiddle-thirdiftheresultwasbetween0.
34and0.
66;andinthedistal-third(closesttotheexternalurethralostium)iftheresultwasbetween0.
67and1.
0.
TheOmniViewvolumecontrastimaging(VCI)mode(GEHealthcare,Zipf,Austria)wasusedduringtheimageanalysis,slidingdigitallywithastraightlinepassingthroughtheloweredgeofthepubicsymphysis,theurethra,andthelowertape.
Inordertoimprovevisibility,VCIwasselected,withathicknessof3.
0mm,whichallowedthevisualizationofthepubis,theurethra,thevagina,thetape,andtherectum(Fig.
2).
15TheOmniView-VCImodewasusedtoevaluatetheangleformedbythetapearms(Ao),aswellasthedistancebetweentheposteriorinferiorsymphysismarginandtheechogeniccenteroftheurethra(PU),andthedistancebetweentheechogeniccenteroftheurethraandthetape(UT)(Fig.
2).
ThemobilityoftheurethraduringmovementwascalculatedasthedifferencebetweenthePUatrestandthePUduringtheValsalvamaneuverorpelvicoorcontraction.
StatisticalanalyseswereperformedusingtheMinitabsoftware(Minitab,Inc.
,StateCollege,PA,US),version16.
TheMann-Whitneytestwasusedforthecontinuousnon-parametricvariables,andtheStudentt-testwasusedforthecontinuousparametricvariables.
TheChi-squared,Fisher,Kruskal-Wallis,andPearsoncorrelationtestswereusedforthenominalvariables.
Analysesofvariance(ANOVAs)forcontinuousvariableswereperformedusingtheTukeymultiplecomparisonprocedure.
Ap-value37Minis-lingTVT-S)weresimilarintermsofage,bodymassindex(BMI),thenumberofvaginalorcaesareandeliveries,andhormonalstatus,asshowninTable1.
AtthetimeoftheFig.
1Patientselectionowchart:thepatientselectionprocessisdepicted.
Abbreviations:TVT,tension-freevaginaltape(retropubicsling);TVT-O,tension-freevaginaltape-obturator(transobturatorsling);TVT-S,tension-freevaginaltape-Secur(single-incisionsling).
RevBrasGinecolObstetVol.
39No.
9/2017PelvicFloor3D-USofWomenwithTVT,TVT-O,orTVT-SforUrinaryIncontinenceat3-yearFollow-upRodriguesetal.
474evaluation,thepostoperativetimerangedbetween36and40months.
The2D-USmeasurementsobtainedinthemid-sagittalplanearepresentedinTable2.
TheULatrest,duringtheValsalvamaneuver,andduringpelvicoorcontractiondidnotsignicantlydifferamongthethreegroups.
Incontrast,thereweredifferencesamongthegroupsregardingtheBT.
SpecicallyfortheTVTgroup,thetapewassignicantlyFig.
2Exampleimages:(A)a2D-USmid-sagittalplane(left)and3DOmniViewaxialimage(right)imageofthepelvicoorareshown.
Notetheslingposition(whitehyperechoicstructure–T)andurethra(hypoechoicstructure–U).
Twoimagesbelow-OmniViewmode:TheaxialplaneontheOmniViewmodewithpelvicoororgans,attheleft(B),andmeasurements,attheright(C),isshown.
Abbreviations:Ao,anglebetweenthetwoarmsofthesling;P,symphysispubis;PU,distancebetweenthesymphysispubisandtheurethra;R,rectum;T,polypropylenetape(sling);U,urethra;UT,distancebetweenthetapeandtheurethra;V,vagina.
Table1PatientcharacteristicsTVT(n26)Mean(SD)TVT-O(n42)Mean(SD)TVT-S(n37)Mean(SD)pAge(Years)58.
35(9.
79)55.
00(10.
77)54.
51(13.
2)0.
384aBMI(Kg/m2)27.
87(3.
66)30.
41(5.
16)29.
50(5.
35)0.
121aCaesareandelivery0.
42(0.
86)0.
52(0.
89)0.
62(0.
83)0.
372bVaginaldelivery1.
89(1.
11)2.
71(2.
11)3.
05(2.
73)0.
130bMenopause(%)22(84.
60%)26(61.
90%)24(64.
86%)0.
122cAbbreviations:BMI,bodymassindex;SD,standarddeviation;TVT,tension-freevaginaltape(retropubicsling);TVT-O,tension-freevaginaltape-obturator(transobturatorsling);TVT-S,tension-freevaginaltape-Secur(single-incisionsling).
Notes:aANOVA;bKruskal-Wallistest;cChi–squaredtest.
ThevaluesarerepresentedasmeanandSD(range)andn(%),andareattributedtopatientswhounderwentsurgicaltreatmentforstressurinaryincontinenceusingaretropubicsling(TVT),atransobturatorsling(TVT-O),orasingle-incisionsling(TVT-S).
RevBrasGinecolObstetVol.
39No.
9/2017PelvicFloor3D-USofWomenwithTVT,TVT-O,orTVT-SforUrinaryIncontinenceat3-yearFollow-upRodriguesetal.
475closertothebladderneckcomparedwiththeothergroupsduringrest(p0.
001),butnotduringtheValsalvamaneu-ver(p0.
08)orpelvicoorcontraction(p0.
11).
Therewasnosignicantdifferenceinthedisplacementofthetapeamongthethreegroups.
Thelocationoftheslingrelativetotheurethrawasdifferentamongthegroupsatrestandduringmovement(rest:p37tapes(89.
2%)werelocatedinthemid-urethraatrest.
Furthermore,duringtheValsalvamaneuver,78.
6%oftapesintheTVT-Ogroupand78.
4%intheTVT-Sgroupwerelocatedinthemid-urethra.
Duringpelvicoorcontraction,only73.
8%ofthetapesintheTVT-0groupand86.
5%intheTVT-Sgroupwerelocatedinthemid-urethra.
Ofthe15patientswiththetapelocatedinthedistalurethra,66.
7%hadaBMI>30kg/m2(obesestatus).
Incontrast,ofthe90patientswiththetapelocatedinthemid-urethra,only34%wereobeseasassessedbyBMI(mid-urethraversusdistalurethra:p0.
003).
Thetotalsamplehad40/105(38%)obesepatients.
ThemeasurementstakenusingtheOmniView-VCImodeareshowninTable2.
TheangleformedbythearmsoftheslingwasnotsignicantlydifferentbetweentheTVTandTVT-Sgroups,butwasmoreobtuseintheTVT-Ogroupcomparedwiththeothergroupsduringrest(pcomparedwiththeTVT-Sgroup.
NosignicantdifferencesamongthegroupsregardingurethralmobilityduringtheValsalvamaneuverandduringpelvicoorcontractionwerefound(p0.
78andp0.
51respectively).
InformationonsubjectiveandobjectivecureispresentedinTable3.
Asubjectivecurewasachievedby88ofthe105patients(83.
8%),withnodifferenceamongthegroups(p0.
701).
Anobjectivecurewasveriedin92/105(87.
8%)patients,withnodifferenceamongthegroups(p0.
514).
Thepresenceofurgency-relatedsymptomsTable2MidsagittalsonographicandOmniView-VCImodemeasurementsTVT(n26)Mean(SD)TVT-O(n42)Mean(SD)TVT-S(n37)Mean(SD)pUrethrallength:rest(cm)3.
34(0.
37)3.
24(0.
40)3.
36(0.
45)0.
38Urethrallength:Valsalva(cm)3.
26(0.
30)3.
18(0.
40)3.
25(0.
42)0.
63Urethrallength:contraction(cm)3.
56(0.
42)3.
34(0.
39)3.
53(0.
49)0.
07BT:rest(cm)1.
65(0.
26)1.
93(0.
38)1.
95(0.
51)0.
01BT:Valsalva(cm)1.
67(0.
24)1.
85(0.
37)1.
89(0.
50)0.
08BT:contraction(cm)1.
81(0.
38)2.
03(0.
39)2.
03(0.
57)0.
11Mid-urethratapen(%):rest26(100%)31(73.
8%)33(89.
2%)0.
008Mid-urethratapen(%):Valsalva26(100%)33(78.
6%)29(78.
4%)0.
036Mid-urethratapen(%):contraction26(100%)31(73.
8%)32(86.
5%)0.
013A°:rest119.
94(19.
66)141.
93(14.
25)121.
06(14.
24)comparisons.
ThemidsagittalsonographicmeasurementsandOmniView-VCImodemeasurementsofpatientswhounderwentsurgicaltreatmentforstressurinaryincontinenceusingaretropubicsling(TVT),atransobturatorsling(TVT-O),orasingle-incisionsling(TVT-S)areprovided.
RevBrasGinecolObstetVol.
39No.
9/2017PelvicFloor3D-USofWomenwithTVT,TVT-O,orTVT-SforUrinaryIncontinenceat3-yearFollow-upRodriguesetal.
476Table3UrinarysymptomsTVTTVT-OTVT-STOTALpSubjectivecure23(88.
5%)36(85.
7%)29(78.
4%)88(83.
8%)0.
514aObjectivecure23(88.
5%)38(90.
5%)31(83.
8%)92(87.
8%)0.
701bUrgencysymptoms8(30.
8%)9(21.
4%)8(21.
6%)25(23.
8%)0.
630aTOTAL26(100%)42(100%)37(100%)105(100%)Abbreviations:TVT,tension-freevaginaltape(retropubicsling);TVT-O,tension-freevaginaltape-obturator(transobturatorsling);TVT-S,tension-freevaginaltape-secure(single-incisionsling).
Notes:aChi-squaredtest;bFisherexacttest.
Thesubjectiveandobjectivecureratesandtherateofurgency-relatedsymptomsforpatientswhounderwentsurgicaltreatmentforstressurinaryincontinenceusingaretropubicsling(TVT),atransobturatorsling(TVT-O),orasingle-incisionsling(TVT-S)areprovided.
Table4AssociationsbetweenultrasoundmeasurementsandurinarysymptomsSubjectivecureObjectivecureUrgencysymptomsYESNOpYESNOpYESNOp(n88)(n17)(n92)(n13)(n25)(n25)MMMMMM(SD)(SD)(SD)(SD)(SD)(SD)BT:rest(cm)1.
871.
860.
961.
851.
980.
501.
761.
760.
25(0.
38)(0.
62)(0.
38)(0.
66)(0.
52)(0.
52)BT:Valsalva(cm)1.
81.
950.
291.
792.
020.
241.
851.
850.
74(0.
35)(0.
59)(0.
35)(0.
66)(0.
48)(0.
48)BT:contraction(cm)1.
962.
010.
801.
952.
120.
371.
931.
930.
60(0.
44)(0.
60)(0.
43)(0.
64)(0.
50)(0.
50)RatioBT/UL:rest0.
570.
550.
620.
560.
570.
710.
530.
530.
09(0.
09)(0.
12)(0.
09)(0.
12)(0.
11)(0.
11)RatioBT/UL:Valsalva0.
560.
570.
680.
560.
580.
610.
560.
560.
64(0.
09)(0.
13)(0.
09)(0.
14)(0.
02)(0.
02)RatioBT/LU:contraction0.
570.
570.
100.
570.
580.
620.
560.
560.
56(0.
09)(0.
09)(0.
10)(0.
10)(0.
10)(0.
10)A(o):rest129.
2°127.
9°0.
81128.
3°133.
9°0.
35128.
5°128.
5°0.
89(18.
5)(21.
3)(18.
8)(19.
6)(21.
5)(21.
5)A(o):Valsalva136.
6°133.
2°0.
58135.
6°139.
3°0.
94136.
3°136.
3°0.
99(23.
0)(22.
6)(23.
0)(22.
2)(21.
4)(21.
4)A(o):contraction132.
4°132.
5°0.
99131.
4°139.
9°0.
26133.
3°133.
3°0.
82(18.
9)(25.
2)(19.
0)(24.
8)(23.
2)(23.
2)Urethralmobility:rest-Valsalva(cm)-0.
03-0.
060.
73-0.
04-0.
050.
87-0.
08-0.
080.
31(0.
24)(0.
31)(0.
25)(0.
31)(0.
23)(0.
23)Urethralmobility:rest-contraction(cm)0.
030.
040.
360.
030.
030.
520.
0110.
0110.
86(0.
21)(0.
31)0.
21(0.
32)(0.
27)(0.
27)Abbreviations:A,Angleofthetwoarmsofthesling;BT,distancebetweenthebladderneckandtape;M,mean;SD,standarddeviation;UL,urethrallength.
Notes:Studentt-test.
Theresultsoftheanalysesexaminingthepotentialassociationsbetweensonographicmeasurementsandurinarysymptomsareprovidedforpatientswhounderwentsurgicaltreatmentforstressurinaryincontinenceusingaretropubicsling(TVT),atransobturatorsling(TVT-O)orasingle-incisionsling(TVT-S).
RevBrasGinecolObstetVol.
39No.
9/2017PelvicFloor3D-USofWomenwithTVT,TVT-O,orTVT-SforUrinaryIncontinenceat3-yearFollow-upRodriguesetal.
477wasobservedin25/105(23.
8%)patients,withnodifferenceamongthegroups(p0.
630).
Correlationsbetweenthetape'sspatialpositionandtheclinicalresultsareshowninTable4.
Nosignicantrela-tionshipswerefound,exceptforthedisplacementofthetapeinrelationtotheULbetweenrestandcontraction,whichwasslightlygreaterinthedirectionofthebladderneckinpatientswithurgency-relatedsymptomscomparedwiththosewithoutsymptoms(p0.
03).
Nosignicantdiffer-encesamongthegroupswerefoundforthedomainsoftheKHQ(Table5).
DiscussionThree-dimensionalUSimagingofthepelvicoorisanon-invasiveandreproducibletechniquefortheevaluationofpostoperativeMUS,anditenablesadynamicassessmentofthepolypropyleneslingtape,withgoodvisibilityduringrest,pelvicoorcontraction,andtheValsalvamaneuver.
7TheBTfoundinthepresentstudyisconsistentwithpreviouslypublisheddata.
18,19Inaddition,forthemajorityofthepatients(85.
7%),theslingwaslocatedinthemid-urethra,andallotherpatientshadslingslocatedinthedistalurethra(14.
3%).
Theseresultsarealsosimilartothoseobtainedbyothersresearchers.
19–21Weobservedthat66.
7%ofthepatientswiththetapelocatedinthedistalurethrahadaBMI>30kg/m2(obesestatus),whileamongthosewiththetapelocatedinthemid-urethra,only34%wereobese.
Thus,obesityappearstobeafactorfavoringamoredistalpositionofthesling.
However,thetaperemainedlocatedinthemid-urethrainallindividualsintheTVTgroup,thusshowingabetterlocationinobesepatientsaswell,threeyearsafterthesurgery.
TheangleformedbythetapearmswaslessobtuseintheTVTandTVT-SgroupscomparedwiththeTVT-Ogroup(atrest,duringtheValsalvamaneuver,andduringpelvicoorcontrac-tion),withnodifferencesbetweentheTVTandTVT-Sgroups.
Thisndingwasasweexpected,anditmaybeexplainedbyfeaturesoftheslinginsertiontechnique.
7,22FortheTVT-O,theinsertionwasina"hammock"position,whilefortheTVTandTVT-S,theinsertionwasina"U"position.
The"U"positionwasconsideredthebestwaytoinserttheTVT-Sbeforeitscom-mercializationwasdiscontinued.
Itisinterestingtonotethatnodifferencesamongthesurgicaltechniqueswereidentiedwithregardtotapedisplacementorurethramobility,inrestorduringmove-ment,whichisasexpected,giventhatthethreesurgicalproceduresaremeanttostabilizeurethralmobility.
ThedistancebetweentheurethraandthetapewassmallerintheTVTgroupcomparedwiththeTVT-SgroupduringtheValsalvamaneuveronly.
Thisndingcouldsug-gestahigherfrequencyofpostoperativeurgency-relatedsymptomswiththeTVT.
However,similarlytopreviousstudies,wedidnotobserveanydifferencesbetweenTVTandTVT-Ogroupsintermsofthissonographicmeasure.
22EventhoughnoassociationsbetweenthepositionoftheMUStapeandtheclinicalresultswerefound,itwasnotedthat,inpatientswithurgency-relatedsymptoms,thetapetendedtomovemoretowardthebladderneckduringtheValsalvamaneuver.
Ontheotherhand,duringpelvicoorcontraction,therewasagreaterdisplacementofthetapetowardthebladderneckinpatientswhoreportedurgency-relatedsymptomscomparedwithpatientswithoutthesesymptoms.
Thismaybeamechanismthatexplainstheonsetofdenovourgencyinthepostoperativeperiod.
Alackofcorrelationbetweenthetapepositionandtheclinicaloutcomeshasbeenpreviouslyreported6,20,23andwasconrmedinthepresentstudy,suggestingthatfactorsotherthantapepositioncouldinuencetheresultsoftheinsertionoftheMUS.
23,24Althoughsomesonographicmeas-urementsreachedstatisticalsignicanceinthegroupcom-parisons,thedifferencesareontheorderofmillimeters,andarenotclinicallysignicant.
Thelimitationsofthepresentstudyincludethecross-sectionaldesign,withonlyamidtermpostoperativefollow-up.
Therefore,wewerenotabletocomparethepreoperativeandpostoperativeresultsorevaluatetheearlierfailuresrequiringsurgicalre-intervention,whichcouldberelatedtotapeposition,assuggestedbyotherstudies.
24,25However,ourstudysampledoesreproducetheresultsfromtheliteratureregardingtheobjectiveandsubjectivecureratesandthefrequencyofurinaryurgencysymptoms,accordingtothedifferentsurgicaltechniques.
1,2ConclusionInconclusion,weobserveddifferencesinthesyntheticslingpositionthreeyearsaftersurgerywhencomparingdifferentroutesofinsertion.
Intheretropubicapproach,thetapewasTable5Qualityoflifeassessments(KingHealthQuestionnaire)TVT-RMeanTVT-OMeanTVT-SMeanpGeneralhealth29.
8124.
4025.
680.
28Incontinenceimpact12.
8213.
4913.
510.
92Limitationstodailyactivities10.
268.
3313.
060.
67Limitationstophysicalactivities11.
547.
1411.
560.
56Sociallimitations10.
263.
706.
010.
62Impactonpersonalrelationships3.
923.
095.
360.
86Impactonemotions6.
419.
529.
310.
73Impactonsleeparrangement8.
976.
755.
410.
58Severitymeasure13.
1410.
529.
010.
69Abbreviations:TVT,tension-freevaginaltape(retropubicsling);TVT-O,tension-freevaginaltape-obturator(transobturatorsling);TVT-S,tension-freevaginaltape-secur(single-incisionsling).
Notes:KruskalWallistest.
QualityoflifedataasassessedusingtheKingHealthQuestionnaireareprovidedforpatientswhounderwentsurgicaltreatmentforstressurinaryincontinenceusingaretropubicsling(TVT),atransobturatorsling(TVT-O)orasingle-incisionsling(TVT-S).
RevBrasGinecolObstetVol.
39No.
9/2017PelvicFloor3D-USofWomenwithTVT,TVT-O,orTVT-SforUrinaryIncontinenceat3-yearFollow-upRodriguesetal.
478morefrequentlylocatedinthemid-urethracomparedwiththetransobturatorrouteandthesingle-incisionsling.
Regardingtheangleoftheslingarms,itwasmoreobtusewiththetransobturatorroute,anditwas,inasimilarmanner,moreacutewiththeretropubicrouteandthesingle-incisionsling.
AlthougharelationshipbetweenthepositionoftheMUStapeandthesubjective/objectivecurethreeyearsaftersurgerywasnotdemonstrated,therewasacorrelationbetweenthemovementofthetapeduringpelvicoorcontractionandthepresenceofsymptomsofurgency.
FundingThisworkwassupportedbyUniversidadeFederaldeSoPaulo.
ConictsofInterestAuthorshavenoconictsofinteresttodisclose.
RegistrationClinicalTrials.
govProtocolRegistrationSystem,http://www.
clinicaltrials.
gov,NCT02406638,PelvicFloor3DUSGThreeYearsAfterMid-urethralSlings(TVT-R,TVT-O,TVT-S).
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