Natale Franca, Illiano Ester, La Penna Chiara, Balsamo Raffaele, Costantini Elisabetta
Urogynecology Unit, San Carlo di Nancy Hospital, Rome, Italy.
Department of Urology and Andrology Clinic, Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy.
Eur J Obstet Gynecol Reprod Biol. 2018 Feb;221:64-69. doi: 10.1016/j.ejogrb.2017.12.003. Epub 2017 Dec 6.
It is hypothesized that urethral dysfunction is central in mixed urinary incontinence (MUI) in women, since urine entering the proximal urethra under increased intra-abdominal pressure provokes a urethro-detrusorial reflex and involuntary detrusor contraction. Mid-urethral slings have been proposed as a solution. Our primary objective was to evaluate the long-term subjective and objective outcomes on continence and other urinary symptoms of a trans-obturator mid-urethral sling (TOT) procedure. Our secondary objectives were to determine its impact on quality of life (QoL), and to investigate which factors influence outcomes.
This is a single-centre prospective study on a consecutive series of 86 women who underwent TOT for MUI as defined by ICS/IUGA. Since the definition of MUI that we used is symptom-based, we included patients both with and without associated detrusor overactivity. All patients underwent placement of Monarc Subfascial Hammocks.
We used the McNemar chi-square test, the paired t-test and Fisher's exact test. A logistic regression model and odds ratios were used to assess age, parity, body mass index, menopausal status, preoperative detrusor over-activity, and detrusor pressure at maximum flow as possible factors for treatment failure. Only those that were statistically significant in the univariate analysis were included in the multivariate analysis.
With a mean follow-up of 59 months, SUI was cured objectively in 83.7% of patients and subjectively in 87.2%. Three patients underwent further anti-incontinence surgery. The continence rates were 74.4% for urgency urinary incontinence (UUI) and 66.3% for SUI-UUI. The patient-reported success rate was 87.2% ('much better' or 'very much better' on Patient Global Impression of Improvement scale). There were statistically significant improvements in all domains except general health. The univariate analysis found no significant risk factor for persistence of SUI. Median age >60 years and menopause were predictive for persistence of UUI. Median and mean age >60 years were predictive of persistence of overall incontinence. In the multivariate model, all variables lost their statistical significance.
Our study demonstrates TOT surgery can be performed for patients with MUI following unsuccessful conservative therapy. We also demonstrate that menopause and age >60 are risk factors for failure. This should be considered when counselling preoperatively.
据推测，尿道功能障碍在女性混合性尿失禁（MUI）中起核心作用，因为腹内压升高时尿液进入尿道近端会引发尿道 - 逼尿肌反射和逼尿肌不自主收缩。已提出经闭孔尿道中段吊带术作为一种解决方案。我们的主要目的是评估经闭孔尿道中段吊带术（TOT）对尿失禁及其他泌尿系统症状的长期主观和客观疗效。次要目的是确定其对生活质量（QoL）的影响，并研究哪些因素会影响治疗结果。
这是一项单中心前瞻性研究，纳入了连续86例因国际尿控学会（ICS）/国际妇科泌尿学会（IUGA）定义的MUI而接受TOT手术的女性。由于我们使用的MUI定义基于症状，所以纳入了伴有和不伴有逼尿肌过度活动的患者。所有患者均接受了Monarc筋膜下吊带置入术。
我们使用了McNemar卡方检验、配对t检验和Fisher精确检验。采用逻辑回归模型和比值比来评估年龄、产次、体重指数、绝经状态、术前逼尿肌过度活动以及最大尿流率时的逼尿肌压力作为治疗失败的可能因素。单因素分析中具有统计学意义的因素才纳入多因素分析。
平均随访59个月，83.7%的患者客观上治愈了压力性尿失禁（SUI），主观治愈率为87.2%。3例患者接受了进一步的抗尿失禁手术。急迫性尿失禁（UUI）的控尿率为74.4%，SUI - UUI的控尿率为66.3%。患者报告的成功率为87.2%（在患者总体改善印象量表上为“好多了”或“非常好多了”）。除总体健康外，所有领域均有统计学意义的改善。单因素分析未发现SUI持续存在的显著危险因素。年龄中位数>60岁和绝经是UUI持续存在的预测因素。年龄中位数和平均数>60岁是总体尿失禁持续存在的预测因素。在多因素模型中，所有变量均失去统计学意义。
我们的研究表明，对于保守治疗失败的MUI患者可以进行TOT手术。我们还表明，绝经和年龄>60岁是治疗失败的危险因素。术前咨询时应考虑这一点。
