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Commented Abstracts

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  • Determinants of patient dissatisfaction after a tension-free vaginal tape procedure for urinary incontinence.
    Deval B, Jeffry L, Al Najjar F, Soriano D, Darai E.
    J Urol 2002 May;167(5):2093-7 


PURPOSE: We identified the determinants of patient satisfaction after a tension-free vaginal tape procedure.

MATERIALS AND METHODS: We retrospectively analyzed the records of 187 consecutive women with genuine stress (133) and mixed (54) incontinence. The objective cure rate was determined by clinical and urodynamic examination, and the subjective cure rate was assessed by a visual analog scale and the Contilife questionnaire.

RESULTS: Mean follow-up was 27 months (range 6 to 34). The overall complication rate was 35.3%. The major perioperative and postoperative complications were bladder injury in 9.6% of cases, urinary retention in 6.4%, difficult voiding in 10.7% and new onset urge symptoms in 21.3%. The overall objective and subjective cure rates were 90.4% and 70.6%, respectively. The mean preoperative and postoperative visual analog scale score plus or minus standard deviation was 6.2 +/- 2.4 and 0.9 +/- 2.2, respectively (p = 0.0001). The subjective cure rate was significantly lower in women who underwent the procedure under general or spinal anesthesia than in those who received local anesthesia (p = 0.01). This difference was related to the rate of new onset urge symptoms. The mean postoperative visual analog scale score in women with and without new onset urge symptoms was 2.2 +/- 3.2 and 0.2 +/- 0.7, respectively (p = 0.0001). No difference in the subjective cure rate was detected according to patient age, menopausal status, previous incontinence surgery, the body mass index, additional procedures associated with tension-free vaginal tape surgery or the Ingelman-Sundberg classification. CONCLUSION: These results confirm that the tension-free vaginal tape procedure is associated with a high objective but lower subjective cure rate. The procedure performed using local anesthesia was associated with a lower incidence of difficult voiding and new onset urge symptoms.

                                     EDITORIAL COMMENT

The use of the TVT has been increased considerably in Brazil in the last years. The simplicity of the technique, the quickness of the execution and low morbidity have allowed the adoption of this procedure by a considerable portion of urologists and gynecologists that are involved in the treatment of SUI. However, the high cost of the Kit has limited the access to patients of a lower income. Success rates are high, with a variation of 70 to 95%. There was a significant difference of satisfaction among patients that were submitted to this procedure with a local anesthesia and a general or regional anesthesia. Even though the author does not discuss this finding, it is probable that the difficulty of modulating the position of the prolene tape in an ideal position, below the urethra is linked to the development of urge incontinence symptoms in the post operatory.  In patients with a local anesthesia, effort maneuvers may, in thesis, be executed in a more dependable way according to reality. On the other hand, patients with a regional or general anesthesia cannot be evaluated adequately and it is probable that the tape will be closer to the urethra inducing an obstruction and/or urgency symptoms. This is an aspect that must be made salient, and does not appear with the same frequency in other articles, it was the presence of elevated rates of peri operatory and post operatory complications, with bladder lesions in 9.6% of the cases, urinary retention in 6.4%, urinary difficulty in 10.7% and urgency symptoms in 21.3% of the patients. Success rates, for the follow-up period are similar to the consecrated techniques such as Burch´s surgery or the pubovaginal sling.

Aparecido Donizeti Agostinho

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