Int Urogynecol J DOI 10.1007/s00192-015-2783-9
CLINICAL OPINION
What is the best surgical intervention for stress urinary incontinence in the very young and very old? An International Consultation on Incontinence Research Society update Dudley Robinson 1 & David Castro-Diaz 2 & Ilias Giarenis 1 & Philip Toozs-Hobson 3 & Ralf Anding 4 & Claire Burton 5 & Linda Cardozo 1
Received: 28 April 2015 / Accepted: 23 June 2015 # The International Urogynecological Association 2015
Abstract An increasing number of continence procedures are being performed in women of all ages. An overview of the existing literature and consensus regarding surgery for stress urinary incontinence (SUI) in the young and the old was presented and discussed at the International Consultation on Incontinence Research Society Think Tank. This manuscript reflects the Think Tank's summary and opinion. Despite the increasing number of continence procedures, there are relatively few data to guide management in the very young and the very old. When considering continence surgery in the young, long-term efficacy and safety are paramount, and the future effects of pregnancy and childbirth need to be carefully considered. Conversely, in the elderly, minimally invasive procedures with low morbidity are important, especially in the frail elderly who may have significant co-morbidities. Further research including prospective randomised trials, cohort studies and national registries, should help guide our management in these two challenging groups of patients.
* Dudley Robinson
[email protected] 1
Department of Urogynaecology, Kings College Hospital, Denmark Hill, London SE5 9RS, UK
2
Department of Urology, Hospital Universitario de Canarias Universidad de La Laguna, Canary Islands, Spain
3
Department of Urogynaecology, Birmingham Women’s Hospital, Birmingham, UK
4
Department of Neurourology, Rheinische Friedrich-Wilhelms-Universitaet Bonn, Bonn, Germany
5
Department of Obstetrics and Gynaecology, Queen Alexandra Hospital, Portsmouth, UK
Keywords Elderly . Mid-urethral tapes . Single-incision tapes . Stress urinary incontinence . Urethral bulking agents . Young
Abbreviations BMI Body Mass Index BSUG British Society of Urogynaecology ICIInternational Consultation on Incontinence – RS Research Society (ICI-RS) LUTD Lower Urinary Tract Dysfunction OAB Overactive Bladder PGI-I Patient Global Impression of Improvement QoL Quality of Life SIMT Single-Incision Mini-Tape SMUT Standard Mid-Urethral Tape SUI Stress Urinary Incontinence TT Think Tank TVT Tension free Vaginal Tape TVTO Tension free Vaginal Tape Obturator
Introduction Urinary incontinence (UI) is a common and distressing condition, and the incidence is known to increase with age. Whilst epidemiological studies suggest that stress urinary incontinence (SUI) is the more common type in younger, more active, women, a significant number of elderly women complain of troublesome SUI symptoms [1]. Although there is a large number of surgical trials evaluating outcome of continence surgery, the majority tend to focus on women in middle age, and there is a paucity of data assessing outcomes in the very young and the very old.
Int Urogynecol J
The purpose of this paper is to review the limited evidence assessing outcome of surgery for SUI both in the very young and very old and make recommendations for further research, which may allow a more evidence-based approach to choice of surgery.
Methods The International Consultation on Incontinence, Research Society (ICI-RS) is a forum for addressing lower urinary tract dysfunction (LUTD). The structure and working strategy of the ICI-RS have been previously published [2]. With the aim of organising discussion at the ICI-RS Think Tank (TT), the first authors (DR and DCD) reviewed the English-language scientific literature after searching PubMed, MEDLINE and the Cochrane library and searching conference proceedings by hand up to May 2013. The existing evidence and relevant TT discussion are presented for these two arbitrarily defined cohorts (very young and very old).
Surgical intervention in the very young Whilst there is as yet no generally accepted definition of the very young, we considered this term to refer to premenopausal women younger than 40 years and particularly to those who have still not completed their families. Consequently, whilst it is important to consider the effects of future pregnancy and delivery in this group following surgical intervention, there is a lack of evidence to support clinical decision making. In addition, continence surgery that is performed at a younger age may be associated with higher recurrence rates and an increased risk of long-term complications. Assessing long-term outcome Continence surgery in the young should be durable, with documented long-term efficacy and few unwanted adverse effects. However, the majority of surgical trials only report short-term outcome, often at 6–12 months, and there are far fewer studies that report longer-term outcome, at 5 years and beyond. Colposuspension has been shown to be a safe and effective procedure, with success rates of 69 % at 20 years [3]. However, colposuspension is known to be associated with an increased risk of urogenital prolapse, especially in the posterior compartment, voiding dysfunction and detrusor overactivity, which are causes of morbidity and have a significant adverse effect on quality of life (QoL) in the longer term. The outcome of colposuspension has also been compared with that of pubovaginal fascial slings in a large multicentre study of 655 women, with a 2-year follow-up. Whilst success rates
tended to be slightly higher in the pubovaginal sling arm, there was also a greater incidence of adverse effects, including recurrent urinary tract infections (UTIs) , voiding difficulties and UI [4]. More recently robust long-term efficacy data have been reported for retropubic tape procedures at 17 years [5], with objective cure rates of 90 %. Reassuringly, a number of studies suggest that there is no negative impact on sexual function after tape insertion in young women. When coital or orgasm incontinence is present, there is even a significant improvement in sexual function after tape insertion [6]. However, there has also been an increase in the number of tape-related complications reported, and recent evidence would suggest that this is approximately 4 % [7]. Consequently, performing midurethral tape procedures in the young may be associated with good initial outcomes, but there may also be the risk of long-term morbidity. The use of urethral bulking agents has also been proposed in the young in order to reduce the risk of complications, although—once again—there is lack of longer-term data, with only a few studies assessing outcome at 2 years, with improvement rates of 84 % [8]. Whilst this is supported by systematic review and meta-analysis with success rates of 75 % in the short-term and 73 % in the medium-term, the long-term success rates are only 36 % [9]. Many of these women will subsequently benefit from repeat continence procedures, although the outcome following a failed bulking agent has been poorly studied. Furthermore, injection of bulking agents in the young may affect periurethral tissue characteristics and could lead to worse outcomes of recurrent incontinence procedures in the future. In addition, few specialists within the field would consider bulking agents to be an efficacious first-line therapy. In light of these issues, there remains a need for long-term surgical series or cohort studies to assess the longevity of continence surgery and establish risks and concomitant effects that may be associated, in a similar manner to that already proposed for prolapse surgery [10]. What is the effect of subsequent pregnancy following continence surgery? In general, it is believed that continence surgery should be deferred until after the completion of childbearing; however, there is a paucity of prospective data investigating the outcome of continence surgery following subsequent childbirth and delivery. A small retrospective study assessed the effect of pregnancy following colposuspension in four women; incontinence recurred in three by the third trimester [11]. All three were delivered by caesarean section, and although incontinence persisted in two for 6 months, all were continent by 12 months. Furthermore, in a small series of nine women (seven vaginal deliveries and two caesarean sections) following pubovaginal fascial sling surgery, five remained continent,
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one became incontinent and three had no change in symptoms, and the outcome was not associated considering mode of delivery [12]. Evidence from small case series [13] would suggest that the majority of women following successful retropubic and transobturator tape procedures remain continent in the short term following subsequent delivery. Recurrence of SUI was seen in 15 % of cases antenatally: 20 % following vaginal delivery compared with 12.5 % following caesarean section. However, the authors do not recommend a systematic elective caesarean section in these patients because of the morbidity and mortality associated with the procedure and the effect it may have on any subsequent incontinence procedure. Overall, the evidence—although only based on small series—would suggest that outcomes are mixed, and recurrence rates after subsequent childbirth tend to increase. These findings indicate that it may be preferable to delay surgery until after childbearing is completed. This is particularly important in the young when the long-term risk of late mesh complications remains largely unknown. Research agenda: surgery in the very young 1. Should we be using synthetic tape materials? Should colposuspension and autologous fascial slings be used rather than retropubic or transobturator tape procedures? Can long-term observational studies or national registries give reliable data on success and complication rates? 2. What is the effect of pregnancy and childbirth on continence procedures? Could a national or international surveillance system for pregnancies after continence procedures provide robust evidence?
Surgical intervention in the very elderly Whilst there is no formal definition of very elderly, many would use the definition initially used by Prince Otto von Bismarck (1815–1898), who defined the very elderly as being >70 years old, which is associated with the right to draw their pension. However, given the improvements in health and functional independence, a more recent proposal is to define the very elderly as being >75[14]. In addition, it is also important when considering age to take account co-morbidities in order to differentiate between biological age and chronological age. With the increasing number of elderly, the number of continence procedures in the elderly and frail elderly is likely to increase. The advent of day-case and minimally invasive procedures in addition to safer anaesthesia also means that many women who historically may not have been offered surgery are now having operations. Whilst minimally invasive procedures may be preferable in terms of lowering morbidity, long-
term efficacy may be less relevant when considering surgical intervention due to the shorter life expectancy than in the young.
What is the effect of age on the outcome of continence surgery? Several recent papers have investigated the effect of age on the outcome of continence surgery, and evidence would suggest that surgical procedures are being more commonly performed in the elderly [15]. Data from Medicare Australia has shown a doubling of procedures for SUI over a 3-year period since the introduction of midurethral tapes. Over a 15-year period, there was an 87 % increase in such surgery in women >55 years compared with a 1 % increase in younger women. Although now less commonly performed, both colposuspension and pubovaginal sling insertion remains efficacious for SUI. The Stress Incontinence Surgical Treatment Efficacy Trial investigated the effect of age on both perioperative and postoperative outcomes in 659 women [16]. The older group (mean age 69.7 years) were compared with a younger group (mean age 49.4 years). Overall, older women had slightly longer return to normal activities (50 days vs 42 days; p=0.05), although there were no differences in return to normal voiding (14 days vs 11 days; p=0.42). In addition, older women were more likely to have a positive stress test at follow-up [odds ratio (OR) 3.7; 95 % confidence intereval (CI) 1.70–7.97; p=0.001), less subjective improvement in both stress and urgency symptoms and were also more likely to require repeat surgery (OR 3.9; 95 % CI 1.30–11.48; p= 0.015). The safety and efficacy of midurethral sling surgery has also been investigated in a large Australian series of 1225 women (955 retropubic and 270 transobturator) comparing outcomes in the elderly (96 women≥80 years) with those in younger women (1016 women
