COMPARATIVE ANALYSIS OF URINARY INCONTINENCE SEVERITY AFTER PUBOVAGINAL SLING OR TENSION FREE VAGINAL TAPE

D.M. Morgan, K. Smith, D.E. Fenner, G. Faerber, J.O.L. DeLancey, E.J. McGuire, J.T. Wei

University of Michigan, Ann Arbor, MI

OBJECTIVE: Autologous fascia, pelvicol and prolene tape are common materials used in suburethral anti-incontinence procedures.  A comparative analysis of these variations in materials and procedures using validated outcome measures is lacking.  This study’s objective was to explore the relative efficacy of autologous fascia pubovaginal slings (Autologous Fascia-PVS), pelvicol pubovaginal slings (Pelvicol-PVS), and the tension free vaginal tape (TVT) on health related quality of life (HRQOL).

MATERIALS AND METHODS: From a larger cross sectional study of HRQOL outcomes after anti-incontinence surgery, we focused an analysis on 151 women who had undergone an AF-PVS (n=72) , P-PVS (n=26), or TVT (n=53) one to three years after surgery.  The study response rate was 73%.  Post operative urinary incontinence (UI) severity was assessed with self administered instruments—the Incontinence Severity Index (ISI), completed by 148 patients, and the Hunskaar index, completed by 135.  Higher scores are consistent with greater UI severity for the ISI (range 0-32) and the Hunskaar index (range 0-12).  Patients completed the Patient Health Questionnaire to screen for major depression and several items on medical, surgical, obstetrical, gynecologic and social history.  Explicit chart review was done to abstract diagnostic and procedure details associated with the index surgery.  Generalized linear models were used to adjust for and identify those factors independently predicting UI severity as measured by the ISI and Hunskaar.  Pairwise comparisons were done when a factor involved more than two values.

RESULTS: Suburethral graft material and procedure (p<0.0001) and major depression (p=0.003) were strongly associated with UI severity.  The respective ISI and Hunskaar scores for those who underwent TVT were 5.5 and 2.6, AF-PVS 8.2 and 3.8, and P-PVS 14.6 and 7.2.  Pairwise comparisons revealed significant differences between Autologous Fascia-PVS and Pelvicol-PVS and between TVT and Pelvicol-PVS (all p<0.001).  There was no statistical difference between patients who had Autologous Fascia-PVS or TVT.  Patients with depression had estimated ISI and Hunskaar scores that were 5.4 and 2.1 points higher than those who were not depressed.  Patients who had surgical intervention for prolapse before the index surgery had an ISI score 5.0 points (p=0.001) higher those who had not.  Patients who required anticholinergic medications at anytime in the post operative period had an ISI score 4.0 points (p=0.03) higher than those who did not.  Each year of age was associated with a 0.5 point increase (p=0.04) in the Hunskaar index. 

CONCLUSIONS:  Pelvicol-PVS was associated with greater UI severity than either Autologous Fascia-PVS or TVT.  Potentially modifiable risk factors identified as independent predictors of UI severity include major depression and the choice of surgical material and procedure.

Key Words: Stress incontinence, pubovaginal sling, tension free vaginal tape, pelvicol

Disclosure – Consultant: J. DeLancey, Lilly, SuRx, Kimberly Clark, Johnson & Johnson, Shaw Science. Grant/Research: J.T. Wei, Sanofi Synthelabo, GlaxoSmithKline.