Body Mass Index and Outcome of Tension-Free Vaginal Tape

doi:10.1016/S0302-2838(03)00009-5

European Urology

Volume 43, Issue 3, March 2003, Pages 288-292

https://doi.org/10.1016/S0302-2838(03)00009-5 Get rights and content

Abstract

Objectives: To assess the effectiveness of tension-free vaginal tape (TVT) in women with high body mass indices (BMIs).

Methods: Thirty-eight consecutive patients with BMIs exceeding 30 who underwent tension-free vaginal tape were compared with 149 consecutive patients with BMIs of 30 or less who underwent the same procedure. Body mass index was calculated pre-operatively and at follow-up. Women were classified as being of normal weight (BMI 20–25), overweight (BMI 26–30), or obese (BMI >30). Patient characteristics, operative and post-operative complications, reported continence rates were analyzed according to BMI.

Results: There were no significant differences between groups in terms of age, parity, menopausal status, previous surgery, type and degree of incontinence. Estimated blood loss, operative times, bladder injuries, post-operative urgency and voiding disorders did not differ significantly between women with high BMIs and those with low BMIs. Women with BMIs exceeding 30 had a significantly higher incidence of post-operative urge urinary incontinence (17.9 versus 3.4 and 6.4% p=0.02) without any effects on the objective and subjective cure rates (82 versus 88.7 and 93% p=0.1, 71.7 versus 72.1 and 74% p=0.9).

Conclusion: We did not find pre-operative obesity to be a risk factor for failure of tension-free vaginal tape.

Introduction

In France, the prevalence of obesity, defined by a body mass index (BMI) above 30 kg/m², is 8–10% of the adult population [1]. Between 1980 and 1991, there was a slight increase in prevalence of obesity (from 6.3% to 7.0%) and of overweight (from 26.8% to 27.5%) in French women [2]. The prevalence of obesity is similar to those reported in other European countries, such as Sweden and The Netherlands, and lower than in the UK, USA and Canada. Obesity is described as a risk factor for genuine stress incontinence and detrusor instability [3], [4], [5]. Some authors have described an increase of intra-abdominal pressure in obese patients [6]. This phenomenon possibly can stress the pelvic floor, causing nerve and muscular injury which might lead to a higher prevalence of SUI. The surgical treatment of SUI is frequently perceived to be less effective in obese females, increased failure rates among obese women undergoing needle suspension and retropubic procedures have been reported [7]. Tension-free vaginal tape (TVT) is a popular operation for the surgical treatment of stress urinary incontinence. This technique is now considered an alternative to classic surgical methods because it is easy to learn, has a low incidence of peri-operative and post-operative complications and a high short-term success rate [8].

Only two studies have evaluated the effectiveness of TVT in obese women. Mukherjee and Constantine [9] found that the BMI had no incidence on the subjective cure rate, even if obese women had significantly worse bladder-related “Quality of Life” scores. Chung and Chung [10] evaluated retrospectively 91 patients who underwent a TVT procedure; 60% of the patients in their study were obese women. They reported a 100% cure rate after the TVT procedure regardless of the patients’ BMI. In these two studies there were no differences regarding the procedure or the post-operative outcomes between the obese and normal weighted patients. However, in those studies there was no information on the rate of de novo urgency and on the rate of voiding disorders after the TVT procedure in obese patients. The aim of our study was to assess the feasibility, and the peri-operative and post-operative morbidity of TVT in obese patients and to assess the rates of de novo urgency and voiding disorders induced by this procedure in obese and overweight patients.

Section snippets

Materials and methods

From June 1998 to February 2001, 187 consecutive patients with proven urinary incontinence underwent the tension-free vaginal tape procedure in the gynecology department at our institution. Patients with a neurological disorder or bladder instability were excluded from the study. The severity of urinary incontinence was classified using the Ingelman–Sundberg scale, including grade I—urinary incontinence when coughing or sneezing, grade II—urinary incontinence when running or picking up objects

Characteristics of the patients, indication and associated procedures

The characteristics of patients undergoing a tension-free vaginal tape according to the BMI are given in Table 1. A difference in the mean body mass index was found between the groups (p<0.0001). The mean BMI was significantly different between the three groups. No difference in age, menopausal status, rate of previous SUI surgery, pre-operative VAS, use of pads was noted according to the groups.

The indications for surgery in each group are given in Table 1. No significant difference in

Discussion

The present study has confirmed the feasibility, the safety and the efficacy of tension-free vaginal tape for obese and overweight women.

Surgical treatment of genuine stress incontinence is technically more difficult in obese patients especially when this is performed as an abdominal procedure; there is, in this group, an increased risk of intra-operative and post-operative complications [3], [14]. In our study the TVT procedure could be performed in overweight and obese patients without

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Cited by (96)

Pelvic floor dysfunction and obesity
2023, Best Practice and Research: Clinical Obstetrics and Gynaecology
Obesity is a growing condition within the society and more patients, who have underlying obesity, are presenting with lower urinary tract symptoms (LUTS) and pelvic floor dysfunction (PFD). The effect of obesity on general health has been well documented, and its impact on the cardiovascular, endocrine, and musculoskeletal systems has been extensively studied. There is now a growing body of evidence on the effects of obesity on the female urogenital system. It seems to influence the prevalence, presentation, assessment, management, and outcome of various types of LUTS and PFD.
A holistic approach is needed to assess and manage these patients. A clear understanding of the functions of the pelvic floor and the way it can be affected by obesity is essential in providing holistic care to this group. A frank discussion about patient weight is required in the clinics handling PFD. A multimodal approach to weight loss would help improve PFD symptoms and progression.
Patients with obesity should still be offered standard treatment options for all PFDs and should not be forced to lose weight as a prerequisite before starting treatment. However, they should also be made aware of the impediments that being overweight adds to their care and their expectations should be managed accordingly.
Can obesity impact mesh exposure rate after mid-urethral sling operation? Medium term follow-up
2023, European Journal of Obstetrics and Gynecology and Reproductive Biology
To study mesh exposure rates among obese (BMI ≥ 30 kg/m²) vs non-obese women after mid-urethral sling (MUS) operation.
This retrospective cohort study included all patients who underwent MUS surgery for stress urinary incontinence April 2014–April 2021 in a tertiary-level university hospital. Data from obese and non-obese patients were compared.
A total of 120 (41 %) obese patients and 172 (59 %) non-obese patients who had mid-urethral sling surgery were compared. Of the cohort, 265 (90.7 %) underwent TVT-obturator, 15 (5.1 %) mini-sling TVT, and 12 (4.1 %) retro-pubic TVT. Diabetes mellitus was significantly more prevalent in the obese group (p =.01), without other demographic differences. Mesh post-operative exposure rate was 5.4 % during the study. The obese group had lower incidence of mesh exposure than the non-obese group (1.6 % vs 8.1 % respectively, p =.018). Mean follow-up was 51 months (range 8–87 months) without significant differences between groups (49.9 ± 21.2 vs 51.5 ± 22.3, p =.548). Pelvic organ prolapse, cystocele, and rectocele stages were significantly higher in non-obese patients. Similar numbers of post-menopausal women were in each group.
This follow-up after MUS surgery showed an association between obesity and lower rate of mesh exposure. Further research is needed to evaluate correlations between estrogen and mesh exposure.
Comparison of subjective long-term follow-up after mid-urethral sling in obese and non-obese patients
2022, European Journal of Obstetrics and Gynecology and Reproductive Biology
Obesity is a key factor for stress urinary incontinence. Our aim was to evaluate the long-term, subjective surgical satisfaction rate among obese (BMI ≥ 30) women after mid-urethral sling (MUS) procedure in a tertiary-level university hospital.
This retrospective, case-control study compared the outcomes of obese and non-obese patients who underwent MUS surgery for stress urinary incontinence (SUI), March 2014–January 2020. Patients were followed-up using Urogenital Distress Inventory-6 (UDI-6) and Patient Global Impression of Improvement (PGI-I) telephone questionnaires.
Among 264 patients who had MUS surgery, 107 (40.6%) patients with BMI ≥ 30 kg/m² were matched with 157 (59.4%) non-obese patients (BMI < 30 kg/m²). Mean follow-up was 41.4 (8–73) months. Obese women had higher post-operative urinary symptom scores in UDI-6 (32.3 vs. 25.7, p =.015) and PGI-I questionnaires (2.9 ± 1.7 vs. 2.3 ± 1.7, p =.03). More patients in the obese group (p =.03) had urinary stress symptoms. Subjective failures (PGI-I ≥ 4) totaled 46 (17.4%), 18 in obese and 28 in non-obese patients, giving cure rates of 83.2% and 82.2%, respectively (p = 1).
Although obese patients had higher UDI-6 scores, an interpretation of this score did not show an increase in distress due to urinary incontinence symptoms (>33.33 points).
Predictors of further anti-incontinence interventions or transvaginal urethrolysis after a pubovaginal sling procedure in women with and without neurologic disorders
2021, Journal of the Formosan Medical Association
The impact of neurologic disorders on the clinical outcome of suburethral sling procedures has seldom been studied. Our aim is to elucidate factors predicting further anti-incontinence interventions or transvaginal urethrolysis after a re-adjustable pubovaginal sling procedure (PVS), especially in patients with neurologic disorders.
Medical records of all consecutive women who underwent re-adjustable PVS for stress urinary incontinence (SUI) were reviewed.
A total of 589 women were enrolled, 152 (25.8%) women were found to have persistent or recurrent SUI after surgery, and 39 (6.6%) women underwent further anti-incontinence interventions. Postoperative voiding dysfunction was found in 46 (7.8%) women, and 23 women (3.9%) underwent transvaginal urethrolysis. Low body mass index (hazard ratio = 0.92) and low functional bladder capacity (dL, hazard ratio = 0.83) were factors predicting the presence of persistent/recurrent SUI. However, the presence of spinal cord disorder (hazard ratio = 8.91) and a history of prior surgery for pelvic organ prolapse (hazard ratio = 2.51) were factors predicting further anti-incontinence interventions. A high post-void residual volume (PVR, dL, hazard ratio = 1.52) and preoperative bladder outlet obstruction (BOO, hazard ratio = 5.39) were factors predicting postoperative voiding dysfunction. Similarly, a high PVR (dL, hazard ratio = 1.50) and preoperative BOO (hazard ratio = 5.38) were factors predicting transvaginal urethrolysis. A PVR >1.51 dL was an optimal cut-off value for predicting transvaginal urethrolysis.
The presence of spinal cord disorder and prior surgery for pelvic organ prolapse were predictors of further anti-incontinence interventions after re-adjustable PVS. In addition, a large PVR and preoperative BOO were predictors of transvaginal urethrolysis after re-adjustable PVS.
The effect of body mass index on retropubic midurethral slings
2019, American Journal of Obstetrics and Gynecology
Citation Excerpt :
The comparative data for perforation at different BMI groups between consultants and trainees is very interesting, with a dampening of the effect of BMI on perforation with experience. Again, a previous paper did not find this to be the case; however the highest group in this paper was patients with a BMI of 30.21 The major strength of this established database and this study is the large number of “real-life” outcomes from a wide range of different centers and surgeons, rather than the more restrictive patient groups included in randomized controlled trials.
Analyzing surgical databases uses “real-life” outcomes rather than highly selected cases from randomized controlled trials. Retropubic midurethral slings are a highly effective surgical treatment for stress urinary incontinence; however, if modifiable patient characteristics alter outcomes, thereby rendering treatments less effective, patients should be informed and given the opportunity to change that characteristic.
The aim of this study was to evaluate the effect of body mass index on patient-reported outcome measures by analyzing midurethral slings from the British Society of Urogynaecology database.
The British Society of Urogynaecology approved analysis of 11,859 anonymized midurethral slings from 2007 to 2016. The primary outcome of this retrospective cohort study was to assess how body mass index affects patient-reported outcome measures. Outcomes were assessed at 6 weeks, 3 months, 6 months, or 12 months after surgery, depending on local arrangements. Outcomes were compared by body mass index groups using χ² tests.
As BMI increased, Patient Global Impression of Improvement (PGI-I) scores declined. Women with a normal body mass index (18 to <25) reported feeling better in 91.6% of cases compared to lower rates in BMI groups >30 (87.7−72%) (P < .001). Patient-reported outcome measures for stress urinary incontinence inversely correlated with body mass index, with 97% of women with normal body mass index stating that they were cured/improved compared to women in higher body mass index groups (84−94%) reporting lower rates (P < .005). Patient-reported outcome measures for overactive bladder show that as body mass index increases, patients reported higher rates of worsening symptoms (P < .05). There were higher rates of perforation at the low and high extremes of body mass index.
Our results suggest increased body mass index is associated with poorer outcomes after midurethral sling surgery, and that patients should be given the opportunity to change their body mass index. These data could help to develop a model to predict personalized success and complication rates, which may improve shared decision making and give an impetus to modify characteristics to improve outcomes.
Tension-free Vaginal Tape–Obturator for Treatment of Pure Urodynamic Stress Urinary Incontinence: Efficacy and Adverse Effects at 10-year Follow-up
2017, European Urology
Inside-out transobturator tape (tension-free vaginal tape–obturator [TVT-O]) is currently one of the most effective and popular procedures for the surgical treatment of female stress urinary incontinence (SUI). However, data reporting long-term outcomes are lacking.
To assess the efficacy and safety of TVT-O 10 yr after implantation for the treatment of female pure SUI.
A multicenter, prospective study was conducted in five tertiary referral centers in three countries. All consecutive women with urodynamically proven pure SUI treated by TVT-O were included. Patients with mixed incontinence and/or anatomic evidence of pelvic organ prolapse were excluded.
TVT-O implantation.
Data regarding subjective outcomes (International Consultation on Incontinence Questionnaire–Short Form, Patient Global Impression of Improvement, and patient satisfaction scores), objective cure (stress test) rates, and adverse events were collected during follow-up. Univariable analysis was performed to investigate outcomes.
One hundred sixty-eight women had TVT-O implantation. At 10-yr follow-up, 160 patients (95%) were available for the evaluation. We did not find any significant change of the surgical outcomes during this time. At 10 yr after surgery, 155 of 160 patients (97%) declared themselves cured (p = 0.7). Similarly, at 10-yr evaluation, 148 of 160 patients (92%) were objectively cured. No significant deterioration of objective cure rates was observed over time (p = 0.4). The history of failure of previous anti-incontinence procedures (hazard ratio: 5.34; 95% CI, 2.61–11.9; p = 0.009) was the only predictor of recurrence of SUI. The onset of de novo overactive bladder was reported by 23 of 160 patients (14%) at 10-yr follow-up. No other late complications were reported.
The 10-yr results of this study showed that TVT-O is a highly effective and safe option for the treatment of SUI.
At long-term follow up, tension-free vaginal tape-obturator is highly effective and safe for the treatment of stress urinary incontinence.

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Body Mass Index and Outcome of Tension-Free Vaginal Tape

Abstract

Introduction

Section snippets

Materials and methods

Characteristics of the patients, indication and associated procedures

Discussion

Urology

J. Urol.

Urology

J. Urol.

Obesity: epidemiology and public health

Ann. Endocrinol. (Paris)

Trends in the prevalence of obesity in the French adult population between 1980 and 1991

Int. J. Obes. Relat. Metab. Disord.

Obesity and urinary incontinence in women

Br. J. Obstet. Gynaecol.

Obesity and stress urinary incontinence: significance of indices of relative weight

Urol. Int.

Body mass index and adult female urinary incontinence

World J. Urol.

The relationship of body mass index to intra-abdominal pressure as measured by multichannel cystometry

Int. Urogynecol. J. Pelvic Floor Dysfunct.

The effect of obesity on the outcome of successful surgery for genuine stress incontinence

Aust. NZ J. Obstet. Gynaecol.