Impact of the Midurethral Sling Procedure on Quality of Life in Women with Urinary Incontinence

The surgical technique of the midurethral sling (MUS) procedure is much simpler than previous anti-incontinence surgeries, and the procedure can be performed under local anesthesia. The success rate of the procedure is reported to have reached 90% [1-4]. Interlocked with the increase in social interest in urinary incontinence and in social activities of aged women, these advantages of the MUS procedure have resulted in an explosive increase in operations for female urinary incontinence.

Most previous reports regarding MUS outcomes generally tended to investigate only patients' subjective satisfaction, but recent reports have strived to systematically observe improvement in quality of life (QoL) by means of objective methods.

We intended to investigate the impact of the MUS procedure on not only cure and satisfaction with the surgery but also on the objective QoL of incontinent patients. In addition, we intended to define clinical and urodynamic factors that affect the QoL of female patients with urinary incontinence.

On the basis of the Stamey grading system, the number of female patients with grade I incontinence was 74 (79.6%), the number with grade II was 14 (15.1%), and the number with grade III was 5 (5.4%). The average operation time was 23.9±6.45 minutes. Clinical and urodynamic data and results from the preoperative tests are shown in Table 1 and Table 2.

TABLE 1
Characteristics of the 93 patients

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TABLE 2
Results of the preoperative and perioperative evaluations

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In the preoperative assessment of I-QoL, the total I-QoL score and subscale points (AL, PI, and SE points) were 61.1±21.0, 45.9±23.4, 48.4±26.2, and 34.9±26.5 points, respectively. At 1 month after surgery, the I-QoL scores were higher than preoperatively (89.0±17.9, 75.1±16.7, 79.0±20.9, and 72.1±24.1 points, respectively; p<0.01). At 1 year, I-QoL scores were higher than at 1 month (98.4±20.7, 83.7±24.9, 89.8±22.8, and 86.5±24.5 points, respectively; p<0.05) (Fig. 1).

FIG. 1
Changes in the total I-QoL and I-QoL subscale scores before and after surgery. I-QoL: incontinence-quality of life, ^a: p<0.01, ^b: p<0.05.

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At 1 year after surgery, 67.7% of patients were rated as "cured", 87.1% as "cured and improved", and 71.0% as "satisfied." There was no significant difference between SUI and MUI in terms of cure and satisfaction (p>0.05) (Table 3). Preoperative average I-QoL scores of "cured", "Improved", and "failed" patients were 62.7±21.7, 56.7±17.2, and 66.2±22.1 points, respectively. I-QoL scores at 1 year after surgery were 107.7±4.3, 94.7±7.3, and 54.6±7.3 points, respectively. I-QoL scores of the cured and improved patients increased at 1 year after surgery (p<0.01). There were no statistically significant differences in the increase in I-QoL between cured and improved patients (p>0.05). Patients in whom the operation had failed did not show any improvement of QoL after the procedure (p>0.05) (Fig. 2).

FIG. 2
Comparison of the total I-QoL score between before surgery and at 1 year of follow-up (sorted by objective operation results). I-QoL: incontinence-quality of life, MUS: midurethral sling, ^a: p<0.01.

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TABLE 3
One-year outcomes of the MUS procedure in patients with MUI and genuine SUI

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Patients who had urgency or large amounts of urine leakage (more than 10 g in a 1 hour pad test) before surgery showed lower total I-QoL scores than did patients without urgency or with small amounts of leakage (p<0.05).

At 1 year after surgery, total I-QoL and the increase in the I-QoL score of the patients who had large amounts of urine leakage preoperatively were higher than in the patients with small amounts of leakage (p<0.01) (Table 4).

TABLE 4
Clinical and urodynamic comparisons of I-QoL scores between before surgery and at 1 year of follow-up

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Medical reports on the success rates or treatment effects of various treatments have been precisely performed with objective methods. Reports about QoL and patient satisfaction after treatment, however, generally tend to rely on only simple subjective measures. Recently, many medical reports have strived to objectively observe the QoL associated with disease and its change after treatment. Accordingly, several questionnaires have been developed and used in the field of female urology, including urinary incontinence. Many questionnaires for assessment of QoL in urinary incontinence are being used internationally after proper official linguistic validation; typical questionnaires include the I-QoL and the King's Health Questionnaire [9]. The I-QoL questionnaire, which was used in the present study, was recommended most preferentially at the 2nd International Consultation on Incontinence for assessing the QoL of patients with urinary incontinence [10].

Papanicolaou et al assessed the negative impact of urinary incontinence on QoL in female European patients through use of the I-QoL questionnaire [11]. They reported that the I-QoL scores of patients with "low grade" or "middle or high grade" incontinence were 84.5 and 64.5 points, respectively, and that decreases in the I-QoL score of incontinent patients were significantly dependent on symptom grade [11]. In several studies of the MUS procedure, the I-QoL questionnaire has been used to assess the QoL of incontinent patients and changes in QoL after the procedure. Campeau et al reported an increment of 38.7 points in the I-QoL after the TVT procedure (from 57.8 to 96.5 points) [2], and Kim et al reported an increment of 32.9 points in the I-QoL after the IVS procedure (from 61.5 to 94.4 points) [3]. Also, Kocjancic et al reported an increment of 40 points in the I-QoL after the TOT procedure (50.6 to 90.6 points) [12]. Scores in our study at 1 year after the MUS procedure showed an increment of more than 30 points in the I-QoL from the preoperative state (61.1 to 98.4 points). Our study included all patients who underwent the TVT, IVS, and TOT procedures. Because there are differences in approach and in the types of mesh used in each type of MUS procedure, however, objections to the design of our study may arise. However, many articles have observed that there are no differences in cure or satisfaction between each type of MUS [13, 14].

The Stamey grades of the patients in this study tended toward grade I and II. Because the success rate of the MUS procedure in patients with Stamey grade III incontinence is lower than that in patients with grade I and II, grade III patients received the REMEEX system [15] procedure if indicated. This was the reason for the inclination in Stamey grade.

In this study, the significant rise in I-QoL at 1 month and 1 year after surgery can be shown as gradual improvement in QoL as time elapsed after the procedure. At 1 month after surgery, however, surgical wound pain, temporary vaginal bleeding or discomfort caused by vaginal discharge may affect QoL. Because patients are prohibited from sexual intercourse for 1 month after surgery, question no. 22 on the I-QoL about sexual intercourse may cause confusion. Therefore, in order to observe the changes in the QoL by time more accurately, the first postoperative I-QoL assessment should be measured at least 3 months after surgery.

In this study, patients who had urgency or large amounts of urine leakage before surgery showed lower total I-QoL scores than did patients without urgency or with small amounts or urine leakage. However, this difference in I-QoL scores was no longer evident after the procedure. Higher I-QoL and increment of I-QoL scores were observed at 1 year after surgery in patients with large amounts of urine leakage. It may be that patients with large amounts of urine leakage were severely bothered by their symptoms and experienced a higher satisfaction with the MUS procedure, resulting in a larger increase in 1-year I-Qol. Our finding of no difference in the average increase in I-Qol between the cured and improved groups implies that simply improving symptoms through MUS considerably enhances the QoL of incontinent patients. Therefore, for the improvement of QoL, the MUS procedure should be actively applied in incontinent patients, even in patients with urgency or large amounts of urine leakage.

The I-QoL assessment revealed a significant impairment of QoL in incontinent women compared with that in continent women without voiding symptoms, but the MUS procedure effectively improved these women's QoL.

Although urinary urgency and large amounts of urine leakage significantly reduced the preoperative QoL in patients with urinary incontinence, the MUS procedure effectively improved the QoL regardless of these factors. Even the QoL of patients with only symptom improvements and who were still incontinent showed significant recovery; therefore, the MUS procedure should be actively applied to improve QoL in incontinent patients, even in women with urgency or large amounts of urine leakage.