Retropubic vs. Single-Incision Mid-Urethral Sling for Stress Urinary Incontinence

Study Overview
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Brief Summary
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One in five women will undergo prolapse surgery in their lifetime, and there is a strong correlation between prolapse and urinary incontinence. Pelvic floor surgeons aspire to improve relevant quality of life outcomes for women with pelvic floor disorders while minimizing complications and unnecessary procedures. There has been an experience of disappointment and frustration when a patient returns following POP repair with new symptoms of SUI that she ranks as a greater disruption to her quality of life than her original vaginal bulge. While retropubic (RP) slings are considered to be the gold-standard referent for other slings with long-term outcomes data, they are associated with the highest risks of intra- and post-operative complications including bladder injury, bleeding, and post-operative voiding dysfunction. Single-incision slings (SIS) are the latest iteration in sling development that build upon the benefits of slings but avoid passage through the muscles of the inner thigh. The hypothesis for this study is that single-incision slings (Altis ™) are non-inferior to Retropubic mid-urethral slings when placed at the time of native tissue vaginal repair.

Detailed Description
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Pelvic floor surgeons aspire to improve relevant quality of life outcomes for women with pelvic floor disorders while minimizing complications and unnecessary procedures. Efficacy and risk always compete for equilibrium. Level I evidence has demonstrated a positive efficacy benefit of a concomitant synthetic mid-urethral sling in women with, and without, pre-operative symptoms of SUI who are undergoing POP repair. Concomitant sling placement has been shown to reduce the risk of de novo or persistent SUI from 50% to 23%. The combination of surgical treatment of POP and SUI at the same time, however, increases the risk of incomplete bladder emptying. While retropubic (RP) slings are considered to be the gold-standard referent for other slings with long-term outcomes data, they are associated with the highest risks of intra- and post-operative complications including bladder injury, bleeding, and post-operative voiding dysfunction. Single-incision slings (SIS) are the latest iteration in sling development that build upon the benefits of slings but avoid passage through the muscles of the inner thigh. As the combination of POP and sling surgery increases the risk of voiding dysfunction, and rates of incomplete bladder emptying appear significantly lower for SIS than RP slings, the study team hypothesizes that the use of the Altis ™ SIS will be non-inferior to RP slings in efficacy and superior in irritative voiding symptoms/voiding dysfunction at one year after combined surgery.

Official Title
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Randomized Trial of Retropubic Versus Single-incision Mid-Urethral Sling (Altis ) for Concomitant Management of Stress Urinary Incontinence During Native Tissue Vaginal Repair

Conditions
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Stress Urinary Incontinence, Pelvic Floor Disorders

Intervention / Treatment
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* Device: RP sling placement
* Device: SIS placement


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: At least 21 years of age Women being considered for a native tissue vaginal repair in any vaginal compartment or colpocleisis POP ≥ stage II of any vaginal compartment, according to the pelvic organ prolapse quantification (POP-Q) system Vaginal bulge symptoms Positive standardized cough stress test on clinical examination, or on urodynamic testing Surgical plan that includes a native tissue vaginal repair including colpocleisis for symptomatic POP in any compartment Understanding and acceptance of the need to return for all scheduled follow-up visits English speaking and able to give informed consent Willing and able to complete all study questionnaires Exclusion Criteria: Prior surgery for stress urinary incontinence Status post reconstructive pelvic surgery with transvaginal mesh kits or sacrocolpopexy with synthetic mesh for prolapse Any serious disease, or chronic condition, that could interfere with the study compliance Unwilling to have a synthetic sling Inability to give informed consent Pregnancy or planning pregnancy in the first postoperative year Untreated urinary tract infection (may be included after resolution) Poorly-controlled diabetes mellitus (HgbA1c > 9 within 3 months of surgery date) Prior pelvic radiation Incarcerated Neurogenic bladder/ pre-operative self-catheterization Elevated post-void residual (>150 ml) that does not resolve with prolapse reduction testing (pessary, prolapse reduced uroflow or micturition study) Prior augmented (synthetic mesh, autologous graft, xenograft, allograft) prolapse repair Planned concomitant bowel related surgery including sphincteroplasty and perineal rectal prolapse surgery, rectovaginal fistula repair, hemorrhoidectomy.

Ages Eligible for Study
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Minimum Age: 21 Years

Sexes Eligible for Study
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Female

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: RP sling group<br>Participants assigned to the retropubic (RP) sling group will have the RP sling placement procedure. | Device: RP sling placement<br>* A 1.5 cm incision will be made at the mid-urethra through a separate vaginal incision with lateral dissection with Metzembaum scissors. After placement of both trocars, cystoscopy with a 70-degree scope will be performed to assess for bladder and urethral injury. Surgeons will set the tension of the tension-free vaginal tape (TVT) slings so that a spacer can be placed between the sling and the urethra. Sling tensioning will be performed after anterior and apical prolapse is corrected.<br>|
| Experimental: SIS group<br>Participants assigned to the single-incision sling (SIS) group will have the SIS placement procedure. | Device: SIS placement<br>* The sling is introduced through a single anterior vaginal incision of 1.5 cm at the mid-urethra. The sling/needle assembly is advanced behind the ischiopubic rami in a transobturator trajectory toward the obturator space bilaterally.The needle is then removed by simply sliding the fixating tip back out. The other side is then completed in an identical fashion. After the fixation of the two anchors at the 2 and 10 o'clock positions, the patient's bladder is filled with 250 mL of NaCl. Afterward, an intraoperative crede maneuver is performed and the tension adjustment suture is pulled, when necessary, to achieve the desired continence. The mesh will lie in direct apposition to the urethra. The adjustment thread is then cut short and the vaginal incision is closed with an absorbable suture.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of participants with subjectively bothersome stress incontinence | Dichotomous outcome (Yes/No), measured by a positive response of > 1 to Question 17 on Pelvic Floor Distress Inventory short form-20 (PFDI-20). Response scale from 0 to 4. Symptoms Not Present = NO 0 = not present Symptoms Present = YES, scale of bother: 1 = not at all, 2 = somewhat, 3 = moderately, 4 = quite a bit | 12 months post-operatively | 
| Retreatment for stress incontinence | This includes pelvic floor physical therapy; incontinence pessary; urethral bulking injection; repeat incontinence surgery. | 12 months post-operatively | 
| De novo or worsening urge incontinence symptoms | Dichotomous outcome (Yes/No), measured by a worsening change in response to Question 16 on PFDI-20 with at least somewhat bothersome symptoms. Response scale from 0 to 4. Symptoms Not Present = NO 0 = not present Symptoms Present = YES, scale of bother: 1 = not at all, 2 = somewhat, 3 = moderately, 4 = quite a bit | 12 months post-operatively | 
| Requirement for bladder drainage | Beyond 2 weeks post-operatively with PVR > 150 ml OR > 1/3 total voided volume up to 12 Month post-operatively.. | 12 Month post-operatively | 
| Surgical intervention for urinary retention | Sling lysis or revision at any time point post-operatively up to 12 Month post-operatively. | 12 Month post-operatively | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Adverse events | Reporting of adverse events intra- and post-operatively and include adverse events as measured by the Dindo classification system. | 12 months post-operatively | 
| Change in pain | Pain will be measured on a visual analogue scale for 14 days post-operatively and at 6 weeks and 12 months post-operatively. The scale has a score range of 0-10, with 0=no pain and 10=worst pain . | up to 12 months post-operatively | 
| Surgeon satisfaction | Surgeon satisfaction with the sling will be assessed with a 10-point Likert Scale. The scale has a score range of 0-10, with 0=no satisfaction 10=extremely satisfied. | post-operatively up to 12 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Retropubic sling, Single-incision sling, Vaginal repair, Management