Foley guide likely unnecessary during midurethral sling surgery

SCOTTSDALE, ARIZ. – Using a Foley catheter guide during midurethral sling surgery does not appear to reduce the risk of injury to the bladder and urethra, according to a retrospective study presented at the annual scientific meeting of the Society of Gynecologic Surgeons.

Surgeons used the guide in 24.5% of the 310 women undergoing retropubic midurethral sling surgery, reported first author Dr. Jeannine M. Miranne, an ob.gyn. at Medstar Washington Hospital Center and Georgetown University, Washington.

The rate of cystotomy was 1.3% in the guide group and 5.6% in the no-guide group, a statistically indistinguishable difference and one that remained so even after adjustment for potential confounders. None of the patients studied experienced a urethrotomy.

"Foley catheter guide use does not decrease the risk of intraoperative lower urinary tract injury. However, larger prospective studies are needed to confirm this finding, given the possibility of a type 2 error," Dr. Miranne concluded.

Session attendee Dr. Eric Sokol, an assistant professor of obstetrics and gynecology, and of urology at Stanford (Calif.) University, wondered if injury rates were affected by the specific sling used.

"What I imagine has possibly influenced your results is the fact that you have changed also the sling that you use. As I understand it, you are using a lot of Advantage Fit slings," he said. In his experience in training residents, the bladder is often inadvertently punctured when this sling is used. "When I use other slings, with a rigid handle and a bigger curve, they don’t go in the bladder. So do you think there might be an influence of the exact sling that you are using?"

"There definitely may be an influence," Dr. Miranne replied. "Unfortunately, the majority of physicians in our group used the Advantage Fit sling for approximately 90% of their cases that were included. So it’s really hard to determine whether or not that played a role in the cystotomy rate in our study. But that’s definitely something to consider when you think about cystotomy – the type of retropubic sling."

Another attendee commented that using a Foley catheter guide adds an annoying, time-consuming step to the surgery. "It wasn’t our idea, but we have used the cystoscope shaft, and we will use that to manipulate the urethra. You have to put that in anyway to scope the patient, and it saves a lot of time putting things in and taking them out," he said at the meeting, which was jointly sponsored by the American College of Surgeons.

Giving some background to the study, Dr. Miranne said that "synthetic midurethral sling has become a gold-standard surgical procedure for stress urinary incontinence. Different techniques have been introduced to decrease the risk of intraoperative lower urinary tract injury during sling placement. One such technique involves use of a rigid Foley catheter guide during retropubic sling placement."

"Although the manufacturer of the original tension-free vaginal tape continues to recommend Foley catheter guide use in its instructions, it is unclear whether use of this device decreases the risk of intraoperative lower urinary tract injury," she noted.

For the study, the investigators included women undergoing retropubic midurethral sling surgery at a single academic center during 2011 and 2012. They excluded any who underwent autologous bladder neck, transobturator, or mini-/single-incision sling surgery.

On average, the patients were 57 years old and had a body mass index of 28 kg/m², according to Dr. Miranne. Overall, 17% had previously undergone anti-incontinence surgery and 20% had previously undergone prolapse surgery, with no significant difference between groups.

Patients in the no-guide group were more likely to have anterior prolapse (95% vs. 78%) and to have a concomitant prolapse repair (65% vs. 51%). They were less likely to have a resident or fellow as first assistant in the surgery (91% vs. 99%) and to have local retropubic anesthesia (71% vs. 96%). Similar proportions had a concomitant hysterectomy.

In addition to showing no significant difference in injury rates, analyses revealed that the groups were statistically the same with respect to mean intraoperative time; mean blood loss; and mean hospital stay, which was less than 1 day for the entire cohort.

Dr. Miranne disclosed no relevant conflicts of interest.

SCOTTSDALE, ARIZ. – Using a Foley catheter guide during midurethral sling surgery does not appear to reduce the risk of injury to the bladder and urethra, according to a retrospective study presented at the annual scientific meeting of the Society of Gynecologic Surgeons.

Surgeons used the guide in 24.5% of the 310 women undergoing retropubic midurethral sling surgery, reported first author Dr. Jeannine M. Miranne, an ob.gyn. at Medstar Washington Hospital Center and Georgetown University, Washington.

The rate of cystotomy was 1.3% in the guide group and 5.6% in the no-guide group, a statistically indistinguishable difference and one that remained so even after adjustment for potential confounders. None of the patients studied experienced a urethrotomy.

"Foley catheter guide use does not decrease the risk of intraoperative lower urinary tract injury. However, larger prospective studies are needed to confirm this finding, given the possibility of a type 2 error," Dr. Miranne concluded.

Session attendee Dr. Eric Sokol, an assistant professor of obstetrics and gynecology, and of urology at Stanford (Calif.) University, wondered if injury rates were affected by the specific sling used.

"What I imagine has possibly influenced your results is the fact that you have changed also the sling that you use. As I understand it, you are using a lot of Advantage Fit slings," he said. In his experience in training residents, the bladder is often inadvertently punctured when this sling is used. "When I use other slings, with a rigid handle and a bigger curve, they don’t go in the bladder. So do you think there might be an influence of the exact sling that you are using?"

"There definitely may be an influence," Dr. Miranne replied. "Unfortunately, the majority of physicians in our group used the Advantage Fit sling for approximately 90% of their cases that were included. So it’s really hard to determine whether or not that played a role in the cystotomy rate in our study. But that’s definitely something to consider when you think about cystotomy – the type of retropubic sling."

Another attendee commented that using a Foley catheter guide adds an annoying, time-consuming step to the surgery. "It wasn’t our idea, but we have used the cystoscope shaft, and we will use that to manipulate the urethra. You have to put that in anyway to scope the patient, and it saves a lot of time putting things in and taking them out," he said at the meeting, which was jointly sponsored by the American College of Surgeons.

Giving some background to the study, Dr. Miranne said that "synthetic midurethral sling has become a gold-standard surgical procedure for stress urinary incontinence. Different techniques have been introduced to decrease the risk of intraoperative lower urinary tract injury during sling placement. One such technique involves use of a rigid Foley catheter guide during retropubic sling placement."

"Although the manufacturer of the original tension-free vaginal tape continues to recommend Foley catheter guide use in its instructions, it is unclear whether use of this device decreases the risk of intraoperative lower urinary tract injury," she noted.

For the study, the investigators included women undergoing retropubic midurethral sling surgery at a single academic center during 2011 and 2012. They excluded any who underwent autologous bladder neck, transobturator, or mini-/single-incision sling surgery.

On average, the patients were 57 years old and had a body mass index of 28 kg/m², according to Dr. Miranne. Overall, 17% had previously undergone anti-incontinence surgery and 20% had previously undergone prolapse surgery, with no significant difference between groups.

Patients in the no-guide group were more likely to have anterior prolapse (95% vs. 78%) and to have a concomitant prolapse repair (65% vs. 51%). They were less likely to have a resident or fellow as first assistant in the surgery (91% vs. 99%) and to have local retropubic anesthesia (71% vs. 96%). Similar proportions had a concomitant hysterectomy.

In addition to showing no significant difference in injury rates, analyses revealed that the groups were statistically the same with respect to mean intraoperative time; mean blood loss; and mean hospital stay, which was less than 1 day for the entire cohort.

Dr. Miranne disclosed no relevant conflicts of interest.

SCOTTSDALE, ARIZ. – Using a Foley catheter guide during midurethral sling surgery does not appear to reduce the risk of injury to the bladder and urethra, according to a retrospective study presented at the annual scientific meeting of the Society of Gynecologic Surgeons.

Surgeons used the guide in 24.5% of the 310 women undergoing retropubic midurethral sling surgery, reported first author Dr. Jeannine M. Miranne, an ob.gyn. at Medstar Washington Hospital Center and Georgetown University, Washington.

The rate of cystotomy was 1.3% in the guide group and 5.6% in the no-guide group, a statistically indistinguishable difference and one that remained so even after adjustment for potential confounders. None of the patients studied experienced a urethrotomy.

"Foley catheter guide use does not decrease the risk of intraoperative lower urinary tract injury. However, larger prospective studies are needed to confirm this finding, given the possibility of a type 2 error," Dr. Miranne concluded.

Session attendee Dr. Eric Sokol, an assistant professor of obstetrics and gynecology, and of urology at Stanford (Calif.) University, wondered if injury rates were affected by the specific sling used.

"What I imagine has possibly influenced your results is the fact that you have changed also the sling that you use. As I understand it, you are using a lot of Advantage Fit slings," he said. In his experience in training residents, the bladder is often inadvertently punctured when this sling is used. "When I use other slings, with a rigid handle and a bigger curve, they don’t go in the bladder. So do you think there might be an influence of the exact sling that you are using?"

"There definitely may be an influence," Dr. Miranne replied. "Unfortunately, the majority of physicians in our group used the Advantage Fit sling for approximately 90% of their cases that were included. So it’s really hard to determine whether or not that played a role in the cystotomy rate in our study. But that’s definitely something to consider when you think about cystotomy – the type of retropubic sling."

Another attendee commented that using a Foley catheter guide adds an annoying, time-consuming step to the surgery. "It wasn’t our idea, but we have used the cystoscope shaft, and we will use that to manipulate the urethra. You have to put that in anyway to scope the patient, and it saves a lot of time putting things in and taking them out," he said at the meeting, which was jointly sponsored by the American College of Surgeons.

Giving some background to the study, Dr. Miranne said that "synthetic midurethral sling has become a gold-standard surgical procedure for stress urinary incontinence. Different techniques have been introduced to decrease the risk of intraoperative lower urinary tract injury during sling placement. One such technique involves use of a rigid Foley catheter guide during retropubic sling placement."

"Although the manufacturer of the original tension-free vaginal tape continues to recommend Foley catheter guide use in its instructions, it is unclear whether use of this device decreases the risk of intraoperative lower urinary tract injury," she noted.

For the study, the investigators included women undergoing retropubic midurethral sling surgery at a single academic center during 2011 and 2012. They excluded any who underwent autologous bladder neck, transobturator, or mini-/single-incision sling surgery.

On average, the patients were 57 years old and had a body mass index of 28 kg/m², according to Dr. Miranne. Overall, 17% had previously undergone anti-incontinence surgery and 20% had previously undergone prolapse surgery, with no significant difference between groups.

Patients in the no-guide group were more likely to have anterior prolapse (95% vs. 78%) and to have a concomitant prolapse repair (65% vs. 51%). They were less likely to have a resident or fellow as first assistant in the surgery (91% vs. 99%) and to have local retropubic anesthesia (71% vs. 96%). Similar proportions had a concomitant hysterectomy.

In addition to showing no significant difference in injury rates, analyses revealed that the groups were statistically the same with respect to mean intraoperative time; mean blood loss; and mean hospital stay, which was less than 1 day for the entire cohort.

Dr. Miranne disclosed no relevant conflicts of interest.