腹圧性尿失禁に対する研究

doi: 10.1007/s00345-018-2445-x. Epub 2018 Aug 16.

Comparison between erbium-doped yttrium aluminum garnet laser therapy and sling procedures in the treatment of stress and mixed urinary incontinence

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Free PMC article

Abstract

Purpose: Stress urinary incontinence (SUI) and mixed urinary incontinence (MUI) lead to poor quality of life. In Japan, urinary incontinence is treated with tension-free vaginal tape (TVT) or transobturator tape (TOT) sling procedures, which involves inserting a synthetic material; however, problems arise with artificial mesh in some instances, requiring new treatment methods. Hence, laser therapy, whereby an erbium-doped yttrium aluminum garnet laser is directed into the vagina and urethra, may be useful. The study aimed to compare the effects of these three treatments.

Methods: Subjects included patients who received TVT, TOT, or laser therapy (n = 50 each). The 1-h pad test, International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF), and overactive bladder symptom score were used to assess the patients before and 12 months after treatment. For laser therapy, a probe was inserted into the vagina after applying a local anesthetic to the vaginal wall, and irradiation was performed for 20 min at a wavelength of 2940 nm. This treatment was performed three times every alternate month.

Results: As per the 1-h pad test and ICIQ-SF, the TVT, TOT, and laser therapy groups showed comparable improvements in SUI. For patients with MUI, some in the TVT and TOT groups showed exacerbation; however, all patients in the laser therapy group tended to improve.

Conclusions: The efficacy of laser therapy for urinary incontinence was confirmed. This is the first study to report on the effect of laser therapy on urinary incontinence in Japanese women.

Keywords: International Consultation on Incontinence Questionnaire Short Form; Non-ablative erbium yttrium aluminum garnet laser; One-hour pad test; Overactive bladder symptom score; Tension-free vaginal tape; Transobturator tape.

Introduction

Stress urinary incontinence (SUI) is a condition, wherein increased abdominal pressure, such as that from coughing, causes urinary leakage [1]; it affects up to 49% of all women. Mixed urinary incontinence (MUI) affects up to 29% of all women [2] and is a combination of SUI and urge incontinence, in which a strong urge to urinate is accompanied by urinary leakage.

Among various surgical techniques for SUI, sling procedure is effective [1]. In recent years, this procedure has been used to support the bladder neck and urethra with a synthetic material called prolene mesh tape as a sling [3,4,5,6]. In Japan, tension-free vaginal tape (TVT) and transobturator tape (TOT) are generally used for these procedures [1]. The TVT procedure involves placing a mesh tape mid-urethra, extending from the posterior surface of the pubis to the subepithelium above the pubis. The TOT procedure involves placing the tape from the obturator foramen to the vagina (or from the vagina to the obturator foramen). These procedures have shown good treatment outcomes; however, a long-term risk of complications can occur due to the artificial nature of the tape [7].

At present, a surgical procedure that does not introduce a foreign object is desirable. Attention has thus been drawn toward non-ablative erbium-doped yttrium aluminum garnet (Er:YAG) laser therapy, which consists of transvaginal laser irradiation of the urethra [8]. This laser therapy is thought to improve blood flow to the surrounding tissue and promote tissue regeneration [9]. In studies on Caucasian women, an improvement in SUI was observed, and most subjects exhibited no adverse effects [10]. A shortcoming of the treatment is that it is effective only for a few years [8,9,10]. However, to our knowledge, there are no comparative studies on the TVT and TOT procedures [11]. Furthermore, there are no reports on Japanese women.

Discussion

Findings from the present study

In the present study, the state of laser therapy has been clarified by comparing it with that of the TVT and TOT procedures. In the 1-h pad test and ICIQ-SF, comparable therapeutic results were seen for the three procedures; however, the results of the OABSS and complications differed. In other words, from the perspective of SUI, the results were comparable among the three groups; however, from the perspective of MUI and complications, laser therapy is superior. Next, the results of the present study are examined with a discussion of the literature.

Complications and urinary urgency in the TVT and TOT procedures

Serious short-term complications have been reported in 17.3% of the TVT procedures [14], and postoperative urinary urgency occurs in 9.4% at 5 years and in 11.4% at 7 years after treatment [15]. In the present study, short-term complications occurred in 6% of patients and long-term complications occurred in 0% of patients in the TVT group; thus, the surgical techniques are considered comparable.

In the TOT procedure, short-term complications include bladder perforation in 0.4% [16] and femoral pain in 12% of patients [17]. In the present study, the incidence of complications is 4% in the short term and 2% in the long term, which shows that the surgical techniques are comparable. Due care is important, because both groups have some residual urine.

Patients with moderate preoperative urge incontinence correspond to patients with 4 points for OABSS Q4 in the present study. A postoperative increase in urge incontinence leads to postoperative exacerbation of OABSS overall and an increase in the number of patients with great dissatisfaction on ICIQ-SF. This result shows that surgery carries the risk of MUI. In the abovementioned literature, sling procedure for MUI cures urinary urgency and urges incontinence 30–85% of the times [18]. In other words, SUI did not improve, but was exacerbated in some patients. Therefore, the TVT and TOT procedures are not necessarily recommended for all patients.

In the United Kingdom, it has been reported that the use of an artificial object in female urological surgery causes problems [7]. This predicts that artificial objects may no longer be approved for use in surgery for incontinence in the UK in the future.

Literature review of laser therapy

Laser therapy, which is addressed in the present study, is a promising new treatment. The first report [9] indicates that laser therapy may be used for vaginal relaxation, SUI, pelvic organ prolapse, and vaginal atrophy, with no serious adverse effects. The only shortcoming is that the effects of treatment are temporary and presumed to last for a limited number of years. Furthermore, there are no reports of long-term follow-up. In a cohort study [19] surveying 73 women and a prospective study [20] of 42 women, no adverse effects were observed, and the ICIQ-SF scores improved. In many reports with evaluations including the ICIQ-SF and pad test only, improvement was observed with no adverse effects. Such reports are consistent with the present study.

For MUI, one report used the King’s Health Questionnaire [10], in which an improvement was observed. However, the observation period was only 6 months. In the present study, after 12 months of observation, a comparable improvement in MUI was observed.

The mechanism by which MUI is treated includes tissue changes. It has been reported that laser therapy increased vascularization of the vaginal mucosa by 64%, and regeneration of vaginal tissue is pathologically observed in 61% [21]. It has also been reported that laser therapy improves urethral sphincter dysfunction with urethral sphincter failure [22], implying tissue regeneration.

Outlook for laser therapy

Based on the present study and literature review, the TVT and TOT procedures are comparable for SUI; however, laser therapy is superior in terms of MUI and complications. This is an important finding, as there are no previous comparative studies of laser therapy.

According to the literature, a shortcoming of laser therapy is that it is effective for only a few years. From a positive point of view, laser therapy is considered safe, because even if unexpected adverse effects occur, they are reversible. It may be beneficial for women who desire temporary treatment and who do not want an artificial object.

Conclusion
For SUI, Er:YAG laser therapy in women improved urinary incontinence as effectively as the TVT and TOT procedures with few complications and may be a good treatment option for MUI as well.

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