2. Methods
A prospective study was conducted at the Soroka University Medical Center (SUMC), in accordance with the provisions of the Declaration of Helsinki (Soroka University Medical Center IRB approval 0186-19). SUMC is a large tertiary teaching center, treating a population of close to a million residents of southern Israel. The study population included patients who underwent a TOT procedure to treat SUI or stress-predominant mixed urinary incontinence, were over the age of 18 years, and were able to walk without support. Exclusion criteria included patients with congenital deformity or other diseases of the hip joint, those who have undergone previous surgeries of the hip joints or were using wheeled mobility devices. Patients with previous SUI surgeries were excluded as well. Participants were recruited before surgery, after they were provided with a verbal explanation of the study rationale and signed an informed consent form. Participants background characteristics were collected from the electronic medical records including demographics (age, ethnicity, city of residence, years of formal education) and general, surgical, and obstetrical history (menopause status, background chronic medical conditions, number of previous pregnancies and deliveries, weight, height, smoking). Surgical information that was collected included estimated blood loss during surgery, duration of surgery, concomitant procedures undertaken during the TOT operation (e.g., colporrhaphy, hysterectomy, sacrospinous ligament fixation) and perioperative complications.
To assess lower extremity function after surgery, the following measurement were taken and tests performed at baseline and 6-8 weeks following surgery, by a licensed and experienced physical therapist:
  1. Range of motion and hip joint function in both hips including flexion, extension, external rotation, and internal rotation, measured using a Goniometer (14).
  2. Manual strength testing of the hip joint muscles involved in flexion, adduction, and abduction. Grading was on a 0 to 5 Medical Research Council scale (15), were ”0” represents no muscle contraction, and ”5” represents normal muscle strength (able to overcome full resistance), and the numeric grades in-between represent raising levels of contraction against resistance.
  3. Validated condition-specific quality-of-life (QoL): Urogenital Distress Inventory (UDI-6) questionnaire to evaluate the QoL and symptom distress in patients suffering from urinary incontinence (16) and the Incontinence Impact Questionnaire short form 7 (IIQ-7) to measure the impact of urinary incontinence on activities, roles, and emotional states in patients (17).
  4. To examine mental and physical quality of life we used the 12-Item Short Form Survey (SF-12) (18, 19).
  5. The Forgotten Joint Score (FJS) questionnaire was used to assess the ability of the patient to forget having a problem with a certain joint following surgery (20, 21).
  6. ”Get Up and Go” test (22, 23) and the 10-Meter Walk Test (10mWT) (24) were used to assess gait performance. During the former, the patient is observed while rising from a chair, walking a short distance, turning around, and sitting back on the chair. The 10mWT assesses walking speed over a fixed distance.
  7. Direct measurement of leg length, measuring the distance between the anterior superior iliac spine (ASIS) and the medial malleolus (25, 26).