Marshall-Marchetti手术治疗压力性尿失禁

我院于1995～1998年间采用Marshall-Marchetti手术（膀胱尿道悬吊固定术）治疗女性压力性尿失禁5例，效果显著，现报告如下。 1　资料与方法 1.1　临床资料 　　本组5例，年龄38～50岁，病程0.5～5年。常因咳嗽、大笑、站立过久出现溢尿症状，其中1例平卧时亦有溢尿。按压力性尿失禁分期均为3～4期。 1.2　手术方法 　　作硬膜外腔麻醉，取截石位。下腹正中切口，将腹膜返折向上推移，分离耻骨尿道韧带，在耻骨联合下方游离膀胱颈和前面部分尿道。牵拉气囊导尿管，确定膀胱颈和尿道位置。钝性分离后尿道及膀胱颈两侧壁，使之与阴道分离。     

女性不同类型尿失禁临床及尿动力学特点

目的 探讨女性不同类型尿失禁临床及尿动力学特点，提高临床诊治水平。方法 对76例女性患者常规行尿动力学检查，包括尿流率、压力流率研究、尿道压力测定、漏尿点压测定。结果 76例患者中，压力性尿失禁30例，运动紧迫性尿失禁15例，反射性尿失禁19例，混合型压力性／紧迫性尿失禁2例，不稳定尿道3例，假性尿失禁7例。运动紧迫性尿失禁中，DLPP≥40cmH2O者14例，均有不同程度双肾积水。结论 腹压漏尿点压测定可以协助确定压力性尿失禁的手术方式。神经性膀胱尿道功能障碍和膀胱出口梗阻均可能出现膀胱顺应性下降，逼尿肌漏尿点压可以帮助决定膀胱顺应性下降时手术治疗时机。当逼尿肌漏尿点压≥40cmH2O，或者膀胱充盈200ml时逼尿肌压力≥40cmH2O时，必须进行治疗，否则会导致上尿路损害。     

自体筋膜尿道悬吊治疗女性压力性尿失禁的探讨

目的：探讨自体筋膜尿道悬吊术在女性压力性尿失禁治疗中的效果。方法：采用经耻骨上人路自体筋膜尿道中段悬吊术治疗女性压力性尿失禁,回顾性分析2000年2月～2007年12月采用该手术方式治疗28例女性压力性尿失禁患者的临床资料和治疗效果。结果：所有患者无耻骨后血肿形成,无尿道损伤;膀胱损伤1例,延长导尿管留置时间后治愈;28例患者术后拔除尿管均能自行排尿并满意控尿,6例患者出现不同程度不稳定膀胱症状,经对症处理缓解。随访9～21个月,平均15个月,无压力性尿失禁症状复发及排尿困难。结论：自体筋膜尿道悬吊术治疗女性压力性尿失禁简单易行,操作安全,损伤性较小,费用低廉。     

女性尿道及括约肌重建术二例报告

我们应用重建尿道与重建横纹括约肌术治疗女性尿道缺如患者 2例 ,疗效良好。现报告如下。例 1,2 9岁。因咳嗽、跑步时尿失禁2 0年 ,于 2 0 0 0年 3月在外院诊断为压力性尿失禁行阴道前壁修补、膀胱颈悬吊术 ,术后呈现完全性尿失禁。查体 :完全性尿道下裂、膀胱颈开口于阴道。行阴道黏膜瓣尿道成形术。手术方法 :12F双腔尿管置入膀胱 ,于阴道前壁中线相距 2cm作平行切口 ,近端绕过膀胱瘘口 ,远端达阴蒂下 1cm ,形成长 4cm尿道瓣。将瓣的创缘向中线靠拢围绕导尿管 ,用 5 0可吸收缝线缝合成尿道 (图1) ,同时缩窄膀胱颈 ,用Foley导尿管量取新…     

亲水性聚丙烯酰胺凝胶腔内注射治疗女性压力性尿失禁

目的 评估亲水性聚丙烯酰胺凝胶(生物凝胶)经尿道腔内注射治疗女性压力性尿失禁的疗效。方法 24例女性压力性尿失禁患膀胱镜直视下于后尿道近膀胱开口0．5-lcm的3,6，9点处黏膜下穿刺注射生物凝胶平均12．2(6．20)ml／次。结果 腔内注射一次18例，二次5例，三次1例，累积平均注射量18．9(6—38)ml。术后尿道平均延长1．03cm，膀胱颈部尿道121周径平均缩小3．1lcm，症状消失13例，占54．2％；改善11例，占48．5％；无并发症和不良反应发生。结论 生物凝胶腔内注射治疗女性压力性尿失禁疗效确切，创伤微小，可重复注射，可选择为压力性尿失禁的外科治疗方法。     

尿动力学联合膀胱尿道造影在女性压力性尿失禁诊断中的价值

目的探讨尿动力学检查联合排泄性膀胱尿道造影在女性压力性尿失禁诊断中的应用价值。方法回顾性分析56例临床诊断为女性压力性尿失禁（SUI）的患者,年龄（59．2±8．2）岁,每例均行尿动力学和排泄性膀胱尿道造影检查,评估膀胱顺应性、逼尿肌稳定性、尿道压、膀胱及尿道的形态。鳍杲尿动力学检查提示最大尿流率（33．6±7．7）mL／s,残余尿（17．8±14．7）mL,膀胱顺应性正常,膀胱容量（356．3±99．3）mL,33例测得腹压漏尿点压（49．8±17．6）cmH2O,最大尿道闭合压（47．4±10．5）cmH2O,功能性尿道长度（2．6±0．6）cm。相关性分析显示病程与腹压漏尿点压高度负相关（r=-0．816,P〈0．01）。排泄性膀胱尿道造影见膀胱颈及近端尿道下移34例,膀胱尿道后角变钝或消失44例,静息期膀胱颈和近端尿道呈漏斗形7例,咳嗽时47例见造影剂从尿道溢出。结论在无影像尿动力学设备的单位,尿动力学检查和排泄性膀胱尿道造影联合应用对SUI的诊断和术前评估具有重要的价值,比单用一种方法更具有临床意义。     

肌瓣转移治疗女性压力性尿失禁：附13例报告

为探讨女性压力性尿失禁患者的治疗效果，对１３例女性压力性尿失禁病人使用股薄肌肌瓣翻转移位包围尿道、加强尿道括约肌功能，同时游离尿道并给以延长。结果１３例病人手术治疗后随访６～２４个月，１０例病人排尿通畅，３例病人有尿线变细，经过尿道扩张后排尿正常。本术式方法易掌握，取材方便，成功率高，并发症少，是一种治疗女性压力性尿失禁较理想的手术方法。     

应用膀胱三角区壁瓣成形尿道治疗女性外伤性尿道缺损(附5例报告)

目的：探讨膀胱三角区壁瓣成形尿道治疗女性外伤性尿道损伤的疗效。方法：自膀胱颈后唇向上，取梯字形壁瓣，形成锥状管，经膀胱颈口，自阴道前壁外拉至外阴部，在原尿道外口处固定，替代尿道。结果：3例随访8年，1例6年，1例5年，平均随访7年，均排尿通畅，无尿失禁和尿道狭窄。结论：女性外伤性尿道缺损，应用膀胱三角区壁瓣形成锥状管替代尿道法治疗，手术简单，对患者打击小，成功率高，远期效果好。     

经耻骨上膀胱尿道悬吊术治疗女性压力性尿失禁(附8例报告)

目的：探讨一种新的手术方法经耻骨上膀胱尿道悬吊术（SPARC）治疗女性压力性尿失禁的初步疗效及安全性。方法：2002年7月～2004年3月采用SPARC治疗临床诊断为女性压力性尿失禁的患者8例。结果：手术时间25～40min。平均32min。出血15-40ml,平均30ml。住院3～7天,平均5天。8例患者术后尿控满意。随访3个月。1例有轻度尿失禁,余无排尿困难、尿失禁及尿路感染。结论：SPARC治疗女性压力性尿失禁具有简单、安全、创伤小、疗效好的优点,值得在临床上推广使用。     

经耻骨上膀胱尿道悬吊带治疗女性压力性尿失禁(附8例报告)

目的:探讨尿道悬吊带(SPARC)治疗女性压力性尿失禁的疗效.方法:局麻下对8例女性压力性尿失禁患者施行经耻骨上膀胱尿道悬吊带手术治疗.结果:平均手术时间45 min(30～70 min),平均住院2天(1～3天).术后留置导尿管24 h.8例患者术后尿失禁症状均消失,无并发症.结论:SPARC尿道悬吊带治疗女性压力性尿失禁疗效确切,操作简便,对患者损伤少,并发症发生率低,是一种治疗女性压力性尿失禁的有效方法.     

应用Y形补片治疗阴道前壁膀胱膨出及压力性尿失禁的临床研究

目的评价经阴道Y形补片治疗阴道前壁膀胱膨出及压力性尿失禁的近期疗效。方法2003年4月．2006年5月，对确诊为阴道前壁及膀胱膨出合并不同程度压力性尿失禁的34例行经阴道尿道中段、膀胱膨出部位Y形补片悬吊修复术，并对手术后主观症状的改善、术后复发率进行评估。结果34例术后24h拔除导尿管后能自行排尿，残余尿〈100ml。随访3-37个月，平均26个月，无尿潴留、尿路感染、膀胱功能障碍及复发。结论应用Y形补片不仅治疗阴道前壁及膀胱膨出，而且能同时治疗压力性尿失禁。     

Genitourinary spheroidal membrane (GSM) for the treatment of female stress urinary incontinence

Fourteen female patients with stress urinary incontinence were implanted with the genitourinary spheroidal membrane (GSM) device (Bard), a percutaneous implantable spheroidal membrane for the treatment of urinary incontinence through localized tissue expansion. Most patients had undergone previous pelvic surgery and suffered from significant medical problems. The placement of the GSM was performed under local anesthesia, with the help of fluoroscopy, cystoscopy and digital examination. The GSM was inserted and inflated close to the posterior urethra, causing its coaptation. Mean patient follow-up is 33 months. Eight patients are now completely dry (57.1%) and 2 are significantly improved (14.3%), with a success rate of (71.4%). The remaining 4 patients (27.6%) are considered failures. Migration of the GSM into the bladder was noticed on three occasions. Two extrusions into the vaginal wall were encountered. GSM replacements were performed without ill effects. Preliminary findings suggest that the GSM prosthesis may be a simple and safe alternative for the treatment of female stress urinary incontinence. The device is still in the experimental stage and further studies in Europe have been started.     

Abnormal urethral motor function is common in female stress, mixed, and urge incontinence

AIM: To investigate the urethral motor function in incontinent women. MATERIALS AND METHODS: The intraurethral pressure was measured continuously in the high-pressure zone of the urethra at rest and during repeated short squeezes around the microtip transducer catheter in a group of 205 women with clinically manifest urinary incontinence (severe), and compared with the findings of investigations in 87 middle-aged women (53-63 years) with treatment na?ve incontinence (mild-to-moderate) and healthy controls. RESULTS: Women with established incontinence significantly (P < 0.001) more often (66%) had a pressure fall during or immediately following squeeze than women with treatment na?ve incontinence (35%) or asymptomatic women (25%). The acceleration of urinary flow and the maximal flow rate were significantly (P < 0.01) increased in patients with incontinence: acceleration was 13 +/- 2.2 (17.8), 20 +/- 2.8 (18.9), and 32 +/- 4.9 (24.9) degrees (mean +/- SEM; SD) for incontinence, na?ve incontinence and no incontinence, respectively; maximum urinary flow rate was 23, 22, and 16 ml/sec. No statistical differences in any of these measures were seen when stress and urge incontinence were compared. CONCLUSION: Women with stress, urge, and mixed urinary incontinence seem to have a primary neuromuscular disorder in the urethra, which presents itself as an overactive opening mechanism with a urethral pressure fall instead of a pressure increase on provocation during the filling phase of the bladder, and during bladder emptying a more efficient opening of the bladder outlet than in normal women. We suggest that one and the same pathophysiological mechanism participates in female stress, urge, and mixed incontinence.     

Transrectal ultrasound versus cystography in the evaluation of anatomical stress urinary incontinence

Thirty-two female patients with clinical and urodynamic findings of genuine stress urinary incontinence were evaluated before and 6 months after surgery for stress urinary incontinence. Twenty-nine control patients had identical evaluations before and 6 months after surgery which did not involve the urethrovesical junction. Twenty-four patients with primary bladder instability had similar evaluations and served as a second control group. Anatomical landmarks indicating support to the urethrovesical junction were evaluated by the position of the urethra at the most dependent point in the bladder on straining and the urethral descent on straining to beneath the posterior ramus of the symphysis pubis on bead chain cystography. The urethrovesical junction drop on straining was evaluated by transrectal ultrasonography. Cystographic and ultrasonographic tests for the position of the urethrovesical junction at the most dependent position in the bladder during straining were very sensitive in women with stress urinary incontinence (94 and 87% respectively) but much less specific (45 and 48% respectively). When evaluating anatomical support to the urethrovesical junction and its descent on straining, these tests were both highly sensitive (97 and 94% respectively) and specific (76 and 96% respectively) in women with genuine stress urinary incontinence. Simple clinical tests for support of the urethrovesical junction, such as the Q tip test, are non-specific in patients with stress urinary incontinence. Transrectal ultrasonography is a simple and quick out-patient procedure. The availability of ultrasound equipment in most clinics and the high sensitivity and specificity of the test make it an attractive and cost-effective alternative to X-ray cystography in the pre-operative evaluation of anatomical support to the urethrovesical junction.     

Colpo-wrap: a new continence procedure

OBJECTIVE: To present a new surgical method to increase bladder outlet resistance for the treatment of urinary incontinence in girls and women. PATIENTS AND METHODS: Six patients (mean age 9.6 years), with urinary incontinence were operated using the new technique within the last 3 years. The principle of the procedure is tightening of the bladder neck by mobilizing the anterior vaginal wall and wrapping it around the bladder neck and proximal urethra, in the sense of a vaginoplication (colpoplication). The underlying conditions and causes for urinary incontinence was neurogenic bladder-sphincter dysfunction caused by myelodysplasia in three girls and anorectal malformation combined with a tethered spinal cord in one. In one case incontinence was caused by a cloacal anomaly and one girl had intrinsic sphincter insufficiency after repetitive Otis urethrotomies. The colpo-wrap was combined with a bladder augmentation and Mitrofanoff in three patients, the three other girls undergoing isolated procedures. RESULTS: The result of the method is a constant increase in outlet resistance and coaptation of the urethra, comparable with the effect of a vaginal sling procedure. Five patients are completely dry after surgery, one girl with cloaca needed an additional bladder neck injection with hyaluranon/dextranomer copolymer. Transurethral catheterization was possible after surgery with no problems in all patients who required intermittent catheterization. CONCLUSION: Considering the feasibility of this technique the colpo-wrap is a reasonable alternative for treating urinary incontinence in females.     

ANATOMICAL AND FUNCTIONAL RESULTS OF PUBOVAGINAL SLING PROCEDURE USING POLYPROPYLENE MESH FOR THE TREATMENT OF STRESS URINARY INCONTINENCE

PURPOSE: The anatomical and functional results of pubovaginal sling procedure using polypropylene mesh were investigated. MATERIALS AND METHODS: A total of 50 women with stress urinary incontinence, including 26 with type 2, 7 with mixed type 2/3 and 17 with type 3 disease, underwent the pubovaginal sling procedure using polypropylene mesh. A self-fashioned 2 cm. polypropylene mesh sling was used in all cases. The slings were fixed without tension at each side of the bladder neck. The sling was further suspended to elevate the bladder neck in patients with type 2 disease and those with a hypermobile bladder base, while it was placed without further tension in those with type 3 disease and those with a nonmobile bladder base. After the operation video urodynamics and transrectal sonography were done to evaluate functional and anatomical results. RESULTS: At a median followup of 24 months 42 women were cured, 6 had improvement and treatment had failed in 2. Although the maximum flow rate increased, no changes were noted in detrusor pressure, post-void residual urine or cystometric capacity at month 3. Transrectal sonography revealed that mean sling width plus or minus standard deviation had decreased to 13.5 +/- 3.3 mm. at 3 months. The endopelvic fascia was thicker in women with type 2 than in those with types 2/3 or 3 disease (mean 5.3 +/- 1.5 versus 3.5 +/- 1.3 mm., p = 0.001). The position of bladder neck on video urodynamics was elevated a mean of 2.01 +/- 2.01 and 3.07 +/- 2.07 cm. compared to baseline elevation during resting and straining, respectively (p = 0). No hypermobility was noted while the patients coughed and no kinking of the urethra was observed while they performed the Valsalva maneuver. Detrusor instability resolved in 6 of 8 women (75%) and new onset detrusor instability was noted in 7 (14%). In 2 women with persistent stress urinary incontinence a repeat sling procedure was necessary to treat type 3 disease and cure incontinence. The overall success rate was 96%. One patient with sling erosion into the vaginal wall was treated with simple revision. CONCLUSIONS: Fixation of a polypropylene mesh sling at the bladder neck and adequate suspension may effectively achieve a hammock effect without creating bladder outlet obstruction in patients with types 2 and 2/3 stress urinary incontinence. The anatomical and functional results of this study show that a well suspended bladder neck did not create bladder outlet obstruction after a pubovaginal sling procedure using polypropylene mesh.     

Stress incontinence investigated with urodynamics 30 years ago

An article published in 1961 is reviewed. It reported on the simultaneously measured pressures in the urethra and bladder of both healthy women and women afflicted by stress incontinence. It was found that the difference between the two pressures was crucial for the preservation of continence. If pressure in one section of the urethra was higher than in the bladder, urine could not enter that section and closure was maintained. In patients with stress incontinence it was noted that when the difference in pressure, closure pressure, was lowered to zero during coughing, leakage would be noted. This was due to low urethral muscle tone causing a low resting closure pressure, as well as to an incomplete transmittance of abdominal pressure to the upper urethra. An operation for stress incontinence causes the upper urethra to be more fully exposed to increases in intra-abdominal pressure, so that physical activity has less effect on closure pressure.     

Results of the tension-free vaginal tape procedure for the treatment of type II stress urinary incontinence at a minimum followup of 1 year

PURPOSE: We evaluated the safety and efficacy of the tension-free vaginal tape procedure for treating type II stress urinary incontinence in females. MATERIALS AND METHODS: Between April 1998 and April 1999, 62 women 28 to 86 years old (mean age 62.8) were treated consecutively for stress urinary incontinence with the tension-free vaginal tape procedure. Preoperative evaluation included history, physical examination and multichannel video urodynamics. All patients had type II stress urinary incontinence, none had preoperative detrusor instability or significant pelvic prolapse and in 16 previous surgery for stress incontinence had failed. RESULTS: All patients were followed at least 12 months after the procedure (median 16.2). A total of 42 and 20 women received spinal and local anesthesia, respectively. We noted 6 bladder perforations, including 5 in patients with a history of surgery for stress urinary incontinence. Blood loss was less than 200 cc in all cases. We observed no prolonged postoperative pain, infection or sling rejection. Post-void residual urine was less than 100 cc the day after surgery in 59 cases. Only 3 patients self-catheterized a maximum of 4 days. At followup 54 women (87.1%) were cured of stress urinary incontinence, 6 were improved (9.6%) and 2 had failure (3. 3%), while 4 (6.4%) had new onset detrusor instability without evidence of bladder outlet obstruction. CONCLUSIONS: The tension-free vaginal tape procedure appears to be a minimally invasive, safe and effective treatment for type II stress urinary incontinence. A history of surgery for stress incontinence seems to be a risk factor for bladder perforation.     

Four-corner bladder and urethral suspension for moderate cystocele

The classical approach to cystocele repair involves the approximation of lax pubocervical fascia through the anterior vaginal wall with narrowing of the bladder neck and proximal urethra by the Kelly-type plication. This procedure corrects the prolapse but when performed for the treatment of incontinence it has a high failure rate because the bladder neck and urethra are not placed into a high, supported, nonobstructed retropubic position. Furthermore, due to elevation of the bladder base without simultaneous elevation of the bladder neck and urethra, de novo stress urinary incontinence may occur. We developed a transvaginal needle suspension operation for the bladder and urethra that repairs anterior vaginal wall prolapse with excellent support of the bladder base and repositions the bladder neck in the high retropubic position, all during a simple and rapid operation that is tolerated well by the patient.