Modified urethral sling for the treatment of genuine stress incontinence and latent incontinence

The results of 143 women who underwent a modified urethral sling using Marlex mesh for the correction of stress urinary incontinence and latent stress incontinence, as diagnosed by clinical and urodynamic testing, are examined. The overall success rate for the surgical correction of genuine stress urinary incontinence was 99% during a median follow-up time of 1 year (range 0.12–4 years). There was a 12% postoperative incidence of varying degrees of genital prolapse. Difficulty with voiding resulting in the need for self-catheterization occurred in 17% of patients in the first 6 weeks, but only 2.8% were needing self-catheterizing after 1 year. There was a difference in peak flow preoperatively compared with 1 year postoperatively (20.5 ml/s v 15.7 ml/s, P=0.0003). Patients with a normal peak flow preoperatively (>20 ml/s) were more compromised at 1 year postoperatively (28 ml/s preoperatively, 18.4 ml/s postoperatively, P=0.00001), than women with an abnormal preoperative flow (<20 ml/s), (13.2 ml/s preoperatively, 13.5 ml/s postoperatively). Whether the operation was done for overt or latent stress incontinence did not affect postoperative flow results. It was not possible to predict by preoperative uroflow testing which patients were likely to need intermittent self-catheterization postoperatively. One year after surgery there were no significant alterations in bladder capacity (CMG) or urethral pressure profile measurements. There were no statistically significant changes in uroflow patterns when comparing primary and secondary surgical groups.     

Clinical and urodynamic evaluation of the polypropylene (marlex) sling for genuine stress incontinence

Ten women undergoing a polypropylene suburethral sling procedure for treatment of genuine stress incontinence were assessed pre- and post-operatively by standard urodynamic methods and by urethral pressure profile measurements at rest and on stress. Eight patients were subjectively and seven objectively cured of stress incontinence. A significant reduction in urine flow rate was found although this appeared to be of little relevance to the successful outcome of surgery. An increase in resting urethral profile length was seen in both successful and unsuccessful cases. The former also had an improvement in maximum urethral closure pressure on stress due to improvement in pressure transmission in the proximal three quarters of the functional urethral length. The urethra appeared relocated in a retropubic position following successful and unsuccessful operations. It is likely that failure was associated with periurethral fibrosis causing failure of pressure transmission despite adequate elevation.     

A comparison of the cough and standing urethral pressure profile in the diagnosis of stress incontinence

Controversy over the accuracy of the urethral pressure profile (UPP) and its role in the diagnosis of stress urinary incontinence (SUI) is unresolved. Different UPP methods and techniques have been introduced. In this study, we examined 78 female patients with mixed symptoms of stress and urge incontinence. Each had a history, physical examination, cystoscopy, and urodynamic assessment, which consisted of a cystometrogram (CMG), UPP (supine and standing), and “cough profile” by the Brown and Wickham (BW) method and also UPP (supine) and “cough profile” with the microtip transducer (MTT). The final diagnosis in 38 patients was SUI (group I) and in 40 patients, no SUI (group II). The maximum urethral closure pressure (MUCP) supine and standing was significantly lower in group I, but there was no significant difference between the two groups in the transmission index (TI) of the “cough profile.” MUCP standing showed the least overlap between the two groups, and with a cutoff point at 40 cm H₂O, the overall diagnostic accuracy was 69%, with 39% sensitivity and 98% specificity. By combining MUCP supine and standing and using cutoff points at 40 cm H₂O and 35 cm H₂O, respectively, the overall diagnostic accuracy was 72%, with 47% sensitivity and 95% specificity. We believe that the UPP is a useful ancillary tool in the assessment of complicated cases of urinary incontinence in the female.     

Correlation between valsalva leak point pressure and maximal urethral closure pressure in women with stress urinary incontinence

This study analyzed the relationship between valsalva leak point pressure (VLPP) and maximal urethral closure pressure (MUCP) in women with stress urinary incontinence. One hundred sixty-one patients were selected with diagnosis of mixed or stress urinary incontinence. During urodynamics we measured VLPP and MUCP. Patients were gathered according to VLPP and analysis of variance (ANOVA) was performed. Pearsons correlation coefficient and linear regression were also utilized. The group with VLPP under 60 cm H₂O had mean MUCP of 44.5 cm H₂0; the group with VLPP between 60 and 90 cm H₂O had mean MUCP of 54.3 cm H₂O; and the group with VLPP over 90 cm H₂O had mean MUCP of 60.1 cm H₂O. We observed correlation between MUCP and VLPP when we used Pearsons correlation coefficient (r=0.22) and linear regression (p<0.05). There was weak correlation between MUCP and VLPP, and MUCP was significantly lower in patients with leak point pressure inferior to 60 cm H₂O. Editorial Comment: This is a retrospective study of 161 female patients with stress urinary incontinence in which the authors analyze the relationship between urodynamic valsalva leak point pressure (VLPP) and maximal urethral closure pressure (MUCP). In analyzing their data with Pearsons correlation coefficient and linear regression, the authors found a weak correlation between VLPP and MUCP. In addition, they found a significantly lower MUCP in patients with VLPP less than 60. The authors conclude that MUCP values less than 45 cm H₂O are not sensitive in diagnosing intrinsic sphincter deficiency. Although this study supports the known correlation between VLPP and MUCP, it adds little new information to the literature. This subject has previously been studied and evaluated and numerous published articles have already confirmed this correlation. It is already generally accepted that the diagnosis of intrinsic sphincter deficiency should be based on a compilation of factors including patient history, urodynamic, anatomic, and clinical severity criteria     

Narrative review of male urethral sling for post-prostatectomy stress incontinence: sling type,patient selection,and clinical applications

Male stress urinary incontinence (SUI) following prostate treatment is a devastating complaint for many patients. While the artificial urinary sphincter is the gold standard treatment for male SUI, the urethral sling is also popular due to ease of placement, lack of mechanical complexity, and absence of manual dexterity requirement. A literature review was performed of male urethral sling articles spanning the last zz20 years using the PubMed search engine. Clinical practice guidelines were also reviewed for comparison. Four categories of male urethral sling were evaluated: the transobturator AdVance and AdVance XP, the bone-anchored InVance, the quadratic Virtue, and the adjustable sling series. Well selected patients with mild to moderate urinary incontinence and no prior history of radiation experienced the highest success rates at long-term follow up. Patients with post-prostatectomy climacturia also reported improvement in leakage after sling. Concurrent penile prosthesis and sling techniques were reviewed, with favorable short-term outcomes demonstrated. Male urethral sling is a user-friendly surgical procedure with durable long-term outcomes in carefully selected men with mild stress urinary incontinence. Multiple sling types are available with varying degrees of efficacy and complication rates. Longer follow-up and larger cohort sizes are needed for treatment of newer indications such as climacturia as well as techniques involving dual placement of sling and penile prosthesis.     

Comparative data from history,clinical examination and urodynamics in patients with genuine stress urinary incontinence and recurrent stress urinary incontinence after surgery

In this study 272 patients with genuine stress urinary incontinence (GSUI) were initially considered. Of these, 247 were divided into three groups based on: positive history for GSUI (group 1); positive history and clinical examination for GSUI (group 2); and positive history, clinical examination, and cough urethral pressure profile for GSUI (group 3). When compared with a group of 30 normal women (control group) the values for the urethral functional length (FL) and the maximum urethral closure pressure (MCUP) decreased progressively from group 1 to group 3. The pressure transmission ratio (PTR) was signficantly lower only in group 3.Tonometric values calculated for a group of 25 patients with GSUI recurring afterprevious surgical correction (group 4) were found to be comparable with group 3. These patients with recurrent GSUI had a FL decreased to 70% and a MCUP decreased to 48% of the normal values. The PTR was maintained at a normal value of 97% in patients with degree I recurrence, but was decreased to 68% in patients with degree II–III recurrence having the most severe impairment of the periurethral environment.     

Tension-free vaginal tape sling for recurrent stress incontinence after transobturator tape sling failure

The transobturator tape (TOT) sling is a new minimally invasive technique to treat stress urinary incontinence (SUI). Short-term follow-up studies show high success rates; however, as with any surgical treatment of SUI, failures are known to occur. The treatment of recurrent or persistent stress urinary incontinence after a TOT sling is therefore a new dilemma as well. In this paper, we describe the successful use of a retropubic tension-free vaginal tape (TVT) sling in five patients after failed TOT sling. We present case series of five patients who had TOT slings placed for stress incontinence that failed and subsequently had TVT slings placed for persistent SUI. The TVT slings were placed under local/regional anesthesia without removal of the TOT sling. Retrospective chart review of office and hospital charts was completed, and both objective and subjective data were collected. Five patients had TVT slings placed 6–30 weeks after early failure of TOT slings that were placed for stress urinary incontinence. Postoperatively, all patients with urodynamic testing showed evidence of intrinsic sphincter deficiency; however, all maintained urethral mobility of 30°. All five patients had successful treatment of their incontinence with the retropubic tension-free sling procedure with a mean follow-up of 17 months. Recurrent or persistent stress urinary incontinence after TOT sling may be treated with TVT sling without removal of the TOT sling. Further studies with larger numbers and longer-term follow-up is warranted.     

Concurrent genuine stress incontinence and detrusor instability

Forty-six patients with both genuine stress incontinence (GSI) and detrusor instability (DI), as determined by urodynamic evaluation, were treated with medication or surgery and followed for 6 months. It was found that 60% responded favorably to medical therapy with imipramine hydrochloride, oxybutynin chloride, or dicyclomine hydrochloride. Surgery for stress incontinence was performed in 24 patients, including 17 started initially on medication. Surgical cure was achieved in 38% of these 24 patients, and a further 29% of the surgical group were cured with additional drug therapy. Overall, 85% of patients responded favorably to medication and/or surgery. Patients with combined GSI and DI require detailed urodynamics and may be candidates for surgery, in spite of the coexistent DI.     

Change of sexual function after midurethral sling procedure for stress urinary incontinence

Objectives:   To compare sexual function in women before and after the midurethral sling procedure for stress urinary incontinence (SUI).
Methods:   A total of 75 women undergoing surgery for SUI between September 2005 and September 2006 were recruited for this study. Those who completed the Female Sexual Function Index (FSFI) preoperatively and 6 months postoperatively were included in the analysis. The FSFI is a validated, 19-item questionnaire, which assesses six domains of sexual function, including desire, arousal, lubrication, orgasm, satisfaction, and pain.
Results:   Data were analyzed for 47 patients. Overall sexual function after the midurethral sling procedure was not significantly different. There were no significant differences in overall sexual function or any of the individual FSFI domain scores between patients with and without concomitant posterior colporrhaphy. There were no significant differences in sexual function between the transobturator and the retropubic surgical routes.
Conclusions:   There is no significant change in overall sexual function in women undergoing the midurethral sling procedure. Posterior colporrhaphy and operative methods do not affect overall sexual function.     

Collagen injections for genuine stress urinary incontinence: Patient selection and durability

The questions of patient selection parameters and durability of response in the use of collagen injections for genuine stress incontinence are addressed. A total of 181 women with a mean age of 64 years (range 26–94) underwent collagen injections for urethral incompetence. Treatment outcome was determined by a change in individual incontinence grades before and after injection. Of the 181 women 42 (23%) are cured, 94 (52%) are improved and 45 (25%) failed. Follow-up in the successful patients, either cured or improved, was a mean of 21 months (range 4–69) after their last collagen injection. No difference in outcome was seen in relation to patient age or pretreatment grade of incontinence. Of the 30 patients with bladder instability, 18 (60%) had a favorable outcome. No significant difference in outcome was seen in patients with or without hypermobility (P=0.2889). Patients with type III incontinence required the largest amount of collagen for a successful outcome. The persistence of continence in 78 patients who were cured for at least 2 months were plotted on a Kaplan-Meier survival curve. The probability of remaining dry without additional collagen was 72% at 1 year, 57% at 2 years and 45% at 3 years. It was concluded that, collagen injection into the urethra is a safe and well-tolerated procedure. Pretreatment bladder instability may be an adverse factor. Patients with or without hypermobility had equal benefit. Long-term durability was seen. If deterioration occurred repeat collagen injections restored success. The current literature is reviewed and the use of collagen relative to other treatments is discussed.     

Transobturatory tension-free composite sling for urethral support in patients with stress urinary incontinence: Favorable experience after 1 year follow up

OBJECTIVE: Symptomatic, anatomic and urodynamic results of a composite transobturatory tension-free sling with an absorbable middle part, in patients with stress urinary incontinence (SUI), were studied. METHODS: A prospective study in 40 women with SUI was performed. Symptoms, urodynamics and anatomical improvements were evaluated separately. Surgery was performed with the transobturatory approach. RESULTS: All patients had both clinically and urodynamically confirmed SUI. Clinical outcome was favorable in 36/40 (90%) patients, after 1 year. Operation improved the position of the bladder neck (2.8 cm and 1.4 cm below the pubic bone, respectively) and significantly decreased mobility of the bladder neck during abdominal straining (3.3 cm and 1.7 cm, respectively). Both symptoms and quality of life were significantly improved 1 month after the surgery. Postoperative maximum flow was lower than the preoperative one but with borderline significance (25.8 and 23.7 mL/s; P = 0.05). Pressure flow study showed unobstructed voiding both preoperatively and postoperatively. Detrusor pressure at the maximum flow was increased (20, 4 and 22, 8 cmH(2)O, respectively) but not significantly. CONCLUSION: Our results confirmed a high objective cure rate, improvement of symptoms and quality of life, and at the same time, corrected position of the bladder neck and unobstructed voiding.     

Gore-tex sling urethral suspension in type III female urinary incontinence: Clinical results and urodynamic changes

The authors prospectively evaluated 24 consecutive female patients with type III stress urinary incontinence, ranging in age from 36 to 70 years (mean 55 years). All patients were operated upon and had a vesicourethral suspension by a Gore-Tex suburethral sling. All were evaluated urodynamically 6 and 30 months after surgery. In this group of patients clinical cure of incontinence was observed in 83.3% (20) and in the remaining 4 patients it was significantly improved. In 2 patients there was an erosion of the urethra and the sling had to be removed 3.5 years later. Five other women remained dry but complained of occasional irritative symptoms, and several urinary tract infections were recorded (2–3 per year), which were documented by positive urine cultures. In the remaining 17 patients no erosion was observed and no irritative symptoms were reported. The urodynamic evaluation revealed an excellent postoperative result both 6 months and 30 months after surgery. EDITORIAL COMMENTS: This study reports the author’s experience with the use of the Gore-Tex suburethral sling procedure in women with type III stress incontinence, excluding patients with urethrovesical junction hypermobility. Diagnosis is based on videourodynamic criteria, as is postoperative follow-up and the definition of cure/failure. It is interesting that the technique used specifically refrains from placing extensive tension on the sling, although extra sutures are placed attaching the sling to ‘fascial tissue in the vicinity of the puboiliac bone’, even including the periosteum. Typically the use of a sling procedure in patients with a fixed drainpipe urethra has been based on the obstructive characteristics of the sling, rather than giving support to an already well supported urethrovesical junction. Previous reports have described postoperative voiding dysfunction requiring intermittent self-catheterization, recurrent urinary tract infections, elevated postvoid residuals and detrusor instability as possible consequences of ‘tight’ slings. Hints that these sequelae did occur in the study population include the high incidence of urinary tract infections and detrusor instability (persistent and de novo), and the fact that 2 patients required removal of the sling because of erosion into the urethra. Although the authors report a significant cure rate (84%) of stress incontinence, clearly this report again cautions against the use of slings in patients with ISD and a well supported bladder neck.     

中段尿道吊带术治疗女性压力性尿失禁的多中心研究

目的 探讨中段尿道吊带术治疗女性压力性尿失禁的临床疗效、手术指征和并发症的处理.方法 单纯压力性尿失禁的患者304例和混合性尿失禁的患者8例,均为女性,纳入本研究.其中接受TVT吊带术134例,TVTO吊带术167例,Monarc吊带术11例.围手术期评估包括:手术时间、出血量、术中术后并发症.手术效果分为治愈、显效、无效.在患者出院时、术后3个月、术后每年评价疗效和并发症.结果 TVT组手术时间(18.5±9.6)min和出血量(32.2±12.6)ml多于TVTO组(11.5±3.1)min,(12.8±8.5)ml和Monarc组(11.1±2.6)min,(12.3±3.5)ml(P<0.05).三种术式均有较高的治愈率和显效率,不同术式的近期和中长期治愈率、显效率和无效率差异无统计学意义(P>0.05).单纯压力性尿失禁患者治愈率(95.7% )显著高于混合性尿失禁患者(37.5% )(P<0.01).3种术式的总并发症发生率差异无统计学意义,但膀胱损伤仅发生在TVT组,闭孔神经损伤和阴道损伤仅发生在TVTO组.术后排尿困难和尿潴留是中段尿道吊带术的最常见并发症.结论 经耻骨上途径(TVT)和经闭孔途径(TVTO、Monarc)中段尿道吊带术治疗压力性尿失禁均具有手术简单、微创、中长期疗效好、并发症少等优点.     

Outcomes of autologous fascial slingplasty procedure for treating female urinary incontinence

The aims of this study were to compare the pre- and postoperative urodynamic findings of the suburethral autologous rectus fascial sling procedure and to determine patient satisfaction with the procedure by telephone interviews. Eight-four female patients with urodynamic stress incontinence completed a multi-channel urodynamic study and pad test before and after the operation. Subjective and objective satisfaction were also recorded. Significant changes were noted in the stress maximal urethral closure pressure, pad test, voided volume, and peak flow rate (P < 0.05). The success rate was about 94%, and subjective satisfaction was about 72%. The most common complication was transient urinary tract infections. The suburethral sling resolved 50% of detrusor overactivity (DO), but de novo DO was 24%. The procedure combined with anterior colporrhaphy corrected or improved 97% of anterior vaginal wall prolapses (> or =stage II). This retrospective study demonstrates that suburethral autologous facial slingplasty has a high cure rate, high patient satisfaction, and is a less complicated procedure. It can also correct and prevent a recurrence of anterior vaginal wall prolapse when combined with anterior colporrhaphy.     

自制可调TVT吊带术后腹压漏尿点压和最大尿道闭合压变化分析

目的观察自制可调TVT吊带术后腹压漏尿点压(VLPP)和最大尿道闭合压(MCP)变化,探讨自制TVT吊带临床效果。方法女性压力性尿失禁患者134例,术前行尿流动力学检查测定VLPP、MCP,行自制TVT吊带手术治疗后随访患者再次检测VLPP和MCP,分析检查结果。结果按照世界尿控协会(ICS)标准有39例患者未检出VLPP,剩余95例患者VLPP手术前为(77.2±21.6)cm H2O(1cm H2O=0.098 k Pa),手术后为(99.7±26.3)cm H2O,二者比较差异具有统计学意义(P<0.05)。MCP手术前(32.5±14.3)cm H2O,手术后(57.2±13.3)cm H2O,二者差异具有统计学意义(P<0.05)。结论自制TVT吊带术后可以取得较满意的手术效果,并具有灵活的术后调整性,较传统手术具有自身优势。     

Clinical experience with urethral retro-resistance pressure measurement: a prospective pre- and postoperative evaluation in women with stress urinary incontinence

AIMS: To identify possible correlations of urethral retro-resistance pressure (URP) with clinically and urodynamically proven stress urinary incontinence (SUI) and the outcome of anti-incontinence surgery. MATERIALS AND METHODS: URP was measured using the Monitorr system in women with clinically and urodynamically proven SUI without prolapse before and after anti-incontinence surgery (colposuspension n = 8, tension-free vaginal tape n = 6, tension-free transobturator tape n = 34). RESULTS: Forty-eight women (mean age 61.8 +/- 8.9 years) were evaluated preoperatively and on average 10 weeks postoperatively. Mean URP was 75.6 +/- 20.8 cm H(2)O preoperatively versus 75.4 +/- 17.9 cm H(2)O postoperatively (P = 0.898). The type of anti-incontinence surgery performed had no significant effect on postoperative URP. While no association was found between age and URP (P = 0.35), there was a positive correlation between URP and body mass index (BMI; r = 0.49, P = 0.0004). There was no correlation of URP with the preoperative pad test (P = 0.17) and urethral closure pressure at rest (P = 0.51). Finally, URP did not correlate significantly with the preserved length of the continence zone (0-1/3-2/3-3/3) as determined by the urethral stress profile (P = 0.37-0.72) or with the objective cure rate (negative pad test). CONCLUSIONS: Preoperative URP does not correlate with SUI in all women, has no predictive value, and does not correlate with the outcome of anti-incontinence surgery. However, there seems to be an association with biomechanical factors such as obesity, which may open up a new area of application for URP measurement in urogynecologic diagnosis.     

Sonographic urethrocystography — Methods and application in patients with genuine stress incontinence

Radiologic urethrocystography has recognizable disadvantages including the risk of excessive irradiation, the time required for the test, and the discomfort of the patient. In women with genuine stress inontinence sonographic urethrocystography provides similar information to that obtained by conventional radiological procecdures without side effects. Among the numerous techniques, perineal scanning and introital sonography are particularly suitable for dynamic examination of the bladder, the urethra, and the urethrovesical junction. Moreover, concomitant sonographic urethrocystography complements pressure measurement regardless of the type of urodynamic investigation, and thus helps to exclude tonometric artifacts. All the sonographic observations are easier to review from video records than from still pictures. Ultrasound is helpful for selection of the proper operative procedure and above all can be applied during surgical correction of female incontinence, irrespective of vaginal or abdominal approach.     

Factors associated with the presence of genuine stress incontinence in females

Forth-five premenopausal women were enrolled in the study. All patients underwent a complete diagnostic evaluation, which included the completion of a standardized questionnarie, a detailed history, a complete physical examination and multichannel urodynamic testing. Clinical findings and urodynamic parameters were recorded. Logistic regression analysis and ² comparisons were used to determine which factor(s) were most associated with the presence of genuine stress incontinence. Thirty patients had genuine stress incontinence, and 15 asymptomatic volunteers without subjective and objective lower urinary tract dysfunction served as controls. A significant difference in age, maximum urethral closure pressure, strength of cough and bladder-neck mobility was found between the two groups. Logistic regression analysis revealed that bladder-neck mobility was the variable most associated with the presence of genuine stress urinary incontinence. This study supports the concept the genuine stress incontinence is probably multifactorial, and its etiology remains unknown.Editorial Comment: This is one of the few studies that has attempted to correlate possible etiologic factors for genuine stress incontinence in both symptomatic subjects as well as asymptomatic controls. The factor found to be most associated with stress incontinence was the mobility of the urethrovesical junction, as measured by the angle of the Q-tip from the horizontal, when compared to the controls. We should not be misled by this, however, since hypermobility is so common that many patients have this anatomical abnormality without ever having stress incontinence. The diagnosis of stress incontinence cannot therefore be made by the simple presence of urethral hypermobility. The authors correctly conclude that the etiologic factors in stress incontinence are multifactorial, and the collage of information presented by the patient in both clinical and urodynamic terms must be considered in the determination of the ultimate diagnosis.