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.     

Urodynamic appraisal of the Marshall-Marchetti test in women with stress urinary incontinence

To determine the reliability of the Marshall-Marchetti test as a diagnostic and prognostic preoperative screening test for stress urinary incontinence, the changes observed in urethral pressure profiles under resting and stressful situations were recorded and compared following varying degrees of elevation of the urethra and the urethrovesical junction. The characteristic similarity of changes was evident in the functional profile length, urethral closure pressure, and cough pressure profile of the urethra during performance of the Marshall-Marchetti test and intentional urethral occlusion. This study clearly invalidated the Marshall-Marchetti test by objectively demonstrating that the Marshall-Marchetti test restored continence under stress of coughing by occluding the urethra and the urethrovesical junction.     

Laparoscopic burch repair compared to laparotomy Burch for cure of urinary stress incontinence

Sixty-two women underwent either laparoscopic Burch urethropexy or open Burch urethropexy for surgical correction of genuine stress urinary incontinence. Only patients with no prior incontinence surgery and with demonstrated genuine stress incontinence were included. Clinical evaluations were done preoperatively, at 3 months and 1 year postoperatively for objective cure. The preoperative evaluation included a 24-hour urolog, urology questionnaire, Q-tip test, cough stress test, perineal ultrasound, cystourethroscopy and simple-channel cystometrics. At follow-up all patients had repeat Q-tip test, perineal ultrasound and cough stress test. If there was any sign of leaking a repeat single-channel cystometrogram was done. Only patients with a negative objective study were considered cured. Differences in laparoscopic versus laparotomy cure rates at 1 year were insignificant (94% versus 93%). Both procedures stabilized the urethrovesical junction and prevented its descent during straining, as demonstrated by the postoperative Q-tip test and the perineal ultrasound. The two bladder procedures had comparable operative times but patients with laparoscopy voided earlier, were outpatients, and returned to work earlier. In conclusion, short-term results suggest that the laparoscopic Burch urethropexy can give similar results to laparotomy Burch urethropexy for correction of genuine stress incontinence.Editorial Comment: This is one of the more complete comparative studies of the laparoscopic and open Burch procedures. Although the study is not prospectively randomized, nor were sophisticated urodynamic studies done in all patients, it contains valuable pre- and postoperative information, particularly about the correction of urethrovesical junction mobility as measured by perineal ultrasound. This test demonstrated that both procedures are equally successful in stabilizing the urethrovesical junction. Unfortunately, the cure of stress incontinence was based on stress test alone, with only 4 patients having a CMG postoperatively. By that standard the cure rates of both procedures do not differ. However, we should be cautious in recommending the laparoscopic procedures of research protocols until a prospective randomized comparison utilizing objective urodynamic studies is available. The American Urogynecologic Society has such a multicenter study under way, and we await the results.     

Ultrasonography in urinary incontinence

Linear array ultrasound techniques were utilized in place of conventional radiologic procedures to study the dynamics of the urethrovesical junction and proximal urethra in patients with urinary incontinence. This ultrasound procedure provided an objective demonstration of the mobility of the urethrovesical junction and documented the presence of an anatomic defect. It aided in the selection of patients suitable for surgical correction of stress incontinence and their postoperative follow-up. Ultrasound was also employed to demonstrate uninhibited detrusor contractions in patients with vesical instability.     

The use of prophylactic Stamey bladder neck suspension to prevent post-operative stress urinary incontinence in clinically continent women undergoing genitourinary prolapse repair

The present study was undertaken to evaluate the efficacy of Stamey bladder neck suspension in preventing post-perative stress urinary incontinence in clinically continent women undergoing surgery for genitourinary prolapse. Thirty clinically continent women with severe genitourinary prolapse were found to have a positive stress test with re-positioning of the prolapse. They all had significant urethrovesical junction hypermobility. In addition to the genitourinary prolapse repair, these patients underwent a prophylactic Stamey procedure to prevent the possible development of post-operative stress urinary incontinence. The mean duration of follow-up was 8+/-4.5 months (range, 3-19 months). Seven (23.30%) patients developed overt post-operative stress urinary incontinence that was confirmed urodynamically. Eleven (36.7%) other patients denied stress incontinence; however, post-operative urodynamics demonstrated sphincteric incontinence. Post-operative complications were uncommon and minor. In conclusion, continent patients with a positive stress test demonstrated on re-positioning of the prolapse during pre-operative urodynamic evaluation are considered to be at high risk of developing post-operative stress urinary incontinence. In these patients, an additional, effective anti-incontinence procedure should be considered during surgical correction of genitourinary prolapse. The Stamey procedure, although simple and safe, does not appear to be the optimal solution to this clinical problem.     

Low urethral pressure and stress urinary incontinence in women: risk factor for failed retropubic surgical procedure

Nineteen women with stress urinary incontinence (SUI) and low urethral pressure were compared with 106 patients with SUI and normal urethral pressure. All underwent either a revised Pereyra procedure or Burch retropubic urethropexy, and all had detailed clinical and urodynamic evaluations before their operation and one year postoperatively. Surgical procedures effectively stabilized the bladder base and enabled adequate abdominal pressure transmission to the urethra in both groups of women. In spite of these urodynamic findings, the failure rate in women with stress urinary incontinence and low urethral pressure was significantly higher compared with women with good urethral pressure (50% vs 23% for the Pereyra procedure and 33% vs 12% for the Burch procedure [p less than 0.05]), indicating an etiology for their incontinence other than poor support to the urethrovesical junction; therefore, the need for another approach to cure stress incontinence.     

A new method for correction of urinary stress incontinence in women

Twenty-two patients with urinary stress incontinence confirmed by urodynamic recordings were operated on by using absorbable Dexon sutures combined with a two-component fibrin sealant, which induced fibrosis, for the fixation of the urethrovesical junction to the retropubic periostium. The postoperative observation period ranged from 12 to 30 months, and so far no relapses or complications have been observed.     

Role of ultrasound in urinary incontinence evaluation

Transrectal ultrasound was used to assess anatomic support of the urethrovesical junction (UVJ) in continent and stress incontinent women. UVJ drop on straining of less than 1 cm as assessed by transrectal ultrasound correlated well with good support to the UVJ. Drop of UVJ of more than 1 cm on straining correlated with poor support to bladder neck and stress urinary incontinence. The transrectal technique is quick and easy to perform and interpret.     

Visual assessment of urethrovesical junction mobility

The aim of the study was to compare visual assessment of anterior vaginal wall descent with the Q-tip test in evaluating urethrovesical junction mobility. One hundred and eleven patients with prolapse and/or urinary incontinence were examined in the supine lithotomy position with an empty bladder. Maximum straining Q-tip tests and maximum descent of the anterior vaginal wall were measured. Using each centimeter of descent as a cutoff value, the sensitivities, specificities and positive and negative predictive values were compared to those of the Q-tip test. As the cutt-off points were moved distally, specificity increased at the expense of sensitivity. There was no single cut-off point that provided adequate sensitivity and specificity to be clinically useful to replace the Q-tip test. It was concluded that visual assessment of anterior vaginal wall descent does not provide diagnostic accuracy and acceptable sensitivity and specificity to determine urethrovesical junction mobility. Other methods should be employed to assess support.Editorial Comment: Many clinicians claim that they can assess urethrovesical junction mobility visually and thus avoid employing other means, such as the Q-tip test, ultrasonography, bead-chain cystography or fluoroscopy. Montella et al. evaluate a technique of visual assessment of urethrovesical junction mobility based on the International Continence Society's Standardization of Terminology of Female Organ Prolapse and Pelvic Floor Dysfunction as compared to evaluation with the Q-tip test. Their results clearly indicate that this technique (measurement of the descent of point Aa) does not provide adequate sensitivity or specificity in determining urethrovesical junction descent compared to the Q-tip test. Although this technique was only compared to the Q-tip test and not all other modalities available, it is doubtful that visual assessment of anterior wall descent at any level would correspond to urethrovesical junction mobility, as is discussed very succinctly by the authors.     

In situ anterior vaginal wall sling formation with preservation of the endopelvic fascia for treatment of stress urinary incontinence

The indications for sling procedures have evolved and encompass patients with either intrinsic sphincteric deficiency (ISD), anatomic incontinence or both. We have refined a technique that can be performed in a minimally invasive fashion with low attendant morbidity to provide a reproducible method of sling formation. Twenty patients with stress urinary incontinence underwent the in situ sling (ISS) with bone fixation. Subsequent evaluation at 24–29 months (mean =26.2 months) revealed that 95% of patients were cured. No recurrent cystoceles, paravaginal defects or significant detrusor instability have been noted. Urinary retention appeared transiently in only 3 patients and resolved in under 3 weeks. We feel the in situ sling with bone fixation provides a safe and effective means of management for stress urinary incontinence. Furthermore, the reduced surgical dissection may minimize the incidence of postoperative ISD and recurrent paravaginal defects that may accompany more traditional needle suspension procedures.Editorial Comment: The authors present an interesting approach to the performance of a suburethral sling procedure which utilizes the anterior vaginal mucosa beneath the urethra as the supportive section of the sling, similar to the Raz vaginal wall sling technique. The patch is secured with sutures which are transported to the suprapubic site and attached to the symphysis pubis with bone anchors. Whether this procedure will provide longterm support to the urethrovesical junction will only be judged with time, and with prospective studies with pre-and postoperative objective urodynamic evaluation. The present study is truly an initial report of the technique, performed on a small group of patients with genuine stress incontinence or intrinsic sphincter deficiency with or without urethrovesical junction hypermobility. One major concern with any technique utilizing bone anchors attached to sutures coming from the perivaginal tissue following dissection of the anterior vaginal compartment is the potential risk of introducing pathogens to the bone, with resultant osteitis pubis or osteomyelitis.     

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.     

Application of transrectal ultrasonography in modified Stamey procedure for stress urinary incontinence

From June 1989 to August 1990, 21 women with genuine stress urinary incontinence were treated with the Gittes procedure combined with transrectal ultrasonography. The urethrovesical junction was well pinpointed on an ultrasonographic image. The strength of suspension providing the optimal posterior urethrovesical angle was changed by each patient. Posterior urethrovesical angles averaged 89.3 +/- 9.5 degrees at operation and 93.6 +/- 9.5 degrees (mean +/- standard deviation) on a postoperative lateral cystourethrogram with the patient straining while in the standing position. An indwelling urethral catheter was removed on postoperative day 1. None of the patients had residual urine of more than 50 ml. by 4 days postoperatively. Furthermore, the average maximum urinary flow rates significantly increased from 21.0 +/- 7.1 ml. per second preoperatively to 26.1 +/- 9.8 ml. per second postoperatively (p less than 0.01). Therefore, application of ultrasonography during bladder neck suspension is simple and reliable for determination of the optimal suspension as well as identification of the suspension site.     

Urogynecologic ultrasound is a useful aid in the assessment of female stress urinary incontinence--a prospective study with TVT procedure.

The aims of the study were to study the suitability of certain urogynecologic ultrasound parameters, e.g. descent of the urethrovesical (UV) junction on Valsalva, posterior urethrovesical (PUV) angle both at rest and on Valsalva, and funneling of the vesical neck, in the pre- and postoperative assessment of stress urinary incontinence (SUI) and to evaluate the efficacy and safety of tension-free vaginal tape (TVT) for the surgical treatment of SUI. Forty-six consecutive women (mean age 61 years) with symptoms of SUI underwent TVT placement. The patients were examined prior to and on average of 11 weeks after the operation with perineal ultrasound. An upright coughing test on standing was performed every time. Operative success rate was 94% in this series. Urogynecologic perineal ultrasound examination seemed strongly to support an anamnestic diagnosis of genuine SUI, and TVT proved to be a safe and effective ambulatory procedure for the surgical treatment of SUI.     

Urogynecologic Ultrasound is a Useful Aid in the Assessment of Female Stress Urinary Incontinence – A Prospective Study with TVT Procedure

The aims of the study were to study the suitability of certain urogynecologic ultrasound parameters, e.g. descent of the urethrovesical (UV) junction on Valsalva, posterior urethrovesical (PUV) angle both at rest and on Valsalva, and funneling of the vesical neck, in the pre- and postoperative assessment of stress urinary incontinence (SUI) and to evaluate the efficacy and safety of tension-free vaginal tape (TVT) for the surgical treatment of SUI. Forty-six consecutive women (mean age 61 years) with symptoms of SUI underwent TVT placement. The patients were examined prior to and on average of 11 weeks after the operation with perineal ultrasound. An upright coughing test on standing was performed every time. Operative success rate was 94% in this series. Urogynecologic perineal ultrasound examination seemed strongly to support an anamnestic diagnosis of genuine SUI, and TVT proved to be a safe and effective ambulatory procedure for the surgical treatment of SUI.     

Why do women have stress urinary incontinence?

This article reviews progress made in understanding the causes of stress urinary incontinence. Over the last century, several hypotheses have been proposed to explain stress urinary incontinence. These theories are based on clinical observations and focus primarily on the causative role of urethral support loss and an open vesical neck. Recently these hypotheses have been tested by comparing measurements of urethral support and function in women with primary stress urinary incontinence to asymptomatic volunteers who were recruited to be similar in age, race, and parity. Maximal urethral closure pressure is the parameter that differs the most between groups being 43% lower in women with stress incontinence than similar asymptomatic women having as effect size of 1.6. Measures of urethral support effect sizes range from 0.5 to 0.6. Because any one objective measure of support may not capture the full picture of urethrovesical mobility, review of blinded ultrasounds of movements during cough were reviewed by an expert panel. The panel was able to identify women with stress incontinence correctly 57% of the time; just 7% above the 50% that would be expected by chance alone, confirming that urethrovesical mobility is not strongly associated with stress incontinence. Although operations that provide differential support to the urethra are effective, urethral support is not the predominant cause of stress incontinence. Improving our understanding of factors affecting urethral closure may lead to novel treatments targeting the urethra and improved understanding of the small but persistent failure rate of current surgery. Neurourol. Urodynam. 29:S13–S17, 2010. © 2010 Wiley‐Liss, Inc.     

Simultaneous perineal ultrasound and urodynamic assessment of female urinary incontinence: Initial observations

Simultaneous perineal ultrasound and urodynamic evaluation was performed in 35 female patients suffering from urinary incontinence of varying etiologies and in 5 healthy continent women. The digitized ultrasound signals and urodynamic curves were simultaneously monitored on a computer screen. During cystometry, urethral pressure profile during stress, and micturition, this simultaneous technique correlates pressure measurements with the behavior of the urethrovesical junction. The influence of intra-abdominal pressure changes (coughing, straining) on the anatomy of the urethra and the urinary bladder, or the effect of pelvic floor and urethral sphincter contractions on the intraurethral and intravesical pressure, thereby becomes evident. The synchronous imaging of pressure variations and structural changes provides valuable information about the functional anatomy of the urethrovesical junction. On the one hand urodynamic phenomena, and on the other hand ultrasound findings, can be better understood than when the techniques are performed separately. With this simultaneous evaluation additional knowledge is acquired about the pathyophysiology of micturition disorders and incontinence. An advantage of ultrasound compared with radiological techniques is that the urethrovesical anatomy and the surrounding tissues are clearly imaged without irradiation and without the need for contrast medium.EDITORIAL COMMENT: The authors describe the simultaneous recording of urodynamic tracings on an ultrasound screen while visualizing the bladder neck, urethra, and bladder by perineal ultrasonography. Although this idea is not entirely new, having first been described by Kohorn et al. (1987) and confirmed by Koelbl et al. (1988), in this pilot study the urodynamic tracing is visualized on the same screen as the ultrasound image in real time. The result may be somewhat overwhelming at first, but may actually clarify functional aspects to the lower urinary tract hitherto unknown. This newest melding of sonographic and urodynamic information also has the distinct advantage of requiring no radiation or contrast medium exposure. With further experience and a larger study population, it will be interesting to see how this technique adds to our understanding and clinical evaluation of female incontinence.     

腹膜外入路腹腔镜下膀胱颈悬吊术治疗压力性尿失禁TVT-O术后失败或复发患者的初步经验

目的报道6例经腹膜外途径腹腔镜下膀胱颈Cooper韧带悬吊术(Burch手术)治疗女性压力性尿失禁行经阴道经闭孔尿道中段无张力悬吊术(TVT-O)术后失败或复发患者的初步经验。方法回顾分析2015年6月至2019年9月我们采用经腹腔镜下腹膜外途径Burch手术治疗的6例女性压力性尿失禁TVT-O术后失败或复发患者。自脐下2 cm处切开皮肤并制造腹膜外空间,用2#0薇荞线将尿道旁侧的阴道壁肌层“8字”缝合后再缝合到同侧Cooper韧带上。观察患者手术时间、出血量、住院时间等。结果所有手术均成功,手术时间(37±6)min,术中出血量(17±7)ml,术后住院时间(4.5±0.5)d。6例随访时间3~45个月,所有病例尿失禁症状均消失,均无感染、膀胱损伤、排尿困难、复发等并发症。结论女性压力性尿失禁患者行TVT-O术失败或复发后,选择腹腔镜下经腹膜外途径Burch术安全、有效,可以获得完全尿控,为临床可选方案。     

New and simplified vaginal approach for correction of urinary stress incontinence in women

Twenty-lour patients with urodynamically confirmed urinary stress incontinence were operated upon with a new and simplified vaginal approach. This new technique is a simplification of a previously described transahdominal surgical method, in which a two-component fibrin sealant (Tissel^R) was used. The sealant resulted in an excess of fibrin, which induced fibrosis. securing the urethrovesical junction in an elevated position to the retropubic periosteum. In the present study, the sealant was deposited retropubically with a specially designed needle through the anterior vaginal wall. A great advantage with this procedure is that only local anesthesia is used and the patient can leave the outpatient clinic I hour after the operation The minimum duration of the follow-up period was 18 months The success rate was as high as 6.3%, and no side effects were observed. © 1995 Wiley-Liss, Inc.     

Perineal Assessment of Urethrovesical Junction Mobility in Young Continent Females

This paper describes the application of perineal ultrasound (7 MHz transducer) in the assessment of the urethrovesical junction (UVJ) in 40 continent nulliparous females. Measurements of UVJ vertical and horizontal movements were assessed in relation to the inferior border of the pubic symphysis from resting to the maximum straining position. Participants were examined in the dorsal lithotomy position with no more than 50 ml of urine in the bladder. Volunteers’ average age was 16 years (range 10–25). The mean vertical movement was 5.3 ± 2.4 mm (maximum 9 mm). In 95% of participants the measurement for horizontal movement did not exceed 11.2 mm. Perineal ultrasound in patients with the bladder practically empty is an easy way to assess urethrovesical junction mobility objectively. It avoids the possible influence of detrusor contraction. A standard method for this assessment can provide accurate essential information for classification, management and follow-up of urinary incontinence.     

Examination of the urethrovesical junction using perineal sonography compared to urethrocystography using a bead chain

Morphologic investigation of the urethrovesical junction combined with urodynamic findings is necessary to choose the correct surgical procedure for female stress incontinence. This study compares colpourethrocystography and perineal sonography in 41 patients with genuine stress incontinence, 30 patients after Burch colposuspension and 40 healthy control women. The study determined the inclination angle, the pubourethral angle, the posterior vesicourethral angle and as the distance H between the lower pubis and the internal urethral meatus. Introital sonography avoids exposure of the patient to X-irradiation and gives similar findings to urethrocystography. Sonography is a fast, easy to perform, inexpensive and reproducible method which is well accepted to the patient. It may be very important in evaluating the morphologic effect of incontinence surgery instead of urethrocystography.