Modifications of the urethral rest and stress profiles after different types of surgery for urinary stress incontinence

Full urodynamic assessment, including urethral profiles at rest and under stress, using microtransducers, was made before and at least 6 months after surgery for urinary stress incontinence in 86 patients. Cure was assessed objectively. Procedures compared were Burch colposuspension, Pereyra urethrovesical suspension and anterior colporrhaphy. The Burch colposuspension increased the pressure transmission ratio more efficiently than the vaginal operations and the cure rate was 91%. Only 50% of Pereyra operations were successful and success was related to an increase in the functional urethral length and in the pressure transmission ratio. The success rate for anterior colporrhaphy was 57% and was associated with a significant decrease in the maximal urethral closure pressure and the continence area. The prognostic value of the urethral profiles at rest and under stress and the therapeutic implications are discussed.     

Suprapubic versus transurethral bladder drainage after surgery for stress urinary incontinence

Fifty-one patients with clinical and urodynamic diagnoses of stress urinary incontinence were randomly allocated to either suprapubic (N = 24) or transurethral (N = 27) bladder drainage after vaginal surgery for stress incontinence (revised Pereyra procedure). Postoperative use of suprapubic bladder drainage significantly reduced febrile morbidity (calculated as fever index; P less than .01) and length of hospitalization (P less than .05). Postoperative normal bladder functions resumed more quickly when suprapubic drainage was used (P less than .05), so that most patients did not need bladder catheterization upon discharge, as opposed to more than half of those with Foley catheters, who left the hospital with a catheter in place (P less than .05). We conclude that it is both beneficial and cost-effective to use suprapubic bladder drainage after a Pereyra operation for stress urinary incontinence.     

Clinical predictors of urinary retention after pelvic reconstructive and stress urinary incontinence surgery

OBJECTIVE: To evaluate the impact of perioperative variables on length of postoperative catheterization. STUDY DESIGN: A multicenter, prospective, cohort study of women undergoing pelvic reconstructive and/or incontinence surgery was performed. Perioperative variables associated with length of catheterization and prolonged catheterization (catheterization >30 days) were analyzed. Univariate logistic regression was used identify variables associated with urinary retention. Multivariate logistic regression analysis was performed on variables identified by univariate analysis to construct the best model predicting prolonged postoperative catheterization. RESULTS: Catheterization data were available for 408 patients. Mean catheterization length was 11 +11 days. Thirty-four patients required prolonged catheterization. Logistic regression analysis selected 3 variables as predictors of prolonged catheterization: performance of pubovaginal sling (OR 5.44), performance of vaginal apex suspension (OR 2.32) and preoperative presence of grade 3/4 vaginal apex descent (OR 2.75) (all p < or =0.05). The probability of prolonged catheterization occurring in the absence of any of the predictors was 2% and increased to 5-11% if 1 predictor was present. When all 3 were present, the probability of prolonged catheter use increased to 45%. CONCLUSION: The performance of a pubovaginal sling and of a vaginal apex suspension or the preoperative presence of grade 3/4 vaginal apex descent are associated with prolonged postoperative catheterization.     

The surgery of stress urinary incontinence

The repertoire of procedures available for surgical correction of stress urinary incontinence is reviewed from a historical perspective. All of these procedures fall into three broad groups: transvaginal urethrocystopexies, retropubic cystourethropexies including needle suspension operations, and urethrovesical sling procedures. The difficulties and requirements of some procedures are discussed critically. Argument is made that the urogynecologist needs to be familiar with the technical aspects of all urogynecologic procedures. The choice of procedure or combination of operations in any one patient needs to be determined by the specific abnormalities, both urologic and gynecologic, that are present in that individual patient.     

压力性尿失禁患者手术后性生活质量的研究

目的探讨手术治疗对压力性尿失禁(SUI)患者性生活质量的影响。方法应用盆腔器官脱垂-尿失禁患者性功能(PISQ)问卷,对术后6个月至3年有活跃性生活的62例接受腹腔镜下膀胱颈悬吊(Burch)术或经阴道无张力性尿道中段悬吊(TVT)术的患者进行评分,按照手术方式、手术后时间(1年以内与1年以上)及手术前性生活中有无不自主溢尿进行分组,比较手术前后PISQ评分的变化,评分越高,提示性生活质量越高;对于评分变化无显著差别的分组进行手术满意率及性生活改善率的比较;并应用多因素logistic回归分析患者年龄、产次、体重指数、月经情况、手术史、内科合并症、SUI程度、手术中是否同时切除子宫及围手术期并发症等临床指标,是否影响手术后性生活的变化。结果56例回答了PISQ问卷,问卷回复率为90%(56/62)。手术前PISQ总评分为(85·2±10·7)分,手术后为(82·4±17·7)分,两者比较,差异无统计学意义(P>0·05);其中情感因素术后评分为(26·8±10·7)分,手术前为(30·5±6·6)分,两者比较,差异有统计学意义(P<0·05)。手术后1年以内患者,手术前后的PISQ总评分分别为(86·0±10·7)分和(77·7±18·6)分,两者比较,差异有统计学意义(P<0·05);其中情感因素评分,手术前后分别为(31·0±7·2)分和(23·7±11·3)分,两者比较,差异有统计学意义(P<0·01)。手术后1年以上患者,手术前后的PISQ总评分分别为(84·4±10·8)分和(86·5±16·1)分,两者比较,差异无统计学意义(P>0·05);其中生理因素评分,手术前后分别为(34·5±5·6)分和(36·9±4·3)分,两者比较,差异有统计学意义(P<0·05)。性生活改善率,TVT术组为54%(21/39),Burch术组为12%(2/17),两组比较,差异有统计学意义(P<0·01)。有溢尿组患者的性生活改善率为62%(16/26),无溢尿组为23%(7/30),两组比较,差异有统计学意义(P<0·01)。患者各临床指标均不是术后性生活变化的影响因素。结论手术治疗SUI,不会对患者的性生活造成损害,在术后1年内,可对患者的性生活产生一定负面影响,但1年后可望恢复;TVT术较Burch术更有利于性生活改善;手术前有性生活中不自主溢尿的患者,手术后可改善性生活的质量。     

A urethral diverticulum presenting with pure stress urinary incontinence

ObjectiveTo report the management for a urethral diverticulum presenting with pure stress urinary incontinence (SUI).Case ReportA 67-year-old postmenopausal woman resorted to urogynecological outpatient department for the treatment of bothersome SUI. She denied other lower urinary tract symptoms and previous pelvic surgeries. On examination, there was stage I anterior vaginal wall prolapse. Urinalysis showed negative findings. Urodynamic studies revealed negative findings. An ultrasound disclosed a complex paraurethral lesion and no urethral hypermobility. A magnetic resonance image of the pelvis revealed a 4-cm circumferential urethral diverticulum. A urethral diverticulectomy was performed. Histopathological examination confirmed the diagnosis of urethral diverticulum. The patient recovered uneventfully and reported freedom from SUI postoperatively.ConclusionIn women deemed uncomplicated stress urinary incontinence after undertaking a holistic urogynecological evaluation including detailed clinical history, physical examination, and urodynamic studies, further image studies investigating lower urinary tract is required for disclosing other rare conditions that necessitate different management from anti-incontinence surgery.     

Spontaneous voiding after surgery for urinary incontinence

Eighty patients with urinary incontinence were treated by colposuspension and bladder neck plication. Fourteen patients had difficulty in establishing normal micturition postoperatively. Of these, 10 patients took longer than 21 days to void and had reduced peak urine flow rates after surgery; the other four patients voided within ten days of surgery but had reduced peak urine flow rates before and after surgery and all had residual urines in excess of 100 ml following surgery. The value of the preoperative diagnosis of pre-existent bladder dysfunction by symptomatology and the peak urine flow rate is discussed.     

Urodynamic and radiologic parameters before and after loop surgery for recurrent urinary stress incontinence

In recent years, accurate preoperative diagnosis has been increasingly emphasized as an important therapeutic aspect of urinary incontinence in women. Forty patients suffering from recurrent stress incontinence underwent a dura-sling operation, i.e. loop surgery. The mean period od incontinence complaints prior to secondary surgery was 2.6 years. Follow-up urodynamic parameters revealed a slight improvement in urethral closure pressure (UCP) as well as significant improvement in functional urethral length and depression quotient. Radiologic investigations before and after sling surgery demonstrated good morphological results (angle beta). One year after surgery, 85% of the women had both clinical and urodynamic continence. Medium-term micturition complaints, however, have to be accepted in some of the patients.     

Bladder training after surgery for stress urinary incontinence: is it necessary?

Eighty-nine consecutive patients with a clinically and urodynamically proved diagnosis of genuine stress urinary incontinence entered this study. Forty women had a revised Pereyra procedure and 49 had a Burch retropubic urethropexy. All had a suprapubic Bonnano catheter for postoperative bladder drainage. Postoperatively, patients were randomly allocated to "bladder training" (N = 44) or "nonbladder training" (N = 45) protocols. "Bladder training" consisted of scheduled clamping and unclamping of the catheter, whereas the "nonbladder training" patients had continuous bladder drainage throughout their postoperative period. Postvoiding residual urine volume was measured twice daily after the patient had voided with a symptomatically full bladder. The catheter was removed once residual volume was 50 mL or less. The bladder training protocol had no effect on resumption of spontaneous voiding after surgery. There was no significant change in length of postoperative bladder catheterization or in urinary tract infection rate among women with or without bladder training.     

Pharmacological treatment of women awaiting surgery for stress urinary incontinence

OBJECTIVE: Duloxetine, a serotonin/norepinephrine reuptake inhibitor, has been effective in the treatment of mild and moderate stress urinary incontinence. The aim of this trial was to assess its efficacy for women with severe stress urinary incontinence. METHODS: One hundred nine women, aged 33-75 years, enrolled into this double-blind, randomized, placebo-controlled study. Subjects had to have a predominant symptom of stress urinary incontinence with an incontinence episode frequency 14 per week or more, pure urodynamic stress urinary incontinence, and continence surgery already scheduled. Women were randomized to placebo (n = 54) or duloxetine 80 mg/d (n = 55) for 4 weeks, escalated to 120 mg/d for 4 weeks. Assessment variables included incontinence episode frequency, continence pad use, the Incontinence Quality of Life (I-QOL) questionnaire, and the Willingness to Consider Surgery rating. A responder was defined as a subject with an incontinence episode frequency reduction of 50% or more. RESULTS: There were significant improvements with duloxetine compared with placebo in incontinence episode frequency (-60% versus -27%, P <.001), I-QOL score (+10.6 versus +2.4, P =.003), and pad use (-34.5% versus -4.8%, P =.008). At the conclusion of the 8-week study, 10/49 (20%) duloxetine-treated women were no longer interested in surgery, compared with 0/45 placebo-treated women (P =.001). Duloxetine-treated subjects were significantly more likely to be classified as responders (relative risk 4.68, 95% confidence interval 2.27-9.66). The number of subjects-needed-to-treat to gain an additional incontinence episode frequency responder with duloxetine was 2.02. All duloxetine responses were observed within 2 weeks. Side effects and discontinuations because of side effects were significantly more common with duloxetine. CONCLUSION: The data support duloxetine's efficacy in women with severe stress urinary incontinence and suggest that some women responding to duloxetine may reconsider their willingness to undergo surgery.     

Two-year outcomes after surgery for stress urinary incontinence in older compared with younger women

OBJECTIVE: To estimate whether perioperative and postoperative outcomes after Burch colposuspension or pubovaginal sling for stress urinary incontinence (SUI) differed with age. METHODS: This study was a prospective secondary analysis of the Stress Incontinence Surgical Treatment Efficacy Trial. Baseline characteristics, adverse events, and 2-year outcomes of women at least 65 years old were compared with those younger than 65 years using chi(2) and t tests. Multivariable analyses were performed, including age and outcomes that differed between age groups on univariable analysis, adjusting for variables that differed by age group at baseline and by surgical treatment group. RESULTS: Six-hundred fifty-five women were included in analyses of perioperative events and 520 for 2-year outcomes. Mean age (+/-standard deviation) was 69.7 (+/-3.7) years in the older group and 49.4 (+/-8.2) in the younger group. Older women had slightly longer time to normal activities (50 days compared with 42 days, P=.05), but there was no difference in time to normal voiding (14 days compared with 11 days, P=.42). Older women were more likely to have a positive stress test at follow-up (odds ratio [OR] 3.7, 95% confidence interval [CI] 1.70-7.97, P=.001), less subjective improvement in stress (8 point lesser decrease, 95% CI 1.5-14.1, P=.02), and urge incontinence (7 point lesser decrease, 95% CI 1.5-12.2, P=.01) by the Medical and Epidemiologic Social Aspects of Aging questionnaire, and were more likely to undergo surgical retreatment for SUI (OR 3.9, 95% CI 1.30-11.48). Perioperative adverse events and length of stay did not differ between groups. CONCLUSION: Older women undergoing surgery for stress incontinence can expect to do as well as younger women with respect to perioperative outcomes, but experience 2-year outcomes that are worse.     

Sexual function after surgery for stress urinary incontinence: vaginal sling versus Burch colposuspension

Objective We prospectively investigated the effect of surgery for stress urinary incontinence (SUI) on sexual function and also compared preoperative and postoperative sexual functions according to vaginal or abdominal surgery for SUI. Methods The study included 94 women who underwent surgery for SUI, and the women were divided into two groups: 53 women had vaginal sling, and 41 women had Burch colposuspension. Female sexual function was evaluated with a detailed 19-item questionnaire, the female sexual function index (FSFI), including sexual desire, arousal, lubrication, orgasm, satisfaction, and pain. In all women, sexual function was compared before and after surgery for SUI, and the differences in postoperative sexual functions were also compared between the women undergoing vaginal sling and Burch colposuspension. Results In all women, total sexual function score significantly decreased from 20.8 ± 9 to 17.3 ± 9.3 after surgery (P = 0.000). Total sexual function score decreased from 19.2 ± 10 to 17.2 ± 9.9 in the vaginal sling group and decreased from 23.6 ± 6.2 to 17.6 ± 7.7 in the Burch colposuspension group, revealing significant difference between the two groups (P = 0.011). Statistically significantly higher decreases in postoperative sexual desire (P = 0.014), arousal (P = 0.026), lubrication (P = 0.004), and orgasm scores (P = 0.008) were also observed in the Burch colposuspension group than in the vaginal sling group. Based on total score, postoperative sexual function improved in 13 women (24.5%) of the vaginal sling group and in 5 women (12.2%) of the Burch colposuspension group, remained unchanged in 15 (28.3%) and 10 (24.4%), respectively, and deteriorated in 25 (47.2%) and 26 (63.4%), respectively. Conclusion Our findings show that sexual functions may be impaired after surgery for SUI. Burch colposuspension may deteriorate sexual functions much more than vaginal sling surgery in women. Therefore, women who will need surgery for SUI should be informed of the risk of deterioration of sexual function after surgery.     

Spatial urethral rest pressure and stress pressure profile in women with stress incontinence. Doppler microtransducer studies

The functional urethral length (FUL), the maximum urethral closure pressure (MUCP), and the urethro vesical quotient (u/v) have been measured in 32 women suffering from urinary stress incontinence. The pressure was registrated in four different sectors of the urethra (left, posterior, right, anterior). We found statistical significant differences (t-Test, Wilcoxon-Test). The average FUL at the anterior urethral wall was 27.5 mm, at the posterior wall 30.2 mm. Concerning the UVDR and the u/v-quotient we found higher values at the ventral wall than at the posterior and lateral sides (9.79 kPa and 6.87 kPa and 1.63 and 1.14 resp.). Because of spatial different results of pressure distribution along the urethra walls the microtransducer had to be marked to enable the investigator to localize the direction of the pressure chip during registration. The pressure profile should be registrated only at the dorsal or dorsolateral parts of the urethra. Measurements at the anterior walls of the urethra showed no correlation between history, clinical tests, and urodynamic measurements. By reason of the submitted results we developed a new 5-channel microtransducer for simultane measurements of the urethra pressure profile at rest and at stress in four directions and we proved it in patients with and without urinary stress incontinence. New aspects are visible concerning the functional and morphological states of the urethra by use of the spatial urethral pressure profile.     

Feasibility and results of mid-urethral sling surgery after transurethral injections for stress urinary incontinence in women

ObjectiveTo assess feasibility and results of mid-urethral sling placement for stress urinary incontinence (SUI) in adult women after transurethral injection therapy failure.Patients and methodsEleven patients were operated on for a mid-urethral sling placement after at least one transurethral injection therapy, from January 2005 to February 2008. Injections were performed for moderate non-daily SUI, or according to patient willingness, or for SUI surgical history. Mean age at the time of surgery was 59.9 years (range: 33 to 84).ResultsMean operative time, including control cystoscopy time during TVT placement, was 26 minutes (20–35). There were no peri-operative complications, nor problems for dissection or tape placement. At a mean follow-up of 9.9 months (5–20), 9/11 (81%) patients were dry with no lower urinary tract disorders.Discussion and conclusionSUI treatment by mid-urethral sling after transurethral injections failure is feasible not bothered by the injected material and effective at short-term.     

Proposed management of low urethral pressure type of genuine stress urinary incontinence

One hundred and twenty-one patients with genuine stress urinary incontinence underwent urodynamic examination before and after Burch colposuspension. They were divided into two groups, one with preoperative urethral pressure of 20 cm water or less (n = 17), and the other with urethral pressure greater than 20 cm water (n = 104). Success rates at 12 months were significantly lower in women with low urethral pressure as compared with those with normal urethral pressure (65 vs. 88%; p less than 0.01). Starting in January 1987, all patients with low urethral pressure preoperatively underwent a surgical procedure which combined the techniques of the Ball and Burch procedures. Short-term cure rate (at 3 months postoperative follow-up) in women with low urethral pressure was 83% as opposed to 70% with the Burch urethropexy (p less than 0.05).