Short-term outcome analysis of total pelvic reconstruction with mesh: the vaginal approach

PURPOSE: We describe our experience with transvaginal total pelvic reconstruction using a mesh with 4-point fixation for patients with genitourinary prolapse with or without stress urinary incontinence. MATERIALS AND METHODS: A total of 29 consecutive patients who underwent sacrospinous fixation using mesh material since March 1999 for genitourinary prolapse were analyzed retrospectively. In all patients defect specific repair was done, including hysterectomy (in 13). For isolated vault prolapse a rectangular mesh was interposed between the peritoneum and vaginal vault, with each corner anchored to the sacrospinous ligament using a suture-capturing device. For vault prolapse associated with anterior vaginal wall prolapse an "H" shaped, 1-piece sling was used to support both entities. Additionally, posterior and perineal repairs were done through separate incisions if needed. RESULTS: Of the 29 patients 19 (65.5%), 7 (26.92%) and 11 (39.29%) had associated symptoms of stress urinary incontinence, urgency and frequency, respectively, and 79.31% had associated anterior and 44.8% had associated posterior prolapse. Average operative time was 175.6 minutes, blood loss was 340 cc and hospital stay was 2.46 days. Early adverse events following the procedure were perineal pain, vaginal discharge and irritative voiding symptoms. At 6 month followup (mean 25.14 months) mild constipation and dyspareunia were encountered in a small subset of patients. Two patients (6.89%) have genital prolapse recurrence and none has reported erosion or nonhealing to date. CONCLUSIONS: Transvaginal technique of 4-point vaginal vault fixation using mesh is a safe and effective procedure at 2 years.     

Pubovaginal sling: 4-YEAR outcome analysis and quality of life assessment

PURPOSE: Stress urinary incontinence is a common disease with a devastating impact on patient quality of life. Needle suspension procedures, which produce disappointing long-term results for type II stress incontinence, are being replaced by pubovaginal slings which previously were reserved solely for the treatment of type III stress incontinence. We report the long-term outcomes of pubovaginal slings for the treatment of types II and III stress urinary incontinence, and assess its quality of life impact. MATERIALS AND METHODS: From January 1993 until December 1996, 247 females 10 to 84 years old (mean age 54.5) with type II (54%) or III (46%) stress urinary incontinence diagnosed by fluoroscopic urodynamics received a pubovaginal sling. Concomitant urge incontinence was present in 109 patients (44%). Quality of life was assessed with the Urogenital Distress Inventory short form. RESULTS: At a mean followup of 51 months (range 22 to 68) the continence rates were 88% overall, 91% for type II and 84% for type III. Preoperative urge incontinence resolved in 81 of 109 patients (74%), while de novo urge incontinence developed in 10 (7%). Intermittent urethral catheterization duration averaged 8.4 days, with 5 women undergoing urethrolysis for a hypersuspended urethra. Secondary procedures were required in 9 patients with type II and 5 with type III incontinence, and included transurethral collagen injections in 6 and repeat pubovaginal slings in 8. There was a 4% complication rate due to pelvic hematoma in 2 cases, incisional hernia in 2, deep venous thrombosis in 1 and pulmonary embolus in 1. Of the 247 patients 235 (95%) completed the quality of life questionnaire with 92% reporting a high degree of satisfaction with low (less than 20 of 100 points) symptom distress scores. CONCLUSIONS: Pubovaginal slings are effective and durable, and significantly improve quality of life in patients with types II and III stress urinary incontinence.     

Double forced sling by combining in situ vaginal wall and Infast pubic bone suburethral stabilization techniques: a new method

PURPOSE: We evaluated the results and effectiveness of the double forced sling by combining in situ vaginal wall and Infast (Influence, Inc., San Francisco, California) pubic bone suburethral stabilization techniques as a new method. MATERIALS AND METHODS: The new technique was used in 40 patients, of whom 32 completed 2 years of followup. Previous surgery included hysterectomy in 8 cases, anterior and posterior vaginal wall repair in 6, and 1 or 2 incontinence procedures in 24. Types 2, 3 and mixed incontinence were diagnosed in 12, 12 and 8 patients, respectively. With this technique a gelatin coated synthetic sling was fixed to the previously prepared vaginal sling surface with watertight stitches to create a doubled forced sling, which was fixed to the pubic bone with 2 screws using an Infast inserter. Patient outcomes were evaluated by questionnaire analysis and the pad test. RESULTS: The cure, improvement and failure rates were 81.25%, 6.25% and 12.5% in the 32 patients who completed 2 years of followup. Surprisingly successful results were achieved in all 24 secondary cases. Moderate cystocele in 4 patients and rectocele in 8 were corrected simultaneously. Temporary urinary retention in 4 patients resolved in 2 weeks. Of the 32 patients 28 reported that they would repeat the procedure and recommend it to others. CONCLUSIONS: The double forced sling has 2 advantages that make it superior to other techniques, namely a minimal complication rate and enhanced support accomplished by an easy and noninvasive technique.     

Complications of silicone sling insertion for stress urinary incontinence

PURPOSE: A pilot study was performed to evaluate the suitability of silicone as a substance for suburethral sling placement. Using rectus sheath for sling placement can be time-consuming and can result in increased morbidity. Adjustable synthetic materials of consistent strength are available. Silicone has previously been used successfully and was chosen for this trial. MATERIALS AND METHODS: Slings were inserted in 7 women with stress urinary incontinence. Of the patients 3 had a history of continence surgery and presented with reduced vaginal mobility, and 2 who had not previously undergone continence surgery had intrinsic sphincter deficiency. RESULTS: In all women stress urinary incontinence was subjectively cured. However, after 7 slings were inserted the study was terminated due to a high complication rate related to erosion and sinus formation in 5 slings which were removed. Complications developed immediately or up to 11 months after sling insertion. Continence was maintained in 4 of the 5 women after the slings were removed. CONCLUSIONS: Silicone is an inappropriate material for suburethral sling placement when used as described in our cases, caution should be exercised when placing silicone slings at this site.     

Absorbable versus nonabsorbable graft: outcome of bone anchored male sling for post-radical prostatectomy incontinence

PURPOSE: We determined the outcome of the bone anchored male sling procedure for stress urinary incontinence in men regarding the graft material used. MATERIALS AND METHODS: A total of 39 men with post-radical prostatectomy incontinence received a perineal bone anchored male sling. Patients with previous salvage external beam radiotherapy and high serum prostate specific antigen, incontinence due to neurogenic or posttraumatic etiology, or previous benign prostatectomy were excluded. Urodynamic evaluation was performed preoperatively. The number of pads daily used by patients was recorded preoperatively and during postoperative visits. To compress the urethra 2 types of materials were used. Absorbable biomaterials were used in the first 12 patients and nonabsorbable material was used in the following 27. RESULTS: Mean patient age +/- SD was 67.3 years (range 50 to 79). The mean duration between radical prostatectomy and male sling surgery was 57.9 +/- 40.4 months (range 5 to 135). The procedure was successful in 26 patients (96.2%) in the nonabsorbable group and in 1 (8.3%) in the absorbable group at a mean followup of 18.9 and 28.8 months, respectively. CONCLUSIONS: The absorbable sling materials that were used for the bone anchored male sling demonstrated disintegration of the material. Autolysis of these absorbable materials removed active compression forces on the urethra after a short period. Nonabsorbable graft is associated with the best outcome following the perineal bone anchored male sling procedure.     

Cadaveric prolapse repair with sling: intermediate outcomes with 6 months to 5 years of followup

PURPOSE: We present the prospective, intermediate-term results for cadaveric prolapse repair with sling as combined treatment of stress urinary incontinence and cystocele. MATERIALS AND METHODS: A total of 251 of 295 (85%) patients undergoing cadaveric prolapse repair with sling (CaPS) had at least 6 months of questionnaire and pelvic examination followup. All patients had objectively demonstrated stress urinary incontinence and grade 2 to 4 cystocele before surgery. Followup outcome measures included a validated subjective continence and patient satisfaction questionnaire, SEAPI (stress incontinence, emptying, anatomy, protection, inhibition) scores, pelvic examination for prolapse recurrence and complications, and quality of life scores. RESULTS: The overall patient reported subjective incontinence cured/dry rate (no incontinence episodes of any type) was 114 of 251 (45%), the cured/improved rate (50% improvement or greater) was 192 of 251 (76%) and the failed rate (less than 50% improvement) was 59 of 251 (24%). When considering stress urinary incontinence the cured/dry rate was 141 of 251 (56%), cured/improved rate was 207 of 251 (82%) and failed rate was 44 of 251 (17.5%), with 17 of the 44 (39%) cases having mixed urinary incontinence. Of the 59 failures 33 (56%) occurred after 12 months of followup. Of 153 patients 13 (8.5%) experienced de novo urge incontinence. The symptomatic cystocele recurrence rate was 18 of 251 (7%). There were statistically significant improvements in SEAPI and prolapse quality of life scores. Of 251 patients 200 (80%) were at least 50% satisfied and of 251 193 (77%) stated they would undergo the CaPS procedure again. CONCLUSIONS: With a maximum followup of 5 years in patients undergoing CaPS, we have seen excellent, durable cystocele repair results. While our subjective continence rates have decreased with an increasing number of late failures, we continue to observe significant improvement in SEAPI scores and quality of life with good patient satisfaction and low morbidity.     

Long-term results of the bulbourethral sling procedure

PURPOSE: We evaluated the long-term efficacy of the male bulbourethral sling procedure in the treatment of post-radical prostatectomy urinary incontinence. MATERIALS AND METHODS: Between October 1994 and June 2000, 95 patients with post-radical prostatectomy incontinence underwent bulbourethral sling placement with tetrafluoroethylene bolsters at our hospital. Ultimately 71 of these patients responded to our questionnaire and they were classified into 2 groups. Group 1 consisted of 62 patients who had not undergone prior radiation therapy and group 2 consisted of 9 who had undergone radiation therapy before the sling procedure. Patients were asked to respond to questions regarding continence status as well as the validated Incontinence Quality of Life and International Prostate Symptom Score questionnaires. RESULTS: Mean followup from the most recent sling procedure was 4 years (range 0.27 to 6.55). Average patient age at questionnaire response was 74 years. A total of 86 procedures were performed on 71 patients. Of the 71 patients 7 underwent either sling removal or artificial urinary sphincter placement and were excluded from questionnaire analysis. Including retightening procedures 68% of the patients (72% of group 1, 43% of group 2) required 2 or less pads daily. Of the patients 36% (42% of group 1 and 14% of group 2) required 0 pads. CONCLUSIONS: The male bulbourethral sling procedure remains an effective treatment for post-prostatectomy incontinence at 4-year followup.     

Long-term urinary continence rates after simple sling incision for relief of urinary retention following fascia lata pubovaginal slings

PURPOSE: We examined long-term urinary continence rates in patients after midline simple sling incision for urinary retention following suburethral fascia lata slings. MATERIALS AND METHODS: A retrospective review was completed of 13 women undergoing a simple sling incision for catheter dependent obstruction after suburethral sling surgery more than 4 years previously. Urinary continence was evaluated by use of the Groutz-Blaivas anti-incontinence surgery response score. The scores were statistically compared as binary categories at mean 111-day and 60.8-month followup. RESULTS: A total of 13 women underwent a simple sling incision for catheter dependent urinary retention after sling surgery, and 11 patients (mean age 73.4 years) were available for long-term followup (60.8 months). The simple sling incision procedure was completed an average of 65 days (range 36 to 235) after original sling placement. Mean post-void residual urine volume at least 1 month after sling surgery was 289 ml (range 75 to 500). At a mean followup of 60.8 months, no patient required catheterization. Of 11 patients 5 wore no pads. There was no statistical difference in leakage episodes per day (p = 1.0), pads per day (p = 0.3), or patient perceived condition (p = 0.3) during long-term followup. The mean Groutz-Blaivas score did not change statistically during the 5-year followup period (p = 0.6). CONCLUSIONS: Midline simple sling incision provides relief of catheter dependent obstruction following fascia lata sling surgery while preserving urinary continence in the majority of patients during a 5-year followup period.     

Anatomical correction of vaginal vault prolapse by uterosacral ligament fixation in women who also require a pubovaginal sling

PURPOSE: We describe the anatomical and functional outcome in patients who underwent vaginal vault fixation to the proximal uterosacral ligaments for the treatment of vault prolapse and who also required a concomitant pubovaginal sling for associated stress urinary incontinence as well as the repair of other sector defects. MATERIALS AND METHODS: We retrospectively analyzed the records of 33 patients who underwent such repairs between November 1998 and December 2001. Endopelvic fascial defects were described using the pelvic organ prolapse quantitative system (POPQ). Outcome measures included anatomical and functional assessment of pelvic floor defects and urinary incontinence. RESULTS: Preoperatively all patients complained of a vaginal bulge and stress urinary incontinence, while 17 of the 33 had urge incontinence, and 24 and 9 had POPQ stage III or IV and stage II prolapse, respectively. Mean followup was 28 months (range 6 to 43). There was significant improvement in all POPQ measurements (p <0.05). Most notably vaginal cuff support improved by a mean of 7 cm. Stages IIAp (rectocele) and IIC (cuff) prolapse developed in 4 and 2 failed cases, respectively. Stress urinary incontinence was cured in all 33 patients and urge incontinence was cured in 14 of 17, while in 27 vaginal prolapse symptoms resolved and most had improved defecation dysfunction. No patients had urinary obstructive symptoms. There were no ureteral, bladder or rectal complications but 1 patient required blood transfusion. CONCLUSIONS: Suspension of the vaginal cuff to the proximal uterosacral ligaments with site specific repair of other associated endopelvic fascial defects provides excellent anatomical and functional correction of vault prolapse. Furthermore, a concomitant pubovaginal sling is a compatible repair for associated stress urinary incontinence. It did not compromise vaginal repair and prolapse repair did not jeopardize the outcome of the sling.     

Transobturator vaginal tape inside out for the surgical treatment of female stress urinary incontinence: anatomical considerations

PURPOSE: We have recently described a novel surgical technique for female stress urinary incontinence, that is the transobturator vaginal tape inside out, which uses specific instruments for the passage of a synthetic tape from beneath the urethra toward the thigh folds. Herein we report the results of cadaver dissection performed to determine the anatomical trajectory of the tape and its relationships with neighboring neurovascular structures and organs. MATERIALS AND METHODS: Insertion of the transobturator vaginal tape inside out tape was performed by different surgeons in 12 freshly frozen female cadavers according to the standard procedure. The thigh, obturator, perineal and pelvic regions were dissected and tape trajectory was recorded. An additional cadaver was dissected without prior tape placement. RESULTS: The tape was inserted according to a certain consistent path, that is penetration from the suburethral space into a strictly perineal region limited medial and cranial by the levator ani muscle, caudal by the perineal membrane and lateral by the obturator internus muscle. This region corresponded to the most anterior recess of the ischiorectal fossa. The tape then perforated the obturator membrane and muscles, and exited through the skin after traversing adductor muscles and subcutaneous tissue. The tape was coursed away from 1) the dorsal nerve to the clitoris located more superficially below the perineal membrane, 2) the obturator nerve and vessels, and 3) the saphenous and femoral vessels. CONCLUSIONS: These findings strongly suggest that our transobturator technique is highly accurate, reproducible and safe, and it does not require perioperative cystoscopy.     

The male sling for post-prostatectomy incontinence: mean followup of 18 months

PURPOSE: We review our experience with 42 consecutive patients undergoing the bone anchored male sling procedure. MATERIALS AND METHODS: A retrospective chart review was performed, and complete data and followup were available in 38 of the 42 patients. Success was defined as wearing 1 thin pad or less per day, or social continence. Variables such as severity of incontinence, age, detrusor overactivity, previous artificial urinary sphincter, history of radiation and intraoperative flow pressures were analyzed for success and risk of failure. RESULTS: With a mean followup of 18 months (range 6 to 26), 39.5% (15 of 38) were considered a success (socially continent). A statistically significant trend in the degree of preoperative incontinence predicting success was identified. Social continence in mild, moderate and severe cases was achieved in 67%, 50% and 0%, respectively (p =0.001/95% CI). Only 15.8% of patients were completely dry and not wearing pads. Significant perineal pain was reported in the early postoperative period but resolved in all patients. Infection occurred in 3 patients with erosion found in 1. CONCLUSIONS: Although these results are not as encouraging as previous reports, carefully selected patients with mild to moderate incontinence are good candidates for the male sling. Patients with a history of radiation, previous artificial urinary sphincter or severe incontinence should be counseled about the higher risk of treatment failure. Patients should be informed of the possibility of progressive failure with time and the occurrence of significant perineal pain in the early postoperative period.     

Association between valsalva and cough leak point pressures and pelvic organ prolapse quantification in women with stress incontinence

PURPOSE: Women with urodynamically documented stress urinary incontinence (SUI) and urethral hypermobility may have a higher pelvic organ prolapse quantification (POP-Q) stage according to anterior POP-Q measurements. In this study we determined if POP-Q system anterior components representing the urethrovesical junction (anterior wall point Aa/Ba) and/or POP-Q stage has a relationship with leak point pressure testing. MATERIALS AND METHODS: Of the 1,511 women who underwent video fluoro-urodynamics during 1997 to 2003 at our institution 88 with only evidence of SUI with negative Valsalva leak point pressure and positive cough leak point pressure (CLPP) were selected. RESULTS: Average patient age was 58.6 years (range 32 to 89). Of the 88 women 82 had complete POP-Q examinations available, which revealed stages 0 to III in 21 (25.61%), 20 (24.39%), 40 (48.78%) and 1 (1.22%), respectively. The association between POP-Q stage/components and positive CLPP showed no significant difference in mean positive CLPP among POP-Q stages (p = 0.178) or components (p = 0.42 to 0.97). The test for linear trend was not significant (p = 0.636) for POP-Q stages/components (p = 0.40 to 0.93). No significant difference in volume at which positive CLPP occurred was observed among POP-Q stages (p = 0.283) or components (p = 0.13 to 0.75). The proportion of patients with leakage at 200 cc did not differ significantly among POP-Q stages (p = 0.119) or components (p = 0.15 to 0.60). CONCLUSIONS: Analysis of women with urodynamic evidence of SUI with negative Valsalva leak point pressure and positive CLPP did not show any significant association with components of the POP-Q system or with POP-Q stages. Findings support that POP-Q measurements should not be interpreted as indicators of urethral hypermobility when evaluating women with SUI.     

Urologic diseases in America project: urinary incontinence in women-national trends in hospitalizations, office visits, treatment and economic impact

PURPOSE: We describe temporal trends in hospitalizations, outpatient visits and the treatment of female urinary incontinence (UI), and estimated the costs of incontinence using national databases. MATERIALS AND METHODS: The analytic methods used to generate these results have been described previously. RESULTS: The rate of hospitalization with a primary diagnosis of UI decreased from 51/100,000 women in 1994 to 44/100,000 in 2000 and mean length of stay decreased from 3.1 days to 2.1. In contrast, outpatient visits for UI more than doubled during the same period from 845/100,000 women to 1,845/100,000. Rates of inpatient surgical treatment for UI decreased slightly from 1994 to 2000, while ambulatory surgical center visit rates for Medicare beneficiaries 65 years or older more than doubled from 60/100,000 in 1992 to 142/100,000 in 1998. Medical expenditures for UI increased substantially during the 1990s, almost doubling from 128.1 million dollars in 1992 to 234.4 million dollars in 1998 for Medicare beneficiaries 65 years or older. This increase was due almost entirely to increased outpatient costs, which increased from 25.4 million dollars or 9.1% of total costs in 1992 to 329 million dollars or 27.3% of total costs in 2000 in this group. CONCLUSIONS: While existing national databases generally capture only the minority of incontinent women with UI who seek and receive care for UI, they are useful for documenting treads in service use and surgical treatments, and estimating economic impact. This data can be helpful when formulating public policy and designing observational and clinical studies.     

Anastomotic contracture and incontinence after radical prostatectomy: a graded approach to management

PURPOSE: We present a heterogeneous group of men presenting with varying degrees of anastomotic contracture (AC) and associated stress urinary incontinence (SUI) following radical prostatectomy. It is particularly important that AC should be resolved before artificial urinary sphincter (AUS) implantation, because instrumentation through the AUS can risk erosion. MATERIALS AND METHODS: The records of 54 consecutive men who were referred for the management of AC and associated SUI were reviewed. Patient treatment and outcomes were stratified according to their unique characteristics. RESULTS: A total of 54 patients underwent radical prostatectomy alone (48), or in combination with radiation therapy (7) or cryotherapy (1). In group 1, 35 patients had previously undiscovered AC, or 1 or more prior contracture incisions (CIs) with SUI. CI and AUS were performed simultaneously in 33 patients and sequentially in 2. In group 2, 7 patients with intractable AC following multiple CIs/dilations and self-calibration, or an indwelling urethral or suprapubic catheter underwent simultaneous (3) or sequential (2) CI/AUS or CI only (2). Five patients required temporary self-calibration. In group 3, in 12 patients with total outlet obliteration recanalization was accomplished with combined antegrade/retrograde endoscopy and CI. Ten patients had re-obliteration, of whom 1 underwent suprapubic diversion and 9 underwent repeat recanalization with placement of a UroLume stent (American Medical Systems, Minnetonka, Minnesota) across the anastomosis. Eight patients underwent artificial urinary sphincter (AUS) placement 4 to 6 weeks later and 1 awaits an AUS. Of those implanted with an AUS 2 required repeat endoscopic procedures because of recurrent but manageable stent ingrowth. CONCLUSIONS: Most ACs are treated successfully with simultaneous, aggressive CI/AUS. A history of many CIs or long, dense contractures suggest the need for staged management. In those with obliterated outlets we prefer to reestablish patency and if rapid recurrence develops, we place a UroLume stent. Regardless of a history of radiation therapy, continence is restored with an AUS.     

RESULTS OF PUBOVAGINAL SLING FOR STRESS INCONTINENCE: A PROSPECTIVE COMPARISON OF 4 INSTRUMENTS FOR OUTCOME ANALYSIS

PURPOSE: Presently to our knowledge there are no standardized techniques to assess outcomes after surgery for stress incontinence. We performed a prospective blinded study to assess the correlation among physician and patient assessments, and a validated 24-hour pad test and voiding diary. MATERIALS AND METHODS: A total of 84 women were evaluated before and after pubovaginal sling for stress incontinence with a voiding diary, pad test and symptom questionnaire (patient assessment) administered by a blinded third party. The operating surgeon evaluated the patient using history, physical examination, pad test and voiding diary but was blinded to results of the outcome questionnaire. Preoperative focused neurourological examination and video urodynamics confirmed stress incontinence. Patients were assessed at least 1 year postoperatively. We compared patient assessment (cured, improved, failure) to the outcome of the pad test, voiding diary and physician assessment. The physician and questioner were blinded to each other. We considered patients with a pad test of 0 to 2 ml. as cured, 50% or more volume reduction as improved and less than 50% volume reduction as failure. Postoperative assessment did not differentiate between stress and urge incontinence. The kappa coefficient was used for statistical comparison. RESULTS: Average patient age was 58 years and average followup for the entire group was 4 years. Agreement among the 4 instruments to assess outcome was excellent (k >0.9) with respect to cured/improved versus failure but only good for cured versus improved versus failure (k >0.5). CONCLUSIONS: Outcomes following incontinence surgery may vary depending on how the analysis was performed, patient selection, definition of success and so forth. Our results indicate that a pad test and voiding diary are reliable and should be part of the normal followup after pubovaginal sling for sphincteric incontinence. When these tests are used in conjunction with defined parameters of success, there is excellent agreement with patient feelings in regard to success or failure of surgery. Nevertheless, these instruments and methods are imperfect at best.     

Early experience with small volume periurethral polytetrafluoroethylene for female stress urinary incontinence

PURPOSE: Injectable polytetrafluoroethylene paste has been used to treat female stress urinary incontinence. Since the substance is antigenically nonreactive we postulated that the reported morbidity may be due in part to the relatively large volumes injected. Therefore, we assessed the outcome of injecting small volumes of polytetrafluoroethylene with attention to the durability of success and morbidity. MATERIALS AND METHODS: A total of 46 women with a median age of 73.8 years (range 26 to 88) with stress urinary incontinence were treated. The procedure was done on an outpatient basis using topical urethral lidocaine and periurethral lidocaine as anesthesia. A 20Fr urethroscope was used to inject polytetrafluoroethylene through an 18 gauge needle periurethrally. Patients were reinjected 1 to 3 months after initial injection if not cured (no incontinence or no pads). Continence was assessed by questionnaire from an interviewer not known to the patient. Subsequent top-up injections were given if required. Morbidity was monitored with clinical examination and imaging as required. RESULTS: Of the patients 14 (30.4%) were dry, 19 (41.3%) were improved and 13 (28.3%) had treatment failure at a mean of 17.9, 15. 9 and 9.1 months, respectively, after last injection. For cured and improved patients (71.7%) an average of 2 treatments were needed, for a total mean volume of 5.4 cc polytetrafluoroethylene. Using a Kaplan-Meier survival curve the probability of the 14 patients remaining dry without additional polytetrafluoroethylene was 90% at 1 and 60% at 2 years. Outcome was not affected by radiological type of incontinence (that is with or without hypermobility), age, pretreatment bladder instability or previous interventions. CONCLUSIONS: Periurethral injection of small volumes of polytetrafluoroethylene is effective and safe for treatment of female stress urinary incontinence. Early analysis shows that success is durable with minimal morbidity.     

The effect of fluid intake on urinary symptoms in women

PURPOSE: We determined the effect of caffeine restriction and fluid manipulation in the treatment of patients with urodynamic stress incontinence and detrusor overactivity. MATERIALS AND METHODS: This was a 4-week randomized, prospective, observational crossover study in 110 women with urodynamic stress incontinence (USI) or idiopathic detrusor overactivity (IDO) to determine the effect of caffeine restriction, and of increasing and decreasing fluid intake on urinary symptoms. Data were recorded in a urinary diary for the entire study period on urgency episodes, frequency, pad weight increase, wetting episodes and quality of life. RESULTS: A total of 69 women with a mean age of 54.8 years completed the study, including 39 with USI and 30 with IDO. In the IDO group decreasing fluid intake significantly decreased voiding frequency, urgency and wetting episodes with improved quality of life. In the USI group there was a significant decrease in wetting episodes when fluid intake was decreased. Changing from caffeine containing to decaffeinated drinks produced no improvement in symptoms. CONCLUSIONS: Conservative and life-style interventions are first line treatments in the management of incontinence and storage lower urinary tract symptoms. This study shows that a decrease in fluid intake improves some of these symptoms in patients with USI and IDO and, therefore, it should be considered when treating such patients.