A suburethral sling procedure with polytetrafluoroethylene for the treatment of genuine stress incontinence in patients with low urethral closure pressure

One indication for suburethral sling procedures has been recurrent genuine stress incontinence after previous incontinence surgery. Patients with low urethral closure pressures (20 cm H2O or less) in association with genuine stress incontinence are at particular risk for failure of standard anti-incontinence procedures. Urodynamic evaluation was used to select 17 patients with genuine stress incontinence and low urethral closure pressures for surgical treatment with a sling procedure using polytetrafluoroethylene. The technique of the procedure, cure rate, and postoperative complications were assessed. An 85% subjective and objective cure rate was found on urodynamic testing three months postoperatively. Complications included wound seroma, urinary tract infection, and urinary retention.     

Effects of pubovaginal sling procedure on patients with urethral hypermobility and intrinsic sphincteric deficiency: would they do it again?

OBJECTIVE: This study was undertaken to assess the cure rate of stress urinary incontinence, long-term effects on other lower urinary tract symptoms, and quality of life in a cohort of patients who underwent pubovaginal sling procedures for treatment of incontinence related to intrinsic sphincteric deficiency and urethral hypermobility. STUDY DESIGN: This was a retrospective analysis of 57 patients with 90% follow-up who underwent pubovaginal autologous fascial sling procedures for stress urinary incontinence related to urethral hypermobility and intrinsic sphincteric deficiency. Objective postoperative urodynamic evaluation was performed in 34 (60%) of the cases. Telephone interviews to assess quality-of-life parameters were performed in all cases. RESULTS: The mean follow-up period was 42 months and the median follow-up period was 34 months, with a range of 0.5 to 134 months. The age at the time of the sling procedure ranged from 18 to 84 years, with a median parity of 3.0 (range, 0-6). Preoperative body mass index ranged from 19.5 to 39.1 kg/m(2). Five percent of patients had detrusor instability before the operation. Forty-one percent (41%) of the patients who underwent postoperative urodynamic evaluation had voiding dysfunction. The postoperative objective cure rate for stress urinary incontinence was 97%. Of all patients 88% indicated that the sling had improved the quality of life, 84% indicated that the sling relieved the incontinence in the long-term, and 82% would choose to undergo the procedure again. CONCLUSION: Construction of a pubovaginal sling is an effective technique for relief of severe stress urinary incontinence. Voiding dysfunction is a common side effect. Despite this problem, a significant number of patients would elect to undergo the procedure again.     

The Aldridge Sling Procedure in the Treatment of Urinary Stress Incontinence

Summary: The long-term results of the Aldridge sling procedure for the treatment of recurrent urinary stress incontinence were assessed in 50 women most of whom had had previous failed vaginal surgery; 78% of patients were cured of all symptoms and a further 20% were symptomatically improved—a 2% failure rate. Only one patient reverted from a cure to improved during the lengthy follow-up. The procedure is not difficult to perform and is a good surgical option in patients with failed vaginal surgery.     

阔筋膜悬吊术用于治疗女性压力性尿失禁

目的探讨自体阔筋膜吊带行尿道悬吊术治疗女性压力性尿失禁的疗效和安全性。方法对13例压力性尿失禁伴子宫脱垂及阴道前后壁膨出的患者,取自体大腿外侧阔筋膜条作为吊带,经下腹阴道联合切口,行尿道近端悬吊术,同时行阴式全子宫切除及阴道前后壁修补术,平均随访30个月。结果13例患者均获得治愈,无阴道出血、感染、排斥反应等并发症发生。5例患者在术后出现轻度、暂时性排尿困难,1个月内症状消失。结论自体阔筋膜吊带行尿道悬吊术是治疗女性压力性尿失禁的安全有效术式。     

The modified Aldridge fascial sling (cruciate bladder sling) for genuine stress incontinence: a review of 50 patients.

We set out to assess the success rate and complications of the modified Aldridge sling for genuine stress incontinence (GSI). This was a retrospective study involving 50 women with urodynamically proven GSI who underwent the above procedure at a tertiary referral teaching hospital in Birmingham. The subjective cure rate at 2 years was 94%. Failures were apparent by 1 year and there were no recurrences by 2 years. Age, weight, parity and previous incontinence surgery did not make a statistical difference to the success rate. Postoperative retention and bacteriuria were the commonest complications. We conclude that the modified Aldridge sling procedure should be considered as an alternative to colposuspension in cases in which vaginal mobility is limited. Preoperative urodynamics is essential. The subjective cure rate at 2 years of 94% is respectable, especially when 26.8% of the patients had had at least two unsuccessful incontinence operations.     

The fascia lata suburethral sling for treating recurrent urinary stress incontinence

OBJECTIVE: The purpose of this study was to evaluate the effectiveness of the fascia lata suburethral sling procedure in the treatment of recurrent genuine urinary stress incontinence. STUDY DESIGN: This study was a retrospective analysis of 60 patients who had a suburethral fascia lata sling placement between January 1992 and December 1995. Follow-up ranged from 6 months to 3.5 years. The database was obtained by a retrospective chart review, a written questionnaire, and telephone interview. RESULTS: Between January 1992 and December 1995, 72 patients who had at least one previous incontinence procedure were assessed by urodynamic testing and cystourethroscopic examination before undergoing a fascia lata sling placement. Of this population, 60 were available for follow-up. Of this 60, 54, or 90%, had complete cure or marked improvement in the urinary incontinence. There were six failures, two of which had no bladder neck mobility and two of which had detrusor instability and were unable to take medication because of medical contraindications. In addition, two slings were sacrificed because of postoperative complications. The most common postoperative complication was urinary retention, which resulted in eight, or 13.4%, of slings needing to be released. CONCLUSION: Our data support the use of the suburethral fascia lata sling as an effective method for the treatment of recurrent genuine urinary stress incontinence, with urinary retention being the most common postoperative complication.(Am J Obstet Gynecol 1997;177:6)     

Outcome of the Laparoscopic Two-Team Sling Procedure,Tension-Free Vaginal Tape Insertion,and Transobturator Tape Insertion in Women With Recurrent Stress Urinary Incontinence

ObjectiveAlthough the surgical treatment of primary stress urinary incontinence (SUI) has been well studied, the optimal treatment of persistent or recurrent SUI represents a significant challenge to the surgeon, and there are limited relevant published data. The aim of this study was to document outcome data for various surgical techniques used at our centre for the treatment of recurrent SUI, and to assess the immediate and long-term complications associated with these procedures.MethodsThis retrospective study assessed the outcome of the laparoscopic two-team sling procedure, tension-free vaginal tape (TVT) insertion, and transobturator tape (TOT) insertion in the treatment of recurrent SUI in women. Data collected included patient demographics, urodynamic data, postoperative subjective cure and objective cure (negative cough stress test), and intraoperative and postoperative complications.ResultsForty-six women with recurrent SUI were included in the study: 24 had had laparoscopic two-team sling procedures, 15 had had TVT insertion, and 7 had had TOT insertion. For each procedure, objective cure rates were 91.7%, 73.3%, and 85.7%, respectively, and subjective cure rates were 79.2%, 60%, and 57.1% respectively. In the laparoscopic two-team sling group, one woman developed an infected hematoma and one required surgery for a small bowel obstruction.ConclusionThe laparoscopic two-team sling procedure or TVT or TOT insertion may be used in experienced hands for surgical management of patients with recurrent stress urinary incontinence. We found no statistically significant differences in outcomes between the three groups, possibly because of the small sample size. Larger sample size and longer follow-up within prospective randomized trials are warranted to identify any possible differences.     

Laparoscopic Burch colposuspension for recurrent stress urinary incontinence

STUDY OBJECTIVE: To evaluate the effectiveness of laparoscopic Burch colposuspension in the treatment of recurrent stress urinary incontinence in women with previous vaginal or abdominal retropubic continence surgery. DESIGN: Retrospective analysis over 36 months (Canadian Task Force classification III). SETTING: Community hospital. PATIENTS: Thirty-three consecutive patients. INTERVENTION: Laparoscopic Burch colposuspension. MEASUREMENTS AND MAIN RESULTS: Data were obtained by retrospective chart review, telephone interviews, and follow-up physical examinations. Of the 33 patients, 17 (52%) had undergone open retropubic procedures (Burch or Marshall-Marchetti-Krantz), 11 (33%) had had vaginal retropubic needle suspension, and 5 (15%) pubovaginal sling operation. Additional laparoscopic and/or vaginal reconstructive surgery was completed in 32 women (97%) at time of laparoscopic Burch. Average overall operating time was 165 minutes (range 60-287 min), mean estimated blood loss was 178 ml (range 50-600 ml), and hospital stay was 1.1 days. Three intraoperative complications occurred, two cystotomies and one serosal bowel injury. Postoperative objective evaluation over average follow-up of 18.6 months revealed a 90% stress urinary incontinence cure rate. CONCLUSION: Laparoscopic Burch colposuspension is safe and effective treatment of recurrent stress urinary incontinence in women who have undergone previous procedures for retropubic continence.     

Surgical management of recurrent stress urinary incontinence: A 12-year experience

Objective: The goal of the study was to evaluate the surgical procedures used to manage recurrent stress urinary incontinence in a tertiary referral center, to compare the procedures with respect to efficacy and failure rates, and to identify risk factors for failure. Study Design: The health records of patients who underwent surgical treatment of recurrent stress urinary incontinence performed by the senior author (H.P.D.) between 1984 and 1995 were reviewed. The objective cure rate was evaluated by means of urodynamic studies and physical assessment, and the subjective cure rate was determined by means of historical report. In light of our selection criteria, the time to failure, the number of previous anti-incontinence procedures needed to give the best cure rate, and the risk factors for failure of the 3 predominantly used surgical techniques were determined. The statistical methods used were the χ² test with 95% confidence interval, the Cox proportional hazard model with logistic regression, and survival analysis. Results: One hundred ninety-eight female patients were surgically treated for recurrent stress urinary incontinence between January 1, 1984, and December 31, 1995. Four surgical techniques were used: (1) the combined abdominovaginal (2-team) polypropylene (Marlex; Phillips Petroleum Company, Bartlesville, Okla) sling (group 1, n = 70), (2) the modified urethral Marlex sling (group 2, n = 68), (3) Burch retropubic colpourethropexy (group 3, n = 49), and (4) suburethral Marlex sling (group 4, n = 11). The study population consisted of 118 patients. The rest of the original 198, including all the patients in group 4, were excluded. Objective and subjective cure rates of 69% and 89%, 66% and 96%, and 69% and 88% were calculated for groups 1, 2, and 3, respectively. By 6 years after the operation 100% of the failures in groups 1 and 2 had occurred, and 88% of the group 3 failure occurred within 2 years after the operation. Cure rates of 77%, 73%, and 38% (P = .320) were achieved with the 2-team sling procedure (group 1) after 1, 2, and 3 previous anti-incontinence operations, respectively, whereas cure rates of 81%, 25%, and 0% (P = .001) were obtained with the Burch procedure (group 3) after 1, 2, and 3 previous anti-incontinence operations, respectively. This indicates that the Burch procedure should be avoided after >1 previous operation, whereas the 2-team sling can be used after ≥3 previous anti-incontinence procedures. Statistical significance could not be determined for group 2 because that procedure was not used to treat any patient with 3 previous operations. Age was a marginal risk factor for failure in group 1. No statistically significant risk factors were identified for group 2. The number of previous anti-incontinence procedures was the major risk factor for failure in group 3 when age, parity, gravidity, weight, hormone replacement therapy, number of previous anti-incontinence procedures, and urethral closure pressure were covariables. Conclusion: According to our data, both sling procedures and Burch retropubic colpourethropexy can be used to surgically manage recurrent stress urinary incontinence with selection criteria such as those that we used. In our opinion comparative prospective studies of different surgical techniques with similar selection criteria, long-term follow-up of ≥10 years, and the inclusion of urodynamic studies may be the most ethical way to determine the right operations for recurrent stress urinary incontinence. (Am J Obstet Gynecol 1999;181:1296-309.)     

Factors influencing the outcome of a no incision endoscopic urethropexy.

A urethropexy without incision has been used in 108 women with a minimum of one year follow-up evaluation. Most of the patients (81 percent) experienced postoperative urinary retention, with the mean period of retention being 22 days. The cure rate was 81.5 percent. The technique was successful in women with grade I stress urinary incontinence (97 percent), but not as effective in women with high grade stress incontinence (45.5 percent in women with grade III stress urinary incontinence). The success rate, therefore, correlated significantly with the grade of incontinence (p less than 0.001). It is noteworthy that there were no failures in 36 women who were premenopausal and the cure rate of 72 percent in the postmenopausal group represented a significant reduction (p less than 0.001). The approach without incision is often effective in patients who have failed previous anti-incontinence procedures, with a cure rate of 82 percent in 22 women in this category, but most patients with a successful outcome in the more complex instances of stress urinary incontinence were also noted to be premenopausal. These data suggest that the success of the repair is dependent on the strength and integrity of the vaginal mucosa. When using the no incision technique, it is advisable to avoid the use of foreign body material in the suprapubic stab sites because of the high incidence of infection and tender nodules.     

Short-term complications of the trans-obturator foramen procedure for urinary stress incontinence.

This paper reports the efficacy and complications of the trans-obturator foramen procedure (TOT). The effect of TOT on co-existing urgency and urge incontinence and voiding difficulty were also noted. It reports on patients (31) undergoing TOT (Obtape) from April 2005 to April 2006, who were sent a questionnaire. The mean age was 53 years, mean parity 2.3, mean duration of incontinence 6.2 years and the mean duration of follow-up was 9 months. All patients had significant stress incontinence. Co-existing urge incontinence was present in 70%; no intraoperative complications. One patient had a urinary tract infection (UTI) and one, catheterisation for 5 days. A total of 16.6% of patients developed sling erosion. There was a 93% response rate to the postal survey, indicating a 31% complete cure of urinary incontinence; 65% a significant improvement and 3.5% failure. Urge incontinence disappeared in 66%, no de-novo urgency and 8% reported slower voiding. Satisfaction was 8.9 on a 1 - 10 Scale. The success rate of the TOT procedure was high, helping both stress and concomitant urge incontinence, but due to an unacceptably high erosion rate, Obtape was discontinued.     

Resolution of urge urinary incontinence with midurethral sling surgery in patients with mixed incontinence and low-pressure urethra

The aim of the study was to determine the rate of persistence of urgency or urge urinary incontinence following midurethral sling surgery compared to standard medication treatment in patients with mixed incontinence and ISD urethra. A prospective study was conducted at a tertiary referral Urogynecology Center. One hundred five women with stress urinary incontinence (SUI) and urgency were identified. Fifty-four consecutive women with SUI and urgency who underwent midurethral sling were compared to 51 women with SUI and urgency but treated with medications first. Women with persistent urgency or urge urinary incontinence (UUI) at 6-month follow-up following a TVT sling procedure were compared with those whose symptoms had resolved, to determine the risk factors for persistent symptoms. Forty out of 54 patients in the operation group also underwent a prolapse repair, either a colpopexy or a colpocleisis. All patients had demonstrated a mean urethral closure pressure of 20?mmHg or lower, indicating an intrinsic sphincteric deficiency. Persistent urgency (6 of 54, 11%) and UUI (3 of 54, 5.5%) were found in patients with mixed incontinence who underwent a sling operation. All 51 patients (100%) persisted with some urgency and urge incontinence despite anticholinergic medication treatment, only (7 of 51, 13.7%) reporting improvement of symptoms. Concomitant prolapse surgery, especially apical correction (OR 0.55, 95% CI 0.37–0.65), decreased the risk of urgency persistence, while age (OR 1.04, 95% CI 1.02–1.05), detrusor overactivity (OR 1.66, 95% CI 1.28–2.53), baseline symptom severity (OR 1.77, 95% CI 1.48–2.36), and previous incontinence surgery (OR 2.08, 95% CI 1.38–3.60) increased the risk of persistent urgency in the operated cohort. Women were happier in the operated cohort (45 of 54, 83.3% cure rate). A sling itself decreased the risk of persistent urge or UUI (OR 0.33, 95% CI 0.15–0.70). The most significant improvement was UUI at night. Urodynamic parameters, baseline urgency symptom severity, age, and concomitant prolapse operation are important predictors of persistent urgency or UUI following midurethral sling for mixed incontinence patients.     

Sling distress: a subanalysis of the IVS tapes from the SUSPEND trial

AIM: To study the incidence of erosions and tape infections following the use of intravaginal slingplasty (IVS) treatment for stress urinary incontinence after the SUSPEND trial period of 30 months. This subanalysis was carried out because of concerns regarding high percentage of delayed sling erosions and infections during follow up of the patients who participated in the trial. MATERIALS AND METHODS: The subanalysis patient group consisted of all IVS patients drawn from the SUSPEND randomised control trial that compared the safety and efficacy of three types of suburethral slings, TVT, SPARC and IVS, for the treatment of urodynamic stress incontinence. RESULTS: A total of 62 patients were reviewed during this study conducted from April 2002 to May 2003. Continence was achieved in 88% the patients. A total of eight (13%) sling erosions were found requiring sling removal. Forty-eight (77.4%) patients were followed up at 12 months with one case of erosion (1.7%). Twenty-nine (46.8%) of the 62 patients were followed up between 12 and 34 months, and seven cases of sling erosions were diagnosed. One patient had purulent suprapubic sinus, five patients had foul-smelling discharge, and one had recurrent urinary tract infection associated with pain and discharge. After the slings were removed the patients had no further symptoms. However, three of them had recurrent stress urinary incontinence. DISCUSSION/CONCLUSION: The delayed presentation of the sling erosion from this subanalysis is a concern, and pelvic reconstructive surgeons using IVS need to be aware of the delayed presentations we found in our cohort of patients.     

Inkontinenz der Frau

Urinary incontinence is a medical, social and economic problem. In Germany, 6 to 8 million patients suffer from urinary incontinence; 88% of them have stress urinary incontinence and require treatment. The incidence of this compromising disease increases with age and is one of the major causes of admission to a care home. Urinary incontinence takes a chronic course and is associated with an increased risk of concomitant diseases, e.g., depression, dermatological conditions and fractures. The disease causes substantial costs, both for nursing care and for treatment of the complications. Early diagnosis and effective treatment may restore continence or at least reduce the symptoms of incontinence. Specific guidelines for the treatment of incontinence are available. Minimally invasive sling techniques are the treatment of choice for patients with stress urinary incontinence. These methods achieve a cure rate of up to 90% and are associated with a high benefit-to-risk ratio.     

Outcomes and surgical therapeutic index of Burch colposuspension in stress urinary incontinence

OBJECTIVE: To apply the new concept of a surgical therapeutic index to patients who suffer from stress urinary incontinence using the cure rate and complication rates of Burch colposuspension and to develop a preoperative counseling tool and objective comparison tool for the many surgical procedures that have been described. STUDY DESIGN: We reviewed the case histories of 22 patients between March 1999 and March 2000 who had stress urinary incontinence and underwent Burch colposuspension and in whom the diagnosis of stress urinary incontinence was made using urodynamic studies and the cotton-tipped-swab test. The surgical therapeutic index was then calculated using the median percentage cure rate and complication rate. RESULTS: The surgical cure rates were 81.8%, 81.8%, 90.9%, 90.9%, 95.4% and 95.4% at postoperative 1st, 3rd, 5th, 7th, 9th and 12th month, respectively, and the surgical complication rates were 69%, 36%, 31.5%, 27%, 22.5% and 27%. The surgical therapeutic indices for each postoperative period were 1.19, 2.27, 2.89, 3.37, 4.24 and 3.53, respectively. The surgical cure rate for Burch colposuspension in stress urinary incontinence was 95.4% 1 year after surgery, and the surgical therapeutic index 1 month and 1 year after surgery was 1.19 and 3.53, respectively. CONCLUSION: Burch colposuspension is a relatively effective and safe surgical procedure for managing stress urinary incontinence.     

Short term complications of the tension free vaginal tape operation for stress urinary incontinence in women

Objective To assess the prevalence of intra- and post-operative complications with the tension free vaginal tape operation for female urinary incontinence.
Design Non-control case series.
Setting University Hospital.
Population One hundred and seventy-seven operations on women who were diagnosed urodynamically to have genuine stress incontinence. In 26 cases (15%) there was symptomatic urge incontinence.
Main outcome measures Intra- and post-operative complications in relation to individual surgeons and mode of anaesthesia (local or spinal), and continence at short term follow up.
Results Bladder or urethral perforation occurred in 26 cases (15%) and three operations were abandoned for these reasons. A failure to void after the first 24 hours was registered in 35 (20%); 21 (12%) had to undergo urethral dilatation while five patients (2.8%) had persistent urinary retention which required excision of the sling. These problems were significantly associated to the experience of surgeon. In seven cases (4%) haemorrhage required intravaginal tamponade. In three (1.7%) sling rejection occurred post-operatively. When followed up six to eight weeks post-operatively, 154 patients (88%) reported subjective cure, 21 (11%) significant improvement and two (1%) no improvement. The use of spinal anaesthesia increased the frequency of peroperative bladder perforation but affected neither the incidence of post-operative bladder obstruction nor the outcome at follow up.
Conclusions This study identifies short term complications which relate partly to the experience of the individual surgeon. Nevertheless the 88% subjective cure rate was independent of these factors.     

Tension-free vaginal tape obturator versus Ajust adjustable single incision sling procedure in women with urodynamic stress urinary incontinence

Objective

To assess the efficacy and complications of inside-out transobturator tension-free vaginal tape (TVT-O) in comparison with a single incision sling procedure (Ajust) for the treatment of urodynamic stress urinary incontinence.

Study design

Prospective closely matched controlled study. In total, 171 patients were included in the study: 86 women underwent the TVT-O procedure, while in other 85 cases the Ajust procedure was performed. Subjective and objective cure, improvement and failure rates, mean operative time, hospital stay and incidence of complications were assessed.

Results

There was no statistically significant difference between the two groups for age, body mass index, parity, menopausal status and severity of prolapse. No major intraoperative complications occurred. There was no significant difference in the mean operative time and the duration of hospital stay between the two groups. The mean follow-up time of the study was 22.3 months (range 12–36 months). For the TVT-O group the objective cure rate was 86%, the improvement rate was 5.9% and the failure rate was 8.1%, while the subjective cure rate was 82.6%. For the Ajust group the objective cure rate was 84.7%, the improvement rate was 4.7%, 10.6% of patients showed no change in their symptoms and the subjective cure rate was 81.2%.

Conclusions

The Ajust sling procedure presents success rates, at 22 months’ mean follow up, comparable to the TVT-O method. Both techniques seem to be safe and effective for the treatment of urodynamic stress urinary incontinence.     

Clinical and urodynamic assessment of the porcine dermis bladder sling in the treatment of genuine stress incontinence

Fifty women, aged between 37 and 76 years, underwent a bladder sling operation for urinary incontinence using porcine dermis. All patients had undergone previous unsuccessful vaginal surgery for genuine stress incontinence and had stable bladders. Thirty-nine patients (78%) were made continent of urine, both subjectively and on urodynamic testing.     

Use of a pedicled rectus abdominis muscle flap sling in the treatment of complicated stress urinary incontinence

OBJECTIVE: A pedicled rectus muscle flap sling in the treatment of complicated stress urinary incontinence was evaluated. STUDY DESIGN: Thirty-two women underwent a combined vaginal and abdominal sling operation for stress incontinence with a pedicled muscle flap developed from the rectus abdominis muscle. All operations were performed jointly by the same two surgeons. The procedure involved transecting one rectus abdominis muscle just above its first tendinous intersection and isolating the muscle as a flap on its inferior vascular pedicle. The muscle flap was then swung beneath the urethra and bladder neck, pulled into the retropubic space on the contralateral side, and sewn to the obturator internus fascia or to Cooper's ligament. All patients undergoing the procedure had demonstrable stress incontinence on physical examination and underwent preoperative fluoroscopic video urodynamics. The diagnosis of complicated stress incontinence was based on the presence of one or more of the following factors: previous failed antiincontinence surgery (33 operations in 22 patients, average 1.5 operations), open vesical neck on fluoroscopy (14 patients), urethral closure pressure ≤30 cm H₂O by the Brown-Wickham technique (16 patients), or massive vaginal prolapse and demonstrable stress incontinence with the prolapse reduced and the urethra supported in a normal position (16 patients). Follow-up ranged from 2 to 13 months (average 6 months). Surgical outcome was assessed by physical examination and a detailed telephone interview conducted by a physician who was not involved in the operations. RESULTS: Twenty-eight patients (87.5%) were satisfied with the results of the operation. There were four surgical failures (12.5%). Stress incontinence persisted in three patients after surgery, and one patient who had mixed incontinence before surgery was cured of stress incontinence but continued to have significant urinary leakage as a result of detrusor overactivity. There appears to be less voiding dysfunction with this technique than with other sling procedures for stress incontinence. CONCLUSIONS: The sling procedure with a rectus abdominis muscle flap appears to be a viable surgical technique in the treatment of complicated stress incontinence. Further study is needed to assess the long-term results of this operation and to evaluate its proper place in reconstructive pelvic surgery. (Am J Obstet Gynecol 1996;175:1460-6.)     

Prazosin: a neglected cause of genuine stress incontinence.

Prazosin, a common antihypertensive drug, lowers peripheral vascular resistance by selectively blocking alpha-1 adrenergic receptors on arteriolar smooth muscle. Alpha-1 adrenoceptor inhibition also has a relaxant effect on smooth muscle present in the urethra. Between 1985-1990, 58 of 1335 women (4.3%) seen in our urodynamic clinic with urinary incontinence and other urinary symptoms were taking prazosin. The incidence of genuine stress incontinence was significantly higher in women taking prazosin (86.2%) than in the non-prazosin group (65.7%) (P less than .01). Twenty-five of the 45 women contacted had their urinary incontinence improved or cured by prazosin withdrawal. All of these 25 women with prazosin-related urinary incontinence had stress incontinence. The incidence of previous bladder neck surgery in this group was over 50%, with 11 previous vaginal repairs, one Burch colposuspension, and one Aldridge sling procedure. Seven women who were continent after prazosin withdrawal had their urodynamic studies repeated. There was a significant increase in functional urethral length, maximum urethral closure pressure, and abdominal pressure transmission to the urethra following prazosin withdrawal, although no significant change was found in other cystometric measurements including peak flow rate and residual urine volume. In this study, prazosin was a frequently unrecognized cause of stress incontinence in women, many of whom had unsuccessful and possibly unnecessary surgery.