经闭孔尿道中段悬吊治疗女性压力性尿失禁两种术式的解剖学对比研究

目的:探讨由内向外经闭孔阴道无张力吊带术(TVT-O)和由外向内经闭孔阴道无张力吊带术(TOT)治疗女性压力性尿失禁(SUI)穿刺入路的安全性.方法:在8具新鲜冰冻、未做防腐处理的女尸上 ,分别做TVT-O和(或)TOT;吊带置人后,分别沿吊带穿刺路径逐层进行局部解剖,观察并比较各个解剖层次的吊带与血管、神经及其他器官的关系.结果:闭孔血管束与吊带的平均距离TVT-O组为13 mm(3～34 mm),TOT组35 mm(32～41 mm);吊带和闭孔神经后支平均距离TVT-O组为11 mm(3～15 mm).TOT组26 mm(20～32mm),吊带与闭孔管的平均距离TVT-O组为21 mm(18～24 mm),TOT组38 mm(32～43 mm).两组比较,差异均有统计学意义(P＜0.01).结论:TVT-O路径中吊带与闭孔各结构的距离比TOT近,提示术中损伤血管神经的风险较大;SUI的治疗中采用TOT相对要安全些,可能减少血管和神经等器官损伤的潜在危险性.     

经闭孔无张力尿道中段悬吊术治疗女性压力性尿失禁

目的探讨经闭孔无张力尿道中段悬吊术(transobturator inside-out tension-free urethral suspension,TVT-O)治疗女性压力性尿失禁(stress urinary incontinence,SUI)的效果。方法2005年8月～2006年2月采用经闭孔无张力尿道中段悬吊术治疗女性SUI18例,螺旋穿刺针自阴道前壁尿道旁间隙经闭孔穿刺至大阴唇外侧皮肤后放置网片,调整张力,关闭切口。结果手术时间10～25min,(15±3)min;术中出血量10～20ml,(15±2)ml。1例术后排尿困难,保留尿管3d后自行排尿。18例治愈,随访6个月均无复发。结论TVT-O操作简单,疗效确切,是治疗女性SUI安全有效的方法之一。     

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.     

Transobturator tape for female stress incontinence: follow-up after 24 months

Objective:

The objective of this paper is to evaluate the effectiveness of transobturator vaginal tape (TOT) in the treatment of female stress urinary incontinence (SUI) and to analyze functional results and quality of life after 24 months follow-up.

Methods:

The study included all women with SUI who underwent a TOT procedure in which the sling passes from the obturator foramen from the outside to the inside, under general or regional anesthesia from December 2004 to January 2006. All study patients must have had a minimal follow-up of 24 months. The patients were prospectively evaluated, and the following factors were assessed: number of pads used per day, physical examination including pelvic examination, urinalysis, urogenital distress inventory (UDI-6), analog global satisfaction scale (GSS), pad weight test, and urodynamic studies including filling cystometry and Valsalva leak point pressure (VLPP) test.

Results:

Fifty-two consecutive patients who fulfilled the inclusion criteria underwent TOT procedure by 1 surgeon. The mean age was 50 ±9 (range 37–72) and minimal follow-up was 24 months (range 24–30 months). Two patients were lost to follow-up after 12 months and 3 patients did not come for the 24-month evaluation. The mean operative time was 18 minutes ±4 (range 15–31), with an average amount of bleeding 57 cc ±22cc. Our results demonstrate a 92% cure or improvement rate after 12 months, and an 85% after 24 months.

Conclusion:

The transobturator approach from outside to inside is a very effective treatment of SUI with low morbidity. However, longer follow-up in larger populations should assess the long-term reliability of this procedure.     

Novel surgical technique for the treatment of female stress urinary incontinence: transobturator vaginal tape inside-out

OBJECTIVES: To describe a new, simple surgical technique for the treatment of female stress urinary incontinence (SUI) and to evaluate its feasibility. METHODS: We have developed a novel surgical treatment of SUI, the transobturator inside-out tension-free urethral suspension, which uses specifically designed surgical tools, and in which a synthetic tape is passed from underneath the urethra, through the obturator foramens, towards the thigh folds, without entering the pelvic region at any time during the procedure. The tape is positioned without tension under the junction between mid and distal urethra. RESULTS: The procedure was carried out in 107 consecutive patients (mean age: 62 years) using the same operative protocol in all case subjects, independently of the patient's size and weight. Mean operative time was 14 min (range: 7-20) in case of isolated SUI treatment. No bladder or urethral injuries and no vascular (hematoma or bleeding) or neurological complications were encountered. CONCLUSIONS: The results of this study indicate that our novel transobturator inside-out surgical technique for treating SUI is feasible, accurate, and quick. This technique avoids damage to the urethra and bladder and, therefore, makes cystoscopy not necessary. Further prospective studies are currently ongoing to determine the efficacy of our new surgical approach for treating SUI.     

经闭孔尿道吊带术治疗女性压力性尿失禁206例临床分析

目的 评估经闭孔尿道中段无张力悬吊术(TOT)治疗女性压力性尿失禁(SUI)的临床疗效及安全性.方法 回顾性分析2007年1月至2009年12月206例尿失禁患者行TOT手术的临床资料,其中混合型尿失禁31例.年龄32～81岁,平均54岁.病史1～40年,平均10.3年;随访时间3～39个月,平均17.3个月.以Grouts-Blaivas评分法评估手术效果.结果 单纯TOT手术在局麻下完成,手术时间16～35 min,平均23.9 min;出血量15～30 ml,平均17.8 ml.术后早期并发症:股部疼痛29例(14.08%)、排尿困难12例(5.83%)、排尿姿势改变2例(0.97%)、尿潴留1例(0.49%).远期并发症发生率0.97%,包括1例阴道壁缺损吊带暴露和1例吊带毛刺暴露影响性生活.术后远期症状完全消失202例,治愈率98.06%,总体满意率100.00%.结论 TOT术是治疗压力性尿失禁的一种微创、安全和有效的手术方法.

Abstract：

Objective To assess the safety and efficacy of the transohturator tape (TOT) for surgical treatment of female stress urinary incontinence (SUI). Methods Clinical data of 206 TOT procedures for female urinary incontinence from Jan 2007 to Dec 2009 was retrospectively analyzed.Thirty-one women were identified as having mixed stress urinary incontinence.The mean age was 54.29 years(range,32-81 years),themean disease coursewas 10.31 years (range,1-40 years),and the mean follow-up time was 17.3 months (range,3-39 months).Therapeutic effects were assessed by Grouts-Blaivas outcome score.The results of the operation,complications and changes of urodynarnics were observed. Results The TOT operations were conducted under local anesthesia.The mean operative time was 23.9 min (range,16-35 min),Mean blood loss was 17.8 ml(range,15-30 ml).Short-term complications were as follows:thigh pain 14.08%,dysuria 5.83%,urinary posture change 0.97% and urinary retention 0.49%.The long-term complication rate was 0.97%,including vaginal wall defect and tape exposure in one case:the burr of tape exposure and sex life influence in one case.Long-term symptoms disappeared completely in 202 cases.The cure rate was 98.06%,and the rate of satisfaction was 100%. Conclusions Our results demonstrate that TOT procedure is a minimally invasive,safe and effective surgical treatment for stress urinary incontinence.     

Transobturator adjustable tape for severe stress urinary incontinence and stress urinary incontinence with voiding dysfunction

Introduction and hypothesis  

This prospective multicenter study was conducted to evaluate the efficacy and safety of an adjustable mid-urethral sling (MUS) using transobturator adjustable tape (TOA) in women with severe stress urinary incontinence or combined stress urinary incontinence (SUI) and voiding dysfunction (VD).     

Transobturator slings for stress incontinence: using urodynamic parameters to predict outcomes

The purpose of this study is to evaluate the ability of preoperative urodynamic urethral function parameters to predict the success rate of transobturator slings (TOS). Seventy women urodynamically diagnosed with stress incontinence with urethral hypermobility underwent a Monarc™ TOS (American Medical Systems, Minnetonka, USA). Postoperative continence status was correlated with preoperative urodynamic urethral function parameters. Mathematical modeling was used to determine whether urodynamic parameters can be used to predict postoperative continence. Average follow-up was 8.1 (6–12) months; 56 (80%) patients were continent based on a standardized stress test and subjective report. The median Valsalva leak point pressure at 150 cc (VLPP₁₅₀) in the failures and successes was not different (p = 0.12). The median VLPP at cystometric capacity (VLPP_cap) in the failures was 32 cmH₂O compared to 71 cmH₂O in the successes (p < 0.001). The maximum urethral closure pressure (MUCP) had a median of 20 cmH₂O in the failures and 45 cmH₂O in the successful patients (p < 0.001). No correlation existed between the degree of urethral hypermobility, as measured by the cotton swab test, and surgical success (p = 0.17). There was no correlation between level of preoperative urethral function and persistent overactive bladder symptoms, post-void residual, voids/day, and nocturia. Using a combined model, the cutoff values of VLPP_cap > 60 cmH₂O and MUCP > 40 cmH₂O were the most predictive of surgical success, revealing a sensitivity of 83% (0.55, 0.95) and specificity of 79% (0.67, 0.88). A combination of urodynamic parameters can be used to predict continence rates after a TOS. A TOS should be used with caution in women with impaired urethral function. G. Willy Davila is a consultant to American Medical Systems.     

Polytetrafluoroethylene sling for failure in female stress incontinence surgery

Summary Surgery for stress urinary incontinence (SUI) in women with previous interventions is often difficult and yields poor results. A total of 33 women with recurrent SUI underwent placement of a polytetrafluoroethylene (PTFE) sling after a mean of 1.5 (range, 1–3) unsuccessful operations. Preoperative bladder instability (BI) was ruled out in all cases. The patients' mean age was 54 (range, 34–79) years. In all, 64% had SUI and 36% had SUI and incontinence at rest. The Aldrige-Stoeckel technique is used with insertion of a 2×30 cm sling instead of fascia lata. Mean operating time was reduced in 40 minutes. After a mean follow-up period of 13 months, 72% of the patients achieved continence without retention (complete success). Altogether, 16 patients (48%) required self-catheterization after discharge, with the voiding imbalance lasting for more than 3 months in only 4 cases (12% of the total). Three patients underwent surgery for outlet obstruction. There were five abdominal wound infections but no vaginal wound infection. Two slings have since been removed (one partially), but none has eroded through the urethra. The PTFE sling is a reasonable option for this group of patients. Retention is usually self-limited, and most complications can be managed successfully.     

Transobturator crossover readjustable sling for severe female incontinence: technique and preliminary results

We present a technique that provides circumferential coaptation of the urethra as a salvage procedure for severe subset of patients. We prospectively evaluated 16 patients who had a transobturator crossover sling. Adjustable hybrid slings were used, and silicone washers were used over the anchoring columns to keep them in place and to facilitate any posterior readjustment. Mean age was 58 years and mean follow-up was 12 months. At presentation, patients had undergone at least two anti-incontinence procedures and wore a mean of six pads daily. There was a mean 93.7% overall cure in symptoms. There was one intraoperative complication (urethra perforation) that was resolved by closing the urethral wall. De novo urge incontinence developed in 2/16 patients. All patients (3/16) who had preoperative urge incontinence achieved resolution after the procedure. The transobturator crossover sling is an effective salvage procedure that may be considered in a selected subset of female patients with a nonfunctional urethra.     

Comparison of retropubic and outside-in transoburator sling systems for the cure of female genuine stress urinary incontinence

OBJECTIVES: Retropubic tension-free slings are a well established procedure in the treatment of SUI. There were and still are relevant complications and side effects. The transobturator approach is said to be safer and equally effective. This paper compares our data of the first TVT- and TOT-procedures to share our experience. METHODS: In this study (from May 1998 to November 1999 for TVT and from February 2003 to September 2003 for TOT) only patients (n=220 in each group) with genuine SUI due to urethral hypermobility and/or intrinsic sphincter deficiency not showing signs of vaginal prolapse were evaluated. The results of pre- and postoperatively conducted examinations, quality-of-life assessments and urodynamic studies are reported. RESULTS: TOT is equally effective with less intraoperative and postoperative complications (including induction of urge). The procedure is faster and does not necessarily need intraoperative cystoscopy (even though cystoscopy adds to the procedure's safety)--it is thereby cheaper. CONCLUSIONS: performed under the right indication the transobturator approach seems to be preferable when a low-tension midurethral sling procedure is the method of choice.     

膀胱颈悬吊术与尿道中段悬吊术治疗女性压力性尿失禁疗效比较

目的分析膀胱颈悬吊术和尿道中段悬吊术治疗女性压力性尿失禁的疗效、合并症和费用,以探讨尿道中段悬吊术的临床应用价值。方法1998-2004年手术治疗女性压力性尿失禁患者46例,平均年龄52岁(25～84岁),行膀胱颈悬吊术18例(A组),尿道中段悬吊术28例(B组)。平均随访20个月(3～69个月)。根据患者主诉,排尿正常、完全自控、无尿失禁为治愈,尿失禁减少>50%为改善,症状未减轻或加重为失败;总有效率为治愈率加改善率。结果45例有效,总有效率98%,其中治愈40例(87%)。A、B组平均手术时间分别为(66.7±9.8)min和(35.1±12.1)min,P<0.01;平均住院日分别为(12.8±8.4)d和(4.8±2.3)d,P<0.05;留置尿管时间分别为(9.6±4.5)d和(2.4±1.2)d,P<0.01。A组13例治愈,4例改善,1例失败,平均手术费用人民币9112.2元;B组27例治愈,1例改善,平均费用人民币11210.4元,P>0.05。术后近期A组发生尿潴留5例(28%),B组3例(11%),P<0.05;A组术后3～7年发生侵蚀,造成尿道阴道瘘3例,而B组尚未发生严重远期合并症。结论尿道中段悬吊术治疗女性压力性尿失禁手术简单、安全、未明显增加手术费用,是治疗女性压力性尿失禁的首选术式。     

经闭孔无张力阴道吊带术治疗女性压力性尿失禁(附16例报告)

目的 探讨经闭孔无张力阴道吊带术(TVT-O)治疗女性压力性尿失禁(SUI)的疗效.方法 经临床和尿动力学检查确诊16例女性SUI患者,手术自尿道外口与阴道外口之间的切口向耻骨和耻骨降支的联合处钝性分离间隙并穿过闭孔,将聚丙烯网吊带无张力置于尿道中段.结果 手术时间平均20分钟,术中出血量平均18ml,术后平均留置导尿...