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

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

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

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

Transrectal ultrasound versus cystography in the evaluation of anatomical stress urinary incontinence

Thirty-two female patients with clinical and urodynamic findings of genuine stress urinary incontinence were evaluated before and 6 months after surgery for stress urinary incontinence. Twenty-nine control patients had identical evaluations before and 6 months after surgery which did not involve the urethrovesical junction. Twenty-four patients with primary bladder instability had similar evaluations and served as a second control group. Anatomical landmarks indicating support to the urethrovesical junction were evaluated by the position of the urethra at the most dependent point in the bladder on straining and the urethral descent on straining to beneath the posterior ramus of the symphysis pubis on bead chain cystography. The urethrovesical junction drop on straining was evaluated by transrectal ultrasonography. Cystographic and ultrasonographic tests for the position of the urethrovesical junction at the most dependent position in the bladder during straining were very sensitive in women with stress urinary incontinence (94 and 87% respectively) but much less specific (45 and 48% respectively). When evaluating anatomical support to the urethrovesical junction and its descent on straining, these tests were both highly sensitive (97 and 94% respectively) and specific (76 and 96% respectively) in women with genuine stress urinary incontinence. Simple clinical tests for support of the urethrovesical junction, such as the Q tip test, are non-specific in patients with stress urinary incontinence. Transrectal ultrasonography is a simple and quick out-patient procedure. The availability of ultrasound equipment in most clinics and the high sensitivity and specificity of the test make it an attractive and cost-effective alternative to X-ray cystography in the pre-operative evaluation of anatomical support to the urethrovesical junction.     

Laparoscopic Burch colposuspension and overlapping sphincteroplasty for double incontinence.

OBJECTIVES: 1. To assess the effectiveness of laparoscopic Burch and overlapping sphincteroplasty in treating urinary and fecal incontinence. 2. To determine the importance of unilateral pudendal neuropathy in fecal incontinence. METHOD: Forty-six women with proven genuine stress incontinence and anal sphincter tears were treated with a laparoscopic Burch colposuspension. Patients with detrusor instability, intrinsic sphincter dysfunction, idiopathic fecal incontinence, and prior anal surgery were excluded. Objective postoperative testing for urinary continence included a cough stress test and bladder neck ultrasound, with repeat urodynamic studies if either test was positive. Fecal incontinence was graded with a clinical scoring index. The anal evaluation included sonography, sigmoidoscopy, manometry, and pudendal nerve terminal motor latency. Patients were divided into 2 groups. Group I (n = 34) had no neuropathy, and Group II (n = 12) had unilateral neuropathy. RESULTS: At 1-year follow-up, 40 patients (89%) were objectively dry, but 3 (7%) had recurrent genuine stress incontinence, and 2 (4%) had detrusor instability. Fecal incontinence cure rate was 82% in Group I and 58% in Group II. Group I had greater improvement in anal physiology studies than did Group II. Sphincter breakdown was the most common cause of recurrent fecal incontinence in Group I, but 4 of 5 patients with persistent incontinence in Group II had intact sphincters. DISCUSSION: Burch colposuspension is effective in treating genuine stress incontinence. Anal sphincteroplasty is effective in treating fecal incontinence due to obstetrical tears in the absence of pudendal neuropathy. Even unilateral neuropathy can significantly impair surgical outcomes.     

Bladder neck suspension for stress urinary incontinence: how does it work?

The objective of this study was to compare urethral resistance as determined in pressure-flow studies before and after Burch retropubic urethropexy. Urethral resistance was retrospectively determined from pressure-flow studies in 178 patients before and 1 year after Burch retropubic urethropexy. Results of cotton swab tests, pressure transmission to the proximal urethra, and urethral functional length were also recorded. Results were analyzed statistically using the two-tailed paired t-test. Voiding studies in 176 patients were analyzed before and after Burch retropubic urethropexy. Mean urethral resistance increased significantly over preoperative values after successful surgery, from 0.051 to 0.099. The mean urethral resistance in patients in whom surgery failed to cure stress incontinence was unchanged from the preoperative value of 0.041. There was no direct correlation between stabilizing the bladder base, as evaluated by the cotton swab test, and cure of stress incontinence. When successful in curing genuine stress urinary incontinence, the Burch retropubic urethropexy increases urethral resistance. Creating bladder neck support without affecting urethral resistance does not, by itself, restore continence. Neurourol. Urodynam. 18:623-627, 1999.     

Ultrasonography in urinary incontinence

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

Urodynamic changes in voiding after anti-incontinence surgery: an insight into the mechanism of cure

Objectives. To measure the effect on voiding pressure and flow rate of three different operations for stress urinary incontinence.Methods. In a previous study of cure rates, 289 women with genuine stress incontinence and genital prolapse were prospectively allocated in a randomized manner to one of three procedures: the Burch retropubic urethropexy, anterior repair, or the modified Pereyra procedure. In the current derivative study, we retrospectively evaluated the urodynamic indicators of voiding dysfunction in the original subjects preoperatively and at the 1-year postoperative follow-up visit.Results. One hundred thirty-two charts were available for review. One year after surgery, pressure and flow during voiding were altered to more obstructive levels with the suspension procedures (Burch and modified Pereyra). The proportion of patients with obstructive and equivocal voiding patterns after the suspension procedures was significantly greater than after anterior repair.Conclusions. This post hoc comparison of randomized data shows a difference in postoperative voiding indexes between suspension procedures and anterior colporrhaphy. Successful bladder neck suspension depends on altering the pressure and flow during voiding to more obstructive levels. Suspension procedures alter the voiding pressure and flow toward obstruction to a greater extent than anterior repair.     

Laparoscopic Mesh and Staple Burch Colposuspension

Our objective was to describe our experience with laparoscopic Burch colposuspension and to relate our results to traditional open Burch procedures for the treatment of genuine stress incontinence. Retrospective case series were compared to historical controls. Forty-six women found to have only genuine stress incontinence by history, examination and clinical urodynamics, underwent a mesh and staple laparoscopic Burch procedure. Follow-up ranged from 3 to 50 months. Thirty-seven women were dry, 6 were improved and 3 showed no improvement. This compared to between 75% and 90% of women cured of stress incontinence by the traditional open Burch procedure. We concluded that the results of a mesh and staple laparoscopic Burch procedure in a carefully selected population of women with genuine stress incontinence appears comparable to that reported in the literature for an open Burch procedure.     

Comparison of laparoscopic Burch and tension-free vaginal tape in treating stress urinary incontinence in obese patients.

OBJECTIVE: To compare the efficacy and safety of the tension-free vaginal tape (TVT) and laparoscopic Burch procedures in treating genuine stress urinary incontinence in obese patients. METHODS: This was a retrospective evaluation of 91 consecutive cases of TVT alone or TVT combined with other procedures from April 1999 through March 2000 and 51 consecutive cases of the laparoscopic Burch procedure from January 1998 through February 1999. All procedures were performed in a private practice and community hospitals in the midwest. One hundred forty-two women (ages 34 to 79) with stress urinary incontinence documented by clinical examination and preoperative cystometric and urodynamic evaluation were included in the study. They were also divided into 5 groups based on their body mass index (BMI): NL (normal-BMI < 25), OW (overweight-BMI 25 to 29), OBI (obesity I-BMI 30 to 34), OBII (obesity II-BMI 35 to 39), OBIII (obesity III-BMI > 40). In the TVT group, 66% were obese (OBI-21, OBII-17. OBIII-22) versus 36% in the laparoscopic Burch (OBI-13, OBII-5) group. RESULTS: All TVT patients remain cured or symptoms improved in their genuine stress urinary incontinence, which favorably compares with the laparoscopic Burch procedure after 1 year. Operating time for the TVT portion ranged from 18 to 40 minutes. The laparoscopic Burch procedure in general took over 1 hour. No bladder, bowel, or vascular injuries have occurred in the TVT group. Superficial suprapubic ecchymoses have occurred in the TVT group occasionally but required no intervention. The average length of stay was 1 day; TVT-only patients usually were released on the same day. Ninety percent of patients were voiding normally by postoperative day 7. Most of the patients with continued urinary retention had had combined procedures. CONCLUSIONS: This preliminary study indicates that TVT is a safer, more effective, and easier minimally invasive surgery for genuine stress urinary incontinence regardless of the patients' BMI and favorably compares with the laparoscopic Burch procedure, which requires advanced surgical skills.     

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

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

Ultrasonography in stress urinary incontinence

Evaluation of the urethrovesical junction in stress urinary incontinence is essential. For this reason the Q-tip test, a clinical test with debatable specificity; lateral cystourethrography, a conventional method; and videourethrocystography, a sophisticated method, have been in use. Because ultrasonography is inexpensive, reliable, easy to apply and free of any contrast material and X-ray exposure, it has practically replaced all the former methods in the evaluation of the urethrovesical junction in stress urinary incontinence patients within the last decade.     

The position of the urethrovesical junction after incontinence surgery: early postoperative changes

This study prospectively evaluated the position of the urethrovesical junction using the Q-tip angle to assess early postoperative changes for different anti-incontinence surgeries. All procedures resulted in a statistically significant change in resting angle from the intraoperative value. The mean change for the transvaginal tape was 25.74° (27.43 to 3.28); Burch 11.18° (–20.44 to –10.0) and fascia sling 13.9° (26.57 to 15.68). The mean change in Q-tip angle was greater after transvaginal tape placement than after Burch (p=0.000) and fascial sling (p=0.022) procedures. These findings show that the resting position of the urethrovesical junction after surgery is different for all procedures. The transvaginal tape results in the greatest change in angle. This may help to negate the so-called tension-free nature of the procedure. Surgeons need to be aware of this, as it may be an etiological factor in cases of late urinary retention and urethral erosion. Editorial Comment: The authors present a prospective observational study which compares the changes in position of the urethrovesical junction measured in the immediate postoperative period and at 6 weeks in patients undergoing transvaginal tape procedures, the Burch procedure and fascial slings for urinary incontinence.There was no attempt at randomization of subjects, and the study groups were poorly matched. Only 15% of the patients undergoing transvaginal tape procedures reported previous surgery for urinary incontinence, compared to 29% of those undergoing Burch procedures. The number of Burch procedures studied was comparatively small.However, this study does provide evidence that there are significant postoperative changes in the position of the urethrovesical junction, which appear more marked for the transvaginal tape procedures than for the Burch or fascial sling procedures. This study also questions the tension-free nature of the transvaginal tape procedures.The findings from this study should be confirmed in a larger prospective randomized trial with longer patient follow-up.     

Sonographic urethrocystography — Methods and application in patients with genuine stress incontinence

Radiologic urethrocystography has recognizable disadvantages including the risk of excessive irradiation, the time required for the test, and the discomfort of the patient. In women with genuine stress inontinence sonographic urethrocystography provides similar information to that obtained by conventional radiological procecdures without side effects. Among the numerous techniques, perineal scanning and introital sonography are particularly suitable for dynamic examination of the bladder, the urethra, and the urethrovesical junction. Moreover, concomitant sonographic urethrocystography complements pressure measurement regardless of the type of urodynamic investigation, and thus helps to exclude tonometric artifacts. All the sonographic observations are easier to review from video records than from still pictures. Ultrasound is helpful for selection of the proper operative procedure and above all can be applied during surgical correction of female incontinence, irrespective of vaginal or abdominal approach.     

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

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

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

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

Low Valsalva Leak-Point Pressure and Success of Retropubic Urethropexy

The aim of this study was to determine whether an isolated low Valsalva leak-point pressure (VLPP) is predictive of intrinsic sphincter deficiency (ISD) and can be an independent risk factor for retropubic urethropexy failure in patients with a normal maximal urethral closure pressure (MUCP). Twenty-four women with urodynamically proven genuine stress incontinence with low VLPP (<60 cmH₂O) and normal MUCP (>20 cmH₂O) were evaluated subjectively and objectively by complex urodynamic testing before and after undergoing a modified Burch urethropexy. Success rates were then compared to historical success rates for subjects with ISD treated with retropubic urethropexy using an exact one-sample test for binomial proportions. Patients were followed postoperatively for a mean of 11.1 months, with a range of 5–16 months. Twenty-two of the 24 (91.7%) were continent on postoperative cystometry. This differs significantly from the published success rates of 50% (P<0.001), if a low VLPP alone were predictive of ISD. Retropubic urethropexy was successful in the majority of our patients with genuine stress incontinence with a low VLPP and normal MUCP.     

Factors associated with the presence of genuine stress incontinence in females

Forth-five premenopausal women were enrolled in the study. All patients underwent a complete diagnostic evaluation, which included the completion of a standardized questionnarie, a detailed history, a complete physical examination and multichannel urodynamic testing. Clinical findings and urodynamic parameters were recorded. Logistic regression analysis and ² comparisons were used to determine which factor(s) were most associated with the presence of genuine stress incontinence. Thirty patients had genuine stress incontinence, and 15 asymptomatic volunteers without subjective and objective lower urinary tract dysfunction served as controls. A significant difference in age, maximum urethral closure pressure, strength of cough and bladder-neck mobility was found between the two groups. Logistic regression analysis revealed that bladder-neck mobility was the variable most associated with the presence of genuine stress urinary incontinence. This study supports the concept the genuine stress incontinence is probably multifactorial, and its etiology remains unknown.Editorial Comment: This is one of the few studies that has attempted to correlate possible etiologic factors for genuine stress incontinence in both symptomatic subjects as well as asymptomatic controls. The factor found to be most associated with stress incontinence was the mobility of the urethrovesical junction, as measured by the angle of the Q-tip from the horizontal, when compared to the controls. We should not be misled by this, however, since hypermobility is so common that many patients have this anatomical abnormality without ever having stress incontinence. The diagnosis of stress incontinence cannot therefore be made by the simple presence of urethral hypermobility. The authors correctly conclude that the etiologic factors in stress incontinence are multifactorial, and the collage of information presented by the patient in both clinical and urodynamic terms must be considered in the determination of the ultimate diagnosis.     

Comparison between two laparoscopic retropubic urethropexy

BACKGROUND: To compare two different transperitoneal laparoscopic urethropexy procedures. METHODS: In this prospective randomized open trial, 60 women affected by genuine stress incontinence were enrolled and randomized in two groups of surgical technique. Group A was treated with transperitoneal laparoscopic retropubic urethropexy using non absorbable sutures, and group B with prolene meshes fixed with tackers or staplers. The failure rate was defined subjectively and objectively. The subjective evaluation was performed asking the patients if they had urine loss and expressing the symptomatology using a visual analog scale before surgery and after each follow-up visit. The objective evaluation was performed with clinical evaluation and/or with the use of multichannel urodynamic studies. RESULTS: No significant differences in intra- operative and postoperative complications between the two groups were observed. The subjective failure rate was not significantly different between the two groups at 3, 6, and 12 months from surgery. At 3 and 6 months follow-up, the objective failure rate was not significantly different between the two groups. Moreover, at 12 months from surgical procedure the objective failure rate was significantly lower in group A than in group B. CONCLUSIONS: Transperitoneal laparoscopic retropubic urethropexy performed using sutures is more effective than the mesh technique.     

Visual assessment of urethrovesical junction mobility

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