A Comparison of Urethral Profilometry using Microtip and Fiberoptic Catheters

This paper compares urethral profilometry measurements using two different types of catheter: the Millar microtip transducer and the FST fiberoptic catheter. Outcome variables were functional urethral length (FUL), maximum urethral closure pressure (MUCP), and mean pressure/transmission ratio (PTR). Thirty women presenting to the urodynamics laboratory with symptoms of stress urinary incontinence were evaluated with both catheters. All subjects underwent two passive urethral pressure profiles and two dynamic (cough) urethral pressure profiles with each catheter. For FUL and MUCP, the means of the two passive measurements were compared between catheters. For PTR, the means of the two dynamic measurements were compared between catheters. There was no difference in FUL between the two catheter types. The FST measurements of MUCP and PTR were lower than the microtip measurements. Twenty per cent of patients would have been diagnosed with low-pressure urethra with the FST catheter, but not with the microtip catheter. Caution must be used when applying urethral measurements taken with the fiberoptic catheters to standards set with microtip catheters.     

Effect of narcotic anesthesia and skeletal muscle paralysis on passive and dynamic urethral function of stress continent and incontinent women

The aim of this study was to assess the importance of conscious skeletal muscle activity on the resting and stressed urethral sphincteric mechanism in stress continent and stress incontinent women. We evaluated the effects of loss of consciousness induced by a narcotic-based general anesthetic technique, with and without concurrent skeletal muscle paralysis, urethral sphincteric function. Nine premenopausal women who underwent vaginal hysterectomy without continence surgery had passive and dynamic urethral pressure profilometry performed within 24 hours before surgery, while asleep and totally paralyzed following endotracheal intubation before the start of surgery, while asleep and totally nonparalyzed at the end of surgery, and at the time of discharge from the hospital on the second or third postoperative day. Five subjects were stress incontinent and four had mild genuine stress incontinence but did not desire continence surgery with their hysterectomy. Measurements analyzed included urethral maximum closure pressure (MUCP) and functional length (FUL) from the passive profiles and bladder to urethra pressure transmission ratios (PTR) for each quarter of the urethra from the dynamic profiles. We found significant attenuation of urethral sphincteric function with stress due to muscle paralysis and loss of consciousness independent of muscle paralysis. Passive urethral function was more significantly depressed by paralysis than by loss of consciousness. These changes were statistically sifnificant only in stress continent subjects and not in the stress incontinent subjects, an observation that supports other evidence suggesting that there are important neuromuscular components in the pathogenesis of stress incontinence.     

Value of urethral pressure profilometry in the female incontinent patient: a prospective trial with an 8-channel urethral catheter

Objectives. To measure the pressure profiles at different positions of the urethral circumference simultaneously.Methods. Twenty-two women with symptoms of genuine stress incontinence underwent urogynecologic assessment and multichannel urethral pressure profilometry (UPP) at rest with a specially designed 8-channel urethral catheter with radial openings.Results. The distribution pattern of maximum urethral closure pressure (MUCP) and functional urethral length (FUL) values were significantly different (P = 0.004 and P = 0.0004, respectively). Most of the highest MUCP values per patient were found between channels 2 and 4 (P = 0.015); most of the greatest FUL values per patient were found between channels 3 and 4 (P = 0.15).Conclusions. The data of our study substantiate asymmetric radial pressure distribution within the urethra and underline the necessity of cautious interpretation of results of conventional single-channel UPP, which might vary because of transducer orientation.     

Mechanism of Postoperative Urinary Continence

Stress incontinence used to be attributed mostly to urethral hypermobility, and consequently most surgical techniques focused on the region of the bladder neck and proximal urethra. This article reviews our knowledge about the mechanism of postoperative urinary continence based on anatomic, imaging and urodynamic studies. Reduction of urethral mobility, as measured by cotton swab testing or imaging studies, is not the only reason why continence surgery succeeds. Imaging techniques are of limited value for elucidating the continence mechanism because radiologic landmarks and criteria are not reproducible. Urodynamically, the increased pressure transmission after successful continence surgery is attributed to the retropubic repositioning of the urethra, its compression against the anterior vaginal wall, and improved transmission of intra-abdominal pressure during stress. The role of the ‘functional’ urethral obstruction remains to be studied. In incontinent patients with hypermobility of the bladder neck and proximal urethra continence can be achieved by surgical correction. However, stress incontinence is possible in the absence of urethral hypermobility, and standard surgical techniques can fail to restore continence in these patients.     

The relationships of urethral and pelvic floor muscles and the urethral pressure measurements in women with stress urinary incontinence

OBJECTIVES: To investigate the relationships between urethral and paraurethral anatomy and urethral pressure measurements in women with stress urinary incontinence (SUI). MATERIALS AND METHODS: A total of 83 women with SUI and 33 with frequency urgency syndrome but not SUI were included in the study. The parameters of transrectal sonography of the urethra and urethral pressure profilometry were compared among the subjects with each of four types of SUI and non-SUI subjects. RESULTS: Videourodynamic study revealed that 26 women had type 0 SUI, 39 had type 1 SUI, 19 had type 2 SUI and 9 had type 3 SUI. The urethral striated muscular area was significantly smaller in subjects with type 3 SUI than in subjects with type 0 SUI and in non-SUI subjects. The thickness of the urethropelvic ligaments was thinner in subjects with SUI than in non-SUI subjects. Maximal urethral closure pressure (MUCP) was also significantly smaller in subjects with SUI than in non-SUI subjects. Pressure transmission ratio (PTR) was lower in subjects with type 1, 2 and 3 SUI than in subjects with type 0 SUI and no SUI. Pelvic floor contractility was significantly lower for subjects with type 3 SUI than for the other groups of subjects. Leak point pressure (LPP) showed a significantly progressive decrease from type 1 to 3 SUI subjects. CONCLUSIONS: This study found that SUI in women is a condition in which the urethral and paraurethral structures become progressively deficient. The intrinsic and extrinsic structural deficiencies result in a lower MUCP, smaller PTR, insufficient pelvic floor contractility on the urethra, and a lower LPP in SUI patients.     

Clinical and urodynamic features of intrinsic sphincter deficiency

AIMS: A prospective analysis of 92 patients with genuine stress incontinence was performed to identify the clinical and urodynamic features of intrinsic sphincter deficiency (ISD). METHODS: We divided the patients into two categories: 50 patients affected by pure ISD as they had severe stress incontinence and no urethral mobility; 42 patients suffering from stress urinary incontinence without ISD as they had mild stress incontinence and marked urethral hypermobility. Cystometry was normal in all patients. The presence/absence of ISD was considered the dependent variable and was correlated against the following independent variables: age, vaginal deliveries, menopause, previous urogynecological surgery and/or hysterectomy, supine stress test, irritative and/or obstructive symptoms, Valsalva leak point pressure (VLPP), maximum urethral closure pressure (MUCP), urethral functional length (UFL), and leakage during cystometry. RESULTS: The statistical analysis showed close correlations between ISD and age (P < 0.001), menopausal status (P < 0.001), previous surgery (P < 0.0001), supine stress test (P < 0.0001), leakage during cystometry (P < 0.001), and UFL (P < 0.01). The VLPP was below the cut-off value (相似文献   

Urethral pressure profile: Is it affected by position?

The aim of this study was to investigate the difference between sitting and standing passive urethral pressure measurements, and to determine the accuracy of urethral pressure profilometry in each position. Urethral pressure profilometry was performed in the sitting and standing position in 98 women. Stress incontinence due to urethral sphincter incompetence was demonstrated in 59 of whom 6 also had detrusor instability. The others were normal volunteers (7), women with a normal cystometrogram (23), and women with detrusor instability (9). MUCP tended to be higher in the standing than the sitting position but this did not reach statistical significance. Urethral lengthening appeared to occur on standing with a mean increase of FUL of 5 mm on standing. For both FUL and MUCP, there was a wide variation in the difference between sitting and standing values. There was poor reproducibility of measurements of MUCP and FUL in the standing position, limiting its clinical applicability. The difference between sitting and standing MUCP and FUL was not affected by age, parity, weight, height, BMI, or oestrogen status. In women with genuine stress incontinence, there was less difference between sitting and standing MUCP, but this explained only a small part of the variability. The increase in FUL in the standing position was unaffected by diagnosis.     

Urethral profilometry in women with uterovaginal prolapse

The aim of the study was to investigate the continence mechanism in women with uterovaginal prolapse by analysing urethral pressure profiles. Twenty-four women (mean age 59.0±11.9 years, mean parity 3.1±1.6) with prolapse underwent urodynamic evaluation. Urethral pressure profiles were obtained with prolapse and after reduction of the prolapse with a swab stick in the posterior vaginal fornix. After reduction the maximum urethral closure pressure (MUCP) and pressure transmission ratios (PTR) in all four quartiles of the urethra decreased, the position of the MUCP was shifted proximally and the functional urethral length was increased. Thirteen women reported a history of continence and 11 reported incontinence. Ten of 13 women (77%) who reported continence with prolapse were incontinent with their prolapse reduced. In these women, MUCP and PTRs in the first three quartiles of the urethra decreased significantly upon prolapse reduction. In the patients who reported incontinence with prolapse, only the MUCP decreased significantly upon prolapse reduction. Comparisons between the historically continent and incontinent women showed a statistically significant difference only for PTRs in the second and third quartiles of the urethra before prolapse reduction. Because the position of maximum urethral closure pressure before reduction was located in the distal half of the urethra in all patients, we conclude that direct pressure of the prolapsed mass on the urethra (rather than kinking) is the mechanism masking incompetence of the urethral closure mechanism in women with uterovaginal prolapse. The 77% rate of latent incontinence in this series suggests that women with severe pelvic relaxation should undergo careful urogynecologic evaluation before an attempt at surgical correction.Editorial Comment: Masked incontinence associated with genital prolapse is a well known problem for urogynecologists. The causes for this finding, e.g. kinking or compression, are not yet clear. The present study supports the compression theory. To gain a better understanding in the future, two points are important: to find a standard procedure for prolapse repositioning (pessary v speculum v swab stick) and to combine functional and radio- or sonomorphological findings in order to see whether compression and/or kinking occurs and with what consequences.     

Repeat mid-urethral sling for recurrent female stress urinary incontinence

Introduction and hypothesis

The aim of the study was to assess the effectiveness of repeat mid-urethral sling after a failed primary sling for stress urinary incontinence.

Methods

A total of 112 women with recurrent stress incontinence after primary mid-urethral sling underwent a repeat procedure between 2000 and 2011. All patients had a preoperative clinical and urodynamic evaluation. Outcomes were divided into three groups: cured (no more leaks), improved (decrease of leaks), or failed.

Results

All patients had urethral hypermobility and 12.9 % had intrinsic sphincter deficiency [maximum urethral closure pressure (MUCP)?≤?20 cmH₂O]. Median MUCP was 41 cmH₂0. Overactive bladder was found in 5.7 % of women. The second sling placed was one of the following: retropubic Tension-free Vaginal Tape (49 %), transobturator tape (48 %), or mini-sling (3 %). No intraoperative morbidity was reported. After the second sling was placed, 68 (60.7 %) patients were subjectively cured and 18 (16.1 %) improved (76.8 % success overall) with a mean follow-up of 21 months. Success rates were 72.2 and 81.8 % for transobturator and retropubic slings, respectively, with no significant difference. Multivariable analysis showed higher odds of cure and improvement with the retropubic approach after adjusting for MUCP. Late complication rates were comparable to those observed after a first sling. Urodynamic parameters were not associated with postoperative success.

Conclusions

Repeat mid-urethral sling for recurrent female stress urinary incontinence is nearly 77 % successful ?in a group of patients with persistent urethral hypermobility. ?A retropubic approach might be preferred for patients with low urethral closure pressures.     

排尿期尿道压力测定在膀胱出口梗阻疾病诊断中的应用

目的　研究排尿期尿道压力测定 (MUPP)在膀胱出口梗阻 (BOO)疾病诊断中的应用。方法　下尿路梗阻患者 4 5例 ,其中良性前列腺增生 (BPH) 38例 ,前尿道狭窄 3例 ,女性尿道狭窄 4例。对照组为健康志愿者 4例。按常规方法行压力 流率测定 ,静态尿道压力测定 (UPP)及MUPP。以压力下降梯度计算梗阻程度。数据分析采用t检验。研究不同疾病梗阻患者尿道压力下降点及下降梯度 ,MUPP对梗阻部位的诊断价值 ,MUPP与压力 流率研究对可疑梗阻诊断的比较 ,MUPP与压力 流率研究判断梗阻程度的比较。　结果　对照组 2例男性 ,外括约肌以上尿道内压与膀胱内压力相等 ,尿道压在外括约肌处快速下降 ;2例女性 ,膀胱压与全部尿道压几乎相等 ,尿道末端 1cm处尿道压下降。 38例BPH患者最大排尿压增高 ,平均为 (99.33± 4 1.0 9)cmH2 O(1cmH2 O =0 .0 98kPa) ,尿道压力在膀胱颈或前列腺尖部下降。 3例前尿道狭窄患者后尿道近端压力与膀胱压相等 ,球部及远端尿道压力下降。 4例女性远端尿道狭窄患者尿道压力在狭窄远端区域下降。BPH、前尿道狭窄、女性远端尿道狭窄平均MUPP压力下降梯度分别为 (71.6 3± 37.4 1)cmH2 O、(43.5 1± 15 .71)cmH2 O、(41.4 8± 17.34)cmH2 O ,与正常对照组的 (2 4 .2 5± 2 .99)cmH2 O相比 ,差别有     

Predictive value of maximum urethral closure pressure, urethral hypermobility and urethral incompetence in the diagnosis of clinically significant female genuine stress incontinence

PURPOSE: We determined the value of urethral hypermobility, maximum urethral closure pressure (MUCP) and urethral incompetence in the diagnosis of stress urinary incontinence (SUI). MATERIALS AND METHODS: In this study 369 women with clinical symptoms suggestive of SUI without symptoms of bladder overactivity were evaluated in regard to urethral incompetence, urethral hypermobility and mean MUCP. The cohort was divided into 2 groups according to continence/incontinence status. ROC curves were used to test the performance of the various predicting factors. These factors were combined in forward stepwise logistic regression to find the cutoff point that simultaneously optimized sensitivity and specificity. RESULTS: Continent and incontinent patients differed with regards to urethral incompetence and hypermobility (each p <0.0001). Incontinent patients had a greater probability of a higher grade of each factor. Even after adjusting for the older age of incontinent patients by ANCOVA. MUCP was significantly lower in the incontinent group (p <0.001). The best univariate optimized cutoff point for discriminating continence from incontinence was obtained with urethral incompetence greater than grade I. CONCLUSIONS: The best single predictor of clinically significant SUI is urethral incompetence, followed by urethral hypermobility and MUCP. When combining several factors, namely grade II urethral incompetence with grade III hypermobility, grade III urethral incompetence with grades I to III hypermobility and grade IV urethral incompetence with or without urethral hypermobility, all indicated more than a 90% probability of clinically significant SUI.     

A new technique combining both polypropylene and vaginal wall sling procedures: can it minimize the risk of urethral and vaginal erosion occurring with synthetic materials?

We describe a new technique combining in situ vaginal wall and polypropylene mesh slings that may decrease potential erosive complications caused by synthetic materials. A folded mucosal patch harboring the polypropylene mesh was placed between mid-urethra and bladder neck. Using this technique, 12 consecutive women (age range 44–66 years) were operated. Preoperative evaluation included a detailed history, pelvic examination, stress test, cystourethroscopy, basic urodynamic evaluation (cystometry, Valsalva leak point pressure measurement), and urine culture. Based on these evaluations, three, seven, and two patients had type I, II, and III stress urinary incontinence, respectively. A paraurethral cyst excision was carried out in one patient and anterior colporrhaphy in four patients during the same operation. No ischemia or sloughing at the operation site occurred in any case. Pelvic examination was repeated in all patients after 3 and 6 months of follow-up and symptoms were determined after 12 months of follow-up in eight patients by telephone interview. Average follow-up was 10 months (range: 6–14 months). None of the patients were incontinent, or complained of sexual dysfunction or erosive complications after 1 year. Since there are two distinct barriers between the sling and both urethra and vagina, our technique covers all advantages of a sling procedure with synthetic materials and avoids the risk of urethral and vaginal erosion. The other advantage of this technique is the concomitant utilization of the vaginal wall as sling material.     

Urethral pressure measurement in stress incontinence: does it help?

Introduction and objectives  The resting urethral pressure profile (UPP), used for the assessment of women with stress incontinence, is routine in many urodynamic units. It is time- and effort-consuming, and its diagnostic value is controversial, as well as its value in the prediction of outcome of anti-incontinence surgery. Herein, we assessed its value in the prediction of the outcome of surgery. Patients and methods  Sixty women were randomized to fascial sling or TVT. Urodynamics were performed preoperatively, 6 months and annually thereafter. After filling and voiding cystometry, resting UPP was performed while sitting. Automated catheter pulling, at a rate of 1 mm/s, was adopted. Averaged readings were obtained. Comparison of maximum urethral closure pressure (MUCP) in success and failure, as well as in sling and TVT, was performed, utilizing ANOVA. Results  Preoperative MUCP and functional urethral length (FUL) were 72.9 ± 27.9 cmH2O and 2.4 ± 0.7 cm. At last follow-up, they were 71.1 ± 20.7 cmH2O and 2.7 ± 0.7 cm, respectively. The differences between sling and TVT as regards value of MUCP and FUL were not significant. The relationship of the outcome of surgery and UPP parameters showed no statistical difference. No significant effect was shown for the success of surgery, duration of follow-up, and interaction of outcome and time over MUCP (P = 0.82, 0.56 and 0.69, respectively) or FUL (P = 0.82, 0.11 and 0.67, respectively). Conclusion  The routine use of resting UPP has no added value in terms of the prediction of success of incontinence surgery. It does not help with follow-up and adds to the time and cost of the examination.     

Decrease in urethral pressure following repeated cough efforts: A new concept for pathophysiology of stress urinary incontinence

AIMS: To describe the decrease in maximum urethral closure pressure (MUCP) following repeated coughs in women with stress urinary incontinence (SUI). METHODS: MUCP was recorded at rest and after seven cough efforts in 70 women under age 40 referred for urodynamic investigation (47 women with SUI and 23 women without SUI). RESULTS: The intraclass correlation coefficient for repeatability was very good at 400 mL filling volume: 0.94 (95%CI: 0.85-0.98), as compared to the mean and standard-deviations of the MUCP measurements. A decrease in MUCP >20% after seven cough efforts was observed in 18(38%) patients in the SUI group and in just 1(4%) woman in the non-SUI group (P = 0.0069). CONCLUSIONS: Many women with SUI exhibit a sharp decrease in MUCP after repeated coughs. Many hypotheses may explain this phenomenon, including increased fatigue of the periurethral muscles.     

Electrical stimulated graciloplasty in the male goat: An animal model for urethral pressure measurement

The feasibility of dynamic urinary graciloplasty as a treatment for incontinence is currently investigated. Therefore an animal model is developed to improve the technique of dynamic urinary graciloplasty. This article is a report of the urethral pressure measurements in the male goat. This study compares the graciloplasty around the bulbous urethra with the graciloplasty around the bladderneck. The male goat as an animal model of urethral pressure measurements is discussed. Under anaesthesia in ten male goats the penile shaft outside the pelvis was dissected. Urethral pressure profilometry was performed. The bulbous urethra was dissected and a split sling graciloplasty was performed around the bulbous urethra. The contralateral gracilis was used for bladderneck graciloplasty. Urethral pressure profilometry was done without and with electrical muscle stimulation. The highest native urethral pressure was 136 cm water at the pelvic outrance. Without stimulation the bladderneck graciloplasty pressure was 97 cm water. The bulbous urethra graciloplasty pressure was 122 cm water. These pressures were not significantly different from the pelvic outrance pressure. With stimulation the highest bladderneck and bulbous urethra graciloplasty pressures were 183 cm water and 294 cm water respectively. The stimulated bulbous urethra graciloplasty pressure was significantly higher than the highest native urethral pressure. In conclusion, the male goat is a suitable animal model for urethral pressure measurement. The highest native urethral pressure is located at the pelvic outrance. A nonstimulated graciloplasty acts like a sling with regard to generated urethral pressure. With stimulation sphincterlike activity of the graciloplasty can be observed. In male goats the graciloplasty around the bulbous urethra is superior to the bladderneck graciloplasty. © 1996 Wiley-Liss, Inc.     

Urodynamic changes after tension-free sling procedures: Mycromesh-Plus® vs TVT sling®

Assortments of suburethral sling procedures have become increasingly important in the treatment of stress urinary incontinence (SUI). This study compared a consecutive series of patients undergoing two types of no-tension, midurethral sling procedures: a traditional pubovaginal technique and graft (modified polytetrafluoroethylene graft; Mycromesh-Plus® [MMP]) and the more recently introduced tension-free vaginal tape (TVT) sling. We observed for differences in success rates, urodynamic parameters, and complications of the two procedures. One group received a MMP sling, which was placed at the midurethra without tension. The other group underwent a minimally invasive TVT sling. Multichannel urodynamic studies were performed pre- and postoperatively. Cure rates for SUI were similar for the two groups (95 vs 95%). Urgency and urge incontinence symptoms improved substantially in both groups. Comparison of pre- and postoperative urodynamic indices demonstrated no differences in changes in average functional urethral lengths, changes in maximum urethral closure pressures, or improvement in pressure transmission ratios. Both groups showed a decrease in urethral mobility postoperatively. However, the TVT group demonstrated a lesser degree of change. While the TVT group did spontaneously void earlier than the MMP group (5.7 vs 9.7 days, p?相似文献   

Observations on the function of the female urethra: III: An overview with special reference to the relation between urethral hypermobility and urethral incompetence

AIMS: To analyze the relation between urethral hypermobility and urethral incompetence, and to summarize the interdependence between maximum urethral closure pressure (MUCP), urethral hypermobility, and urethral incompetence. PATIENTS AND METHODS: A group of 255 patients was selected from a large bank of cases. Inclusion criteria were age 20 years or above, no neurological disease, stable bladder, and no previous incontinence surgery or hysterectomy. The degree of hypermobility (cysto-urethrocele) and the degree of urethral incompetence (abdominal leak point pressure (ALPP)) were determined. Statistical analyses between urethral hypermobility and incompetence were performed with Spearman's correlation and the Jonckherre-Terpstra test. RESULTS: The Spearman's rank correlation test showed a statistically significant relation between urethral hypermobility and the degree of urethral incompetence (P = 0.0049). CONCLUSIONS: The statistically significant relation between urethral incompetence and hypermobility suggests that urethral incompetence will increase as the degree of urethral hypermobility does. Optimal conditions for urinary continence include a high maximum urethral closure pressure, absence of hypermobility, and a low degree of urethral incompetence. This last factor is assured by a strong support underneath the urethra permitting compression of the latter during straining. Failure of the urethral closure mechanism is highly probable with a diminished maximum closure pressure accompanied by urethral hypermobility often associated with a high degree of urethral incompetence. Clinically significant urinary incontinence may appear in many intermediate circumstances between these two extreme states, but stress urinary incontinence is essentially an activity-related phenomenon.     

Urgency of voiding and abdominal pressure transmission in women with mixed urinary incontinence

AIMS: To ascertain whether abdominal pressure transmission (a.p.t.) to the urethra would be affected by urgency of voiding in women with mixed urinary incontinence. METHODS: We urodynamically assessed 80 consecutive women. Group 1 (n = 40), with stress incontinence, had stable bladders and no urgency. Group 2 (n = 40), with mixed (stress + urge) incontinence and overactive bladders, were split into Groups 2A (n = 20) and 2B (n = 20) according to the delay time of urgent void at cystometry (CMG) equating at least 2 min (taken as an index of moderate urgency) or, respectively, less than 2 min (taken as an index of severe urgency). Nonparametric statistics checked for significant differences in a.p.t. and in pelvic floor (peri-urethral) muscle strength level. We defined a.p.t. at stress (cough) urethral pressure profilometry (UPP) by the pressure transmission ratio (PTR). Pelvic floor muscle strength was defined at "holding" UPP by the maximum urethral pressure developed during attempts "to hold urine" (hMUP). RESULTS: PTR was reduced in all women, but PTR (and hMUP) proved relatively higher in Group 2, though nonsignificantly different values of PTR (and hMUP) were seen in Groups 2B and 1. CONCLUSIONS: Transmission of abdominal pressure to the urethra was reduced in all of the incontinent women. The mixed incontinence group, however, had a relatively less reduced (active component of) a.p.t., most likely dependent on a greater pelvic floor (peri-urethral) muscle strength level secondary to frequent contractions in response to urgency. Yet, of the same mixed incontinence patients, those with the most severe urgency degrees had relatively low pelvic floor (peri-urethral) muscle strength levels (eventually resulting from muscle fatigue? or primarily due to peri-urethral tissue atrophy?), which prevented (the active component of) a.p.t. from increasing.     

In situ anterior vaginal wall sling formation with preservation of the endopelvic fascia for treatment of stress urinary incontinence

The indications for sling procedures have evolved and encompass patients with either intrinsic sphincteric deficiency (ISD), anatomic incontinence or both. We have refined a technique that can be performed in a minimally invasive fashion with low attendant morbidity to provide a reproducible method of sling formation. Twenty patients with stress urinary incontinence underwent the in situ sling (ISS) with bone fixation. Subsequent evaluation at 24–29 months (mean =26.2 months) revealed that 95% of patients were cured. No recurrent cystoceles, paravaginal defects or significant detrusor instability have been noted. Urinary retention appeared transiently in only 3 patients and resolved in under 3 weeks. We feel the in situ sling with bone fixation provides a safe and effective means of management for stress urinary incontinence. Furthermore, the reduced surgical dissection may minimize the incidence of postoperative ISD and recurrent paravaginal defects that may accompany more traditional needle suspension procedures.Editorial Comment: The authors present an interesting approach to the performance of a suburethral sling procedure which utilizes the anterior vaginal mucosa beneath the urethra as the supportive section of the sling, similar to the Raz vaginal wall sling technique. The patch is secured with sutures which are transported to the suprapubic site and attached to the symphysis pubis with bone anchors. Whether this procedure will provide longterm support to the urethrovesical junction will only be judged with time, and with prospective studies with pre-and postoperative objective urodynamic evaluation. The present study is truly an initial report of the technique, performed on a small group of patients with genuine stress incontinence or intrinsic sphincter deficiency with or without urethrovesical junction hypermobility. One major concern with any technique utilizing bone anchors attached to sutures coming from the perivaginal tissue following dissection of the anterior vaginal compartment is the potential risk of introducing pathogens to the bone, with resultant osteitis pubis or osteomyelitis.     

Tension‐free vaginal tape retropubic sling for recurrent stress urinary incontinence after Burch colposuspension failure

Objectives: To verify the efficacy and to clarify the mechanism of the tension‐free vaginal tape retropubic sling for recurrent stress urinary incontinence after Burch colposuspension failure. Methods: A total of 24 women having tension‐free vaginal tape retropubic sling placement for recurrent stress urinary incontinence after a previous failed Burch urethropexy were enrolled in the present study. Median follow up was 57 months (range 12–96). Pre‐ and postoperative urethral mobility and urodynamics were evaluated. Results: Preoperatively, all 24 patients had intrinsic sphincter deficiency and 14 had urethral hypermobility. Postoperatively, 15 patients were completely dry and two had a leakage of urine less than 5 g/h. The overall success rate was 70.8%. There was a significant postoperative increase of maximum urethral closure pressure (P < 0.001), and a decrease of average flow rate (P = 0.001) and urethral hypermobility (P < 0.001). When comparing successful with failure cases, only elevated maximum urethral closure pressure (P = 0.002) was significantly different. Multivariate logistic regression showed the change of maximum urethral closure pressure (P = 0.011) was the only independent parameter significantly correlated with the outcome of sling placement. Conclusions: Recurrent stress urinary incontinence with intrinsic sphincter deficiency after Burch colposuspension might be well treated with the tension‐free vaginal tape retropubic sling by effectively elevating the maximum urethral closure pressure.