Dynamic suburethral suspension with pedicled external oblique aponeurosis in the management of female urinary incontinence.

PURPOSE: Despite excellent postoperative continence with pubovaginal sling procedures, the resultant morbidities of de novo urgency and urinary obstruction due to sling tension remain valid concerns. The feasibility and outcome of dynamic suburethral suspension using bilateral strips of external oblique aponeurosis left attached medially to the anterior rectus sheath and joined beneath the urethra under no tension were determined. MATERIALS AND METHODS: Between May 1995 and April 1998, 25 women with stress urinary incontinence were evaluated and underwent a dynamic suburethral suspension procedure. All patients were followed annually with a 10-point questionnaire by an independent registered nurse who analyzed the results, complications and satisfaction outcome. RESULTS: At a mean followup of 26 months all patients (100%) were cured of stress incontinence. Associated urge incontinence due to detrusor overactivity persisted in 3 patients postoperatively and, thus, the overall postoperative cure/dry rate was 88% for the study group. Of the 18 patients with preoperative urgency 12 (66%) were cured postoperatively. De novo urgency developed in 1 patient after surgery. No patient had prolonged urinary retention. Overall 92% of the patients were satisfied with the outcome of surgery. CONCLUSIONS: This dynamic suburethral suspension procedure cured stress incontinence in the majority of patients with no resultant urinary obstruction. The mechanism of action is believed to work by providing a viable suburethral "backboard" of support and by dynamic lifting of the proximal urethra cradled by the fascial loop precisely at the time of abdominal strain. Pronounced urge incontinence due to detrusor overactivity is unlikely to benefit from suspension procedures.     

Mixed urinary symptoms: What are the urodynamic findings?

AIM: To define the urodynamic diagnoses of women with mixed urinary incontinence (MUI) symptoms. MATERIALS AND METHODS: Women with MUI symptoms were studied. They were divided into stress predominant MUI; urge predominant MUI; or equal severity of stress and urge MUI on the basis of the most severe symptom scored on the King's Health Questionnaire. The frequency of different urodynamic diagnoses for the all women with MUI and in each of the above groups was calculated. RESULTS: Overall 3,338 women were studied. Of these 49% (1,626/3,338) reported MUI symptoms and were included. In this group 29% (464/1,626) had stress predominant MUI, 15% (248/1,626) had urge predominant MUI and 56% (912/1,626) had equal severity of urge and stress MUI. On urodynamics 42% (665/1,626) had pure urodynamic stress incontinence, 25% (414/1,626) had pure detrusor overactivity, 18% (299/1,626) had both detrusor overactivity and urodynamic stress incontinence and 15% (248/1,626) had normal urodynamic studies. In those with stress predominant MUI, 82% had urodynamic stress incontinence; in those with urge predominant MUI, 64% had detrusor overactivity. The urodynamic diagnoses were significantly different for the different balance of symptoms (P < 0.05, Chi-Square test). In women with equal severity of urge and stress incontinence, 46% had detrusor overactivity while 54% had urodynamic stress incontinence. CONCLUSIONS: The relative severity of MUI symptoms from a symptom questionnaire significantly distinguishes between different urodynamic diagnoses. Women with urge predominant MUI are more likely to have detrusor overactivity while those with stress predominant MUI are more likely to have urodynamic stress incontinence.     

Development of de novo urge incontinence in women post sling: the role of preoperative urodynamics in assessing the risk

AIMS: The study was undertaken to investigate if there are specific identifiable risk factors on the preoperative history or urodynamics testing associated with an increased risk for the development of symptoms of de novo urge urinary incontinence after a minimally invasive sling procedure. METHODS: Two hundred eighty-one women who had undergone minimally invasive sling surgery for stress urinary incontinence between January 2000 and December 2003 were identified. The records of 92 patients were included in this review. RESULTS: Twenty-five patients (27%) reported urge urinary incontinence on postoperative questioning. Clinical and urodynamic parameters were correlated with the development of de novo urge urinary incontinence. Preoperative history parameters were not predictive of the increased risk of de novo urge urinary incontinence, with the exception of increased preoperative daytime frequency (OR 3.3 (1.2, 9.1)). Of 16 women whose detrusor pressure during the filling phase of cystometry exceeded 15 cm H(2)O, de novo urge urinary incontinence developed in 9 (56%) vs. 16 (21%) of 76 women, whose detrusor pressure was < or = 15 cm H(2)O (OR 4.6 (1.4, 15.0)). CONCLUSIONS: Directed patient history is only minimally helpful in the identification of women at increased risk for the development of de novo urge urinary incontinence, with the exception of the complaint of increased daytime frequency. Women with elevated detrusor pressure during the filling phase of cystometry were more likely to develop urge urinary incontinence postoperatively. Therefore, we suggest that preoperative urodynamic evaluation, and specifically detrusor pressure > 15 cm H(2)O may help identify patients at increased risk of developing de novo urge urinary incontinence following the minimally invasive sling procedure.     

Reference urodynamic values for stress incontinent women

OBJECTIVE: To determine reference urodynamic values for preoperative urodynamic studies in women undergoing surgery for pure or predominant stress urinary incontinence (SUI). MATERIALS AND METHODS: Six hundred fifty-five women with pure or predominant SUI were enrolled in a multicenter surgical trial and were randomized to undergo a Burch or autologous fascia sling procedure as part of the Urinary Incontinence Treatment Network (UITN) Stress Incontinence Surgical Treatment Efficacy Trial (SISTEr). Preoperative free uroflowmetry, filling cystometry, and pressure flow studies were performed in all women using a standardized research protocol and standardized urodynamic interpretation guidelines. We define the normal range of urodynamic values in this population as the values that encompass 95% of the results. RESULTS: In 655 women undergoing filling cystometry in the standing position, baseline vesical and abdominal pressures were between 12 and 60 cm H(2)O. The upper limit of detrusor pressure increase during bladder filling to maximum cystometric capacity was 16 cm H(2)O. Ten percent of women who qualified for stress incontinence surgery with a positive cough stress test on physical exam did not demonstrate urodynamic stress incontinence (USI) and less than 10% of subjects in this study demonstrated detrusor overactivity. CONCLUSIONS: Results from a large cohort of women with SUI are now available for quantitative plausibility assessments or as reference values when interpreting urodynamic studies.     

Analysis of early outcome: Burch procedure versus pubovaginal sling

The Burch vesicourethral suspension (BUVS) has long been the procedure of choice for female stress urinary incontinence (SUI) because of its low complication rate and high success rate for all but those patients with type 3 SUI. The pubovaginal sling (PVS) procedure yields a high success rate in those with type 3 SUI but has not gained wide use for all types of SUI, owing to initial reports of a higher complication rate. A retrospective review of early effectiveness and complications associated with BUVS performed on 36 women without type 3 SUI compared to that for PVS performed on 42 women (24 with and 18 without type 3 SUI) at our institution was carried out. To ensure reasonable comparability between groups, homogeneous subsets of 18 women undergoing BUVS and 18 women undergoing PVS were defined. Using conservative criteria for early complications. PVS patients experienced half the complications of BUVS patients with a comparable rate of success.Editorial Comment: The authors present short-term results of the Burch procedure performed for GSI with documented urethrovesical junction hypermobility compared to the results of the suburethral sling performed for any type of GSI, regardless of urethral function or bladder neck support. The real decision on surgical procedure is clearly stated to be which surgical department performed the operation. There are therefore more than two different patient populations undergoing different procedures by different surgeons. The short-term results presented by the authors indicate that the sling procedure, although more costly, has fewer complications than the Burch procedure, with equivalent success rates even when applied to patients with varying degrees of GSI. Other centers have consistently over time reported higher incidences of postoperative complications, including postoperative voiding dysfunction, detrusor instability, urinary tract infection and wound healing problems (when using foreign sling material), in association with the sling procedure. Added to the short follow-up time, the lack of objective postoperative evaluation and poor assessment of subjective patient response and change in quality of life, it is premature to conclude that the sling procedure should be performed on all patients with stress loss of urine with no preoperative urodynamic testing.     

Clinical and urodynamic outcomes of pubovaginal sling procedure with autologous rectus fascia for stress urinary incontinence

AIM: We report the clinical and urodynamic outcomes of the pubovaginal sling procedure with autologous rectus fascia for stress urinary incontinence (SUI) and determined the urodynamic parameters that could predict the occurrence of postoperative voiding difficulty. METHODS: Between 1998 and 2005, a total of 29 consecutive women with SUI underwent pubovaginal sling surgery with autologous rectus fascia. Patients were preoperatively and postoperatively evaluated with regard to symptoms and urodynamic findings including uroflowmetry (UFM), postvoid residual urine volume (PVR), filling cystometry (CMG) and pressure flow study (PFS). RESULTS: Overall SUI was cured in 23 patients (80%) and improved in 3 patients (10%). Three patients (10%) who developed persistent urinary retention or severe voiding difficulty after surgery underwent urethrolysis. Of 17 patients who had urgency before the pubovaginal sling, urgency was cured postoperatively in seven, while de novo urgency appeared in one patient. Maximum flow rate (Qmax) in UFM was significantly decreased (P < 0.05) and PVR was increased (P = 0.08) after surgery. PFS showed a significant increase in detrusor opening pressure and detrusor pressure at Qmax (P < 0.01) after surgery. Eight patients (28%) needed prolonged intermittent self-catheterization. Patients who had PVR >100 mL (P < 0.05) or Qmax < or = 20 mL/s (P = 0.09) in preoperative UFM were more likely to require prolonged intermittent catheterization after surgery. CONCLUSIONS: The pubovaginal sling procedure with autologous rectus fascia is an effective treatment for SUI. A comparison of preoperative and postoperative urodynamic parameters indicates an increase in urethral resistance after pubovaginal sling surgery. PVR >100 mL and Qmax < or = 20 mL/s before surgery are risk factors for postoperative voiding difficulty.     

Urodynamic characteristics of mixed urinary incontinence and idiopathic urge urinary incontinence

PURPOSE: To evaluate and compare the clinical and urodynamic findings in patients with either mixed urinary incontinence (MUI) or simple urge urinary incontinence (UUI). MATERIALS AND METHODS: A series of 100 consecutive female patients with MUI and UUI were identified from a database. Patients with neurogenic bladder, fistula, urethral diverticulum, prior urologic surgery or known urinary tract obstruction were excluded. All patients were classified according to the urodynamic classification of overactive bladder of Flisser et al. and all patients underwent history, physical examination, validated incontinence questionnaire, 24-hour voiding diary, 24-hour pad test, video urodynamic study (VUDS), and cystoscopy. RESULTS: A significantly higher proportion of patients with UUI exhibited detrusor overactivity at VUDS, (67% of the patients with UUI vs. 24% of the MUI, P < 0.05). Patients with UUI had fewer episodes of incontinence (6.7 vs. 4.2, P < 0.05) with slightly less objective urine loss (24-hour pad test 94 gm vs. 128 g of loss, P < 0.05) and voided at higher pressures (p(det) at Q(max) 21.4 vs. 15.6 cm H(2)O, P < 0.05). Patients in both groups had functional and urodynamic bladder capacities that were not statistically different. CONCLUSIONS: Women with UUI were more likely to exhibit detrusor overactivity but experienced fewer episodes of incontinence and less urinary loss when compared with women who had MUI. The "urge incontinence" component of MUI appears to be different than that of UUI, and suggests that urge incontinence may be overdiagnosed in patients with SUI who misinterpret their fear of leaking (because of SUI) for urge incontinence.     

Porcine small intestinal submucosa as a percutaneous mid-urethral sling: 2-year results

OBJECTIVE: To report the 2-year follow-up results on patients treated with a novel minimally invasive outpatient procedure for placing a mid-urethral sling, using porcine small intestinal submucosa (SIS). PATIENTS AND METHODS: Thirty-four women with urodynamic evidence of stress urinary incontinence (SUI, 19) or of SUI with a positive cough test (15) were treated. A curved ligature carrier was used to create a tract between bilateral suprapubic stab incisions and a 2-cm mid-urethral vaginal incision. A suture secured to each end of the SIS sling was placed through the eyelet of the ligature carrier. Extraction was used to position the sling at the mid-urethra, providing a backboard of support that was remodelled with ingrowth of the patient's autologous tissue. RESULTS: SUI was reportedly cured in 27 of the 34 women (79%) at the 2-year follow-up; three (9%) of those with no complete resolution were pleased with their results, because the improvement allowed them to wear an average one or fewer pads per day. One patient developed de novo urge incontinence. Three patients (9%) developed suprapubic inflammation at 10, 21 and 45 days after surgery; all resolved, but one had a recurrence of SUI. No prolonged retention, erosion or other complications were noted. CONCLUSIONS: Early results with the percutaneous mid-urethral placement of SIS are promising and potentially comparable with those after using synthetic minimally invasive slings.     

Long-term results of fascial sling procedure

In a retrospective study 108 patients (average age: 56.5 years) could be evaluated, who were treated with a fascial sling plasty because of pure genuine stress incontinence (n=90) or combined stress/urge incontinence (n=18). 72 patients (66.6%) had recurrent incontinence after previous surgery. The average follow-up was 5 years.Patients without previous surgery related to urinary incontinence (n=36) showed the best results and remained continent in 78% (n=28).Patients with 1 to 4 (average 1.4) previous surgical procedures because of incontinence (n=52) remained continent in 62% (n=32), and in those who had between 1 and 6 (average 3.6) previous surgical procedures using even alloplastic material the continence rate dropped to 60% (n=12). In patients with pure genuine stress incontinence the overall success rate was 74.7%, whereas in cases with a proven preoperative urge component, the success rate dropped to 37%. Fascial sling plasty is a very useful procedure to treat patients with primary and especially recurrent urinary incontinence, when a functional urethra is missing. However, one has to be very cautious with patients in whom a preoperative urodynamic evaluation shows detrusor instability.     

Outcomes of autologous fascial slingplasty procedure for treating female urinary incontinence

The aims of this study were to compare the pre- and postoperative urodynamic findings of the suburethral autologous rectus fascial sling procedure and to determine patient satisfaction with the procedure by telephone interviews. Eight-four female patients with urodynamic stress incontinence completed a multi-channel urodynamic study and pad test before and after the operation. Subjective and objective satisfaction were also recorded. Significant changes were noted in the stress maximal urethral closure pressure, pad test, voided volume, and peak flow rate (P < 0.05). The success rate was about 94%, and subjective satisfaction was about 72%. The most common complication was transient urinary tract infections. The suburethral sling resolved 50% of detrusor overactivity (DO), but de novo DO was 24%. The procedure combined with anterior colporrhaphy corrected or improved 97% of anterior vaginal wall prolapses (> or =stage II). This retrospective study demonstrates that suburethral autologous facial slingplasty has a high cure rate, high patient satisfaction, and is a less complicated procedure. It can also correct and prevent a recurrence of anterior vaginal wall prolapse when combined with anterior colporrhaphy.     

Functional results after the suburethral sling procedure for urinary stress incontinence: a prospective randomized multicentre study comparing the retropubic and transobturator routes

OBJECTIVES: To compare short-term functional outcomes, urodynamic parameters, and quality of life of transobturator and retropubic routes in the cure of urinary stress incontinence. POPULATION AND METHODS: This prospective, multicentre study involved 88 women undergoing suburethral sling procedure for stress urinary incontinence (SUI). The retropubic route (RPR) and the transobturator route (TOR) were used in 42 and 46 women, respectively. No difference in epidemiologic and preoperative urinary functional status (SUI stage, and pollakiuria, nocturia, and urgency rates) was found between the groups. Functional results and quality of life were evaluated before surgery and at 1, 3, 6, and 12 mo postoperatively. Urodynamic examinations were performed before and 3 mo after surgery. RESULTS: The mean follow-up was 10 mo. No difference in the rate of de novo urge incontinence and immediate and late voiding dysfunction was noted between the groups. No difference in the cure rate was observed between the groups (89.3% in the RPR group and 88.6% in the TOR group). RPR was associated with a significant decrease in maximum urinary flow and an increase in residual urine volume. Quality of life was significantly improved after surgery without difference between the groups. CONCLUSIONS: Retropubic and transobturator routes for treatment of female SUI have similar high cure rates and quality of life improvement. Because of advantages in the rate of complications and postoperative pain previously demonstrated on the same population, the transobturator route appears to be the best option for the treatment of urinary incontinence.     

An assessment of the surgical outcome and urodynamic effects of the pubovaginal sling for stress incontinence and the associated urge syndrome.

PURPOSE: We assessed the urodynamic changes after pubovaginal sling procedure for stress incontinence, particularly in regard to the associated symptoms of urgency, frequency, nocturia and urge incontinence, known as the urge syndrome. MATERIALS AND METHODS: A total of 85 women with proved stress incontinence underwent a pubovaginal sling procedure using rectus fascia between 1992 and August 1996. Of the women 41 (48%) had undergone previous anti-incontinence surgery and 59 (69%) had the associated urge syndrome. There was at least some degree of hypermobility in 51 cases and type III stress incontinence was diagnosed in 34. Patients were assessed with a questionnaire and video urodynamics preoperatively and 3 months postoperatively. Preoperative and postoperative ambulatory studies were performed in 25 cases. RESULTS: Of the 85 patients 83 (97%) were symptomatically cured of stress incontinence. The urge syndrome resolved in 32 patients (69%), almost all of whom had a closed bladder neck at rest. Overall bladder neck incompetence at rest decreased from 57 to 18% (p<0.001). Of 27 patients with the persistent urge syndrome postoperatively 9 (41%) had an open bladder neck at rest compared to 4 of 50 (8%) without urge incontinence (p<0.01). Despite symptomatic control of stress incontinence in 83 patients (97%), only 66 were satisfied with the surgical result, mainly because of the persistent urge syndrome in 27. Despite care to avoid obstruction overall, there were statistically significant obstructive changes in detrusor pressure at maximum flow rate, maximum flow rate and residual urine volumes. CONCLUSIONS: The pubovaginal sling is effective in curing genuine stress incontinence and, when correctly placed at the right tension, the associated urge syndrome also can be managed, usually by achieving bladder neck closure at rest. However, despite careful maneuvers, obstruction occasionally persists.     

Gore-tex sling urethral suspension in type III female urinary incontinence: Clinical results and urodynamic changes

The authors prospectively evaluated 24 consecutive female patients with type III stress urinary incontinence, ranging in age from 36 to 70 years (mean 55 years). All patients were operated upon and had a vesicourethral suspension by a Gore-Tex suburethral sling. All were evaluated urodynamically 6 and 30 months after surgery. In this group of patients clinical cure of incontinence was observed in 83.3% (20) and in the remaining 4 patients it was significantly improved. In 2 patients there was an erosion of the urethra and the sling had to be removed 3.5 years later. Five other women remained dry but complained of occasional irritative symptoms, and several urinary tract infections were recorded (2–3 per year), which were documented by positive urine cultures. In the remaining 17 patients no erosion was observed and no irritative symptoms were reported. The urodynamic evaluation revealed an excellent postoperative result both 6 months and 30 months after surgery. EDITORIAL COMMENTS: This study reports the author’s experience with the use of the Gore-Tex suburethral sling procedure in women with type III stress incontinence, excluding patients with urethrovesical junction hypermobility. Diagnosis is based on videourodynamic criteria, as is postoperative follow-up and the definition of cure/failure. It is interesting that the technique used specifically refrains from placing extensive tension on the sling, although extra sutures are placed attaching the sling to ‘fascial tissue in the vicinity of the puboiliac bone’, even including the periosteum. Typically the use of a sling procedure in patients with a fixed drainpipe urethra has been based on the obstructive characteristics of the sling, rather than giving support to an already well supported urethrovesical junction. Previous reports have described postoperative voiding dysfunction requiring intermittent self-catheterization, recurrent urinary tract infections, elevated postvoid residuals and detrusor instability as possible consequences of ‘tight’ slings. Hints that these sequelae did occur in the study population include the high incidence of urinary tract infections and detrusor instability (persistent and de novo), and the fact that 2 patients required removal of the sling because of erosion into the urethra. Although the authors report a significant cure rate (84%) of stress incontinence, clearly this report again cautions against the use of slings in patients with ISD and a well supported bladder neck.     

Long-term surgical results of pubovaginal sling procedure using polypropylene mesh in the treatment of stress urinary incontinence

INTRODUCTION: Surgery for stress urinary incontinence (SUI) in women might cure incontinence symptom but develop new problems. This study assessed the long-term outcome of pubovaginal sling procedure using polypropylene mesh in patients with SUI. MATERIALS AND METHODS: A total of 108 patients with various types of SUI received pubovaginal sling procedure using polypropylene mesh. A surgical technique that did not create bladder outlet obstruction after operation was used in all the patients. Video urodynamic study was performed at baseline, 2 weeks and 3 months after operation. The long-term surgical results and patients' satisfaction were assessed. RESULTS: The age of patients ranged from 33 to 94 years (mean 62.6 +/- 12.0 years). The follow-up period ranged from 24 to 72 months (median 46 months). Among the 108 patients, a successful result was noted in 92 (85.2%), including a continence rate of 65.7% and mild SUI in 19.4% of patients. Treatment failure was noted in 16 patients (14.8%), including 13 (12%) with urge incontinence and 3 (2.8%) with severe SUI that was cured by a second sling. There were 104 patients (96.3%) who could void volitionally with little residual urine, whereas 4 (3.7%) needed transvaginal urethrolysis. Urodynamic study revealed no significant changes in the mean values of parameters at 3 months after operation. However, 22 (20%) patients had an increase in voiding pressure by 50% at 3 months postoperatively. The reported satisfactory rate was 89.8%. CONCLUSIONS: Pubovaginal sling procedure using polypropylene mesh had a high success rate in all types of SUI. The continence rate was suboptimal, indicating that the absence of bladder outlet obstruction might result in inadequate urethral compression after pubovaginal sling procedure.     

Voiding dynamics in women with stress urinary incontinence and high‐stage cystocele

Objectives: The aim of this study was to identify the urodynamic features of women with stress urinary incontinence (SUI) or with high‐stage (stage 3 or greater) cystocele (HSC) as compared with symptom‐free women. Methods: Fifty‐six neurologically intact women with SUI and 47 women with HSC but without SUI were prospectively evaluated. All patients underwent full urodynamics, in addition to basic clinical evaluations. The urodynamic parameters of SUI and HSC were compared to the ones obtained from 78 urologically symptom‐free normal women over the same period. Results: Patients with HSC, after correction of cystocele using a temporary vaginal pessary, had consistently lower maximum urinary flow rate with a lower detrusor pressure during micturition than the controls or those with SUI. On the other hand, patients with SUI had an equivalent to higher maximum urinary flow rate, normal detrusor contraction strength with a lower detrusor pressure during micturition than the controls. Both maximum Watts factor and bladder contractility index were significantly lower in the whole HSC cohort in comparison to the controls and patients with SUI. The urodynamic characteristics observed among the three groups were all maintained even after adjusting for age. Conclusions: Women with SUI demonstrate voiding with low‐pressure, normal contraction strength with an equivalent to high urinary flow rate. Women with HSC demonstrate voiding with low pressures with weak contraction strengths and low urinary flow rates, suggesting a higher prevalence of detrusor underactivity. Chronically decreased or increased urethral resistance might alter voiding dynamics and performance.     

Stress incontinence surgery for patients presenting with mixed incontinence and a normal cystometrogram

OBJECTIVE: To evaluate the outcome of surgery for stress urinary incontinence (SUI) in patients presenting with a combination of stress and sensory urge UI. PATIENTS AND METHODS: The study comprised 75 women presenting with mixed incontinence; the most important inclusion criterion was a negative cystometrogram for detrusor overactivity. Based on random selection, a third of the patients received a 6-month course of anticholinergic treatment (group 1) and 50 (group 2) had surgery for SUI. The surgical procedure depended on the Valsalva leak-point pressure (VLPP); those with a VLPP of > or = 90 cmH2O underwent Burch retropubic bladder neck suspension (group 2a, 24 patients) while 26 (group 2b) with a VLPP of < 90 cmH2O had pubovaginal sling (PVS) surgery. A further group of 20 patients with pure SUI (no urge UI) underwent surgery (PVS in 12 and Burch in eight) as a control group (group 3). After at least 6 months of follow-up (mean 9.3, sd 1.7), 68 patients were evaluable; they were assessed subjectively and objectively for dryness, and by a urodynamic evaluation and quantitative assessment using the SEAPI scoring system. RESULTS: In group 1 none of the patients became completely dry; there was persistent stress with and without urge UI in nine (43%) and 12 (57%) of the available 21 patients, respectively. Only three of those who had persistent SUI with no urge in the whole study group were satisfied and chose to continue anticholinergic therapy despite SUI. In this group the mean (sd) improvement in the subjective and objective SEAPI score was 3.4 (1.0) and 2.3 (3.8), respectively. In group 2a, 20 of the available 23 patients (87%) became completely dry (both stress and urge continent). The mean improvement in the SEAPI scores was 7.8 (0.9) and 7.8 (1.3), respectively. In group 2b, 20 of the 24 patients (83%) became completely dry, with mean improvements in SEAPI scores of 8.2 (0.4) and 7.9 (0.3), respectively. The improvement was statistically significant after surgery, vs anticholinergic therapy, for all variables (P < 0.05). The incidence of persistent urge UI was highest in group 1 (43%), being 13% in group 2 (13% and 12% in 2a and b, respectively). In group 3 there was de novo urge UI in four of the 20 patients, and not significantly different from that in group 2. CONCLUSION: Most patients with mixed stress and urge UI and a normal cystometrogram were cured of both symptoms by surgery. The incidence of residual urge in such patients was no higher than that of de novo urge after surgery in patients with genuine SUI.     

Resolution of urge symptoms following sling cystourethropexy

PURPOSE: Persistence of urinary urge symptoms in women after pubovaginal sling cystourethropexy is a distressing problem. We assess the ability of preoperative video urodynamics to identify patients in whom urinary urge symptoms failed to resolve postoperatively. MATERIALS AND METHODS: The records of 84 consecutive women who had undergone pubovaginal sling cystourethropexy were reviewed. Preoperative video urodynamics revealed stress urinary incontinence in all cases and concomitant detrusor instability in some. Cases of motor urge, defined as urge symptoms plus detrusor instability, were divided into low and high pressure categories. Patients with urge symptoms but no demonstrable detrusor instability on video urodynamics were diagnosed with sensory urge. Postoperatively complete urge resolution was defined as total absence of symptoms without pharmacological therapy. Mean followup was 26.7 months (range 2 to 62). RESULTS: Of the 84 patients 41 with motor urge and 28 with sensory urge had preoperative urge symptoms. Complete resolution or improvement in urge symptoms occurred in 24 (58.5%) and 7 (17.1%) of the motor urge, and 11 (39.3%) and 9 (32.1%) of sensory urge cases, respectively. Of the 41 patients with motor urge 23 had low pressure instability, which completely resolved in 21 (91.3%) and improved in 2 (8.7%). Of the 18 remaining patients with high pressure motor urge only 5 (27. 8%) had complete resolution of urge and 5 (27.8%) had improvement. CONCLUSIONS: Our results suggest that patients with low pressure motor urge are significantly more likely to experience resolution of urinary urge symptoms after pubovaginal sling cystourethropexy than those with high pressure motor urge or sensory urge.     

The impact of detrusor overactivity on the management of stress urinary incontinence in women

The presence of overactive bladder symptoms, urodynamic detrusor overactivity, and urge incontinence can complicate the diagnosis and management of stress urinary incontinence in women. The exact pathophysiology of mixed incontinence is not well characterized; in some patients, the stress and urge etiology may be pathologically linked. The role of urodynamics in evaluating patients with mixed incontinence remains controversial. Conservative therapies, such as bladder training, pelvic floor exercise, biofeedback, and electrical stimulation, offer moderate success in women with mixed incontinence. Surgery (colposuspension, bladder neck pubovaginal slings, and midurethral slings) offers excellent subjective and objective cure rates in patients with mixed incontinence. Preoperative detrusor overactivity is cured consistently ≥ 50% of the time with colposuspension and slings. Overall, the presence of preoperative detrusor overactivity does not appear to significantly worsen the outcome of conservative and surgical treatments for stress urinary incontinence in women.     

Overactive bladder symptoms after midurethral sling surgery in women: Risk factors and management

Introduction

Overactive bladder syndrome (OAB) including urgency and urgency urinary incontinence (UUI) occurs frequently after stress urinary incontinence (SUI) surgery. It is important to identify the risk factors for the occurrence of OAB symptoms in order to adequately inform the patient before surgery. Furthermore, when facing OAB after sling surgery it is crucial to know how to manage these symptoms.

Methods

We conducted a literature review in order to assess the risk factors and management of OAB symptoms after SUI surgery. We searched for relevant articles in PubMed that specifically addressed the topic of OAB symptoms after midurethral sling surgery.

Results

The incidence of de novo and persistent urgency and UUI is reported around 15% and 30%, respectively. Several studies demonstrated that women with mixed incontinence who have a predominant urge component will have worse outcomes after surgery. Older age was also found to be a predictive factor in three studies. Furthermore, urodynamic signs of overactive bladder (eg, DO, low bladder capacity, elevated detrusor pressure) can predict postoperative urgency or UUI. The management of OAB symptoms after SUI surgery is essentially the same as in idiopathic OAB. However, before commencing therapy it is crucial to rule out other factors than can cause urgency, including bladder outlet obstruction, urinary tract infection, or sling erosion.

Conclusions

OAB symptoms are frequently reported after sling surgery. Women with mixed incontinence and older women are at risk of developing post‐operative OAB symptoms. We have proposed an algorithm for the treatment of these symptoms which can be useful in clinical practice.     

A microbiological and immunohistochemical analysis of periurethral and vaginal tissue in women with de novo urge symptoms after mid-urethral sling procedures—a prospective case-controlled study

The aims were to determine whether bacteria-infection-elicited immune response after mid-urethral sling (MUS) may cause de novo urge symptoms (DNUS) and to evaluate the efficacy of suburethral sling excision for relieving the urgency. In a period of 40 months, 360 consecutive subjects with urodynamic stress incontinence had undergone one of three different MUS. Sixty-eight women with DNUS were included after exclusion. The suburethral sling of 24 of the 68 women needed to be excised because of refractory urgency. The excised vagina, or periurethral tissue, included sling of the study and control groups were sent for microbiological and immunohistochemical analyses. Statistically significant differences in the cell density percentage of CD68, CD25, CD4+CD25 and positive rate of Gram (+) bacteria were noted between two groups (p=0.024, p=0.053 and 0.016, respectively, p<0.001). The success rate of sling excision was 80.2%. In conclusion, bacteria-infection-related immune hyperreactivity might explain the pathologic basis of DNUS after MUS.