A new colpocystourethropexy for female stress urinary incontinence

A new technique for the treatment of female stress urinary incontinence is described. It consists of colposuspension obtained by suprapubic placement of two double monofilament sutures in a spiral fashion on the lateral vaginal walls, which are fixed proximally to a Cooper's ligament and tied distally one to the other over the rectus fascia. This technique has been successfully employed in a preliminary series of 26 patients and it appears to be easy to perform and with a wide application range.     

Colpovesical neck suspension for the correction of female stress urinary incontinence

A new surgical approach for the correction of female urinary stress incontinence has been devised. The retropubic space is entered through a dome-shaped incision in the vaginal vestibule. The bulbocavernosus muscles are separated from the urethra and the layers of the genitourinary diaphragm are opened beginning behind the symphysis pubis. The retropubic cavity is exposed and the junction of the vesical neck and vagina is identified. Double helical bites with 2-zero polypropylene sutures are taken from each side of the junction. The 2 ends of the sutures are brought ventrally with a suture carrier through a small incision just above the symphysis pubis in the midline and tied. This procedure moves the bladder neck forward and upward to the desired level by observing movement of the bladder neck through the vestibule. Of 20 patients treated 17 are fully continent and 3 remain much improved after 2 years.     

A new method for correction of urinary stress incontinence in women

Twenty-two patients with urinary stress incontinence confirmed by urodynamic recordings were operated on by using absorbable Dexon sutures combined with a two-component fibrin sealant, which induced fibrosis, for the fixation of the urethrovesical junction to the retropubic periostium. The postoperative observation period ranged from 12 to 30 months, and so far no relapses or complications have been observed.     

Long-term results of surgical treatment for female stress urinary incontinence

OBJECTIVE: To compare the long-term success rates of bladder neck suspension (BNS) and pubovaginal sling procedure in different types of female stress urinary incontinence (SUI) in order to identify appropriate treatment strategies for SUI. METHODS: A total of 157 women who received anti-incontinence surgery were followed-up for a mean period of 58.1 +/- 33.9 months. The surgical outcome was analyzed and was compared among the different types of SUI and among BNS and pubovaginal sling procedures. RESULTS: SUI was classified as type I in 16 patients, type II in 111 patients, and type III in 34 patients. Surgical procedures included Gittes BNS (n = 62), Raz BNS (n = 53), and pubovaginal sling procedure (n = 42). The total success rate was 77.1%, including a 38.2% cure rate and a 38.9% significantly improved rate. Analysis of the results revealed that type III SUI had the lowest success rate (67.6%), while the pubovaginal sling procedure had the best success (93.9%) and cure rates (54.8%). The success rates of BNS were significantly lower than that of pubovaginal sling in type III SUI, less favorable in type II SUI, but remained high in type I SUI. 75% of patients with treatment failure had recurrence within the fist postoperative year. CONCLUSIONS: In this series of patients, the long-term cure rates of anti-incontinence surgeries are not satisfactory. BNS procedures had satisfactory results only in type I SUI while the pubovaginal sling procedure had better results in both types II and III SUI. The pubovaginal sling procedure might have better long-term results in the treatment of all types of SUI.     

Minimally invasive surgical treatment of female stress urinary incontinence

The purpose of this study was to evaluate the safety and efficacy of a new minimally invasive surgical procedure for the treatment of female stress urinary incontinence (SUI). Four miniature bone anchors, each attached to a suture, are inserted transvaginally into the retropubic bone using an inserter on each side of the urethra without opening the vaginal mucosa. Tying the suture on each ipsilateral side creates colposuspension, as is the aim of previously described procedures such as the Marshall-Marchetti-Krantz. Sixty-one women (mean age 52±SD 9.9 years) with a mean follow-up of more than 12 months (range 12–30 months) were treated for SUI. Fifty patients (82%) are dry, 7 (14%) reported great improvement and 4 are considered surgical failures. The data presented suggest that our new minimally invasive procedure provides an effective treatment for female SUI. Its main advantages over other procedures are the transvaginal approach and short operating time.Editorial Comment: The search for the best surgical therapy for stress urnary incontinence continues with this presentation of a minimally invasive procedure involving no vaginal incisions, bone anchors and the tying of sutures in the vagina. The study is well designed except for a few issues that are important for the long-term determination of the viability of the procedure. Of particular importance is that the authors recognized that osteomyelitis is a problem with bone anchor procedures, and therefore used a 3-day 91 day preoperative and 2 postoperative) coverage of antibiotics, consisting of a thirdgeneration cephalosporin and gentamicyin, which is required to achieve therapeutic levels of antibiotic in bone. Bone anchor procedures have to date been done in a relatively contaminated environment, either by pulling sutures in and out of the vagina into the retropubic space or, as in this study, by directly penetrating the vaginal wall with bone anchors, with the attendant risk of driving bacteria into the bone along with the anchor. Postoperative X-rays were not done routinely to detect osteomyelitis, so that the true incidence of this problem remains unknown. Patients must be informed of this major potential complication and that the frequency is low, but yet an exact estimation of this frequency cannot be made. One case in 70 has been reported with the Vesical bone anchor procedure, by Appell [1]. The two major problems with this study are the lack of prospective comparison to a standard operation for stress incontinence, and the lack of objective postoperative follow-up. The success rate stands at 80% at 12 months based on mostly subjective data. The literature is clear that objective success rates are always lower than subjective success rates, so the objective success rate of this procedure may be lower. In this study pad testingor counts were used to determine success. Unfortunately, the exact type of pad test is not specified. Objective documentation of lack of urine loss under specific volumes of bladder filling and stress maneuvers was not done. Pad counting alone introduces a new element of subjectivity into the postoperative follow-up. Of concern with any minimally invasive procedure is that the retropubic space is relatively unviolated, and little occurs that may induce scarification of the paraurethral tissue to the pelvic sidewall or the retropubis. It is well known that sutures in tissue under tension tend to pull through tissue. All retropublic urethropexies suffer from this problem, and reliance on patient rest until enough scarification occurs is necessary to ensure a reasonable chance of success. Concern with this procedure is that in the long term sutures may pull through, with little chance for scarification to occur. Future reports from the authors on this same group of patients will be necessary to answer these concerns, along with more objective postoperative determinates of success.     

经阴道无张力性尿道中段悬吊术治疗女性压力性尿失禁10例分析

目的：探讨经阴道无张力性尿道中段悬吊术(TVT)在治疗女性压力性尿失禁中的意义。方法：10例患者，年龄45—58岁，平均48．4岁。临床表现为用力、咳嗽等时尿液不自主流出。病史4个月-15年。经详细地尿动力学检查证实为压力性尿失禁。行腹压漏尿点压(abdominal leak-point pressure，ALPP)测定，按照McGuire的方法分型，ALPP＞9．81kPa(I型)2例，ALPP6．38—9．81kPa(Ⅱ型)3例，ALPP＜6．38kPa(Ⅲ型)5例。结果：术后10例均无尿失禁，8例患者拔除导尿管当日即可顺利排尿，1例出现尿潴留，1例膀胱穿孔。结论：TVT手术安全易行，手术时间短，创伤小，患者康复快，治疗压力性尿失禁近期效果确切，远期疗效有待进一步研究。     

Laparoscopic correction of stress urinary incontinence

The laparoscopic correction of stress urinary incontinence continues to be evaluated. Early results have been encouraging with cure/dry rates equivalent to those with traditional suspensions, but with shorter hospitalization and no significant morbidity. The approach continues to take longer in the operating room than traditional suspensions, although new innovations and refinements have shortened the time. We are still lacking long-term outcome data and well-constructed prospective randomized trials. Cost effectiveness studies are also not consistent.     

Future treatment for the female stress urinary incontinence

Stress urinary incontinence (SUI) is a major urologic health problem and the number of patients with SUI will rise dramatically as the population of elderly people continues to increase in Japan. This condition causes unnecessary and detrimental psychological distress, social isolation, and public expense for care. Surgery remains the cornerstone of treatment for female SUI and also in those who have failed to improve with conservative measures. Many surgical procedures, however, have been described with varying degree of success. The ideal surgical treatment for this disease should be effective in QOL improvement, minimal invasive and durable for the long-term. Based on a new understanding of the pathophysiology of SUI as well as the development of surgical techniques and devices, mid urethral sling operations such as TVT (tension-free vaginal tape) have become widely used and they provide significant short-term and long-term cure rates. However, perioperative complications, including serious problems like bowel, vascular and bladder injuries have been reported. Most complications are related to blind trocar passage in the retropubic space. The alternative procedure transobturator procedure was developed to minimize these complications, in which tape is introduced through the obturator foramen. This technique provides high short-term cure rates, similar to those achieved with TVT, but with fewer complications. A number of injectables have been used for the treatment of SUI, including collagen, coated-beeds and Teflon. Although injectable treatment is convenient and minimally invasive, efficacy and durability are lower than other surgical procedures. Modification by tissue-engineering techniques using autologous stem cells or precursors of mature cells showed regeneration and reconstitution of urinary sphincteric function. In the future this strategy may be an attractive therapy for SUI. The choice of operation should be tailored to suit each individual case based on the clinical and urodynamic findings, as well as the age and the expectations of treatment outcome.     

无张力阴道吊带术治疗女性压力性尿失禁

目的：探讨无张力阴道吊带术(TVT)治疗女性压力性尿失禁的初步疗效和手术安全性。方法：对20例经过临床和尿动力学检查诊断为压力性或混合性尿失禁的女性患者进行TVT手术治疗，并对手术效果和并发症进行初步的随访研究。结果：平均手术时间40min(25—100min)，平均术后住院3．2d(1—28d)。18例单纯性压力性尿失禁患者16例治愈，治愈率为88．89％(16／18)，另2例显效(11．1％)。2例混合性尿失禁患者中1例显效，另1例无效。术后发生尿潴留3例，2例作松解术，1例延长导尿管留置时间后缓解。发生局部血肿1例经保守治疗后康复。结论：TVT手术是一种治疗压力性尿失禁的安全有效的方法，具有手术简单、创伤小、并发症少、患者康复快等优点。     

New and simplified vaginal approach for correction of urinary stress incontinence in women

Twenty-lour patients with urodynamically confirmed urinary stress incontinence were operated upon with a new and simplified vaginal approach. This new technique is a simplification of a previously described transahdominal surgical method, in which a two-component fibrin sealant (Tissel^R) was used. The sealant resulted in an excess of fibrin, which induced fibrosis. securing the urethrovesical junction in an elevated position to the retropubic periosteum. In the present study, the sealant was deposited retropubically with a specially designed needle through the anterior vaginal wall. A great advantage with this procedure is that only local anesthesia is used and the patient can leave the outpatient clinic I hour after the operation The minimum duration of the follow-up period was 18 months The success rate was as high as 6.3%, and no side effects were observed. © 1995 Wiley-Liss, Inc.     

Prognostic factors for the operative correction of stress urinary incontinence

Investigating the reliability of using some clinical and laboratory parameters as long-term prognostic factors in properly selected patients for stress urinary surgery could help in the prediction of the long-term result in each case. Toward this goal 51 women were examined prospectively, after they were assessed by clinical and laboratory exams with particular emphasis on urodynamic studies. Out of this group, 41 patients had genuine stress incontinence, and 10 had mixed stress incontinence. Twenty-seven women underwent Burch colposuspension while 24 had Stamey endoscopic bladder neck suspension. In all patients clinical and urodynamic evaluation was done with the same methodology before the operation, and after one month and six months, respectively. The study indicated that 73% of the incontinent women were cured. According to the “analysis of variance” and “correlation analysis” methods the factors which were found to influence the operative result were as follows: (1) Clinical factors including preoperative urgency, U.T.I. and previous gynaecological operations. These factors had negative prognostic value, while the grade of incontinence did not influence at all the outcome of surgery. (2) Urodynamic factors including preoperative residual urine, immediate operative first sensation of micturition, maximum urine flow rate, pre- and immediate postoperative bladder capacity and functional length. These factors influence the operative result negatively or positively according to the deviation from the normal values. Furthermore, the important immediate postoperative change of the urodynamic values was found to determine the result of the operation.     

Simplified correction of female stress incontinence.

A simplified operation for female stress incontinence, using a pair of double-prong needles, is described. A 90.4 per cent cure was achieved in 62 patients followed for a mean of 11.2 months. Merits of this procedure include operative simplicity and brevity, short hospitalization and a high rate of cure.