Changes in urethral resistance after surgery for stress urinary incontinence

Seventy women with stress urinary incontinence underwent simultaneous voiding-urethrocystometry using microtip transducers and an 8-channel recorder, before and three to twelve months after either the modified Burch (48/70) or the modified Pereyra (22/70) retropubic urethropexy. Increase in urethral resistance (p less than 0.005) was more marked following the Pereyra procedure (0.042 +/- 0.039 to 0.07 +/- 0.061) and 30 percent experienced postoperative voiding difficulties, compared with the Burch procedure (0.035 +/- 0.029 to 0.055 +/- 0.03) where 20 percent experienced postoperative voiding difficulties. Of those patients who voided without a detrusor contraction prior to surgery (35/70), in 50 percent a detrusor contraction component developed to their voiding mechanism postoperatively (p less than 0.05) and overcame the increased urethral resistance with no postoperative voiding difficulties. In the remaining 50 percent a detrusor contraction failed to develop during postoperative voiding and 90 percent of them demonstrated reduced flow rates and increased use of Valsalva maneuver, and needed prolonged postoperative bladder drainage prior to resumption of spontaneous voiding (p less than 0.005). Inability to develop a detrusor contraction during voiding in face of increased urethral resistance promoted by the incontinence surgery provided a suitable explanation for post surgery voiding difficulties in 20 to 30 percent of patients.     

Urethral injections for female stress incontinence

Emphasis on minimally invasive options for the surgical treatment of stress urinary incontinence (SUI) has resulted in the development of agents and techniques that improve these conditions substantially towards social continence, but currently give suboptimal cure/dry rates. The application of injectable therapy as an office procedure implies the potential for cost-efficient treatment for selected patients with UI. Continuous advances in materials technology have provided the possibility that many new urethral bulking agents will soon be available. Experience continues to accrue in clinical trials for urethral bulking with these agents, while parallel use for the indication of paediatric vesico-urethral reflux has also provided evidence of biological activity related to these compounds. The agents that are closest to complete analysis are synthetic and represent various material types and characteristics. As these materials develop, understanding of the preferred injection technique also is being gained. The delivery method and site might prove to substantially alter the biological activity of these compounds.     

Urethral bulking for recurrent stress urinary incontinence after midurethral sling failure

Aims

To assess the effectiveness of a polyacrylamide hydrogel (PAHG; Bulkamid®) in treating recurrent stress urinary incontinence (SUI) following a previous midurethral sling (MUS) implant.

Methods

This observational study, conducted since 2009, included 60 patients with recurrent SUI or mixed urinary incontinence (MUI) after a previous MUS and who chose to be treated with PAHG. Objective and subjective outcomes were assessed at 1, 6, and 12 months after the initial injection. Patients were classified as cured based on a negative cough test (supine and standing) and <2 g urine on 1‐hr pad test and a VAS score improved by ≥90%. Improved were those with the loss of only a few drops of urine during the cough test and 2–10 g urine on 1‐hr pad test or a reduction >50% compared with preoperative urine loss and a VAS score improved by ≥75%.

Results

The volume of PAHG injected in the current study ranged from 1–3 ml. Cured/improved rates were 93.3% (56/60), 88.3% (53/60), and 83.6% (46/55) at 1, 6, and 12 months, respectively. Patients with MUI had a cured urgency urinary incontinence rate of 36.8%, 47.4%, and 38.9%, respectively. Voiding dysfunction rates were 13.3% (8/60), 8.3% (5/60), and 1.8% (1/55) at 1, 6, and 12 months and urinary tract infection rates were 5% (3/60), 11.7% (7/60), and 3.6% (2/55), respectively. Other adverse events were short‐term and/or observed in <4% of patients.

Conclusions

PAHG can be used to treat recurrent SUI after MUS failure with good outcome and low complication rates. Neurourol. Urodynam. 36:722–726, 2017. © 2016 The Authors. Neurourology and Urodynamics published by Wiley Periodicals, Inc.     

Urethral devices for managing stress urinary incontinence

Although surgery remains the gold standard for managing the majority of patients with stress urinary incontinence or retention, not all patients are suitable candidates or desire surgery. For these patients, several urethral caps and inserts are available, which are described. In approximately 50% of patients, satisfactory control is achieved. Further investigation undoubtedly will yield better devices to serve the large number of patients with urinary control problems.     

Quality of life after surgery for stress incontinence

This study investigated changes in condition-specific quality of life (QOL) after surgery for stress urinary incontinence. Data from 655 women in a clinical trial comparing the Burch and fascial sling were examined. Improvement in QOL, measured with the Incontinence Impact Questionnaire (mean decrease 133.1; SD 109.8), was observed 6 months after surgery and persisted at 24 months. Women for whom surgery was successful (regardless of surgery type) had greater improvement in QOL (mean decrease 160.0; SD 103.9) than did women for whom surgery was not successful (mean decrease 113.6; SD 110.9; p < 0.0001), although not statistically significant after adjusting for covariates. Multivariable analysis showed that QOL improvement was related to decreased urinary incontinence (UI) symptom bother, greater improvement in UI severity, younger age, Hispanic ethnicity, and receiving Burch surgery. Among sexually active women, worsening sexual function had a negative impact on QOL. Improved QOL was explained most by UI symptom improvement.     

Urethral resistance measurement: a new method for evaluation of stress urinary incontinence in women

The aim of this study was to evaluate a new method to measure urethral resistance among 66 women with urinary incontinence. A stainless steel sphere attached to a guide wire was developed. The sphere is inserted into the bladder and withdrawn through the urethra at a steady rate. Serial measurements with spheres of 5, 6 and 7 mm were performed. The mean urethral resistance as measured by the largest sphere (0.07±0.03) was significantly greater than that measured by the medium sphere (0.06±0.02, p<0.0001), which was significantly larger than that measured by the smallest sphere (0.04±0.01, p<0.0001). There was good correlation of urethral resistance with maximum urethral closure pressure (MUCP) by this technique, but no correlation with Valsalva leak point pressure (VLPP).Editorial Comment: This study attempts to demonstrate the validity and reproducibility of measuring maximum urethral resistance. Further studies will need to be performed to see if this technique will be clinically useful, i.e., comparing values in continent and incontinent women, old vs. young population, etc. There is a need to better test to measure urethral function than leak point pressure and urethral pressure profile/MUCP     

Retropubic surgery for stress urinary incontinence

More than 150 surgical techniques have been proposed in the literature for treating stress urinary incontinence. Many of the original published approaches were vaginal, but through the years the literature has expanded to include needle suspension, pubovaginal slings, and retropubic procedures. In this chapter, we focus on retropubic approaches for the treatment of SUI and discuss the physiology, indications, technical details and the complications of these procedures.     

The etiology of urinary retention after surgery for genuine stress incontinence

Transient postoperative urinary retention after stress incontinence surgery is common, and there is no widely accepted method of hastening the return to normal voiding. The etiology of this retention is poorly understood. Failure of the relaxation of the striated external urethral sphincter has been proposed as an etiologic agent, but has not been documented. Ten patients about to undergo a Burch colposuspension or sub-urethral sling, who demonstrated normal preoperative voiding, were recruited to a study of postoperative retention. Hook-wire electromyographic (EMG)probes were placed into the external urethral sphincter while the patients were under anesthesia, and a suprapubic catheter was placed. We performed instrumented voiding trials 1 or 2 days after surgery while continuously recording urethral EMG and intravesical pressure. Two patients demonstrated normal voiding. Two patients were able to void but demonstrated no EMG silencing. Six patients were unable to void and demonstrated persistent EMG activity. Four of these demonstrated no detrusor contraction, whereas two demonstrated detrusor contractions. All patients resumed normal voiding by clinical parameters within 14 days of surgery. Our study supports other research that suggests that failure of relaxation of the striated urethral sphincter contributes to postoperative urinary retention.     

De novo pudendal neuropathy after TOT-O surgery for stress urinary incontinence

Background and Objectives:

Five cases of pelvic nerve complications after transobturator tape (TOT) inside-out surgical procedures for stress urinary incontinence are presented.

Methods:

We conducted a chart review of patients with complications referred to our practice.

Results:

Five patients with nerve complications after TOT inside-out procedures were investigated. Pudendal neuropathy and interstitial cystitis were seen in this series of patients with several patients having myofascial pain in the lower abdominal area.

Conclusions:

Although not commonly reported, complications from needle placement and from the area of needle exit in a TOT procedure can exist, and the surgeon must be careful when placing the needle through the area of the obturator fossa.     

Quality of life after tension-free vaginal tape surgery for female stress incontinence

OBJECTIVE: To undertake a long-term follow-up evaluation of the quality of life (QOL) of women who had undergone a tension-free vaginal tape (TVT) procedure. MATERIAL AND METHODS: During the period 1995-2001, 970 women with urinary stress incontinence underwent TVT surgery at the Department of Obstetrics and Gynecology, Falun Hospital. A questionnaire was mailed on average 5.7 years after the TVT procedure. Two incontinence-specific QOL instruments--the Incontinence Impact Questionnaire-7 (IIQ-7) and the Urogenital Distress Inventory-6 (UDI-6)--were administered. An additional questionnaire included general questions and questions about chronic diseases that may be associated with urinary incontinence. RESULTS: The mean age at surgery was 58.7 years (range 29-89 years). Of 913 eligible women, 768 (78.9%) responded. Mean IIQ-7 and IDU-6 scores as estimated by the women improved dramatically at follow-up as compared to preoperative values: from 43.7 to 11.5 for the IIQ-7 and from 54.2 to 24.0 for the UDI-6 on a scale from 0 to 100 (p = 0.0001 for both). There were few differences in mean QOL scores even 8 years after TVT surgery, compared to those determined a shorter time after the operation. Women with diabetes, chronic constipation, chronic bronchitis and preoperative recurrent urinary infections had a relative improvement in QOL of the same magnitude as that of the remaining study population. Advanced age was negatively associated with an improvement in QOL scores. CONCLUSIONS: Improvements in measures of QOL after TVT surgery are dramatic and persist for years. Women with concomitant diseases that may be associated with urinary incontinence can be assured that there is a good chance of success with TVT surgery.     

Urethral pressure profiles before and after Ornade administration in patients with stress urinary incontinence.

Urethral pressure profilometry was done on 12 women with stress urinary incontinence and in 6 women with no history of incontinence, before and 1 to 2 hours after the administration of Ornade. Eleven of the 12 women with stress urinary incontinence had increases in the maximal urethral pressure of 20 per cent or more over the control value. Only 1 of the 6 control women exhibited an increase in the maximal urethral pressure of greater than 20 per cent after the administration of Ornade. It is believed that the phenylpropanolamine component of Ornade stimulates alpha-adrenergic receptors at the vesical neck and in the proximal urethra to achieve the therapeutic effect of reducing or eliminating stress urinary incontinence. This drug is preferred over ephedrine primarily because of its sustained release, allowing dosage twice a day, and because of its relative freedom from side effects.