Early outcomes of mid-urethral slings for female stress urinary incontinence stratified by valsalva leak point pressure

AIMS: To assess the early results of mid-urethral slings placed via the transobturator approach (TVT-O) for stress urinary incontinence (SUI) in women with high (>60 cm H(2)O) and low (60 cm H(2)O) or low (60. CONCLUSIONS: With limited follow up, TVT-O appears to be a safe and effective surgical treatment for female SUI producing excellent results in patients with VLPP >60 cm/H(2)0. Patients with low VLPP may consider conventional, retropubic mid-urethral slings or other procedures as treatment for SUI.     

Predictive value of urethral mobility before suburethral tape procedure for urinary stress incontinence in women

PURPOSE: We determined whether preoperative urethral mobility predicts the outcome of the suburethral tape procedure outcome in women with urinary stress incontinence. MATERIALS AND METHODS: This retrospective study included 78 women who underwent preoperative cystourethrography while standing. Proximal urethral support was assessed by lateral cystourethrograms at rest and during straining. The 2 images were anatomically superimposed and the angle formed by the 2 proximal urethra axes determined urethral mobility. Surgical outcome was assessed by stress and pad tests. RESULTS: Median followup was 9 months (range 1 to 37) and the objective success rate was 85% (66 of 78 cases). Median rotation of the proximal urethra was 67 degrees in cases without previous surgery for incontinence, 33 degrees in those with 1 and 28 degrees in those with 2 or more procedures (p <0.0001). The success rate was 97% (29 of 30 cases) when urethral mobility exceeded 60 degrees versus 86% (18 of 21) for mobility between 30 and 60 degrees, and 70% (19 of 27) when it was less than 30 degrees (p = 0.023). The success rate was 96% (26 of 27 cases) without previous surgery for incontinence versus 84% (31 of 37) when 1 unsuccessful procedure had been performed and 64% (9 of 14) with 2 or more surgical failures (p = 0.026). Patient age at surgery, menopausal status, mixed incontinence, body mass index, parity, overactive bladder and low maximal urethral closure pressure had no significant prognostic value. CONCLUSIONS: The suburethral sling procedure takes advantage of urethral mobility to avoid leakage. The more the proximal part of the urethra moves while under stress, the better the continence achieved. Risk factors for failure are poor proximal urethral mobility and previous surgery for incontinence.     

Correlation of abdominal leak point pressure with objective incontinence severity in men with post-radical prostatectomy stress incontinence

AIMS: To determine if the abdominal leak point pressure (ALPP) correlates with objective incontinence severity in patients suffering from post-prostatectomy stress incontinence. METHODS: Twenty-nine men were evaluated for urinary incontinence after radical prostatectomy with videourodynamics and a 24-hr pad test. ALPP was determined with and without a 7-French urodynamics catheter and the lowest value was accepted. Six patients with urgency incontinence associated with detrusor overactivity or decreased bladder compliance were excluded leaving 23 patients for analysis. The relationship between the variables of ALPP, 24-hr pad weight, age and time from prostatectomy were examined with Pearson correlation. RESULTS: The mean age was 66.4 years (SD +/- 7.9, range: 45-81) and the median time from radical prostatectomy was 23 months (IQR = 14-64, range: 9-204). The mean ALPP was 92.8 cm H(2)O (SD +/- 42.4 cm H(2)O) and the mean pad weight was 279.1 g (SD +/- 238.3 g). There was only a weak inverse correlation between ALPP and 24-hr pad weight which was not statistically significant (r = - 0.191, P = 0.38). Age and time from prostatectomy did not significantly correlate with ALPP (r = - 0.122, P = 0.58 and r = - 0.23, P = 0.29, respectively). CONCLUSIONS: ALPP did not correlate significantly with the 24-hr pad test in patients with post-prostatectomy stress incontinence. This suggests that in this patient subset, the ALPP is a relatively poor predictor of incontinence severity and, therefore, has limited clinical value in the urodynamic evaluation of post-prostatectomy incontinence. The urodynamic assessment of these patients should focus on the presence or absence of stress incontinence and on the presence of associated bladder dysfunction.     

应用Y形补片治疗阴道前壁膀胱膨出及压力性尿失禁的临床研究

目的评价经阴道Y形补片治疗阴道前壁膀胱膨出及压力性尿失禁的近期疗效。方法2003年4月．2006年5月，对确诊为阴道前壁及膀胱膨出合并不同程度压力性尿失禁的34例行经阴道尿道中段、膀胱膨出部位Y形补片悬吊修复术，并对手术后主观症状的改善、术后复发率进行评估。结果34例术后24h拔除导尿管后能自行排尿，残余尿〈100ml。随访3-37个月，平均26个月，无尿潴留、尿路感染、膀胱功能障碍及复发。结论应用Y形补片不仅治疗阴道前壁及膀胱膨出，而且能同时治疗压力性尿失禁。     

女性压力性尿失禁患者盆底肌锻炼方案的构建与实证研究

目的规范女性压力性尿失禁患者盆底肌锻炼方案,并评价其实施效果。方法以自我管理理论为框架,采用德尔菲法构建女性压力性尿失禁患者盆底肌锻炼方案,并对38例女性压力性尿失禁患者采用该方案实施盆底肌锻炼。结果方案实施后患者1h尿垫试验、盆底肌锻炼自我效能得分与实施前比较,差异有统计学意义(P0.05,P0.01);Valsava漏尿点压力、最大尿道关闭压较实施前显著升高(均P0.01),但功能性尿道长度没有明显变化。结论女性压力性尿失禁患者盆底肌锻炼方案的实施,统一规范了盆底肌锻炼要领,能提高患者训练依从性,改善患者尿失禁症状。     

Evaluation of different techniques to create chronic urinary incontinence in the rat

OBJECTIVE

To evaluate models for chronic urinary incontinence (UI) in the rat.

MATERIALS AND METHODS

Two models were fully evaluated: one of repeated dilatation of the vagina, simulating birth trauma, the vaginal dilatation (VD) group; the other, with surgical transposition of the urethra to a vertical position, the urethral transposition (UT) group. The VD rats were evaluated by the sneeze test. When negative, vaginal dilatation was repeated in a similar way. The UT group was evaluated by observation of continuous urine leakage. The leak‐point pressure (LPP) was measured at study end in all the rats.

RESULTS

All the VD rats had occasional negative sneeze tests and all had to be dilated again. This resulted in persistent UI on sneeze testing for the entire period. In the UT group, 12 rats leaked continuously during the whole study period; in the other four UI became less at 4, 5, 6, and 7 weeks, respectively. The LPP in the rats with UI was significantly lower than in the respective control groups.

CONCLUSIONS

These models permit study of chronic stress UI and continuous UI in the rat. Spontaneous recovery of continence was seen mostly in the VD group.     

Polypropylene mesh tape for stress urinary incontinence: complications of urethral erosion and outlet obstruction

PURPOSE: Gynecare tension-free vaginal tape (Ethicon, Inc., New Brunswick, New Jersey) is a propylene mesh tape recently introduced in the United States as minimally invasive treatment for stress urinary incontinence. We report the combined experience at 3 tertiary care institutions with graft erosion and bladder outlet obstruction after procedures performed elsewhere. MATERIALS AND METHODS: We reviewed the records of 5 patients with complications who presented to 1 of 3 institutions after polypropylene mesh tape placement. All pertinent information was obtained from the medical records and the operating surgeon at the referring institution. RESULTS: Treatment was required in 2 patients with urethral erosion, 1 with vaginal and bladder erosion, and 2 with bladder outlet obstruction. Common presenting symptoms included urge, urge incontinence and gross hematuria. Cystoscopy showed polypropylene graft erosion at the urethra or through the bladder wall. Each patient required explantation of the polypropylene mesh tape and further surgery to restore continence. The graft was divided transvaginally in the 2 patients presenting with outlet obstruction. Urge incontinence resolved and they returned to complete spontaneous voiding. CONCLUSIONS: High clinical suspicion is necessary when evaluating patients presenting with urinary symptoms after polypropylene mesh tape placement. Bladder outlet obstruction and possible graft erosion should be considered.     

Comparison of leak point pressure methods in an animal model of stress urinary incontinence

We compared three different methods of testing leak point pressure (LPP) in rats with or without the pudendal nerves and nerves to the iliococcygeus/pubococcygeus muscles transected: (1) sneeze induced with a whisker in the nostril (sneeze LPP), (2) manually increased abdominal pressure (Crede LPP), and (3) increased intravesical pressure using the vertical tilt table method (vertical tilt table LPP). In sham rats, passive intravesical pressure rises in Crede and vertical tilt table methods induced active urethral closure mechanisms that contributed to high LPPs (41.4 and 35.5 cmH₂O, respectively), which were significantly reduced by nerve transection. During sneezing, leakage was observed in nerve-transected rats, but not in sham rats, indicating that sneezing can activate an additional urethral closure mechanism. Measuring LPP during sneezing or passive intravesical pressure rises in the vertical tilt table and Crede method seems to be useful for assessing the continence mechanisms under different stress conditions in rats.     

Effect of detrusor function on the therapeutic outcome of a suburethral sling procedure using a polypropylene sling for stress urinary incontinence in women

OBJECTIVE: To assess the effect of detrusor function on the therapeutic outcome of a suburethral sling procedure in women with stress urinary incontinence (SUI). MATERIAL AND METHODS: A total of 192 women with SUI who had undergone a suburethral sling procedure were enrolled. According to the baseline urodynamic results, patients' bladder functions were classified as follows: (i) normal detrusor function; (ii) detrusor overactivity; and (iii) detrusor underactivity or acontractile detrusor. Surgical results, urodynamic parameters and patient satisfaction were compared among these three groups. RESULTS: Overall, 106 patients had normal detrusor function, 36 had detrusor overactivity and 50 had detrusor underactivity or an acontractile detrusor. A continent outcome was achieved in 135 women (70.3%), urge incontinence in 23 (12%), minimal SUI in 32 (16.7%) and moderate SUI in two (1%). Persistent urge incontinence was noted in 13 women (36%) with detrusor overactivity, and recurrent SUI occurred in 18 women (36%) with detrusor underactivity or an acontractile detrusor. No significant change in urodynamic parameters between baseline and after treatment was found in any of the patient groups. The satisfaction rate was 98.1% in patients with normal detrusor function, 82% in patients with detrusor underactivity or an acontractile detrusor and 75% in patients with detrusor overactivity (p<0.05). CONCLUSION: Compared to women with normal detrusor function, those with preoperative detrusor overactivity and those with detrusor underactivity or an acontractile detrusor experienced an unfavorable therapeutic outcome of the suburethral sling procedure in terms of urge incontinence and recurrent SUI after surgery.     

Persistent groin pain following a trans-obturator sling procedure for stress urinary incontinence: a diagnostic and therapeutic challenge

Groin pain after a tension-free vaginal tape–obturator (TVT-O) procedure can occur but mostly disappears within 4 weeks. Persistent groin pain is extremely rare and there is a paucity of literature on how to diagnose and manage this adverse event. We present two cases with severe persistent groin pain after uncomplicated TVT-O, in which magnetic resonance imaging and electromyography did not reveal the cause. We concluded that the tape entrapped or cut through peripheral branches of the obturator nerve. We removed as much of the tape as possible in both cases. Removal partially relieved the pain although sensory loss of the obturator nerve persisted 1 year after surgery. In case of abnormal post-operative groin pain, soon removal of the tape enhances the chance that damage to the obturator nerve is reversible, although it is important to counsel patients with similar pathology that recovery can take long and may be only partial.     

State of the art of where we are at using stem cells for stress urinary incontinence

AIMS: This review aims to discuss: 1) the neurophysiology, highlighting the importance of the middle urethra, and treatment of stress urinary incontinence (SUI); 2) current injectable cell sources for minimally-invasive treatment; and 3) the potential of muscle-derived stem cells (MDSCs) for the delivery of neurotrophic factors. METHODS: A PUB-MED search was conducted using combinations of heading terms: urinary incontinence, urethral sphincter, stem cells, muscle, adipose, neurotrophins. In addition, we will update the recent work from our laboratory. RESULTS: In anatomical and functional studies of human and animal urethra, the middle urethra containing rhabdosphincter, is critical for maintaining continence. Cell-based therapies are most often associated with the use of autologous multipotent stem cells, such as the bone marrow stromal cells. However, harvesting bone marrow stromal stem cells is difficult, painful, and may yield low numbers of stem cells upon processing. In contrast, alternative autologous adult stem cells such as MDSCs and adipose-derived stem cells can be easily obtained in large quantities and with minimal discomfort. Not all cellular therapies are the same, as demonstrated by the differences in safety and efficacy from muscle-sourced MDSCs versus myoblasts versus fibroblasts. CONCLUSIONS: Transplanted stem cells may have the ability to undergo self-renewal and multipotent differentiation, leading to sphincter regeneration. In addition, such cells may release, or be engineered to release, neurotrophins with subsequent paracrine recruitment of endogenous host cells to concomitantly promote a regenerative response of nerve-integrated muscle. The dawn of a new paradigm in the treatment of SUI may be near.     

The role of neutrophil elastase in elastin metabolism of pelvic tissues from women with stress urinary incontinence

OBJECTIVE: Altered elastin metabolism is implicated in pelvic floor disorders. We studied neutrophil elastase (NE) and matrix metalloproteinase (MMP) activities in vaginal tissues from premenopausal women with stress urinary incontinence (SUI). METHODS: Elastase and NE activities in vaginal tissues were assessed. Protein and mRNA expressions were determined by RT-PCR and Western blot. Total elastin and collagen contents were evaluated. To compare the relative elastolytic effect of NE and MMP-2, we used their respective antibodies to immunoprecipitate these proteins from vaginal fibroblast extracts prior to assessing elastase activity. RESULTS: Elastase activity in vaginal wall tissues was significantly higher in the secretory compared to the proliferative phase. NE mRNA and protein expressions were similar between control and SUI tissues from the secretory phase. However, NE activity in the SUI tissues was higher compared to control tissues. The mRNA expression of alpha-1 antitrypsin (ATT) was higher in control tissues from the proliferative phase compared to those from the secretory phase, while no difference was observed in SUI tissues between either phase. Protein expression of the active form of ATT was decreased in SUI tissues compared to controls during the secretory phase. Anti-NE antibody reduced total elastase activity by 60-70%, compared to less than 20% reduction with anti-MMP-2 antibody. CONCLUSION: During the secretory phase, elastolytic activity is increased in pelvic tissues from women with SUI, through an increase in NE activity and a concurrent decrease in ATT expression. The serine protease, NE, appears to be a more significant modulator of elastase activity compared to MMP-2.     

The effects of periurethral muscle-derived stem cell injection on leak point pressure in a rat model of stress urinary incontinence

 Our goal was to determine whether periurethral injection of allogenic muscle-derived stem cells (MDSC) could increase the leak point pressure (LPP) in a denervated female rat model of stress urinary incontinence. Cells isolated from the gastrocnemius muscle of normal female rats were purified for a myogenic population by the preplate technique. Three experimental groups were established: a control group (C) had a sham operation without injections; a sciatic nerve transection group (D) had periurethral saline injections; and a sciatic nerve transsection group had periurethral MDSC injections (M). One week following treatment the LPP of groups C, D and M were 25.2±1.9 cmH₂O, 28.6±0.8 cmH₂O and 36.7±2.3 cmH₂O, respectively. At 4 weeks the LPP of groups C, D and M were 25.8±2.5 cmH₂O, 18.6±5.2 cmH₂O and 44.1±6.6 cmH₂O, respectively. Allogenic MDSC significantly improved the LPP in sciatic nerve-transected animals after both 1 and 4 weeks compared to denervated animals injected with saline. Received: 9 November 2002 / Accepted: 2 September 2002 Acknowledgement This work was supported by NIDDK SUPPORT: NIH RO1 DK55387; DK K12, Pittsburgh Tissue Engineering Initiative.     

Morphology of the suburethral pubocervical fascia in women with stress urinary incontinence: a comparison of histologic and MRI findings

To correlate MRI with histologic findings of the suburethral pubocervical fascia in women with urodynamic stress incontinence. Thirty-one women with urodynamically proven stress urinary incontinence without relevant prolapse underwent preoperative MRI. Tissue specimens obtained from the pubocervical fascia were examined immunohistochemically (types I and III collagen, smooth muscle actin) and the results compared with the MRI findings. MRI demonstrated an intact pubocervical fascia in 61.3% of the cases and a fascial defect in 38.7%. A fascial defect demonstrated by MRI was associated with a decrease in actin (P<0.09) and an increase in collagen III (P<0.01) compared to an intact fascia. In women with stress urinary incontinence, smooth muscle actin in the pubocervical fascia is decreased, changed in structure, and replaced by type III collagen. MRI allows evaluation of the pubocervical fascia and its morphologic changes.