Rectus fascial sling for the treatment of neurogenic sphincteric incontinence in boys: is it safe and effective?

PURPOSE: While a fascial sling for treating children with intractable urinary incontinence is often successful in girls, its effectiveness in boys remains unclear. We determined the long-term efficacy of a rectus fascial sling in boys with neurogenic sphincteric incontinence and defined its urodynamic characteristics for achieving continence. METHODS AND METHODS: We reviewed the charts of all boys who underwent a rectus fascial sling procedure for neurogenic incontinence to determine urinary continence status at the most recent office visit or by telephone interview, the type and dose of anticholinergic and sympathomimetic medications, the frequency of intermittent clean intermittent catheterization, status of the upper urinary tract and comparative urodynamic findings preoperatively and postoperatively. RESULTS: We evaluated 7 boys 7 to 19 years old, of whom 4 were postpubertal, who fulfilled study criteria and had a followup of 1 to 9 years. In 4 patients a continent stoma was created concurrently at surgery. Postoperatively all patients were dry during the first 3 months after surgery. At the last followup 1 patient was completely dry, 3 had occasional nighttime wetting, 2 had occasional stress incontinence, and 1 had frequent daytime and nighttime wetting requiring subsequent bladder neck closure. Prepubertal and postpubertal males performed catheterization without difficulty and all required less frequent clean intermittent catheterization and medication postoperatively compared to preoperative status. None had hydronephrosis. Postoperatively urodynamic evaluation revealed normal bladder compliance, improved urethral resistance that did not decay with bladder filling and no uninhibited contractions. CONCLUSIONS: The rectus fascial sling is effective for increasing bladder outlet resistance and decreasing the degree of incontinence in prepubertal and postpubertal males with neurogenic sphincteric incontinence. It has no long-term deleterious effects on bladder function and does not impair the ability to catheterize postoperatively. A fascial sling is an effective alternative to bladder neck closure when creating a continent stoma.     

The volume at which women leak first on urodynamic testing is not associated with quality of life, measures of urethral integrity or surgical failure

PURPOSE: We determined if the bladder volume at which urodynamic stress incontinence is first detected is related to preoperative quality of life, urethral sphincter assessment or surgical outcome in women undergoing continence surgery. MATERIALS AND METHODS: Charts of consecutive women who underwent a sling or Burch procedure were reviewed. Preoperative and postoperative assessment included the Incontinence Impact Questionnaire and Urogenital Distress Inventory. Urodynamic stress incontinence volume is the bladder volume at which urodynamic stress incontinence was first detected. Women were divided into 4 groups according to urodynamic stress incontinence volume, and compared with respect to maximum urethral closure pressure, Valsalva leak point pressure, Incontinence Impact Questionnaire and Urogenital Distress Inventory. Urodynamic stress incontinence persistence was evaluated only in patients who had sling surgery. RESULTS: A total of 168 women were recruited for the study. Urodynamic stress incontinence volume was 100 ml for 31% of women, 200 ml for 17%, 300 ml for 17% and 400 ml or greater for 35%. Baseline and postoperative Urogenital Distress Inventory, Incontinence Impact Questionnaire, maximal urethral closure pressure and Valsalva leak point pressure did not differ by urodynamic stress incontinence volume. Among the 116 patients who had the sling procedure, urodynamic stress incontinence persistence did not differ by urodynamic stress incontinence volume (p=0.72). CONCLUSIONS: Women who demonstrate urodynamic stress incontinence at lower bladder volumes do not report greater bother from incontinence than women who leak at higher volumes, suggesting leakage severity on urodynamics is not an adequate reflection of incontinence related quality of life.     

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.     

The long-term results of pubovaginal sling surgery using acellular cross-linked porcine dermis in the treatment of urodynamic stress incontinence

PURPOSE: Acellular cross-linked porcine dermis is a potential substitute for rectus fascia as a sling material with the advantage of decreased morbidity. However, the long-term efficacy is unknown. We compared the 3-year efficacy of PD vs autologous rectus fascia as a sling material for pubovaginal sling surgery in the treatment of urodynamic stress incontinence. MATERIALS AND METHODS: Between July 2000 and December 2001 a total of 101 consecutive, nonrandomized patients with USI underwent a PD (51) or RF (50) sling procedure. Patients were assessed at 6 weeks, and at 3, 6 and 12 months postoperatively. Urodynamic study was repeated in cases of treatment failure. A detailed survey questionnaire was mailed to all patients at least 36 months after surgery and all responders were then retested by telephone interview by a blinded assessor. The primary outcome measure was patient perceived success rate (cured or improved) at least 36 months after PVS. Secondary outcome measures were patient satisfaction 36 months after surgery, durability of success with time and reoperation rate. RESULTS: Complete data were available on 94 patients (48 treated with PD and 46 treated with RF sling). The groups were well matched for age, leak point pressure, prior incontinence surgery and urge symptoms. Pubovaginal sling was successful (cured or improved) in 37 (80.4%) patients treated with RF but in only 26 (54%) patients treated with PD 36 months after surgery (Fisher's exact test p = 0.009; 95% CI 8.03, 44.4). Treatment failure occurred by 9 months after RF and by 24 months after PD sling procedure. Repeat urodynamic study showed USI to be the cause of treatment failure in 18 (37.5%) of 20 patients treated with PD but in only 3 (6.5%) of 8 patients treated with RF. CONCLUSIONS: We have shown that use of the PD sling, although reducing early morbidity, results in a significantly inferior long-term cure rate in comparison to the RF sling. Therefore, acellular cross-linked porcine dermis should not be used as a substitute for rectus fascia.     

Pediatric urinary incontinence: evaluation of bladder wall wraparound sling procedure

PURPOSE: In 1996 a surgical procedure for sphincter deficiency was reported in patients with neurogenic urinary incontinence. To our knowledge we report the first series that assesses this procedure since it was initially described. MATERIALS AND METHODS: Seven female and 7 male patients with spinal dysraphism and neurogenic intrinsic sphincter deficiency underwent surgery between 1997 and 2005. All patients had an associated poorly compliant or small capacity bladder. Patient age ranged from 8 to 22 years (mean 14) and all patients presented with persistent urinary incontinence despite intermittent catheterization and pharmacotherapy. Evaluation was based on clinical examination, as well as preoperative and postoperative urodynamic assessments. The surgical procedure involved wrapping a pedicle strip of anterior bladder wall around the bladder neck and fixing it on the pubic symphysis. Bladder augmentation cystoplasty was also routinely performed during the same procedure. RESULTS: Of 14 patients 13 were completely dry and 1 had stress incontinence. Followup was 2 to 8 years (mean 5). Postoperative urodynamic evaluation showed a maximum urethral pressure increase of 40%. We also observed an increase in bladder capacity of 105% and improved bladder compliance (7 ml/cm H(2)O preoperatively vs 35 ml/cm H(2)O postoperatively). CONCLUSIONS: The bladder wall wraparound sling procedure provides excellent results for continence in association with bladder augmentation.     

Comparison of video urodynamic results after the pubovaginal sling procedure using rectus fascia and polypropylene mesh for stress urinary incontinence

PURPOSE: Video urodynamic changes were compared after the pubovaginal sling procedure using rectus fascia or polypropylene mesh in women with stress urinary incontinence. MATERIALS AND METHODS: A total of 50 women with various types of stress urinary incontinence were treated with the pubovaginal sling procedure using randomly abdominal rectus fascia in 24 or polypropylene mesh in 26. The sling was placed at the level of the bladder neck and tied with sufficient tension to prevent urinary leakage without obstructing the bladder outlet. Video urodynamics were performed preoperatively, and 7 to 14 days and 3 to 6 months postoperatively in all cases. Surgical results and urodynamic changes after the pubovaginal sling procedure were compared in the 2 groups. Long-term results were evaluated at a mean followup of 2 years. RESULTS: Complete continence was achieved in 23 patients (95.8%) in the rectus fascia group and 26 (100%) in the polypropylene mesh group, including 1 initial failure with reoperation, at a median followup of 24 and 23 months, respectively. The subjective success rate was 91.6% for rectus fascia and 92.3% for polypropylene mesh. The main cause of dissatisfaction was persistent urge incontinence and dysuria in 2 cases each. In each group video urodynamics revealed a mild but nonsignificant decrease in maximum urinary flow and a significant increase in bladder neck opening time at 7 to 14 days versus baseline. However, these parameters returned to baseline within 3 to 6 months postoperatively. Voiding pressure, cystometric capacity and post-void residual urine also showed no significant change in either group after the pubovaginal sling procedure. Patients treated with a polypropylene mesh sling had a shorter operative time and hospital stay, a higher spontaneous voiding rate after catheter removal and a lower incidence of wound pain after surgery. One patient treated with polypropylene mesh had sling margin extrusion. The incidence of new onset detrusor instability and persistent dysuria was similar in the 2 groups. Transrectal sonography of the sling showed that it was located beneath the bladder neck and proximal urethra in all patients in each group. CONCLUSIONS: The results of this study show that the pubovaginal sling procedure using rectus fascia or polypropylene mesh as the sling material had similar effectiveness for treating female stress incontinence but the polypropylene group had more rapid recovery. Postoperatively video urodynamics demonstrated that the pubovaginal sling using either sling material did not cause bladder outlet obstruction with proper surgical technique.     

Long-term urinary continence rates after simple sling incision for relief of urinary retention following fascia lata pubovaginal slings

PURPOSE: We examined long-term urinary continence rates in patients after midline simple sling incision for urinary retention following suburethral fascia lata slings. MATERIALS AND METHODS: A retrospective review was completed of 13 women undergoing a simple sling incision for catheter dependent obstruction after suburethral sling surgery more than 4 years previously. Urinary continence was evaluated by use of the Groutz-Blaivas anti-incontinence surgery response score. The scores were statistically compared as binary categories at mean 111-day and 60.8-month followup. RESULTS: A total of 13 women underwent a simple sling incision for catheter dependent urinary retention after sling surgery, and 11 patients (mean age 73.4 years) were available for long-term followup (60.8 months). The simple sling incision procedure was completed an average of 65 days (range 36 to 235) after original sling placement. Mean post-void residual urine volume at least 1 month after sling surgery was 289 ml (range 75 to 500). At a mean followup of 60.8 months, no patient required catheterization. Of 11 patients 5 wore no pads. There was no statistical difference in leakage episodes per day (p = 1.0), pads per day (p = 0.3), or patient perceived condition (p = 0.3) during long-term followup. The mean Groutz-Blaivas score did not change statistically during the 5-year followup period (p = 0.6). CONCLUSIONS: Midline simple sling incision provides relief of catheter dependent obstruction following fascia lata sling surgery while preserving urinary continence in the majority of patients during a 5-year followup period.     

Preoperative urodynamic evaluation may predict voiding dysfunction in women undergoing pubovaginal sling

PURPOSE: We determine which urodynamic parameters can best predict postoperative voiding dysfunction following pubovaginal sling surgery. MATERIALS AND METHODS: The records of 98 consecutive women who had undergone pubovaginal sling surgery with allograft fascia lata between July 1998 and July 2000 were reviewed. Urodynamic and followup data were sufficient for evaluation for 73 patients. Urodynamic and clinical parameters were correlated with urinary retention, time to return of efficient voiding and development of postoperative urgency symptoms. RESULTS: Average time to return of efficient voiding was 3.92 days (median 3). Of 21 women who voided without a detrusor contraction urinary retention developed in 4 (23%) versus 0 of 48 who voided with detrusor contraction (p = 0.007). Urinary retention was defined as the need to perform even occasional self-catheterization. All 4 women with urinary retention had a detrusor pressure of less than 12 cm. H(2)O (0 in 3, 4 in 1). None of the women with a detrusor pressure of greater than 12 cm. H(2)O had urinary retention (p = 0.047). The presence of Valsalva voiding in women without a detrusor contraction did not affect the incidence of urinary retention (11.1%) compared to those who did not demonstrate Valsalva voiding (5.1%) (p = 0.603). Peak flow rate, detrusor instability on preoperative urodynamics and post-void residual urine volume were not associated with postoperative urinary retention. Finally, post-void residual urine volume predicted delayed return to normal voiding (p = 0.001). There were no other urodynamic parameters that were significantly associated with urinary retention, delayed return to normal voiding or postoperative urgency symptoms including peak flow rate, capacity or compliance. CONCLUSIONS: Women who void without or with a weak detrusor contraction are most likely to have urinary retention postoperatively. Therefore, we conclude that preoperative urodynamic evaluation may be used to counsel women regarding the risk of urinary retention following the pubovaginal sling procedure.     

The Ibero-American experience with a re-adjustable minimally invasive sling

OBJECTIVE: To report our experience with the Safyre (Promedon, Cordoba, Argentina), a new re-adjustable and minimally invasive sling for treating stress urinary incontinence (SUI), which combines the efficacy of slings with re-adjustability. PATIENTS AND METHODS: In all, 126 consecutive patients with a clinical and urodynamic diagnosis of SUI had a Safyre sling procedure (mean age 63 years, range 40-71). Seventy-six patients (60%) presented after previous failed anti-incontinence procedures; all had a physical and clinical examination, a stress test, urodynamic study and assessment of pad use before the surgery. All the patients presented with symptoms of SUI and 37 (29%) also reported mild urgency. RESULTS: The mean (range) follow-up was 18 (12-36) months, and the mean operative duration 25 min. Dystopia was repaired whenever necessary during the same procedure. The mean hospital stay was 24 h. In three implants (2%) the bladder was perforated. After surgery 26 patients (21%) developed urgency symptoms; during the follow-up 116 (92%) were continent, three (2%) reported an improvement and seven (6%) were dissatisfied. CONCLUSION: The Safyre is a safe and quick procedure that allows for postoperative readjustment; this technique may be an attractive alternative if the good results obtained so far prove to be durable.     

The outcome of bladder neck closure in children with severe urinary incontinence

PURPOSE: We evaluated the outcome of children who underwent bladder neck closure for the management of severe urinary incontinence. MATERIALS AND METHODS: Bladder neck closure was performed in 12 patients with bladder exstrophy, 4 with myelomeningocele and 4 with urogenital sinus anomalies for severe urinary incontinence that persisted after multiple failed bladder outlet procedures. The effectiveness of bladder neck closure and the need for subsequent surgeries were ascertained. RESULTS: Mean followup was 5.4 years (range 1 to 12). At 3 months after surgery 40% of the patients were completely dry, 20% had leakage via the stoma and 40% had a urethral fistula. After additional surgeries 85% of the patients were completely continent 2 years following bladder neck closure (15% declined further surgeries or had an ileal conduit). Of the 15 patients with followup longer than 3 years only 40% remained completely dry, and leakage via the stoma developed in 47% after being dry for 1 year. Repeat urodynamic studies did not show any adverse changes in bladder dynamics in the incontinent patients. Stomal stenosis occurred in 30% of the patients and bladder stones developed in 40%. None of the patients had hydronephrosis or bladder perforation. The early complication of fistula formation and the late development of leakage via the stoma appear to be related in part to compliance with intermittent catheterization. CONCLUSIONS: Bladder neck closure is an effective method of achieving urinary continence in children in whom other bladder outlet surgery has failed. However, its success is dependent in part upon compliance with intermittent catheterization. Finally children who have undergone bladder neck closure are at an increased risk for stomal stenosis and bladder stones.     

Long-term durability of the distal urethral polypropylene sling procedure for stress urinary incontinence: minimum 5-year followup of surgical outcome and satisfaction determined by patient reported questionnaires

PURPOSE: We report on the long-term outcomes of the distal urethral polypropylene sling. MATERIALS AND METHODS: We performed a prospective study of all consecutive patients who underwent a distal urethral polypropylene sling procedure between November of 1999 and April of 2000 for treatment of SUI. Surgical outcome was determined by patient self-assessment, and included symptom, bother and quality of life questionnaires. Physicians were blinded to patient responses. All patients had a minimum 5-year followup. Every patient treated was included in reporting outcomes in the intent to treat analysis. RESULTS: There were 69 patients treated a minimum of 5 years before the analysis. Cases lost to followup were defined as treatment failures. At a minimum followup of 5 years patient determined subjective success rate was 88%. More than 5 years after surgery 72% of patients reported no symptoms of SUI and 74% reported never being bothered by SUI. Patients reported an overall mean improvement of symptoms of 81%, and quality of life due to urinary symptoms between pleased and mostly satisfied. CONCLUSIONS: The distal urethral polypropylene sling procedure has low morbidity and excellent durability in treating patients with SUI.     

Expanded PTFE bladder neck slings for incontinence in children: the long-term outcome

OBJECTIVE: To assess the long-term outcome of circumferential expanded PTFE (Gore-tex, WL Gore Associates, Scotland) bladder neck slings for achieving urethral continence in children with a neuropathic bladder. PATIENTS AND METHODS: The records were reviewed of 19 children undergoing bladder reconstruction (most with a neuropathic bladder) who had a Gore-tex sling placed circumferentially at the bladder neck, over a 5-year period. Of these, seven had spina bifida; two each spinal dysraphism, surgery for anorectal anomalies and an idiopathic neuropathic bladder; five who developed a neuropathic bladder from other causes, and one born with bladder exstrophy. All children had an uncompliant bladder with a low urethral leak-point pressure on preoperative urodynamics. In all children conventional clean intermittent catheterization and pharmacotherapy had failed. Four had had previous augmentation surgery while 15 had concomitant bladder augmentation and formation of a Mitrofanoff stoma. The main outcome measure was achieving dryness. The original intention of the procedure was also to maintain urethral catheterization. RESULTS: Full details of the follow-up were available in 17 patients. Despite initial good short-term results, at a median follow up of 7 years, in 14 patients the sling had to be removed because of erosion, often with transient urethral leakage before the bladder neck subsequently closed. A bladder calculus was associated with each case of erosion except one. CONCLUSION: Although in the short term this technique had favourable results, it was not a useful technique in the long term.     

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.     

The surgical results of the pubovaginal sling procedure using polypropylene mesh for stress urinary incontinence

OBJECTIVE: To investigate the surgical results after a pubovaginal sling procedure using polypropylene mesh in women with stress urinary incontinence (SUI). PATIENTS AND METHODS: Sixty-four women with different types of SUI underwent a pubovaginal sling procedure, using polypropylene mesh. The sling was placed at the level of the proximal half of the urethra and tied with adequate tension, but not obstructing the bladder outlet. A video-urodynamic study and transrectal ultrasonography were undertaken before and after surgery. The surgical results were assessed and the urodynamic changes compared at different stages. RESULTS: At a median follow-up of 24 months, 52 patients (81%) were completely continent, 10 (16%) had an improvement but with mild SUI, and two had persistent SUI requiring a second sling procedure. The treatment result was considered satisfactory by 55 patients (86%). The video-urodynamic study showed no significant change in voiding pressure, cystometric capacity and residual urine volume after surgery. The bladder neck opening time was increased at 7 days and the maximum flow rate increased at 3 months after surgery. Transrectal ultrasonography showed that all the polypropylene mesh slings were located beneath the bladder neck and proximal urethra, with no notable granuloma formation around the sling. CONCLUSION: The pubovaginal sling procedure is effective in treating female SUI, using polypropylene mesh as the sling material. The video-urodynamic results showed that a pubovaginal sling of polypropylene mesh causes no bladder outlet obstruction when the correct surgical technique is used.     

Management of vesicoureteral reflux in patients with neurogenic bladder dysfunction

We studied 20 cases of neurogenic bladder with vesico-ureteral reflux retrospectively. Seven patients voided with Valsalva's maneuver and 12 patients were managed with clean intermittent catheterization, but one patient required permanent urinary diversion because of uncontrollable urinary tract infection. The patients were followed by intravenous pyelography, radioisotope renogram, voiding cystourethrography, determination of serum creatinine level and urodynamic study. Anti-reflux surgery was performed in 22 ureters and reflux resolved in 19 ureters. Among 12 ureters not treated by anti-reflux surgery, reflux disappeared in 5 ureters and improved in 2 ureters. Of 5 ureters, reflux resolved after clean intermittent catheterization in 2 ureters, and remained stable without recurrent infection or renal deterioration in the remaining 5 ureters. Regardless whether antireflux surgery was done or not, most of the patients who had high grade reflux and obstructive renal damage on radioisotope examinations had marked low compliance bladders. Our experience suggested the necessity of a suitable treatment to improve bladder compliance before considering anti-reflux surgery.     

Long-term followup of patients after redo bladder neck reconstruction for bladder exstrophy complex

PURPOSE: The aim of this study was to determine whether redo bladder neck reconstruction is effective in achieving continence after a failed bladder neck reconstruction procedure. MATERIALS AND METHODS: We retrospectively reviewed the hospital records of patients with bladder exstrophy who had undergone redo bladder neck reconstruction. There were 30 patients in the study, including 20 boys and 10 girls. Mean patient age at redo bladder neck reconstruction was 9.3 years (range 3.2 to 15.5). The patients were divided into 3 groups on the basis of the preoperative pattern of incontinence--incomplete wetters, complete wetters and those on continuous suprapubic drainage. Of the patients 15 already had undergone bladder augmentation, 12 had undergone a Mitrofanoff procedure and 12 had been treated with bulking agents injected in the bladder neck in an attempt to achieve continence. Four patients had undergone more than 1 bladder neck procedure. The patients were investigated with a combination of noninvasive urodynamics, cystoscopy, cystogram and ultrasound. All patients underwent Mitchell's modification of Young-Dees-Leadbetter bladder neck reconstruction. Additional procedures performed included augmentation cystoplasty and Mitrofanoff formation. RESULTS: Mean followup was 6.9 years (range 1.2 to 15.5). Postoperatively 28 patients were using clean intermittent catheterization to empty the bladder (5 per urethra, 23 via Mitrofanoff). Two patients remained on continuous suprapubic catheter drainage. A total of 18 patients (60%) were dry postoperatively (80% of girls and 50% of boys). Among dry patients only 3 were performing clean intermittent catheterization per urethra and 15 via a Mitrofanoff channel. No patient was able to void per urethra without the need for clean intermittent catheterization. The 2 patients on continuous suprapubic catheter drainage continued to remain so. At night only 50% of the patients were dry (5 on free drainage, 4 on clean intermittent catheterization, 6 not on any drainage). Those patients who did not respond satisfactorily to redo bladder neck reconstruction underwent subsequent additional procedures, which included injection of bulking agents (3 patients), insertion of an artificial urinary sphincter (1), Mitrofanoff formation (2) and bladder augmentation plus Mitrofanoff channel (1). Postoperative complications included difficulty with clean intermittent catheterization (8 patients), perivesical leak (1), recurrent epididymo-orchitis (1), upper urinary tract dilatation (2) and incisional hernia (1). Bladder neck closure was being considered in 5 patients. CONCLUSIONS: In our experience redo bladder neck reconstruction cannot achieve continence with volitional voiding per urethra. Although redo bladder neck reconstruction can render a significant number of patients dry, it is only effective if performed in conjunction with augmentation. Failure of the initial bladder neck reconstruction may be a reflection of a bladder that is of inadequate capacity and/or compliance. Therefore, bladder augmentation should be considered in all patients requiring redo bladder neck reconstruction. Bladder neck closure may be a better alternative to redo bladder neck reconstruction.     

Surgical treatment of stress urinary incontinence after radical hysterectomy

Stress urinary incontinence is not infrequent after radical hysterectomy for cervical cancer. Eight women who underwent surgery for correction of stress incontinence after radical hysterectomy were studied with urodynamic techniques before and 1 year after incontinence surgery. Five patients underwent a Marshall-Marchetti-Krantz (MMK) operation, 1 a Burch colposuspension, 1 a sling procedure and 1 an anterior repair. Two patients remained incontinent after an MMK operation, as did the patient who had an anterior repair. The patient who underwent a sling procedure had to practice intermittent selfcatheterization. We conclude that an appropriate operation can cure stress incontinence after radical hysterectomy, but that patients should be selected carefully.     

Further experience with seromuscular colocystoplasty lined with urothelium

PURPOSE: We report our continuing experience with seromuscular colocystoplasty lined with urothelium. This procedure is designed to preserve the urothelium and potentially decrease the incidence of complications associated with standard bladder augmentation. MATERIALS AND METHODS: We retrospectively reviewed the charts of 32 patients who underwent seromuscular colocystoplasty lined with urothelium between April 1994 and July 1999. Data were collected on patient demographics, surgical indications, previous and adjunctive surgical procedures, preoperative and postoperative urinary continence, upper urinary tract changes, urodynamic parameters, surgical complications and histological findings. RESULTS: Mean patient age at surgery plus or minus standard deviation was 11.1 +/- 4.8 years. Mean followup was 1.6 +/- 1 years. A mean of 1.5 +/- 0.9 years postoperatively urodynamic studies available in 28 cases showed that total and safe bladder capacity increased by 1.8 and 2.4-fold, respectively. Continence was achieved in 71% of patients after the initial procedure, increasing to 81% after secondary procedures. Hourglass deformity developed in 7 cases (22%), augmentation failed in 4 (12.5%) and there were bladder calculi in 2 (6%). New onset or increased hydronephrosis and reflux were present in 6 of 62 (10%) and 9 of 60 (15%) evaluated renal units, respectively. Of the 7 interpretable biopsies 5 revealed various degrees of repeat colonic mucosal growth. There was no bladder perforation or metabolic abnormalities, and mucous production was not clinically significant. CONCLUSIONS: Seromuscular colocystoplasty lined with urothelium is a viable alternative to standard bladder augmentation. The 2 procedures have a similar overall complication rate. Comparatively there appears to be a low incidence of bladder calculi, mucous production has not been clinically significant, metabolic disturbances have not developed and perforation has not occurred during short-term followup. We are enthusiastic about this technique and continue to apply it in select patients.     

Colpo-wrap: a new continence procedure

OBJECTIVE: To present a new surgical method to increase bladder outlet resistance for the treatment of urinary incontinence in girls and women. PATIENTS AND METHODS: Six patients (mean age 9.6 years), with urinary incontinence were operated using the new technique within the last 3 years. The principle of the procedure is tightening of the bladder neck by mobilizing the anterior vaginal wall and wrapping it around the bladder neck and proximal urethra, in the sense of a vaginoplication (colpoplication). The underlying conditions and causes for urinary incontinence was neurogenic bladder-sphincter dysfunction caused by myelodysplasia in three girls and anorectal malformation combined with a tethered spinal cord in one. In one case incontinence was caused by a cloacal anomaly and one girl had intrinsic sphincter insufficiency after repetitive Otis urethrotomies. The colpo-wrap was combined with a bladder augmentation and Mitrofanoff in three patients, the three other girls undergoing isolated procedures. RESULTS: The result of the method is a constant increase in outlet resistance and coaptation of the urethra, comparable with the effect of a vaginal sling procedure. Five patients are completely dry after surgery, one girl with cloaca needed an additional bladder neck injection with hyaluranon/dextranomer copolymer. Transurethral catheterization was possible after surgery with no problems in all patients who required intermittent catheterization. CONCLUSION: Considering the feasibility of this technique the colpo-wrap is a reasonable alternative for treating urinary incontinence in females.     

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.