The modified Pereyra procedure: a clinical and urodynamic review.

OBJECTIVE: To review the clinical and urodynamic outcome of treatment by the modified Pereyra procedure in 93 women with genuine stress incontinence. DESIGN: Retrospective review. SETTING: Harbor/UCLA Medical Center and Los Angeles County Women's Hospital, Los Angeles, California, USA. MAIN OUTCOME MEASURES: Clinical and urodynamic assessment one year after modified Pereyra procedure. RESULTS: Overall 82% of patients were subjectively cured while only 63% were objectively cured. Women with failed surgery had significantly lower pre-operative maximum urethral closure pressures. The procedure had a low operative and postoperative morbidity with no significant disturbance of voiding function noted at one year follow-up. CONCLUSIONS: Our results with the modified Pereyra procedure for stress incontinence showed a significantly lower success rate than has been reported from many previous studies.     

Modified Burch versus Pereyra retropubic urethropexy for stress urinary incontinence

Sixty-four women underwent either the modified Burch retropubic urethropexy or the modified Pereyra procedure for surgical correction of stress urinary incontinence. All were evaluated clinically and urodynamically before and one year after surgery. The Burch procedure proved to be superior to the Pereyra procedure in terms of improving pressure transmission to the proximal two-thirds of the urethra (P less than .001), correcting the anatomic defect (P less than .001), avoiding postoperative voiding difficulties (20 versus 30%), and presenting an objective cure rate of 98 versus 85%. The age, parity, and degree of mobility of the urethra and urethrovesical junction did not influence the ability of the Burch and Pereyra procedures to produce efficient postoperative pressure transmission capacity ratio. Both types of surgical procedures were closely comparable in terms of curing stress urinary incontinence, operative time and blood loss, and total hospital stay.     

Retropubic cystourethropexy: a review of two operative procedures with long-term follow-up

The purpose of this report is to present a personal experience, with an up to 16-year follow-up, in the management of stress urinary incontinence using a retropubic cystourethropexy. An attempt is made to prove that, in addition to the standard Kelly anterior colporrhaphy, a transvaginal retropubic cystourethropexy helps to improve long-term results. Also, the results of transvaginal retropubic cystourethropexy (modified Pereyra procedure) and abdominal retropubic cystourethropexy (modified Marshall-Marchetti-Krantz procedure) are reviewed. Two hundred fifty-two patients received a modified Pereyra procedure and 490 patients underwent a modified Marshall-Marchetti-Krantz procedure in a 17-year period. The final corrected results of both of these procedures indicate that the percentage of patients clinically cured are almost identical (93%). Thus, for the treatment of genuine stress urinary incontinence, either the modified Pereyra procedure plus anterior colporrhaphy or the Marshall-Marchetti-Krantz procedure can be used with almost identical results. The route of the procedure performed, either abdominally or vaginally, is often determined by associated findings.     

Surgical management of stress incontinence in patients with low urethral pressure

Thirty-four women with genuine stress incontinence and low urethral closure pressure were studied pre- and postoperatively. A modified Burch retropubic urethropexy was performed in 29 patients with a cure rate of 78%, improvement in 7%, and failure in 15%. The modified Stamey procedure was performed in 5 patients with significant pelvic floor relaxation with a cure rate of 40% and improvement in 60%. If urethral mobility is present, traditional anti-incontinence procedures appear to be a reasonable alternative in patients with low urethral pressure.     

The Stamey endoscopic bladder neck suspension: a clinical and urodynamic investigation, including actuarial follow-up over four years.

OBJECTIVE--To assess a modified Stamey endoscopic bladder neck suspension as a management for genuine stress incontinence in women unsuitable for colposuspension because of vaginal narrowing or inefficient voiding. DESIGN--Uncontrolled observational study. SETTING--Regional university gynaecological urology unit. SUBJECTS--A hundred women, median age 58 years, with genuine stress incontinence confirmed by urodynamic investigation; 65 had had previous surgery for the same problem. TREATMENT--A Stamey procedure with monofilament nylon and short buffers of silastic tubing at each anchor site. MAIN OUTCOME MEASURES--Urodynamic reassessment 3 months after surgery and clinical follow-up for up to 4 years, using life table methods. The median follow-up was 27 months. RESULTS--At 3 months the objective cure rate was 83%. Subjectively the cure rates at 4 years were 53% in patients under 65 years of age and 76% in those who were older. Overall mean bladder capacity decreased from 506 to 458 ml after surgery (P less than 0.05) and, in those who were cured, mean peak flow rate fell from 25.5 to 19.6 ml/s (P less than 0.05). The urethral functional length and the pressure transmission in the proximal three quarters were increased by successful surgery (P less than 0.01) but the resting urethral profile, voiding pressure and the frequency of detrusor instability were unchanged. CONCLUSIONS--This modification of the Stamey operation has an important role in the management of elderly patients those with previous unsuccessful operations, and those with inefficient voiding pre-operatively.     

A urodynamic appraisal of success and failure after retropubic urethropexy

Fifty patients were evaluated with microtransducer urodynamic evaluation before and three months after retropubic urethropexy. Despite a 92% subjective success rate (46 of 50 patients), 13 patients (26%) were found to be surgical failures on postoperative urodynamic evaluation. Prior incontinence surgery (28 patients) was not a statistically significant risk factor except in those with prior Marshall-Marchetti-Krantz procedures; they were found to be at increased risk of failure (67%) (P less than .001). Prior hysterectomy had no effect on surgical outcome. Functional length in the sitting position was augmented by 4.3 mm (P less than .01) after the modified Burch procedure. However, there was no significant change in closure pressure. Patients who failed incontinence surgery had significantly lower preoperative closure pressures (P less than .005) and functional lengths (P less than .025). Urethral pressure profiles may be used to identify those patients with low-pressure, short urethras; they are at increased risk of surgical failure.     

Modified Pereyra procedure under local anesthesia

The modified Pereyra procedure, a retropubic urethropexy for the correction of anatomic stress urinary incontinence represents a safe, rapid, and well-tolerated technique for restoration of the normal retropubic position of the urethrovesical junction in selected patients. When general or regional anesthesia seem contraindicated due to age, medical risk, or anatomic factors, the procedure may be performed satisfactorily under local anesthesia. Of ten patients who underwent this procedure, nine reported excellent tolerance of the local technique. The postoperative hospital stay averaged three days. The average time from the injection of anesthesia to the termination of the surgical procedure was 45 minutes. Results were successful in 90%. This dependable surgical procedure for the correction of anatomic stress urinary incontinence may be performed in selected patients under local anesthesia with a high degree of patient tolerance.     

Suprapubic versus transurethral bladder drainage after surgery for stress urinary incontinence

Fifty-one patients with clinical and urodynamic diagnoses of stress urinary incontinence were randomly allocated to either suprapubic (N = 24) or transurethral (N = 27) bladder drainage after vaginal surgery for stress incontinence (revised Pereyra procedure). Postoperative use of suprapubic bladder drainage significantly reduced febrile morbidity (calculated as fever index; P less than .01) and length of hospitalization (P less than .05). Postoperative normal bladder functions resumed more quickly when suprapubic drainage was used (P less than .05), so that most patients did not need bladder catheterization upon discharge, as opposed to more than half of those with Foley catheters, who left the hospital with a catheter in place (P less than .05). We conclude that it is both beneficial and cost-effective to use suprapubic bladder drainage after a Pereyra operation for stress urinary incontinence.     

Primary stress urinary incontinence and pelvic relaxation: prospective randomized comparison of three different operations

There were 289 women with clinical and urodynamic diagnosis of primary stress urinary incontinence, stable bladder, and pelvic relaxation who underwent a single-stage surgical procedure because of incontinence and pelvic relaxation. Patients underwent one of three surgical procedures because of stress incontinence--anterior colporrhaphy, revised Pereyra procedure, or Burch retropubic urethropexy. Decisions with regard to the type of bladder neck suspension and the surgeon were made randomly with a randomization table. Each patient had a complete clinical and urodynamic evaluation before surgery and at 3 and 12 months after surgery. Cure rate as defined by strict clinical and urodynamic criteria was not significantly different among the three groups at the 3-month postsurgical evaluations; however, at the 12-month postsurgical evaluations, the cure rate among women who underwent Burch urethropexy (n = 101) was significantly higher than that of either Pereyra or anterior colporrhaphy (cure rates were 87%, 70%, and 69%, respectively; p less than 0.01). The Burch urethropexy was more effective than the Pereyra procedure or anterior colporrhaphy in the stabilization of the bladder base and resulted in a significantly better cure rate in women with primary stress urinary incontinence and pelvic relaxation.     

Predicting postoperative urinary incontinence development in women undergoing operation for genitourinary prolapse

A total of 67 female patients with pelvic relaxation (cystocele beyond the vaginal orifice) and with no urinary incontinence were clinically and urodynamically evaluated before and after a reconstructive surgical procedure. Of these, 24 patients had a significant decrease in abdominal pressure transmission to the urethra once the cystocele was reduced by vaginal pessary (abdominal pressure transmission ratio to urethra: bladder of less than 1.0). All 24 had a revised Pereyra procedure in addition to the cystocele repair. The other 43 patients had adequate abdominal pressure transmission to the urethra once the cystocele was reduced by vaginal pessary (abdominal pressure transmission ratio to urethra: bladder of greater than or equal to 1.0). These 43 patients underwent cystocele repair only with no surgical repair to the urethra or urethrovesical junction. Evaluation was repeated at 3 to 6 months after the operation. No patient developed urinary incontinence after operation. All 67 patients had urodynamically good abdominal pressure transmission to the urethra while coughing. Women with significant genitourinary prolapse may be continent in spite of a weak urethral sphincter because of kinking of the poorly supported urethra. Urodynamic testing can identify those women at risk of developing postoperative urinary incontinence so that prophylactic measures can be undertaken.     

The Stamey procedure for stress incontinence

The Stamey procedure represents a significant advance in the surgical management of stress incontinence. It involves limited dissection and has a short operating time and low associated morbidity in comparison to open procedures. It is therefore particularly appropriate for the elderly or frail, and is also easily performed in the ‘surgically difficult pelvis’. The procedure works by bladder neck elevation, and has negligible effect on outflow resistance; it may therefore also be employed in patients with stress incontinence and abnormal voiding patterns. Results vary, but even in these situations a cure rate of around 75% may be anticipated.     

The Pereyra procedure. Favorable experience with 200 operations.

This communication documents experience with 200 Pereyra operations performed for stress urinary incontinence over a 9 year period. The majority of patients were 35 to 55 years of age, were obese, and had varying degrees of uterovaginal prolapse. More than one fourth also had excessive bleeding and all were best managed by vaginal surgery. Important points in surgical technique are emphasized. Of 188 patients followed, 82 per cent had complete symptomatic relief and another 10.5 per cent were improved. There was a 7.5 per cent failure rate and morbidity was minimal. We conclude that the Pereyra procedure should be considered for stress urinary incontinence whenever vaginal surgery is indicated.     

Delayed reaction to the Dacron buttress used in urethropexy

Eleven patients developed a delayed reaction to the Dacron buttress used in Stamey urethropexy. The reaction was characterized by pain, dyspareunia, vaginal discharge and/or bleeding, induration of the abdominal incision, vaginal granulation tissue and draining abdominal or vaginal sinus tracts. This complication occurred in 5% of the 163 patients we treated with the Stamey procedure for stress urinary incontinence. Treatment consisted of removal of the nylon suture and Dacron buttress. None of the 11 patients developed recurrent incontinence. The subjective cure rate for stress urinary incontinence was 92% using the Stamey procedure.     

Prostaglandins for enhancing detrusor function after surgery for stress incontinence in women

Sixty-nine women with a clinically and urodynamically proven diagnosis of genuine stress incontinence underwent urethropexy in the form of the revised Pereyra procedure (n = 28) or Burch colposuspension (n = 41). Postoperatively the patients were assigned randomly to one of three study groups. Group 1 received a daily saline injection to the bladder (control group, n = 24), group 2 received daily intravesical injections of 250 mg of prostaglandin F2 alpha (PGF2 alpha) (n =23), and group 3 received a daily 10-mg PGE2 (PGE2) vaginal suppository (n = 22). The patients' suprapubic catheter was removed once the postvoiding residual urine volume was less than or equal to 50 mL. Both PGE2 and PGF2 significantly reduced the length of time required for postoperative bladder drainage after both the Burch and Pereyra procedures as compared to that in the control group (P less than .05). Hospital stay and bacteriuria were reduced as well in women receiving postoperative prostaglandins as compared to the control group. Clinically there were no differences between PGE2 and PGF2 alpha. Both produced no side effects, were well tolerated by the patients and were effective in reducing both the number of days required for bladder catheterization and the incidence of significant bacteriuria when administered after the surgical procedures.     

Negative Q-tip test as a risk factor for failed incontinence surgery in women

Fifteen women with a clinical and urodynamic diagnosis of stress urinary incontinence had a negative Q-tip test (greater than or equal to 30 degrees Q-tip angle change on straining). All 15 had retropubic surgical procedures for stress incontinence in the form of a revised Pereyra procedure (n = 6) or Burch retropubic urethropexy (n = 9). Five of the nine patients undergoing the Burch procedure (55%) and three of the six undergoing the Peyreya procedure (50%) failed the procedure, for an overall failure rate of 53%. This rate was five times higher than that among women with stress urinary incontinence and a positive Q-tip test who underwent the same procedures (P less than .01). We conclude that women with stress urinary incontinence and no anatomic defect in the support of the urethrovesical junction should not undergo retropubic procedures because of their high failure rate. Other occlusive procedures, such as sling operations, should be considered for this group.     

The modified rectus fascial sling for the treatment of genuine stress incontinence.

We aimed to assess the results of the modified rectus fascial sling for the treatment of genuine stress incontinence (GSI), using an observational study of patients at a South Wales Teaching Hospital. Seventy-three patients with proven GSI underwent a modified rectus fascial sling. Thirty-seven also had a significant urge component to their symptoms though only two had demonstrable detrusor instability. Fifty-one had undergone previous incontinence surgery. All had pre-operative videourodynamics and 50 agreed to follow up urodynamics. Of these who had undergone previous surgery 48 (94%) were subjectively dry, though four (8%) still demonstrated GSI on videourodynamics. There were no failures in the previously unoperated group. Three require long-term intermittent self-catheterisation and three others catheterise occasionally. Overall, 29 patients (78%) were improved or cured of their urge component but three were worse, with urge incontinence. From our data, it seems that the modified rectus fascial sling is superior to standard techniques for GSI especially in patients who have undergone previous surgery. However loosely the sling is placed, a small but significant group are obstructed by the procedure, and may require self-catheterisation.     

Modifications of the urethral rest and stress profiles after different types of surgery for urinary stress incontinence

Full urodynamic assessment, including urethral profiles at rest and under stress, using microtransducers, was made before and at least 6 months after surgery for urinary stress incontinence in 86 patients. Cure was assessed objectively. Procedures compared were Burch colposuspension, Pereyra urethrovesical suspension and anterior colporrhaphy. The Burch colposuspension increased the pressure transmission ratio more efficiently than the vaginal operations and the cure rate was 91%. Only 50% of Pereyra operations were successful and success was related to an increase in the functional urethral length and in the pressure transmission ratio. The success rate for anterior colporrhaphy was 57% and was associated with a significant decrease in the maximal urethral closure pressure and the continence area. The prognostic value of the urethral profiles at rest and under stress and the therapeutic implications are discussed.     

Live births in poor prognosis IVF patients using a novel non-contact human endometrial co-culture system

Patients with repeated implantation failures or poor embryo quality may benefit from embryo culture using the co-culture technique; growth factors secreted by co-culture cells may act as survival factors. Autologous endometrial co-culture has been suggested as a safe alternative to animal cells for co-culture of human embryos. However, the technique is fairly labour intensive and its effectiveness can vary from patient-to-patient. This study presents clinical outcome data on a novel noncontact co-culture system using a human endometrial cell line rather than autologous tissue. Embryos from 316 poor prognosis patients with repeated IVF failures, previous cycles with poor embryo quality or advanced maternal age were cultured in Transwell chambers with a monolayer of endometrial cells. The clinical pregnancy rate in patients less than 39 years of age was 53% and for patients aged between 39 and 42 years it was 33%. To date, 76 patients have delivered 111 healthy infants with no congenital anomalies and 18 pregnancies are ongoing. This is the first report on the potential benefits of a non-contact co-culture system in the IVF laboratory. This study shows that an established human endometrial cell line can be used to obtain the benefits of co-culture without the potential disadvantages associated with using autologous endometrial tissue.     

Hysteroscopic sterilization with the use of formed-in-place silicone plugs

Hysteroscopic sterilization with the use of a formed-in-place silicone plug is an office procedure which can be done with paracervical block anesthesia. It appears to be an effective method of sterilization. The present study is a review of 206 of the author's patients who chose this procedure. Thirty-four patients (16.5%) had more than one procedure for a total of 244 cases. Sterilizations were achieved in 188 patients (91.3%). The sterilization was accomplished in 166 patients (80.6%) at the time of the first procedure, in 20 of 40 patients (9.7%) at the second procedure, and in two of four patients (1.0%) at the third procedure. The primary reason for failure to achieve sterilization was tubal spasm. Of the 18 patients (8.7%) who were not sterilized, 16 were considered as failures and dropped from the study and two are awaiting a repeat procedure. No patients have become pregnant and there have been no significant complications.     

Compliance after loop electrosurgical excision procedure or cold knife cone biopsy

OBJECTIVE: To examine rates and predictors of compliance with follow-up recommendations in low-income women from a county hospital clinic undergoing loop electrosurgical excision procedure (LEEP) and cone knife cone biopsy. METHODS: A retrospective cohort study of 135 patients who underwent LEEP or cold knife cone biopsy was performed. Demographic data, results of cytology, colposcopy biopsy, excision specimen pathology, and indication for the LEEP or cold knife cone biopsy were collected. Compliance was determined by whether the patient adhered to the recommended follow-up within 1 year from the date of the procedure. Multivariable analysis was performed by using logistic regression. RESULTS: A total of 135 patients were included for analysis (81 LEEP and 54 cold knife cone cases). Type of procedure was significant in predicting compliance: 74.1% of cold knife cone patients were compliant compared with 43.2% of LEEP patients (adjusted relative risk 1.64, 95% confidence interval 1.30-1.87). There was a trend for older patients to be more compliant than younger patients in the univariable analyses but not in multivariable analysis. After adjusting for age, LEEP patients were still significantly less compliant than cold knife cone patients. Pathologic indication (severity of disease), race, payor source, and gravidity were not significant predictors of compliance and not included in the multivariable analysis. CONCLUSION: Compared with LEEP, cold knife cone patients were significantly more compliant with follow-up. Because LEEP is a less invasive in-office procedure, it may convey to patients the idea that their condition is less severe. LEVEL OF EVIDENCE: II.