The stamey endoscopic bladder neck suspension

The Stamey procedure has gained a favourable reputation as a highly effective operation for the treatment of genuine stress incontinence in the female. Technical ease, short operating time, brief hospitalization and minimal postoperative morbidity have all been claimed as particular advantages of this procedure. With correct patient selection and attention to operative detail, this technique has much to offer both young and old women who require surgical correction of genuine stress incontinence.     

An unusual foreign body in the bladder 7 years after a Stamey endoscopic bladder neck suspension

Delayed migration of the suture and bolster after an endoscopic bladder neck suspension across tissue planes, with subsequent erosion into the bladder, is uncommon. We present a case of late migration of the suture and bolster occurring 7 years after a Stamey endoscopic bladder neck suspension. A 56-year-old woman had undergone a Stamey procedure in June 1990. In January 1997 she presented with discomfort in the left iliac fossa and the groin. A midstream sample of urine showed microscopic hematuria. Imaging and endoscopic examinations revealed a calcified lesion on the left lateral wall of the bladder, attached to the Stamey sutures. Cystolitholapaxy was attempted, but during the procedure it became obvious that there was a calcified cuff attached to the suture. This was removed endoscopically, along with its suture. Cystoscopy should be considered early in the evaluation of patients presenting with lower abdominal discomfort or irritative voiding symptoms after retropublic bladder neck suspension.     

Readjusting the loop tension for resolving postoperative urination difficulties and recurrent stress incontinence after stamey suspension of the vesical neck

Excessive tension of the vesical neck sutures produces postoperative urinary retention or difficulties in urination after anti-stress urinary incontinence operations. We have demonstrated that these complications after the Stamey operation and its modifications can be resolved by readjusting the suspending loops to an adequate tension under local anesthesia, since these operations use non-absorbable monofilament loops for the suspension of the vesical neck. The technique was also applied for the correction of insufficient suspension which caused persistent or recurrent stress incontinence after these operations. The procedure was performed for 7 patients with postoperative difficulties in urination, and for 7 with postoperative recurrence of stress incontinence, and all of them recovered normal urination without stress incontinence. These procedures have been performed successfully even 27 months after a Stamey operation. These cases suggest that a recurrence of stress incontinence, even several years after the Stamey operation, can be cured with our procedure, as long as the supporting tissue of the suspending loops is not damaged.     

Delayed reaction to the Dacron buttress used in Stamey bladder neck suspension

Stamey bladder neck suspension is thought to be an excellent procedure for stress urinary incontinence in selected groups of patients. However we must not ignore the complications of this procedure. We report a case of a patient who developed a delayed reaction with bladder wall erosion to the Dacron buttress used in Stamey urethropexy 19 years before. She was presented with pelvic pain and persisting irritative bladder symptoms. The treatment of choice was cystoscopic removal of suture and buttress. Tissue intolerance is a common problem with the use of different kinds of biomaterials in incontinence surgery. Careful cystourethroscopy is essential for early diagnosis and treatment if pain, infections and severe irritative symptoms occur postoperatively.     

Long-term chronic complications from Stamey endoscopic bladder neck suspension: a case series

Purpose/objective Long-term complications from anti-incontinence surgical procedures are rarely reported. We report on delayed presentation of complications relating to the synthetic bolster placed for the Stamey bladder neck suspension. Materials and methods: Patients undergoing re-operative surgery following prior Stamey endoscopic bladder neck suspension were selected from a surgical database. Four women with lower urinary tract and/or vaginal symptoms following prior Stamey endoscopic bladder neck suspension were identified. All patients had undergone removal of the bolster material by a single surgeon (ESR) at re-operation. Preoperative, operative, and postoperative inpatient and outpatient records were reviewed. Results: Patients presented with a variety of symptoms including urinary incontinence, recurrent cystitis, vaginitis, and urinary frequency at 9, 11, 11, and 12 years after Stamey bladder neck suspension. In addition, two patients presented with recurrent, intermittent bloody vaginal discharge and two patients complained of recurrent urinary tract infections and irritative voiding symptoms. All patients underwent transvaginal excision of the Dacron bolster. Three patients also underwent placement of an autologous pubovaginal sling for symptomatic recurrent stress urinary incontinence. At a mean follow-up of 30 months all four patients were improved. There was no recurrence of vaginal discharge or urinary tract infections. Irritative voiding symptoms resolved. Conclusions: Delayed complications from surgically implanted synthetic materials can present many years after initial implantation. The clinical findings are often subtle and require a high degree of suspicion. Vaginal discharge and irritative urinary symptoms in patients with even a remote history of Stamey bladder neck suspension should prompt a thorough vaginal exam and cystoscopy. Excision of the bolsters can be performed and is usually followed by symptomatic improvement.     

Patient satisfaction following bladder neck suspension

Stress urinary incontinence is a common problem; 107 women undergoing bladder neck suspension between 1982 and 1989 were reviewed. Seventyfour responded via questionnaire and underwent chart review. Leakage resolved in 83%, with a mean follow-up of 23 months. Sixty-eight per cent were satisfied with the procedure outcome. Preoperative leakage with coughing and work-related activities predicted procedure success, while symptom resolution, number of postoperative pads required, leakage with preoperative coughing and work-related activities predicted patient satisfaction. Postoperative detrusor instability caused the discrepancy between leakage resolution and patient satisfaction. A complication rate of 15.9% was significantly higher in patients who had undergone prior procedures (p<0.001).     

Stamey膀胱颈悬吊术治疗女性压力性尿失禁远期疗效观察

目的　评价Stamey膀胱颈悬吊术治疗女性压力性尿失禁的远期疗效。　方法　 5 2例接受Stamey手术患者 ,平均年龄 46岁 ,平均尿失禁 7.5年 ,Ⅰ°尿失禁 18例、Ⅱ°2 1例、Ⅲ°13例。　结果　 1994年以前手术 3 2例因并发症失败 3例 ,随访 3 .6年时治愈率 87.5 %、改善率 6.2 %、失败率 6.2 % ,随访 9.6年时治愈率 68.8%、改善率 9.3 %、失败率 2 1.9% ;1994年以后手术 2 0例随访 4.3年 ,治愈率 90 .0 %、改善率 10 .0 % ,无失败病例。　结论　Stamey手术治疗压力性尿失禁疗效随时间延长而下降 ,术前准确区分尿失禁类型和发病机制、降低并发症是提高疗效的关键     

Complications of endoscopic bladder neck suspension

Endoscopic bladder neck suspension for female urinary incontinence can result in both intraoperative and postoperative complications. Intraoperative complications include hemorrhage and injury to the urethra, bladder or ureters. Postoperative complications include infection, myocardial infarction, pulmonary embolus, suprapubic pain, persistent incontinence, bladder calculi and urinary retention. All of these potential complications can be managed successfully by applying the guidelines outlined.     

Stamey与TVT手术治疗女性压力性尿失禁的疗效比较

目的评价Stamey膀胱颈悬吊术和无张力阴道吊带术（TVT）治疗女性压力性尿失禁的疗效.方法总结2种方法治疗49例女性压力性尿失禁的临床资料.Stamey组26例,平均年龄57岁.尿失禁Ⅰ度3例,Ⅱ度15例,Ⅲ度8例.TVT组23例,平均年龄58岁.尿失禁Ⅰ度2例,Ⅱ度13例,Ⅲ度8例.对2组术中记录,术后控尿、合并症以及复发情况进行比较.结果 Stamey和TVT组平均手术时间分别为43 min和27 min.术中膀胱穿孔发生率为19%（5/26）和4%（1/23）.拔尿管后无尿失禁者分别为92%（24/26）和96%（22/23）;尿潴留发生率为8%（2/26）和0%.术后6个月,无尿失禁者分别为89%（23/26）和100%（23/23）.合并耻骨上区疼痛者分别为58%（15/26）和9%（2/23）;排尿不畅或剩余尿＞50 ml者分别为15%（4/26）和9%（2/23）;尿频尿急发生率分别为54%（14/26）和17%（4/23）.结论 2种方法治疗女性压力性尿失禁初期疗效均较好,但TVT法术后指标优于Stamey法.     

Unrecognized perforation of the cecum at needle suspension of the bladder neck: a case report

Perforation of the cecum at needle suspension of the bladder neck was detected at abdominal surgery for recurrent stress urinary incontinence 4 years later.Editorial Comment: When performing needle urethral suspension procedures there are a number of precautions that can be taken to avoid the most common complications, including intravesical suture placement, ureteral obstruction and bowel perforation. Trendelenburg positioning during these procedures can help to displace the bowel. Additionally, as the authors discuss, these injuries can be avoided by adequate dissection of the retropubic space, and by proper placement of the suprapubic incisions for the needle. This editor recommends placement of the needle approximately 1–2 cm lateral to the urethrovesical junction, and at the level of the pubic symphysis. Procedures in which the retropubic space is dissected, such as the Pereyra procedure, allow the surgeon to direct the needle vaginally along the posterior aspect of the symphysis with a finger in the retropubic space. Needle procedure such as the Raz, the Stamey and the Gittes procedures do not allow for this. Finally, cystoscopy after needle placement is an essential part of these procedures to detect intravesical suture material and/or bowel. The authors present the case of a rare, but potentially serious, complication of needle suspension procedures for the treatment of stress incontinence. The patient in this case had previously undergone two prior intra-abdominal procedures, which placed her at risk for intraperitoneal bowel adhesions and bowel perforation with a needle suspension procedure.     

Sling transection of urethra: a rare complication

Common postoperative complications associated with suburethral sling procedures include voiding disorders and urinary retention, de novo development of detrusor instability, sling graft rejection and, rarely, erosion of the graft into the urethra. The authors present a case of a late postoperative complication of polytetrafluoroethylene graft erosion and partial transection of the urethra, with resultant acute urinary retention. A 50-year-old patient presented with acute urethral outflow obstruction due to sling graft erosion into the urethra nearly 2 years after she underwent a curative sling procedure for recurrent genuine stress incontinence. After relieving the acute urinary retention by inserting a suprapulic catheter under ultrasound guidance, the sling graft was accessed and removed. The urethral defect was repaired successfully. At follow-up 5 months later, the patient was continent subjectively and by urodynamic criteria, with no voiding abnormalities. Although erosion of the sling graft into the urethra and transection of this structure is a rare complication after a sling procedure, it should be considered in the patient who experiences progressive voiding difficulties, has transvaginal urinary leakage, and/or cannot be catheterized transurethrally. Expedient relief of the urinary retention and outflow obstruction is necessary, as well as careful surgical reconstruction of the urethra. To minimize the development of this complication we recommend plication of paraurethral connective tissue in the midline beneath the sling graft, and placement of minimal tension on the sling.     

Effectiveness of the TVT procedure as a repeat mid-urethra operation for treatment of stress incontinence

Introduction and hypotheses  The aim was to evaluate the long-term (5 years) effect of performing a retropubic tension-free vaginal tape (TVT) operation after a prior failed mid-urethra sling procedure and try to identify reasons for failure of the primary operation. Methods  We identified 26 women to whom a repeat mid-urethra sling procedure (using the TVT Gynecare device) had been performed. Both the primary and repeat operations were retropubic procedures. Four different tape materials had been utilized in the primary procedure. Results  Twenty women (77%) of the identified 26 women participated in the study. Seventy-five percent of the women were cured or significantly improved after the repeat TVT procedure. Reasons for failure of the primary procedure were grouped as follows: inadequate tape material (four out of 20), inadequate surgical technique (six out of 20), patients' medical condition (four out of 20), and unrecognized reasons (six out of 20). Conclusions  A retropubic mid-urethra sling operation can be considered after failed mid-urethra sling surgery.     

Acute and long-term outcomes of radio frequency bladder neck suspension.

PURPOSE: A new treatment modality for women with stress urinary incontinence secondary to urethral hypermobility is radio frequency bladder neck suspension. Radio frequency energy is a form of electromagnetic energy that is reliable and highly controllable. This thermal therapy can produce well-defined areas of tissue heating. The technology has been used extensively in dermatological and orthopedic surgery for tissue shrinkage and ablation. Radio frequency thermal therapy is now being applied to the endopelvic fascia at the bladder neck and urethra for treating hypermobility in patients with stress urinary incontinence. The purported mechanism is shrinkage of the collagenated tissue that supports the bladder neck and proximal urethra. We report our acute and long-term experience with laparoscopic radio frequency bladder neck suspension for stress urinary incontinence. MATERIALS AND METHODS: Enrolled in this prospective multicenter trial were 94 women with a mean age of 48.4 +/- 7.6 years who had urethral hypermobility with an average cotton swab angle change of 41 degrees and Valsalva leak point pressures greater than 90 cm. water at 250 ml. bladder capacity. Detrusor instability was excluded by cystometry. In all cases precisely controlled radio frequency energy was applied to the endopelvic fascia to heat and shrink the tissue. The primary end points were physician assessment of continence, patient reported pad use and the number of patient reported episodes of urinary incontinence daily 1, 3, 6 and 12 months after surgery. RESULTS: Average operative time was less than 60 minutes and 98% of the patients were discharged home from the recovery room. Treatment surface area decreased an average of 17% in length and 21% in width. Preoperatively 78% of patients had an average of 1 or more episodes of urinary incontinence daily. At 1, 3, 6 and 12 months there was an average of 1 or fewer episodes of urinary incontinence daily in 84.7%, 85.6%, 85.9% and 77.4% of patients, respectively, and at 12 months 83.5% reported being continent or improved. Preoperatively 41.2% of patients reported using 1 pad or less daily, while at 1, 3, 6 and 12 months 85.6%, 90.4%, 87.2% and 86.9%, respectively, required 1 pad or less daily. Urodynamic evaluation at 12 months showed no leakage during the Valsalva maneuver in 78% of cases. There were no major postoperative complications and the minor complication rate was 5.3%. CONCLUSIONS: Early results of thermal treatment of the endopelvic fascia indicate that radio frequency bladder neck suspension is safe and effective for improving stress urinary incontinence in women. The improvement in symptomatology appears to be durable in most patients at the 1-year followup. Longer followup is needed to assess the durability of results and it is currently in progress.     

膀胱颈悬吊术与尿道中段悬吊术治疗女性压力性尿失禁疗效比较

目的分析膀胱颈悬吊术和尿道中段悬吊术治疗女性压力性尿失禁的疗效、合并症和费用,以探讨尿道中段悬吊术的临床应用价值。方法1998-2004年手术治疗女性压力性尿失禁患者46例,平均年龄52岁(25～84岁),行膀胱颈悬吊术18例(A组),尿道中段悬吊术28例(B组)。平均随访20个月(3～69个月)。根据患者主诉,排尿正常、完全自控、无尿失禁为治愈,尿失禁减少>50%为改善,症状未减轻或加重为失败;总有效率为治愈率加改善率。结果45例有效,总有效率98%,其中治愈40例(87%)。A、B组平均手术时间分别为(66.7±9.8)min和(35.1±12.1)min,P<0.01;平均住院日分别为(12.8±8.4)d和(4.8±2.3)d,P<0.05;留置尿管时间分别为(9.6±4.5)d和(2.4±1.2)d,P<0.01。A组13例治愈,4例改善,1例失败,平均手术费用人民币9112.2元;B组27例治愈,1例改善,平均费用人民币11210.4元,P>0.05。术后近期A组发生尿潴留5例(28%),B组3例(11%),P<0.05;A组术后3～7年发生侵蚀,造成尿道阴道瘘3例,而B组尚未发生严重远期合并症。结论尿道中段悬吊术治疗女性压力性尿失禁手术简单、安全、未明显增加手术费用,是治疗女性压力性尿失禁的首选术式。     

Stress urinary incontinence following radical hysterectomy with and without radiation therapy: Surgical results in 13 patients

Only a few articles have reported clinical experience of treating patients with stress urinary incontinence following radical hysterectomy and postoperative irradiation. These cases are generally characterized by detrusor areflexia, small bladder capacity, and low bladder compliance. During the past 5 years, 13 such patients were operated upon, including 6 patients without irradiation. Of these 8 had the Stamey procedure, 3 had a vaginal wall sling, and 2 had a pubovaginal sling. The success rate was 71% for the group with irradiation and 100% for the group without irradiation, while the overall success rate was 85%. Surgery significantly improved two anatomic parameters in a chain cystourethrogram: the posterior urethrovesical angle and the conjugata incontinentia. Surgical indications relevant to successful outcome are discussed.Supported partly be a research grant for aging from the Japanese Ministry of Health and Welfare.Editorial Comment: Little is known regarding the therapy of genuine stress incontinence following radical hysterectomy, especially when associated with radiation therapy. The surgeon is faced with potentially severely altered urethrovesical function due to the decentralization of the lower urinary tract secondary to the radical surgery. Non-compliant low capacity bladders make therapy of stress incontinence difficult. When radiation therapy is added marked alterations in tissue plasticity and blood supply result. The combination of all these factors complicate the medical and surgical therapy of incontience, and frequently the surgeon decides not to operate because of the increased possibility of failure. Although the numbers are small this paper demonstrates that good success rates for surgical therapy of genuine stress incontinence is possible when the proper surgical procedure is chosen.     

The clinical and urodynamic effects of the tension free bladder neck sling procedure

This study evaluated the clinical and urodynamic findings before and after tension-free bladder neck sling (TBS) procedure with Prolene tape. We enrolled 32 women who underwent TBS for genuine stress incontinence without intrinsic sphincter deficiency or severe uterovaginal prolapse. All subjects received 1-h pad test, Q-tip test, multichannel urodynamic testing, introital ultrasonography, and the Bristol Female Lower Urinary Tract Symptoms Questionnaires before and 1 year after surgery. Of the 32 subjects 27 were cured of stress incontinence, two improved, and three failed. The incidence of irritative symptoms and incomplete bladder emptying were significantly lower after surgery. The mean urethral straining angle showed a significant decrease from 73.8° preoperatively to 30.1° postoperatively. At rest the postsurgical position of the bladder neck (BN) was localized more cranially. During straining both ventral and caudal mobility of the BN decreased significantly following TBS, causing a more cranial and dorsal position of the BN. Urodynamic parameters including functional urethral length, maximal urethral closure pressure, and pressure transmission ratio showed significant increases after surgery. TBS could decrease the hypermobility of the BN and restore the BN support to prevent urinary leakage during straining, instead of urethral obstruction. The subjective and objective cure rate of stress incontinence is 84%, similar to those results reported after retropubic urethropexy and tension-free vaginal tape procedure. It is also worth emphasizing that no postoperative urinary retention occurred, although the limited number of cases makes it hard to confirm the significance of findings over the retention rate of tension-free vaginal tape.Editorial Comment: The paper challenges the concept that to be successful a TVT must be placed at the midurethra. Recent reports tell us that even when thought to be placed at the midurethra, often a TVT is closer to the bladder neck, yet it remains successful. This contribution reports on a select group of patients who had the tension-free tape placed knowingly at the UVJ rather than the traditional midurethra location. Unfortunately, this case series provides the weakest type of medical evidence, and no serious conclusions can be drawn from it. It should lead to a prospective, randomized study of the two techniques with objective outcome reporting. Only then can a truly scientific conclusion be made.     

Bladder neck suspension techniques with osseous screw fixation

Summary We investigated the technical feasibility and clinical results of bone fixation techniques in combination with needle suspension for correction of female stress urinary incontinence. In our experience the screw-like bone anchor, which is drilled into the pubic tubercle, represents a minimally invasive but very stable and reliable technique. However, the needle suspension fixed to the bone anchor turned out to be critical. Even though the suspension was fixed in the paraurethral tissue with a deep Z-stitch between the bladder neck and the midurethra, the 1-year recurrence rate was 76 %. Our data showed that the suspension sutures pull through the paraurethral tissue because there is no paravesical scar formation as in open procedures. Modifications of the suspension technique (four-point suspension, simultaneous laparoscopic or digital dissection of the paravesical space, combination with sling procedures) revealed significantly improved short-term results. Therefore we conclude that after improvement of the suspension technique the bone anchor will represent a valid option for minimally invasive fixation of a bladder neck suspension.      

膀胱颈和盆底肌联合悬吊术治疗儿童神经源性尿失禁

目的　评价膀胱颈和盆底肌联合悬吊术治疗括约肌功能不全所致儿童神经源性尿失禁的临床效果。　方法　先天性脊髓发育不良所致神经源性尿失禁患儿 2 3例 ,年龄 5～ 1 4岁 ,均行锥状肌膀胱颈悬吊和髂腰肌盆底悬吊术 ,1 4例同时行双层回肠浆肌层膀胱扩大术。　结果　 2 3例术后随访 5～ 32个月 ,平均 1 8个月 ,控尿满意 (昼夜均能保持 3h以上完全干燥 ) 1 3例 ,好转 (部分控尿 ,白天偶有尿失禁或夜间尿床 ) 7例 ,无效 (症状无改善 ) 3例 ,总有效率为 87%。术前最大膀胱容量 (1 51 .5± 72 .8)ml、漏点压 (32 .3± 6 .5)cmH2 O(1cmH2 O =0 .0 98kPa)、最大尿道压 (38.4± 1 3 .7)cmH2 O、最大关闭压 (2 2 .8± 1 3 .2 )cmH2 O、功能尿道长度 (3 .9± 1 .8)cm ;术后分别为 (2 1 1 .6± 63 .3)ml、(49.8± 1 6 .4)cmH2 O、(50 .8± 1 2 .3)cmH2 O、(32 .9± 1 2 .5)cmH2 O、(5 .6± 2 .0 )cm ,均较术前明显增高 (P<0 .0 1 )。膀胱造影显示膀胱颈漏斗状开放下垂状态得到明显改善。　结论　膀胱颈和盆底肌联合悬吊术可增加尿道静息压和动力压 ,改善盆底肌功能 ,提高控尿能力 ,是治疗儿童膀胱出口阻力较低所致神经源性尿失禁的较好方法之一     

Calcification of glutaraldehyde cross-linked collagen in bladder neck injections in children with incontinence: a long-term complication

PURPOSE: We report the incidence of calcifications developing at the bladder neck/urethra in pediatric patients treated with glutaraldehyde cross-linked collagen for urinary incontinence. MATERIALS AND METHODS: We reviewed charts of patients treated with glutaraldehyde cross-linked collagen injections for urinary incontinence between 1994 and 1999. Etiology of incontinence, pertinent medical history, operative details and postoperative imaging were examined. RESULTS: Of 31 patients 4 (13%) had development of submucosal calcifications in the bladder neck/urethra. All 4 patients had received multiple injections of glutaraldehyde cross-linked collagen for incontinence secondary to neurogenic bladder. The calcifications were confirmed surgically. Pathology reports available for 2 of 4 patients showed chronic inflammation without dysplasia or malignant changes. Mean followup was significantly different between calcified and noncalcified cases (10.3 vs 7.2 years, p = 0.009), as was total volume of collagen injected (21 vs 12 cc, p = 0.012). Mean time to diagnosis of calcifications was 8.8 years (range 7 to 11) after first injection. A total of 24 patients without calcification underwent bladder imaging at a mean of 6.8 years (+/-2.2) after glutaraldehyde cross-linked collagen injection, which was not significantly different than the time to diagnosis (p = 0.089). The number of injections was not significantly different between the 2 groups (p = 0.426). CONCLUSIONS: Of our patients 13% had development of calcifications at the site of prior glutaraldehyde cross-linked collagen injections for incontinence. These calcifications were surrounded by chronic inflammation. Patients who have undergone glutaraldehyde cross-linked collagen injections may benefit from long-term followup with bladder imaging to detect and follow calcifications at prior injection sites.