The effect of spinal anaesthesia on urethral function

This study was to assess the effect of spinal anaesthesia on urethral retro-resistance pressure (URP), cough pressures and tendency to leak. The population consisted of 32 women undergoing a tension-free vaginal tape (TVT) operation under a spinal anaesthetic. URP, cough pressures and an assessment of the degree of leak were performed before the spinal anaesthetic was placed. A standard anaesthetic technique was used, and measurements were repeated after the spinal anaesthetic was inserted. The degree of leak was assessed on a five-point scale with 350 ml in the bladder. The cough pressures and URP values were averaged over three or more measurements. The mean URP value fell from 75.0 to 54.0 cm/H₂O (p = 0.0003) after the spinal was inserted. There was a non-significant fall in mean cough pressure from 85.0 to 67.5 cm/H₂O (p = 0.06). The degree of leakage increased (p = 0.005). Spinal anaesthesia causes a fall in the resistance in the urethra but does not cause a significant fall in the pressure generated by a cough. Women are more likely to leak after coughing during the TVT operation under spinal anaesthesia than they are before the spinal is inserted. The cough test under spinal anaesthesia does not mimic the result of coughing without a spinal.     

The effects of duloxetine on urethral function and sphincter morphology

The aim of our study was to investigate the effect of duloxetine on urethral function and sphincter ultrasound morphology in 54 women, who were referred to a urogynecology unit, with urodynamic stress incontinence. All completed a King’s Health Questionnaire and a patient global assessment of improvement (PGI-I) question and underwent urethral pressure profilometry, measurement of urethral retro-resistance pressure (URP), and ultrasound of the striated urethral sphincter. The investigations were repeated after 8 weeks of duloxetine 40 mg twice daily in 36 women who continued the medication. After 8 weeks of duloxetine, the mean URP increased significantly compared to baseline (53.8 to 60.8 cm H₂O; p = 0.001), and sphincter thickness was significantly higher (1.8 to 2.0 mm; p < 0.001). There was a significant increase in the maximum urethral closure pressure (MUCP) (52.7 to 59.2 cm H₂O; p = 0.006) but not of functional urethral length. Subanalysis of responders (improved on duloxetine) showed a significant increase in URP (50.3 to 59.1 cm H₂O; p = 0.001), sphincter thickness (1.7 to 2.1 mm; p < 0.001), and MUCP (50.2 to 58.1 cm H₂O; p = 0.03). These changes were not seen in nonresponders. This study has demonstrated objective changes in urethral ultrasound morphology and function after duloxetine therapy, which relate to improved continence. A larger longer term study is required to assess if these changes persist over time. In summary, duloxetine therapy for urodynamic stress incontinence results in an increase in urethral closure pressure, URP measurement, and urethral striated sphincter thickness.     

The tension-free vaginal tape in women with a non-hypermobile urethra and low maximum urethral closure pressure

The objective of this study was to estimate the cure rate and to identify risk factors that predict failure of the tension-free vaginal tape (TVT) in women with stress urinary incontinence (SUI), a non-hypermobile urethra, and low maximum urethral closure pressure. Thirty-six women with SUI, a non-hypermobile urethra (straining urethral angle ≤35°), and low maximum urethral closure pressure (MUCP ≤25 cm H₂O) underwent a TVT. Cure was defined as resolution of subjective SUI symptoms and a negative cough stress test, which were measured after 4, 12, 18, and 24 months. Patient characteristics were compared and receiver–operator curves were used to identify risk factors for failure. The mean age was 71 years, and mean follow-up was 20.9 months. The overall cure rate was 78%. Risk factors for failure of the TVT were a straining urethral angle ≤20° (cure rate 50%, odds ratio 7.7, p = 0.02) and a MUCP ≤15 cm H₂O (cure rate 60%, odds ratio 6.3, p = 0.03). For women with both risk factors, the cure rate was only 17% (p < 0.001). No other risk factors were identified. The TVT has moderate success (50-60%) for women with SUI and one risk factor (a straining urethral angle </=20 degrees or a MVCP </=15 cm H₂O), but has poor success (17%) when both risk factors are present. Presented at the annual meeting of the Society for Gynecologic Surgeons, Dallas, TX, March 5–7, 2002. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.     

Sequential comparisons of postoperative urodynamic changes between retropubic and transobturator midurethral tape procedures

Objectives  To sequentially compare the postoperative urodynamic changes in patients with urodynamic stress incontinence (USI) who underwent tension-free vaginal tape (TVT) or transobturator tape (Monarc TOT) procedure. Methods  Between January 2001 and December 2005, 50 consecutive patients with USI who underwent TVT (n = 24) or TOT (n = 26) procedures were studied, and postoperative urodynamic changes were sequentially compared by one-way ANOVA test with Bonferroni’s correction. Results  There were no significant between-group postoperative changes in urodynamic parameters of uroflowmetry, filling and voiding cystometry. However, the TVT group had a higher objective cure rate (100% vs. 69.2%, P = 0.004) by pad test, urethral closure pressure area [40.4 cm² H₂O, 95% confidence interval (CI) = 22.3–58.5 cm² H₂O vs. 3.9 cm² H₂O, 95% CI = −10.9 to 18.7 cm² H₂O, P = 0.036], and continence area (34.4 cm² H₂O, 95% CI = 16.1–52.7 cm² H₂O vs. −3.5 cm² H₂O, 95% CI = −16.7 to 9.8 cm² H₂O, P = 0.001) at 12 months than those of the TOT group. Conclusions  This study demonstrated that tension-free vaginal tape and transobturator tape procedures had no significant difference of impact on bladder voiding and storage functions. However, this study demonstrated that TVT procedure resulted in a higher cure rate with a significantly increased urethral closure pressure area and continence area than did TOT procedure 12 months postoperatively. Thus, TVT procedure might be a better therapeutic choice to achieve continence than TOT.     

Prophylactic single-dose prulifloxacin for catheter-associated urinary tract infection after tension-free vaginal tape procedure

The purpose of the study was to evaluate whether antibiotic prophylaxis with a single dose of prulifloxacin after tension-free vaginal tape (TVT) procedure decreases catheter-associated urinary tract infections (UTIs). Patients undergoing TVT procedure receiving a single dose of prulifloxacin (600 mg) 10 h before catheter removal (n = 54) were compared with historical controls who have had no treatment (n = 60). All patients had an indwelling urethral catheter in situ for 24 h. Urine specimens for culture were collected preoperatively, before Foley removal, and 7 days postoperatively in both groups. Main outcome measures were significant bacteriuria and symptomatic UTI at catheter removal and 1 week postoperatively. No patient had a positive urine culture in the prulifloxacin group compared with 14 (23.3%) in the control group at catheter removal (P = 0.0001). Ten out of 14 (71.4%) women with a positive catheter urine culture had a symptomatic UTI. One week after surgery no difference was found in the rate of significant bacteriuria between groups. Our data suggest that a prophylactic single dose of prulifloxacin could help to reduce the rate of symptomatic and asymptomatic UTIs after short-term urethral catheterization in women undergoing TVT procedure.     

Tension-free vaginal tape for the treatment of urodynamic stress incontinence with intrinsic sphincteric deficiency

The purpose of this study was to evaluate the outcome of tension-free vaginal tape (TVT) procedure in women with urodynamic stress incontinence diagnosed as having intrinsic sphincteric deficiency (ISD). The combination of a maximal urethral closure pressure <20 cm H₂O and a Valsalva leak point pressure <60 cm H₂O was considered as diagnostic of ISD. Subjects with detrusor overactivity on preoperative urodynamics were excluded. A total of 35 patients with both low closure pressure and leak point pressure were enrolled. Bladder perforation occurred in three (8.6%) cases. Postoperative urinary voiding difficulties occurred in nine (25.7%) women. Two patients underwent surgical detension of the tape, with complete resolution of urinary retention and no relapse of incontinence. Women with postoperative voiding dysfunction had a significantly lower detrusorial pressure at the peak flow on preoperative urodynamics compared to those who voided efficiently after TVT. The mean (range) follow-up time was 12.5 months (3–36). The objective cure rate for stress incontinence was 91.4%. Two of the three (66%) patients in whom the TVT procedure failed had a fixed urethra. De novo urge incontinence was found in five (14.3%) patients.     

Transobturator slings for stress incontinence: using urodynamic parameters to predict outcomes

The purpose of this study is to evaluate the ability of preoperative urodynamic urethral function parameters to predict the success rate of transobturator slings (TOS). Seventy women urodynamically diagnosed with stress incontinence with urethral hypermobility underwent a Monarc™ TOS (American Medical Systems, Minnetonka, USA). Postoperative continence status was correlated with preoperative urodynamic urethral function parameters. Mathematical modeling was used to determine whether urodynamic parameters can be used to predict postoperative continence. Average follow-up was 8.1 (6–12) months; 56 (80%) patients were continent based on a standardized stress test and subjective report. The median Valsalva leak point pressure at 150 cc (VLPP₁₅₀) in the failures and successes was not different (p = 0.12). The median VLPP at cystometric capacity (VLPP_cap) in the failures was 32 cmH₂O compared to 71 cmH₂O in the successes (p < 0.001). The maximum urethral closure pressure (MUCP) had a median of 20 cmH₂O in the failures and 45 cmH₂O in the successful patients (p < 0.001). No correlation existed between the degree of urethral hypermobility, as measured by the cotton swab test, and surgical success (p = 0.17). There was no correlation between level of preoperative urethral function and persistent overactive bladder symptoms, post-void residual, voids/day, and nocturia. Using a combined model, the cutoff values of VLPP_cap > 60 cmH₂O and MUCP > 40 cmH₂O were the most predictive of surgical success, revealing a sensitivity of 83% (0.55, 0.95) and specificity of 79% (0.67, 0.88). A combination of urodynamic parameters can be used to predict continence rates after a TOS. A TOS should be used with caution in women with impaired urethral function. G. Willy Davila is a consultant to American Medical Systems.     

Urodynamic characterization of obese women with urinary incontinence undergoing a weight loss program: the Program to Reduce Incontinence by Diet and Exercise (PRIDE) trial

The purpose of this study was to describe urodynamic characteristics of overweight or obese women with urinary incontinence and explore the relationship between urodynamic parameters, body mass index (BMI), and abdominal circumference (AC). One hundred ten women underwent a standardized cough stress test and urodynamic study. Eighty-six percent of women had urodynamic stress incontinence and 15% detrusor overactivity. Intra-abdominal pressure (Pabd) at maximum cystometric capacity (MCC) increased 0.4 cm H₂O per kg/m² unit of BMI (95% confidence interval [CI] = 0.0,0.7, p = 0.04) and 0.4 cm H₂O per 2 cm increase in AC (CI = 0.2, 0.7, p < 0.01). Intravesical pressure (Pves) at MCC increased 0.4 cm H₂O per 2 cm increase in AC (CI = 0.0, 0.8, p = 0.05) but was not associated with BMI (p = 0.18). BMI and AC had a stronger association with Pabd than with Pves, suggesting a possible mechanism for the association between obesity and urinary incontinence.     

Intentional urethral closure with a TVT (tension-free vaginal tape) for intractable urinary incontinence: a preliminary report of three cases

Bladder neck and urethral closure with urinary diversion is offered as a last resort to patients with intractable urinary incontinence. Various techniques have been described to achieve bladder neck and urethral closure. Most of these are associated with either operative morbidity or long-term complications. A modification of the conventional tension-free vaginal tape (TVT) procedure is described. As the name suggests, during the conventional TVT procedure, the tape is inserted relatively without tension in such a manner that the urethra retains its function and post-operative voiding is possible. In the cases described in this short series, the aim was to achieve urethral and bladder neck closure with minimal operative morbidity. This was achieved by inserting the TVT exactly as in a conventional TVT procedure, but the tape was inserted under greater tension than is normally used to ensure continence. A long-term suprapubic catheter was used for urinary diversion. This procedure is simple to perform, is associated with low operative morbidity [Agostini et al., Eur J Obstet Gynecol Reprod Biol, 124(2):237–239, 2006] and results in functional urethral closure. Results suggest that it may be a useful alternative to other bladder neck and urethral closure procedures in selected patients.     

Weak VLPP and MUCP correlation and their relationship with objective and subjective measures of severity of urinary incontinence

The aims of the present study were to find the correlation between Valsalva leak-point pressure (VLPP) and cough leak-point pressure (CLPP) and to determine whether the water perfusion maximum urethral closure pressure (MUCP) correlates with VLPP. Seventy-nine women with previously untreated stress urinary incontinence were recruited to participate in a clinical study. Their mean age was 56.4 years, mean BMI was 27.8, and mean parity was 1.9. The mean values of VLPP and CLPP were 50.4 and 52.9 cm H₂O, respectively. We did not find statistically significant differences in the mean values of VLPP and CLPP. The mean value of MUCP at rest was 44.2 cm H₂O and the mean value of MUCP during maximal Valsalva maneuver was 37.2 cm H₂O; with 500 ml of sterile saline in the bladder the difference between them is statistically significant. In the study group (n=79), 56 patients (77%) had low VLPP (≤60 cm H₂O), 21 patients (30%) had low MUCP (≤30 cm H₂O), and 8 patients had MUCP≤20 cm H₂O (all at rest). Of the 56 patients with low VLPP, 16 also had a low MUCP (≤30 cm H₂O). This study mainly compares two parameters—the MUCP and the VLPP. Based on our results we can conclude that there is no correlation between these parameters. MUCP measures urethral resistance at rest and VLPP measures urethral resistance during increased intra-abdominal pressure (Valsalva maneuver). This work was supported by the Grant Agency of the Ministry of Health of the Czech Republic, grant NH 7378-3.     

Tension-free vaginal tape,suprapubic arc sling,and transobturator tape in the treatment of mixed urinary incontinence in women

We evaluated the outcome at least 6 months after tension-free vaginal tape (TVT), suprapubic arc (SPARC) sling, or transobturator tape (TOT) procedure in women with mixed urinary incontinence and identified factors predicting the outcome in these patients. A total of 144 women, 29 to 77 years old (mean age 57.3), were included in the study; TVT (n = 72), SPARC (n = 22), and TOT (n = 50). The mean follow-up time was 10.9 months (range 6 to 52). There were no significant differences in the three groups in terms of the cure rate for stress urinary incontinence (SUI; TVT, 95.8%; SPARC, 90.0%; TOT, 94.0%; P = 0.625) and urinary incontinence (UUI; TVT, 81.9%; SPARC, 86.4%; TOT, 82.0%; P = 0.965). In the multivariate model, there is no influencing factor for treatment failure of SUI, while maximum urethral closure pressure (MUCP) and the diagnosis of uninhibited detrusor contraction during cystometry were independent risk factors for treatment failure of UUI. Decreasing MUCP was associated with an increased likelihood of treatment failure of UUI [odds ratio (OR), 0.974; 95% confidence interval (CI), 0.950–0.998; P = 0.034]. In the same model, uninhibited detrusor contraction was associated with 3.4-fold risk of treatment failure of UUI (OR, 3.351; 95% CI, 1.031–10.887; P = 0.044). Our findings suggest that low MUCP and the presence of uninhibited detrusor contraction during cystometry should be considered to be at high risk of treatment failure of UUI after surgery in these patients.     

The relationship of urethral resistance pressure and pressure flow parameters in women with lower urinary tract symptoms

This prospective study aims to evaluate the relationship between urethral resistance pressure (URP) and pressure flow parameters in women with lower urinary tract symptoms (LUTS). Consecutive women with LUTS attending three tertiary referral urodynamic clinics were asked to undergo urodynamic evaluation, pressure flow studies and URP measurement. The pressure flow parameters such as detrusor pressures at the start of flow (ODP), detrusor pressure at peak flow rate (PdetQmax), peak flow rate (Qmax) and detrusor pressure at the end of flow (CDP) were measured. The relationship between URP and pressure flow parameters was evaluated as well as differences between each urodynamic group. Two hundred seventy-nine women attended for urodynamic investigations. Two hundred twenty-three (79.9%) women had good quality pressure flow measurements and were included in the study. The mean age was 58 years (range 21–83). Women with urodynamic stress incontinence had significantly lower URP and ODP than those with detrusor over-activity [54.8 (±17.9) and 12.4 (±4.1) cmH₂O, respectively, vs 85.6 (±21.4) and 33.7 (±13.3) cmH₂O, respectively) (p<0.05, Bonferroni test). Furthermore, women with urodynamic stress incontinence have significantly lower PdetQmax values as well as higher Qmax than women with competent urethral sphincters (p<0.05, Bonferroni test). There was a significant correlation between ODP, PdetQmax, Qmax and URP measurements. In urodynamic stress incontinence, both URP and pressure flow parameters are reduced. Although the trend for values of both tests were similar and there was a significant correlation between these tests, we should consider that urethral function at rest differ from that during voiding due to activation of additional mechanisms. Therefore, further study is needed to confirm our results.     

Lead placement and associated nerve distribution of an implantable periurethral electrostimulator

The aim of this study was to determine gross and neuroanatomic features of a novel periurethral neuromuscular electrostimulator. Periurethral leads were placed in eight female cadavers. In two cases, leads were imaged after placement to enhance anatomic understanding. Pelvic viscera were removed en bloc for analysis of lead placement in the six remaining cadavers. Excised tissue was sectioned and immunostained to identify general, afferent, sympathetic, and nitric oxide synthase efferent nerve fibers. The electrodes were found within/lateral (n = 4), within/posterolateral (n = 9), and anterolateral (n = 1) to the external urethral sphincter (distance 0.25 ± 0.5, 2.9 ± 3.3, and 1.0 ± 0.0 mm, respectively). The electrode to the urethra and vagina distance averaged 7.6 ± 3.4 and 8.8 ± 4.3 mm, respectively. Variable density staining for all nerve types was found around the electrode. A periurethral electrode interfaces the external urethral sphincter, and the adjacent distribution of nerve fibers supports proposed neuromuscular therapeutic mechanisms.     

The efficacy of the tension-free vaginal tape in the treatment of five subtypes of stress urinary incontinence

Purpose: To determine the efficacy of tension-free vaginal tape (TVT) for the treatment of five sub-types of stress urinary incontinence (SUI).Materials and methods: A retrospective review was performed from November 1998 to November 2001 on all patients with SUI who underwent a TVT procedure either alone or with other reconstructive pelvic procedures. The patients were subdivided into five categories. Intrinsic sphincter deficiency (ISD) was defined by a maximum urethral closure pressure <20 cm H₂O or a mean Valsalva leak point pressure <60 cm H₂O above baseline. Urethral hypermobility (UH) was defined by a straining Q-tip angle greater than 30° from the horizontal. Cure was defined as the subjective resolution of SUI without the development of voiding dysfunction or de novo urge incontinence. Improvement was defined as the subjective improvement of SUI without complete resolution or the subjective resolution of SUI occurring with the development of prolonged voiding dysfunction lasting greater than 6 weeks or de novo urge incontinence. Failure was defined as the subjective lack of improvement of SUI, the need for an additional procedure to correct SUI or the need for revision or takedown of the TVT for persistent voiding dysfunction or mesh erosion.Results: The cure, improvement and failure rates for each of the following groups are respectively as follows: group 1 (+UH, -ISD) (n=121): 101 (83.5%), 13 (10.7%), 7 (5.8%); group 2 (-UH, +ISD) (n=22): 17 (77.3%), 3 (13.6%), 2 (9.1%); group 3 (+UH, +ISD) (n=32): 26 (81.3%), 4 (12.5%), 2 (6.2%); group 4 (-UH, -ISD) (n=25): 21 (84.0%), 3 (12.0%), 1 (4.0%); group 5 (occult SUI) (n=67): 57 (85.1%), 10 (14.9%), 0 (0%).Conclusion: This study shows that the TVT is effective in treating all five sub-types of SUI.     

Transvaginal vs transobturator approach for synthetic sling placement in patients with stress urinary incontinence

We present comparative short-term experience with the transvaginal (TVT) and the transobturator (TVT-O) approaches for the treatment of stress urinary incontinence (SUI). We studied 315 women with SUI, treated with a tension-free tape placement. The TVT approach was applied in 265 women, while 50 women were treated by the TVT-O approach. The mean operation time was 25 and 17 min in the TVT and TVT-O group, respectively (p < 0.001). In the TVT group, continence rates were 87% after 1 year, while in the TVT-O group, the continence rate was 94%. Postoperative pain was reported in 14.4 and 28% of the TVT and TVT-O patients, respectively (p = 0.02). Complications such as bladder perforation, retropubic hematoma, and urinary retention took place only in the TVT group. Urinary tract infections were recorded in 20 and 8% of the TVT and TVT-O patients, respectively (p = 0.04), while vaginal erosion took place in 1.5 and 2% and de novo urgency in 14 and 8%. Both approaches show high rates of cure at the first postoperative year, while complications are less with the TVT-O procedure.     

Factors predictive of outcome in tension-free vaginal tape procedure for urinary stress incontinence in a teaching hospital

Introduction  A study was performed to determine which patients’ characteristics before tension-free vaginal tape (TVT) for stress incontinence are predictive of a failed outcome. Methods  A prospective cohort of 305 women with urinary stress incontinence underwent a TVT procedure in a teaching hospital. TVT was considered successful when the patient was fully satisfied and no leakage was seen at the standardized stress test. Logistic regression analysis examined the relationship between outcome and 32 pre-, intra-, and postoperative patient characteristics. All operations were done by trainees under supervision and assistance. Results and conclusions  Eighty one percent was successfully treated. Independent predictors of TVT failure were previous surgery for incontinence (P = 0.006), >2 pads/diapers per day before treatment (P = 0.012), chronic use of psychotropic medication (P = 0.012), and a more advanced age of the patient (P = 0.005). Postoperative urgency was independently related to preoperative urgency (P < 0.001). Independent predictors of postoperative dissatisfaction were urgency symptoms (P < 0.001) and the need for a re-intervention (P < 0.001).     

Urethral retro-resistance pressure: a new clinical measure of urethral function

AIMS: The urethral retro-resistance pressure (URP) is a new retrograde measurement of urethral function. URP is the pressure required to achieve and maintain an open sphincter. The assessment of any potential diagnostic measure must include an evaluation in individuals both with and without disease. In this study, we examined URP values in women without urinary incontinence. METHODS: Four centers enrolled 61 women who did not report symptoms of urinary incontinence, and who had negative standing stress tests (SST). Each center was to perform three consecutive URP measurements on each subject. At two centers, 32 subjects returned in 3-7 days for three additional URP measurements. We compared the average URP in this asymptomatic population to the average URP from women symptomatic of stress urinary incontinence (SUI) derived from a previous study. We evaluated the within-subject variation of the URP measurement at a single visit and the within-subject change in URP over time using test and retest values. RESULTS: The mean age was 33 +/- 9 years and the mean body mass index (BMI) was 24 +/- 6. URP values were normally distributed. The mean URP at visit 1 was 112.6 +/- 39.2 cm H2O (n = 60). This was statistically significantly different from the mean URP of symptomatic women (69.9 cm H2O, P < 0.0001). The within-subject standard deviation of URP at visit 1 was 12.6 +/- 12.6 cm H2O (n = 60) and at retest visit was 9.3 +/- 6.2 cm H2O (n = 32). For the retest cases, the mean URP at visit 1 was 113.9 +/- 39.9 cm H2O (n = 32) and at retest visit was 125.5 +/- 33.9 cm H2O (n = 32) (Wilcoxon Signed Rank test, P = 0.145). CONCLUSIONS: The mean URP measurement obtained in this study of asymptomatic women showed significantly higher values when compared to our study in women with SUI. The URP measurements were consistent within the same subject. Furthermore, there was no statistically significant difference in the URP measurement from visit 1 to retest visit. The data suggest that URP shows promise as a physiological urethral pressure measurement.     

Minimally invasive surgery for female urinary incontinence: experience with periurethral microballoon implantation

PURPOSE: To assess the effectiveness of periurethral microballoon implantation for management of female urinary incontinence. PATIENTS AND METHODS: A total of 45 women with urinary incontinence (age range 47-88 years) were treated between May 2000 and June 2001. Microballoons were placed in the proximal periurethral tissue using endoscopic instrumentation under local anesthesia. Follow-up assessment including urodynamic study and quality- of-life assessment was performed at 1, 3, and 6 months. RESULTS: Implantation was successful in all cases with no significant adverse effects. Cure was achieved in 60% and improvement in 5%. The failure rate was 35%. Microballoon implantation significantly increased the mean urethral closure pressure, from 35.2 cm H(2)O (SD 14.9; range 15-72 cm H(2)O) to 46.5 cm H(2)O (SD 19.7; range 16-87 cm H(2)O) (P = 0.001). The best predictors of successful outcome in univariate analysis were initial urethral closure pressure (P = 0.047) and degree of incontinence (P < 0.001). CONCLUSIONS: Periurethral microballoon implantation is a useful technique for the management of female urinary incontinence, especially in elderly and inoperable patients. The microballoons do not present the adverse effects associated with other bulking agents.     

The latissimus dorsi bladder myoplasty to assist detrusor function

The objective of this study was to evaluate whether an innervated skeletal muscle might augment detrusor function. In four dogs we performed the latissimus dorsi myoplasty, a transfer of the latissimus muscle as an innervated free flap wrapped around the bladder. Stimulation of the latissimus dorsi free flap initially achieved an average bladder pressure of 45.8 ± 8.41 cm H₂O, sufficient for partial evacuation. After 4 months the muscle generated a maximal pressure of 82 cm H₂O, resulting in an evacuation of 27.7%. For selected patients, the latissimus dorsi bladder myoplasty may provide an alternative to intermittent catheterization in the future. Received: 14 March 1997 / Accepted: 12 January 1998     

Intrinsic Sphincter Deficiency: Do the Maximum Urethral Closure Pressure and the Valsalva Leak-Point Pressure Identify Different Pathogenic Mechanisms?

A prospective analysis of 166 women with genuine stress incontinence was performed comparing Valsalva leak-point pressure (VLPP) and maximum urethral closure pressure (MUCP) with age, previous urogynecologic surgery and/or hysterectomy, poor urethral mobility, weight, menopause and vaginal deliveries, to find correlations with intrinsic sphincter deficiency (ISD). Cut-off value for VLPP were 60 cmH₂O and for MUCP 30 cmH₂O. MUCP ≤30 cmH₂O identifies a group of patients with more severe incontinence, a shorter urethral functional length (UFL) (P= 0.02), more previous urogynecologic operations and the menopause (P= 0.004 and P= 0.000), and older age (P= 0.000). VLPP ≤60 cmH₂O identifies a group of patients with more severe incontinence, a shorter UFL (P = 0.005), more previous urogynecologic surgery (P = 0.006) and poorer urethral mobility (P= 0.004). As these two tests measure different components of urethral functions we can hypothesize that they detect different pathogenic processes contributing to ISD. When one or both tests is abnormal incontinence is more severe and the incidence of poor prognostic factors is increased.