Arcus to arcus microsling: technique and preliminary results

Sling procedures have been around for decades in the management of female stress urinary incontinence (SUI), but only in the past decade have they become the preferred technique. The arcus to arcus microsling is an anatomical approach that involves placing a midurethral low-tension tape anchored to the obturator internus muscles bilaterally at the level of the tendinous arc. From February 2005 to July 2006, 20 female patients (mean age = 53 years old) with SUI underwent arcus to arcus microsling procedure. Of these, 18 were available for a minimum follow-up of 12 months. After 12 months, 16 (88%) patients were dry, 1 (5.5%) improved, and 1 (5.5%) was incontinent. The arcus to arcus microsling is emerging as a promising option in the management of women with SUI.     

Planned cesarean section versus planned vaginal delivery: comparison of lower urinary tract symptoms

We compared the prevalence and risk of lower urinary tract symptoms in healthy primiparous women in relation to vaginal birth or elective cesarean section 9 months after delivery. We performed a prospective controlled cohort study including 220 women delivered by elective cesarean section and 215 by vaginal birth. All subjects received an identical questionnaire on lower urinary tract symptoms in late pregnancy, at 3 and 9 months postpartum. Two hundred twenty subjects underwent elective cesarean section, and 215 subjects underwent vaginal delivery. After childbirth, the 3-month questionnaire was completed by 389/435 subjects (89%) and the 9-month questionnaire by 376/435 subjects (86%). In the vaginal delivery cohort, all lower urinary tract symptoms increased significantly at 9 months follow-up. When compared to cesarean section, the prevalence of stress urinary incontinence (SUI) after vaginal delivery was significantly increased both at 3 (p < 0.001) and 9 months (p = 0.001) follow-up. In a multivariable risk model, vaginal delivery was the only obstetrical predictor for SUI [relative risk (RR) 8.9, 95% confidence interval (CI) 1.9–42] and for urinary urgency (RR 7.3 95% CI 1.7–32) at 9 months follow-up. A history of SUI before pregnancy (OR 5.2, 95% CI 1.5–19) and at 3 months follow-up (OR 3.9, 95% CI 1.7–8.5) were independent predictors for SUI at 9 months follow-up. Vaginal delivery is associated with an increased risk for lower urinary tract symptoms 9 months after childbirth when compared to elective cesarean section.     

Colposuspension for urinary stress incontinence in postmenopausal patients

Eighty-seven postmenopausal patients had a colposuspension for urinary stress incontinence. A significant postoperative reduction (p<0.001) of symptoms of frequency, nocturia, urgency and urge incontinence was obtained. The cure rate for urinary incontinence was 77%. Twenty patients were found to be wet postoperatively, 8 due to stress incontinence and 12 due to detrusor instability, 9 of whom had detrusor instability preoperatively.No differences were found pre- and postoperatively in the cystometric and uroflowmetric values or in the urethral pressure profile measurements. The pressure transmission ratios were significantly improved postoperatively.During operation and postoperatively, minor complications occurred in this group of patients. In 5 patients blood transfusion was needed. Urinary tract infection was diagnosed in 21 patients, wound infections in 4 patients and enterocele in 5 patients.Colposuspension for urinary stress incontinence in postmenopausal patients is a safe procedure with a reasonable cure rate indicating that a surgical approach should be adopted in such patients.Editorial Comments: This is an extension of the authors' previously published series in SGO [2] now dealing exclusively with postmenopausal patients. Although they state that their overall cure rate was 77%, in fact the cure rate for stress incontinence was 79/87 or 91%. Adding the patients with detrusor instability gives the lower cure rate of 77%. An important contribution of this article is the documentation of a decrease of symptoms of urgency, frequency and urge incontinence subsequent to a modified Burch colposuspension. In addition they document that the pressure-transmission ratios were less than 100% in all of their failed cases. Further studies are needed in the elderly to document success or failure in this group since we will be faced with an ever increasing elderly population in years to come.     

The Ethnic Cultural and Social Aspects of Incontinence – A Pilot Study

This cross-sectional study aimed to study the religious and cultural practices of ethnic minorities that might affect the experience and ideas that sufferers of incontinence have. Subjects were multiparous women from the local community who suffered from incontinence. Structured and unstructured interviews were conducted to assess the effect of incontinence and menstruation on home life, sexual life, personal and communal prayer, rules and customs associated with menstruation, and the ability to discuss problems with their doctor and partners. Individual women differed in how they rated their daily activities, and this was not related to religious or ethnicity. Higher restrictions on activity were perceived for fecal than for urinary incontinence. Sexual relationships were restricted for Jewish and Muslim women during menses. Incontinence led to religious restriction, which was most marked for Jewish and Muslim women, and this was related to the need for cleanliness for prayer. Less then 50% of patients sought help, and this was not related to duration and severity of symptoms. Only Muslim women had a strong preference for female doctors, and this was for cultural reasons.     

The safety of the inside-out transobturator approach for transvaginal tape (TVT-O) treatment in stress urinary incontinence: French registry data on 984 women

This study examines the safety of the inside-out transobturator approach for transvaginal tape (TVT-O™, Gynaecare) treatment in stress urinary incontinence (SUI) in women based on a French registry of patients. A total of 984 women from 86 centres were enrolled in the study. Patients with predominant overactive bladder or significant pelvic organ prolapse were excluded from the study. Perioperative and post-operative complications were reported as well as urinary function at 4 and 12 weeks. Pain was assessed by the patients using a visual analog scale (VAS). The overall perioperative complication rate was 2.2%. The most commonly reported morbidities were vaginal wall perforation (1.3%) followed by haematoma (0.7%). Post-operative complication rate was 5.2%; the most common complication was residual pain (2.7%). The other complications of paravesical haematoma, urinary retention, vaginal erosion and re-intervention had an incidence of less than 1.0%. This study demonstrates that the transobturator transvaginal tape approach to the treatment of SUI is a safe procedure.     

Combined estrogen and ghrelin administration restores number of blood vessels and collagen type I/III ratio in the urethral and anal canal submucosa of old ovariectomized rats

We compare the effects of estrogen and/or ghrelin on vascular counts and collagen I/III ratio of urethral and anal canal submucosa in old vs young-adult ovariectomized rats. Ovariectomized Fisher 344 rats (18 and 3 months old, n = 24 x 2) received 42 daily intraperitoneal 17-ss estradiol (10 microg/kg), ghrelin (2 microg/kg), both, or vehicle (n = 6 x 4 per group). Blood vessel counts and collagen I/III ratio were measured, respectively, by light microscopy and Western blot analysis with immunohistochemistry of ghrelin receptors. Estrogen significantly increased urethral and anal vascular counts and collagen I/III ratio in young-adult rats. In old rats, only combined estrogen/ghrelin administration significantly increased both variables. This was not observed with estrogen or ghrelin separately. Ghrelin receptors were immunostained in urethral and anal submucosa of all samples. Combined estrogen/ghrelin administration restored postovariectomy urethral and anal canal submucosal vessel number and collagen I/III ratio in old rats suggesting independent ageing effect.     

Long-Term Outcome of Overlapping Anal Sphincter Repair

PURPOSE: This study reviews the long-term outcome of overlapping anal sphincteroplasty for acquired anal incontinence. METHODS: Seventy-one consecutive patients underwent overlapping sphincteroplasty from 1989 to 1996. Current degree of continence and associated quality of life were determined by telephone interview using the Fecal Incontinence Severity Index and Fecal Incontinence Quality of Life Scale, as validated by The American Society of Colon and Rectal Surgeons. Both the patient-rated and the surgeon-rated Fecal Incontinence Severity Index scores were recorded. Demographic and perioperative data were obtained from patient charts. RESULTS: Forty-nine (69 percent) of the 71 patients, with a median age of 38.5 (range, 22–80) years, could be contacted at a median of 69 (range, 48–141) months after sphincter repair. Four patients were diverted at the time of follow-up. Twenty-four (54 percent) patients were incontinent to liquid or solid stool, and only six patients (14 percent) were totally continent. Fifteen patients (34 percent) had the best possible Fecal Incontinence Quality of Life score of 16. The median patient-rated and surgeon-rated Fecal Incontinence Severity Index scores were 20 (range, 0–61) and 20 (range, 0–57), respectively. The patient-rated score correlated to the surgeon-rated score (r = 0.98, P < 0.001) and the Fecal Incontinence Quality of Life score (r = 0.64, P < 0.001). CONCLUSION: Years after sphincter repair surgery more than half of the patients are incontinent to liquid or solid stool. The American Society of Colon and Rectal Surgeons-validated Fecal Incontinence Severity Index and Fecal Incontinence Quality of Life scores are useful and complementary tools for evaluation of fecal incontinence.