Location of maximum intraurethral pressure related to urogenital diaphragm in the female subject as studied by simultaneous urethrocystometry and voiding urethrocystography

Sonography as a Diagnostic Tool in Midurethral Sling Complications: A Narrative Review

Despite the established safety and efficacy of midurethral slings (MUS), which are the current gold standard treatment for stress urinary incontinence (SUI), the potential for postoperative complications remains a significant concern for both healthcare professionals and patients. Meanwhile, sonography has emerged as a significant diagnostic tool in urogynecology, and one of the applications of this imaging modality may be the evaluation of complications arising from MUS procedures. This review, based on a comprehensive literature search, focuses on the use of pelvic floor ultrasound (US) in the context of MUS complications. It includes analyses of randomized controlled trials, prospective, and retrospective studies, covering preoperative and postoperative investigations, to assess complications such as persistent and recurrent SUI, urinary retention and obstructive voiding, de novo urgency/overactive bladder, vaginal exposure, sling erosion, pain, and hematoma. The review critically examines the existing literature, with a particular focus on recent publications. Despite the variability in findings, it appears that for each of the discussed complications, the application of pelvic floor US can significantly support the diagnostic and therapeutic process. The paper also identifies potential future directions for the development of US applications in diagnosing MUS complications.

Midurethral sling position and surgical outcome: A meta-analysis

There is still ongoing debate as to whether the outcome of the sling is determined by the position of the midurethral sling. In order to evaluate the potential impact of sling position on the outcomes of retropubic and transobturator sling procedures for stress urinary incontinence, it is necessary to conduct further investigations. We conducted a comprehensive search across various electronic databases such as PubMed, EMBASE, MEDLINE. Relevant data were extracted, organized in a table format, and analyzed using RevMan software for further analysis. This review comprised a total of 9 studies. The findings indicate that patients with TVT tape placement in the midurethra exhibited a slightly higher cure rate compared to those with proximal placement. Conversely, tape placement in the midurethra was associated with a significantly higher cure rate compared to distal placement [RR = 0.84, 95% CI (0.74-0.95), P < .05]. In the case of transobturator slings, tape positioning beneath the midurethra or distal urethra yielded better outcomes compared to placement near the bladder neck [RR = 0.74, 95% CI (0.57-0.94), P = .02; RR = 0.61, 95% CI (0.39-0.96), P = .03]. Based on 2D and 3D ultrasound imaging, differences in TVT placement appear to have minimal impact on the cure rate. However, the highest rate of failure after transobturator sling surgery is closely linked to the positioning.

Do the Ultrasonographic Measures of Midurethral Sling Location Relate With Surgical Outcomes?

IMPORTANCE

The proper placement of a midurethral sling (MUS) is the key factor for a successful surgical outcome.

OBJECTIVE

This study aimed to evaluate the relationship of perineal ultrasonographic measures of the tape location with subjective and objective outcomes after MUS surgery at midterm follow-up of women.

METHODS

The tape percentile (TP; total urethral length/bladder neck tape distance×100) and urethra tape distance (UTD; the shortest distance from the longitudinal smooth muscle complex of the urethra to the midpoint of the tape) were correlated with midterm surgical success. Patient satisfaction measured with the visual analog scale (VAS) was considered as the primary outcome. The presence of stress urinary incontinence on direct questioning, the Urinary Distress Inventory 6 (UDI-6) scores, findings of the cough stress test, free uroflowmetry, postvoid residual volume, and single-cycle voiding ambulatory urodynamic monitoring (AUM) were the other outcomes.

RESULTS

Seventy-eight women were evaluated at a mean follow-up of 4.4 ±3.3 years. Women who were highly satisfied (VAS ≥ 8) had a significantly higher TP (64.7% vs 50.8%, P < 0.001) and lower UTD (3.6 vs 4.5 mm, P = 0.018). Irritative, stress, and obstructive scores at UDI-6 increased as the tape was located closer to the bladder neck (P < 0.001, P < 0.001 and P = 0.044, respectively), and stress symptoms decreased with a tape closer to the urethra (P < 0.001). Women with detrusor overactivity at AUM were found to have a lower TP (P < 0.001).

CONCLUSION

The perineal ultrasonographic evaluation of tape location with UTD and TP seems to be well correlated with the women's midterm MUS surgical outcomes.

The female urethra: urethral function throughout a woman's lifetime

INTRODUCTION AND HYPOTHESIS

The objective of this narrative review is to describe changes in urethral function that occur during a woman's lifetime. Evaluation of urethral function includes measurements of urethral closure pressure, at rest and during stress, leak point pressure, and the detailed study of anatomical and histological changes of the urethral sphincteric mechanism.

METHODS

A literature search in MEDLINE, PubMed, and relevant journals from 1960 until 2020 was performed for articles dealing with urethral function and the impact of aging, pregnancy, and childbirth, female hormones, and menopausal transition on the urethral sphincteric mechanism. Longitudinal and cross-sectional epidemiological surveys, studies on histological changes in urethral anatomy during aging, and urodynamic data obtained at different points in a woman's lifetime, during pregnancy, after childbirth, as well as the effects of female hormones on urethral sphincter function are reviewed. Relevant studies presenting objective data are analyzed and briefly summarized.

RESULTS AND CONCLUSIONS

The findings lead one to conclude that a constitutional or genetic predisposition, aging, and senescence are the most prominent etiological factors in the development of urinary incontinence and other pelvic floor disorders. Vaginal childbirth dilates and may damage the compressed pelvic supportive tissues and is invariably associated with a decline in urethral sphincter function. Pregnancy, hormonal alterations, menopausal transition, weight gain, and obesity are at best of secondary influence on the pathology of lower urinary tract dysfunction. The decline of circulating estrogens during menopausal transition may play a role in the transition of fibroblasts to cellular senescence.

Stress urinary incontinence is caused predominantly by urethral support failure

Whales are mammals that can dive to depths of > 1000 m without the high water pressure pushing open their mouth or anus. The same is true for the female urethra. The meatus externus and internus are seals that cannot be pushed open by high water pressures. Recent evidence suggests that the female meatus internus is pushed open when the bladder pressure exceeds the urethral pressure. For a relaxed detrusor, this opening is not possible for at least three reasons: the law of elastic collision, Pascal’s law of hydrostatics and the Hagen-Poiseuille law. The three laws do not support that urethral function failure is the predominant cause of stress urinary incontinence (SUI); however, they do support that urethral support failure is. Influential urogynecologists claim the opposite. TVT surgery, according to the integral theory of SUI (IT), has high failure rates because it does not principally prevent the urethra from hanging on a less mobile bladder neck. In the case of a long urethra, the tape is set too distally, and in hypomobile SUI, the use of a tension-free suburethral tape is unwarranted/ineffective, because the proximal urethra is not elevated above its resting position. A successful operation corrects urethral support failure and not urethral function failure.

The impact of vaginal cone therapy on stress urinary incontinence compared with transobturator tape

OBJECTIVE

To emphasize the efficiency of vaginal cone (VC) therapy in stress urinary incontinence (SUI) through a comparison with transobturator tape (TOT).

MATERIALS AND METHODS

A prospective randomized controlled study was conducted at the Etlik Zübeyde Hanım Maternity and Women Hospital during a one year study period. Forty women were allocated into two equal groups; those treated with VCs for a 3 month period, and women who underwent TOT procedures. These women were followed up at 6 weeks and 6 months after the treatments. Subjective cure was assessed using Wagner's Quality of Life Questionnaire. Objective cure was evaluated through a cough stress and pad test results.

RESULTS

Maternal demographic features were comparable among groups. We observed improvement in pad weight test among groups when compared with the pretreatment state (p=0.015, p=0.005). Although the subjective cure rate was similar in both groups at the 6th week and 6th month follow up (65% vs. 75%; 75% vs. 80%) (p>0.05), the objective cure rate was significantly higher in the TOT group than in the VC group, as expected (10% vs. 80%; 30% vs. 75%) (p<0.05).

CONCLUSION

The main treatment of SUI is surgery; however, VC could be offered as an alternative treatment for women who refuse surgery, those at high risk for surgery or it could be used temporarily before surgery.

Urethral length and bladder neck behavior: can dynamic magnetic resonance imaging give the same results as introital ultrasound?

PURPOSE

To compare dynamic magnetic resonance imaging (dMRI) and introital ultrasound results with regard to urethral length measurements and the evaluation of bladder neck changes.

METHODS

Retrospective analyses of urethral length measurements and detection of bladder neck changes (rotated/vertical bladder neck descent, urethral funneling) were conducted in women-scheduled for surgical treatment with alloplastic material-who had undergone introital ultrasound and dMRI presurgery and 3 months postsurgery. Measurement differences between both imaging modalities were evaluated by assessing the confidence interval for the difference in means between the datasets using bootstrap analysis.

RESULTS

Based on data from 40 patients (320 image series), the urethra could be clearly measured on every pre- and postsurgical dMRI dataset but not on preoperative ultrasound images in nine women during Valsalva maneuver due to a large cystocele. The estimation of the mean difference distribution based on 500,000 bootstrap resamples indicated that the urethral length was measured shorter by dMRI pre- and postsurgery at rest and postsurgery during Valsalva maneuver (median 1.6-3.1 mm) but longer by dMRI (median 0.2 mm) during Valsalva maneuver presurgery. Rotated/vertical bladder neck descent and urethral funneling diagnoses showed concordance of 67-74% in the direct comparison of patients; the estimation of the concordance indicated poorer outcomes with 50-72%.

CONCLUSIONS

Metric information on urethral length from dMRI is comparable to that from introital ultrasound. dMRI is more advantageous in cases with an extended organ prolapse. At present, dMRI does not give the same diagnosis on bladder neck changes as introital ultrasound does.

Sonographic sling position and cure rate 10-years after TVT- O procedure

AIM

To examine the position of the TVT-O sling 10 years postoperatively and its association with outcome.

METHODS

A total of 124 patients who received a TVT-O sling at two centers in 2004 and 2007 were invited for follow-up. The position of the sling on perineal ultrasound was described relative to the bladder neck and the lower margin of the pubic symphysis at rest and on Valsalva. Objective cure was defined as a negative cough stress test at 300 ml. Subjective cure was evaluated with the Kings´ Health Questionnaire (KHQ), Incontinence Outcome Questionnaire (IOQ), Female Sexual Function Index Questionnaire (FSFI) and the Patient Global Impression of Improvement score (PGII).

RESULTS

78 of 124 patients (57%) were available for follow-up 10 years after surgery. I Eleven (14%) had undergone reoperation and were excluded. Tapes were visualized in the remaining 67 (54%) women. The subjective and objective cure rates in this sub-cohort were 67% (45/67) and 77% (52/67), respectively. In these 67 women the mean distances from the bladder neck to the proximal edge of the tape (BNTD) during Valsalva maneuver were significantly higher in cured women compared to the not-cured women (11.2 vs. 9.4mm). The distance between tape and urethra (TUD) was significantly lower in cured vs. not cured patients (2.6 vs. 4.1mm). All women with a TUD of >5mm (n = 5) were incontinent. Tape position was not associated with overactive bladder symptoms.

CONCLUSIONS

Tape position near the bladder neck and large distance to the urethra is associated with incontinence 10 years after TVT-O.

Preoperative and postoperative ultrasound assessment of stress urinary incontinence

INTRODUCTION

The role of ultrasound imaging in urogynecology is not defined. Significant developments in visualization techniques and interpretation of images allowed to study structures of the lower genitourinary tract and pelvic floor.

EVIDENCE ACQUISITION

PubMed and Scopus database were searched for publications on the following item: stress urinary incontinence, ultrasound, perineal ultrasound and preoperative and postoperative assessment.

EVIDENCE SYNTHESIS

The role of ultrasound in urogynecology could be helpful in diagnosing of urinary incontinence and urethral hypermobility, to document pelvic floor anatomy and to assess anatomic and functional changes before and after surgery.

CONCLUSIONS

Ultrasound could be an important step during preoperative and post-operative assessment of patients affected by stress urinary incontinence.

Demographic features of female urethra length

AIMS

To determine cohort urethral length, identify epidemiological factors influencing the parameter and to establish the percentage of cases with clinically relevant outsized urethras.

METHODS

Prospective cohort study conducted in two tertiary clinical centers between 2013 and 2017. Nine hundred and twenty seven consecutive adult, Caucasian females attending outpatients' clinics were included. The urethral length has been measured in pelvic floor ultrasound examination. The exclusion criteria were inadequate bladder filling (<200 mL; >400 mL), previous history of pelvic floor surgery, and no consent.

RESULTS

Urethral length varied from 19 to 45 mm. The distribution of the examined parameter was normal. Obese patients had significantly longer urethras as compared to non-obese subjects. Number of vaginal deliveries was connected with shorter urethral length. The limitations of the study are: analysis only of Caucasian patients and subjects without previous pelvic floor surgeries.

CONCLUSIONS

Differences in urethral length in the female population were demonstrated. Thirty percent of patients have atypical urethras that may be a risk factor for sling surgery failure. We therefore postulate introduction of urethral measurement before the procedure.

Impact of radical hysterectomy on the transobturator sling pathway: a retrospective three-dimensional magnetic resonance imaging study

INTRODUCTION AND HYPOTHESIS

Morphological and functional anomalies of the urethra may cause stress urinary incontinence after radical hysterectomy (RH). We introduce a novel three-dimensional (3D) magnetic resonance imaging (MRI) technique to assess the impact of RH on the transobturator sling pathway.

METHODS

3D-MRI reconstruction models were retrospectively developed for the measurement of various parameters before and after RH, including puncture angle, orientation and distance from the midurethral puncture site to the obturator membrane (DUO), in 31 patients with cervical cancer. Additionally, the correlations between DUO and body height and interspinal diameter were evaluated.

RESULTS

No significant differences were noted between the preoperative and postoperative inclination angle (-7.1 ± 33.5° vs. -0.68 ± 23.9°, ranges -62.4 to 46.8° vs. -54.1 to 42.2°, respectively) or between the preoperative and postoperative left and right mean rotation angles (left 69.0 ± 8.0° vs. 67.8 ± 9.2°; right 65.1 ± 8.38° vs. 64.3 ± 10.5°). Similarly, there were no statistically or clinically significant differences between the preoperative and postoperative DUO, although slight differences were noted between the two sides before and after RH (P = 0.018 and P = 0.023, respectively). None of the parameters differed significantly between the groups with and without postoperative urodynamic stress incontinence. Further, there was no clinically significant correlation between DUO and height or interspinal diameter.

CONCLUSIONS

The sling procedure via the transobturator approach is technically safe from a 3D anatomical standpoint. However, wide variability in the anatomical parameters must be taken into account when planning the procedure.

Architectural differences in the anterior and middle compartments of the pelvic floor of young-adult and postmenopausal females

The pelvic floor guards the passage of the pelvic organs to the exterior. The near-epidemic prevalence of incontinence in women continues to generate interest in the functional anatomy of the pelvic floor. However, due to its complex architecture and poor accessibility, the classical 'dissectional' approach has been unable to come up with a satisfactory description, so that many aspects of its anatomy continue to raise debate. For this reason, we opted for a 'sectional' approach, using the Chinese Visible Human project (four females, 21-35 years) and the Visible Human Project (USA; one female, 59 years) datasets to investigate age-related changes in the architecture of the anterior and middle compartments of the pelvic floor. The puborectal component of the levator ani muscle defined the levator hiatus boundary. The urethral sphincter complex consisted of a circular proximal portion (urethral sphincter proper), a sling that passed on the vaginal wall laterally to attach to the puborectal muscle (urethral compressor), and a circular portion that surrounded the distal urethra and vagina (urethrovaginal sphincter). The exclusive attachment of the urethral sphincter to soft tissues implies dependence on pelvic-floor integrity for optimal function. The vagina was circular at the introitus and gradually flattened between bladder and rectum. Well-developed fibrous tissue connected the inferior vaginal wall with urethra, rectum and pelvic floor. With eight-muscle insertions, the perineal body was a strong, irregular fibrous node that guarded the levator hiatus. Only loose areolar tissue comprising a remarkably well developed venous plexus connecting the middle and superior parts of the vagina with the lateral pelvic wall. The posterolateral boundary of the putative cardinal and sacrouterine ligaments coincided with the adventitia surrounding the mesorectum. The major difference between the young-adult and postmenopausal pelvic floor was the expansion of fat in between the components of the pelvic floor. We hypothesize that accumulation of pelvic fat compromises pelvic-floor cohesion, because the pre-pubertal pelvis contains very little fibrous and adipose tissue, and fat is an excellent lubricant.

Ultrasound imaging in urogynecology - state of the art 2016

The role of ultrasound imaging in urogynecology is not clearly defined. Despite significant developments in visualization techniques and interpretation of images, pelvic ultrasound is still more a tool for research than for clinical practice. Structures of the lower genitourinary tract and pelvic floor can be visualized from different approaches: transperineal, introital, transvaginal, abdominal or endoanal. According to contemporary guidelines and recommendations, the role of ultrasound in urogynecology is limited to the measurement of post-void residue. However, in many instances, including planning and audit of surgical procedures, management of recurrences or complications, ultrasound may be proposed as the initial examination of choice. Ultrasound may be used for assessment of bladder neck mobility before anti-incontinence procedures. On rare occasions it is helpful in recognition of pathologies mimicking vaginal prolapse such as vaginal cyst, urethral diverticula or rectal intussusception. In patients subjected to suburethral slings, causes of surgery failure or postsurgical voiding dysfunctions can be revealed by imaging. Many reports link the location of a tape close to the bladder neck to unfavorable outcomes of sling surgery. Some postoperative complications, such as urinary retention, mesh malposition, hematoma, or urinary tract injury, can be diagnosed by ultrasound. On the other hand, the clinical value of some applications of ultrasound in urogynecology, for example measurement of the bladder wall thickness as a marker of detrusor overactivity, has not been proved.

Long-term efficacy and safety of tension free vaginal tape in a historic cohort of 463 women with stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

We report retrospective data on the long-term safety and efficacy of the retropubic midurethral sling (MUS) in a large series of women with stress urinary incontinence.

METHODS

In all, 517 patients were treated during the period January 2005 to June 2012 at a single centre in France. The Urinary Symptoms Profile score was used to identify women who were subjectively cured or improved or in whom treatment had failed. The rates of peroperative, and early (<30 days) and late postoperative complications were recorded.

RESULTS

A total of 463 patients were evaluable at a mean (±SD) follow-up of 71 ± 23 months. At the last follow-up, 344 patients (74.3 %) demonstrated subjective cure, 55 (11.9 %) were improved and 64 (13.8 %) had treatment failure. Bladder perforations occurred in 33 patients (7.1 %); however, this had no effect on cure rate. In the early postoperative period, temporary intermittent self-catheterization was required in 10 patients (2.2 %) due to voiding difficulties. The most frequent long-term postoperative complication was de novo urge incontinence that was reported by 59 patients (12.7 %); seven patients (1.5 %) needed tape excision due to voiding difficulties and six (1.3 %) needed tape removal due to erosion or chronic pain.

CONCLUSIONS

The retropubic MUS was shown to be durable at a mean follow-up of 71 ± 23 months, with a high success/improvement rate and no serious long-term tape-induced adverse effects.

Urinary Incontinence in the Young Woman: Treatment Plans and Options Available

Urinary incontinence is a common and distressing condition, which, although not life-threatening, is known to have a significant effect on quality of life. The incidence of urinary incontinence increases with age and while stress urinary incontinence is more common in younger women, symptoms suggestive of overactive bladder are more common with increasing age. All women complaining of incontinence require simple investigation, and many will benefit from conservative and medical treatments, which may be instituted in primary care. Further investigation in the secondary-care setting should be reserved for those women with refractory or unusual symptoms. The aim of this paper is to review the epidemiology and pathophysiology of common causes of urinary incontinence in younger, premenopausal women, and to review the current algorithms for investigation and management. In addition, treatment paradigms covering conservative, medical and surgical treatment for stress urinary incontinence and overactive bladder will be reviewed.

Both the middle and distal sections of the urethra may be regarded as optimal targets for 'outside-in' transobturator tape placement

Purpose

To investigate whether the position of the tape under the urethra may influence ‘outside-in’ transobturator sling (TOT) outcome.

Methods

The study comprised 141 women who underwent TOT for clinically and urodynamically proved stress urinary incontinence. The postoperative ultrasound examination with an endovaginal biplane probe was performed before discharging the patients from hospital. The measurements obtained described the position of the tape relative to the urethra and pubic symphysis, as well as anatomical relationships in the anterior compartment.

Results

Ninety-six (68.1 %) patients were cured, 27 (19.1 %) significantly improved, and in 18 cases (12.7 %), the surgery failed. The tape position under the midurethra (40–70th percentile of the urethral length) or distal urethra (>70th percentile) coincided with better results (cure rate 67.1 and 82.4 %, respectively) than the location in the proximity of the bladder neck (<40th percentile) (21.4 % cured, p = 0.0015 and p < 0.001, respectively). However, the risk of failure was the lowest when the tape was located under the distal urethra. Other ultrasonographic findings were not related to treatment results.

Conclusions

The highest failure rate for ‘outside-in’ TOT is associated with the location of the tape under the proximal third of the urethra. Both the middle and distal sections of the urethra may be regarded as targets for transobturator tape placement.

Can we place tension-free vaginal tape where it should be? The one-third rule

OBJECTIVES

The tension-free vaginal tape (TVT) insertion technique generally does not take into account individual urethral length. In this study we investigated whether preoperative sonographic measurement of individual urethral length allows for reliable TVT positioning under the midurethra, which is a critical segment for the continence mechanism.

METHODS

Urethral length was measured by preoperative introital ultrasonography in 102 consecutive female patients with stress urinary incontinence. TVT procedures were performed as recommended by the manufacturer. The suburethral incisions were initiated at one-third of the sonographically measured urethral length. TVT position and tape-urethra distance were followed up 6 months postoperatively.

RESULTS

At 6-month examination of the 102 study participants, 93.1% were cured and 6.9% showed improved continence. TVTs were found in the target range of 50-70% of the urethral length in 88.2% of the cohort. Women with the TVT in the 50-70% urethral length range and a 3-5-mm tape-longitudinal smooth muscle distance had a greater likelihood of being cured without complications (P < 0.001).

CONCLUSIONS

Preoperative sonographic measurement of urethral length, combined with the one-third rule, may aid in reliable midurethral TVT positioning.

Role of perineal ultrasound in the evaluation of urinary stress incontinence and pelvic organ prolapse: A systematic review

AIMS

A review of the international literature on urogynecology was performed to focus on the actual role of perineal ultrasound. It is an increasingly used tool for the assessment of pelvic floor dysfunction and incontinence. In recent years ultrasound studies have predominated but there is little information on normal values and confusion on methodology and measurements. The aim of this study is to report the data available in the Literature about ultrasound as investigational evaluation helpful in diagnosing of urinary incontinence and urethral hypermobility, to document pelvic floor anatomy and to assess anatomic and functional changes after surgery.

METHODS

A MEDLINE search was conducted using combinations of heading terms: perineal, ultrasound, pelvic floor, urinary incontinence, pelvic organ prolapse.

RESULTS

Ultrasound has become an indispensable diagnostic procedure in urogynecology. Perineal, introital, and endoanal ultrasound are the most recommended techniques and the results comprise qualitative and quantitative findings. These are important for determining the localization of the bladder neck and vesico-urethral junction and also for pre- and postoperative comparisons, and moreover for clinical applications and scientific investigations.

CONCLUSIONS

There are as yet little data and there is a need to find in the near future more standard and objective parameters for the diagnosis of urinary incontinence. They will be obtained by means of more accurate analysis and comparison of the parameters, leading to a more clinically useful diagnostic test and assuring reliable and reproducible results.

Bladder neck pubovaginal slings

Over the past 30 years, the pubovaginal sling has surpassed retropubic and transvaginal suspensions as the most common surgical operation for correcting stress urinary incontinence. This resurgence has been due in part to innovative technological advances that have shortened operative times and expedited postoperative recovery. The introduction of novel allografts, xenografts and synthetic materials has also been accompanied by unique complications, previously not encountered with autologous materials. The aim of this review is to compare the available sling materials in the context of biocompatibility and efficacy.

Perineal ultrasound evaluation of urethral angle and bladder neck mobility in women with stress urinary incontinence

OBJECTIVES

1. To assess the reproducibility of an electronic ultrasonographic technique for the measurement of urethral angulation; 2. to test the ability of measurement of the urethral angle and bladder neck mobility to predict genuine stress incontinence; 3. to compare ultrasound variables in stress incontinent women and in controls.

DESIGN

Case-control study.

POPULATION

Twenty-three incontinent women and 50 controls.

METHODS

Electronic measurements of the distance between the bladder neck and the symphysis pubis, the bladder neck and the symphysis pubis line and the midline of the symphysis (alpha angle) and the angle between the proximal and distal urethra (beta angle) by means of perineal ultrasonography with a comfortably full bladder at rest, during the Valsalva manoeuvre and during maximal pelvic floor contraction. The same procedure was performed by a second investigator. Repeatability was evaluated by the technique described by Bland and Altman. Statistical analysis was performed using Student's t test and the two-tailed paired t test.

MAIN OUTCOME MEASURES

To test the possible role of the urethral angle in maintaining female continence.

RESULTS

Ultrasound analysis showed good repeatability between the two observers and is not influenced by vesical volume. Beta angle and urethrovesical mobility are inversely proportional, both in continent and in incontinent women. Urethral angle identifies genuine stress incontinence better than urethrovesical mobility (sensitivity 96% vs 87%; specificity 92% vs 68%; positive predictive value 85% vs 55%). There are significant differences in all ultrasound variables between incontinent women and continent controls.

CONCLUSIONS

This study suggests a significant role of the urethral angle in maintaining female continence (in incontinent women it is lower at rest and lowers with straining). Measurement of the urethral angle can provide useful additional information to that provided by ultrasound evaluation of bladder neck mobility.

The tension-free vaginal tape procedure: innovative surgery for incontinence

This article reviews the most recent studies of the tension-free vaginal tape procedure. It describes studies investigating the procedure's mechanism in correcting stress incontinence and its efficacy and morbidity. Additionally, the article identifies areas for future research.

Surgical treatment of stress urinary incontinence

The treatment of stress urinary incontinence (SUI) is one of more controversial aspects of pelvic floor surgery. The indications for the surgical approach are related to the international classification as: Type 1 and Type 2 (Anatomical Incontinence), and Type 3 urinary incontinence (Intrinsic Sphincteric Dysfunction). The procedure of choice for Type 1 and Type 2 is Bladder Neck Suspension (BNS) that create a strong hammock against which the urethra can be compressed with sudden changes of abdominal pressure. Type 3 has to be treated by coaptation or compression of the deficient sphinteric unit (slings or injections). The mean cure rate after Marshall-Marchetti-Krantz is 77%, that of the Burch is 81%, and that of the Needle Suspension is 79%. Laparoscopy, Bone Anchors BNS and Tension-Free Vaginal Tape represent a promising option to the traditional techniques. The contribution of minimal invasive surgery consisting in: short recovery or possibility of day surgery, reduced trauma and pain, and success rate similar to the conventional techniques, is changing the SUI treatment.

A three-year follow up of tension free vaginal tape for surgical treatment of female stress urinary incontinence

OBJECTIVE

To study the long term results of tension-free vaginal tape, a new ambulatory surgical procedure for treatment of female stress urinary incontinence.

STUDY DESIGN

A prospective open study using a standardised protocol for pre- and post-operative evaluation.

PARTICIPANTS

Fifty consecutive women participated in the study. All suffered from genuine stress incontinence. The mean age was 57 years (SD 11), 42 women (84%) were multiparous, 8 (16%) nulliparous.

SURGICAL METHOD

Tension-free vaginal tape implies the implantation of a prolene tape around mid-urethra via a minimal vaginal incision. The procedure is carried out under local anaesthesia, allowing the surgeon to check intra-operatively that continence has been obtained.

RESULTS

All the women except one could be operated on an ambulatory basis under local anaesthesia. Mean operation time was 29 minutes (range 1647). Ninety percent of the women were able to micturate spontaneously within 24 hours with insignificant residual volumes. In another 10% of the women an in-dwelling catheter had to be used temporarily. There was no need for long term postoperative catheterisation (> 14 days). Post-operative evaluation was carried out after 2 to 6, 12, 24 and 36 months. According to the protocol, 86% of the women were completely cured and another 11% were significantly improved. No signs of deterioration of the results over time were observed. No defect in healing or rejection of the tape occurred.

CONCLUSION

We consider the tension-free vaginal tape operation to be a safe and effective surgical procedure for the treatment of female urinary stress incontinence. The technique can be considered as an ambulatory procedure performed under local anaesthesia, allowing the majority of the women to be discharged from the clinic the same day or the day after the procedure.

Clinical outcome and changes in connective tissue metabolism after intravaginal slingplasty in stress incontinent women

The intravaginal slingplasty procedure (IVS) was carried out on 75 patients with genuine stress urinary incontinence. The main aims of the operation are to create an artificial pubourethral ligament and to tighten the suburethral vaginal wall. An important ingredient in the supportive structures of the genitourinary region is fibrous connective tissue, consisting mainly of collagen. To analyse this component biopsies were obtained transvaginally, close to the position of the sling, both preoperatively and 2 years after surgery, from 6 patients. Collagen was analysed for concentration and extractability. Extractability by pepsin digestion was increased by 60% 2 years following surgery. Postoperative follow-up studies from 12 months to 3 years showed complete restoration of continence in 63 patients (84%) and considerable improvement in 4 others (5%). The 8 failures (9%) were all related to early rejection of the sling. The IVS procedure is an attractive surgical procedure as it necessitates minimum invasion and can be performed under local anesthesia, with a short hospital stay and sick-leave period. The enhanced collagen extractability indicates a changed metabolism, most likely induced by the implanted sling, resulting in a restoration of the elastic properties of the connective tissue.

An ambulatory surgical procedure under local anesthesia for treatment of female urinary incontinence

The object was to study prospectively the results of a modified intravaginal slingplasty for the surgical treatment of female stress incontinence, carried out under local anesthesia as a day procedure. Seventy five patients with genuine stress incontinence were operated upon and followed for a 2-year period. All patients were diagnosed urodynamically to have genuine stress incontinence. Pad tests and quality of life assessments were carried out in all patients both pre- and postoperatively. There were no intra- or postoperative complications and 63 patients (84%) were completely cured throughout the 2-year follow-up period. Six patients (8%) were significantly improved, i.e. they did not loose urine apart from an occasional leakage during severe cold etc. In the remaining 6 patients (8%) no improvement was seen. These failures were obvious at the first postoperative check-up after 2 months. Thus, there were no relapses after 2 months. All but 5 patients were able to void properly directly after surgery. These 5 needed an indwelling catheter during the night directly after the operation. All 75 patients were released from the hospital the same day or the day after surgery without catheterization. Mean sick leave was 10 days and mean operation time 22 minutes. No defect healing or rejection of the sling occurred. It is concluded that the procedure described is a promising new technique for the surgical treatment of female stress incontinence. Prospective long-term studies including more patients are in progress to establish the definitive place of this technique in the clinical routine.

Intravaginal slingplasty (IVS): an ambulatory surgical procedure for treatment of female urinary incontinence

A new ambulatory procedure for treatment of female urinary incontinence (intravaginal slingplasty, IVS) was performed on 50 patients. In all patients the surgical procedure was carried out under local anaesthesia and without postoperative urinary catheterization. The technique has been elaborated from previous experimental and clinical studies and aims at restoration of the pubourethral ligament and the suburethral vaginal hammock. Thirty-eight patients suffered from genuine stress incontinence as objectively verified and 12 patients had symptoms and signs of both urge and stress incontinence. Thirty-nine (78%) patients were completely cured from their stress incontinence symptoms. Another six patients (12%) reported a considerable improvement of their urinary incontinence leaking only occasionally. Concerning urge incontinence symptoms a significant relief of the symptoms was obtained in 6 of 12 patients. No intra- or post-operative complications occurred.

Reduction of urethral pressure in response to stress: relationship to urethral mobility

It has been postulated that one factor involved in the pathophysiology of stress urinary incontinence is the sustained decrease in urethral closure pressure in response to a sudden increase in intra-abdominal pressure. Twenty-one patients with stress-related pressure decrease (group 1) and seven patients with stable pressures (group 2) were studied. Although closure pressure in group 1 decreased approximately 27% in response to a single cough in a static setting, when studied dynamically with pressure profiles before and after coughing, there was no pressure decrease seen. The evidence presented suggests that the phenomenon of pressure decrease is in actuality an artifact of measurement and not a true physiologic event. The degree of urethral mobility is related to the perceived pressure decrease.

Anatomical and functional changes in the lower urinary tract after radical hysterectomy with lymph node dissection as studied by dynamic urethrocystography and simultaneous urethrocystometry

Seventeen urologically healthy women undergoing standardized radical hysterectomy with lymph node dissection for stage I carcinoma of the cervix were evaluated urodynamically before, immediately after, and 1 year after surgery, by dynamic videourethrocystography and simultaneous urethrocystometry. The surgical technique had been developed in order to preserve as much of the nerve and blood supply to the bladder and urethra as possible. Major dysfunction was found in the early postoperative state, but the lower urinary tract almost always regained its preoperative functional status in the course of approximately 1 year. There were no long-lasting functional changes which interfered with daily life, although small static and dynamic changes were observed. The changes occurred chiefly above the urogenital diaphragm. The results of the two urodynamic examinations, each giving different information, corresponded well. Used together they gave a more complete picture than used separately. Dynamic videourethrocystography offered information about the function of the bladder and urethra which could not be obtained by urethrocystometry alone.