Management of intrinsic sphincteric deficiency in women

Outcome of rolled fortified vaginal flap operation on female patients with intrinsic sphincteric deficiency: 2-year follow-up

INTRODUCTION AND HYPOTHESIS

We evaluate the 2-year outcome of the rolled fortified vaginal flap (RFVF) operation for the treatment of stress urinary incontinence (SUI) due to intrinsic sphincteric deficiency (ISD).

METHODS

A prospective study of 20 women suffering from SUI due to ISD was conducted. All patients were subjected to history-taking, clinical examination, cough stress test, and urodynamics. Symptom severity and quality of life (QoL) were assessed using the Arabic version of the International Consultation on Incontinence Questionnaire Urinary Incontinence Short Form (ICIQ-UI-SF). All studied women were followed up for 24 months to detect success rate, any postoperative complications, and reveal changes in the quality of life.

RESULTS

Mean age was 53 ± 8 years. Preoperative Valsalva leak point pressure was 50.1 ± 11.3 cmH₂O. After a follow-up period of 24 months, only 2 patients (10%) showed mild stress incontinence with mean VLPP 80± 3 cm H₂O. Postoperative mean maximum flow rate (Q-max) and mean Pdet-Qmax showed no significant difference from the preoperative results (P = 0.115 and 0.187 respectively). The quality of life domain of the ICIQ-UI-SF decreased significantly from 73.5 ± 12.1% (preoperatively) to 2.6 ± 8.1% (after a 1-year follow-up), P < 0.001 and then showed a slight increase to 4.5 ± 10.6 at 24 months' follow-up.

CONCLUSION

The RFVF operation has a success rate of 90% after a 24-month follow-up. It significantly improved the quality of life of women with SUI due to ISD.

Severe complications and failures of incontinence surgery using the Remeex(®) adjustable tension sling (external mechanical regulator)

OBJECTIVES

Since 1999, we have performed implantations of Remeex® adjustable prosthetics as rescue treatment for complex or persistent stress urinary incontinence (SUI) after failure of other surgical treatments (Burch colposuspension, Marshall-Marchetti-Krantz (MMK) or tension-free transvaginal tape [TVT] until 2003 and transobturator tape [TOT] since 2003). We present the results of our series, which include cases with severe complications.

MATERIAL AND METHOD

Retrospective study of women diagnosed with complex or refractory SUI who underwent Remeex(®) implantation between October 1999 and December 2013. In 5 cases, we conducted cystocele correction in the same operation as the placement of the Remeex(®).

RESULTS

Sixty women, with a mean age of 66.87 years (range 39-85), underwent operations. The procedure was successful in 68.33% of the cases. The failures consisted of the following: 10% of the women had mixed urinary incontinence (UI) with multiple bladder diverticula; 8.33% had mild SUI; and 13.33% had urgency urination without UI. Thirty-five percent required adjustments. We recorded 3 cases with severe complications: disabling severe UI in a patient who underwent multiple operations, massive pelvic hemorrhage in a patient undergoing standard antiplatelet therapy and infected vaginal calculi measuring 7cm on an extruding Remeex thread in a paraplegic patient 4 years after the implantation.

CONCLUSIONS

Remeex(®) is an effective and safe procedure for achieving continence in cases of complex or refractory SUI, although it is not exempt from severe complications. Following rigorous protocols can help detect complications and treat them in a timely manner.

[Female incontinence surgery: state of the art]

Female urinary incontinence represents a medical and social problem with huge impact regarding both patient's quality of life and social costs. The diagnosis is important for therapeutic choice and should consider some factors: the degree of urethral mobility, urodynamics parameters, patient's will and expectations, information about surgical complications and risks. Nowadays suburethral sling evolution and bulking therapy for selected cases consent to perform miniinvasive surgery; the most relevant problem concerns the management of postoperative complications: in this sense autologous slings are used after urethrolisis. In most difficult cases, it is possible to consider artificial sphincter as the best option.

Pubovaginal sling materials and their outcomes

Stress urinary incontinence (SUI) is the most common type of urinary incontinence, and approximately 200 different methods have been described for its surgical management. A better understanding of the pathophysiology of SUI has led to the development of surgical therapies focused on creating a strong suburethral supportive layer and urethral resistance. The most important advantage of the pubovaginal sling (PVS) procedure is that it restores urethral resistance during stress maneuvers to prevent incontinence, while improving urethral coaptation at rest and allowing for spontaneous micturition. Various autologous, allograft, xenograft and synthetic materials have been used for the PVS. The autologous PVS procedure for the treatment of SUI offers the highest success rate and is the most commonly used PVS surgical method. Unlike xenograft and allograft materials, the autologous procedure does not result in a tissue reaction and is associated with a low rate of material-related complications.

Positioning of a suburethral sling at the bladder neck is associated with a higher recurrence rate of stress urinary incontinence

OBJECTIVES

The purpose of this study was to investigate the relationship between the suburethral sling position and the outcome of anti-incontinence surgery.

METHODS

From 1998 to 2010, the medical records of 153 consecutive women with stress urinary incontinence undergoing the pubovaginal sling procedure were retrospectively reviewed. All patients received preoperative and postoperative transrectal sonography of the bladder and urethra, and the suburethral sling position was used to compare the postoperative continence status and lower urinary tract symptoms.

RESULTS

The mean patient age ± SD was 60.7 ± 10.6 years (range, 34-85 years), and the mean follow-up was 66.3 ± 42.1 months (range, 6-149 months). The slings were located at the bladder neck in 18 patients (11.8%), proximal urethra in 81 (52.9%), middle urethra in 45 (29.4%), and distal urethra in 9 (5.9%). The overall rate of recurrent stress urinary incontinence was 24.2% (37 patients). Among the 153 patients, there was a significantly higher stress urinary incontinence recurrence rate in the bladder neck group (bladder neck, 50.0%; proximal urethra, 18.5%; middle urethra, 22.2%; and distal urethra, 33.3%; P = .037). De novo urge and voiding symptoms occurred in 19.0% and 20.3% of overall patients, respectively. There was no significant difference in either de novo urge or voiding symptoms among groups.

CONCLUSIONS

Positioning of the suburethral sling at the bladder neck appears to be associated with a higher stress urinary incontinence recurrence rate. Patients with slings located at the proximal and middle urethra had the best postsurgical continence rates. The suburethral sling position had no direct association with de novo urge or voiding symptoms.

The effect of a bioactive tissue-engineered sling in a rat of stress incontinence model

In this study, we attempt to examine the feasibility of the bioactive tissue-engineered sling by using muscle precursor cells (MPCs)-seeded Poly(ε-caprolactone) (PCL) nanofiber sheet in a rat model of stress urinary incontinence (SUI). In vitro, MPCs were cultured on a PCL nanofiber sheet for one week, where the MPCs-seeded PCL nanofiber sheet showed constant twitching contraction by electrical field stimulation in an organ bath. In vivo, MPCs-seeded PCL nanofiber sheet was placed under the female rat's urethra after pudendal nerve denervation (animal model of SUI). The leak point pressure (LPP) was evaluated with the vertical tilt table after the operation for four weeks. The resulting LPP of MPCs-seeded PCL nanofiber sheet group was observed to be significantly higher than the denervation-only group's. Furthermore, PKH-26-labeled MPCs were observed under the urethral sphincter by immunohistochemistry. These results indicated that, the MPCs-seeded PCL nanofiber sheet have not only provided support for the deficient sphincter, but also actively improved the sphincter's function overall. In conclusion, this bioactive tissue-engineered sling could be used as an ideal material for the treatment of SUI.

Complications of grafts used in female pelvic floor reconstruction: Mesh erosion and extrusion

Introduction:

Various grafts have been used in the treatment of urinary incontinence and pelvic prolapse. Autologous materials such as muscle and fascia were first utilized to provide additional anatomic support to the periurethral and pelvic tissues; however, attempts to minimize the invasiveness of the procedures have led to the use of synthetic materials. Complications such as infection and erosion or extrusion associated with these materials may be troublesome to manage. We review the literature and describe a brief overview of grafts used in pelvic floor reconstruction and focus on the management complications specifically related to synthetic materials.

Materials and Methods:

We performed a comprehensive review of the literature on grafts used in pelvic floor surgery using MEDLINE and resources cited in those peer-reviewed manuscripts. The results are presented.

Results:

Biologic materials provide adequate cure rates but have associated downfalls including potential complications from harvesting, variable tissue quality and cost. The use of synthetic materials as an alternative graft in pelvic floor repairs has become a popular option. Of all synthetic materials, the type I macroporous polypropylene meshes have demonstrated superiority in terms of efficacy and fewer complication rates due to their structure and composition. Erosion and extrusion of mesh are common and troublesome complications that may be managed conservatively with observation with or without local hormone therapy, with transvaginal debridement or with surgical exploration and total mesh excision, dependent upon the location of the mesh and the mesh type utilized.

Conclusions:

The ideal graft would provide structural integrity and durability with minimal adverse reaction by the host tissue. Biologic materials in general tend to have fewer associated complications, however, the risks of harvesting, variable integrity of allografts, availability and high cost has led to the development and use of synthetic grafts. Synthetic grafts have a tendency to cause higher rates of erosion and extrusion; however, these complications can be managed successfully.

Intrasphincteric injections of autologous muscular cells in women with refractory stress urinary incontinence: a prospective study

INTRODUCTION AND HYPOTHESIS

Cell therapy for stress urinary incontinence (SUI) management has been experienced with encouraging results.

METHODS

We conducted an open prospective study on 12 women presenting severe SUI with fixed urethra, after previous failed surgical management. Patients underwent intrasphincteric injections of autologous progenitor muscular cells isolated from a biopsy of deltoid muscle. Primary endpoint focused on safety (measurement of Q(max) variation after 3 months). Secondary endpoints assessed side effects and efficacy.

RESULTS

No variation was diagnosed on Q(max) measurements. Efficacy data show that three of 12 patients are dry at 12 months, seven other patients are improved on pad test but not on voiding diary, and two patients were slightly worsened by the procedure. Quality of life was improved in half of patients.

CONCLUSIONS

Cell therapy for severe multioperated cases of SUI is a mini-invasive, feasible, and safe procedure that can improve urinary condition in as a second line therapy.

Autologous bone-marrow-derived mesenchymal stem cell transplantation into injured rat urethral sphincter

OBJECTIVES

To evaluate the functional and histological recovery by autologous bone-marrow-derived mesenchymal stem cell (BMSC) transplantation into injured rat urethral sphincters.

METHODS

BMSC were harvested from female Sprague-Dawley retired breeder rats for later transplantation. The cells were cultured, and transfected with the green fluorescence protein gene. The urethral sphincters were injured by combined urethrolysis and cardiotoxin injection. One week after injury, the cultured BMSC were injected autologously into the periurethral tissues. Controls included sham-operated rats and injured rats injected with cell-free medium (CFM). Abdominal leak point pressures (LPP) were measured before and after surgery during the following 13 weeks. The urethras were then retrieved for histological evaluation. The presence of green-fluorescence-protein-labeled cells and the regeneration of skeletal muscles, smooth muscles, and peripheral nerves were evaluated by immunohistochemical staining.

RESULTS

LPP was significantly reduced in the injured rats. It increased gradually after transplantation, but there was no significant difference between the BMSC and CFM groups. In the BMSC group, transplanted cells survived and differentiated into striated muscle cells and peripheral nerve cells. The proportions of skeletal muscle cells and peripheral nerves in the urethra were significantly greater in the BMSC group compared to the CFM group.

CONCLUSIONS

Despite a clear trend towards recovery of LPP in BMSC-transplanted urethras, no significant effect was detected. Further study is required for clinical applications for the treatment of stress urinary incontinence.

Results 1 year after the Reemex system was applied for the treatment of stress urinary incontinence caused by intrinsic sphincter deficiency

We present 1-year results obtained with Reemex for the cure of intrinsic sphincter deficiencies (ISDs). We recruited all patients with primary cases of stress urinary incontinence (SUI) due to an ISD (Valsalva leak-point pressure less than 60 cm or maximal urethral closure pressure less than 20 cm) who did not receive previous surgery. Thirty-eight patients were operated on. Postoperative pain was 3 (range, 1-5, visual analogue scale) at 24 h from surgery. Immediate regulation (the day after surgery) was necessary in three of 38 patients (7.9%), two for obstructive voiding difficulties and one for incontinence. Late regulation was necessary in three of 38 patients (7.9%), two for obstructive voiding difficulties (after 6 months) and one for incontinence (1 year). Symptoms resolved after the sling adjustment. Our results suggest that sling adjustments resolve postoperative failures and maintain the success rate of the Reemex system even in the midterm.

Comparison of solvent-dehydrated allograft dermis and autograft rectus fascia for pubovaginal sling: questionnaire-based analysis

OBJECTIVES

To evaluate the efficacy of pubovaginal sling using human cadaveric dermis processed by solvent dehydration and compare results to those of another group in which autograft rectus fascia was used.

MATERIAL AND METHODS

The efficacy of autologous rectus fascia (group 1, n=25) or solvent-dehydrated cadaveric dermis (group 2, n=24) for pubovaginal sling were compared in women with stress urinary incontinence (SUI). Surgical outcome, patient satisfaction and quality of life was assessed by the urogenital distress inventory (UDI-6) and the incontinence impact questionnaire (IIQ-7).

RESULTS

Mean follow-up for patients in group 1 and group 2 were 18 and 13 months, respectively. Our questionnaire-based assessment revealed that SUI was either cured or improved in a total of 21 (84%) patients in group 1 and 19 (79%) patients in group 2. No statistically significant difference was found for the overall success (P<0.05) and no major complications were encountered in both groups.

CONCLUSIONS

Use of allograft dermis as an alternative to autologous rectus fascia for pubovaginal sling had comparable improvement in patient satisfaction and quality of life at intermediate term.

The striated urethral sphincter of the pig shows morphological and functional characteristics essential for the evaluation of treatments for sphincter insufficiency

PURPOSE

New treatments are currently under investigation for intrinsic sphincter insufficiency. However, animal models in which to study the resting urethral tone generated by the striated urethral sphincter are still lacking. We describe the striated urethral sphincter in the pig. We investigated its participation in resting urethral tone with the aim of developing new tools for evaluating therapies for sphincter insufficiency.

MATERIALS AND METHODS

A total of 15 female pigs were used in this study. Anatomy of the striated urethral sphincter was described via transpubic and endoscopic approaches. Participation of the striated urethral sphincter in resting urethral tone was assessed by analysis of urethral pressure profilometry (maximum urethral closure pressure, functional urethral length and area under the curve) before and after curare injection or by destruction of the striated urethral sphincter by endoscopic electrocautery. Serial urethral cross sections were immunostained for slow/fast myosin and digitalized for 3-dimensional reconstructions to determine striated urethral sphincter volume.

RESULTS

The striated urethral sphincter was Omega-shaped and it encircled the distal third of the urethra. A mean peak intraurethral pressure +/- SEM of 58.9 +/- 13.4 cm H(2)O was noted in front of the striated urethral sphincter. Curare injection and endoscopic injury decreased maximum urethral closure pressure by 48.4% and 51.1%, functional urethral length by 10.3% and 15.3%, and area under the curve by 47% and 64%, respectively. The striated urethral sphincter consisted of 52% slow and 48% fast myofibers. Its mean volume was 0.87 cm.

CONCLUSIONS

The striated urethral sphincter of the female pig shows the morphological and functional features of a tonic muscle. Methods of measuring resting urethral tone generated by the striated urethral sphincter represent original tools for evaluating therapies for intrinsic sphincter insufficiency.

Injectable biomaterials for incontinence and vesico-ureteral reflux: current status and future promise

Many injectable biomaterials have been produced as bulking agents for compression of urethral sphincter or ureteral orifice for treating adult stress incontinence or vesico-ureteral reflux in pediatrics. The agents being developed include glutaraldehyde crosslinked collagen, dextranomer/hyaluronic acid copolymer, pyrolytic carbon-coated zirconium oxide beads, polydimethyl-siloxane microparticles, polytetrafluoroethylene paste, autologous fats, autologous chondrocytes, and others. Though less invasive nature of these agents has gained their popularity as a quick solution of the disease symptoms, most of such treatments fail to produce good long-term efficacy. The failure is likely caused by the rapid degradation of material implants and the lack of tissue regeneration/integration properties. We thus believe that a good injectable biomaterial for incontinence should possess the following two properties: (1) to resist degradation and to reside in the implantation sites for a long period of time or (2) to enhance tissue regeneration and to establish permanent periurethral or subureteric tissue. Here we report some recent results for supporting this hypothesis.

High rate of vaginal erosions associated with the mentor ObTape

PURPOSE

The transobturator tape method is a newer surgical technique for the treatment of stress urinary incontinence. Limited data exist related to complications with this approach or the types of mesh products used. We report our experience with vaginal erosions associated with the Mentor ObTape and American Medical Systems Monarc transobturator slings.

MATERIALS AND METHODS

Beginning in December 2003 selected female patients with anatomic urinary incontinence were prospectively followed after placement of the Mentor ObTape. Beginning in January 2004 we also began using the American Medical Systems Monarc in similar patients. Patients were admitted overnight after surgery, discharged on oral antibiotics, and seen in the clinic at 6 weeks postoperatively.

RESULTS

A total of 67 patients have undergone placement of the Mentor ObTape and 9 of those patients (13.4%) have had vaginal extrusions of the sling. Eight patients reported a history of persistent vaginal discharge. One patient presented initially to an outside facility with a left thigh abscess tracking to the left inguinal incision site. Each patient was taken back to the operating room for mesh removal. A total of 56 patients have undergone placement of the AMS Monarc and none have had any vaginal erosions.

CONCLUSIONS

Our high rate of vaginal extrusion using the ObTape has led us to discontinue the use of this product in our institution. Continued followup of all of these patients will be of critical importance.

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.

Solvent-dehydrated cadaveric dermis: a new allograft for pubovaginal sling surgery

AIM

The aim of this study was to evaluate the efficacy of solvent-dehydrated cadaveric dermis in pubovaginal sling surgery for the first time in the literature.

METHODS

Twenty-five women with stress urinary incontinence underwent pubovaginal sling surgery using 2 x 12 cm allograft dermis. Preoperatively, all patients were evaluated by a detailed urogynecologic evaluation, voiding diary, pelvic examination and urodynamic investigation. Outcome was assessed by the Urogenital Distress Inventory short form and standardized follow-up questionnaires.

RESULTS

Twenty (80%) patients were cured of stress incontinence symptoms. Seventeen wore no pad and three reported occasional stress urinary incontinence and used no or one pad at a mean follow up of 12 months. Five (20%) patients in our series experienced the same amount of leakage as before the surgery. Seventy-six percent of the patients indicated that urinary incontinence was no longer negatively affecting their daily life and were satisfied with the procedure.

CONCLUSIONS

Questionnaire-based assessment of outcome suggests that solvent-dehydrated cadaveric dermis is effective in the treatment of stress urinary incontinence. However, larger and comparative prospective studies with long-term results and randomized comparison of tissue preparation techniques are warranted.

A tissue-engineered suburethral sling in an animal model of stress urinary incontinence

OBJECTIVE

To create and evaluate the functional effects of a tissue-engineered sling in an animal model of stress urinary incontinence (SUI).

MATERIALS AND METHODS

Twenty female Sprague-Dawley rats were divided into four equal groups: a control group (C) had no intervention before the leak-point pressure (LPP) was measured; a denervated group (D) had bilateral proximal sciatic nerve transection (PSNT) and periurethral dissection with no sling placed; group S had concomitant bilateral PSNT and a suburethral sling of small intestinal submucosa (SIS) placed; and group (M) had concomitant bilateral PSNT with implantation of a tissue-engineered sling. The suburethral sling was placed via a transabdominal approach with the sling sutured to the pubic bone. Tissue-engineered slings were prepared with muscle-derived cells obtained via the pre-plate technique and subsequently seeded for 2 weeks on a SIS scaffold. Suburethral slings were implanted 2 weeks before LPP testing, using the vertical-tilt method.

RESULTS

Surgically placing a suburethral sling is feasible in the female rat, with few complications. LPPs from both sling groups (S and M) were not significantly different from untreated controls (C). The S, M and C groups all had significantly higher LPPs than group D. Importantly, no rat from either sling group (S and M) had signs of urinary retention.

CONCLUSIONS

Placing tissue-engineered slings in an animal model of SUI resulted in LPP values that were not significantly different from those in untreated control or SIS (S) groups. These data show that incorporating muscle stem cells into SIS slings does not adversely alter the advantageous mechanical properties of the SIS sling in a model of SUI, and provide the basis for future functional studies of tissue-engineered sling materials with long-term retention.

LONG-TERM EFFICACY OF A VAGINAL SLING PROCEDURE IN A RAT MODEL OF STRESS URINARY INCONTINENCE

PURPOSE

We examined the long-term efficacy of a newly created vaginal sling procedure for the restoration of leak point pressure (LPP) in a rat model of stress urinary incontinence (SUI).

MATERIAL AND METHODS

A total of 20 female Sprague-Dawley rats were randomly assigned to 1 of 4 groups, namely normal control, SUI plus vaginal sling, SUI plus sham sling and SUI only. SUI was created in the latter 3 groups by bilateral pudendal nerve transection (PNT). In the sling procedure a 2 x 0.3 cm strip of polypropylene mesh was placed at the mid urethral level. Animals in the SUI plus sham sling group underwent vaginal dissection only. After 5 weeks LPP was measured 4 or 5 times in each rat and the mean was determined. The Kruskal-Wallis and Wilcoxon rank sum tests were used to evaluate whether levels of measurements differed across and between groups.

RESULTS

Mean LPP +/- SD in control rats was 48.8 +/- 10.2 cm H2O. PNT decreased LPP to 23.5 +/- 7.4 cm H2O. Sling placement improved LPP at 5 weeks to 35.5 +/- 2.3 cm H2O, whereas LPP in the sham sling group was 29.1 +/- 4.9 cm H2O. LPP recovery in the sling group was significantly above levels for PNT (p = 0.037). LPP in the sling group did not differ statistically from that in the control group (p = 0.11).

CONCLUSIONS

The newly created vaginal sling model restores the LPP in the rat model of SUI in the long term (5 weeks). This model could be used to address research questions related to the sling procedure.

Transurethral polydimethylsiloxane implantation: a valid option for the treatment of stress urinary incontinence due to intrinsic sphincter deficiency without urethral hypermobility

PURPOSE

In this study we evaluated the 5-year followup results of periurethral polydimethylsiloxane (PDMS) injection for female stress urinary incontinence (SUI) secondary to intrinsic sphincter deficiency (ISD) without hypermobility of the vesicourethral junction.

MATERIALS AND METHODS

A total of 61 female patients with ISD were enrolled in this prospective, observational study. Preoperative and postoperative assessment included a standardized urogynecologic history with questions regarding urinary function, urogynecologic and neurological physical examination, and urodynamic assessment. All patients underwent periurethral PDMS injection. Patient followup was performed 1, 6, 12, 24, 36, 48 and 60 months after surgery.

RESULTS

At 60 months after injection the SUI cure rate was 18%, the improvement rate was 39% and the failure rate was 43%. The success rate was 57%. Of the patients 45 (74%) subjectively improved with respect to the severity of urinary incontinence. No postoperative early complications were found. At 60 months of followup only minor complications were reported (11%).

CONCLUSIONS

Careful patient selection by optimal diagnostic tools are essential for maximizing the results of urethral bulking agent therapy. PDMS injection in women with SUI due to ISD with limited urethral mobility is a valid, minimally invasive procedure.

Efficacy of a vaginal sling procedure in a rat model of stress urinary incontinence

PURPOSE

We validated the efficacy of the vaginal sling procedure for the restoration of leak point pressure (LPP) in the rat model of stress urinary incontinence (SUI).

MATERIALS AND METHODS

SUI was created in 10 female Sprague-Dawley rats by bilateral pudendal nerve transection (PNT) under urethane anesthesia. Vaginal dissection was performed, followed by placement of a 2 x 0.3 cm strip of Prolene (Ethicon, Somerville, New Jersey) mesh at the mid urethral level. LPP was measured before and after PNT through a suprapubic tube using a Credé maneuver. It was also measured after vaginal dissection (sham sling) and after true sling placement. All procedures and measurements were done at the same experimental setting. In each animal LPP was measured 4 or 5 times and the mean was taken. Pairwise differences in LPP between the true and sham slings were calculated using the Wilcoxon signed rank test with p <0.05 considered significantly different.

RESULTS

Mean LPP at baseline in all rats was 65.1 +/- 6.0 cm water. LPP decreased to 42.7 +/- 3.7 cm water after PNT. The sham sling further decreased LPP to 26.5 +/- 2.2 cm water, whereas the true sling restored LPP to 56 +/- 4.8 cm water. LPP after true sling placement was not different from baseline (p = 0.16), whereas LPP after sham sling placement was significantly different from baseline (p = 0.002).

CONCLUSIONS

This rat vaginal sling model represents a valid surgical method for LPP restoration in the rat model of SUI. This animal model could be used for future studies related to SUI and its treatment relevant to sling surgery.

Tension-free vaginal tape procedure for the treatment of female stress urinary incontinence: long-term results

PURPOSE

The tension-free transvaginal tape (TVT) procedure has apparently become the most popular technique for genuine stress urinary incontinence (GSUI). Long-term followup data on the outcome of the procedure are sparse. We evaluated the long-term results of TVT for treating women with GSUI.

MATERIALS AND METHODS

We performed a retrospective analysis of the records of 55 patients 37 to 83 years old (mean age 63.4) with GSUI, for which they underwent the TVT procedure at our department as of December 1999.

RESULTS

Of the 52 patients who were followed a mean of 55 months (range 48 to 65) 41 (78.9%) were dry. There were 4 intraoperative complication (7.3%), including bladder injury in 3 patients and urethral injury in 1. None required surgical re-intervention. Urgency was reported in 6 women (11.5%). There were 5 postoperative tape related complications (9.6%), consisting of bladder erosion in 1 woman, vaginal erosion in 2 and an obstructed urethra in 2. Four of these 5 women underwent corrective surgery, after which all remained dry.

CONCLUSIONS

TVT is a safe and effective procedure for female stress urinary incontinence with an enduring, high success rate. There is a significant rate of intraoperative complications, which do not cause further problems when identified and treated during surgery. One must be alert to the significant rate of postoperative complications that usually require repeat surgery, which is relatively simple and causes practically no long-term morbidity. It also does not influence the continence rate in most cases.

BLADDER CONTRACTION STRENGTH PARAMETERS POORLY PREDICT THE NECESSITY OF LONG-TERM CATHETERIZATION AFTER A PUBOVAGINAL RECTUS FASCIAL SLING PROCEDURE

PURPOSE

We verified if the necessity of long-term catheterization after a pubovaginal rectus fascial sling procedure can be predicted by preoperatively determined bladder contraction strength.

MATERIALS AND METHODS

We analyzed the files of 58 consecutive nonneurogenic women who underwent a sling procedure for severe or refractory stress urinary incontinence. Preoperative urodynamic measurements in these patients were re-analyzed using the power factor WF and the bladder contractility index as bladder contraction strength parameters. Catheterization was considered necessary if the patient self-catheterized at least once daily.

RESULTS

One patient was lost to followup. Three and 6 months after surgery 24 (42%) of 57 and 18 (33%) of 54 patients were on catheterization. On average patients who were not on catheterization had a stronger bladder but the results were not consistently statistically significant.

CONCLUSIONS

A trend toward higher bladder contraction strength in patients not on catheterization was found. However, preoperative urodynamic examination can only poorly predict the necessity of long-term catheterization after sling surgery.

When the sling is too proximal: A specific mechanism of persistent stress incontinence after pubovaginal sling placement

OBJECTIVES

To review a series of patients with persistent stress urinary incontinence (SUI) after pubovaginal sling (PVS) placement because of an excessively proximal position of the graft on the bladder neck.

METHODS

Four women, who had previously undergone PVS placement for SUI, presented for evaluation of persistent SUI. All underwent investigations, including history, symptom questionnaire, quality-of-life assessment, physical examination, voiding cystourethrography, and multichannel urodynamic studies. Subsequently, takedown of the primary PVS and placement of an autologous fascial PVS were performed on all patients. A detailed case review of one of the patients is presented.

RESULTS

All patients had persistent severe SUI confirmed by a positive supine stress test and Valsalva leak point pressure determination. Malposition of the graft was diagnosed preoperatively on the basis of severe distortion of the bladder base and a wide-open bladder neck at rest on the lateral standing voiding cystourethrography images. The diagnosis was confirmed on operative exploration. All patients were continent after takedown of the prior PVS and placement of an autologous fascial sling.

CONCLUSIONS

Persistent SUI after PVS placement may occur secondary to positioning of the graft excessively proximally on the bladder neck. True lateral voiding cystourethrography views are essential for the precise diagnosis. In our experience, optimal management involves takedown of the primary PVS and placement of an autologous fascial PVS.

Is the leak point pressure alone an accurate indicator of intrinsic sphincteric deficiency?

The aim of this study was to determine the characteristics of women who meet the criteria for intrinsic sphincteric deficiency (ISD) on maximum urethral closure pressure (MUCP) but not on leak point pressure (LPP) measurement. We performed a cross-sectional chart review of every patient who underwent multichannel, microtransducer urodynamic testing in our center between 1994 and 1996 (n=423). From this population we culled a sub-population of women who fit into one of the following two groups: women with no evidence of ISD on MUCP or LPP and women with evidence of ISD on MUCP only. Logistic regression was used to identify independent predictors of group membership. Increasing age (>60.5 years) and a positive supine empty stress test were the only independent predictors of membership in the group of women with ISD on MUCP only. Knowledge of these risk factors may help clinicians in choosing appropriate pre-operative testing.

New perineal bone-anchored male sling: lessons learned

OBJECTIVES

To identify factors affecting outcome after the male sling procedure for stress urinary incontinence.

METHODS

A total of 46 incontinent men, with a mean age of 67 years, underwent perineal bone-anchored male sling placement. Three titanium bone screws with preattached pairs of No. 1 polypropylene sutures were placed directly into the medial aspect of each inferior ramus of the pubic bone. To compress the urethra, three different types of materials were used: absorbable biomaterial, silicone-coated polypropylene mesh, or a composite graft. Patient characteristics, incontinence etiology and severity before surgery, prior collagen injections, and type of material used were assessed, and the association with the outcome of the male sling procedure was determined.

RESULTS

The procedure was successful in 35 (76%) of 46 patients at a mean follow-up of 18 months (range 6 to 30). Nineteen patients were totally dry and 16 had improved 50% or more compared with before surgery. Failure occurred in 11 patients (24%). Patients who received a composite graft or mesh alone had a better outcome compared with the absorbable sling group (97% and 75% versus 0%, respectively, P = 0.001). The severity of pretreatment incontinence also had a negative impact on the outcome.

CONCLUSIONS

Patients with mild-to-moderate incontinence and the use of a composite graft had the best outcomes after the perineal bone-anchored male sling.

Le TVT (tension-free vaginal tape) a-t-il une place dans le traitement de l’insuffisance sphinctérienne ?

OBJECTIVE

The objective of this article is to estimate results and place of TVT in female stress urinary incontinence with intrinsic sphincter incompetence.

MATERIAL AND METHOD

This was a retrospective study over a period of 57 months in a population of 38 patients treated by TVT for sphincter incompetence with or without inefficient pressure transmission. Mean patient age was 52 years. Fourteen patients (37%) had a history of incontinence surgery. The physical examination demonstrated urethral mobility in 22 patients (58%) and positive Bonney or Jacquetin tests in 15 patients (39%). Mean maximum urethral closure pressure was 40 cm H2O, with 12 patients (32%) 30 cm. Six patients (16%) had detrusor instability. Seven patients (18%) had pure sphincter incompetence.

RESULTS

Median follow-up was eight months (two months to 32 months). Twenty five patients (66%) were cured, nine (24%) improved and treatment failed in four (10%). Results are less satisfactory for patients with preliminary failure of incontinence surgery, fixed urethra, pure sphincter incompetence or with detrusor instability without inefficient pressure transmission. The only major complication was an expulsion of the prosthesis.

CONCLUSION

Results of TVT in sphincter incompetence are slightly less satisfactory than in pure urinary stress incontinence. In a short follow-up, they are comparable in sphincter incompetence to those of sling procedures which are the current gold standard. Risk of urinary retention is lesser. The minimally invasive nature of TVT suggests that it will replace sling procedures in the future for this particular indication. Longer follow-up will be necessary for confirmation.

Time Dependent Variations in Biomechanical Properties of Cadaveric Fascia, Porcine Dermis, Porcine Small Intestine Submucosa, Polypropylene Mesh and Autologous Fascia in the Rabbit Model: Implications for Sling Surgery

PURPOSE

We investigated time dependent variations in tensile strength, stiffness, shrinkage and distortion in 6 materials commonly used for transvaginal anti-incontinence surgery.

MATERIALS AND METHODS

A total of 15 rabbits were randomized into 3 survival groups (2, 6 and 12 weeks, respectively). Each rabbit had human cadaveric fascia, porcine dermis, porcine small intestine submucosa, polypropylene mesh and autologous fascia implanted on the anterior rectus fascia. At harvest tensiometry and image analysis were performed on each sling. Results were compared to baseline for each sling type and the percent decrease from baseline was compared among sling types.

RESULTS

Each type of human cadaveric fascia and porcine allografts showed a marked decrease (60% to 89%) in tensile strength and stiffness from baseline. Polypropylene mesh and autologous fascia did not differ in tensile strength from baseline. Polypropylene mesh increased in stiffness from baseline. Autologous fascia and small intestinal submucosa demonstrated a 41% and 50% decrease in surface area, respectively, at 12 weeks.

CONCLUSIONS

To our knowledge the relative contribution of biomechanical properties of sling material to the success of anti-incontinence surgery is unknown. However, rapid loss of tensile strength and stiffness in porcine and cadaveric materials may contribute to the early re-emergence of symptoms following successful sling surgery. The results of this study add scientific validity to the increasing use of synthetics in anti-incontinence surgery. Urologists selecting a sling material should be aware of its time dependent biomechanical fate relative to other sling materials.

Current Management of Urinary Incontinence

Urinary incontinence is an underreported, underdiagnosed, and undertreated condition erroneously thought by many patients to be a normal part of aging. This article briefly discusses transient urinary incontinence and then focuses on the different types of established incontinence. Specifically, the article discusses preferred terminology associated with urinary incontinence and describes the different types, causes, nonpharmacologic options, and pharmacologic options for managing overactive bladder syndrome, stress incontinence, and overflow incontinence. It briefly discusses mixed urinary incontinence and functional incontinence. The role of the pharmacist in working with patients, caregivers, and other health care professionals to optimize management of urinary incontinence is discussed throughout.

Urodynamic effects of a percutaneously controlled static hydraulic urethral sphincter in canine cadavers

OBJECTIVE

To describe a percutaneously controlled static hydraulic urethral sphincter (SHUS) and evaluate urodynamic effects of the SHUS in canine cadavers.

SAMPLE POPULATION

Cadavers of 6 adult female dogs.

PROCEDURE

Cadavers were obtained immediately after dogs were euthanatized. Baseline maximal urethral closure pressure (MUCP) and cystourethral leak point pressure (CLPP) were measured by use of a urethral pressure profilometer. An SHUS system was constructed by use of a silicone vascular occluder and subcutaneous infusion port. The SHUS system was then placed around the pelvic urethra in each cadaver. Measurements of MUCP and CLPP were repeated after varying occlusion of the SHUS (0%, 25%, and 50% occlusion). Baseline MUCP and CLPP values were compared with values obtained at 0%, 25%, and 50% occlusion of the SHUS by use of repeated-measures ANOVA.

RESULTS

Mean +/- SD MUCP for canine cadavers was 7 +/- 1.3 cm H2O at baseline, which increased to 127 +/- 53 cm H2O after 50% occlusion of the SHUS. Mean CLPP was 11 +/- 8.6 cm H2O at baseline, which increased to 73 +/- 38 cm H2O after 50% occlusion of the SHUS. Mean MUCP and CLPP were significantly associated with the amount of occlusion.

CONCLUSIONS AND CLINICAL RELEVANCE

The SHUS had positive effects on MUCP and CLPP in canine cadavers. Therefore, additional evaluation of the SHUS in live dogs is warranted.