Why do women have voiding dysfunction and de novo detrusor instability after colposuspension?

[Predictive factors of immediate post-operative acute urinary retention or voiding dysfunction following mid-urethral sling surgery: A literature review]

OBJECTIVE

Immediate postoperative urinary retention (UR) and voiding dysfunction (VD) are some factors limiting outpatient procedure for mid-urethral sling (MUS) surgery in women presenting with stress urinary incontinence. The objective of the current review was to report the main predictive factors associated with immediate postoperative UR/VD following MUS surgery in women.

METHODS

A systematic review was performed using Medline database, according to PRISMA methodology, using following keywords midurethral sling; tension-free vaginal tape; TVT; transobturator tape; TOT; predicting factor; voiding dysfunction; urinary retention; postvoid residual; postoperative residue of urine.

RESULTS

Thirteen studies were included. Main clinical predictive factors associated with immediate postoperative urinary retention (UR) and voiding dysfunction (VD) were: previous pelvic surgery (hysterectomy, incontinence or pelvic organ prolapse surgery) [OR: from 3.7 ((CI95%: 1.14-12.33); P=0.029)] to 8.93 [(CI95%:1.17-61.1); P=0.035)], previous UR [OR: 415 (CI95%: 20-8619); P<0.001], age over 65 y/o [OR: 3,72 (CI95%:1.40-9.9); P<0.01], and general anesthesia [OR: 4.5 (CI95%:1.1-18.9); P=0.02]. Urodynamic predictive factors were underactive bladder at cystometry [OR: from 2.52 ([CI95%: 1.03-6.13]; P=0.042) to 5.6 ([IC95%: 1.6-19.2]; P=0.02] and preoperative maximum flow rate (Qmax) (the prevalence of UR was ranging from 12 to 35% when Qmax was under 15ml/s, versus 0% when Qmax was over 30ml/s).

CONCLUSION

Predictive factors associated with immediate postoperative UR/VD following MUS surgery in women were age over 65 y/o, previous pelvic surgery or previous UR, underactive bladder and preoperative Qmax under 15ml/s.

No. 248-Guidelines for the Evaluation and Treatment of Recurrent Urinary Incontinence Following Pelvic Floor Surgery

OBJECTIVE

To provide general gynaecologists and urogynaecologists with clinical guidelines for the management of recurrent urinary incontinence after pelvic floor surgery.

OPTIONS

Evaluation includes history and physical examination, multichannel urodynamics, and possibly cystourethroscopy. Management includes conservative, pharmacological, and surgical interventions.

OUTCOMES

These guidelines provide a comprehensive approach to the complicated issue of recurrent incontinence that is based on the underlying pathophysiological mechanisms.

EVIDENCE

Published opinions of experts, and evidence from clinical trials where available.

VALUES

The quality of the evidence is rated using the criteria described by the Canadian Task Force on Preventive Health Care (Table).

RECOMMENDATIONS

Complications of synthetic slings used in female stress urinary incontinence and applicability of the new IUGA-ICS classification

OBJECTIVES

To analyze different complications of synthetic suburethral slings, and to apply the new "IUGA-ICS classification of complications directly related to the insertion of prosthesis (meshes, implants, tapes) and grafts in female pelvic floor surgery" to the list of complications, check its applicability, and give suggestions regarding possible improvements.

STUDY DESIGN

This study is an analysis of complications of synthetic suburethral slings. Data on type of complication, time interval between the insertion of the prosthesis and the onset of symptoms of complication, type and nature of prosthesis, and management process were documented. Additional descriptions of the sling position in relation to lower urinary tract, shrinkage or prominence of the prosthesis, and intra-operative nature of the prosthetic material were collected for analysis.

RESULTS

From the year 2003 to 2010, 376 women with complications of synthetic suburethral slings were managed surgically and the data were analyzed. Overactive bladder (OAB) at 54%, lower urinary tract obstruction (48%), vaginal exposure (19%), and pain (14%) were the most frequent complications. Infection, fistulae, urinary tract penetration, and groin/thigh pain were other complications. The new IUGA-ICS classification could be applied to most of the types of complications, a notable exception being de novo development of overactive bladder. Also category 4B of IUGA-ICS classifications encompasses a wide clinical variety of complications and may need reconsideration.

CONCLUSION

De novo OAB seems to be the commonest complication of synthetic suburethral slings, followed by obstruction, vaginal exposure, and long term pain. The new IUGA-ICS classification on complications has good general applicability; some minor changes may be useful in the future.

[Urodynamic aspects of feminine urinary incontinence treated with slings]

OBJECTIVES

Treatment of feminine stress urinary incontinence (SUI) with slings aims to supplement the function of the damaged ligaments, favoring the correct transmission of the tensions. Our objective is to determine which preoperative variables could predict the outcome of surgical treatment of SUI and to study the urodynamic changes produced by the surgery.

MATERIAL AND METHODS

139 women (age X =61.7; σ=10.88) operated on due to SUI were studied retrospectively. In 118 cases (84.8%), sling techniques (TVT, TOT, TVT-Safyre, REEMEX) were used. Clinical evaluation and complete preoperative video -urodynamics were made pre-operatively and at 3 months of surgery. A statistical study (Fisher's test, Wilcoxon, Friedman, Student's T and Pearson's χ(2)) and analysis of multivariant logistic regression analysis by step elimination method were performed.

RESULTS

Post-operatively, the SUI (p=0.000) and bladder hyperactivity syndrome decreased. The success percentages (urodynamic absence of SUI) for each technique were: TVT-Safyre (75%), TOT (73%), TVT (60%) and REEMEX (57%), without significant differences. Age (ROC cut-off: 61 years) was a prognostic factor of success (p=0.024). Preoperative maximum flow (Qmax) (16 ml/s) constituted the only urodynamic parameter with a predictive value for success (p=0.026). An open bladder neck was a risk factor for persistence of postoperative SUI (RR=2.78). A significant decrease of the postsurgical Qmax (p=0.017) was verified, without increase of the post micturation residue or of the Wmax. An increase of the postsurgical urethral resistance (UR) was also observed (p=0.004).

CONCLUSIONS

The pre-operative Qmax is the most important urodynamic prognostic parameter in feminine SUI surgery, its normality being associated to a greater probability of cure of the incontinence. In the cases of decreased preoperative flow, use of slings that increase urethral resistance more (REEMEX) is not recommended. Hyperactivity of the preoperative detrusor does not significantly modify the results of surgery of the SUI.

Pelvic floor ultrasound in incontinence: what's in it for the surgeon?

There is increasing interest in imaging techniques such as magnetic resonance and ultrasound amongst pelvic floor surgeons, as evidenced by the number of workshops and conference presentations in this field. Ultrasound is employed more commonly, due to much lower costs, greater accessibility and practicability. Consequently, this review focuses on sonography. At this time, imaging is probably under-utilised in urogynaecology and female urology, although it has the potential to greatly benefit our patients. In this review, I will outline the main uses of imaging in the work-up of women with urinary incontinence, before and after treatment, and focus on areas in which this benefit to patients and clinicians is most evident.

Guidelines for the evaluation and treatment of recurrent urinary incontinence following pelvic floor surgery

OBJECTIVE

To provide general gynaecologists and urogynaecologists with clinical guidelines for the management of recurrent urinary incontinence after pelvic floor surgery.

OPTIONS

Evaluation includes history and physical examination, multichannel urodynamics, and possibly cystourethroscopy. Management includes conservative, pharmacological, and surgical interventions.

OUTCOMES

These guidelines provide a comprehensive approach to the complicated issue of recurrent incontinence that is based on the underlying pathophysiological mechanisms.

EVIDENCE

Published opinions of experts, and evidence from clinical trials where available.

VALUES

The quality of the evidence is rated using the criteria described by the Canadian Task Force on Preventive Health Care (Table).

RECOMMENDATIONS

1. Thorough evaluation of each patient should be performed to determine the underlying etiology of recurrent urinary incontinence and to guide management. (II-3B) 2. Conservative management options should be used as the first line of therapy. (III-C) 3. Patients with a hypermobile urethra, without evidence of intrinsic sphincter deficiency, may be managed with a retropubic urethropexy (e.g., Burch procedure) or a sling procedure (e.g., mid-urethral sling, pubovaginal sling). (II-2B) 4. Patients with evidence of intrinsic sphincter deficiency may be managed with a sling procedure (e.g., mid-urethral sling, pubovaginal sling). (II-3B) 5. In cases of surgical treatment of intrinsic sphincter deficiency, retropubic tension-free vaginal tape should be considered rather than transobturator tape. (I-B) 6. Patients with significantly decreased urethral mobility may be managed with periurethral bulking injections, a retropubic sling procedure, use of an artificial sphincter, urinary diversion, or chronic catheterization. (III-C) 7. Overactive bladder should be treated using medical and/or behavioural therapy. (II-2B) 8. Urinary frequency with moderate elevation of post-void residual volume may be managed with conservative measures such as drugs to relax the urethral sphincter, timed toileting, and double voiding. Intermittent self-catheterization may also be used. (III-C) 9. Complete inability to void with or without overflow incontinence may be managed by intermittent self-catheterization or urethrolysis. (III-C) 10. Fistulae should be managed by an experienced physician. (III-C).

Detrusor overactivity: an overview

Detrusor overactivity (DO) is a common clinical problem having profound effects on the quality of life (QOL) of women. With the use of meshes in the antiincontinence surgery, a new onset of DO, de novo DO has become an important issue in postoperative QOL of women. A systematic review of English language literature was conducted from Pubmed and publications of the last 7 years were analyzed and presented in this review. Multiple pathological events in the urothelium, sub-urothelium and possibly in the detrusor muscle seem to underlie the pathophysiology of DO. A variety of approaches, from life style modification to minimal-invasive surgery are available to treat DO and it is the responsibility of the physician to properly select and apply these modalities with the ultimate aim in improving the QOL of the patients. It is imperative to know the various pathophysiological processes that underlie the causation of DO to select proper management approach.

Predicting short-term urinary retention after vaginal prolapse surgery

AIMS

Identification of risk factors for urinary retention after vaginal prolapse surgery.

METHODS

The medical records of 345 women undergoing surgical correction for symptomatic pelvic organ prolapse were analyzed. Independent risk factors for the development of post-operative urinary retention were identified by performing univariate and multivariate logistic regression analysis. Variables included in the analysis were age, parity, body mass index, previous prolapse surgery, previous hysterectomy, menopausal status, degree of prolapse, type of anesthesia, type and technique of surgery, operation time, intra-operative blood loss, preoperative urinary stress-incontinence, and other co-morbidities. Main outcome measure was the occurrence of urinary retention defined as a residual volume after voiding higher than 200 ml as measured by bladder scan.

RESULTS

High grade cystocele (OR 2.5, CI 1.3-4.7), performing levator plication (OR 4.3, CI 2.0-9.3), performing Kelly plication (OR 5.1, CI 1.7-15.5) and amount of intra-operative blood loss (OR 1.4 per 100 ml, CI 1.1-1.8) were identified as independent risk factors for the occurrence of urinary retention after vaginal prolapse surgery.

CONCLUSIONS

Urinary retention after vaginal prolapse surgery occurs more frequently in women with larger cystoceles, severe intra-operative blood loss and the application of levator plication and Kelly plication.

Culdocele repair in female pelvic organ prolapse

OBJECTIVES

To review patients with a culdocele, a wide and deep cul-de-sac, and to report the results of treatment by sacrocolpopexy.

METHODS

A retrospective review of 117 patients with a culdocele identified by clinical examination and intraoperatively.

RESULTS

The mean age and parity of the patients were 61.4 years and 3.1, respectively. Bladder complaints occurred in 46% of patients and bowel problems in 74% (mainly obstructed defecation). Something protruded through the vaginal introitus in 84% of patients. All patients were treated with a sacrocolpopexy: 96% with mobilization and elevation of the rectum (rectopexy), and 79% with Burch colposuspension. Follow-up results were obtained for 98% of the patients (mean, 14.7 months). Recurrent prolapse occurred in 10% of patients.

CONCLUSIONS

A culdocele differs from an enterocele because it a distended and deep cul-de-sac without a true hernia between the distal vagina and rectum. Sacrocolpopexy resulted in a 10% recurrence rate of prolapse.

The predictive value of preoperative pressure-flow studies in the resolution of detrusor overactivity and overactive bladder after tension-free vaginal tape insertion

OBJECTIVE

To determine whether preoperative pressure-flow studies (PFS) predict the resolution of detrusor overactivity (DO) and overactive bladder (OAB) symptoms after a tension-free vaginal tape procedure (TVT).

PATIENTS AND METHODS

Thirty-five consecutive women with mixed DO and urodynamic stress incontinence (USI) undergoing a TVT had PFS before and afterward reviewed, and the results compared.

RESULTS

There was resolution of OAB symptoms in 51%; the persistence of OAB symptoms was predicted by a significant decrease (20.0 to 14.0 mL/s) in the maximum flow rate after the TVT (P = 0.027) and a significant increase in the detrusor pressure at maximum flow after the TVT (P = 0.04). DO was absent on cystometry in 46% of women after the TVT. Women with persistent DO on cystometry had a significantly lower (P = 0.02) maximum flow rate before the TVT (mean 19.3 mL/s) than those with no persistent DO (mean 26.9 mL/s). This finding persisted when flow rates were corrected for voided volume (P = 0.04). Before and after TVT there were no significant differences between the groups in voiding time and acceleration of flow. USI was objectively cured in 92% of the women.

CONCLUSIONS

Women whose maximum flow rate decreases significantly after the TVT are more likely to have persistent OAB symptoms. The urinary flow rate before the TVT was significantly higher in women with an objective cure of DO after TVT than in women with persistent DO. These findings support an obstructive cause in women in whom DO does not resolve.

Frequency of de novo urgency in 463 women who had undergone the tension-free vaginal tape (TVT) procedure for genuine stress urinary incontinence—A long-term follow-up

BACKGROUND

To determine risk factors for the appearance of de novo urgency symptoms, and subsequent accompanying problems, after the tension-free vaginal tape (TVT) procedure in women with stress urinary incontinence.

METHOD

A structured preoperative analysis of the incontinence symptoms was made. A mailed questionnaire was distributed to 970 women that underwent the TVT procedure between 1995 and 2001. Average follow-up was 5.2 years (range 2-8 years). The questionnaire included specific questions on current urinary symptoms and incontinence. The disease-specific quality of life instruments IIQ-7 and UDI-6 were used to compare women with, and those without de novo urgency.

RESULTS

Seven hundred and sixty women (78.3%) responded and 463 of those were identified as genuine stress incontinence preoperatively. De novo urgency occurred in 67 (14.5%) of the women. The frequency was similar irrespective of duration since the TVT procedure. The women that reported de novo urgency symptoms were compared with those without symptoms. Risk factors for occurrence of de novo urgency symptoms were older age (64.7 years versus 60.9 years; p=0.01), parity (2.6 versus 2.3; p=0.05), history of cesarean section (9.5% versus 2.5%; odds ratio 5.4), and history of recurrent urinary infections (29.7% versus 18.8%; odds ratio 1.6, but non-significant. De novo urgency had a severe impact on quality of life, as compared to the remaining study population.

CONCLUSION

Old age, parity and history of cesarean section were risk factors for de novo urgency after TVT surgery. Postoperative de novo urgency symptoms are as bothersome for the patient as the preoperative stress urinary incontinence.

Chapitre H - Les conséquences neuro-urologiques de la chirurgie de l’incontinence urinaire d’effort et de la statique pelvienne

It is difficult to prove the neurourological origin of a voiding disorder, pain or postoperative functional disorders after stress urinary incontinence and pelvic repair surgery and their incidence is difficult to evaluate. The purpose of this chapter is to review the data of the literature concerning complications of this type of surgery, possibly related to a neurological injury, regardless of the site. The most frequently encountered postoperative problem is acute urinary retention. Prevention of acute urinary retention must be based on preoperative assessment looking for risk factors and the quality of postoperative resumption of voiding after removal of the bladder catheter Medium-term and long-term de novo dysuria and/or urgency must be analysed according to a neurourological approach, looking for obstruction (that must be removed) and complications related to the implanted prosthetic material or to the operative technique. The most difficult symptom to assess is postoperative pelvic pain "induced" by surgery. It can be accentuated by a previously undiagnosed concomitant spinal or regional lesion (hip) and the diagnostic assessment must be based on a multidisciplinary approach. This review emphasizes the low level of proof of data of the literature in this field and supports the impression that prospective data from homogeneous cohorts must be recorded in registries, for example, despite the difficulty of long-term evaluation (> 5 years). In the future, patients in whom prosthetic material is implanted should probably be encouraged to more readily cooperate in this field to ensure continuing improvement of the quality of surgical care.

Is the role of Burch colposuspension fading away in this epoch for treating female urinary incontinence?

The role of Burch colposuspension as the primary surgical treatment of stress urinary incontinence has been challenged by less invasive new surgical methods. The aim of this study was to evaluate the long-term results of Burch colposuspension in terms of subjective self-reported outcomes. Between 1993 and 1997, 159 women who underwent Burch colposuspension as the first operation for treating urodynamic stress incontinence were recruited for this study. We recorded the findings of preoperative and postoperative urodynamic studies and early postoperative complications or adverse effects related to the operation. In 2005, after a median follow-up of 10 years, telephone interviews were carried out and 152 (95.5%) women responded. Two main questions were asked of these women to evaluate the overall impression of improvement after the operation. Eighty-four (55.3%) women were dry according to their subjective reports, 55 (36.2%) women had improved, and 13 (8.5%) women had failed after an 8- to 12-year follow-up. One hundred and twenty-five (82.2%) women were satisfied with the outcome of the operation and 27 (17.8%) women were not. Among these 27 women, 16 (59.2%) women complained of urinary frequency and 9 (33.3%) women complained of urinary urgency as the reasons for their dissatisfaction. Our long-term subjective outcomes revealed that Burch colposuspension is an effective alternative surgery for urodynamic proven stress incontinence.

A surgical technique to adjust bladder neck suspension in laparoscopic Burch colposuspension

STUDY OBJECTIVE

To evaluate the anatomic and functional efficacy of a surgical technique designed to prevent overcorrection of the bladder neck in laparoscopic Burch colposuspension for primary urodynamic stress incontinence.

DESIGN

Prospective, observational study (Canadian Task Force classification II-2).

SETTING

Medical center, Taipei, Taiwan.

PATIENTS

One hundred fifty-five consecutive women, aged 33 to 71 years, undergoing laparoscopic Burch colposuspension for primary (not previously operated on) urodynamic stress incontinence were prospectively assessed over a 6-year period.

INTERVENTIONS

A bladder neck suspension technique, derived from serial perioperative ultrasound examinations for open Burch colposuspension, was incorporated into laparoscopic Burch procedure.

MEASUREMENTS AND MAIN RESULTS

The outcome measures included duration of postoperative voiding trials, morphologic changes on ultrasound scanning within 1 month of operation, postoperative continence rate, persistent or de novo urge symptoms or detrusor overactivity, and therapeutic satisfaction for laparoscopic Burch colposuspension. At 1-year follow-up, the objective cure rate was 94.8% (110/116), subjective cure rate was 95.7% (111/116), and overall therapeutic satisfaction was 92.2% (107/116). Kaplan-Meier analysis revealed the cumulative rates for subjective cure of stress incontinence and freedom from urge symptoms at 1, 3, and 5 years were 95.7%, 90.7%, and 76.5%, and 92.7%, 90.4%, and 90.4%, respectively. Four women (2.6%) had prolonged voiding trials greater than 1 week. Urge symptoms occurred in 12 women (7.7%), and de novo detrusor overactivity occurred in 6 (3.9%). Demographic factors, concomitant surgical procedures, and perioperative morphologic variables did not correlate with prolonged voiding trials or postoperative urge symptoms.

CONCLUSIONS

Our standardized surgical technique may help to avoid overelevation and associated postoperative complications without compromising the success of laparoscopic colposuspension for primary urodynamic stress incontinence.

The very obese woman and the very old woman: tension-free vaginal tape for the treatment of stress urinary incontinence

A mailed questionnaire was sent to 970 consecutive women who underwent a tension-free vaginal tape (TVT) procedure between 1995 and 2001 at the Department of Obstetrics and Gynecology in Falun Hospital. Seven hundred and sixty (78.4%) women responded. The outcome was compared between women older than 75 years (n=113) and younger women, and between women with a body mass index (BMI) above 35 (n=61) and those who had normal weight. Mean follow-up was 5.7 years. Thirty-six elderly women and one of the obese women were deceased at the long-term follow-up. TVT was easy to perform and was a safe procedure for women in all groups. There was a sharp decrease in cure rate of any urinary incontinence problems among women aged 75 years or more (55.7%), as compared to those who were younger (79.7%). The cure rate moderately decreased from BMI groups 19-24 to 30-34. BMI > or =35 seemed to be the best explanatory cutoff level. The overall cure rate in women of normal weight was 81.2%, as compared to 52.1% in the very obese. The cure rate for urinary incontinence with tension-free vaginal tape in women above 75 years of age and in women with a BMI above 35 was acceptable, but lower as compared to the remaining study population.

Urethral hypermobility after anti-incontinence surgery - a prognostic indicator?

The aim of this study was to define the concept of hypermobility of the bladder neck and determine its effects on the cure rate and postoperative complications in patients undergoing colposuspension. In a retrospective study, 310 patients who underwent primary colposuspension for urodynamically proven genuine stress urinary incontinence were assessed by introital ultrasound before surgery and during follow-up for up to 48 months postoperatively. A total of 152 women completed 48 months of follow-up. Mobility of the bladder neck during straining was described as linear dorsocaudal movement (LDM) with LDM >15 mm being defined as hypermobility. The overall objective cure rate was 90.0% at 6-month follow-up vs 76.8% at 48-month follow-up (Kaplan-Meier estimators). Urge symptoms occurred in 12.6% (39/310) of the women and de novo urge incontinence in 2.3% (7/310). Bladder neck hypermobility was significantly reduced after anti-incontinence surgery, from 67.1% (208/310) before surgery to 5.5% (17/310) immediately after surgery (P<0.0001). Postoperative hypermobility was associated with a higher recurrence rate. In the hypermobility group, 52.9 and 34.0% of the patients were continent for up to 6 and 48 months, respectively, as opposed to 92.2 and 79.2% in the group without hypermobility (P<0.0001). Women with postoperative hypermobility had a 3.2-fold higher risk of recurrence within 48 months. Bladder neck hypermobility after surgery was also associated with postoperative voiding difficulty (P=0.0278). Patients in whom hypermobility of the bladder neck diagnosed before surgery persists after colposuspension have a higher risk of recurrence and are more likely to develop postoperative complications than those without this hypermobility.

Urinary retention following tension-free vaginal tape successfully treated by sacral neuromodulation

Postoperative urinary retention following anti-incontinence surgery has traditionally been thought to be due to overcorrection. There is increasing evidence, however, that a neurogenic component may also play a significant role. This is a case report of a 72-year-old woman who developed delayed partial urinary retention following a tension-free vaginal tape which resolved with initial sacral neuromodulation.

The development of pelvic organ prolapse after colposuspension: a prospective, long-term follow-up study on the prevalence and predisposing factors

The objectives of this prospective study were to determine the prevalence of pelvic organ prolapse (POP) after colposuspension and to investigate possible preoperative and operative risk factors. Seventy-seven women who underwent colposuspension between 1996 and 1997 were investigated. POP was assessed before colposuspension using the pelvic organ prolapse quantification system (POPQ). Women were reassessed at one and seven to eight years (or when referred with symptomatic POP). By seven to eight years, of the 77 women, 29 (38%) had developed symptomatic prolapse, 29 (38%) had asymptomatic prolapse, 7 (9%) had no symptoms and no prolapse, and 12 (15%) could not be assessed. POP at one year was significantly associated with the presence of posterior vaginal descent before colposuspension (odds ratio 3.07, 95% CI 1.10-8.60, p = 0.03). No variable reached statistical significance by eight years postcolposuspension. In conclusion, this is the first study to assess POP prospectively using a validated method before and after colposuspension. The results add support to the view that there is an association between colposuspension and the development of symptomatic POP (requiring surgery).

Long-term efficacy of Burch colposuspension: a 14-year follow-up study

BACKGROUND

The aim of this study is to investigate the long-term efficacy of the Burch colposuspension and to analyze the risk factors for an unsuccessful outcome at the long-term follow-up of more than 10 years.

METHODS

Data from patient files of 190 women on whom surgery was performed with Burch colposuspension during 1980-1988 and answers from a postal questionnaire performed median 14 years after the Burch colposuspension concerning the lower urinary tract function were retrieved retrospectively.

RESULTS

Subjectively significant urinary incontinence was experienced by 56% of the responders. Only 19% reported no incontinence episodes. Among the significant urinary incontinent women, symptoms of stress incontinence occurred in 26%, urge incontinence in 17%, and mixed incontinence in 42%. In 15%, the symptom of incontinence was atypical and could not be categorized. Feeling of incomplete bladder emptying post-operatively and pre-operative obesity was associated with the long-term outcome of Burch colposuspension (odds ratio (OR) = 2.33; 95% confidence interval (95% CI) = 1.20-4.54 and OR = 2.52; 95% CI = 1.10-5.77, respectively). Age, obesity at the long-term follow-up or having had surgery for fecal incontinence, genital prolapse, or hysterectomy were not significantly associated with the outcome of the Burch colposuspension.

CONCLUSIONS

The subjective cure rate decreases with time after Burch colposuspension. Lower urinary tract symptoms are very common at the long-term after Burch colposuspension with more than three-fourth experiencing these. Feeling of incomplete bladder emptying post-operatively and pre-operative obesity seem to be long-term risk factors for an adverse outcome. A standard definition for follow-up periods is suggested.

Intra-operative introital ultrasound in Burch colposuspension reduces post-operative complications

OBJECTIVE

To determine the effect of intra-operative monitoring of bladder neck elevation on cure rate and post-operative complications in patients undergoing colposuspension.

DESIGN

Prospective, observational study.

SETTING

Urogynaecology units, university hospitals.

POPULATION

Ninety women operated on for genuine stress urinary incontinence.

METHODS

The topography of the bladder neck and proximal urethra was assessed with pre-, intra- and post-operative introital ultrasound. These measurements were repeated during follow up for up to 48 months after surgery. Burch colposuspension of the bladder neck was performed under intra-operative introital ultrasound control, with reference to the patients' individual pre-operative ultrasound, to achieve a vertical height correction of 1-10 mm.

MAIN OUTCOME MEASURES

Mid-term surgical outcome and post-operative complications.

RESULTS

Ninety patients underwent colposuspension and 50 (56%) completed 48 months of follow up; 85 women (94%) were objectively continent at 12-month follow up and 42 of 50 (82%) at 48-month follow up. Surgical elevation of the bladder neck resulted in a median intra-operative elevation of 9 mm (7 mm at 48 months). All post-operative measurements demonstrated a significant decrease in linear dorsocaudal movement of the bladder neck during straining (P < 0.001). Funnelling and hypermobility were still decreased 48 months after incontinence surgery (P < 0.001). Voiding difficulty and urgency were uncommon and associated with evidence of funnelling and hypermobility.

CONCLUSION

Intra-operative introital ultrasound standardises Burch colposuspension and thus might help to avoid overelevation and associated post-operative complications such as voiding difficulties and de novo urge incontinence without compromising the success of the operation.

Outcome of the use of tension-free vaginal tape in women with mixed urinary incontinence, previous failed surgery, or low valsalva pressure

AIM

To assess the safety and efficacy of the use of tension-free vaginal tape (TVT) for the treatment of stress urinary incontinence (SUI) in women with mixed incontinence, previous failed incontinence surgery or low valsalva leak point pressure (VLPP).

METHODS

Six hundred and fifty-eight women with SUI underwent the TVT procedure. These included women with mixed stress and urge incontinence (n=128), previous surgery for SUI (n=118), low VLPP (n=80), and those over 70 years old (n=68). The procedure was carried out under spinal anesthetic and operative and immediate postoperative data was collected for all women. Six-month follow-up data was available on 454 women, with the first 300 women completing a quality of life (QOL) questionnaire before and after surgery.

RESULTS

The overall subjective cure rate at 6 months was 91%, with 8% of women reporting significant (>50%) improvement in their symptoms. Subgroups with a body mass index > 30, age > 70 years, coexisting instability, previous failed surgery, and low VLPP showed cure rates of 81-89%. QOL improvements for all groups were highly significant. Significant complications included voiding difficulties in 29 women (4.4%), retropubic hematomas in four (0.6%), and thromboembolic episodes in three (0.5%).

CONCLUSION

The simplicity and high efficacy of the TVT makes it the first choice for the treatment of women with SUI, including those with more complex problems or coexisting risk factors.

Determination of bladder neck position by intraoperative introital ultrasound in colposuspension: outcome at 6-month follow-up

OBJECTIVE

To determine whether open colposuspension modified by intraoperative ultrasound to prevent overcorrection is a safe and effective procedure.

METHODS

Ninety women operated on for urodynamically proven genuine stress urinary incontinence underwent intraoperative introital ultrasound in a prospective observational clinical study. The positions of the bladder neck and proximal urethra were assessed by determining the parameters height (H), distance (D) and the urethrovesical angle (beta) perioperatively and for up to 6 months postoperatively. Colposuspension of the bladder neck was performed with a vertical height correction, DeltaH (resting H(intraop) - resting H(preop)) of 1 to 10 mm. Bladder neck positions were determined on an individual basis by introital ultrasound before, during and after surgery.

RESULTS

Surgical elevation of the bladder neck (median height correction, DeltaH 4 mm) resulted in a median intraoperative elevation of 9 mm (6 months: 8 mm). All postoperative measurements showed a significant reduction of the median linear movement of the bladder neck during straining (P < 0.0001). Anti-incontinence surgery resulted in a significant reduction of funneling and hypermobility 6 months after surgery (P < 0.0001). At 6-month follow-up, 94% (85/90) of the women were continent. Evaluation immediately after surgery showed voiding difficulties and urge symptoms in 9% (8/90) of the patients each and de novo urge incontinence in 1% (1/90).

CONCLUSIONS

Intraoperative introital ultrasound can help to optimize the colposuspension procedure. Ultrasonographic measurement of height H allows for objectively assessing the surgical procedure and can reduce postoperative complications by preventing excessive correction.

Introital ultrasound of the lower genital tract before and after colposuspension: a 4-year objective follow-up

OBJECTIVE

To assess the topography of the bladder neck by introital ultrasound before and after open colposuspension.

METHODS

Three hundred and ten women with urodynamically proven stress urinary incontinence were included in this long-term study to investigate the position and function of the bladder neck at rest and during straining. Height (H), distance (D), and urethrovesical angle of the bladder neck (beta) were measured by means of preoperative and postoperative introital ultrasound. Women were followed up; 152 of them (49%) completed 48 months of follow-up.

RESULTS

At the 6-month follow-up examination, 90.0% of the women were continent (279/310), 3.5% (11/310) showed voiding difficulties, 3.5% (11/310) had urgency, and 1.6% (5/310) had developed de novo urge incontinence. At the 48-month follow-up, 76.8% of the patients were still continent. All postoperative measurements yielded significantly lower values for angle beta at rest and during straining compared with the preoperative results (P < 0.0001). The median linear movement of the bladder neck during straining decreased from 18.0 mm before surgery to 6.4 mm at the 48-month follow-up (P < 0.0001). The median level of ventrocranial elevation of the vesicourethral junction was 14.3 mm immediately after surgery, 9.9 mm after 6 months and 6.6 mm after 48 months. The degree of surgical bladder-neck elevation was associated with postoperative urgency/de novo urge incontinence (P < 0.0001) and voiding difficulty (P < 0.0001).

CONCLUSIONS

The colposuspension procedure reduces angle beta at rest and during straining, restricts linear movement with straining, and elevates the bladder neck. Perioperative introital ultrasound improves understanding of this surgical procedure and might help to prevent postoperative complications.

Effects of Burch colposuspension on the relative positions of the bladder neck to the levator ani muscle: An observational study that used magnetic resonance imaging

OBJECTIVE

The purpose of this study was to use magnetic resonance imaging to observe the changes of the position of the levator ani muscle relative to the bladder neck after Burch colposuspension.

STUDY DESIGN

Women with urodynamic stress incontinence underwent Burch colposuspension. Magnetic resonance imaging was performed 1 week before surgery and 1 year after the operation. The levator ani muscle and the bladder neck were imaged in the parasagittal and sagittal planes, respectively; and their position was measured in relation to the pubococcygeal line. The reproducibility of these measures was investigated. Changes that occurred to levator ani muscle anatomy after the operation were correlated to surgical success. Surgical outcome was assessed objectively at 1 year with urodynamic testing.

RESULTS

Of the 73 women who were studied, only 28 women were included in the study because the medial edge of the levator ani was visible clearly on a parasagittal magnetic resonance image. At the 1-year follow-up, the objective cure rate was 86%. Measures of bladder neck and levator ani position in relation to the pubococcygeal line were found to be reproducible. Burch colposuspension produces a significant elevation of the levator ani, with a reduced distance between the bladder neck and the levator ani muscle. Surgical success was associated significantly with a shorter distance between bladder neck and levator ani muscle.

CONCLUSION

The anatomy of the levator ani muscle is changed by colposuspension. The apposition of the levator ani muscle to the bladder neck may play a role in the restoration of continence.

Colposacrosuspension for severe genital prolapse

OBJECTIVE

A descriptive study of 140 patients with severe genital prolapse managed by colposacrosuspension with mesh interposition and a modified Burch colposuspension.

METHODS

A laparotomy was performed with mobilization of the rectum and exploration of the rectovaginal septum. Vaginally, a longitudinal incision was made in the posterior vaginal wall which was completely separated from the rectum. A perineal repair was done, whereafter a strip of Vypro (Johnson & Johnson, Brussels, Belgium) mesh was inserted from the perineum to the sacrum at S1. It was fixated to the perineum and vagina while the rectum was elevated and attached to the mesh. Where a perineal repair was deemed not necessary, the mesh extended from the mid-vagina to the sacrum. A second mesh strip was placed anteriorly of the vagina, covering the upper third of the vagina and extending to the sacrum. After closure of the pelvic peritoneum, covering the mesh, a modified Burch colposuspension was performed. Follow-up was done at 6 weeks, 6 months and yearly thereafter.

RESULTS

The median age was 61 years with a median parity of 3. All patients presented with grade 2 (extending to the vaginal introitus) or 3 (outside the vaginal introitus) prolapse. Approximately one-third had urinary incontinence and a similar proportion complained of difficulty in defecation. All the patients underwent colposacrosuspension with the mesh extending to the perineum in 67% of the patients. A Burch colposuspension was performed in 79% of the women. Postoperatively, 97% of the patients were followed for 1-29 months with a median of 8.5 months (mean 10.2 months). Recurrent prolapse, grade 2 or 3, developed in 11 patients (8%) and 17 patients (12%) developed urinary incontinence, needing a transvaginal tape procedure. Removal of the mesh was necessary in one patient (0.7%).

CONCLUSION

Colposacrosuspension for severe genital prolapse delivered satisfactory short-term results. It is, however, a major surgical procedure and elderly or compromised patients may require less invasive procedures.