Transobturator midurethral sling: surgical technique and outcomes

Transobturator tape midurethral sling is the latest method for treatment of female urinary incont-inence. The authors describe their technique via an outside-in approach under local anesthetic to ensure proper tightening of the sling. Placement through the obturator foramen is straightforward and virtually eliminates risk of serious intraoperative major organ or vessel injury. Although outcome data lack the long-term follow-up of colposuspension and tension-free vaginal tape, similar short-term continence results are encouraging with less associated operative morbidity.

Effect of laparoscopic hysterectomy on the vascularization of the lower urinary tract

INTRODUCTION

The aim of this prospective study was to evaluate the changes in the vascularization of the lower urinary tract following laparoscopic hysterectomy (LH).

METHODS

Seventy women undergoing LH not under the indication of a uterine myoma were included. All subjects underwent urinalysis, pelvic examination, and introital color Doppler ultrasonography and completed a urinary questionnaire before and 6 months after LH. One-hour pad tests and urodynamic studies were performed in clinically incontinent women pre- and postoperatively.

RESULTS

Evaluation of the Doppler velocimetric parameters of bladder neck and periurethral vessels before and after LH, including number of vessels, pulsatility index, systolic peak, and minimum diastole, revealed no statistically significant differences (p > 0.05). In addition, the prevalence of stress urinary incontinence (SUI) decreased significantly from 37.1% (n = 26) preoperatively to 17.1% (n = 12) postoperatively (p < 0.01). A total of 19 patients reported no further SUI following LH. Their urinary leakages on the pad tests had all <10 g before surgery. When we analyzed the data of the women reporting no further SUI (n = 19) and de novo SUI (n = 5) following LH, the changes in the pulsatility index also showed no significant difference from the pre-LH values (p > 0.05).

CONCLUSIONS

The results of our study suggest that LH has little impact on the blood flow of bladder neck and urethra. Although some women experienced relief of the symptoms of mild or de novo SUI after LH, this being unrelated to changes in the vascularization of the lower urinary tract.

A randomized comparative study of the effects of oral and topical estrogen therapy on the lower urinary tract of hysterectomized postmenopausal women

OBJECTIVE

To compare the effects of oral and vaginal estrogen therapy (ET) on the lower urinary tract in postmenopausal women with prior hysterectomy.

DESIGN

Randomized, prospective study.

SETTING

Tertiary teaching hospital.

PATIENT(S)

Fifty-seven hysterectomized, postmenopausal women.

INTERVENTION(S)

Patients were randomized to receive either oral (0.625 mg of conjugated equine E per tablet; n = 27) or topical (0.625 mg conjugated equine E per 1 g vaginal cream; n = 30) E, administered once daily.

MAIN OUTCOME MEASURE(S)

All subjects had E2 measurements, urinalysis, pelvic examination, introital color Doppler ultrasonographies, and personal interviews with the Bristol Female Lower Urinary Tract Symptoms Questionnaires before and 3 months after ET.

RESULT(S)

A higher serum level of E2 was noted in the oral group compared with the topical group after ET. The post-ET pulsatility index of periurethral vessels and bladder neck revealed statistically significant decreases in both groups. The incidences of urinary frequency and nocturia were significantly decreased after 3 months of ET in both groups. Changes in the incidence of other symptoms, including stress incontinence and urge incontinence, were not statistically significant. However, subjective improvement of stress incontinence was found in 72.7% of the oral group and 60% of the topical group.

CONCLUSION(S)

The results suggest that ET alone, by an oral or vaginal route, could increase the blood flow around the bladder neck and mid-urethra and relieve the symptoms of overactive bladder and stress incontinence in postmenopausal women with prior hysterectomy. In addition, vaginal preparations are as effective as systemic therapy at the lower serum level of E2.

Method for evaluation of the urethral closure mechanism in women during standardised changes of cross-sectional area

A method for evaluation of the closure mechanism in the female urethra during forced opening has been developed and tested. The cross-sectional area (CA) of the tube and the intraluminal pressure were measured simultaneously by a specially designed balloon catheter. The method enables induction of standardised changes of CA at different rates. Applied in the female urethra the induction results in a distinct pressure response which increases with increasing rate of change of CA as well as size of the induction. The inflation of the balloon simulates a forced opening of the urethra and hence leakage. Obviously, urinary incontinence takes place at forced opening of the urethra. Accordingly, this novel method can give important information on the pathophysiology of stress urinary incontinence in particular and the physiology of sphincter functions in general.

Variations in urethral and bladder pressure during stress episodes in healthy women

Pressure variations in the urethra and bladder during stress episodes and their time separations were investigated in 30 healthy female volunteers. The pressure was measured by means of a double microtip transducer catheter with the distal sensor in the bladder and the proximal sensor at the bladder neck, the mid-urethra and the distal urethra. In advance of the pressure spike during cough a pressure rise was demonstrated in the bladder and at all 3 sites of measurement in the urethra. The urethral pressure increments preceding and following the pressure spike were statistically significantly higher in the mid-urethra than the corresponding bladder pressures. This active urethral pressure generation in the mid-urethra and distal urethra was initiated 200 ms before the bladder pressure began to rise. The pressure in the urethral high pressure zone was higher than the bladder pressure in all cases. Passive pressure transmission to the urethral high pressure zone can take place only insignificantly due to a continuous higher pressure inside the urethra than in the bladder and due to the location of the high pressure zone in the demarcation of the abdominal cavity. It was concluded that the urethral pressure rise in the high pressure zone during stress episodes is mainly generated actively by intra- and/or peri-urethral structures.