Editorial comment

Abstract

Klutke et al. present their evaluation of 132 patients who underwent corrective surgery for genuine stress urinary incontinence. All patients were urodynamically evaluated before surgery and 1 year postoperatively. They compared the results of the Burch retropubic urethropexy, anterior vaginal repair, and the modified Pereyra procedure. Postoperative urodynamic evaluation recorded voiding pressures and flow rates. It is a commendable effort on their part to give us some insight into the possible mechanism of function of the surgical interventions used to correct genuine urinary incontinence. Their success rate was 87% with the Burch retropubic suspension, 70% with vaginal suspension, and 69% with anterior vaginal repair 1 year postoperatively. They came to the conclusion that the Burch retropubic suspension gave the highest success rate, but also had the highest percentage of patients with obstructed voiding patterns. They also came to the conclusion that this was a desirable outcome, assuming this success rate is tied to the obstructed outcome. This conclusion is really a matter of the interpretation of their findings. They stated that of their group of 76 patients who underwent successful retropubic suspension, 9 of them had equivocal voiding patterns preoperatively. One year postoperatively, they had 8 patients who had obstructed patterns and another 20 patients who were in the equivocal obstructed pattern. It seems as if those 8 patients with definite obstructed voiding pattern postoperatively were among the original 9 patients who had an equivocal obstructed pattern preoperatively. Again, looking carefully at their charts, the 20 patients who were in the equivocal obstructed group postoperatively were really voiding with pressures no higher than 45 to 50 cm H2O, and two thirds of them were voiding with pressures of 40 cm H2O or less. Definitely, most of them clearly were nonobstructed, as we all agree that voiding pressures up to 40 cm H2O are acceptable, and if the retropubic suspension improves the outlet resistance, then that is expected. That is also true in their patients with failure who did not show any change in voiding pressure. This is not uncommon in our preoperative evaluation: patients, especially those with a severe degree of urinary incontinence, would void with no rise in intravesical pressure yet with an adequate flow rate. Those patients postoperatively are definitely going to void with some rise in intravesical pressure if they were cured, and that is the outcome of improving outlet resistance.