Anatomic Incontinence Research Articles

A Study of Clinical Predictors Associated With Intrinsic Sphincter Deficiency in Women With Stress Urinary Incontinence.

PurposeRecently, intrinsic sphincter deficiency (ISD) has been identified as one important factor in the outcome of stress urinary incontinence (SUI) related surgery. Clinical factors that can predict ISD are uncommon. The aim of this study was to determine predictive clinical factors for ISD in female patients with SUI.MethodsThe patients were classified into 3 groups according to the value of Valsalva leak point pressure (VLPP)>90 cm H2O (anatomical incontinence, AI), between 61 and 90 cm H2O (equivocal, EV), and <60 cm H2O (ISD). All groups underwent a full examination, history evaluation, physical examination, uroflowmetry, and complete urodynamic study. Univariate analysis was performed by chi-square or t-test for categorical variables, respectively. A multivariate study was performed by Pearson correlation analysis in order to get clinical predictors of VLPP<60 cm H2O. Statistical significance was set at P<0.05.ResultsThere were 3 groups with a total of 189 patients: 56 patients (AI, 29.7%), 64 patients (EV, 33.8%), and 69 patients (ISD, 36.5%). The univariate analysis revealed a significant difference associated with maximal urethral closing pressure (P=0.03) and Stamey classification (P=0.006) between ISD and AI. The more severe the urinary symptom grade, the higher the frequency of ISD. However, the multivariate analysis showed the independent predictor of ISD is only present in grades II and III symptoms in the Stamey classification (P=0.001).ConclusionsIt was found that the more severe the symptoms of urinary incontinence, the higher the possibility of ISD. In other words, the degree of urinary incontinence was found to be one relevant clinical factor in predicting ISD. This finding may help in evaluating and identifying the appropriate surgical technique for EV. Currently, absolute cutoff value to diagnose ISD has not yet been determined. More research is needed to identify clinical factors that can predict ISD.

Valsalva leak point pressure-associated Q-tip angle and simple female stress urinary incontinence symptoms.

To clarify the association between clinically defined simple stress urinary incontinence (SUI) symptoms and urodynamic SUI, we examined the relationship between Valsalva leak point pressure (VLPP) as measured by the Q-tip test and Stamey grade in simple female SUI. Two hundred grade I or II female SUI patients with SUI symptom were examined by reviewing medical history; physical examination; urethral mobility as assessed by Q-tip test; stress test; and cystometry, including VLPP measurement. On the basis of the VLPP, patients were classified into urethral hypermobility [UH, subdivided into anatomical incontinence (AI) and equivocal incontinence (EI)] or intrinsic sphincter deficiency groups for analysis of the relationship between VLPP and Stamey grade and Q-tip angle. Seventy-eight patients were included, and the mean patient age was 54 ± 7.5 years, mean SUI symptom duration 2.8 years (range 0.5-6 years), mean VLPP 103.6 ± 18.4 cm H2O, and mean Q-tip angle 28.6° ± 7.2°. Fifty-three patients were categorized as Stamey grade I, 25 as Stamey grade II, 51 as AI, and 27 as EI. VLPP was found to be negatively correlated with Q-tip angle (Rs = -0.798, Y = -0.313X + 60.95, P < 0.001), and classifications of VLPP and Stamey grade have positive correlation (χ (2) = 4.9130, P = 0.0267). In simple female SUI, VLPP is associated with the Q-tip angle and Stamey grade, which may help to reduce some of urodynamic items.

Mixed urinary incontinence—time to uncouple urgency from stress?

"Mixed incontinence" is defined as a combination of stress and urge symptoms. Over time, it has morphed into a single entity, encompassing etiology and treatment. My perspectives are: (a) Stress incontinence (SI) and urge incontinence (UI) are different symptoms with often different anatomical causation and so should be treated separately; (b) It is illogical to group urgency with SI. Urgency may also be associated with frequency, nocturia, abnormal emptying and pelvic pain in patients with no SI ("posterior fornix syndrome"); and (c) There is growing evidence that urgency may be cured by surgical correction of a cystocele and/or apical prolapse in up to 80% of patients who do not have SI. In this anatomical context, sensory urgency, urge incontinence and urodynamic detrusor overactivity may all be hypothesized as different manifestations of a prematurely activated micturition reflex, caused by a lax vagina's inability to support bladder base stretch receptors. This statement can be tested with a simple clinical test, "simulated operations", whereby digitally supporting in turn the midurethra, bladder base and posterior vaginal fornix may cause a significant decrease in the urgency felt by the patient. The term "mixed incontinence" is only valid if both symptoms are caused by a lax pubourethral ligament. However, urgency may be caused by laxity in other parts of the vagina. Regarding stress and urge as separate entities will remove the confusion resulting from this definition, creating new directions for science and therapy.

Clinical Factors Associated with Low Valsalva Leak Point Pressure Among Women with Stress Urinary Incontinence

PurposeThe purpose of this study is to determine the predictive factors that are associated with stress urinary incontinence (SUI) due to intrinsic sphincter deficiency (ISD) in women.MethodsBetween January 2008 and December 2009, 185 women with urodynamically proven SUI were included in this study and retrospectively reviewed the medical record. Preoperative SUI symptoms were classified by Stamey grade. Valsalva leak point pressure (VLPP) determination series was repeated two times in each subject after finishing one series of VLPP measurement. The patients were classified into three groups according to VLPP; 1) ISD: VLPP≤60 cm H2O, 2) equivocal: 60<VLPP≤90 cm H2O, 3) anatomical incontinence (AI): VLPP>90 cm H2O. Chi-square test and multivariate (logistic regression test) analyses were performed to determine the factors associated with ISD.ResultsThe mean patient age was 54.2 years (range, 44.5 to 68.4 years). Seventy-one women (38.3%) were in the ISD group and 70 (37.8%) in the AI group. The results of univariate and multivariate analyses found that women with ISD had a higher symptom grade than women with AI (P=0.001 and 0.0001, respectively). The number of patients in the ISD and AI group in accordance with the symptom grade were 7 (10%) and 44 (62%) in grade I, 50 (54%) and 23 (25%) in grade II, and 14 (63%) and 3 (14%) in grade III respectively. There was no correlation between VLPP and other clinical factors.ConclusionsHigh symptom grade was the only independent clinical factor that predicted the presence of ISD. This should be considered when counseling the patients with SUI.

Obstructive urodynamic findings in idiopathic detrusor overactivity

To investigate the obstructive findings urodynamically in idiopathic detrusor overactivity and compare them (maximum flow rate 'Q max' detrusor pressure at maximum flow 'PQ max') with control group. Cystometric evaluation and pressure flow studies were performed in 25 women with symptoms of idiopathic detrusor overactivity and control group comprised 40 women with anatomic incontinence without cystocele. Patients with pelvic floor prolapse, motor urgency and poor compliance were excluded from the study. Q max less than 15 ml/s and PQ max more than 40 cm water were accepted as obstruction. After cystometric evaluation, obstruction was found in 36% of patients with idiopathic detrusor overactivity and 15% in control group. The range of maximum flow rate and PQ max values were 2-43.7 ml/s (mean 14.47 +/- 10.22) and 10-143 cm water (mean 58.97 +/- 35.13) in idiopathic urge syndrome group. These values were 6.6-51.8 ml/s (mean 23.24 +/- 12.43) and 9.7-61 cm water (mean 25.56 +/- 12.43) respectively in control group. Q max and PQ max parameters were compared statistically between the two groups. Idiopathic detrusor overactivity group had lower mean Q max and higher mean PQ max values than control group (P < 0.001) Table 1. Obstruction percentage was found to be more in idiopathic detrusor overactivity group than the control group.

Complications of transvaginal silicone-coated polyester synthetic mesh sling

Objectives To report a premarket multicenter trial to test the feasibility of a transvaginal silicone-coated polyester synthetic mesh sling in women with anatomic incontinence. Methods Fifty-one patients in four centers underwent transvaginal placement of a silicone-coated polyester synthetic mesh sling (American Medical Systems) during an 8-month period. Of the 51 patients, 31 were part of a prospective institutional review board-approved feasibility trial in three centers funded by American Medical Systems (group 1) and 20 underwent implantation by a single surgeon and their data were retrospectively reviewed (group 2). The studies were done concomitantly, and all slings were fixed transvaginally with bone anchors. All patients in group 1 were followed up at 4 weeks, 6 months, and 1 year (as applicable) with repeat questionnaires, physical examinations, and pad tests. Results In group 1, 20 patients completed 6 months of follow-up. Ten patients (32%) required a second surgical procedure at an average of 183 days (range 68 to 343) postoperatively. Eight patients (26%) had vaginal extrusion of the mesh, one (3%) required sling lysis, and one (3%) required sling removal because of infection. In group 2, 8 patients (40%) underwent sling removal for vaginal extrusion at a mean of 160 days (range 83 to 214). Conclusions Transvaginally placed silicone-coated mesh slings used for the treatment of urinary incontinence demonstrated an unacceptably high vaginal extrusion rate in this study. Once identified, this study was immediately terminated, and this product was not marketed for this application in the United States.

New Approach to the Management of Stress Urinary Incontinence in Patients with Treatment Failure

Urinary incontinence affects about 40 million adults in the Western world. Many mechanical, behavioral, and surgical approaches have been used for its treatment. Many of the surgical techniques are successful, but about 50% of patients need re-treatment after 5 to 7 years. Although intraurethral plug-like devices could block the leak, they create a communication between the bladder and vulva, resulting in high rates of ascending urinary infections. To prevent this communication but block the bladder outlet while allowing it to open voluntarily, a new intravesical device was designed. The device could be inserted easily into the bladder of 35 patients and activated using a remote control. The use of a completely intravesical device for the management of anatomic incontinence is a novel approach. The results obtained in pilot studies showed that the device is effective in the management of stress incontinence in patients who were failures after surgery or who refused surgery.

Endoscopic silicone injection for female stress urinary incontinence due to intrinsic sphincter deficiency: impact of coexisting urethral mobility on treatment outcome

Objectives To evaluate periurethral silicone injection in the treatment of female stress urinary incontinence due to intrinsic sphincter deficiency (ISD) and assess whether coexisting urethral hypermobility has an impact on treatment outcome. Methods A total of 29 female patients with stress urinary incontinence underwent endoscopic periurethral silicone injection. Using abdominal leak point pressure measurement, ISD was shown preoperatively in all cases. In addition, urethral hypermobility was demonstrated in 14 cases by cotton-swab testing. Treatment outcome was assessed at 3 and 24 months by questionnaire and classified as cure, improvement, or failure. Results The morbidity of the procedure was minimal. The median follow-up was 29 months (range 24 to 36). For the entire group, the cure rate was 55% and 45% at 3 and 24 months, respectively. Depending on the existence of urethral hypermobility, the treatment outcome differed significantly. At 3 months, cure was achieved in 73% of the patients with pure ISD and in 36% with urethral hypermobility ( P = 0.04). At 24 months, 67% with pure ISD remained continent, but only 21% with urethral hypermobility ( P = 0.02). Conclusions In our experience, periurethral silicone injection was a safe treatment for female stress urinary incontinence and provided a moderately successful and durable therapeutic effect in those with sphincter deficiency and good anatomic support. Unsatisfactory results in those with both anatomic incontinence and sphincter deficiency highlight the need for careful preoperative assessment of urethral mobility to exclude such patients from injection therapy.

Pubovaginal slings: a review of the technical variables.

The pubovaginal sling, reintroduced in the late 1970s by Maguire and Blaivas, has become the gold standard for managing anatomic incontinence. Newer technology, materials, surgical techniques and even new theories on the mechanism of action are evolving to further reduce the morbidity of these procedures and improve patient satisfaction. In the following review, we will highlight some of the exciting advances we have witnessed over the last year and try to put them into perspective for the reader.

COMPLICATIONS AND INITIAL CONTINENCE RATES AFTER A REPEAT PUBOVAGINAL SLING PROCEDURE FOR RECURRENT STRESS URINARY INCONTINENCE

No AccessJournal of UrologyCLINICAL UROLOGY: Female Urology1 Jun 2001COMPLICATIONS AND INITIAL CONTINENCE RATES AFTER A REPEAT PUBOVAGINAL SLING PROCEDURE FOR RECURRENT STRESS URINARY INCONTINENCE STEVEN P. PETROU and IGOR FRANK STEVEN P. PETROUSTEVEN P. PETROU Financial and/or other relationship with Bard, American Medical Systems, Upjohn Pharmacia and Timm Medical. More articles by this author and IGOR FRANKIGOR FRANK More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(05)66257-XAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract Purpose: We evaluated the safety and efficacy of repeat pubovaginal sling procedures for recurrent stress urinary incontinence. Materials and Methods: We retrospectively reviewed the records of 14 patients in whom an initial suburethral sling procedure failed, who then underwent a repeat pubovaginal sling procedure for recurrent stress urinary incontinence at our institution and who were available for followup evaluation. Mean followup after re-operation was 17 months (range 5 to 41). The response to surgery was assessed using the Blaivas-Groutz anti-incontinence surgery response score. Results: There were no intraoperative complications. Mean blood loss was 155 cc (range 50 to 750) and average operative time was 101 minutes (range 80 to 145). Long-term urinary retention developed in 1 of the 14 patients (7%). There were no deaths. Two patients (14%) had postoperative complications, including a pelvic abscess and osteomyelitis pubis in 1 each. Based on the Blaivas-Groutz anti-incontinence scale 7 of the 14 patients (50%) were cured, 1 (7%) had a good response, 4 (29%) had a fair response, 2 (14%) had a poor response and none had treatment failure. Subjectively 12 of the 14 women (86%) considered themselves cured or improved and 2 (14%) considered the operation to have failed. Conclusions: Our data imply that a repeat pubovaginal sling procedure after an initial failed operation is associated with low complication and acceptable continence rates. It should be considered a reasonable treatment option in select women with recurrent stress urinary incontinence. References 1 : Pubovaginal sling procedure for stress incontinence. J Urol1978; 119: 82. Link, Google Scholar 2 : Pubovaginal fascial sling for all types of stress urinary incontinence: long-term analysis. J Urol1998; 160: 1312. Link, Google Scholar 3 : Favorable outcome of pubovaginal slings for geriatric women with stress incontinence. J Urol1997; 157: 125. Link, Google Scholar 4 : Expanded indications for the pubovaginal sling: treatment of type 2 or 3 stress incontinence. J Urol1996; 156: 1620. Link, Google Scholar 5 : An assessment of the surgical outcome and urodynamic effects of the pubovaginal sling for stress incontinence and the associated urge syndrome. J Urol1999; 162: 135. Link, Google Scholar 6 : Our experience with pubovaginal slings in patients with stress urinary incontinence. J Urol1998; 159: 1195. Link, Google Scholar 7 : A simplified urinary incontinence score for the evaluation of treatment outcomes. Neurourol Urodyn2000; 19: 127. Google Scholar 8 : Results of pubovaginal sling for the treatment of intrinsic sphincter deficiency determined by questionnaire analysis. J Urol1997; 158: 1738. Link, Google Scholar 9 : The effect of study methodology on reported success rates of the modified Pereyra bladder neck suspension. J Urol1995; 154: 1732. Link, Google Scholar 10 : A follow up of silastic sling for genuine stress incontinence. Br J Obstet Gynaecol1995; 102: 143. Google Scholar 11 : Vaginal wall sling for anatomical incontinence and intrinsic sphincter dysfunction: efficacy and outcome analysis. J Urol1996; 156: 166. Link, Google Scholar From the Department of Urology, Mayo Clinic, Jacksonville, Florida© 2001 by American Urological Association, Inc.FiguresReferencesRelatedDetailsCited byRutman M, Deng D, Shah S, Raz S and Rodríguez L (2018) Spiral Sling Salvage Anti-Incontinence Surgery in Female Patients With a Nonfunctional Urethra: Technique and Initial ResultsJournal of Urology, VOL. 175, NO. 5, (1794-1799), Online publication date: 1-May-2006.CHOE J (2018) Suprapubic Sling Adjustment: Minimally Invasive Method of Curing Recurrent Stress Incontinence After Sling SurgeryJournal of Urology, VOL. 168, NO. 5, (2059-2062), Online publication date: 1-Nov-2002. Volume 165Issue 6 Part 1June 2001Page: 1979-1981 Advertisement Copyright & Permissions© 2001 by American Urological Association, Inc.Keywordsurinary incontinence, stressurethrareoperationMetricsAuthor Information STEVEN P. PETROU Financial and/or other relationship with Bard, American Medical Systems, Upjohn Pharmacia and Timm Medical. More articles by this author IGOR FRANK More articles by this author Expand All Advertisement PDF downloadLoading ...

Anterior Vaginal Wall Sling for Female Stress Urinary Incontinence

Background: The purpose of this study was to determine the efficacy and safety of the anterior vaginal wall sling in the management of women with stress urinary incontinence. Materials and Methods: From January 1998 to December 1999, 42 patients(31 with genuine stress urinary incontinence and 11 with mixed urinary incontinence, 38 with anatomical incontinence and 4 with intrinsic sphincteric deficiency) underwent anterior vaginal wall sling at Yeungnam University Hospital were studied retrospectively. The mean age was 49.3 years(ranging from 34 to 66 years of age) and the mean follow-up period was 29.4 months(ranging from 16 to 40 months). Intra- and postoperative complication. success rate and patient's satisfaction were evaluated. Results: The mean operation time was 79 minutes(ranging from 65 to 124 minutes) and the mean hospital stay was 5.1 days(ranging from 4 to 10 days). Mean postoperative Foley catheter drainage was 2.1 days(ranging from 1 to 5 days). As a complication. bladder perforation occurred in one patient(2.4%). residual urine sensation developed in seven patients(16.7%), and suprapubic pain was complained in five patients(11.9%), which improved gradually. Vaginal epithelial inclusion cyst occurred in one patient(2.4%) at postoperative 31 months. Four(9.4%) patients with de novo instability were improved by anticholinergics medication. The success rate was 92.9% and 38 patients(90.5%) were satisfied with this procedure. Conclusion: We consider that the anterior vaginal wall sling to be a safe and effective surgical procedure for the treatment of female stress urinary incontinence, but a longer follow-up is necessary to determine long term effect.

PROSPECTIVE ANALYSIS OF 373 CONSECUTIVE WOMEN WITH STRESS URINARY INCONTINENCE TREATED WITH A VAGINAL WALL SLING: THE COLUMBIA-CORNELL UNIVERSITY EXPERIENCE

We compare the efficacy and morbidity of 373 consecutive women who underwent a vaginal wall sling for stress urinary incontinence due either to anatomical incontinence or intrinsic sphincter deficiency. To our knowledge this series is the largest prospective database on surgical management of stress urinary incontinence in the urological literature. Preoperative evaluation included history, voiding diary, physical examination, cystoscopy, pad count and video urodynamic study. Outcome measures included postoperative presence of incontinence secondary to either stress and/or detrusor instability, number of pads used, complications, operating time, length of suprapubic catheterization, length of hospitalization and loss of work days. A total of 373 consecutive women 18 to 85 years old (mean age 55.7) were followed for a mean of 39.8 months. Of these patients 183 (49%) presented with anatomical incontinence and the remaining 190 (51%) had intrinsic sphincter deficiency. Preoperative detrusor instability was present in 60 (33%) patients with anatomical incontinence and 68 (36%) with intrinsic sphincter deficiency. Postoperatively, 14 patients (4%) had recurrent stress urinary incontinence. De novo detrusor instability and urge incontinence were noted in 30 women (8%), and was persistent in 22 (6%). There was no correlation between the diagnosis of anatomical incontinence or intrinsic sphincter deficiency and persistent stress urinary incontinence or detrusor instability. Daily pad use was decreased from 4.3 to 0.5 and from 4.6 to 0.4, respectively, for patients with anatomical incontinence and intrinsic sphincter deficiency. Operating time, catheter duration, length of hospital stay and days lost from work for patients with anatomical incontinence (33.3 +/- 14.3 minutes, 4.7 +/- 1.1 days, 0.9 +/- 0.7 days and 11.3 +/- 2.9 days, respectively) were similar to patients with intrinsic sphincter deficiency (38.4 +/- 17.8, 4.6 +/- 0.9, 1.1 +/- 0.7, 12.4 +/- 4.7). The most common complications were urinary tract infection (3%), wound infection (4%) and pelvic organ prolapse (7%). The results of this large database suggest that the vaginal wall sling is effective for the management of stress urinary incontinence. Efficacy, morbidity and reduced hospitalization time were similar for patients with either anatomical incontinence or intrinsic sphincter deficiency and independent of surgeon experience.

Modified Pereyra bladder neck suspension in patients with intrinsic sphincter deficiency and bladder neck hypermobility: patient satisfaction with a mean follow-up of 4 years

Objectives. To determine the long-term success rate for the modified Pereyra bladder neck suspension and to identify preoperative characteristics that create differences in surgical outcome. We attempted retrospectively to separate those patients with what we now recognize was significant intrinsic sphincter deficiency (ISD) before routine use of Valsalva leak point pressures (VLPPs) was available. Methods. The charts and videourodynamic reports of 208 patients who underwent a modified Pereyra bladder neck suspension from June 1988 to June 1996 were reviewed, and survey questionnaires were mailed to all patients. All videourodynamic study reports and charts were reviewed to identify those with what we now recognize was significant ISD and compare them with a group that we believed had more pure descent problems. Results. A total of 135 patients or 65% of the population responded. The mean time after surgery was 4.14 years. At the follow-up survey, 14% reported no leakage at all, 42% reported very little or mild leakage, 38% reported moderate leakage, and 6% reported severe leakage. Fifty-three percent of patients continued to wear pads. Seventy-nine percent reported improvement in their leakage compared with the preoperative state, and 69% were satisfied with the results. When patients with preoperative ISD were compared with patients with pure bladder neck hypermobility, the ISD group had more leakage and less improvement after surgery than patients with bladder neck hypermobility. Conclusions. With an average follow-up of greater than 4 years, most women continued to leak with symptoms of stress urinary incontinence. Even though 79% reported improvement over their preoperative condition and 69% were satisfied, the results were disappointing. Patients with significant ISD had a worse outcome (2.6% dry) than patients with pure bladder neck hypermobility (20% dry). Given the above data, significant ISD is a contraindication for a modified Pereyra transvaginal needle suspension, and these data cast further doubt on the ability of the modified Pereyra needle suspension to consistently cure even anatomic incontinence.

In Situ Anterior Vaginal Wall Sling Formation With Preservation of the Endopelvic Fascia for Treatment of Stress Urinary Incontinence

The indications for sling procedures have evolved and encompass patients with either intrinsic sphincteric deficiency (ISD), anatomic incontinence or both. We have refined a technique that can be performed in a minimally invasive fashion with low attendant morbidity to provide a reproducible method of sling formation. Twenty patients with stress urinary incontinence underwent the in situ sling (ISS) with bone fixation. Subsequent evaluation at 24–29 months (mean =26.2 months) revealed that 95% of patients were cured. No recurrent cystoceles, paravaginal defects or significant detrusor instability have been noted. Urinary retention appeared transiently in only 3 patients and resolved in under 3 weeks. We feel the in situ sling with bone fixation provides a safe and effective means of management for stress urinary incontinence. Furthermore, the reduced surgical dissection may minimize the incidence of postoperative ISD and recurrent paravaginal defects that may accompany more traditional needle suspension procedures.

Surgical treatment of stress urinary incontinence

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

In situ anterior vaginal wall sling formation with preservation of the endopelvic fascia for treatment of stress urinary incontinence.

The indications for sling procedures have evolved and encompass patients with either intrinsic sphincteric deficiency (ISD), anatomic incontinence or both. We have refined a technique that can be performed in a minimally invasive fashion with low attendant morbidity to provide a reproducible method of sling formation. Twenty patients with stress urinary incontinence underwent the in situ sling (ISS) with bone fixation. Subsequent evaluation at 24-29 months (mean = 26.2 months) revealed that 95% of patients were cured. No recurrent cystoceles, paravaginal defects or significant detrusor instability have been noted. Urinary retention appeared transiently in only 3 patients and resolved in under 3 weeks. We feel the in situ sling with bone fixation provides a safe and effective means of management for stress urinary incontinence. Furthermore, the reduced surgical dissection may minimize the incidence of postoperative ISD and recurrent paravaginal defects that may accompany more traditional needle suspension procedures.

The UCLA surgical approach to sphincteric incontinence in women.

Stress urinary incontinence (SUI) in the female may be treated by a variety of non-surgical and surgical therapies. However, once the patient has chosen to undergo operative repair the ideal procedure is based on three considerations: the degree of anterior vaginal wall prolapse, the degree of incontinence and associated anatomic abnormalities requiring surgical repair. In the vast majority of cases vaginal wall sling is our procedure of choice for the surgical treatment of SUI in the female. Vaginal wall sling is based on sound anatomic principles, may be performed as an outpatient procedure and is equally efficacious for the treatment of SUI due to anatomic incontinence (urethral hypermobility) and intrinsic sphincter deficiency. Since vaginal wall sling is performed through a transvaginal approach, other associated manifestations of pelvic floor prolapse such as rectocele can be addressed and repaired simultaneously. When necessary the vaginal wall sling can be easily modified to repair large grade cystoceles.

DIAGNOSIS OF STRESS URINARY INCONTINENCE

This article represents an overview of the evaluation and diagnosis of stress urinary incontinence. Lower urinary tract anatomy in women is reviewed with particular attention to the salient features contributing to stress incontinence. Also discussed is the relevance of the distinction between anatomic incontinence and intrinsic sphincter deficiency in the classification of stress urinary incontinence. Various diagnostic techniques are described with emphasis on the importance of urodynamic evaluation in complex cases.

Vaginal Wall Sling for Anatomical Incontinence and Intrinsic Sphincter Dysfunction: Efficacy and Outcome Analysis

Purpose A prospective cohort study was done to determine the efficacy and clinical outcome of a new technique for anterior vaginal wall sling construction to treat urinary incontinence due to intrinsic sphincter dysfunction or anatomical incontinence. Materials and Methods Preoperative evaluation included lateral cystography, video urodynamics, cystoscopy and incontinence staging. Postoperative subjective and objective staging outcome measures were prospectively assigned at predetermined regular intervals by a third party. Results Of the patients 95 had intrinsic sphincter dysfunction and 65 had anatomical incontinence. The repair failed in 7 percent of the 160 patients who had recurrent incontinence during followup and 9 percent had de novo urgency incontinence. Time to failure comparing patients with intrinsic sphincter dysfunction and anatomical incontinence was modeled using Kaplan-Meier survival curves, and the log rank test showed no significant difference between the groups (p greater than 0.05). Logistic regression covariates revealed no significant predictive factors for postoperative failures. Preoperative patient age was the only predictive factor for de novo instability (logistic regression model p less than 0.05). Conclusions Our initial results indicate that the 2 groups are indistinguishable to date based on current clinical and experimental statistics except for time to full recovery of postoperative voiding and incidence of postoperative instability (regression model p less than 0.05).

Vaginal wall sling for intrinsic sphincter deficiency

Urinary incontinence due to urethral dysfunction can be related to urethral hypermobility (anatomic incontinence), intrinsic sphincter dysfunction (ISD), or both. Correction of ISD requires one of several procedures to increase urethral coaptation and support. Since December 1985, we have used the vaginal wall sling for most of our patients with ISD; we have found it to be a simple and effective method of increasing urethral coaptation with minimal morbidity and complications.