Bladder Neck Elevation Research Articles

Assessment of voluntary pelvic floor muscle contraction in continent and incontinent women using transperineal ultrasound, manual muscle testing and vaginal squeeze pressure measurements

The aims of the study were: (1) to assess women performing voluntary pelvic floor muscle (PFM) contractions, on initial instruction without biofeedback teaching, using transperineal ultrasound, manual muscle testing, and perineometry and (2) to assess for associations between the different measurements of PFM function. Sixty continent (30 nulliparous and 30 parous) and 60 incontinent (30 stress urinary incontinence (SUI) and 30 urge urinary incontinence (UUI)) women were assessed. Bladder neck depression during attempts to perform an elevating pelvic floor muscle (PFM) contraction occurred in 17% of continent and 30% of incontinent women. The UUI group had the highest proportion of women who depressed the bladder neck (40%), although this was not statistically significant (p=0.060). The continent women were stronger on manual muscle testing (p=0.001) and perineometry (p=0.019) and had greater PFM endurance (p<0.001) than the incontinent women. There was a strong tendency for the continent women to have a greater degree of bladder neck elevation than the incontinent women (p=0.051). There was a moderate correlation between bladder neck movement during PFM contraction measured by ultrasound and PFM strength assessed by manual muscle testing (r=0.58, p=0.01) and perineometry (r=0.43, p=0.01). The observation that many women were performing PFM exercises incorrectly reinforces the need for individual PFM assessment with a skilled practitioner. The significant correlation between the measurements of bladder neck elevation during PFM contraction and PFM strength measured using MMT and perineometry supports the use of ultrasound in the assessment of PFM function; however, the correlation was only moderate and, therefore, indicates that the different measurement tools assess different aspects of PFM function. It is recommended that physiotherapists use a combination of assessment tools to evaluate the different aspects of PFM function that are important for continence. Ultrasound is useful to determine the direction of pelvic floor movement in the clinical assessment of pelvic floor muscle function in a mixed subject population.

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

To determine the effect of intra-operative monitoring of bladder neck elevation on cure rate and post-operative complications in patients undergoing colposuspension. Prospective, observational study. Urogynaecology units, university hospitals. Ninety women operated on for genuine stress urinary incontinence. 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. Mid-term surgical outcome and post-operative complications. 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. 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.

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

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

The Yearbook of Obstetrics and Gynaecology, Volume 10

It may seem strange that, in an age of high technology, a key topic in obstetrics and gynaecology should be the use of a few centimetres of synthetic tape to support the urethra. Tension-free vaginal tape (TVT), which has only recently gained popularity in the UK though long used in Continental Europe, is awarded a whole chapter in the 2003 Yearbook of Obstetrics and Gynaecology. In this operation for genuine stress incontinence, a vertical incision is made in the anterior wall of the vagina and the tape is inserted to both sides of the urethra and out through two small lateral incisions just above the pubic symphysis. The operation is tension free in that the ends of the tape are not sutured. The long-term success rate with this procedure approaches 80%—about the same as that of the colposuspension and sling operation, but with shorter hospital stays and lower morbidity. It is thought to work by kinking of the mid portion of the urethra rather than bladder neck elevation (the mechanism with colposuspension). Complications are usually minor, although vascular damage and even deaths have been reported: urgent laparotomy is required if large vessel damage is suspected. The technique does not usually require general anaesthesia, and the low-tech equipment means that it is applicable in developing as well as developed countries. With the increasing use of TVT, more women will be cured of the common and distressing condition of genuine stress incontinence. Every chapter in this year's volume is instructive, but let me mention some others that especially caught my interest. Anyone involved with obstetric and labour ward care will appreciate the discussion of cerebral palsy and the new ideas on its aetiology. A widespread belief (fuelled by court cases) that the brain damage occurs during labour—through hypoxia, acidosis or other insults—rather than antenatally, has led to a climate of anxiety in obstetrics, with increasing intervention rates. The chapter makes clear that cerebral palsy is a spectrum of conditions caused by an interplay of factors including extreme prematurity, chorioamnionitis, inborn errors of metabolism and inherited thrombophilias. Postnatal factors may include the use of corticosteroids and hypocapnia from mechanical ventilation. This chapter deals well with a subject poorly covered by some textbooks. Another burning issue is the increasing trend towards elective caesarean section in the UK. For many doctors, it is hard to see why any woman should choose an elective section when there is no 'obstetric' indication. The chapter evaluates recent publications on the risks for mother and baby, and the facts therein will be a helpful resource for clinicians in what can sometimes be a challenging consultation. Though written primarily for obstetricians and gynaecologists, there is much in this yearbook that will interest neonatologists, paediatricians, urologists, endocrinologists and microbiologists—and, indeed, anyone who offers care to women and children.

Do Bladder Neck Position and Amount of Elevation Influence the Outcome of Colposuspension?

Seventy-seven women who underwent colposuspension for treatment of urodynamic stress incontinence were the subjects of a prospective study conducted to determine the association of postoperative bladder neck position and surgical outcome. Magnetic resonance imaging (MRI) studies were made on the day before surgery and on the sixth postoperative day to determine the position of the bladder neck as measured using a system of coordinates similar to those used in perineal ultrasound. One year after surgery, the women were evaluated subjectively and objectively to evaluate the success of surgery. Patients completed the King's Health Questionnaire to provide a subjective assessment of their continence symptoms and underwent urodynamic studies for objective assessment. At the 1-year evaluation, 9 women continued to experience symptoms of stress incontinence. The subjective success failure rate was 11.6%. One patient reported severe symptoms, 1 reported moderate symptoms, and the remaining 7 women reported mild symptoms. Urodynamic studies showed stress incontinence in 8 women resulting in an objective failure rate of 10.5%. There was only 1 patient with both subjective and objective failure. No association with success or failure of treatment subjectively or objectively could be demonstrated for pre- or postoperative bladder neck position, bladder neck elevation, or amount of opposition to the pubic bone.

Modifications of Bladder Neck Support During Vaginal Parturition in Spontaneously and Forceps-Assisted Deliveries

In Brief Background The aim of this longitudinal study was to determine the short-term and long-term effects of spontaneous and forceps delivery on bladder neck (BN) support. Methods One hundred twenty-seven primiparae women underwent repeated clinical and perineosonography examinations during pregnancy and at 10 weeks and 10 months after delivery. Eighty-two had a spontaneous delivery, 25 a forceps delivery, and 20 cesarean section. The parameters measured by perineosonography were BN position measured in a two-axis system in the supine and standing positions, BN mobility, and BN elevation during pelvic floor squeezing. Results At 10 weeks and 10 months after delivery, a significant posterior, but not inferior, displacement of the BN at rest in the supine and standing positions was observed only after spontaneous delivery. In spontaneous and forceps-delivered women, but not in cesarean-delivered women, BN mobility stayed significantly increased and the ability to elevate the BN during voluntary pelvic floor contraction significantly decreased 10 weeks and 10 months after delivery. Women with cystocoeles grade 1 and 2 had significant higher bladder neck mobility compared with women without cystocoele. Conclusions Vaginal delivery is responsible for a significant and persistent impairment of BN support. Forceps delivery does not seem to have a more deleterious effect than spontaneous delivery. A longitudinal study assessing bladder neck behavior in 127 primiparae women before, two months and ten months after delivery demonstrates that vaginal delivery is responsible for a significant and persistent injury of bladder neck anchoring system.

Do bladder neck position and amount of elevation influence the outcome of colposuspension?

To determine whether the amount of bladder neck elevation and the position of the bladder neck after surgery influence the cure rate after colposuspension. Prospective, observational study. Urogynaecology unit, district general hospital. Seventy-seven women undergoing colposuspension for urodynamic stress incontinence. The bladder neck was imaged pre-operatively and one week after surgery using magnetic resonance imaging. The position of the bladder neck after surgery and the amount of elevation were correlated to continence outcome one year after surgery (subjective and objective evidence of stress incontinence). Subjective and urodynamic stress incontinence one year after surgery. At one year the subjective and objective failure rates were 11.6% and 10.5%, respectively. Measures using magnetic resonance imaging were obtained in 73 women. No association was found between continence outcome and post-operative bladder neck position and elevation. The post-operative position of the bladder neck and the amount of elevation do not influence continence outcome. Post-operative morbidity (voiding dysfunction and detrusor instability) might be preventable by avoiding excessive bladder neck elevation and compression, without compromising the success of the procedure.

Do bladder neck position and amount of elevation influence the outcome of colposuspension?

Objective To determine whether the amount of bladder neck elevation and the position of the bladder neck after surgery influence the cure rate after colposuspension. Design Prospective, observational study. Setting Urogynaecology unit, district general hospital. Population Seventy-seven women undergoing colposuspension for urodynamic stress incontinence. Methods The bladder neck was imaged pre-operatively and one week after surgery using magnetic resonance imaging. The position of the bladder neck after surgery and the amount of elevation were correlated to continence outcome one year after surgery (subjective and objective evidence of stress incontinence). Main outcome measures Subjective and urodynamic stress incontinence one year after surgery. Results At one year the subjective and objective failure rates were 11.6% and 10.5%, respectively. Measures using magnetic resonance imaging were obtained in 73 women. No association was found between continence outcome and post-operative bladder neck position and elevation. Conclusion The post-operative position of the bladder neck and the amount of elevation do not influence continence outcome. Post-operative morbidity (voiding dysfunction and detrusor instability) might be preventable by avoiding excessive bladder neck elevation and compression, without compromising the success of the procedure.

A Prospective Multisite Study of Radiofrequency Bipolar Energy for Treatment of Genuine Stress Incontinence

Study Objective To assess the efficacy of radiofrequency electrothermal energy to treat genuine stress incontinence (GSI). Design Multicenter, prospective, single-arm, longitudinal study (Canadian Task Force classification II-1). Setting Six North American university-affiliated and private clinic sites. Patients Ninety-four women undergoing laparoscopic treatment for GSI. Intervention Radiofrequency bipolar treatment of paravaginal tissue to induce tissue shrinkage causing bladder neck elevation. Measurements and Main Results Patients underwent complete urogynecologic evaluations, with urodynamic testing, including Valsalva leak point pressure, to confirm the diagnosis of GSI. Paravaginal tissue was treated lateral from the urethra and bladder neck out to the arcus white line, with bipolar electrothermal energy to shrink bladder-supporting connective tissue. Treatment resulted in 30% shrinkage in paravaginal endopelvic fascia surface area by direct measurement. At 1 year the objective cure rate was 79% by urodynamic testing, improvement in quality of life by questionnaire was 81%, decrease in leaking episodes and pad use was significant (p <0.001), and patient satisfaction was 83%. Complications (7%) were secondary to laparoscopy. There were no injuries from the radiofrequency probe. Conclusion Radiofrequency bipolar electrothermal energy appears to be a safe an efficient means of treating mild to moderate GSI. It results in shrinkage and elevation of paravaginal connective tissue, stabilizing the urethra and bladder neck, thereby restoring continence. Long-term follow-up is necessary.

Objective assessment of bladder neck elevation and urethral compression at colposuspension

Objectives 1. To assess whether magnetic resonance imaging and intra-operative measurements are useful in assessing bladder neck elevation and urethral compression at colposuspension; 2. to see if intra-operative measurements could be a substitute for magnetic resonance scan measurements. Design Prospective, observational study. Setting Urogynaecology Unit, NHS Trust hospital. Population Seventy-seven women undergoing colposuspension. Methods Bladder neck elevation was assessed using magnetic resonance imaging and measuring the amount of suture bow-stringing intra-operatively. Urethral compression was assessed using magnetic resonance imaging and by two intra-operative measurements: the distance between the medial sutures (with a ruler) and the distance between the urethra and the pubic bone (using paired Hegar dilators). Results The assessment of bladder neck elevation and compression against the pubic bone using magnetic resonance imaging was reliable (95% limits of agreement: −7.1mm to +7.1mm and −1.7mm to +3.8mm, correlation coefficient 0.92 and 0.87, respectively). The intra-operative assessment of urethral compression with a ruler was also reproducible at both paravaginal and pectineal sites (95% limits of agreement −2.6mm to +2mm and −2.1mm to +2.4mm, respectively; correlation coefficient 0.99 for both distances). Other intra-operative measurements of bladder neck elevation (suture bow-stringing) and urethral compression (Hegars) did not correlate with equivalent magnetic resonance scan measurements (kappa = −0.046, P = 0.31; kappa = 0.052, P = 0.41, respectively). Conclusions Measurements have been found that can reliably assess bladder neck elevation and urethral compression at colposuspension. These measurements should be suitable for investigating morbidity following colposuspension.

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

Objective To investigate the causes of voiding dysfunction and new detrusor instability after colposuspension. Design Prospective, observational study. Setting Urogynaecology unit, district general hospital. Population Seventy-seven women undergoing colposuspension for genuine stress incontinence. Methods The following factors were investigated: 1. bladder neck elevation by magnetic resonance imaging before and after surgery; 2. urethral compression by measuring bladder neck approximation to the pubis with magnetic resonance imaging after surgery (anterior compression) and the distance between the medial stitches during surgery (lateral compression); 3. clinical and urodynamic factors. Main outcome measures 1. Post-operative voiding function (i.e. first day of voiding and day of catheter removal); 2. objective evidence of detrusor instability three months post-operatively. Results Pre-operative peak flow rate ( P = 0.004), straining during voiding ( P = 0.005), increasing age ( P< 0.001), operative elevation ( P< 0.001) and anterior urethral compression ( P = 0.001) were associated with the number of days of post-operative catheterisation. Increasing age ( P = 0.02), previous bladder neck surgery ( P = 0.04), operative elevation ( P = 0.049) and anterior urethral compression ( P< 0.001) were associated with detrusor instability at three months. Conclusion Surgical factors (bladder neck elevation and compression) are associated with voiding dysfunction and detrusor instability after colposuspension. These findings have implications for prevention.

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

To investigate the causes of voiding dysfunction and new detrusor instability after colposuspension. Prospective, observational study. Urogynaecology unit, district general hospital. Seventy-seven women undergoing colposuspension for genuine stress incontinence. The following factors were investigated: 1. bladder neck elevation by magnetic resonance imaging before and after surgery; 2. urethral compression by measuring bladder neck approximation to the pubis with magnetic resonance imaging after surgery (anterior compression) and the distance between the medial stitches during surgery (lateral compression); 3. clinical and urodynamic factors. 1. Post-operative voiding function (i.e. first day of voiding and day of catheter removal); 2. objective evidence of detrusor instability three months post-operatively. Pre-operative peak flow rate (P = 0.004), straining during voiding (P = 0.005), increasing age (P < 0.001), operative elevation (P < 0.001) and anterior urethral compression (P = 0.001) were associated with the number of days of post-operative catheterisation. Increasing age (P = 0.02), previous bladder neck surgery (P = 0.04), operative elevation (P = 0.049) and anterior urethral compression (P < 0.001) were associated with detrusor instability at three months. Surgical factors (bladder neck elevation and compression) are associated with voiding dysfunction and detrusor instability after colposuspension. These findings have implications for prevention.

Objective assessment of bladder neck elevation and urethral compression at colposuspension.

1. To assess whether magnetic resonance imaging and intra-operative measurements are useful in assessing bladder neck elevation and urethral compression at colposuspension; 2. to see if intra-operative measurements could be a substitute for magnetic resonance scan measurements. Prospective, observational study. Urogynaecology Unit, NHS Trust hospital. Seventy-seven women undergoing colposuspension. Bladder neck elevation was assessed using magnetic resonance imaging and measuring the amount of suture bow-stringing intra-operatively. Urethral compression was assessed using magnetic resonance imaging and by two intra-operative measurements: the distance between the medial sutures (with a ruler) and the distance between the urethra and the pubic bone (using paired Hegar dilators). The assessment of bladder neck elevation and compression against the pubic bone using magnetic resonance imaging was reliable (95% limits of agreement: -7.1mm to +7.1mm and -1.7mm to +3.8mm, correlation coefficient 0.92 and 0.87, respectively). The intra-operative assessment of urethral compression with a ruler was also reproducible at both paravaginal and pectineal sites (95% limits of agreement -2.6mm to +2mm and -2.1mm to +2.4mm, respectively; correlation coefficient 0.99 for both distances). Other intra-operative measurements of bladder neck elevation (suture bow-stringing) and urethral compression (Hegars) did not correlate with equivalent magnetic resonance scan measurements (kappa =-0.046, P = 0.31; kappa = 0.052, P = 0.41, respectively). Measurements have been found that can reliably assess bladder neck elevation and urethral compression at colposuspension. These measurements should be suitable for investigating morbidity following colposuspension.

Long‐term success after open and laparoscopic colposuspension: a case–control study

ABSTRACTObjective A decade after its development, laparoscopic colposuspension remains a controversial alternative to open colposuspension in the treatment of female genuine stress incontinence. Results from the few published randomized controlled trials vary considerably. The authors therefore intended to define long‐term subjective and objective results in their own patient population.Design Clinical retrospective case–control trial.Setting Urogynaecology service of a tertiary hospital.Subjects 50 patients seen on average 3.3 years after laparoscopic colposuspension, matched with 50 women who had been followed up on average 3.4 years after open colposuspension.Intervention Standardized interview, translabial ultrasound imaging.Main outcome measures Incidence of urinary tract symptoms, bladder neck elevation and mobility, trigonal deformation, funnelling.Results Stress and urge incontinence were non‐significantly more common after open colposuspension, with significantly less frequency and nocturia in the laparoscopic group (P = 0.02). Significantly more patients were completely asymptomatic after laparoscopic colposuspension (P = 0.03). On ultrasound imaging, open colposuspension appeared to more commonly result in permanent distortion of the trigone (P = 0.02), with significantly less bladder neck descent on Valsalva manoeuvre (P = 0.005). These parameters were independent of follow‐up time.Conclusion It appears that, in the population assessed here, laparoscopic colposuspension seems to offer at least equivalent results when compared with open colposuspension.

A Comparison of Bladder Neck Movement and Elevation After Tension-Free Vaginal Tape and Colposuspension

Objective To compare elevation and movement of the bladder neck after tension-free vaginal tape and open Burch colposuspension, using transperineal ultrasound. Design Prospective, non-randomised study using pre- and post-operative transperineal ultrasound of the bladder neck. Setting Tertiary referral urogynaecology unit at a London teaching hospital. Sample Thirty consecutive women who underwent tension-free vaginal tape or colposuspension for primary genuine stress incontinence between March 1998 and June 1999. Methods Women underwent transperineal ultrasound of the bladder neck prior to and three to four weeks after surgery. Main outcome measures Bladder neck elevation, angle and movement in relation to the pubic symphysis. Results For both tension-free vaginal tape and colposuspension the post-operative bladder neck angles at rest and valsalva were more acute than pre-operatively. The post-operative linear movement on valsalva was less than pre-operatively. For colposuspension the rotational movement on valsalva was significantly less post-operatively, but for tension-free vaginal tape there was only a trend towards less post-operative rotational movement. Post-operative angles and movement were significantly less for colposuspension. The resting bladder neck position was elevated significantly more by colposuspension. Conclusion Both tension-free vaginal tape and colposuspension decrease bladder neck angles at rest and valsalva, linear movement on valsalva and elevate the bladder neck. The colposuspension causes significantly more change than the tension-free vaginal tape. This suggests the mechanism of continence for the tension-free vaginal tape is less dependent on bladder neck change than the colposuspension.

Ultrasound imaging of the lower urinary system in women after Burch colposuspension.

Most of the relevant surgical procedures employed in the management of genuine stress urinary incontinence (GSI) involve the technique of bladder neck elevation. The appropriate level of suspension is an important (but frequently overlooked) consideration as the clinical consequences of over-correction of the posterior angle are voiding dysfunction and urgency symptoms. The aim of our study was to compare ultrasound characteristics in women with GSI with those of women before and after Burch colposuspension. The findings of our study should have implications for GSI management. Prospective randomized clinical study at the Department of Obstetrics and Gynecology, Charles University, Prague, Czech Republic. Department of Obstetrics and Gynecology, Charles University, Prague, Czech Republic. Seventy women with previously untreated GSI (preoperative group) and 52 women (42 of whom had been in the preoperative group) who were studied 3-12 months after receiving Burch colposuspension (postoperative group) took part in the study. The standard transperineal and introital ultrasound scans were performed. The mobility of the bladder neck was assessed transperineally with a curved array probe after instillation of 300 mL of saline. The bladder was then evacuated and the thickness of the urinary bladder wall in the sagittal plane in defined regions (base, vertex and anterior wall) was measured. We found significant differences in bladder neck position, mobility, and in bladder wall thickness. Where symptoms of urgency occurred, the average bladder wall thickness was > 5 mm, the gamma angle < 40 degrees, and lower bladder neck mobility was evident. These findings supported our hypothesis that signs of urgency follow over-elevation of the bladder neck. These results helped us significantly to refine our GSI management.

Changes in vesical neck mobility following vaginal delivery

To assess changes in urethral movement during the Valsalva maneuver and pelvic floor muscle contraction following vaginal delivery. In a prospective repeated-measures study, 25 primigravidas, 20 multiparas, and ten women who were to have elective cesarean delivery were examined sonographically at 36-42 weeks of pregnancy and 6-10 weeks after delivery. Vesical neck position at rest and excursion during Valsalva maneuver and maximum pelvic muscle contraction were measured with perineal ultrasound. Data about resting bladder neck position and bladder neck elevation at contraction were compared with findings in age-matched nulligravid volunteers. The bladder neck was significantly lower at rest in women after vaginal delivery than in those who had an elective cesarean delivery and in nulligravid controls. Bladder neck mobility had increased during the Valsalva maneuver in 16 of 25 primigravidas and 15 of 20 multiparas 6-10 weeks after vaginal delivery. The ability to elevate the vesical neck during pelvic muscle contraction was decreased in six of 25 primigravidas and in two of 20 multiparas 6-10 weeks after birth. Two women, one primigravid and one para 2 (with a previous elective cesarean delivery), both of whom had forceps delivery, completely lost the ability to contract voluntarily the pelvic floor muscles. Vaginal delivery alters vesical neck descent during the Valsalva maneuver, and the ability of the pelvic muscles to elevate the urethra in some women.

Two techniques of laparoscopic Burch repair for stress incontinence: A prospective, randomized study

Study Objective. To determine if outpatient laparoscopic Burch procedure performed with mesh and staples is as effective as that done with the suture technique. Design. Prospective, randomized study. Setting. Community hospital. Patients. Sixty–nine women with genuine stress incontinence (GSI) randomly assigned to either the suture group (group 1) or the mesh-staple group (group 2). Interventions. Before surgery each patient had a complete history, physical and neurologic examinations, 24-hour urolog, urology questionnaire, urine culture and sensitivity, Q-Tip test, transperineal ultrasound, cough stress test, cystourethroscopy, and cystometrogram. Stress incontinence was diagnosed by positive Q-Tip, ultrasound, and cough stress tests and a negative cystometrogram for detrusor contraction. The laparoscopic Burch procedures were performed with either sutures for bladder neck elevation or with mesh and staples. Clinical and, if necessary, urodynamic studies were repeated at 6 weeks and 1 year postoperatively. Measurements and Main Results. The cure rate at 1 year was 91% in group 1 and 94% in group 2. Only objective cures by urologic testing are reported. The hypermobile urethra, as tested by transperineal ultrasound, was cured by both procedures. Of the 69 women, 68 were able to void spontaneously within 24 hours. Conclusions. Early results suggest that laparoscopic Burch colposuspension is effective in curing GSI. Both sutures and mesh with staples yield good outcomes.

Perineal bladder neck ultrasound: appearances before and after continence surgery.

An objective method of quantifying suture tension during bladder neck elevation for genuine stress incontinence has long been sought. Perineal ultrasonography has been used to measure bladder neck position and excursion in continent and incontinent women. This study used perineal ultrasound findings to determine surgical positioning of the bladder neck and predict outcome. Eighteen asymptomatic controls and 72 women with genuine stress incontinence were studied before and after continence surgery. Perineal ultrasonography was used to plot bladder neck position at rest and on maximum Valsalva maneuver on an x, y co-ordinate system to allow comparison between groups. Logistic regression analysis was then performed to derive an equation for the likelihood of continence. In both pre-and postoperative analysis, the best correlation with continence was achieved with the use of the patient's age and the distance of the bladder neck resting position measured along the x-axis. An equation was derived to give the probability of continence. The equation is easily calculated using a pocket calculator. The distance of the bladder neck along the x-axis is under the direct control of the surgeon, so the patient's age can be put into the equation and the distance along the x-axis most likely to make the patient continent can be calculated. This can be done during surgery to provide an objective method for evaluating suture tension.

Laparoscopic burch colposuspension—New approaches

Endoscopic surgical developments have produced considerable benefits in reduction of postoperative morbidity and healthcare costs for the community. The Burch colposuspension via a transverse lower abdominal incision has achieved widespread acceptance in the management of stress incontinence. However, the potential benefits of laparoscopic Burch colposuspension include decreased perioperative and postoperative morbidity, shortened hospitalization, reduction of blood loss, and early return to normal activity. We present our initial 10 cases, 7 via the transperitoneal approach, and 3 using balloon distension of the retropubic space via an extraperitoneal approach. In all cases, the bladder neck and iliopectineal ligaments were clearly visualized laparoscopically. Sutures were placed between the paravaginal fascia and iliopectineal ligaments bilaterally, producing good bladder neck elevation. A suprapubic catheter was subsequently inserted. This initial group (N = 10), mean age 41 years (range 35-54 years) all had preoperative urodynamic studies confirming stress incontinence. A mean operating time of 3 hours 7 minutes (range 2-5 hrs) was achieved using the transperitoneal approach. However, switching to the balloon extraperitoneal method (N = 3), mean surgical time diminished to 65 minutes. All patients were managed with postoperative suprapubic catheterization with hospital discharge after 5.5 days (range 4-7 days) and minimal postoperative blood loss. All patients returned to normal activity within 18 days. Initial follow-up confirmed the absence of stress incontinence. Laparoscopic colposuspension would now appear to be the surgery of choice for stress incontinence.