Bladder Suspension Research Articles

Foley catheterization in the postoperative patient

Objective: Foley catheters are used routinely in gynecologic surgery. We wanted to address the issue of whether this was necessary and affected patient outcome. The question asked in this study is, “Does early removal of the Foley catheter after pelvic surgery affect recatheterization, febrile morbidity, symptomatic urinary tract infections, and patient comfort?”Methods: This is a prospective randomized clinical trial conducted at a university teaching hospital on all patients undergoing hysterectomy or cesarean delivery, not requiring bladder suspension or strict fluid management. The Foley catheter was either removed immediately, postoperatively, or on the first postoperative day. The variables studied were recatheterization, febrile morbidity, symptomatic urinary tract infections, and pain.Results: Seventy-eight patients were included in this trial. Twenty-nine patients underwent a cesarean delivery, 38 patients underwent a vaginal hysterectomy, and 11 patients underwent abdominal hysterectomy. The outcome for these patients are as follows: in all cases only five patients had a fever, P value was nonsignificant, two patients had urinary tract infections with a P value that is nonsignificant, and recatheterization occurred in five patients (P value of 0.17). The level of pain was measured using a standardized pain scale, described as mild, moderate, or severe. Evaluating all cases, n = 78 (P = 0.001), patients had significantly less pain with early removal of the Foley catheter. The same was true when done for all cesarean hysterectomies; the pain was significantly less (0.001) in the early removal group. There were no patients with severe pain in the early removal group.Conclusions: Patients who had the Foley catheter removed immediately following surgery had no increase in fever, urinary tract infections, or incidence of recatheterization. There was also significantly less pain in the early removal group. In some patients, the Foley catheter is not required in the postoperative period and patients report less discomfort.

Urinary incontinence: treatment using behavioral therapy protocol

Objective: Confirm previously reported cure rate of 88% with standard protocol using multiple behavioral therapies (BT) in a larger patient population.Methods: Consecutive patients referred to a single physician for urinary incontinence (UI) who met protocol criteria for BT were prospectively followed through their course of therapy and for up to 24 months after completion. Descriptive analysis of outcomes and comparison of successful versus drop-out groups is provided.Results: 504 patients were evaluated and 321 patients entered BT. Seventy-three percent completed BT. Stress UI was the primary diagnosis in 35%, urge UI in 33%, mixed UI in 12%, and fecal incontinence in 4%. Previous bladder suspension had been done in 25%, and 5% had multiple operative procedures. Of those who completed the program, 85% were cured of UI; the remainder were improved. Average increase in EMG pelvic floor muscle strength was 25 microvolts. The only differences between completed and drop-out groups were cognitive ability to grasp the program and motivation. Twenty-four-month follow-up shows no significant change in discharge status.Conclusions: Previously reported remarkable cure rate using standard BT protocol has been verified using a much larger database. Nonsurgical, multiple behavioral technique protocol is effective in the treatment of UI. Follow-up data continue to demonstrate maintenance of discharge status. Age, type, or severity of UI and co-morbid factors did not alter the cure rate.

Surgery by vaginal approach in stress urinary incontinence: Lahodny bladder suspension

Urogenital prolapse and urinary incontinence secondary to multiple defects of the pelvic floor (cystocele caused by lateral and central defect of the pubocervical fascia, hysterocele, rectocele) may also be successfully treated by vaginal approach only. From October ‘95 to September ‘97, 78 women underwent colpohysterectomy, Lahodny bladder suspension and perineoplasty and in 15 of them the vaginal cupola was anchored to the right sacrospinous ligament. In another 3 women Lahodny's procedure was associated with just perineoplasty, since there was a cystocele caused by lateral and central defect of the pubocervical fascia and a rectocele, while the uterus was fixed in place. Prior to operation the 81 patients underwent a colpocytological exam, pelvic ultrasound, a urodynamic exam with flow pressure study and assessment of the leak pressure with Valsalva manoeuvre, and in the cases of constipation or fecal incontinence, coloproctological investigation. The suprapubic catheter that was always positioned at the end of the operation was on average removed on the 10th day, upon the disappearance of significant post-micturitional residue. There is no micturitional difficulty in any patient. Given the short follow-up, the results are given of the 44 women observed for at least one year, 40 of whom are continent. Recurrent prolapse was found in 8 cases, 2 involving the anterior, 40 the rear and 2 the central wall. No patient has had a return of stress incontinence.

Frequency urgency syndrome following urinary bladder suspension.

Bladder suspension for urinary incontinence secondary to bladder neck hypermobility is highly successful. Of those who fail, however, a subset will develop new onset or markedly worsened irritative voiding symptoms. A series of such patients were identified to study the associated urodynamic abnormalities of this symptom complex. The charts of female patients presenting for incontinence from 1992-94 were reviewed. Forty-six patients with a mean age of 59.4 (range 28-79) fulfilled the inclusion criteria of developing new onset or markedly worsened post-operative frequency, urgency and urge incontinence within two years of undergoing bladder suspension. All had been evaluated with thorough history, physical examination, and urodynamic testing. Seventeen patients were found to have recurrent hypermobility. Eighteen had a diagnosis of intrinsic sphincter deficiency (ISD), including six that also had another diagnosis. Four patients were diagnosed with detrusor overactivity and seven with other miscellaneous diagnoses. Patients presenting with this symptom complex should be evaluated so that treatment can be tailored appropriately.

Laparoscopic retropubic urethropexy

We evaluated a simplified extraperitoneal retropubic bladder suspension using balloon distention and mesh suspension in 100 patients to determine operating time, anesthesia, morbidity, voiding time, length of hospital stay, cost, and patient satisfaction. All cases were performed by the same surgeon. The majority of women were medium build; 28 were obese, and 17 thin. Operating time varied little, with most 89 procedures requiring less than 30 minutes. Either epidural anesthesia or general anesthesia can be used. There were two hematomas and six bladder entries. Voiding time varied from 4 hours up to 2 days, with 87% of patients voiding in less than 18 hours. Hospital stay was less than 24 hours for all but two patients, except when other procedures were associated with the bladder suspension. The average cost of the outpatient procedure was $3220.00, and inpatient surgery, with a 3-day stay, averaged $6370.00. Ninety-one patients reproted they were continent. Nine were classed as failures, of whom six were satisfied with the result. Extraperitoneal, retropubic, bladder mesh suspension results in a durable repair, and is associated with minimal operating time and morbidity and maximum patient satisfaction and clinical benefit.

Telesurgical Consultation

Purpose We evaluated the feasibility of "telesurgical" consultation during laparoscopic surgery. Telesurgical consultation is a distinct application of telemedicine in which a surgeon at a primary operating site can consult another experienced surgeon or colleague for complex and/or unexpected problems encountered during surgery. Materials and Methods Telesurgical consultation was used in 6 complex laparoscopic cases, including upper pole nephrectomy, diagnostic laparoscopy with inguinal hernia repair, orchiectomy, gastric augmentation with bladder suspension, bladder reconstruction and ureteral lithotomy. Results In each case an experienced laparoscopic surgeon at the primary operative site consulted a surgical specialist at the remote site who had expertise in the particular procedure being performed. All procedures were accomplished successfully without intraoperative or postoperative complications. Conclusions Complex laparoscopic procedures that normally require a surgical specialist can be performed successfully by an experienced laparoscopic surgeon consulting a remote specialist via the tele-operative system.

Internal fixation in pelvic fractures and primary repairs of associated genitourinary disruptions: a team approach.

Associated urological and orthopedic injuries of the pelvic ring are complex with numerous potential complications. These patients are treated optimally using a team approach. The combined expertise is not only helpful initially when managing these difficult patients, but also later as problems develop. This study describes a treatment protocol and reports the early results of 23 patients with unstable pelvic fractures and associated bladder or urethral disruptions, or both, treated surgically with open reduction and internal fixation of the anterior pelvic ring injuries at the same anesthetic and using the same surgical exposure as the urethral realignments or bladder repairs or both. Early complications occurred in four patients (17%): one patient sustained a fifth lumbar nerve injury caused by the pelvic reduction procedure, and three patients had anterior pelvic internal fixation failures. Late complications occurred in eight patients (35%). There was one deep wound infection (4.3%) that presented 6 weeks after injury. Late urological complications occurred in seven patients (30%). Four of the nine male patients with urethral disruptions had urethral stricture after their primary urethral realignments (44%). Three of the 18 male patients admitted to impotence (16.7%). One of the three had a residual thoracic paraplegia caused by a burst fracture. One of the five female patients had urinary incontinence and required a bladder suspension operation to restore normal function (20%). A low infection rate can be expected despite the use of internal fixation. Early urethral "indirect" realignments avoid more difficult delayed open repairs; however, late urological complication rates are still high. Early "direct" bladder repairs are easily performed at the time of anterior pelvic open reduction and internal fixation. Suprapubic tubes are not necessary to adequately divert the urine when large diameter urethral catheters are used in these patients.

Sixteen-month experience with video-assisted extraperitoneal laparoscopic bladder neck suspension.

After an extensive favorable experience with the Lapides-Ball open retropubic bladder neck suspension, we chose to perform this operation laparoscopically. We describe video-assisted extraperitoneal laparoscopic bladder neck suspension (VELBNS), in which we employ a single laparoscopic cannula and a laparoscopic bladder suspension set for suturing and simultaneously use video-assisted cystoscopy and laparoscopy for precise suture placement. Over 16 months, we operated on 70 patients with stress urinary incontinence secondary to hypermobility of the urethra. We describe the patient evaluation and selection and the surgical principles and techniques. Five procedures were converted to open operations because of bladder lacerations (two cases) or inability to dissect the space of Retzius because of scar tissue (three cases). At 3 months, 4 patients had unresponsive de novo urgency incontinence, and 61 patients were dry and without protection. One patient had a recurrence at 6 months that was corrected by open surgery. All 12 patients seen at 1 year were dry. We intend to survey our patients annually to obtain long-term results.

Ilioinguinal nerve entrapment followingneedle bladder suspension procedures

Ilioinguinal nerve entrapment is a documented complication of inguinalherniorraphy, inguinal lymph node dissection, and appendectomy. This article reports two clinical histories to illustrate the diagnosis and management, and outlines prevention of ilioinguinal nerve entrapment as a complication of needle suspension procedures for stress urinary incontinence.

Laparoscopic Retroperitoneal Needle Suspension Urethropexy*

Recent advances in laparoscopic surgery have allowed urologists to perform laparoscopic bladder suspension; however, laparoscopic suturing techniques have a steep learning curve and make the procedure more difficult and time consuming. We describe a new technique that combines extraperitoneal laparoscopic bladder neck mobilization through a single port with the ease of a needle suspension urethropexy in order to avoid the need for vaginal incisions and the use of laparoscopic suturing techniques. The procedure has been performed in four patients, all of whom are continent and voiding with complete bladder emptying. Postoperative pain was minimal, allowing most patients to be discharged the day after surgery. In the future, the procedure may be performed on an outpatient basis.

Telerobotic assisted laparoscopicsurgery: Initial laboratory and clinical experience

Objectives. To assess the feasibility of telerobotic assisted surgery. Methods. In a laboratory model, a cholecystectomy, splenectomy, and nephrectomywere performed by an inexperienced surgeon who was being mentored by an experienced surgeon stationed at a remote site. The remote surgeon controlled the laparoscopic camera by utilizing a telerobotic system. In patients, laparoscopic cholecystectomy, varix ligation, and bladder suspension were performed by an experienced team utilizing a robotic system controlled by an experienced surgeon from a remote site. Results. In both the laboratory and clinical setting, all procedures were successfully completed without complications. Conclusions. Current technology is available to successfully allow for telerobotic assistedsurgery.

American Urological Association Symptom Index for Women with Voiding Symptoms: Lack of Index Specificity for Benign Prostate Hyperplasia

An evaluation of the American Urological Association (AUA) symptom index was recently published as a valid symptom score for benign prostatic hyperplasia (BPH). To determine the specificity prospectively of the index for BPH and bladder outlet obstruction, we chose to administer the index to 38 consecutive women with voiding symptoms who were previously scheduled for video urodynamic evaluation. In each case the index was self-administered before the urodynamic study. Index determination was then repeated 1 to 4 months after the institution of therapy. Only 3 of the 38 women demonstrated true urethral obstruction. One patient exhibited urethral compression after a pubovaginal sling urethral suspension, 1 with multiple sclerosis demonstrated detrusor external sphincter dyssynergia and 1 suffered bladder neck obstruction caused by a leiomyoma.The AUA symptom index for the 35 nonobstructed women ranged from 4 to 33 (mean 17.6) Of the women 15 scored between 8 and 18, while 14 had a score of greater than 18. The mean score decreased to 9.4 after the institution of therapy, which included bladder suspension surgery, anticholinergics, timed voiding and pelvic floor exercises. Of the 3 women with bladder outlet obstruction the mean score was 22.7 before and 11.0 after therapy. A greater decrease in the AUA symptom index occurred among the obstructed group after urological therapy compared to the nonobstructed group. Our results indicate that the AUA symptom index is not specific for BPH. The index score for the women in our study rivaled the scores reported for men with BPH.

Inter‐ and intra‐observer variation of colpo‐cysto‐urethrography diagnoses

To evaluate the reliability of diagnosing type of bladder suspension defect in incontinent women by means of voiding colpo-cysto-urethrography (CCU), 93 CCU-series with exposures at rest, coughing, withholding and voiding were diagnosed. Three senior and one junior radiologists, a gynecologist and a urologist diagnosed the CCU-series twice with 3-6 months interval. The main diagnostic possibilities were anterior bladder suspension defects, posterior defects and normal, which were in accordance with general practice of choosing an abdominal suspension operation for the anterior suspension defects and a vaginal operation for the posterior defects. The intra-observer agreement varied between 99% and 72%, i.e. 1/5 to 1/4 of the patients changed from one main diagnostic group to another at the two examinations. The inter-observer agreement varied between 43% and 60%. Information of clinical patient data, given to the two clinicians, did not change their CCU-diagnoses significantly. We concluded, that CCU should not be recommended as a routine for evaluation of type of suspension defect since the intra-inter-observer variation was around 25% and 50% respectively. CCU might still be useful preoperatively in selected cases, since it gives an excellent visualisation of bladder base anatomy.

Laparoscopic urology: past, present, and future.

Laparoscopy has begun to have a significant impact on the management of urologic problems. Although initially limited to diagnostic pediatric problems, it has more recently been used to resolve myriad adult urologic conditions. Indeed, during the past year laparoscopic urology has moved well beyond the diagnosis of the undescended testicle and has been successfully used for pelvic lymphadenectomy, varicocelectomy, ureterolysis, drainage of a pelvic lymphocele, bladder suspension, and nephrectomy. Future applications of laparoscopy in urology may well include nephroureterectomy, cystectomy, and creation of an ileal conduit.

Stress Urinary Incontinence And Posterior Bladder Suspension Defects: Results Of Vaginal Repair Versus Burch Colposuspension

Vaginal repair has been recommended in cases of stress urinary incontinence and posterior bladder suspension defect diagnosed by colpocysto-urethrography. Thirty-eight women with stress urinary incontinence and posterior suspension defect have been treated. First, 19 women underwent a vaginal repair. In a second period, another 19 consecutive patients had a colposuspension a.m. Burch. The patients have been evaluated 6 months postoperatively and at a long-term follow-up. No significant difference was found postoperatively in the frequency of symptoms and signs of stress incontinence, either after 6 months or at the long-term follow-up. A significantly smaller frequency of genital prolapse was found in the colposuspension group at long-term follow-up. No side effects such as frequency, urgency or bacteriuria were evident in the group treated by colposuspension. With reservation to the non-randomized allocation, it may be concluded that a radiographic distinction between anterior and posterior bladder suspension defects in choosing the surgical approach is unnecessary.

Operative gynecologic endoscopy

Operative Gynecologic Endoscopy, Second Edition is completely revised and expanded with 17 new chapters that provide, step-by-step, the latest operative techniques for both laparoscopic AND hysteroscopic procedures. New and updated chapters include: - laparoscopic assisted vaginal hysterectomy - vaginal prolapse and bladder suspension - ectopic pregnancy - tubal reconstructive surgery - assisted reproductive technologies - lymphadenectomy and urologic procedures - operative hysteroscopy. In addition, this volume includes comprehensive chapters on instrumentation, photo documentation, anesthesia, operating room personnel, credentialing, and legal issues. More than 350 superb illustrations - with many in full color - complement and clarify the operative techniques. For every surgeon and resident performing gynecologic procedures, this is the definitive, most up-to-date text on gynecologic endoscopy.

Artificial Urinary Sphincter for Recurrent Female Urinary Incontinence: Indications and Results

A retrospective review of our experience with the artificial urinary sphincter in 32 women is presented. All patients had a history of recurrent urinary incontinence after failed bladder suspension procedures. Of 32 devices 31 were functioning, with an average followup of 2.5 years, and 91 per cent of the patients were dry without pads. Mechanical complications requiring surgical repair occurred in 21 per cent of the patients. Indications for artificial urinary sphincter implantation in the female patient and technical aspects of the procedure are discussed. The artificial urinary sphincter appears to be an acceptable treatment modality for urethral sphincter deficiency resulting in recurrent urinary stress incontinence in female patients.

Changes in symptoms and colpo-cystourethrography in 35 patients before and after total abdominal hysterectomy: a prospective study.

35 women, referred for simple total hysterectomy, were evaluated pre- and postoperatively for bladder suspension and urodynamic changes. Although all patients denied urological problems, more than half of the patients had some degree of stress and/or urge incontinence. 40% had radiological signs of bladder suspension defects. At postoperative examination the symptomatology of incontinence had declined but the radiological pathologic findings had increased. On this basis it may be concluded that it is unpredictable what happens to the bladder and its suspension following simple hysterectomy.

THE EFFECTS OF VAGINAL REPAIR ON ANTERIOR BLADDER SUSPENSION DEFECTS

In 22 patients with anterior bladder suspension defect as judged by colpocysto-urethrography (CCU) a vaginal repair was undertaken. In 14 patients urinary stress or urge and stress incontinence was the indication for operation, and in 8, genital prolapse. At follow-up more than 6 months postoperatively the CCU was repeated and a clinical evaluation undertaken. A normalization of the CCU was obtained in only 6 patients and 10 showed a less severe suspension defect. Nine of 14 patients were cured of incontinence. Only 3 of these had a normal follow-up CCU. Improvement of bladder suspension defect was not the sole responsible factor for postoperative continence. Urinary incontinence developed postoperatively in 2 of 8 patients operated on solely because of symptomatic genital prolapse. Very high cure rates for urinary incontinence have been reported following a colposuspension operation. A vaginal repair is not recommended as first-choice operation in incontinent females with anterior bladder suspension defects, if a CCU may be undertaken and the colposuspension technique is mastered.

Incontinence Surgery in Female Motor Urge Incontinence

MEYHOFF, HANS-HENRIK; WALTER, STEEN; GERSTENBERG, THOMAS C.; OLESEN, KNUD P.; NORDLING, JØRGEN; PEDERSEN, POUL H.; HALD, TAGE Author Information