Genuine Stress Incontinence Research Articles

Dexmedetomidine: an alternative for epidural anesthesia in tension-free vaginal-tape surgery

Anesthetic management of tension-free vaginal-tape (TVT) procedures is sometimes difficult to deal with, especially when surgeons request a cough test. Dexmedetomidine has unique sedative and analgesic properties while having minimal respiratory effects, making it suitable for perioperative use in monitored anesthesia care. We aimed to compare dexmedetomidine and epidural anesthesia in TVT patients. Forty-nine women [American Society of Anesthesiologists (ASA 1-3)] with genuine stress incontinence confirmed by preoperative bladder function studies were included in this double-blind, randomized study. The patients were randomly assigned to one of two groups: group D received 0.5 μg/kg dexmedetomidine IV applied as bolus over 10 min and continued with 0.5 μg/kg/h infusion, and local anesthesia (lidocaine 2% with epinephrine) performed by the surgeon. Group E received epidural anesthesia with 15 ml of 0.25% bupivacaine + 100 μg fentanyl. Patients were monitored every 5 min for mean arterial pressure (MAP), heart rate (HR), peripheral oxygen saturation, respiratory rate, sedation, and intraoperative and postoperative pain. Ability to cough was also evaluated by the surgeon. There was no difference in ability to cough, and this was evaluated by the surgeon as adequate, and there was no difference in scores between groups. Significant decreases in MAP and HR were observed 10 min after the start of surgery in group D compared with group E, and they were significantly decreased until first and second postoperative hours, respectively (p < 0.05). None of the patients had respiratory rate decrease or apnea. Side effects encountered postoperatively were similar. Dexmedetomidine can be an alternative to epidural anesthesia in TVT procedure requiring cough test.

Is modified Raz technique of midurethral sling a reliable and cost-effective method of treating stress urinary incontinence?

Objectives:We report our experience of pure stress urinary incontinence (SUI) treated by midurethral synthetic sling placement by modified Raz technique.Materials and Methods:Fifty-three patients with pure SUI operated at our institute between June 2003 and December 2008 were included in this study. Midurethral sling tape, fashioned from commercially available large pore synthetic mesh, was placed using the modified Raz technique. The technique consisted of placing the tape within retropubic space using double-pronged needle, which is passed under finger control through the fascia and retropubic space. Outcomes were assessed on the basis of patient's interview in follow-up OPD.Results:Mean age was 57.68 (28–69) years. Forty-five (85%) patients were totally dry and eight (15%) socially dry at the end of the follow-up. Mean operative time was 46.5 + 11.3 minutes (35–80 minutes). None of the patients required blood transfusion or had bladder/bowel injury. Mean duration of hospital stay was 2.17 days (2–4 days). Mean duration of follow-up was 46.1 months (12–78 months).Conclusions:Modified Raz technique is safe and cost-effective for placing midurethral sling for genuine stress incontinence.

Usage of international continence society standardized terminology: A bibliometric and questionnaire study

We aimed to assess the impact of the 2002 International Continence Society (ICS) standardization report on usage of lower urinary tract terminology in research publications, and compare published usage with awareness of standardized terminology among practicing clinicians. We searched articles indexed in the Scopus database for pairs of words or phrases, where one was introduced by the 2002 report, making the other obsolete or discouraged. We calculated frequencies of publications using each word or phrase by year. We calculated odds ratios and relative risks for usage of each item of 2002 terminology or its obsolete counterpart, comparing the periods 1996-2002 and 2003-2009. We distributed an email questionnaire to members of the British Society of Urogynecologists (BSUG), asking them to identify which items from a list of terms were current standardized or obsolete terminology. Bibliometric trends varied markedly by word pair. The terms "genuine stress incontinence," "detrusor hyperreflexia," and "detrusor instability" became obsolete as recommended by the 2002 report, with a delay of 2-3 years. However, for terms with wider usage beyond the continence field, including "vulvodynia" and "dysuria," there was no significant adoption of the suggested replacements. Members of BSUG were familiar only with those items of standardized terminology that had been widely used in the literature. The 2002 ICS standardization report was associated with significant shifts in usage of some items of terminology. ICS and IUGA should redouble efforts to raise awareness of the 2009 standardization report.

The Urethral Motion Profile Before and After Suburethral Sling Placement

We examined the effect of the Monarc suburethral sling on urethral mobility. We retrospectively studied the records of 54 consecutive women who received a Monarc suburethral sling between July 2005 and November 2008. All patients were examined by volume ultrasound preoperatively and at followup (average 0.7 years). Volume data sets were analyzed using post-processing software. Urethral mobility was described by vectors of movement from rest to a maximum Valsalva maneuver of 6 equidistant points marked evenly along the urethra from bladder neck (point 1) to external urethral meatus (point 6), as identified in the mid sagittal view. Measurements were made of point coordinates relative to the pubic symphysis dorsocaudal margin at rest and during maximal Valsalva maneuver. To determine the urethral motion profile we calculated mobility vectors of the 6 points using the formula, square root [(x(val) - x(rest))(2) + (y(val) - y(rest))(2)], where val represents the value during the Valsalva maneuver and rest represents the value at rest. We compared values before and after sling placement. The subjective cure rate for stress urinary incontinence was 78% (42 cases). There was a statistically significantly decreased mobility at points 2 to 4, corresponding to the urethral central aspect (p = 0.002 to 0.018). No significant change in mobility was noted at the bladder neck and distal urethra (p = 0.39 to 0.89). Monarc suburethral sling placement decreases mid urethral mobility but does not seem to affect the bladder neck.

Sexual Activity and Urinary Incontinence in Women

Urinary incontinence during sexual intercourse refers to overactive bladder (OAB) syndrome and it is divided in incontinence during penetration and during orgasm. 480 women with low urinary tract symptoms (LUTS) were divided in a) affected by probable genuine stress incontinence, b) probable Urge-stress incontinence, c) probable Urge Incontinence, to specify incidence. Materials and Methods In Group C (186 women) 36 women, age range 24 to 56 years, with urinary incontinence only during sexual intercourse, were selected: 16 during orgasm (group I), 20 during penetration (group II). These patients filled in specific validated questionnaires (ICI-9), urinary recordings and, after urine exam, they underwent US study of urinary tract with post-micturition evaluation. The patients with other urological diseases or pelvic prolapse in stage II of POP-Q or higher were excluded. Patients were referred to physiatric evaluation and urodynamic exam with cystomanometry and perineal EMG, with provocative tests and after pressure-flow study. Results Cystocele was found in 4 out of 16 women in Group I, and in 6 out of 20 in Group II. No patients showed basic detrusor hyperactivity during cystomanometry. In Group I: 50% had detrusor hyperactivity and 18.75% had prolonged perineal relaxation. In Group II 30% had detrusor hyperactivity and 35% had prolonged perineal deficit. Results suggest parasympathetic deficiency in Group I and sympathetic deficiency in Group II.

Qualité de vie après cure d’incontinence urinaire d’effort : comparaison de trois techniques

Objectives To assess the health-related quality of life (Contilife ®) after three surgical anti-incontinence procedures (Tension-Free Vaginal Tape [TVT], Transobturator Vaginal Tape [TOT], and Transobturator Vaginal Tape [TVT-O]). Patients and methods We performed a prospective analysis of 90 women (30 TVT, 30 TOT, 30 TVT-0) with genuine stress incontinence pre- and postoperatively at 18 months. The objective cure rate was determined by clinical and urodynamic examination and the subjective cure rate by the Contilife ® questionnaire. Results Prior to surgery, patients complained more of effort activities, followed by global well-being. Postoperatively, all domains improved significantly without statistical difference between the three groups and 90% of the patients would advise the intervention to one of their friends. Discussion and conclusion Surgical outcomes vary greatly depending on the methodology of the study. Health-related quality of life seems paramount to decide time of surgery and to evaluate postoperatory results. We have chosen the Contilife ® questionnaire because of its scientific and clinical validity, reliability, responsiveness and linguistic validation. These results confirm that TVT/TOT/TVT-O procedures are a safe and effective surgical method and that they significantly improved health-related quality of life.

Results of the tension-free vaginal tape procedure for treatment of female stress urinary ıncontinence: a 5-year follow-up study

We evaluated the long-term cure rates, surgical complications rates after treatment of urodynamically confirmed primary genuine stress incontinence with tension-free vaginal tape (TVT). We performed a retrospective review of all patients undergoing the TVT procedure over a 5-year period to report intraoperative complication, postoperative complications and subjective cure rates. TVT was performed on 600 patients under general anesthesia. Among these patients, 563 were followed up for least 5 years; the remaining 47 patients could not be followed up. The mean follow-up interval was 63.1+/-3.1 (range 60-70) months. The mean age of the women was 51.7+/-11.6 years and mean body mass index 31.7+/-3.0 kg/m(2). Sixty-two percent (347) of women underwent the TVT procedure in conjunction with other vaginal surgery, and 38% (216) underwent TVT alone. The subjective analysis of the effect of surgery on the symptom of GSI was that, overall, 86.7% were completely cured, 6.0% were significantly improved and 7.3% found no change in the severity of her incontinence. No major nerve or vessel injury occurred, but 17 patients (3.0%) incurred bladder injury during the surgery. De novo voiding urgency occurred in 36 patients (6.4%). Thirty patients (5.3%) developed voiding problem, of which 19 patients had short-term voiding problem. The TVT procedure is a relatively safe and effective, minimally invasive surgical technique for the treatment of female urinary stress incontinence.

Necrotizing fasciitis following transobturator tape treated by extensive surgery and hyperbaric oxygen

The transobturator sling procedure (TVT-O) was developed to minimize surgical risks involved in treating genuine stress incontinence. All data suggest that most risks associated with the retropubic route such as injuries to the bladder, intestines or vessels are practically obsolete with the obturator route. However, severe soft-tissue infections have been reported with this new technique. In this case report, necrotizing fasciitis (NF) developed shortly after a TVT-O procedure. This life-threatening complication required extensive debridements, a diverting colostomy, antibiotics, and eight sessions of hyperbaric oxygen (HBO) therapy. We emphasize the importance of a unified interdisciplinary clinical approach in severe NF with rapid progression and systemic toxemia. Primary, aggressive but tissue-saving debridements together with antibiotics are the cornerstones of therapy. HBO therapy can oxygenate infected hypoxic tissues to help marginally viable tissues survive, reduce the inflammatory response, improve leukocyte bacterial oxidative killing capacity, and achieve infection control and healing.

Urodynamic Measures Do Not Predict Stress Continence Outcomes After Surgery for Stress Urinary Incontinence in Selected Women

We determined the prognostic value of preoperative urodynamic results in patients with stress urinary incontinence. In a 9-center surgical trial, women with stress urinary incontinence were randomized to a Burch or pubovaginal sling procedure. Women were eligible for the study if they had predominant stress urinary incontinence symptoms, a positive cough stress test, a bladder capacity more than 200 ml and urethral hypermobility. Preoperative free uroflowmetry, filling cystometry and pressure flow studies were performed in all. Overall treatment success required a negative pad test, no urinary incontinence on a 3-day diary, a negative stress test, no self-reported stress urinary incontinence symptoms and no re-treatment for stress urinary incontinence. Stress specific success required all of the last 3 criteria. We examined urodynamic measures, and whether the presence of urodynamic stress incontinence, the presence of detrusor overactivity and Valsalva leak point pressure would predict surgical success. Subjects with urodynamic stress incontinence had a 2-fold greater odds of overall success when compared with the No urodynamic stress incontinence group, but this trend did not quite reach statistical significance (OR 2.26; 95% C.I. 0.99, 5.17). Odds of stress specific success did not differ by urodynamic stress incontinence status. Subjects with detrusor overactivity did not have significantly worse success rates. Stratifying by treatment group, there was no difference in mean Valsalva leak point pressure values between surgical successes and failures. We found a nearly statistically significant trend that women with urodynamic stress incontinence are twice as likely to have a successful overall outcome from surgical management of stress urinary incontinence as women without urodynamic stress incontinence. The level of Valsalva leak point pressure and the presence of detrusor overactivity do not predict the success outcomes after the Burch or autologous fascia sling procedures in women with pure or predominant stress urinary incontinence. The impact of urodynamic studies on surgical outcomes needs further investigation.

Midurethral tissue fixation system (TFS) sling for cure of stress incontinence—3 year results

We have previously reported preliminary (9 month) results using the tissue fixation system (TFS) in patients with stress incontinence. The aim of the study was to assess the effectiveness of the TFS in patients with genuine stress incontinence at 3 years. The TFS uses two small plastic anchors to fix a (adjustable) midurethral polypropylene mesh sling into the pelvic muscles and tissues below the retropubic space. Thirty-six patients with stress incontinence, mean age 55 (35-87), mean weight 76 kg, (33-117 kg), mean 0.8 previous operations for stress incontinence, underwent a TFS midurethral sling operation between 2003 and 2004. The suburethral vaginal fascia was also tightened. The patients were contacted by telephone independently by a nurse. The critical question was "Do you leak when you cough?" A negative answer was taken as a cure. If she said "sometimes", she was asked on a scale of 1 to 100 what her improvement was. Of the 31 patients contacted, total symptomatic cure was reported by 25 patients (80%) and > 70% cure in a further two patients (6.5%). Five patients could not be contacted. There was a slight deterioration in cure rate for stress incontinence between 9 months and 3 years, similar to that seen with retropubic midurethral sling surgery.

Adductor compartment syndrome: An unusual complication of the trans-obturator tape procedure

A 48-year-old woman was admitted for a trans-obturator tape (TOT) procedure. She was known to have genuine stress incontinence on the basis of her urodynamic studies, her predominant symptom being ...

Predictors of Success With Postoperative Voiding Trials After a Mid Urethral Sling Procedure

We identified predictors of passing a voiding trial after incontinence surgery with a mid urethral sling and examined if successful performance on a voiding trial was maintained. A total of 89 women scheduled for incontinence surgery were enrolled from July 2005 until April 2006. Voiding trials were performed the day of discharge from the hospital, with a two-thirds volume void after a 300 ml fill considered passing. Those who passed underwent a second voiding trial 3 hours later. Of the participants 60 (67.4%) underwent tension-free vaginal tape surgery, 29 underwent transobturator tape (32.6%) and 64 (71.9%) underwent concurrent vaginal repairs. A total of 59 (67.0%) participants passed the first voiding trial. Univariate analysis identified 12 potential predicting variables for passing the first voiding trial. From these 12, model building via backward stepwise logistic regression found maximum flow on preoperative uroflowmetry to be the only significant predictive variable (p = 0.0002). Of the 59 women who passed the initial voiding trial 9 (16.4%) failed the second voiding trial. None of the 11 participants who had maximal flow rates greater than 30 cc per second failed the first or second voiding trial, whereas 17 of 22 subjects (77.3%) who had maximal flow rates less than 15 cc per second failed either of these trials. Maximum flow rates on preoperative uroflowmetry were the best predictor of passing an initial voiding trial after undergoing a mid urethral sling procedure for incontinence. However, the ability to maintain performance on a second voiding trial, even only 3 hours after passing an initial trial, is not assured.

The surgical anatomy of rectocele and anterior rectal wall intussusception

The aim of the study was to analyse the dynamic anatomical supports of the posterior vaginal wall from the perspective of rectocele and rectal intussusception repair. Two groups of patients were studied. Group 1 (n = 24) with genuine stress incontinence but no major vault prolapse had vagino/proctomyograms and transperineal ultrasound examinations. Group 2 with vaginal vault prolapse, clinical rectoceles and obstructive defecation symptoms (n = 19 had single-contrast defecating proctography before and after posterior-sling surgery. The posterior vaginal wall is suspended between perineal body, which underlies half its length, and uterosacral ligaments, which also support the anterior wall of rectum. Muscle forces stretch the vagina and rectum against the perineal body and uterosacral ligaments, creating shape and strength, like a suspension bridge. Postoperative proctogram studies indicated that anterior rectal wall intussusception has the same etiology as rectocele, deficient recto-vaginal ligamentous support. Repair to uterosacral ligaments and perineal body should be considered with large rectoceles, anterior rectal wall intussusception and obstructive defecation disorders.

Efficacité de la voie trans-obturatrice dans le traitement de l’incontinence urinaire d’effort par insuffisance sphinctérienne urétrale : à propos de 61 cas

Objectives To evaluate the effectiveness of the transobturator route in the treatment of intrinsic sphincter deficiency in the stress urinary incontinence. Patients and methods This is a retrospective multicenter study. Sixty-one patients with a low-uretral closure pressure were treated for stress urinary incontinence using the transobturator route. The intrinsic sphincter deficiency was defined according to criteria of the Société internationale francophone urodynamique (Sifud). The satisfaction of the patients was appreciated in postoperative consultation in the short run (six to 12 months) and by using the questionnaire “Contilife ®” evaluating the quality of postoperative life in the long run. The failure was defined when the patients declared themselves dissatisfied during the postoperative consultation and/or if their “Contilife ®” score was lower than seven (out of 10). Results The short-term evaluation reveals a rate of satisfaction of 92%. The questionnaire “Contilife ®” reveals 70% of very satisfied or satisfied patients. Eighteen percent of failure is noted. The majority of the patients in failure had urinary urgencies and/or overactive bladder. Discussion and conclusion Transobturator vaginal tape can be used in the treatment of patients having a low-uretral closure pressure. The patients must be informed of a success rate slightly lower than in women having a primary genuine stress incontinence.

360: TVT-O Inside-out: A Promising and Safer Route to Curing Genuine Stress Incontinence

360: TVT-O Inside-out: A Promising and Safer Route to Curing Genuine Stress Incontinence

What is the Variability in Urodynamic Parameters With Position Change in Children? Analysis of a Prospectively Enrolled Cohort

Insufficient data are available regarding the effect of patient position on urodynamic parameters and diagnoses in children. We report on a cohort of pediatric patients, comparing the results of serial urodynamic studies to determine the variability between the supine and sitting positions. Children referred for urodynamic evaluation were prospectively enrolled based on the ability to tolerate position change. Consecutive studies in supine and sitting positions were performed during a single session by the same nursing team. Volume infused and infusion rate did not differ with position change. A total of 48 children were enrolled in the study. Mean patient age was 10.4 years. No statistically significant difference was noted for maximum cystometric capacity, detrusor leak point pressures or pressure specific volumes at 20 and 30 cm water between the supine and sitting positions. Statistically significant lower values were found for the volume of first sensation and volume at which detrusor overactivity was first detected (p <0.05), with a trend toward significance for abdominal or Valsalva leak point pressure. Statistically significant differences were also noted with position changes in regard to detection of detrusor overactivity and incontinence episodes (p <0.05). In our study population no significant differences were detected in several urodynamic parameters with position change, suggesting that clinically valid conclusions can be obtained by performing the study in either position. Studies in the sitting position allow for increased detection of detrusor overactivity and incontinence, thus, being favored over the supine position if well tolerated by the child.

Coping with stress incontinence: women’s experiences of everyday inconveniences

Abstract Stress incontinence (SI) is a growing health concern among women. However, sufferers would choose to accept and not report their condition until it becomes too much to bear. Scant research is available to examine women who begin coping with SI and later decide to seek active advice and treatment. This study examined community‐dwelling women’s experiences of coping with SI and coping strategies used to manage incontinent situations prior to seeking professional help. A qualitative study was conducted on nine women from an out‐patient nurse‐led continence clinic of a Hong Kong hospital. Participants diagnosed with genuine SI and who were first‐time visitors to the clinic were interviewed. Data were content analysed. Five categories emerged to encapsulate the participant’s unique experiences of coping. The essence of coping with SI was for sufferers to gain ‘personal’ understanding of how the physiological problem impacted on daily lives. Based on self‐assessment of the situation, sufferers reassured themselves that the problem was manageable and devised strategies to take control of everyday inconveniences, without needing to seek professional help. However, sufferers eventually succumbed to physical and psychosocial impacts of the condition. SI was difficult to conceal from others, and experiences were fearful and distressing. However, women were eager to share their coping experiences, particularly about fears and useful coping strategies. As it was women’s first visit to the continence clinic, findings will inform the development of interventions to support newly diagnosed women sufferers’ mixed emotions and unique disruptions of SI in daily living.

Our experiences in Trans-Obturator Tape surgery after performing 150 cases

Nearly 30% of adult European women suffers from urinary incontinence. The recently introduced Trans-Obturator Tape (TOT) implant provides a new surgical technique for the treatment of stress incontinence. Preoperative work-up included detailed history taking, stress-test and Q-tip test, general and gynaecological physical examination and completion of the QUID questionnaire. Equivocal cases were further investigated with urodynamic assessment. TOT implantation was performed on 150 patients. Clinical efficacy of the treatment was evaluated with the QUID questionnaire. Mean age of the patients was 50.8 years (SD = 8.64). 69 patients (46%) had genuine stress incontinence, 33 patients (22%) had urge incontinence, 48 patients (32%) had mixed type incontinence with dominant stress component. Mean length of follow-up was 16 months (4-26 months). Preoperative severity score of stress incontinence was 11.78 on average, while that of urge component was 6.63. On average, it took 25 minutes to complete the operation. Four out of the 150 operations were complicated by adverse event. Twelve patients required prolonged catheterisation exceeding 24 hours with a maximum of 5 days. The mean length of hospital stay was 4.76 days (SD = 0.8). Evaluation of postoperative questionnaires resulted in a mean severity score of 2.22 for the stress component and 2.59 for the urge component. In a patient satisfaction survey 46 patients reported the treatment as excellent (47.4%), 39 as good (40.2%), 7 as satisfactory (7.2%), 3 as suboptimal (3.1%) and 2 patients reported the procedure as ineffective (2.1%). The procedure is an effective, quick, minimally invasive method of treating urinary incontinence. The operation requires short hospital stay and carries a low morbidity.

Outcomes Following Repeat Mid Urethral Synthetic Sling After Failure of the Initial Sling Procedure: Rediscovery of the Tension-Free Vaginal Tape Procedure

We evaluated outcomes of the repeat mid urethral sling to treat recurrent or persistent stress urinary incontinence after failure of an initial mid urethral sling. We retrospectively analyzed data on patients who underwent the repeat mid urethral sling procedure due to persistent or recurrent stress urinary incontinence. Repeat slings were placed without removal of the previous sling. All patients were followed at least 1 year after the second mid urethral sling. Of the 31 female patients with a repeat mid urethral sling 29 were followed, including 13 with a retropubic and 16 with a transobturator sling. For the first mid urethral sling 17 patients received a retropubic sling (tension-free vaginal tape) and 12 received a transobturator sling (6 inside out and 6 outside in procedures). Cure and improvement rates irrespective of the approach were 75.9% (22 of 29 patients) and 6.9% (2 of 29), respectively. Cure rates for the retropubic and transobturator slings were 92.3% (12 of 13 patients) and 62.5% (10 of 16), respectively, a difference that did not quite attain statistical significance (p = 0.089). The repeat mid urethral sling for persistent or recurrent stress urinary incontinence has a lower cure rate than the initial sling. However, the retropubic approach tends to have a higher cure rate than the transobturator approach in repeat sling cases.

Assessment of TVT efficacy in the management of patients with genuine stress incontinence with the use of epidural vs intravenous anesthesia

Our aim was to validate the use of intravenous anesthesia as an alternative to epidural anesthesia for the placement of tension-free vaginal tape (TVT) in patients with urodynamic stress incontinence. Eighty-six patients participated in this prospective study. Forty-five patients were operated with intravenous anesthesia and 41 patients with epidural anesthesia. All patients had a full history taken and a complete gynecological examination performed at initial visit. Preoperative and postoperative urodynamic investigations included filling and voiding cystometry, urethral profilometry, uroflow, and cough stress test. Genuine stress incontinence diagnosis was based on the findings of urodynamic investigations. Patients with prolapse more than first degree or detrusor instability were excluded from the study. The objective success rate for patients operated with intravenous anesthesia was 86.6%, whereas for patients operated with epidural anesthesia was 88% at 12 months of follow-up. We had no cases of postoperative bleeding or hematoma development. Postoperative urinary tract infection developed in three cases (3 of 74). Application of TVT procedure with intravenous anesthesia provides comparable results with the use of epidural anesthesia and could be a very good alternative.