Intrinsic Sphincter Deficiency Research Articles

The bone-anchor sub-urethral sling for the treatment of iatrogenic male incontinence: subjective and objective assessment after 41 months of mean follow-up

To evaluate retrospectively the objective and subjective parameters in 42 male patients who underwent bone anchored sub-urethral sling positioning (BAUS) for SUI (stress urinary incontinence) due to ISD (intrinsic sphincter deficiency). Patients with SUI due to radical retropubic prostatectomy (36 patients), transurethral resection of prostate (5 patients) and open simple prostatectomy (1 patient) underwent BAUS positioning between July 1999 and September 2005 (mean FU = 41 months). Before and after surgery, the patients were evaluated by physical examination, urethrocystoscopy, urodynamics, 1 h pad test and QoL questionnaire. Surgical technique involved perineal implantation to the pubic rami using four anchors of a sub-urethral sling made of synthetic (26 patients), biological (4 patients) or mixed (12 patients) material. Patients were stratified into three groups: (1) Cured: dry patients at stress test, pad weight 0-1 g. (2) Improved: patients with mild-moderate incontinence, pad weight 2-50 g. (3) Failed: unchanged patients, pad weight > 50 g. At the final follow-up visit cured, improved and failed patients were 26 (62%), 4 (8%) and 12 (30%), respectively. Mean pad weight significantly decreased from 104.6 to 47.3 g (55%) and mean total questionnaire score significantly increased to 50.7 (66%). Mean ALPP significantly increased to 50.4 cmH2O (44.8%). Better results were seen with synthetic slings. Main complications were perineal pain (76%), detrusor overactivity (12%) and sling infection (4.8%). BAUS implantation is a safe, effective, minimally invasive option for iatrogenic male incontinence due to ISD. It compares favourably with AUS.

Surgery Insight: surgical management of postprostatectomy incontinence—the artificial urinary sphincter and male sling

Stress urinary incontinence in men is usually a result of intrinsic sphincter deficiency following prostate cancer surgery. Active conservative management with fluid restriction, medication management and pelvic floor exercises is indicated for the first 12 months. If bothersome incontinence persists, urodynamic evaluation is indicated in order to assess detrusor storage function, contractility and sphincteric integrity. Standard surgical options include urethral bulking agents, artificial urinary sphincter (AUS) and male sling. Periurethral injection of bulking agents is satisfactory in only a minority of patients, leaving AUS and male sling as the most common surgical treatments. In patients with severe urinary incontinence, AUS seems to have a higher rate of success than the male sling. Furthermore, AUS is indicated in men with detrusor hypocontractility as adequate detrusor contractility is needed to overcome the fixed resistance of the sling. In patients with milder levels of stress incontinence, the two techniques have approximately equal efficacy in the short-to-intermediate term. While current reports of the male sling are generally limited to 1-4 years' follow-up, the infection, erosion, and revision rate for the male sling seem somewhat lower than that for the AUS in appropriately chosen patients.

Combined trans- and periurethral injections of bulking agents for the treatment of intrinsic sphincter deficiency

The purpose of this study was to compare Contigen combined with Durasphere to Contigen injections alone for the treatment of stress urinary incontinence (SUI) with intrinsic sphincter deficiency (ISD). Subjective and objective incontinence outcomes were compared at 2 weeks and 6 months. We compared rates of urinary retention and future incontinence surgery between groups. Thirty-three women underwent combined injections, and 51 underwent Contigen injections. Two weeks postoperatively, more women in the combined group were cured (72.7 vs. 39.2%, P = 0.003), but this difference diminished at 6 months (33.3 vs. 29.4%, P = 0.70). Retention was more common in the combined group (P = 0.002, odds ratio [OR] = 0.062 [95% confidence interval (CI) = 0.007, 0.52]). Twenty-three women in the Contigen and ten in the combined group underwent subsequent incontinence surgery (P = 0.17, OR = 2.03 [95% CI = 0.80, 5.1]). Combining Contigen and Durasphere injections to treat SUI with ISD does not improve outcomes compared to Contigen injections alone.

Clinical and urodynamic evaluation in women with stress urinary incontinence treated by periurethral collagen injection

To evaluate the success of treatment with periurethral collagen injections in patients suffering from stress urinary incontinence (SUI) with bladder neck hypermobility and intrinsic sphincter deficiency. Forty women suffering from (SUI) were selected and divided into GI (consisting of 13 women with SUI and bladder neck hypermobility) and GII (consisting of 27 women with SUI and intrinsic sphincter deficiency). Periurethral collagen was injected followed by a subjective evaluation (the need for urinary protectors) and an objective evaluation through urodynamic study before and after the treatment. It was noticed that after 9 months there was a decrease in the need of urinary protectors in the two groups. It was observed through the urodynamic study that either cure or improvement was achieved in 46% in GI and 40.7% in GII. There was a significant increase in the leak pressure in GII. Moreover, there was a decrease in the volume of urine leak in the two groups, being the results in GII statistically significant. It was concluded that the periurethral collagen injection is useful for the treatment of the SUI. The results in hypermobility are similar to those in intrinsic sphincter deficiency. In fact, it is a very simple out patient's procedure, with little side effects.

Pubovaginal sling with a low-cost polypropylene mesh

The aim of this study was to present the results of pubovaginal sling with a low-cost polypropylene mesh in the treatment of stress urinary incontinence. 118 women diagnosed with stress urinary incontinence (SUI) due to urethral hypermobility or intrinsic sphincteric deficiency, treated with pubovaginal sling (PVS) with a low-cost polypropylene mesh confectioned by the surgeon, were analyzed. All patients had a basic evaluation that included a medical history, physical examination, stress tests and urodynamic investigation. The average follow up was of 42 months. Urethral hypermobility was observed in 67% of the cases. The process was carried out on an outpatient basis on 67 patients. Intra-operative complications included 4 vesical injuries, treated with catheterization for 3 days. There were 13 early complications, of which 8 were urinary retentions treated with vesical drainage for 1 to 3 weeks and 3 vaginal extrusions of the mesh treated with covering of the sections with mucous membrane. There was a need for 6 urethrolysis in patients who presented irritative and postoperative obstructive symptoms; 81.3% of the patients were considered cured, while 9.3% had significant improvement. Three initially unsuccessful cases required sling reconfiguration. All cases were eventually cured. The construction of a pubovaginal sling using a low-cost polypropylene mesh is a safe and effective technique for the relief of SUI. It should be considered an alternative, especially for patients in public health systems with low financial resources.

Continuous urinary incontinence presenting as the initial symptoms demonstrating acontractile detrusor and intrinsic sphincter deficiency in multiple system atrophy

Severe stress incontinence due to intrinsic sphincter deficiency may be common in aged women. However stress urinary incontinence could be the initial symptom of severe neurogenic bladder even if no neurological signs have previously been recognized. Urodynamic study is necessary in such a case. Tension-free vaginal tape surgery and intermittent self-catheterization may be one option, but self catheterization might become difficult when the neurological disorders develop. In this case report, we highlight the need for caution in identifying the presence of an occult neurogenic bladder when intending to carry out surgery for patients with severe stress incontinence.

POS-01.07: Anatomical basis for effective placement of adjustable continence therapy (ACT®) balloons for treatment of female stress urinary incontinence

A peri-urethrally implanted prosthetic, the adjustable continence therapy device (ACT ® ) has been developed for female Intrinsic Sphincter Deficiency (ISD). We aimed to reproduce in cadaveric dissections the recommended ACT placement and determine the exact rela- tionship of this implant to the relevant internal pelvic anatomy and identify the anatomical location of the balloons in order to facilitate consi- stent clinical outcomes. Six hemi-pelves from post menopausal female cadavers were dissected after standardised insertion of 6 ACT balloons which were variously inflated to determine the best initial filling volume and to observe potential damage to the endopelvic fascia or the pelvic floor. Bilateral placement and expansion of the balloons at the posterolateral aspect of the vesico-urethral junction prevents downwards, lateral or posterior displacement. The endo-pelvic fascia forms the roof of the space with the vaginal wall acting as a barrier to movement. The floor is composed of the urogenital membrane which must be pierced by the trocar to permit successful placement. Rapid balloon expansion was associated with rupture of the overlying endopelvic fascia highlighting the importance of the slow expansion recommended by the manufactu- rer. Implantation of the ACT can be safely achieved through a thorough understanding of pelvic anatomy, and by maintaining full thickness between the surgeons' finger and the insertion instrument. Care should be exercised to correctly orientate the insertion instrument, to avoid any unintended trauma to normal structures.

Surgical Therapeutic Index of Tension-Free Vaginal Tape and Transobturator Tape for Stress Urinary Incontinence

Background/Aims: The aim of this study was to obtain the surgical therapeutic index (STI) of tension-free vaginal tape (TVT) and transobturator tape (TOT) and compare it with the previously obtained result of Burch colposuspension. Methods: The study population consisted of 121 patients who were diagnosed as having stress urinary incontinence, underwent TVT or TOT between January 1, 2000 and June 30, 2005 and were followed up for at least 1 year. Patients with detrusor overactivity, urinary tract infection, intrinsic sphincter deficiency and pelvic organ prolapse more than stage II according to the POP-Q system were excluded. The cure and complication rates were investigated, and the STI (median percent cure rate/median percent complication rate) of each operation was calculated. Results: Of the 121 patients, 61 underwent TVT and 60 received TOT. Patient characteristics and the results of preoperative urodynamic studies showed no significant difference between the two groups. The STI of TOT (2.72, 4.08, 4.23, 5.29) was higher than that of Burch colposuspension (1.19, 2.27, 2.89, 3.53) and TVT (2.77, 3.69, 3.23, 3.17) irrespective of follow-up months (at 1, 3, 6, 12 months). Conclusion: TOT seems to be a more suitable surgical procedure for stress urinary incontinence with urethral hypermobility.

Female urinary incontinence: pathophysiology, methods of evaluation and role of MR imaging

Urinary incontinence (UI) is one of the most common conditions that cause a significant psychosocial and hygienic problem in an aging female population. In this article we focus on the sphincteric type of stress UI in women, review the anatomy of the urethral sphincter and its support mechanism, and discuss methods of the evaluation of urethral function. Stress UI is the functional consequence of an anatomical abnormality, urethral hypermobility (UH) and intrinsic sphincter deficiency (ISD). Imaging plays an adjunct role to urodynamics in the assessment of women with UI. MR imaging due to its superior soft tissue contrast resolution contributes many findings that are predictive of UH, such as abnormal descent of the bladder neck, disruption of periurethral ligaments and vaginal attachments, and defects within the levator ani muscle. In ISD, MR imaging may show foreshortening or thinning of the sphincter muscle and bladder neck insufficiency manifested by funneling. MR imaging is ideal to evaluate the anatomy of the bladder neck and urethra; functional implications correlate well with functional studies and make MR imaging central to understanding the causes of stress UI and its thorough evaluation.

Does uroflow predict ISD?

The term superflow has been given to abnormally high flow rates in women, and has been thought to be indicative of intrinsic sphincteric deficiency (ISD), as ISD is associated with low urethral pressure. Pelvic organ prolapse (POP) damages the sphincteric mechanism extrinsic to the urethra. The aim of this study was to determine if ISD can be predicted from voiding flow rates in women with symptomatic POP. The charts of 82 patients who had undergone surgery for repair of symptomatic vaginal prolapse were reviewed. Uroflow and urodynamic endpoints were compared between dry and stress incontinent patients, and correlations between abdominal leak point pressures (LPP) and pressure/flow data evaluated. Average maximum flow (Q(max)) at uroflow was greater than at urodynamics with no significant difference in voided volumes. Twenty eight patients were found to have urodynamic stress incontinence (SUI), and an additional 19 to have "occult" stress incontinence. Patients with SUI had higher flow rates at urodynamics than continent patients. Voiding detrusor pressures and flow rates were not different when categorized by LPP cutoffs of 100 and 60 cm/w. Abdominal leak point pressure did not significantly correlate with any uroflow or urodynamic pressure/flow parameter. Flow rates, whether determined by uroflow testing or at urodynamics, are not predictive of ISD as defined by a low abdominal leak point pressure, in patients with symptomatic POP. Either the effect of ISD on flow rates is a non-linear complex relationship or LPP does not adequately define ISD.

Treatment of Stress Urinary Incontinence—Midurethral Slings: Top-down, Bottom-up, “Outside-in,” or “Inside-out”

Two randomized trials have reported no differences in efficacy between suprapubic arc and tension-free vaginal tape at 2 years. There are no long-term studies comparing the inside-out and outside-in transobturator (TOT) approach, although short-term data show no difference in cure rates or complications. The short-term efficacy of TOT midurethral slings is comparable with the retropubic slings; however, preliminary evidence suggests that TOT slings may have a lower success rate compared with retropubic slings for the treatment of intrinsic sphincter deficiency. The risk of bladder injury may be the least with the "inside-out" approach, whereas retropubic techniques have a higher risk of cystotomy as compared with the TOT approach. Four randomized controlled trials comparing the retropubic and TOT approaches show no differences in rate of de novo urgency, retention, frequency, nocturia, or incomplete voiding.

Intraurethral Transfer of Satellite Cells by Myofiber Implants Results in the Formation of Innervated Myotubes Exerting Tonic Contractions

We investigated a new method of muscle precursor cell transfer in the urethra for the treatment of urinary incontinence, consisting of implanting myofibers with their satellite cells. In preliminary experiments to test the regenerative capacities of satellite cells histological analysis was performed on days 7 and 30 after the implantation of myofiber cores in the urethra of 6 female pigs. In the main experiments 11 pigs underwent baseline urodynamics, followed by endoscopic destruction of the striated urethral sphincter located around the distal urethra (day 0). On day 30 circular myofiber strips in 7 experimental cases and adipocytes in 4 controls were implanted in the proximal urethra. Seven days later (day 37) 1 case was sacrificed to verify satellite cell activation. On day 60 urodynamics were performed without and with curarization. Urethral cryosections were immunostained for desmin (activated satellite cells), fast myosin heavy chain/bungarotoxin (myotubes/acetylcholine receptors), neurofilament/vesicular acetylcholine transporter (nerve endings) and CD45/CD68 (inflammatory response). Preliminary histological studies revealed a myogenic process consisting of myofiber degeneration and satellite cell activation (day 7), followed by myotube formation replacing parental myofibers (day 30). In the main experiments endoscopic injury abolished striated urethral sphincter activity. Implantation of myofiber strips generated a pressure peak that decreased after curarization (mean+/-SEM 71.5+/-17.8 vs 33.5+/-14.8 cm H2O, p=0.031) and reappeared 60 minutes later, revealing that this action was tonic and under neural control. Nerve endings connected to the acetylcholine receptors of myotubes were observed on day 60. An inflammatory response was observed only on day 7 in the myofiber implantation group. Adipocyte implantation resulted in no significant intraurethral pressure changes. Urethral implantation of myofibers regenerates as myotubes that exert tonic activity under neural control. This has potential clinical value as a means to create an additional striated urethral sphincter.

Treatment outcome of tension-free vaginal tape in stress urinary incontinence: comparison of intrinsic sphincter deficiency and nonintrinsic sphincter deficiency patients

The object of this study was to compare the treatment outcomes of tension-free vaginal tape (TVT) for intrinsic sphincter deficiency (ISD) and nonintrinsic sphincter deficiency (NISD) patients in stress urinary incontinence (SUI) and to evaluate whether TVT can be effectively used in both groups of patients. 111 women with SUI treated by TVT procedure from June 2003 to June 2005 with follow-ups for at least 1 year postoperatively were included in this study. The patients were divided into two groups: 31 patients with ISD and 80 patients with NISD. ISD was defined as the cases with low Valsalva leak-point pressure (VLPP) or Maximal urethral closure pressure (MUCP). Patients were followed up at 1, 3, 6, and 12 months postoperatively. There were no significant differences found in demographics between ISD and NISD groups: mean age, parity, body mass index, menopausal status, and hormone replacement therapy (p > 0.05). All urodynamic parameters except for VLPP and MUCP showed no significant differences. The cure rates of the two groups at 1 month follow-up (87.0 vs 100%; p = 0.0053) showed a significant difference, but no significant differences were found at 3, 6, and 12 months. There were no differences in postoperative complication rates (voiding difficulty, de novo urgency, urinary tract infection, retropubic hematoma, and vaginal mesh erosion) between the two groups irrelevant of follow-up months. TVT is effective for SUI in both ISD and NISD patients.

Multicenter Prospective Randomized 52-Week Trial of Calcium Hydroxylapatite Versus Bovine Dermal Collagen for Treatment of Stress Urinary Incontinence

To evaluate the safety and effectiveness of soft-tissue augmentation of the urethral sphincter with calcium hydroxylapatite (CaHA; Coaptite) compared with glutaraldehyde cross-linked bovine collagen (Contigen) in female patients with stress urinary incontinence due to intrinsic sphincter deficiency and without associated urethral hypermobility. This 12-month prospective, randomized, comparative, multicenter, single-blind, parallel, clinical trial of CaHA and collagen for soft-tissue augmentation of the urethral sphincter in the treatment of stress urinary incontinence enrolled 296 women. Up to five injections were performed in the first 6 months of the trial. Twelve-month postinjection efficacy data were available for 231 patients. The results indicated that CaHA and collagen were both well tolerated in this study. No systemic adverse events were observed with either product. We used the Stamey Urinary Incontinence Scale to grade the improvement, which was the primary endpoint of the study. At 12 months, 83 (63.4%) of 131 CaHA patients compared with 57 (57.0%) of 100 collagen patients showed improvement of one Stamey grade or more (P = 0.34). More CaHA patients required only one injection (n = 60; 38.0%) during the study compared with the Contigen patients (n = 36; 26.1%; P = 0.034). Also, the average total volume of material injected during the course of the study was less for CaHA than for collagen (4.0 mL versus 6.6 mL, respectively; P <0.0001). The results of the study have demonstrated that Coaptite is an appropriate and well-tolerated treatment for patients with incontinence due to intrinsic sphincter deficiency. This new soft-tissue augmentation material has a good safety profile and appears to provide durable improvement.

Comparison of Cystographic Findings of Intrinsic Sphincteric Deficiency with Urethral Hypermobility Causing Urinary Incontinence

Objectives: To evaluate the usefulness of standing and lateral cystograms for differentiation of intrinsic sphincter deficiency (ISD) from urethral hypermobility (UH) causing stress urinary incontinence (SUI). Materials and Methods: 67 female patients with urinary incontinence undergoing measurement of the Valsalva leak point pressure (VLPP) were included. 14 patients with VLPP <60 cm H₂O were operated for ISD causing SUI while 53 patients with VLPP >100 cm H₂O were operated for UH causing SUI. Three radiologists compared the cystographic findings. Results: The changes in posterior urethrovesical angle (PUVA) between stress and resting states were 12 ± 7.5° in ISD causing SUI and 32.8 ± 12.7° in UH causing SUI, and showed a statistically significant difference (p < 0.01). The beaking signs of the vesical neck on anteroposterior (AP) projection of the cystogram during a resting state were seen in 76% of ISD causing SUI. The difference was also statistically significant (p < 0.01). The existence of cystocele or the mean PUVA in two groups did not show a statistically significant difference. Conclusion: ISD should be considered in female patients with symptoms of urinary incontinence where there are changes in PUVA <20° on a lateral cystogram between a stress state and resting state in addition to the beaking sign of the vesical neck during a resting state.

Existe-t-il des facteurs pronostiques conditionnant le succès de la chirurgie de l'incontinence urinaire d'effort parbandelette sous-urétrale libre?

To provide a critical assessment on the tension free vaginal tape procedure used to support the urethra in female urinary incontinence. We identified articles related to Tension free vaginal tape through a MEDLINE search of English published literature from May 1998 to May 2006. Randomised control trial (RCTs) and retrospective clinical trials were selected including 478 publications on TVT (Tension-free Vaginal Tape), 55 on TOT) (Transobturator Tape), 17 on SPARC (Supra Pubic Arc), 2 on TPP) (Pre Pubic TVT). For the analysis of the functional results of the tape were not available: papers with a mean follow-up under 6 months, the invitation papers or non reviewed manuscript, the redundant papers in the same department, specific case control study. Preoperative age over 70years old and morbid obesity do not seem to be a risk factor for failure of the TVT procedure; however, there is an increase of de novo urgency for age over 70 years old and BMI over 35. Suburetral tape procedure is highly effective in women with intrinsic sphincter deficiency. The urethral hypermobility increases the efficacy of the procedure, however women with fixed urethra, are at significantly increased risks for failure of the procedure. In the same way, preoperative mixed urinary incontinence and voiding difficulties alter the success rate of the procedure. The mode of anaesthesia and the topography of the tape (retropubic or transobturator) have no incidence on the results. There is a definite learning curve (n=20) for the efficiency and the morbidity of the procedure. Cranial topography of the tape and associated procedures are associated with urgency and voiding difficulties. The prognosis factors having an effect on the success of the procedure are the urethral mobility, the mixed urinary incontinence, the learning curve, and the type of protheses.

Do Clinical or Urodynamic Parameters Predict Artificial Urinary Sphincter Outcome in Post-Radical Prostatectomy Incontinence?

To determine whether urodynamic or clinical parameters can predict artificial urinary sphincter (AUS) outcome in patients who were incontinent after radical prostatectomy (RP). Incontinence after RP is secondary to intrinsic sphincter deficiency, but urodynamics have been advocated before AUS placement to detect factors that could limit surgical success. We reviewed all AUSs placed for RP incontinence from January 1995 to December 2004. The preoperative clinical parameters and urodynamic parameters were correlated with surgical success using linear and logistic regression analysis, respectively. Surgical failure was defined as requiring more than one pad per day. The data from 86 patients (mean age 72 years) were analyzed. Of these 86 patients, 15 (17%) were wearing more than 1 pad per day at the last follow-up visit; 11 patients (13%) considered their operation a failure; and 20 patients (24%) had postoperative urgency. The presence of detrusor overactivity (P = 0.92), low first sensation (P = 0.52), low bladder compliance (P = 0.38), and bladder capacity less than 300 mL (P = 0.58) in patients did not predict for AUS failure compared with patients without these findings. No clinical parameters were found that demonstrated a statistical association with the number of pads per day. Older patients considered themselves less improved (P = 0.012) than did younger patients. No evidence has shown that patients who are incontinent after RP who have detrusor overactivity, a low first sensation, decreased compliance, or a low bladder capacity have worse post-AUS outcomes than other patients. Older patients tended to have decreased perceived improvement. We found no clinical or urodynamic parameter that would be a contraindication to AUS placement for post-RP incontinence.

Editorial Comment on: Prospective Clinical Trial Comparing Obtape® and DUPS to TVT: One-year Safety and Efficacy Results

Suburethral sling procedures are specifically designed to address both urethral hypermobility and intrinsic sphincteric deficiency components of stress urinary incontinence (SUI) in women. Although further studies are needed to establish their long-term efficacy and safety, these procedures seem more efficient than the ones adopted in the era before the development of tension-free vaginal tape (TVT). In their paper, Andonian et al [1] report the outcomes of three types of suburethral sling to treat female SUI. In a prospective, randomised, controlled, clinical trial Obtape and DUPS were compared to the original TVT procedure. The DUPS arm of the randomised clinical trial (RCT) was discontinued after 32 patients because they observed a high postoperative retention rate (18.8%) combined with suprapubic discomfort. This study demonstrates that, at 1-yr follow-up, no statistically significant differences in cure rates were evident, but Obtape, DUPS, and TVT were associated with postoperativecomplications in 14%, 28%, and 8% of patients, respectively (p 0.025). TVT was the only procedure associated with bladder perforation, and this complication was higher in patients who had undergone previous surgery [1]. The perivesical tissue hydrodissection due to local anaesthesia could reduce the risk of bladder perforation, but I agree with the authors that regional anaesthesia is better tolerated by patients. A recurrent SUI is reported in 23 patients (12.1%), but the outcome after retropubic and trans-obturator procedures is not available, so I suppose that the authors do not find any significant differences [1]. The International Consultation on Incontinence underlines that TVT procedure on recurrent SUI has shown promising results, whereas few data on this issue regarding the other type of suburethral slings efficacy are available in literature [2]. Urinary incontinence and pelvic organ prolapse (POP) commonly coexist [3]. SUI is observed in up to 60% of women with POP and prolapse in up to 40% of women presenting with SUI [3–5]. In this study a concomitant prolapse surgery (anterior and posterior colporrhaphy and vaginal hysterectomy) was performed in 29 patients (15.2%) and was associated with postoperative retention only in the Obtape group (38% vs. 4%) [1]. There are no data in the literature, obtained from comparative RCTs, that could clarify whether POP surgery and antiincontinence surgery have to be performed at the same or different times and which anti-incontinence procedure is better. The authors report no statistically significant differences among the three groups in terms of persistent or de novo urgency, but the overall rate of the persistent urgency ranges from 19% to 23% [1]. Recently, Costantini et al [6] reported on the efficacy of the retropubic or trans-obturator approach in the treatment of mixed urinary incontinence (MUI). They compared TVT and trans-obturator tape procedures and found that at a mean follow-up of 24 mo the outcome after TVT seems slightly worse in patients with MUI. ‘‘Urgency remains a postoperative problem especially in the TVT group’’ [6]. IbelievethatmulticentreRCTswithlongerfollowup are needed to establish which suburethral sling procedure in the treatment of MUI or recurrent SUI is better. In addition, comparative RCTs are needed to determine whether POP surgery and the retropubic or trans-obturator anti-incontinence procedure should be performed simultaneously or not.

Pediatric Urinary Incontinence: Evaluation of Bladder Wall Wraparound Sling Procedure

In 1996 a surgical procedure for sphincter deficiency was reported in patients with neurogenic urinary incontinence. To our knowledge we report the first series that assesses this procedure since it was initially described. Seven female and 7 male patients with spinal dysraphism and neurogenic intrinsic sphincter deficiency underwent surgery between 1997 and 2005. All patients had an associated poorly compliant or small capacity bladder. Patient age ranged from 8 to 22 years (mean 14) and all patients presented with persistent urinary incontinence despite intermittent catheterization and pharmacotherapy. Evaluation was based on clinical examination, as well as preoperative and postoperative urodynamic assessments. The surgical procedure involved wrapping a pedicle strip of anterior bladder wall around the bladder neck and fixing it on the pubic symphysis. Bladder augmentation cystoplasty was also routinely performed during the same procedure. Of 14 patients 13 were completely dry and 1 had stress incontinence. Followup was 2 to 8 years (mean 5). Postoperative urodynamic evaluation showed a maximum urethral pressure increase of 40%. We also observed an increase in bladder capacity of 105% and improved bladder compliance (7 ml/cm H(2)O preoperatively vs 35 ml/cm H(2)O postoperatively). The bladder wall wraparound sling procedure provides excellent results for continence in association with bladder augmentation.

Macroplastique Implantation System for Female Stress Urinary Incontinence: Long-Term Follow-Up

To evaluate the 60-month outcome of the Macroplastique Implantation System (MIS) for the treatment of female stress urinary incontinence (SUI) caused by intrinsic sphincter deficiency evaluated by objective and subjective measures, including Quality of Life (QoL) impact. Twenty-one women, mean age 47.4 years, with urodynamically diagnosed intrinsic sphincter deficiency were enrolled. They were assessed preoperatively by physical examination, QoL (King's Health Questionnaire), Stamey grading of incontinence, pad usage, 1-hour pad-weight test, and urodynamic testing. Patients underwent periurethral injection of MIS under local anesthesia. After 24-month follow-up, six patients were discharged from the group, and the remaining 15 patients were reassessed by means of objective and subjective parameters at 6, 12, 24, and 60 months after last treatment. Patients' QoL improved in all domains throughout the study. The overall subjective success rate was 80%. At 60 months, pad usage was reduced from a mean of 3.5/day to 0.9/day, and the 1-hour pad weight decreased from 53.8 to 5.9 g. Valsalva leak-point pressure testing demonstrated a 73.3% rate of cure/improvement. There was no significant statistical difference assessed by Stamey grading and objective cure at 6, 12, 24, and 60 months of follow-up. The data showed a stable overall outcome from 6 to 60 months. The MIS produced promising long-term subjective and objective outcomes, as well as long-lasting improvements in QoL. It should be considered a good option for certain cases of female SUI.