Maximum Urethral Closure Pressure Research Articles

2272 PREOPERATIVE DETRUSOR OVERACTIVITY IS A PREDICTOR OF EARLY URINARY INCONTINENCE AFTER ROBOT-ASSISTED LAPAROSCOPIC PROSTATECTOMY

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Urodynamics Testing1 Apr 20132272 PREOPERATIVE DETRUSOR OVERACTIVITY IS A PREDICTOR OF EARLY URINARY INCONTINENCE AFTER ROBOT-ASSISTED LAPAROSCOPIC PROSTATECTOMY Akihiro Yanagiuchi, Hideaki Miyake, Kazushi Tanaka, and Masato Fujisawa Akihiro YanagiuchiAkihiro Yanagiuchi Kobe, Japan More articles by this author , Hideaki MiyakeHideaki Miyake Kobe, Japan More articles by this author , Kazushi TanakaKazushi Tanaka Kobe, Japan More articles by this author , and Masato FujisawaMasato Fujisawa Kobe, Japan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.2201AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To investigate changes in the bladder and urethral function and to detect preoperative parameters have an impact on early urinary incontinence after robot-assisted laparoscopic prostatectomy (RALP). METHODS This study included 60 consecutive patients who underwent RALP for clinically localized prostate cancer. Urodynamic study (UDS), including filling cystometry, pressure flow study, electromyogram of external urethral sphincter and urethral pressure profile, were performed in the patients before and 3 months after RALP. In this series, continence was defined as free for pad against urinary incontinence. International prostate symptom score (I-PSS), QOL index, and OABSS were also examined before and at 1 and 3 months after RALP. RESULTS All Patients included in this series could void spontaneously before RALP. On UDS, maximum cystometric capacity (MCC) and bladder compliance after RALP were significantly reduced than those before RALP. The degree of obstructive symptoms was markedly improved postoperatively, resulting in the significant decrease in maximum detrusor pressure 3 months after surgery; however, detrusor contractility was significantly deteriorated postoperatively. Furthermore, maximum urethral closure pressure (MUCP) and functional length (FL) after RALP were significantly decreased compared with those before RALP. In patients with postoperative incontinence, preoperative MUCP and FL were significantly lower than those in patients without incontinence. On multivariable analysis, detrusor overactivity was preoperative independent predictor of stress incontinence at 1M after RALP. CONCLUSIONS These findings suggest that both bladder contraction and external urethral sphincter function were not sufficiently recovered 3 months after RALP, and preoperative detrusor overactivity is a predictor of early stress incontinence after RALP. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e931-e932 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Akihiro Yanagiuchi Kobe, Japan More articles by this author Hideaki Miyake Kobe, Japan More articles by this author Kazushi Tanaka Kobe, Japan More articles by this author Masato Fujisawa Kobe, Japan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

The urethra is a reliable witness: simplifying the diagnosis of stress urinary incontinence. Reply to Wagenlehner et al.

Dear Editor, Dr. Wagenlehner and colleagues commented on my editorial, “The urethra is a reliable witness: simplifying the diagnosis of stress urinary incontinence” [1] by proposing a unilateral midurethral anchor test to predict the outcome after midurethral sling surgery. They present ultrasound observations that this procedure can prevent “funneling” of the bladder neck and urine loss, and they present urodynamic urethral pressure profilometry observations that this procedure increases maximum urethral closure pressure and improves the cough pressure transmission ratio. Similar urodynamic observations were reported 30 years ago by Bhatia and Bergman with the Bonney test [2] and the Marshall–Marchetti test [3], and I suspect the observations by Wagenlehner and colleagues are correct. Whether this test accurately reproduces what happens during a midurethral sling surgery or how predictive it is for surgical outcomes would require studies involving a standardized preoperative performance of this test in a large number of patients who have a midurethral sling so that positive and negative predictive values for the midurethral anchor test could be calculated. I do disagree with the statement that Wagenlehner et al. made in their reply with regards to the standing cough stress test. They stated: “We agree, but in our experience, testing in the standing position confers no additional accuracy against testing in the supine position.” The experience of myself and many others is quite different. The symptom of stress urinary incontinence (SUI) in women is more likely to occur in the upright than the supine position. Bladder pressure is higher when standing than when supine. In the Outcomes following vaginal prolapse repair and mid urethral sling (OPUS) trial of women with prolapse but without symptoms of incontinence, 111 of 331 women had a positive preoperative reduction stress test, but in 33, this only became positive in the standing position [4]. When a positive stress test includes both supine and standing positive results, the test predicts a 72% rate of postoperative SUI at 3 months and a 60% rate at 12 months if a midurethral sling is not inserted at the time of vaginal prolapse surgery (Supplementary Table 5) [5]. To maximize the sensitivity of the stress test in detecting SUI, it should be done standing with a full bladder.

Efficacy of a new pelvic muscle exercise for the treatment of female stress urinary incontinence

Objective To evaluate the efficacy of a new pelvic muscle gymnastic exercise in the treatment of stress urinary incontinence (SUI).Methods Prospectively,we randomly recruited 60 cases with mild and moderate SUI.We use ICI-Q-SF,pad Test and urodynamics to assess the degree of incontinence,volume of leakage,maximum urethral pressure and functional urethral length before and after intervention.Results The ICI-Q-SF score,volume of leakage,maximum urethral closure pressure and functional urethral length in study group before treatment were 11.6 ±4.2,(5.9 ±2.2) ml,(39.4 ± 12.5) cm H2O and (2.5 ±1.2) cm.The indicators in control group were 10.3 ±2.2,(5.8 ±1.3) ml,(41.3 ±8.9) cm H2O and (2.1 ± 0.5) cm respectively.There was no significant difference between the 2 groups (P ＞ 0.05).The ICI-Q-SF score,volune of leakage and maximum urethral closure pressure in study group after treatment were 7.7 ± 2.7,(1.8 ± 1.2) ml and (65.9 ± 8.9) cm H2O,which were significantly improved than the values of10.1 ±2.1,(5.7 ± 1.1) ml and (44.6 ±9.5) cm H2O in control group (P ＜0.05).Conclusions The new pelvic muscle exercise may play an important role in the treatment of mild and moderate SUI.Therefore,it could be recommended to the patients with mild and moderate SUI. Key words: Urinary incontinience, stress; Pelvic muscle exercise

Short-Term Functional and Urodynamic Outcome of W-ileal Orthotopic Neobladder with Serosa-Lined Tunneled Uretero-Ileal Anastomosis.

Functional and urodynamic (UDS) outcomes of W-configured ileal orthotopic neobladder (ONB) with extramural serosa-lined tunnel uretero-ileal anastomosis are presented Consecutive 17 patients undergoing ONB during December 2009 to March 2011 were enrolled. Of these 15 men (bladder cancer 14, tuberculosis 1) with mean age 52.7 ± 11.3 years completed the follow-up. Pouch-related quality of life (PQOL) was assessed using a published questionnaire. Uroflowmetry, cystometry/cystography and urethral-pressure profilometry were done at two follow-up visits at least 3 months apart. Mean follow up 10 ± 5 months. Mean length of harvested ileum 48 ± 6 cm. Overall PQOL were similar at both evaluations (55 ± 11 and 54 ± 15, respectively). During first and second follow-up, maximum flow-rate, voided-volume and post-void residual urine were 11 ± 4 mL/sec, 246 ± 99 mL and 68 ± 74.9 mL and 10.4 ± 4.6 mL/sec, 234 ± 138 mL and 86 ± 146 mL, respectively. Mean neobladder capacity, compliance, maximum urethral closure-pressure (MUCP) and functional urethral length were 484 ± 244 mL, 50.5 ± 49.1 mL/cmH2 O, 42 ±20 cmH2 O and 22 ± 12 mm, and 468 ± 250 mL, 46.4 ± 47.5 mL/cmH2 O, 52 ± 27cmH2 O and 23 ± 12 mm, respectively. Patients with smaller pouch (r = 0.828; P = 0.0001), longer urethral length (r = -0.392; P = 0.023) and lesser incontinence (r = 0.429; P = 0.011) had significantly better PQOL. With continued supervised pelvic-floor rehabilitation, a trend in improvement in hesitancy (P = 0.058), MUCP (P = 0.05) and bothersome incontinence (P = NS) was observed. None of the patients had any obstruction or reflux of the upper tracts. The index ONB has reasonable storage and voiding characteristics but with a rider of nocturnal urinary incontinence.

Periurethral skeletal myofibre implantation in patients with urinary incontinence and intrinsic sphincter deficiency: a phase I clinical trial

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Cell therapy using muscle precursor cell (MPC) injections has shown promise for urinary incontinence due to intrinsic sphincter deficiency (ISD), but the cell-preparation process is complex and costly. Implantation of freshly isolated myofibres carrying MPCs, mainly satellite cells, was very efficient in repairing muscle damage in recent animal experiments. In a phase I clinical trial, we investigated whether periurethral myofibre implantation generated local myogenesis and improved continence in 10 patients (five men and five women) with ISD. We found that myofibre implantation increased intraurethral pressure and periurethral electromyographic activity in patients with ISD. There were no serious side-effects. To assess the safety of periurethral myofibre implantation in patients with urinary incontinence due to intrinsic sphincter deficiency (ISD) To assess the resulting myogenic process and effects on urinary continence. An open-label non-randomised phase I clinical trial was conducted in five men and five women with ISD (mean age, 62.5 years). A free muscle strip from the patient's gracilis muscle was implanted around the urethra as a means to deliver locally myofibres and muscle precursor cells (MPCs). Patients were assessed for collection formation and incomplete bladder emptying. The maximum urethral closure pressure (MUCP) and concomitant periurethral electromyographic (EMG) activity were recorded before surgery and 1 and 3 months after surgery. Continence was assessed using the 24-h pad test and self-completed questionnaires, for 12 months. There were no serious side-effects. Continence improved significantly during the 12-month follow-up in four of the five women, including two who recovered normal continence. In the women, MUCP increased two-fold and de novo EMG periurethral activity was recorded. In the men, MUCP and EMG recordings showed similar improvements but the effect on continence was moderate. The few patients enrolled could affect these results. This is the first report of a one-step procedure for transferring autologous MPCs via myofibre implantation in patients with ISD. EMG and urodynamic assessments showed improvement of periurethral muscle activity. Further work is needed to confirm and improve the therapeutic efficiency of this procedure.

Urethral sphincter function before and after radical prostatectomy: Systematic review of the prognostic value of various assessment techniques

Urethral sphincter incompetence is generally considered to be the most important contributing factor to post-radical prostatectomy incontinence (PRPI). The value of various assessment techniques used to objectify urethral sphincter function before and/or after RP is unclear. Our review addresses the following questions: In men having to undergo RP, which measurement techniques that assess pre-operative and post-operative urethral sphincter function have predictive value for the post-operative continence status or correlate with the post-operative continence status. A systematic and comprehensive search was performed using the terms: urethral sphincter, radical prostatectomy (RP), and urinary incontinence. Results were restricted to English-language papers published between 1980 and March 2012. Only techniques described by at least two studies were included. Several assessment techniques for urethral sphincter function and anatomy were identified: sphincter electromyography, magnetic resonance imaging (MRI), perfusion sphincterometry and urethral pressure profilometry (UPP). A shorter urethral sphincter length on preoperative endorectal MRI might be associated with an increased risk of PRPI as well as longer time to achieve continence. UPP showed that both maximum urethral closure pressure (MUCP) and functional profile length (FPL) decrease significantly after RRP. Low preoperative MUCP and FPL are associated with an increased risk of PRPI. The other mentioned assessment techniques are not usable as preoperative diagnostic tools. MRI and UPP might be valuable preoperative diagnostic tools in patients waiting for RRP. However, more and larger studies are needed to show the exact role of MRI and UPP in the preoperative management of patients waiting for RRP and for whom post-operative incontinence is a big concern.

Post-reduction stress urinary incontinence rates in posterior versus anterior pelvic organ prolapse: a secondary analysis

Stress incontinence with vaginal prolapse reduction is less common in women with posterior-predominant prolapse (rectocele) compared with those with anterior-predominant prolapse (cystocele). This was a secondary analysis of a cohort of prospectively enrolled women with symptomatic pelvic organ prolapse at or beyond the hymen and prolapse-reduced stress urinary incontinence (SUI) testing. Subjects were included if they had anterior- or posterior-predominant prolapse with at least a 1 cm difference in pelvic organ prolapse quantification (POP-Q) points Ba and Bp (N = 214). We evaluated the prevalence and risk factors of post-reduction SUI between the two groups. Comparing posterior (n = 45) and anterior (n = 169) prolapse groups, we identified similar rates of post-reduction SUI (posterior: 6/45, 13.3 %; anterior:18/169, 10.7 %; p = 0.52) and SUI without reduction (posterior:4.4 %; anterior:11.2 %; p = 0.26). Maximum prolapse size was slightly larger in anterior than in posterior patients (+3.1 vs +2.0 cm beyond the hymen, p = 0.001), while a higher proportion of posterior subjects reported a prior hysterectomy (p = 0.04). Among posterior subjects, lower maximum urethral closure pressure values (MUCP; p = 0.02) were associated with post-reduction SUI. In contrast, among anterior-predominant prolapse, larger prolapse measured at POP-Q point Ba (p = 0.003) and maximum POP-Q measurement (p = 0.006) were each associated with higher rates of post-reduction SUI and were highly correlated with each other (R = 0.90). We observed similar rates of post-reduction SUI in women with anterior- and posterior-predominant pelvic organ prolapse. Factors affecting the anterior and posterior prolapse groups differed, suggesting different mechanisms of continence protection. These findings suggest that reduction incontinence testing for operative planning would be as relevant to posterior-predominant prolapses as it is to anterior prolapse.

Correlation between clinical presentation and urodynamic findings in women attending urogynecology clinic

Introduction:Urodynamic studies objectively observe lower urinary tract function and dysfunction so that an appropriate treatment can be planned. In the present study, we tried to evaluate the role of urodynamic studies in the final diagnosis and management plan in patients attending an urogynecology clinic.Materials and Methods:This observational study was conducted in an urogynecology clinic. 202 women were included. After detailed history, pelvic examination and introital sonography these women were subjected to urodynamic study. During the filling cystometry detrusor activity, first desire to void and bladder capacity was recorded. This was followed by urethral pressure measurements, when functional urethral length, maximum urethral closure pressure and stress urethral pressure profile was recorded.Results:Most prevalent complaint was mixed urinary incontinence (33.17%), followed by stress incontinence (31.68%) and urge incontinence (13.37%). According to the standard urodynamic definition 66.33% were normal in the population studied. None of the urodynamic parameters individually or in combination were found to be very useful for establishing a diagnosis.Conclusion:Establishment of the final diagnosis of urinary incontinence and planning of management should be based on detailed history, physical examination, bladder diaries, and careful interpretation of urodynamic data. Urodynamic study; however, doesn’t seem to be imperative to establish a diagnosis in uncomplicated cases where symptoms and signs are reliable and correlating.

Most of the patients with suburethral sling failure have tapes located outside the highpressure zone of the urethra

The high-pressure zone of the urethra (HPZ), which is crucial for the continence mechanism, extends between the point of the maximum urethral closure pressure and the urethral knee, and has been calculated to lie between 53% and 72% of the functional urethral length. According to recent studies the best results of suburethral slings are achieved when tapes are positioned under this zone. The aim of the study was to determine the location of tapes relative to the urethral length in patients seeking help due to recurrent stress urinary incontinence (SUI) following sling procedures. The study group comprised 61 patients suffering from recurrent SUI following suburethral slings performed from 6 months to 5 years earlier Forty-nine (80.3%) women were initially treated with a transobturator sling and 12 (19.7%) with a retropubic procedure. Twenty patients had the original sling performed at our department whereas, the other 41 in other institutions. The position of the tapes was determined at the sagittal plane by 3-D transvaginal ultrasound using a linear transducer The length of the urethra was measured from the bladder neck to the external urethral meatus following the urethral lumen, taking into account its curve. The position of the tapes relative to the percentage of the urethral length was calculated assuming the bladder neck as the proximal end of the urethra. The reference point was set at the midpoint on the tape. Only 13 (21.3%) patients had tapes positioned at 50%-75% of the urethral length. In 45 (73.8%) of women examined the tapes were found under proximal half of the urethra and in 3 (4.9%) distally to the 75% of the urethral length. In most patients in whom slings procedures proved unsuccessful the tapes are located under the proximal half of the urethra, that is outside the HPZ The position of a.tape outside the HPZ may be considered as a cause of suburethral sling failure.

Is a sequence of tests during urethral pressure profilometry correlated with symptoms assessment in women?

Our purpose was, applying a strictly defined protocol for urethral profilometry, 1) to test the repeatability of same session rest maximum urethral closure pressure (MUCP) and 2) to search for correlation between women complaint and the changes in MUCP value (rest and dynamic tests). A population of 140 consecutive women referred for evaluation of lower urinary tract dysfunction was stratified in 4 groups according with the urinary symptoms: stress, urge, mixed incontinence and continent and in each group in 3 age groups (young, middle age and old). The sequence of tests recorded in supine position was: urethral pressure profile at rest bladder empty, after bladder filling at 250 mL (reference test), stress profile, fatigability (before (rest) and after 10 successive strong coughs), then in standing position. In all groups, there was no significant difference between the two MUCP values at rest bladder filled. In the three incontinent groups, MUCP was higher bladder empty than bladder filled (p < 0.05) except in the young sub-group. Stress incontinence led to significant decrease of MUCP during dynamic tests in the young group. MUCP was not modified after fatigability test in women with urge complaint whatever age. When recorded following a strictly defined protocol, MUCP at rest bladder filled has a good repeatability in individual. However a complex sequence of tests during urethral pressure profilometry remains discussed in middle-age and old age-groups, it allows specifying the stress component of incontinence in young women and the urgency component in all age-groups.

Investigation of influence of inside out transobturator vaginal tape (TVT-O) procedure on objective, subjective cure rates and different quality of life tests in stress urinary incontinence treatment

This study was aimed at Investigating the influence of the transobturator tape (TOT) procedure used in surgical treatment of stress urinary incontinence on objective and subjective cure rates, as well as quality of life. A total of 156 patients who were diagnosed as stress incontinence and mixed incontinence with stress predominancy, underwent a TOT operation under spinal anesthesia by one surgeon or two surgeons of the team. Transobturator vaginal tape (TVT)-obturator inside out material (TVT-O® (Gynecare) was used in the operation. All patients underwent preoperative and postoperative urodynamic tests and pad tests, and the results were compared. The objective and subjective cure rates were investigated in mean of 30.3 months of follow-up. The objective cure was evaluated with negative cough test and less than 8 g 24-h pad test, while the subjective cure was evaluated with Patient Global Impression of Improvement (PGI). All patients were given IIQ-7, UDI-6, UISS and VAS tests at least once and the influence of the operation upon quality of life was investigated. According to the result obtained, the mean follow up time was 30.3 ± 7.4 months (range 17 - 42). The objective cure rate was found to be 84.6% (132 patients), the subjective cure rate was found to be 89% (139 patients) and the failure rate was found to be 10.8% (17 patients). Preoperative and postoperative pad test results of the patients were found to be statistically significant (38 ± 22.3 vs. 1±2.6 p<005). Among urodynamics and symptoms evaluated pre- and postoperatively, a statistically significant difference was detected between the Q tip test (43.60 vs. 20.8), leaks over 24 h (4 vs. 0), daytime frequency/nocturia (0.95 vs. 0.58) and maximum urethral closure pressure (57.3 vs. 35) (p<0.05). The preoperative and postoperative incontinence impact questionnaire-short form (IIQ-7) (11 vs. 0.6), urogenital distress inventory-short form (UDI-6) (14 vs. 7), urinary incontinence severity score (UISS) (11 vs. 2.8) and the visual analogue scale (VAS) (68 vs. 8) quality of life tests showed a significant difference (p<0.05). Summarily, the objective and subjective cure rates of the TOT procedure in the surgical treatment of female stress incontinence were quite high, thus it is an effective technique. The influence of this operation on quality of life scores evaluated with various parameters is satisfying. Key words: Transobturator tape (TOT), objective and subjective cure rates, urinary incontinence.

Intrinsic sphincter deficiency: what is it and does it matter anymore?

There was a time when intrinsic sphincter deficiency (ISD) had a definition that was clinically relevant and guided the therapeutic decision-making process. However, over time the definition has become muddied and has somewhat morphed into a vague term defined in various ways with various tests. Currently, I doubt that any two clinicians use the same definition, and ISD has become more of a euphemism than a defined disease. So how did we get here? It may be the result of some technology introduced in the mid 1990s that has been described by my colleague T. Fleming Mattox as “The single most important practice altering technology in urogynecology in our lifetime,” the tensionfree vaginal tape (TVT). The term ISD was originally coined by McGuire et al. in the urology literature from the 1980s and was used to describe a severe form of stress urinary incontinence, equating it to an earlier term “type III urinary incontinence” (reported in Blavais and Olsson [1]). In the urogynecology literature ISD was equated with a concept introduced by Sand et al. in 1987 in an article describing the “low pressure urethra” [2]. These terms were urodynamically defined as a Valsalva leak point pressure (VLPP) of less than 60 mm H2O and a maximal urethral closure pressure (MUCP) of less than 20 cm H2O respectively. The disease ISD was a poor prognostic indicator and helped clinicians identify those patients at risk of failing our “gold standard” procedure for treating stress urinary incontinence, the Burch retropubic urethropexy. Subjects with ISD were felt to be better candidates for a pubovaginal sling. This literature contributed to ISD being formally defined in an Agency for Healthcare Research and Quality (AHRQ) 1996 manual on the evaluation and treatment of urinary incontinence in adults as follows:

Treatment options for intrinsic sphincter deficiency

Type III stress urinary incontinence (SUI) is generally defined as a condition that involves intrinsic sphincter deficiency (ISD). Although the clinical parameters for ISD are loosely defined as a Valsalva leak-point pressure <60 cmH(2)O or a maximal urethral closure pressure <20 cmH(2)O, consensus is lacking. As a result, studies evaluating the success of any treatment for ISD are difficult to interpret. Regardless, several studies over the past 20 years have evaluated a number of surgical and nonsurgical treatments specifically for SUI caused by ISD. Surgical options include retropubic suspension, needle suspensions, various types of suburethral slings and the artificial urinary sphincter, whereas nonsurgical options include urethral bulking agents. Assessing urethral function (specifically, leak-point pressure or maximal urethral closure pressure) and urethral hypermobility will enable treating physicians to determine the ideal solution for individual patients, especially as no standardized treatment for ISD exists.

A comparative study of a single-incision sling and a transobturator sling: clinical efficacy and urodynamic changes

In this retrospective study, a comparison is made of the clinical efficacy of two stress urinary incontinence treatment apparatuses, a single-incision sling and a transobturator sling. Eighty-five (single-incision n=43, transobturator n=42) consecutive patients were included in this study. Clinical outcomes were assessed by the cough stress test (CST), the pad test, the Impact Questionnaire-Short Form (IIQ-7), the Urogenital Distress Inventory six-item questionnaire (UDI-6), the Sexual Questionnaire-SF (PIS-Q), the pain score, and the postoperative changes in urodynamic parameters. A comparison of the 1-year follow-up data is presented. Three months post-surgery, 81.8% of the single-incision sling group and 74.4% of the transobturator sling group had a negative cough test and a dry pad test. One year after surgery, significantly decreasing UDI-6, IIQ-7, and increasing PIS-Q scores were observed in both groups, while the complication rates remained similar. Postoperatively, the single-incision sling group seems to show a greater improvement in UDI-6 score, require less operation time, and experience less blood loss, less postoperative pain, and a smaller decrease in maximal urethral closure pressure (MUCP). These results suggest that the single-incision sling and the transobturator sling are equally as effective and safe for the treatment of stress incontinence, as evaluated during the 1-year follow-up. The insertion of a single-incision sling seems to be less painful than that of a conventional sling. One year after surgery, the MUCP and mean flow rate of the transobturator sling group had significantly decreased compared with that of the single-incision sling group.

Value of Maximum Urethral Closure Pressure in Predicting the Outcome of Tension-Free Vaginal Tape and Transobturator Tape Procedure.

The short-term results for the tension-free vaginal tape procedure (TVT) and the transobturator tape procedure (TOT) for stress urinary incontinence (SUI) were compared using the preoperative maximum urethral closure pressure (MUCP). A total of 278 patients treated for SUI was considered: 165 who underwent TVT and 113 who underwent TOT retrospectively. The MUCP in a preoperative urodynamic study before and 3 months after surgery were evaluated. At 3 months after TVT, 159 patients (96.4%) were cured and four patients failed. The mean MUCP of the patients who failed was 22.5 ± 5.3 cmH2 O, which was significantly lower than that among the cured patients (P < 0.007). At 3 months after TOT, 100 patients (88.5%) were cured and seven patients failed. The mean MUCP of the patients who failed was 27 ± 6.3 cmH2 O, which was significantly lower than that among the cured patients (P < 0.001). Furthermore, the mean MUCP among the patients who were cured after TOT was significantly higher than that among the patients who were cured after TVT (P < 0.01). A further analysis using a ROC curve indicated that the MUCP value in the successful patients after TVT was ≧ 24 cmH2 O and that in the failures after TOT was ≦ 30 cmH2 O with selection sensitivity at 80%. These results suggest that the failure cases after TVT or TOT are often found in SUI with a low MUCP and that TVT might be superior to TOT in SUI with a MUCP ≦ 30 cmH2 O.

Maximum Isometric Detrusor Pressure to Measure Bladder Strength in Men With Postprostatectomy Incontinence

To describe the use of isovolumetric detrusor pressure (Piso) in men with postprostatectomy incontinence and compare the rates of detrusor underactivity using Piso versus other common measurements/surrogates of bladder strength. We evaluated 62 men referred to our institution during a 3-year period for workup of postprostatectomy incontinence. During videourodynamic evaluation, the maximum Piso was measured using a mechanical stop test--with the examiner gently occluding the penile urethra during volitional voiding. Statistical analysis was performed to evaluate the effect of patient variables on Piso. The mean Piso was 54.6 ± 25.4 cm H(2)O. The Piso was <50 cm H(2)O in 40%. Isometric strength did not significantly correlate with age, interval since radical prostatectomy, abdominal leak point pressure, maximal urethral closure pressure, or pad use. The bladder contractility index and other approximations of detrusor underactivity were not predictive of low isometric pressure. Detrusor underactivity is relatively common in men with postprostatectomy incontinence, with 40% demonstrating a Piso <50 cm H(2)O. Our data do suggest, however, that the use of common bladder contractility nomograms, such as the bladder contractility index, might not be appropriate in this population.

Repeat mid-urethral sling for recurrent female stress urinary incontinence

The aim of the study was to assess the effectiveness of repeat mid-urethral sling after a failed primary sling for stress urinary incontinence. A total of 112 women with recurrent stress incontinence after primary mid-urethral sling underwent a repeat procedure between 2000 and 2011. All patients had a preoperative clinical and urodynamic evaluation. Outcomes were divided into three groups: cured (no more leaks), improved (decrease of leaks), or failed. All patients had urethral hypermobility and 12.9 % had intrinsic sphincter deficiency [maximum urethral closure pressure (MUCP) ≤ 20 cmH2O]. Median MUCP was 41 cmH20. Overactive bladder was found in 5.7 % of women. The second sling placed was one of the following: retropubic Tension-free Vaginal Tape (49 %), transobturator tape (48 %), or mini-sling (3 %). No intraoperative morbidity was reported. After the second sling was placed, 68 (60.7 %) patients were subjectively cured and 18 (16.1 %) improved (76.8 % success overall) with a mean follow-up of 21 months. Success rates were 72.2 and 81.8 % for transobturator and retropubic slings, respectively, with no significant difference. Multivariable analysis showed higher odds of cure and improvement with the retropubic approach after adjusting for MUCP. Late complication rates were comparable to those observed after a first sling. Urodynamic parameters were not associated with postoperative success. Repeat mid-urethral sling for recurrent female stress urinary incontinence is nearly 77 % successful in a group of patients with persistent urethral hypermobility. A retropubic approach might be preferred for patients with low urethral closure pressures.

A novel cell therapy for stress urinary incontinence, short‐term outcome

The aim of this study was the safety assessment of urethra injections of autologous total nucleated cells (TNCs) along with platelets, which focused on the outcome over a 6 month period. An open, prospective study was conducted on 9 patients with severe stress urinary incontinence (SUI). At the baseline, 1, 3, and 6 months after external urethral sphincteric and submucosal injections of autologous TNCs along with platelets, the patients were assessed according to cough tests, Q-Tip tests, urodynamics, 1 hr pad tests, upper tract ultrasonography (UTU), post voiding residue (PVR), International Consultation on Incontinence Questionnaire-Urinary incontinence (ICIQ-UI), and International Consultation on Incontinence Modular Questionnaire-Quality of Life (ICIQ-QOL). On the 3rd month post-injection, the maximum urethral closure pressure (MUCP) and abdominal leak point pressure (ALPP) were measured in one patient with intrinsic sphincteric deficiency (ISD; the baseline: ALPP < 60 and MUCP < 30 cmH(2)O). No complications were observed after injection. At 6-months' follow up (F/U), all the patients considered themselves clinically cured with eight women completely continent and one marked improvement. Mean age was 48.9 ± 13.8 years. Before the injection, urodynamics, UTU, and PVR were normal and cough tests, 1 hr pad tests were positive in patients. At 1, 3, and 6 months post-injection, there was a significant improvement in ICIQ-UI, ICIQ-QOL (P < 0.05). UTU and PVR were normal, cough tests, and 1 hr pad tests were negative, except for ISD patient with severe coughs (at month 3: ALPP = 92 and MUCP > 30 cmH(2)O). Cell therapy consisting of intrasphincteric and submucosal injections of autologous TNCs along with platelets in SUI patients is a feasible and safe procedure. The results point out those subjects cured or with marked improvement after 6 months F/U.

Bulking agents: an analysis of 500 cases and review of the literature

Stress urinary incontinence (SUI) is common, impacts women's quality of life, and generates high costs. Physiotherapy is the first-line therapy, and if it fails, suburethral slings are the gold standard in SUI surgery. Bulking agents injected periurethrally might be a beneficial alternative, but there is a paucity of data on bulking therapy. The aim of this study was to prospectively analyze the efficacy and safety of bulking agents in the setting of a tertiary referral center. In the last 13 years, 514 elderly women with SUI were treated by injection therapy with either collagen (Contigen), hyaluronic acid (Zuidex), ethylene vinyl alcohol (Tegress), or polyacrylamide hydrogel (Bulkamid). Subjective and objective outcome was recorded at the 12-month postoperative appointment using the King's Health Questionnaire, visual analogue scale (VAS) describing their incontinence severity, standardized pad test, and urethral pressure profile. Demographic data were equally distributed in all four groups of agents used. Sixty-one patients were lost to follow-up (10.6 %). Statistically significant changes were found for maximum urethral closure pressure (MUCP), pad weight, and VAS before and after bulking for the four agents used. Pad test was negative in 73.2 % of patients after bulking therapy. Subjective assessment showed improvements in general health and role limitations. The overall complication rate was low for all agents. This study shows improvement in incontinence after bulking therapy according to subjective and objective outcomes in an elderly population. In contrast to earlier reports, side effects due to injections were few and mild. We can advocate bulking therapy for treating SUI, as it is simple, safe, and shows both objective and subjective improvement and relief.

Maximum urethral closure pressure in women: normative data and evaluation as a diagnostic test

Our goal was to identify correlates of maximum urethral closure pressure (MUCP) and MUCP as a diagnostic test for stress urinary incontinence (SUI). This study was a retrospective review of women with non-neurological referrals for urinary incontinence between1995 and 2006. We studied the characteristics of 8,644 women who underwent urodynamics for non-neurological referrals. Mean MUCP was 48 cm H(2)O in urodynamic stress incontinence (USI), 50 cm H(2)O in mixed urinary incontinence (MUI), 65 cm H(2)O in detrusor overactivity incontinence (DOI) and 67 cm H(2)O for continent women . Age and MUCP were negatively correlated in all groups. Multiple regression analysis showed lower levels of MUCP in women with USI who also had previous hysterectomy or anti-incontinence surgery or who were in an older age group. Previous anti-incontinence surgery and older age were risk factors for lower MUCP in women with MUI and DOI. Receiver operator curves did not show MUCP to have utility as a diagnostic test despite age and parity stratification. MUCP < 20 cm H(2)O showed a sensitivity of 5 % and specificity of 98 % in diagnosing USI. MUCP failed to meet the criteria for a diagnostic test. Women with USI and MUI have lower MUCP than women with DOI and continent women in each decade of life. MUCP decreases with age.