Mean Urethral Closure Pressure Research Articles

Risk factors for failure of repeat midurethral sling surgery for recurrent or persistent stress urinary incontinence.

To study the outcomes following repeat midurethral sling (MUS) surgery in patients with persistent or recurrent stress urinary incontinence after failure of primary MUS surgery and risk factors for surgical failure. The medical records of 24 patients who underwent repeat MUS surgery at a single tertiary center from January 2004 to February 2014 were reviewed. The types of MUS used for the repeat surgey were transobturator, retropubic and single incision slings. Objective cure was defined as no demonstrable involuntary leakage of urine during increased abdominal pressure in the absence of a detrusor contraction observed during filling cystometry, and subjective cure was defined as a negative response to Urogenital Distress Inventory six (UDI-6) question 3 during follow-up between 6months and 1year postoperatively. The change in the inclination angle between the urethra and pubic axis was measured with introital ultrasonography and the cotton swab test performed. The objective and subjective cure rates were 79.2% and 75%, respectively. There were no differences in demographics between the patients with failure of surgery and those with successful surgery. Significant independent risk factors for failure of repeat MUS surgery were a change in cotton swab angle at restand straining of <30° (OR 4.6, 95% CI 2.5-7.9°), a change in inclination angle of <30° (OR 4.6, 95% CI 2.5-7.9°), intrinsic sphincter deficiency (OR 3.4, 95% CI 1.8-6.1) and a mean urethral closure pressure of <60 cmH2O (OR 2.9, 95% CI 1.5-4.5). In one patient the bladder was perforated. Repeat MUS surgery is safe and has a good short-term success rate, both objectively and subjectively, with independent risk factors for failure related to bladder neck hypomobility and poor urethral function.

α1-Blockers for the treatment of recurrent urinary tract infections in women with dysfunctional voiding: a prospective randomized study.

To evaluate the therapeutic effects of tamsulosin on recurrent urinary tract infections in women with dysfunctional voiding. A total of 155 women with recurrent urinary tract infections and dysfunctional voiding were included and randomly assigned to the following groups: uroflowmetry biofeedback (group 1), α1-adrenoceptor antagonists (group 2), uroflowmetry biofeedback combined with α1-adrenoceptor antagonists (group 3) and no treatment (group 4). Patients were evaluated by the American Urological Association Symptom Index at 3, 6 and 12 months. Urodynamics was carried out in patients of groups 1, 2, and 3 at 3, 6 and 12 months, whereas urodynamics was only carried out at 12 months in group 4. All patients were followed up for 1 year with monthly urine cultures. The incidence of storage and emptying symptoms decreased significantly at 3, 6 and 12 months. Mean flow rate, flow time and voiding volume increased significantly (with a better outcome in patients of group 3), whereas post-void residual urine decreased. Mean opening detrusor pressure and detrusor pressure at maximum flow decreased significantly (with a better outcome in patients of group 3). Mean urethral closure pressure and maximum urethral closure pressure decreased significantly with a more significant decrease for patients in group 3. The prevalence of urinary tract infection decreased significantly in all groups after treatment, and this decrease remained stable during the follow up. In women with dysfunctional voiding and recurrent urinary tract infection, tamsulosin associated with uroflowmetry biofeedback might be an effective and safe treatment option for improving urinary symptoms and quality of life.

Triple therapy with Lactobacilli acidophili, estriol plus pelvic floor rehabilitation for symptoms of urogenital aging in postmenopausal women

To assess the effects of the combination of pelvic floor rehabilitation, intravaginal estriol and Lactobacillus acidophli administration on stress urinary incontinence (SUI), urogenital atrophy and recurrent urinary tract infections in postmenopausal women. 136 postmenopausal women with urogenital aging symptoms were enrolled in this prospective randomized study. randomly divided into two groups and each group consisted of 68 women. Subjects in the triple therapy (group I) received 1 intravaginal ovule containing 30 mcg estriol and Lactobacilli acidophili (50 mg lyophilisate containing at least 100 million live bacteria) such as once daily for 2 weeks and then two ovules once weekly for a total of 6 months as maintenance therapy plus pelvic floor rehabilitation. Subjects in the group II received one intravaginal estriol ovule (1 mg) plus pelvic floor rehabilitation in a similar regimen. We evaluated urogenital symptomatology, urine cultures, colposcopic findings, urethral cytologic findings, urethral pressure profiles and urethrocystometry before, as well as after 6 months of treatment. After therapy, the symptoms and signs of urogenital atrophy significantly improved in both groups. 45/59 (76.27%) of the group I and 26/63 (41.27%) of the group II referred a subjective improvement of their incontinence. In the patients treated by triple therapy with lactobacilli, estriol plus pelvic floor rehabilitation, we observed significant improvements of colposcopic findings, and there were statistically significant increases in mean maximum urethral pressure, in mean urethral closure pressure, as well as in the abdominal pressure transmission ratio to the proximal urethra. Our results showed that triple therapy with L. acidophili, estriol plus pelvic floor rehabilitation was effective and should be considered as first-line treatment for symptoms of urogenital aging in postmenopausal women.

Resolution of urge urinary incontinence with midurethral sling surgery in patients with mixed incontinence and low-pressure urethra

The aim of the study was to determine the rate of persistence of urgency or urge urinary incontinence following midurethral sling surgery compared to standard medication treatment in patients with mixed incontinence and ISD urethra. A prospective study was conducted at a tertiary referral Urogynecology Center. One hundred five women with stress urinary incontinence (SUI) and urgency were identified. Fifty-four consecutive women with SUI and urgency who underwent midurethral sling were compared to 51 women with SUI and urgency but treated with medications first. Women with persistent urgency or urge urinary incontinence (UUI) at 6-month follow-up following a TVT sling procedure were compared with those whose symptoms had resolved, to determine the risk factors for persistent symptoms. Forty out of 54 patients in the operation group also underwent a prolapse repair, either a colpopexy or a colpocleisis. All patients had demonstrated a mean urethral closure pressure of 20 mmHg or lower, indicating an intrinsic sphincteric deficiency. Persistent urgency (6 of 54, 11%) and UUI (3 of 54, 5.5%) were found in patients with mixed incontinence who underwent a sling operation. All 51 patients (100%) persisted with some urgency and urge incontinence despite anticholinergic medication treatment, only (7 of 51, 13.7%) reporting improvement of symptoms. Concomitant prolapse surgery, especially apical correction (OR 0.55, 95% CI 0.37–0.65), decreased the risk of urgency persistence, while age (OR 1.04, 95% CI 1.02–1.05), detrusor overactivity (OR 1.66, 95% CI 1.28–2.53), baseline symptom severity (OR 1.77, 95% CI 1.48–2.36), and previous incontinence surgery (OR 2.08, 95% CI 1.38–3.60) increased the risk of persistent urgency in the operated cohort. Women were happier in the operated cohort (45 of 54, 83.3% cure rate). A sling itself decreased the risk of persistent urge or UUI (OR 0.33, 95% CI 0.15–0.70). The most significant improvement was UUI at night. Urodynamic parameters, baseline urgency symptom severity, age, and concomitant prolapse operation are important predictors of persistent urgency or UUI following midurethral sling for mixed incontinence patients.

Effects of intravaginal estriol and pelvic floor rehabilitation on urogenital aging in postmenopausal women

To assess the effects of the combination of pelvic floor rehabilitation and intravaginal estriol administration on stress urinary incontinence (SUI), urogenital atrophy and recurrent urinary tract infections in postmenopausal women. Two-hundred-six postmenopausal women with urogenital aging symptoms were enrolled in this prospective randomized controlled study. Patients were randomly divided into two groups and each group consisted of 103 women. Subjects in the treatment group received intravaginal estriol ovules, such as 1 ovule (1 mg) once daily for 2 weeks and then 2 ovules once weekly for a total of 6 months as maintenance therapy plus pelvic floor rehabilitation. Subjects in the control group received only intravaginal estriol in a similar regimen. We evaluated urogenital symptomatology, urine cultures, colposcopic findings, urethral cytologic findings, urethral pressure profiles and urethrocystometry before, as well as after 6 months of treatment. After therapy, the symptoms and signs of urogenital atrophy significantly improved in both groups. 61/83 (73.49%) of the treated patients, and only 10/103 (9.71%) of the control patients referred a subjective improvement of their incontinence. In the patients treated by combination therapy with estriol plus pelvic floor rehabilitation, we observed significant improvements of colposcopic findings, and there were statistically significant increases in mean maximum urethral pressure (MUP), in mean urethral closure pressure (MUCP), as well as in the abdominal pressure transmission ratio to the proximal urethra (PTR). Our results showed that combination therapy with estriol plus pelvic floor rehabilitation was effective and should be considered as a first-line treatment for symptoms of urogenital aging in postmenopausal women.

Risk Factors for Failure of Retropubic and Transobturator Midurethral Slings

A number of studies have compared retropubic and transobturator midurethral sling procedures for surgical correction of female stress urinary incontinence (SUI). Although the cure rates for these 2 procedures appear to be similar, some evidence suggests that there may be differences in outcomes for certain subgroups of patients. This retrospective cohort study identified and compared statistically significant risk factors for failure of these 2 procedures among women with SUI. Data for 387 women with SUI (80%) and mixed urinary incontinence (MUI, 20%) were collected and analyzed at a large teaching hospital in the Netherlands. The patients had undergone a retropubic (n = 214) or transobturator tape procedure (n = 173). Failure of therapy was defined as patient report of the occurrence of any loss of urine during physical activity, coughing, or sneezing at 2 and/or 12 months after surgery. No statistically significant differences in SUI cure rates were found between retropubic and transobturator midurethral sling procedures. Multivariate analysis showed that independent risk factors for failure in the retropubic group at 12 months were MUI (adjusted odds ratio [aOR], 3.7; 95% confidence interval [CI], 1.5-9.1) and detrusor overactivity (DO) at urodynamic investigation (aOR, 8.6; 95% CI, 1.9-39.4). Independent risk factors for failure in the transobturator group were previous incontinence surgery (aOR, 3.9; 95% CI, 1.3-11.7) and a low mean urethral closure pressure at urodynamic investigation (aOR, 14.5; 95% CI, 1.5-139.0). These findings indicate that a transobturator approach may be beneficial among SUI patients who report MUI or have DO at urodynamics, whereas a retropubic procedure might be beneficial in those with previous incontinence surgery or a low mean urethral closure pressure.

When to perform urodynamics before mid-urethral sling surgery for female stress urinary incontinence?

Introduction and hypothesisDevelopment of a model that can predict in which group of women pre-operative urodynamics can be safely omitted.MethodsThree hundred and eighty-one uncomplicated women who underwent pre-operative urodynamics were evaluated. A multivariate logistic regression model was developed based on medical history and physical examination predicting a high probability group of women with detrusor overactivity or a low (<20 cm H2O) mean urethral closure pressure and, therefore, are likely to benefit from urodynamics.ResultsWomen are likely to benefit from pre-operative urodynamics if they (1) are 53 years of age or older or (2) have a history of prior incontinence surgery and are at least 29 years of age or (3) have nocturia complaints and are at least 36 years of age.ConclusionIf urogynaecologists omitted pre-operative urodynamics in women in the low probability group, in our population, pre-operative urodynamics would be reduced by 29%.

Risk factors for failure of retropubic and transobturator midurethral slings

The aim of our study was to identify and compare risk factors for failure of retropubic and transobturator procedures. This was a retrospective cohort study. Women with predominant stress urinary incontinence who underwent a retropubic (n = 214) or transobturator tape procedure (n = 173) were included. Therapy was considered to have failed in women reporting any amount of urine leakage during stress after 2 and/or 12 months. Risk factors for failure were mixed urinary incontinence (MUI; odds ratio [OR], 3.7; 95% confidence interval [CI], 1.5-9.1) and the observation of detrusor overactivity (DO) at urodynamics (OR, 8.6; 95% CI, 1.9-39.4) in the retropubic group. Reporting a history of previous incontinence surgery (OR, 3.9; 95% CI, 1.3-11.7) and a low mean urethral closure pressure (MUCP) at urodynamics (OR, 14.5; 95% CI, 1.5-139.0) were risk factors for failure in the transobturator group. Women with previous incontinence surgery or a low MUCP might benefit more from a retropubic sling, whereas a transobturator procedure might be preferable in women with MUI or DO.

Cure chirurgicale de l'incontinence urinaire d'effort de la femme par bandelette transobturatrice (de dehors en dedans). Étude de 70 cas

To evaluate the feasibility, the efficacy and the innocuousness of suburethral transobturator support using multifilament polypropylene transobturator tape (TOT) inside out for stress urinary incontinence in women. The study concerns 70 patients representing our team's first experience of this technique. The inclusion criterion was persistent SUI despite perineal rehabilitation. There were no exclusion criteria. Among the 70 patients, 22 (31%) presented with associated genital prolapse. Mean parity was 2.6 (extremes ranging from 0 to 6). Thirty-five patients were menopaused (50%), of whom 12 (34%) were under hormone replacement therapy. We retained five judgement criteria to evaluate this surgical act: duration of surgery and hospitalisation, per- and postoperative complications and functional results on SUI (via a telephone questionnaire). The rate of positive results (healing or improvement) was 84% with a mean follow-up of 14.5 months. The rate of peroperative complications was very low: 1.4% (only one case of bladder injury). The mean duration of surgery was 23 minutes. The mean duration of hospitalisation in the case of isolated TOT was 1.25 days. The transobturator approach is a feasible, safe and efficient short-term surgical technique. Results inferior to those observed in the literature are probably due to the learning curve in a university hospital unit. None of the preoperative data (age, parity, body mass index, history of SUI treatment or hysterectomy, hormonal status, associated prolapse, mean urethral closure pressure, clinical vesical hyperactivity syndrome) appears to influence results; however, the study strength is poor due to the small study population.

87 French multicentric prospective study for treatment of postprostatectomy stress urinary incontinence (SUI) using adjustable continence therapy (PROACT™)

Introduction: This study assessed the feasibility and efficacy of ProACT™ for treatment of postprostatectomy incontinence.Material and methods: Using fluoroscopic control two percutaneous balloons are placed at the vesico‐urethral anastomosis (Prostatectomy; Ablatherm) or the apex (TURP) and filled with isotonic solution. Postoperatively, 1 ml can be titrated monthly until optimum continence is achieved.Results: Fifty‐eight patients were implanted, 52 postcancer treatment (51 Radical Prostatectomy with 11/51 postradiotherapy and 1/52 Ablatherm) and six following benign surgery (four TURP and two other prostatectomies). Mean age was 70.8 years old (56.6–87.2) with time since initial surgery 5.3 years (6 months–20.6 years). Prior surgical incontinence treatments included artificial urinary sphincters (eight), bulking agent injections (three) and male sling (one). Mean urethral closure pressure (n = 36) was 49 cm of H2O at baseline. Average pads/day was 2.9 (1 to 10). Mean quality of life (I‐QoL) was 45 (2–85). At median follow‐up (14 months), 11 patients (19%) were dry, 21 (36%) improved, 17 (29 %) unchanged; 2 (3.4%) worse and seven (12%) had undergone explanation. Quality of Life increased to 61 (17–100). Of the 24 postradical prostatectomy patients without radiotherapy, 92 % are improved, 38 % being completely dry. However six (55%) of postradiotherapy patients failed.Sixteen patients required explanation due to infection (two); urinary retention (one); urethral erosion (one); pain (one), defective balloons (two); other (one) non‐response (eight). Four patients were successfully re‐implanted.Conclusion: ProACT is an effective treatment option as an alternative to the artificial urinary sphincter.

Minimally Invasive Surgery for Female Urinary Incontinence: Experience with Periurethral Microballoon Implantation

To assess the effectiveness of periurethral microballoon implantation for management of female urinary incontinence. A total of 45 women with urinary incontinence (age range 47-88 years) were treated between May 2000 and June 2001. Microballoons were placed in the proximal periurethral tissue using endoscopic instrumentation under local anesthesia. Follow-up assessment including urodynamic study and quality- of-life assessment was performed at 1, 3, and 6 months. Implantation was successful in all cases with no significant adverse effects. Cure was achieved in 60% and improvement in 5%. The failure rate was 35%. Microballoon implantation significantly increased the mean urethral closure pressure, from 35.2 cm H(2)O (SD 14.9; range 15-72 cm H(2)O) to 46.5 cm H(2)O (SD 19.7; range 16-87 cm H(2)O) (P = 0.001). The best predictors of successful outcome in univariate analysis were initial urethral closure pressure (P = 0.047) and degree of incontinence (P < 0.001). Periurethral microballoon implantation is a useful technique for the management of female urinary incontinence, especially in elderly and inoperable patients. The microballoons do not present the adverse effects associated with other bulking agents.

Changes in plasma gonadotropin concentrations and urethral closure pressure in the bitch during the 12 months following ovariectomy

Urinary incontinence due to acquired urethral sphincter incompetence is a common side effect of spaying, for which the underlying cause remains unknown. Spaying not only results in a significant reduction in the urethral closure pressure within 1 year but also in an increase in the plasma gonadotropin concentrations. To investigate the possible link between the post-ovariectomy changes in plasma gonadotropins and in urethral closure pressure, gonadotropin and urodynamic measurements were performed in 10 Beagle bitches before and for a period of 1 year after spaying. Plasma gonadotropin concentrations rose quickly after ovariectomy and peak levels were seen within 3–5 weeks, followed by a sharp drop until week 10. A steady increase was observed subsequently until week 42, when a plateau was reached. One year after spaying, the mean FSH concentration was 75.3±32.1 ng/ml, a 17-fold increase, and the LH was 8.3±3.8 ng/ml, an eightfold increase over the pre-spaying values. Ten months after spaying, the mean urethral closure pressure (9.7 cm H 2O) was significantly reduced when compared to the mean pre-operative value of 15.4 cm H 2O. However, there was no clear relationship between the gonadotropin concentrations and the urethral closure pressure. From these results it seems unlikely that chronically elevated gonadotropins are the underlying cause for reduced urethral closure pressure after spaying resulting in urinary incontinence.

Longterm followup of posthysterectomy vaginal vault prolapse abdominal repair: a report of 85 cases.

There are many surgical procedures to treat posthysterectomy vaginal vault prolapse. Abdominal sacral colpopexy is one of these procedures. The aim of this study was to review the cases of 85 consecutive patients treated by this technique since 1978 by the same surgical team using the same procedure. Our surgical procedure will be explained. Eighty-five patients were treated in our department between 1978 and 1998 for posthysterectomy vaginal vault prolapse. The mean age was 55.42 years. The mean weight was 63.37 kg. Their parity ranged from 0 to 5 (mean, 2.54). The interval of time between hysterectomy and vaginal vault prolapse repair ranged from 1 to 37 years (mean, 17.92 years). The main indication for hysterectomy was uterine leiomyomas. Of these patients, 67.05% had stress urinary incontinence, and mean urethral closure pressure was 48.7 cm H2O. All patients had abdominal sacral colpopexy associated with a Burch procedure and a posterior perineal repair. Seventeen patients had postoperative fever. Twenty-two had urinary tract infections. Two patients had to undergo blood transfusion. Three patients had postoperative urinary retention. The median longterm followup was 10.5 years; 27.05% of patients had relapsing stress urinary incontinence. Two patients had a relapse of the vaginal vault prolapse. The abdominal sacral colpopexy is a safe operation with low morbidity and long-standing good results. It can be recommended for sexually active women. Nevertheless, the Burch procedure performed with this operation failed to prevent recurrence of urinary incontinence.

The Tension–Free Transvaginal Tape Procedure in the Treatment of Female Urinary Stress Incontinence: A French Prospective Multicentre Study

Objective: To evaluate in a prospective multicentre study (five centres) the preliminary results regarding efficacy and morbidity of the new tension–free transvaginal tape (TVT) technique in the treatment of urinary stress incontinence (USI) in women. Methods: From November 1996 to May 1999, 52 women of mean age 64 (range 37–91) years underwent the TVT procedure to treat isolated grade 2 or 3 USI (44 cases) or grade 1 or 2 USI associated with uterine or rectal prolapse surgery (8 cases). Twenty–nine patients (55.8%) presented recurrent USI (1–4 previous procedures). Clinical data showed urethrovesical junction hypermobility in 35 cases (67.3%), isolated intrinsic sphincter deficiency (ISD) in 17 cases (32.6%) and pelvic organ prolapse in 8 cases. Urodynamics confirmed ISD in 27 cases (51.9%) with a mean urethral closure pressure of 18.5 (range 7–25) cm H₂O. All data were collected by surgeons on a questionnaire. Results: The surgical procedure was performed under spinal cord anaesthesia in 82.7% of patients (local anaesthesia 11.5%) with a mean operation time of 30 (range 20–60) min for TVT implantation. Six bladder injuries (11.5%) were identified and the needle was repositioned. Mean hospital stay was 2.5 (range 1–7) days in the group who underwent TVT alone. Mean follow–up of continence was 15.2 (range 6–36) months: 83% of patients were dry and 17% were improved. Nine patients (17.3%) required self–catheterization for 2–10 days postoperatively. No recurrence of USI, defect healing or tape rejection were reported. Conclusion: TVT is a new technique for the surgical treatment of USI which is useful for recurrent cases. The advantages are simplicity, low morbidity, reproducibility and reduced operative time. These early results indicate the technique is effective in correcting incontinence and is locally well tolerated. But these are preliminary data and the long–term outcome on USI and the urethra is needed.

The effect of changes of posture on the urethral closure pressure in stress-incontinent women.

The effects of changes of posture on intravesical and intra-urethral pressures were investigated in 10 women suffering from urinary stress incontinence. The patients were investigated in the supine and erect positions by simultaneous urethrocystometry and recording of the urethral pressure profile. In the supine position, the mean intravesical pressure was 12 mmHg, the mean maximum intra-urethral pressure 35 mmHg, and the mean urethral closure pressure 23 mmHg. When changing to the standing position, there was a statistically significant increase in the bladder pressure to 26 mmHg, and in the maximum intra-urethral pressure to 47 mmHg. The urethral closure pressure fell to 21 mmHg. The absolute length of the urethra increased from 25 to 30 mm, and the functional length from 20 to 22 mm. When compared with values found by the authors in an earlier, similar investigation on normal women, the maximum intra-urethral pressure is lower, and the functional and absolute lengths of the urethra are shorter in stres...