Modified Pereyra Procedure Research Articles

Outcome of Urethral Reconstructive Surgery in a Series of 74 Women

We evaluated the results of vaginal flap reconstructive surgery of the female urethra. A series of 74 consecutive women who presented with urethral pathology requiring surgical reconstruction were assessed for anatomical and functional outcome. Followup was 1 to 15 years (median 1.5). Outcome assessment included success or failure of the anatomical repair based on physical examination as well as voiding habits and continence assessed by voiding diary, questionnaire and patient self-assessment. A total of 74 procedures were performed, including 72 vaginal flap repairs (56 with a concomitant pubovaginal sling). Five vaginal flap repairs were performed with a concomitant modified Pereyra procedure and 1 was done with Kelly plication. A patient in whom vaginal flap repair was planned underwent a Tanagho anterior bladder flap procedure, 1 underwent extensive lysis of urethral and periurethral scarring with primary urethral repair and 12 underwent vaginal flap repair without an incontinence procedure. A total of 72 women with an average age +/- SD of 54 +/- 13 years were followed a median of 1.5 years after vaginal flap reconstruction and 2 were lost to followup. Of the 62 patients with preoperative incontinence 54 (87%) considered themselves cured or improved. Successful anatomical repair by single procedure vaginal flap repair was achieved in all except 5 patients (93%). Single stage vaginal flap reconstruction with concurrent pubovaginal sling and Martius flap graft has a high degree of anatomical and functional success for treating a difficult surgical problem.

Risk of recurrent stress incontinence in women undergoing the combined modified pereyra procedure and transvaginal sacrospinous ligament vault suspension

Objectives. To determine the risk of recurrent stress urinary incontinence in women undergoing the combined modified Pereyra procedure and sacrospinous ligament vault suspension. Methods. A retrospective analysis of 62 patients who underwent the modified Pereyra procedure at Harbor-UCLA Medical Center between October 1, 1993 and July 10, 1999 for stress urinary incontinence was performed. Results. The study group consisted of 62 patients treated for stress incontinence; 34 (55%) of the 62 patients underwent the modified Pereyra procedure for stress incontinence, and 28 (45%) underwent the combined modified Pereyra procedure and sacrospinous ligament vault suspension for stress incontinence and coexistent uterine and/or vaginal vault prolapse. Patients undergoing the modified Pereyra procedure without vaginal vault suspension had higher subjective (91% versus 64%, P = 0.01) and objective (88% versus 61%, P = 0.02) cure rates of stress urinary incontinence compared with the patients undergoing the combined modified Pereyra procedure and sacrospinous ligament vault suspension. The mean follow-up period for the patients undergoing the modified Pereyra procedure (23 ± 14.4 months) was similar to that of the patients undergoing the combined modified Pereyra procedure and sacrospinous ligament vault suspension (26 ± 9.4 months) ( P = 0.3). Compared with the objectively cured patients, patients with objective failure demonstrated postoperative bladder neck hypermobility and a higher rate of recurrent grade 2 or greater anterior vaginal prolapse. Eleven patients had postoperative detrusor instability, and 2 patients who underwent sacrospinous ligament vault suspension developed recurrent grade 3 apical vault prolapse. Conclusions. Patients undergoing the combined modified Pereyra procedure and sacrospinous ligament vault suspension have high rates of recurrent stress urinary incontinence.

Editorial comment

Klutke et al. present their evaluation of 132 patients who underwent corrective surgery for genuine stress urinary incontinence. All patients were urodynamically evaluated before surgery and 1 year postoperatively. They compared the results of the Burch retropubic urethropexy, anterior vaginal repair, and the modified Pereyra procedure. Postoperative urodynamic evaluation recorded voiding pressures and flow rates. It is a commendable effort on their part to give us some insight into the possible mechanism of function of the surgical interventions used to correct genuine urinary incontinence. Their success rate was 87% with the Burch retropubic suspension, 70% with vaginal suspension, and 69% with anterior vaginal repair 1 year postoperatively. They came to the conclusion that the Burch retropubic suspension gave the highest success rate, but also had the highest percentage of patients with obstructed voiding patterns. They also came to the conclusion that this was a desirable outcome, assuming this success rate is tied to the obstructed outcome. This conclusion is really a matter of the interpretation of their findings. They stated that of their group of 76 patients who underwent successful retropubic suspension, 9 of them had equivocal voiding patterns preoperatively. One year postoperatively, they had 8 patients who had obstructed patterns and another 20 patients who were in the equivocal obstructed pattern. It seems as if those 8 patients with definite obstructed voiding pattern postoperatively were among the original 9 patients who had an equivocal obstructed pattern preoperatively. Again, looking carefully at their charts, the 20 patients who were in the equivocal obstructed group postoperatively were really voiding with pressures no higher than 45 to 50 cm H2O, and two thirds of them were voiding with pressures of 40 cm H2O or less. Definitely, most of them clearly were nonobstructed, as we all agree that voiding pressures up to 40 cm H2O are acceptable, and if the retropubic suspension improves the outlet resistance, then that is expected. That is also true in their patients with failure who did not show any change in voiding pressure. This is not uncommon in our preoperative evaluation: patients, especially those with a severe degree of urinary incontinence, would void with no rise in intravesical pressure yet with an adequate flow rate. Those patients postoperatively are definitely going to void with some rise in intravesical pressure if they were cured, and that is the outcome of improving outlet resistance.

Urodynamic changes in voiding after anti-incontinence surgery: an insight into the mechanism of cure

Objectives. To measure the effect on voiding pressure and flow rate of three different operations for stress urinary incontinence. Methods. In a previous study of cure rates, 289 women with genuine stress incontinence and genital prolapse were prospectively allocated in a randomized manner to one of three procedures: the Burch retropubic urethropexy, anterior repair, or the modified Pereyra procedure. In the current derivative study, we retrospectively evaluated the urodynamic indicators of voiding dysfunction in the original subjects preoperatively and at the 1-year postoperative follow-up visit. Results. One hundred thirty-two charts were available for review. One year after surgery, pressure and flow during voiding were altered to more obstructive levels with the suspension procedures (Burch and modified Pereyra). The proportion of patients with obstructive and equivocal voiding patterns after the suspension procedures was significantly greater than after anterior repair. Conclusions. This post hoc comparison of randomized data shows a difference in postoperative voiding indexes between suspension procedures and anterior colporrhaphy. Successful bladder neck suspension depends on altering the pressure and flow during voiding to more obstructive levels. Suspension procedures alter the voiding pressure and flow toward obstruction to a greater extent than anterior repair.

Comparison of the modified Pereyra procedure using permanent suture material and Burch urethropexy

Objective: To evaluate the results of the modified Pereyra procedure, using permanent suture, and Burch urethropexy. Study design: In 49 women undergoing modified Pereyra procedure and 48 women undergoing Burch urethropexy between January 1990 and January 1996 results were evaluated using questionnaire based outcomes analysis. Results: Follow up of all women undergoing needle suspension and Burch urethropexy showed that patient satisfaction was achieved in 86% and 81% respectively. Complete cure was achieved in 65% and 63% respectively. Conclusions: Patient satisfaction in both procedures appeared not totally dependent on the presence or absence of complete cure. The study supports the hypothesis that the modified Pereyra needle suspension using permanent suture is well suited for the treatment of uncomplicated stress urinary incontinence, when compared to Burch urethropexy after a follow up of 1 to 6 years. The results support the impression that permanent suture should be used in the modified Pereyra procedure.

Transvaginal bladder neck suspension to cooper's ligament: A modified pereyra procedure

We describe a modified Pereyra procedure with fixation of the bladder neck to Cooper's ligament. The anterolateral attachments of the paraurethral tissue to the inferior pubic ramus are exposed through a vaginal incision. Sutures are placed in the detached endopelvic fascia together with vaginal wall without epithelium and passed suprapubically through small ipsilateral skin and fascial incisions made slightly lateral to and at the level of the pubic symphysis, allowing visualization of Cooper's ligament. The sutures are passed through Cooper's ligament and tied to suspend the bladder neck. All ten women in whom we have done this operation have been subjectively cured of stress incontinence. Five have had long-term urodynamic follow-up. Four of these were dry by objective criteria, after a mean follow-up time of 18 months (range 15-23). The other patient was subjectively dry but had urodynamic evidence of recurrent stress incontinence.

The modified Pereyra procedure in recurrent stress urinary incontinence: A 15-year review: Holschneider C.H.; Solh S.; Lebherz T.B.; Montz F.J. USA Obstet Gynecol 1994 83/4 (573–578)

The modified Pereyra procedure in recurrent stress urinary incontinence: A 15-year review: Holschneider C.H.; Solh S.; Lebherz T.B.; Montz F.J. USA Obstet Gynecol 1994 83/4 (573–578)

The modified Pereyra (Raz) procedure for genuine stress incontinence—A useful option in the elderly or frail patient?

This is a prospective uncontrolled observational study to assess the modified Pereyra procedure for the treatment of genuine stress incontinence in women over the age of 65. Fifty women with proven genuine stress incontinence had pre- and postoperative clinical and urodynamic assessment with a follow-up for up to 2 years. At 2 months there was a subjective cure rate of 64% and an objective cure rate of 46%. The 2-year objective cure rate was 46%. The operation produced no voiding difficulties. Results were poorer in those who had had previous surgery, had preoperative detrusor instability, or were nulliparous. We conclude that the modified Pereyra may be recommended for parous patients without previous bladder neck surgery. Other patients may be more appropriately dealt with by a colposuspension, sling or periurethral collagen.

The Modified Pereyra Procedure in Recurrent Stress Urinary Incontinence

Department of Obstetrics and Gynecology, University of California Los Angeles, Center for Health Sciences, Los Angeles, California

The Modified Pereyra Procedure in Recurrent Stress Urinary Incontinence

To assess the effectiveness and perioperative morbidity of the modified Pereyra procedure in the treatment of recurrent stress urinary incontinence. Data of 54 patients who underwent a modified Pereyra procedure for the treatment of recurrent stress urinary incontinence between January 1, 1978, and August 1, 1992, were analyzed retrospectively regarding presenting symptoms, preoperative evaluation, surgical procedure, complications, and cure and failure rates. The patients were divided into two groups depending on the preoperative absence (group I) or presence (group II) of risk factors for repeated failure (detrusor instability, low-pressure urethra, fibrotic urethra, negative Q-tip test, and neurogenic incontinence). After a mean follow-up of 36.3 months, the cure rate of 81.6% in group I (N = 38) was significantly (P = .005) higher than that in group II (N = 16; 43.8% cured). The mean time of occurrence of failure was 11.9 months for group I and 6.8 months for group II. The incidence of intraoperative complications (Pereyra suture in bladder, hemorrhage) for both groups was 7.4%. Immediate postoperative complications were found in 25.9% of all patients; these were mainly infectious processes. Late postoperative complications occurred in 33.3%, with the most prevalent being new-onset urge incontinence and de novo detrusor instability (11.1%) and obstructive voiding dysfunction (9.3%). The rates of perioperative morbidity were not significantly different between the groups. The modified Pereyra procedure is well suited for the treatment of uncomplicated recurrent stress urinary incontinence, with a long-term cure rate of over 80%. However, success rates are significantly lower for recurrent stress incontinence in association with persistent risk factors for failure. In either instance, the procedure is associated with appreciable perioperative morbidity.

The modified Pereyra procedure: a clinical and urodynamic review.

To review the clinical and urodynamic outcome of treatment by the modified Pereyra procedure in 93 women with genuine stress incontinence. Retrospective review. Harbor/UCLA Medical Center and Los Angeles County Women's Hospital, Los Angeles, California, USA. Clinical and urodynamic assessment one year after modified Pereyra procedure. Overall 82% of patients were subjectively cured while only 63% were objectively cured. Women with failed surgery had significantly lower pre-operative maximum urethral closure pressures. The procedure had a low operative and postoperative morbidity with no significant disturbance of voiding function noted at one year follow-up. Our results with the modified Pereyra procedure for stress incontinence showed a significantly lower success rate than has been reported from many previous studies.

Needle Suspension Procedures for Urinary Stress Incontinence

Armand J. Pereyra introduced a new approach in the treatment of female urinary stress incontinence which did not require abdominal retropubic dissection. This operation and subsequent modifications by Pereyra serve as the foundation for various needle suspension procedures. The reported cure rates for the Modified Pereyra Procedure and its variations have exceeded 85 per cent in several studies. There has been some suggestion of an increased late failure rate in the Modified Pereyra Procedure compared to abdominal retroubic urethropexy. Additional long-term studies are needed to answer this important question utilizing preoperative and postoperative urodynamic evaluation. Karram and Bhatia in their review of transvaginal needle bladder neck suspension procedures cited three studies which accomplished this in a total of 60 patients. It seems the popularity of needle suspension procedures continues to grow. Increasingly, needle suspension procedures have been used in the outpatient treatment of urinary stress incontinence. A continuing tribute to the operative contributions of Armand J. Pereyra in the treatment of urinary stress incontinence.

Retropubic long-needle suspension procedures for stress urinary incontinence

A brief review of the Pereyra and the Stamey procedures and their modifications, including success rates and potential problems, is presented. A new modified technique is described that has potential advantages of ease, rapidity, less dissection, and less blood loss than may be seen with the modified Pereyra procedure and less chance of foreign body reaction than may be seen with the Stamey procedure. Twenty patients with significant stress urinary incontinence (14 with concurrent severe pelvic relaxation) underwent the procedure with an 80% cure plus 5% significant improvement rate noted 12 to 39 months after operation. All failures occurred in patients who were obese and involved apparent suture pull-through. Complications were minimal. Suggested causes for failures are discussed. (Am J Obstet Gynecol 1990;163:551-7.)

Historical vignette of Armand J. Pereyra, MD, and the modified Pereyra procedure: The needle suspension for stress incontinence in the female

In January of 1959, Armand J. Pereyra introduced a new approach in the surgical treatment of female urinary stress incontinence. Pereyra spent two decades experimenting with operative materials and various surgical techniques, revising his needle suspension procedure into the form we recognize today: the modified Pereyra procedure. This vignette documents events surrounding the development of the operation, its subsequent evolution, and related biographical details of the life of Dr Pereyra. Documentation indicates that all significant modifications of the needle suspension were performed by Pereyra initially.

A modified Pereyra procedure for urinary stress incontinence.

A modified Pereyra procedure for urinary stress incontinence.