Persistent Stress Urinary Incontinence Research Articles

Long-term results of augmentation cystoplasty in spinal cord injury patients.

Prospective monocentric follow-up study. To assess long-term functional and urodynamic results of augmentation enterocystoplasty in spinal cord injury (SCI) patients with detrusor hyperreflexia and reflex incontinence who failed to respond to conservative treatment. Department of Urology (Pitié-Salpétrière Hospital, Paris, France), Department of Neurological Rehabilitation (Raymond Poincaré Hospital, Garches, France), Assistance Publique - Hopitaux de Paris, University Paris VI and V, France. Prospective study of 17 SCI patients (four above T6 level, nine between T6 and T12, and four below T12) with history of refractory urge incontinence to pharmacotherapy. Partial cystectomy (subtrigonal for 15) was performed with Hautmann enterocystoplasty (15) or detubularized clam cystoplasty (two). Mean follow-up was 6.3+/-3.8 years (range 1.25 - 10.5 years). Fifteen of 17 (88.5%) patients were completely continent under self clean intermittent catheterization (CIC) (mean 4.6/day, range 4 - 7). The remaining two patients with pudendal nerve denervation had persistent stress urinary incontinence. No operative complications were noted. Long-term complications included recurrent pyelonephritis for one patient. Maximal cystometric capacity increased from 174.1+/-103.9 to 508.1+/-215.8 ml (P<0.05). Maximal end filling pressure decreased from 65.5+/-50.2 to 18.3+/-7.9 cm H2O (P<0.05). Urodynamic evaluation and clinical assessment demonstrate long-term success of augmentation enterocystoplasty in an homogeneous population (SCI) without delayed complications in SCI patients.

The rectus muscle suburethral sling as a treatment for complicated stress urinary incontinence

Objective: To report the use of a pedicled rectus muscle flap as a suburethral sling for the treatment of complex stress urinary incontinence (SUI).Methods: Thirty-five women underwent a rectus muscle sling procedure for the treatment of complicated SUI. All operations were performed by a single surgeon (JWS) between September 1995 and February 1997 and involved the harvesting of a rectus abdominis muscle flap unilaterally up to the level of its first tendinous intersection. The muscle flap was sewn into a tubular structure and swung down with its blood supply through the space of Retzius. Once underneath the urethra, the flap was brought up on the contralateral side back into the retropubic space and attached to Cooper’s ligament or to the fascia of the obturator internus. All patients had a chief complaint of either SUI alone or significant genital prolapse (to the introitus or beyond) with “unmasked” SUI after the prolapse was reduced. All patients had demonstrable SUI on physical examination, and all underwent multichannel urodynamic testing with fluoroscopy preoperatively. The diagnosis of complicated SUI was based on one or more of the following factors: open bladder neck on fluoroscopy (29 patients), Valsalva leak point pressure less than 60 cm H2O (28 patients), maximum urethral closure pressure less than 30 cm H2O (24 patients), or demonstrable SUI after reduction of major genital prolapse with the urethra supported in its normal position (8 patients). Follow-up ranged from 30 to 48 months, and was assessed by either physical examination or telephone interview.Results: Twenty-eight patients (80%) were satisfied with the results of the operation. Three patients (8.6%) had persistent SUI; two patients (5.7%) had no SUI, but developed new urge incontinence; and two patients (5.7%) who had mixed incontinence preoperatively had persistence of urge incontinence (but no SUI) postoperatively.Conclusions: The rectus muscle sling seems to be a successful technique for the treatment of complicated SUI. In this difficult group of patients with open bladder necks, some with other previously failed procedures, the long-term success rate is comparable with any other incontinence operation published in the literature. When considering other suburethral sling material, muscle seems superior to synthetics because it has no erosion potential, and has the advantage of its own blood supply and presumed longevity when compared with autologous or donor fascia. The major disadvantage is the need for a midline abdominal incision. The long-term follow-up data are promising, and prospective studies are needed to further evaluate this procedure.

Correlation of persistent stress urinary incontinence with quality of life after suspension procedures: is continence the only decisive postoperative criterion of success?

Objectives. To determine objective continence rates and to include in the evaluation subjective assessment of continence and quality of life by the affected patients and correlate these with the objective continence rates in a retrospective study. Methods. One hundred thirty-three female patients in our clinic underwent suspension procedures for stress urinary incontinence, 68 undergoing a Burch colposuspension and 65 a Raz bladder neck suspension. The continence rate was evaluated by questionnaire and compared with patients’ postoperative self-assessment of continence and pre- and postoperative quality of life assessments. Results. For the 105 women returning evaluable questionnaires (57 Burch and 48 Raz procedure), the continence rate was 69.5% (75.4% in the Burch group, 60.4% in the Raz group). Mild incontinence requiring 1 to 2 sanitary pads daily was found in 19.3% of the Burch group and 31.3% of the Raz group. Moderate incontinence requiring 3 to 5 pads daily was found in 5.3% of the Burch and 8.3% of the Raz group. No patients had severe incontinence (more than 5 pads daily). Both groups showed statistically significant improvement in postoperative quality of life. Despite persistent incontinence, the satisfaction rate was comparable to that of continent patients. Conclusions. The results show that in addition to objective parameters, subjective assessment of quality of life is a factor that should be included in the postoperative evaluation of surgical results.

LONG-TERM RESULTS OF COLPOCYSTOURETHROPEXY FOR PERSISTENT OR RECURRENT STRESS URINARY INCONTINENCE

Purpose We review the long-term outcome of colpocystourethropexy for persistent or recurrent stress urinary incontinence after suspension procedure failure. Materials and Methods Medical records and preoperative studies were reviewed of 60 patients (mean age 60.8 years) who had undergone colpocystourethropexy after at least 1 suspension procedure (range 1 to 8, mean 2.7). Patient responses to a standardized questionnaire regarding overall health, degree of satisfaction with colpocystourethropexy, presence or absence of leakage, and pattern and degree of leakage were elicited by telephone or mail and compared with preoperative status. Results were graded according to the degree of satisfaction and number of pads used daily. Patients with persistent incontinence were reevaluated with video urodynamic studies. Results Mean interval since colpocystourethropexy was 6.9 years. Successful results (greater than 80% satisfaction and the use of 1 or no pad daily) were reported by 41 patients (69%), who were significantly younger at the time of surgery than those with unsatisfactory results. In the latter group significant urge incontinence was present in 61% before the repair and in 63% postoperatively, suggesting an additional nonanatomical cause, which was confirmed by postoperative video urodynamic studies. Conclusions When colpocystourethropexy was used for persistent urinary incontinence after previous surgical repair two-thirds of the patients had excellent long-term results. In patients with less satisfactory results a nonanatomical cause of urinary incontinence was a major factor.

Why anti-incontinence surgery succeeds or fails.

Defining success and failure in anti-incontinence surgery is becoming increasingly complex. Except in unusual cases, the impact of urinary incontinence is assessed by the degree of subjective bother to the patient. The amount, frequency, or volume of urinary incontinence is not necessarily related to the degree of bother and may be irrelevant to the patient. Large-volume urinary incontinence may be acceptable to some patients with the appropriate use of incontinence pads. Other women are socially incapacitated by losing a few drops of urine once per month. The amount of bother to the patient and not the amount of leakage is, in fact, what we treat with interventions for urinary incontinence. Success or failure in the treatment of urinary incontinence is tied to the patient's perception of success or failure and may differ from the surgeon's perception. New onset urgency and any unpredictable urgency incontinence may, in fact, be considered failure to the patient, despite the cure of "stress" incontinence. In the medical literature, success is defined by the surgeons (or authors). These definitions are variable and subject to bias. Recent reports showing differences between surgeon- and patient-defined success have refocused the evaluation of therapy for stress urinary incontinence (SUI).1,2 Success or failure in anti-incontinence surgery are increasingly being measured with quality of life questionnaires and outcome evaluations, which are strongly tied to patient satisfaction. The surgical objective for stress incontinence procedures is to create sufficient outlet resistance to prevent urine loss until a socially acceptable time and place. Unsuccessful surgeries fail to do this. Failure includes persistent SUI, de novo or worsened urge incontinence, obstructive or irritative voiding symptoms, urinary retention, and postoperative pelvic prolapse or surgical complications such as bleeding, fistula, infection, and/or dyspareunia. We will discuss the mechanisms for urinary continence and incontinence, describe a successful anti-incontinence operation, and finally discuss the etiologies of failed anti-incontinence surgery.

Sacrospinous Colpopexy in the Management of Uterovaginal Prolapse

OBJECTIVE : To investigate the morbidity and results of vaginal hysterectomy with concomitant sacrospinous colpopexy for uterovaginal prolapse. STUDY DESIGN : An observational study was carried out from June 17, 1986, to September 22, 1992. Patients were selected if it was thought that the cardinaluterosacral ligaments could not be relied upon for vaginal vault support. RESULT : During the study period, 265 vaginal hysterectomies were performed. Forty-five (17%) were with concomitant sacrospinous colpopexy. The mean patient age was 54 years. There was one incidental cystotomy during hysterectomy, and two patients required transfusion. Postoperatively, eight patients were treated for soft tissue infection, one developed new-onset urinary incontinence, and no apparent nerve injuries were diagnosed. The mean day of discharge was 4.4. Six patients were lost to follow-up after the early postoperative period. The mean follow-up for the remaining patients was 29 months (12-66). One patient required subsequent vaginal repair for recurrent cystocele and enterocele. Four patients had persistent stress urinary incontinence. CONCLUSION : Sacrospinous colpopexy at the time of vaginal hysterectomy is reasonably safe and effective for reestablishing upper vaginal support.

Obstruction Following Anti-Incontinence Procedures: Diagnosis and Treatment with Transvaginal Urethrolysis

We reviewed the charts of 41 patients who underwent transvaginal urethrolysis and resuspension of the bladder neck by the Raz technique for urethral obstruction with or without stress urinary incontinence following anti-incontinence surgery. We sought to evaluate the effectiveness of the procedure as well as to determine any factors that had an effect on the outcome of surgery. Patients were evaluated for obstruction and stress urinary incontinence by history, physical examination, video urodynamics (or multichannel urodynamics plus cystogram and voiding cystourethrography) and cystoscopy. All patients reported normal emptying before the procedure that caused obstruction. Several variables were evaluated for individual predictive values for outcome, including type of surgery causing obstruction, number of previous antiincontinence procedures, urodynamic evidence of obstruction (high pressure, low flow), instability, concomitant stress urinary incontinence and total urinary retention, which were evaluated by the Fisher exact test, and the amount of post-void residual, bladder capacity, maximum detrusor pressure, maximum urinary flow and interval since surgery causing obstruction, which were evaluated by logistic regression analysis.Mean patient age was 59 years (range 26 to 86 years) and mean followup was 21 months. A total of 19 patients (46%) suffered from concurrent stress urinary incontinence, 23 (56%) had urodynamic evidence of obstruction (high pressure/low flow) and 6 (15%) had only radiographic or endoscopic evidence with a deviated or kinked urethra. Postoperatively, 29 patients (71%) voided normally without significant residuals. Eight patients (20%) remain on self-catheterization and 1 has persistent stress urinary incontinence. When individual variables were evaluated to determine the predictive values with respect to outcome of urethrolysis, only the preoperative post-void residual was statistically significant (the greater the post-void residual, the more likely was failure, p = 0.021). The presence or strength of the detrusor contraction preoperatively and pressure-flow analysis did not predict outcome. Of the patients with stress urinary incontinence 15 (79%) were cured and 3 (16%) were significantly improved with rare stress urinary incontinence not requiring protection.Overall, 33 patients (80%) had some benefit from surgery. Patients who emptied normally before an anti-incontinence procedure that causes obstruction or impaired emptying should not be excluded from urethrolysis based on low detrusor pressures or pressure-flow analysis alone. Simultaneous radiographic imaging and endoscopy may help to select certain patients with obstruction.

Modified pereyra bladder neck suspension after previously failed anti-incontinence surgery Surgical technique and results with long-term follow-up

Fifty-four female patients with persistent or recurrent stress urinary incontinence who underwent between I and 9 previously unsuccessful operative procedures were treated with transvaginal mobilization of the urethra and anterior vaginal wall with subsequent modified Pereyra bladder neck suspension. The important points of this technique are reviewed. With minimum follow-up of twenty-four months, a 94 per cent cure rate was achieved with minimal morbidity in this difficult group of patients.