Previous Stress Urinary Incontinence Research Articles

Cost-effectiveness of urethral bulking polydimethylsiloxane-Urolastic® compared with mid-urethral sling surgery for stress urinary incontinence: A two-arm cohort study.

To investigate the cost-effectiveness of urethral bulking polydimethylsiloxane-Urolastic® (PDMS-U) compared with mid-urethral sling (MUS) surgery for stress urinary incontinence (SUI) at 1-year follow-up. Prospective, two-arm cohort study with 2-year follow-up. International multicentre. Women with moderate to severe SUI. Primary outcome was subjective cure (Patient Global Impression of Improvement). objective cure (negative cough stress test), Urogenital Distress Inventory (UDI-6), complications and re-interventions. Cost-effectiveness outcomes: total costs, quality-adjusted life year (QALY) using IIQ7-scores (Incontinence Impact Questionnaire) and EQ-5D-5L, incremental cost-effectiveness ratio (ICER) and monetary benefit (adjusted for baseline confounders). In all, 131 PDMS-U and 153 MUS surgery patients were treated. Subjective cure rates for MUS surgery and PDMS-U were, respectively: 101/112 (90%) versus 40/87 (46%), adjusted odds ratio (aOR; for age, body mass index [BMI], severity, type of urinary incontinence and previous SUI procedure) was 4.9. Objective cure rates for MUS surgery and PDMS-U were respectively: 98/109 (90%) versus 58/92 (63%), aOR 5.4. Average total costs for PDMS-U and MUS surgery were €3567 and €6688. ICER for MUS surgery cost €15 598 per IIQ QALY and €37 408 per EQ-5D-5L QALY. With a willingness to pay (WTP) of €25 000, MUS has a 84% chance of being cost-effective using IIQ, whereas PDMS-U has a 99% chance of being cost-effective using EQ-5D-5L. MUS surgery is more cost-effective in realising improved disease-specific quality of life (QoL), while PDMS-U is more cost-effective in realising improved generic QoL.

Efficacy and safety of onabotulinumtoxin A injection in male patients with detrusor overactivity after stress urinary incontinence surgery

Introduction and objectiveThe use of onabotulinumtoxin A (BoNT-A) injection in male patients with detrusor overactivity (DO) after stress urinary incontinence (SUI) surgery has been scarcely described. Our aim was to assess results of this treatment in this specific population. Materials and methodsRetrospective analysis of men with previous SUI surgery who had been treated with a first injection of 100 U BoNT-A because of DO since 2010 in our department. Treatment response was assessed with the Treatment Benefit Scale: 1) greatly improved; 2) improved; 3) not changed; 4) worsened after treatment (Treatment Benefit Scale 1 or 2: treatment response). Complications were classified according to the Clavien-Dindo classification. Treatment continuation was considered present if, at the last visit, patients had received a BoNT-A injection within the preceding 12 months. Pre- and post-treatment urodynamic variables were compared. ResultsEighteen patients were included, median age 71.1 (59.1–83.5) years. Twelve (66.7%) patients reported response to treatment. Two (11.1%) complications were detected: urinary retention requiring clean intermittent catheterization (Clavien-Dindo 2). No complications related to previous SUI surgery were detected. Fifteen (83.3%) patients had a follow-up >12 months (median follow-up 57 [15–89] months) and all of them had discontinued treatment at the end of follow-up. Urodynamic studies showed significant improvement in terms of DO and bladder compliance. ConclusionAlthough most men with DO after SUI surgery respond to intradetrusor BoNT-A injection, all of them discontinue treatment due to personal reasons. It is a safe procedure, with urinary retention requiring clean intermittent catheterization being the most frequent complication.

PD06-06 IMPACT OF ROBOTIC ARTIFICIAL URINARY SPHINCTER IMPLANTATION IN FEMALE PATIENTS ON QUALITY OF LIFE AND PATIENTS-REPORTED OUTCOMES

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Female Incontinence: Therapy I (PD06)1 Sep 2021PD06-06 IMPACT OF ROBOTIC ARTIFICIAL URINARY SPHINCTER IMPLANTATION IN FEMALE PATIENTS ON QUALITY OF LIFE AND PATIENTS-REPORTED OUTCOMES Benoit Peyronnet, Valentine Lethuillier, Louis-Paul Berthelot, Claire Richard, Camille Haudebert, Caroline Voiry, Lucas Freton, Juliette Hascoet, and Andrea Manunta Benoit PeyronnetBenoit Peyronnet More articles by this author , Valentine LethuillierValentine Lethuillier More articles by this author , Louis-Paul BerthelotLouis-Paul Berthelot More articles by this author , Claire RichardClaire Richard More articles by this author , Camille HaudebertCamille Haudebert More articles by this author , Caroline VoiryCaroline Voiry More articles by this author , Lucas FretonLucas Freton More articles by this author , Juliette HascoetJuliette Hascoet More articles by this author , and Andrea ManuntaAndrea Manunta More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001974.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Artificial urinary sphincter (AUS) is commonly used in France in female patients with stress urinary incontinence (SUI) due to intrinsic sphincter deficiency (ISD). However, female AUS has never been assessed using validated questionnaires so far. The aim of the present study was to assess the functional outcomes of robotic artificial urinary sphincter implantation using validated questionnaires METHODS: The data of all female patients undergoing a robotic AUS implantation at a single academic center between 2014 and 2019 were collected prospectively. Preoperativley, all patients underwent urodynamics and filled out an Urinary Symptoms Profile (USP) questionnaire (SUI subscore /9; overactive bladder subscore /21 ; voiding symptoms subscore /9), a ICIQ-SF questionnaire and a Patient Global Impression of Improvement (PGII). The same questionnaires were filled out at 3 months postoperatively. RESULTS: Over the study period, 57 robotic female AUS implantations were performed by two surgeons. Eight patients had neurogenic SUI (14%). The median patients’ age was 66 years and 84.2% had a history of previous SUI surgery. The median cuff size was 75 mm. There were ten intraoperative complications (5 bladder neck injuries and 5 vaginal injuries ; 17.5%) and 16 postoperative complications (28.1%) all Clavien grades 1 or 2 except three Clavien 3B: two early vaginal erosion with AUS explantation and one suspicion of AUS infection with surgical exploration (major complications rate: 5.3%). The median length of stay was 3 days. All patient-reported outcomes were significantly improved at 3 months. The USP SUI subscore decreased from 7.4/9 preoperatively to 0.7/9 at 3 months (p<0.0001), the USP OAB subscore dwindled from 12.6 to 5.2 (p<0.0001) and the ICIQ-SF from 16.3 to 3.1 (p<0.0001). The AUS implantation improved patients’ quality of life with the ICIQ-qol decreasing from 8.4 preoperatively to 1.3 at 3 months (p<0.0001). The 3-month PGII was 1/7 (very much improved) in 41 patients (74.5%), 2/7 (improved) in 5 patients (9.1%), 3/7 in four patients (7.3%) and 4/7 (unchanged) in five patients (9.1%). CONCLUSIONS: Robot-assisted AUS implantation in female patients has a low morbidity and improves the patients-reported outcomes and quality of life of female patients with SUI due to ISD. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e101-e102 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Benoit Peyronnet More articles by this author Valentine Lethuillier More articles by this author Louis-Paul Berthelot More articles by this author Claire Richard More articles by this author Camille Haudebert More articles by this author Caroline Voiry More articles by this author Lucas Freton More articles by this author Juliette Hascoet More articles by this author Andrea Manunta More articles by this author Expand All Advertisement Loading ...

Eficacia y seguridad de la inyección de onabotulinumtoxin A en pacientes varones con hiperactividad del detrusor tras la cirugía para incontinencia urinaria de esfuerzo

Introduction and objectiveThe use of onabotulinumtoxin A (BoNT-A) injection in male patients with detrusor overactivity (DO) after stress urinary incontinence (SUI) surgery has been scarcely described. Our aim was to assess results of this treatment in this specific population. Materials and methodsRetrospective analysis of men with previous SUI surgery who had been treated with a first injection of 100U BoNT-A because of DO since 2010 in our department. Treatment response was assessed with the Treatment Benefit Scale: 1) greatly improved; 2) improved; 3) not changed; 4) worsened after treatment (Treatment Benefit Scale 1 or 2: treatment response). Complications were classified according to the Clavien-Dindo classification. Treatment continuation was considered present if, at the last visit, patients had received a BoNT-A injection within the preceding 12 months. Pre- and post-treatment urodynamic variables were compared. ResultsEighteen patients were included, median age 71.1 (59.1-83.5) years. Twelve (66.7%) patients reported response to treatment. Two (11.1%) complications were detected: urinary retention requiring clean intermittent catheterization (Clavien-Dindo 2). No complications related to previous SUI surgery were detected. Fifteen (83.3%) patients had a follow-up>12 months (median follow-up 57 [15-89] months) and all of them had discontinued treatment at the end of follow-up. Urodynamic studies showed significant improvement in terms of DO and bladder compliance. ConclusionAlthough most men with DO after SUI surgery respond to intradetrusor BoNT-A injection, all of them discontinue treatment due to personal reasons. It is a safe procedure, with urinary retention requiring clean intermittent catheterization being the most frequent complication.

Cystocele Repair by a Modified Surgical Technique of Bilateral Pubococcygeus Plication: Long-Term Surgical and Functional Results.

Here we describe our modified surgical technique of bilateral pubococcygeus plication (BPCP) for cystocele repair and assess its safety and long-term outcomes. This is a prospective study of 147 consecutive women who underwent BPCP for cystocele between January 2010 to January 2018. Inclusion criteria was naïve women with symptomatic cystocele ≥ POP-Q 2nd stage. Exclusion criteria: stress urinary incontinence (SUI), urgency urinary incontinence, other associated vaginal wall prolapses ≥ stage 2, neurological diseases, previous SUI surgeries, and previous radiation/surgery of the pelvic area. BPCP was performed by obtaining the medialization of the pubococcygeus muscle fibers of the right and left sides. Statistical analysis was performed. Objective cure was POP-Q < 2nd stage. Subjective cure and functional outcomes were evaluated by validated questionnaires. Patient’s satisfaction was assessed by a Likert-type scale. Mean operative time was 64 min. At a mean follow-up of 82.4 months, objective and subjective success rates were 89.8% and 92.2% respectively. De novo urgency was 3.2%. Surgery did not alter sexual function. Complications occurred in 4.8%, and were: wrong dissection plane, hematoma, and pain lasting between 24–72 h. BPCP for correction of cystocele is safe and effective, with limited risk of complication and good long-term results.

Treatment validation of the Solomon-Greenwell nomogram for female bladder outlet obstruction.

Bladder outflow in women (bladder outlet obstruction [BOO]) has no well-accepted defining diagnostic criteria. Various nomograms exist based on flow rates, pressure-flow data, and fluoroscopy. We have prospectively evaluated the Solomon-Greenwell bladder outflow obstruction nomogram (SG BOO nomogram) as a measurement of BOO resolution following targeted surgical intervention. The routine posttreatment urodynamics of 21 unselected women with an original urodynamic diagnosis of BOO on fluoroscopy and the SG BOO nomogram (BOO boundary defined as Qmax > 2.2 Pdet.Qmax + 5) were reviewed. All women had symptomatic BOO secondary to anterior pelvic organ prolapse (aPOP), urethrovaginal fistula (UVF), previous stress urinary incontinence (SUI) surgery, urethral stricture (US), or urethral diverticulum (U Div). Following treatment, all presenting symptoms resolved and simple urodynamics were performed as part of routine follow-up. The urodynamic findings preoperatively and postoperatively showed statistically significant changes posttreatment in mean flow rate which increased from 9.38 to 14.71 mL/s, mean Pdet.Qmax which decreased from 38 to 18.38 cmH2 O, and mean SG BOO nomogram probability (PBOO) which reduced from PBOO = 0.68 to 0.08. Mean SG BOO nomogram PBOO was significantly reduced posttreatment in all individual categories except UVF where a nonsignificant reduction from PBOO = 0.55 to 0.05 occurred. All urodynamic parameters significantly improve in women who become asymptomatic following surgical treatment of BOO. This improvement is best demonstrated by the change in probability of BOO according to the Solomon-Greenwell nomogram. These findings underline the validity of the Solomon-Greenwell female BOO nomogram for diagnosing and monitoring BOO in women.

Variation in surgical treatment advice for women with stress urinary incontinence: a study using clinical case vignettes

IntroductionThe aim of this study was to determine how recommendations of gynaecologists on surgical treatment for stress urinary incontinence (SUI) were influenced by patient characteristics.MethodsTwo hundred forty-five gynaecologists in the UK fully responded to an online questionnaire including 18 vignettes describing 7 clinical characteristics of women with SUI (age, body mass index, SUI type, previous SUI surgery, frequency of leakage, bother, physical status). The gynaecologists scored recommendations for surgery ranging from 1 ‘certainly not’ to 5 ‘certainly yes’. Mean scores were used to calculate the relative impact (‘weight’) of each clinical characteristic. Latent class analysis was used to distinguish groups of gynaecologists with a particular practice style because they responded to the patient characteristics captured in the case vignettes in a similar way.ResultsThe gynaecologists’ overall average recommendation score was 2.9 (interquartile range 2 to 4). All patient characteristics significantly influenced the recommendation scores (p always < 0.001) but their impact was relatively small. SUI type was most important (weight 23%), followed by previous SUI surgery (weight 21%). Latent class analysis identified five groups of gynaecologists with practice styles that differed mainly with respect to their mean recommendation score, ranging from 1.3 to 4.0.ConclusionsSurgical treatment advice in response to case vignettes was only minimally influenced by patient characteristics. There were five groups of gynaecologists whose inclination to recommend surgical treatment varied. This suggests that there is lack of consensus on the role of surgery as a treatment for SUI. A considerable number of gynaecologists were reluctant to recommend surgery.

Predictors for de novo stress urinary incontinence following pelvic reconstruction surgery with transvaginal single-incisional mesh

The study aims to identify predictors for de novo stress urinary incontinence (SUI) following Elevate mesh surgery. A total of 164 women who underwent Elevate mesh surgeries between November 2011 and February 2014 in a single center were included. Seventy-three women were excluded due to preoperative incontinence or concomitant mid-urethral sling surgery. Fourteen others were excluded due to incomplete medical records. Fisher’s exact test and χ2 test were applied. The univariate logistic regression was used for odds ratios. Of the 77 continent women, 24 (31.2%) experienced de novo SUI after the operation. Significantly more women with de novo SUI were over the age of 64 years (75.0% vs. 47.2%, p = 0.023, OR 3.36, 95% CI 1.15–9.79). Preoperative occult urodynamic stress incontinence (29.2% vs. 3.8%, p = 0.003, OR 10.0, 95% CI 2.0–50.0) and previous SUI history (41.7% vs. 7.6%, p = 0.001, OR 9.1, 95% CI 2.38–33.3) were 2 other predictors of de novo SUI postoperatively. In conclusion, age over 64 years old, occult urodynamic stress incontinence, and previous history of SUI are 3 significant predictors for de novo SUI following the single-incision mesh surgeries.

Indications and risk factors for midurethral sling revision.

To determine the indications and risk factors for needing midurethral sling revision in a cohort of women undergoing midurethral sling placement. This was a case-control study of all women undergoing midurethral sling placement for stress urinary incontinence (SUI) between January 2003 and December 2013. Cases were patients who underwent midurethral sling placement followed by sling revision (incision, partial or complete excision). Controls were patients who underwent sling placement only. Once all subjects had been identified, the electronic medical record was queried for demographic and perioperative and postoperative data. Of 3,307 women who underwent sling placement, 89 (2.7%, 95% CI 1.9 - 3.4) underwent sling revision for one or more of the following indications: urinary retention (43.8%), voiding dysfunction (42.7%), recurrent urinary tract infection (20.2%), mesh erosion (21.3%), vaginal pain/dyspareunia (7.9%), and groin pain (3.4%). The median time from the index to the revision surgery was 7.8 months (2.3 - 17.9 months), but was significantly shorter in patients with urinary retention. The type of sling placed (retropubic or transobturator) was not associated with indication for revision. Patients who underwent revision surgery were more likely to have had previous SUI surgery (adjusted odds ratio 4.4, 95% CI 1.7 - 6.5) and to have undergone concomitant vaginal apical suspension (adjusted odds ratio 2.4, 95% CI 1.4 - 4.5). The rate of sling revision after midurethral sling placement was 2.7%. Urinary retention and voiding dysfunction were the most common indications. Patients with a history of previous SUI surgery and concomitant apical suspension at the time of sling placement may be at higher risk of requiring revision surgery.

Do predictive parameters exist for therapy with duloxetine in women with stress urinary incontinence?

To determine whether predictive parameters exist for successful duloxetine therapy in women with stress urinary incontinence (SUI). Secondary analysis was performed of 1,714 women who received duloxetine in the Stress Urinary Incontinence Treatment (SUIT) study, a 12-month longitudinal observational study to evaluate the results and direct costs of SUI treatment. Data of 1,087 women were analyzed. Univariate and multivariate analyses (stepwise forward logistic regression) were performed to investigate factors for discontinuation of treatment. Parameters that significantly reduced the probability of treatment termination were smoking and a body mass index (BMI) <20, while obesity (BMI >30) increased the probability in the univariate analysis. In the multivariate analysis significantly reduced likelihoods of duloxetine treatment discontinuation were found for an age >65 years, country, and 7 to 13 incontinence episodes per week. Co-medication, particularly anti-cholinergics, was significantly associated with therapy termination. Previous SUI surgery had no effect. Identification of predictive parameters for successful therapy with duloxetine in women with SUI is desirable, and co-medications should be critically considered.

1348 HYPERCONTINENCE AND CUFF EROSION AFTER ARTIFICIAL URINARY SPHINCTER INSERTION: A COMPARISON OF CUFF SIZES AND PLACEMENT TECHNIQUES

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Incontinence—Evaluation & Therapy1 Apr 20111348 HYPERCONTINENCE AND CUFF EROSION AFTER ARTIFICIAL URINARY SPHINCTER INSERTION: A COMPARISON OF CUFF SIZES AND PLACEMENT TECHNIQUES Paul Smith, Steven Hudak, and Allen Morey Paul SmithPaul Smith Dallas, TX More articles by this author , Steven HudakSteven Hudak Dallas, TX More articles by this author , and Allen MoreyAllen Morey Dallas, TX More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1169AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We have noted that a small percentage of men who undergo placement of an artificial urinary sphincter (AUS) for stress urinary incontinence (SUI) develop transient post-operative urinary retention. Some of these patients become “hypercontinent” requiring prolonged urethral catheterization and/or placement of a suprapubic catheter (SPT). In this study, we evaluated the AUS cuff sizes and techniques associated with hypercontinence. METHODS We analyzed the outcomes of AUS cases performed by a single surgeon from 2007–2010. All patients underwent cuff placement in the most proximal bulb via a perineal incision. Cases were analyzed in three groups according to cuff size–3.5 cm, ≥4.0 cm, or transcorporal cuff (TC). Newer techniques developed for men with periurethral atrophy (3.5 cm cuff and TC cuff) were compared against the traditional cuff size group (≥4 cm). Outcomes relating to urinary retention, SPT placement, and cuff erosion were analyzed. RESULTS Among 138 patients who underwent AUS placement from 2007–2010, 108 cases met inclusion criteria—those placed via a penoscrotal approach or with incomplete follow up data were excluded: 41 men received a 3.5 cm cuff, 46 received a ≥4 cm cuff, and 21 received a TC cuff (all ≥4 cm). TC patients had a significantly higher rate of urinary retention requiring SPT placement compared to the ≥4.0 cm group [5/21 (24%) vs. 2/46 (4%), p = 0.03] and a slightly higher rate than the 3.5 cm group [5/41 (12%), p = 0.3]. The 3.5 cm, ≥4 cm, and TC groups all exhibited similar rates of cuff erosion [3/41 (7%), 2/46 (4%), and 1/21 (5%), p>0.05]. Cuff erosions were much more common in hypercontinent men compared to those without hypercontinence [4/21 (19%) vs 2/87 (2%), p = 0.01], especially in the 3.5 cm and TC group. No significant differences were found between these groups in the rates of diabetes, erectile dysfunction, previous radiation therapy, or previous SUI surgical intervention. CONCLUSIONS Transcorporal AUS placement is associated with a higher rate of postoperative urinary retention and need for suprapubic tube placement compared to traditional 4.0 cm cuff placement. Hypercontinence is a potential risk factor for cuff erosion, likely due to recurrent transurethral instrumentation or prolonged catheterization. The risk of urinary retention requiring further instrumentation and/or SPT placement should be discussed with candidates for TC AUS. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e538-e539 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Paul Smith Dallas, TX More articles by this author Steven Hudak Dallas, TX More articles by this author Allen Morey Dallas, TX More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Exploratory Study Assessing Efficacy and Complications of TVT-O, TVT-Secur, and Mini-Arc: Results at 12-Month Follow-Up

BackgroundContemporary surgical treatment of female stress urinary incontinence (SUI) includes retropubic and transobturator (TO) midurethral slings (MUS). Case series of single-incision slings (SIS) have shown similar outcomes with lower morbidity. ObjectiveOur aim was to assess the cure rates, complications, and quality-of-life impact of one standard TO MUS and two SIS. Design, setting, and participantsNinety consecutive patients with clinically and urodynamically proven SUI were enrolled in an exploratory randomised phase 2 trial. Patients with previous SUI surgery, major pelvic organ prolapse, mixed incontinence, or detrusor overactivity were excluded. InterventionsPatients were treated randomly with TVT-O, TVT-Secur, or Mini-Arc. MeasurementsPostoperative visits were scheduled at 6 and 12 mo. The King's Health Questionnaire (KHQ) was repeated at 6 mo. Cure was defined as the absence of urine leakage, no pad use, and a negative cough test at 12 mo. Pain and other complications were also investigated. Results and limitationsCure rate was 83% after TVT-O, 67% after TVT-Secur, and 87% after Mini-Arc. Improvement was found in 10%, 13%, and 7% of the patients, respectively. Failures were 7% after TVT-O and Mini-Arc and 20% after TVT-Secur.TVT-O and Mini-Arc improved at least 15 points in >80% of the patients in six KHQ domains, whereas TVT-Secur could only achieve improvement in three of the nine domains. The pain score was lower in the Mini-Arc group. Complications were more numerous after TVT-O. This study has the limitations inherent in a phase 2 trial with a follow-up limited to 12 mo. ConclusionsMini-Arc offers cure and improvement rates similar to TVT-O, whereas TVT-Secur may yield an inferior outcome. These findings recommend the urgent launch of large randomised phase 3 studies comparing conventional MUS with SIS, with Mini-Arc the advised option.

Tension-Free Vaginal Tape—A Suitable Procedure for Patients With Recurrent Stress Urinary Incontinence

In a recent report, the 10-year reoperation rate for stress urinary incontinence (SUI) after primary failure of anti-incontinence surgery was 17%. A tension-free vaginal tape (TVT) procedure has been effective for primary surgical treatment of SUI and long-term results have been promising. A number of studies have investigated repeat surgery with TVT for recurrent SUI but only one—a retrospective study—used a control group. Moreover, the follow-up period after a repeat TVT has been short; there has been only one uncontrolled prospective 4-year study. This prospective follow-up study investigated the use of the TVT procedure in women with recurrent SUI and those with primary SUI with respect to cure rates, complications, and safety. All participants had a TVT—60 in the study group (recurrent SUI)—and 70 in the control group (primary SUI). The initial follow-up was at 2 months after surgery and patients completed a questionnaire 3 years later evaluating the success of the operation and urinary symptoms. At a mean of 8 years (range, 6–10 years), patient records were examined for data on any subsequent visits or additional surgery. The primary outcome measures were subjective cure, complications, and voiding symptoms. The rate of transient postoperative retention was similar in the 2 groups (recurrent SUI, 17% vs. primary SUI, 19%, P = 0.78). No significant difference was found between the groups in the number of complications (recurrent SUI, 20% vs. primary SUI, 13%, P = 0.27). Spontaneous micturition resumed in all patients by the 10th postoperative day. At the 2-month follow-up visit, 85% of the patients in recurrent SUI group and 94% of those in the primary SUI group were free of SUI and completely satisfied with the outcome (P = 0.096). These data were almost identical at 3 years. Major complications following surgery were rare. At 2 months, 22% of the recurrent SUI patients and 19% of the primary SUI patients had de novo urge symptoms (P = NS); at 3 years, the rate of voiding difficulties was 17% in the primary SUI group and increased to 33% in the recurrent SUI group (difference between groups, P = 0.037). Subjective voiding dysfunction (feeling of incomplete emptying with or without recurrent urinary tract infections) was reported by 5 patients (8.3%) in the recurrent SUI group and in 17 patients (24%) in the primary SUI group at 3 years after the operation (P = 0.022). These findings suggest that TVT is safe and effective when performed for primary or recurrent SUI. There are no apparent differences in cure and complication rates after TVT between patients with and without previous SUI surgery.

How are women with SUI-symptoms treated with duloxetine in real life practice? - Preliminary results from a large observational study in Germany

Duloxetine was found safe and effective in the treatment of moderate to severe female stress urinary incontinence (SUI) in controlled clinical trials; complementary data from routine clinical practice are still wanted. To explore the use of various initial duloxetine doses by physicians in the treatment of female SUI in routine clinical practice and its implications on drug safety and patients' subjective impression of effectiveness. Adult women treated with duloxetine for SUI symptoms were documented as part of an ongoing large-scale observational study in Germany. Data collected at baseline, after 4 and 12 weeks, were evaluated by initial doses. Statistics were descriptive, 95% confidence intervals were calculated for adverse event (AE) rates. A total of 7888 adult women were treated with duloxetine; their mean age was 61.4 years, body mass index 27 kg/m(2), incontinence episode frequency (IEF) 14.0 per week. Previous SUI treatments were observed in 52.2%, comorbidities in 60.4% of the patients. A total of 90.7% reported reduced frequency of SUI-episodes, 12.1% any AE; nausea (5.7%) and vertigo (1.6%) were reported most frequently. In all, 52.2% of patients were initiated on a duloxetine dose of 40 mg/day. Only minor differences in patient characteristics, effectiveness and tolerability were associated with varying initial duloxetine doses. Many women received lower duloxetine doses than expected based on evidence-based dosing recommendations. Although SUI patients in this study had a higher health risk because of old age and multiple comorbidities than in previous controlled clinical trials, AE rates were lower, possibly because of the observational character of the study and/or the use of rather low doses. Similar AE rates for varying initial doses possibly reflect sensible dose-adjustment to individual needs.

Clinical and demographic factors associated with valsalva leak point pressure among women undergoing burch bladder neck suspension or autologous rectus fascial sling procedures

Many parameters have been utilized to try to estimate severity of stress urinary incontinence (SUI). Valsalva leak point pressure (VLPP) measurements, have been proposed as a reliable means of gauging the severity of SUI during urodynamic studies (UDS). Certain, non-invasive, measures of incontinence severity have been proposed, but the correlation of these measures with VLPP is not known. In addition, the correlation of other important UDS measures and VLPP has not been evaluated. In this study we sought to define the relationship between demographic characteristics, physical exam findings, and non-sphincteric UDS measures with VLPP in a large multicenter randomized surgical trial comparing Burch urethropexy and fascial sling for the treatment of SUI. Pre-surgical, standardized urodynamic measures were obtained in all participants in the Stress Incontinence Treatment Efficacy Trial (SISTEr) trial. All UDS were assessed for quality assurance and protocol compliance. VLPP was assessed using a <8 Fr water transducer catheter during graded Valsalva maneuvers at 200 ml, and then at 100 ml intervals and bladder capacity if no SUI was noted earlier. Only data from women who had SUI on at least two of three consecutive valsalva maneuvers was utilized for this analysis. Delta VLPP was determined as the average value, and the baseline vesical pressure was subtracted from the absolute vesical pressure to arrive at the reported VLPP value. Independent variables studied to assess their relationship to VLPP value included demographic characteristics (age, number of pregnancies, # vaginal deliveries, hormone usage, previous hysterectomy, previous SUI surgery), physical exam parameters [body mass index--BMI, Pelvic Organ Prolapse-Quantified POPQ stage, POPQ Aa measurement, Q-tip angle (rest) and Q-tip angle (strain), and change in angle], and other urodynamic parameters (volume of first leakage, volume at first sensation, presence of detrusor overactivity, maximum cystometric capacity--MCC, maximum flow rate--Q(max), and detrusor pressure at maximum flow rate--pdet.Q(max)). Among the 655 women randomized, 424 were found to have evaluable VLPPs. Thirty-four had stage 3 or 4 prolapse and were excluded from the VLPP analysis. The remaining 390 women had a mean VLPP of 81.1 cm H(2)O. On bivariate analysis, there were significant positive associations with VLPP and BMI (P = 0.026), Q-tip straining angle (P = 0.0002) change in Q-tip angle (P = 0.0046), MCC (P < 0.0001) and pdet.Q(max) (P = 0.0003). Age was negatively associated with VLPP (P < 0.0001). For categorical values, lower POPQ stage (0/1), post menopausal status, and use of hormones were all associated with lower VLPP values. For example, patients with stage 2 had, on the average, VLPP values that were more than 10 cm H(2)O greater than those with stage 0/1. On multivariate analysis, however, only lower age, greater BMI, greater MCC, greater pdet.Q(max), and lower Q(max) were found to be independent associated with higher delta VLPP. Advancing age, lower BMI, higher maximum flow rate, and lower voiding pressures are all independently associated with lower VLPP in women undergoing surgery for SUI. Lower voiding pressures and higher flow rates among women with more severe SUI may reflect the chronic loss of urethral resistance associated with SUI. Interestingly, urethral hypermobility as assessed by Q-tip testing angle does not achieve a statistically significant association with VLPP on multivariate testing when controlling for POP-Q stage. Thus, as clinically suspected, the Q-tip test is not predictive of VLPP in women with urethral hypermobility and SUI.

Résultats à trois ans de la prise en charge d'une incontinence urinaire d'effort avec pression de clôture urétrale basse par fronde sous-urétrale TVT

The aim of this study was to assess, with long-term outcome, the effectiveness of TVT for stress urinary incontinence (SUI) with low maximum urethral closure pressure (MUCP) and to identify predicting factors for failure in this case. This is a bicentric retrospective study including women who underwent a TVT procedure for grade 3-SUI according to the Ingelman-Sundberg's scale. All patients had a low MCUP defined by PCUM < 30 or by the formula 110-the age+/-20% cmH2O. Urethral hypermobility was defined on physical examination and urodynamic investigations. TVT was the only operation performed. Patients were assessed at three months then at longer term with an average follow-up of three years and ever less than one year. A total of 60 women 30 to 78 years old (mean age 55) were so operated. More than third of them (38%) had already been operated for incontinence. Thirty-eight percent had SUI without urethral hypermobility. Thirty percent presented bladder overactivity. The short-term evaluation found that, out of 58 patients, 70,6% cured, 10,3% improved and 18,9% classified as failure. The long-term evaluation, concerning 44 patients, found that 57% remained cured, 16% improved and 27% were classified as failure. Bladder overactivity was cured or improved in more than half of the cases (60%). Ten percent of de novo urgencies were noted, all of which persisted later on. For all that, as much as two thirds of these patients were satisfied with the TVT. Mean age of patients classified as failure, was higher (65 years). Previous SUI surgery did not modify the results. When the MUCP was < 20 cmH2O, success was present only one time out of two. The absence of urethral hypermobility decreased to a significant degree the probability of cure (38 vs. 82,6%, P < 0.01), and more still when bladder overactivity was associated (16,6 vs. 66,6%, P < 0.01). Postoperative voiding troubles constituted a pejorative factor for success of surgery. Even if results of TVT with low MCUP are worse, they do not remain less appreciable. When we confront the benefits awaited with this technique compared to the usually described complications, TVT must represent the first treatment of this indication.