Sphincter Incompetence Research Articles

Indications for antireflux surgery: a clinical experience and review of the literature

Antireflux laparoscopic surgery has excellent results in terms of improvement of symptoms, esophagitis, gastroesophageal sphincter competence and abnormal acid reflux. Indications for surgery are well established, however some of these are controversial. This is a review of the present indications for surgery in gastroesophageal reflux. The surgical indication should be the result of a complex clinical and laboratory work up. Patients with a clear cut surgical indication should be differentiated from those with doubtful indications, that require further analysis and those that are bad candidates for surgery. Young patients with macroscopic esophagitis, an incompetent sphincter, abnormal acid reflux test, that have a partial or negative response to treatment with proton pump inhibitors are those with the best surgical results. Bad candidates are patients with a psychiatric background, with atypical symptoms and those with a normal acid reflux test. In our experience with 935 patients, only 23% had a surgical indication.

Hepatopancreaticobiliary pathology in the PCK model of ARPKD

Autosomal Recessive Polycystic Kidney Disease (ARPKD) results in renal and hepatic fibrocystic pathology. This study evaluated hepatobiliary pathology in PCK rats, an orthologous model of slowly progressive ARPKD. Male and female rats were evaluated from 4–35 weeks, quantifying organ growth, serology, bile flow rates, histology, Microfil organ casts and bile proteomics. PCK hepatofibrocystic disease is progressive (liver weight as % of body weight and hepatic fibrocystic volume), which after 18 weeks was more severe in females vs. males. A retrograde Microfil cast of hepatopancreaticobiliary ducts demonstrated widespread fusiform bile duct cysts. Pancreatic ducts open into the grossly dilated common hepatic duct. Bile flow rate for 12–15 week and 25 week PCK rats was greater than that seen in normal 15 week rats. The bile proteome from females using 2D gels identified significant differences. MS/MS protein identification of 32 spots found overexpressed proteins (triacylglycerol lipase, pancreatic amylase, chymotrypsinogen B and apolipoprotein A‐1) and numerous albumin fragments, i.e., pancreatic enzymes and fragmented proteins. Biliary pathology and proteomic findings suggest that the grossly dilated hepatic duct cause choledochal sphincter incompetence. The reflux of pancreatic enzymes into the biliary tree might exacerbate the hepatobiliary fibrosis and could also occur in human ARPKD.Grant Funding Source: NIH

745 DURABILITY OF CONTINENCE RATE ACHIEVED WITH DEXTRANOMER BASED IMPLANTS (DEFLUX®): A STUDY OF 89 PATIENTS

You have accessJournal of UrologyPediatrics: Bladder Dysfunction - Myelodysplasia, Voiding Dysfunction, Enuresis1 Apr 2010745 DURABILITY OF CONTINENCE RATE ACHIEVED WITH DEXTRANOMER BASED IMPLANTS (DEFLUX®): A STUDY OF 89 PATIENTS Ilona Alova, Marc Margaryan, Michele Bernuy, Stephen Lortat Jacob, Yves Aigrain, and Henri Lottmann Ilona AlovaIlona Alova Paris, France More articles by this author , Marc MargaryanMarc Margaryan Paris, France More articles by this author , Michele BernuyMichele Bernuy Saint Fargeau, France More articles by this author , Stephen Lortat JacobStephen Lortat Jacob Paris, France More articles by this author , Yves AigrainYves Aigrain Paris, France More articles by this author , and Henri LottmannHenri Lottmann Paris, France More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1271AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES It has already been published that after an initial high success rate up to 70%, endoscopic treatment of severe paediatric structural incontinence allows to achieve dryness or acceptable social continence in about 50% of treated patients after 18 months. It has also been reported through relatively small series with limited follow up (FU) that this result remains stable thereafter. The current study evaluates the durability of Dextranomer based implants (DefluxÒ) as a bulking agent for paediatric structural incontinence. METHODS From October 1997, 86 children and adolescents (3-18years) suffering from severe sphincteric incompetence (exstrophy-epispadias 33, neuropathic bladder 44, bilateral ectopic ureters 5, miscellaneous 4) have been treated and followed for a minimum of 18months up to 12 years (median 60 months). A third had had a previous failed bladder neck procedure. Preoperative evaluation consisted in medical history and questionnaire about incontinence, urine culture, urinary tract ultrasound and videourodynamics. This evaluation was repeated at six months and one year after treatment and then on a yearly basis,except for videourodynamics performed only when necessary for further management. 25 patients had two and 13 three treatment sessions. Mean injected volume was 4,6 ml per session. At each evaluation, the patient was classified as cured (dryness interval of four hours ), significantly improved (minimal incontinence requiring no more than one pad per day; no further treatment required) and treatment failure when no significant improvement was observed. RESULTS 32 (37,2%) patient are dry, 13/86 (15,1%) are significantly improved, and 41/86 (47,7%) patients had treatment failure. After 18 months of FU 2 male patients became dry at puberty 2 Female patients became incontinent again. All the other patients remained perfectly stable. CONCLUSIONS Endoscopic treatment of urinary sphincter insufficiency with Deflux® is effective in around 50% of cases after 18months; our study with the largest reported cohort and the longest FU confirms that this result is durable up to 12 years thereafter. © 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e291-e292 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ilona Alova Paris, France More articles by this author Marc Margaryan Paris, France More articles by this author Michele Bernuy Saint Fargeau, France More articles by this author Stephen Lortat Jacob Paris, France More articles by this author Yves Aigrain Paris, France More articles by this author Henri Lottmann Paris, France More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Long-Term Results of Polydimethylsiloxane Endoscopic Injection for the Treatment of Urinary Incontinence: A Retrospective Study of 38 EEC Patients

Purpose We report a retrospective study to assess the efficacy of bladder neck injection with polydimethylsiloxane based implants, over a 10-year period, in bladder exstrophy and epispadias complex (EEC) patients. Material and Methods From January 1998 to December 2008, 38 patients (26 males and 12 females) with a mean age of 11 years old (3-23) were enrolled in the study. They had a structural sphincteric incompetence, secondary to exstrophy-epispadias complex in 32 cases and a pure epispadias in 6 patients. Mean injected volume per session was 3.9 cc (2.5 - 5) and 1.7 procedures per patient were performed. At each evaluation the patient was considered continent or dry (no pads, no diapers) between voids or clean intermittent catheterization (CIC). Results Incidence of dryness during follow-up (after one or two injections) was 58 % (22/38 patients) at 1 year, 55% (21/38) at 2 years, 57% (21/37) at 3 years, 68% (23/34) at 4 years, 69% (22/32) at 5 years, 66% (12/29) at 6 years, 64% (16/25) at 7 years, 63% (12/19) at 8 years, 66% (8/12) at 9 years, 50% (3/6) at 10 years. Some grade of material exstrusion was observed in 5 patients, within the first 4 months after injection. One dried patient worsened 2 years after injection and other 2 patients reached dryness after improving bladder capacity, without more injections. Conclusions Endoscopic treatment of pediatric structural sphincteric deficiency in EEC patients, with polydimethylsiloxane implant, was effective up to a mean follow-up of 6 years. No significant decrease in efficacy was observed in the long-term follow-up.

Influence of Urethral Sphincter Incompetence on Bladder Shape and Function in Myelodysplastic Children.

This study was undertaken to investigate the influence of the urethral function on bladder shape and function in myelodysplastic children. Of 39 myelodysplastic children, 30 were treated with intermittent catheterization. The diagnosis of internal sphincter incompetence (SI) was based on cystographic findings (open bladder neck) and that of external SI on urodynamic findings (underactive external sphincter identified on electromyography and maximum urethral closure pressure of less than 50 cm H2 O). Follow up included evaluation of bladder deformity and compliance. The mean observation period was 8.6 years. In the 11 patients with external SI, bladder deformity and compliance significantly improved as a result of intermittent catheterization. However, of 12 patients with overactive sphincter and/or closure pressure of 50 cm H2 O or more, eight showed deterioration or no improvement in bladder deformity, and three showed upper urinary tract deterioration. These results indicate that an increase in urethral resistance may lead to deterioration of bladder shape.

Upper gastrointestinal investigations before gastric banding

Long-term complications after laparoscopic gastric banding (LAGB) are frequent, leading to reoperations for a substantial number of patients. It is not known whether esophageal motility or the lower esophageal sphincter (LES) play a role in the development of complications. The results of preoperative upper gastrointestinal (GI) testing were compared with outcome after LAGB. Before LAGB, 68 bariatric patients had esophageal manometry, endoscopy, and pH monitoring. For 61 of these patients (90% follow-up rate), the differences in weight loss, complications, and reoperation rate were retrospectively compared. Of these patients, 8.2% had a nonspecific motility disorder of the esophagus, 44.3% had an incompetent sphincter shown by manometry, and 17.5% had acid reflux shown by pH monitoring. Endoscopic evaluation showed esophagitis in 10.3% and hiatal hernia in 33.8% of the patients. Abnormal pH monitoring and endoscopic findings were not predictive for the long-term outcome or complications. The presence of an incompetent LES led to reoperation for a greater number of patients (44.4 vs. 14.7%; p = 0.01), especially if the band was placed using the pars flaccida technique. Endoscopy and pH monitoring do not predict outcome for gastric banding and therefore have no relevance in the selection of patients for gastric banding. Patients with an incompetent LES shown by manometry had a higher reoperation rate. If this finding can be confirmed, patients with LES incompetence may need another intervention.

The value of twenty-four hour intraoesophageal pH monitoring and manometry in the management of patients with upper gastrointestinal symptoms

Functional gastroenterological examinations (intraoesophageal pH monitoring, oesophageal manometry, scintigraphy, impedance examination) play important role in the management of patients with upper gastrointestinal complaints. Four different cases are demonstrated where diagnose and therapy was developed by these examinations. Two patients had typical gastro-oesophageal reflux symptoms and two others had dysphagia. Intraoesophageal pH monitoring was performed by Zinetics twenty-four hour one or two channel pH catheters and oesophageal manometry was carried out by Zinetics EMC four channel catheter with water perfusion method. In one of the patients with typical and extraoesophageal reflux symptoms, lower oesophageal sphincter incompetency by manometry and pathological acid reflux was observed by intraoesophageal pH monitoring, respectively. Furthermore, hiatal hernia was established, peristalsis of the oesophagus proved to be preserved. Because of incomplete efficacy of proton pump inhibitor (PPI) therapy, antireflux surgery was indicated. An other patient with reflux symptoms had physiological pH monitoring and manometric values. Hypersensitive oesophagus was diagnosed and PPI therapy in double dose was applied. Both patients are symptom free up to now. Other two patients complained difficult swallowing and weight loss. Absence of lower oesophageal sphincter relaxation and hypomotility of the oesophagus was observed. After oesophageal dilatation, both patients with achalasia could easy swallow and eat. Our cases confirm the importance of the twenty-four hour intraoesophageal pH monitoring and oesophageal manometry in the diagnosis of gastro-oesophageal reflux disease, non-cardiac chest pain, other extraoesophageal manifestations and dysphagia. These examinations support the decision for the adequate therapeutic strategy (conventional treatment, surgery or operation or endoscopic intervention) and are important in the follow-up of patients.

Outpatient Perineal Sling in Adolescent Boys With Neurogenic Incontinence

Management for urinary incontinence in boys with sphincteric incompetence secondary to a neurogenic etiology is a challenge. Minimally invasive approaches have inconsistent efficacy and may require multiple treatments. Open bladder neck reconstruction requires inpatient hospitalizations and can be associated with a high complication rate. To overcome some of these shortcomings we placed a polypropylene male perineal sling in male adolescents with neurogenic sphincteric incontinence. We retrospectively reviewed the outcome in our initial 6 patients. Six patients 14 to 20 years old underwent placement of a polypropylene male perineal sling on an outpatient basis. Followup was 27 to 39 months (median 33). All patients had a history of myelomeningocele and underwent urodynamics showing normal compliance, adequate capacity and sphincteric incompetence. A suburethral sling was placed on an outpatient basis through a small perineal incision. Sling tension was adjusted for maximal urethral compression while still permitting uncomplicated urethral catheter passage. All 6 patients reported immediate complete continence after sling placement. Two slings were removed after local infection developed and 1 was replaced. Another sling required revision secondary to incomplete bone anchor fixation. No patients had urethral erosion. All 5 patients with a sling currently in place were fully continent on intermittent catheterization every 3 hours and they reported excellent satisfaction with the procedure. Our retrospective study suggests that the male urethral sling may be an outpatient option for neurogenic incontinence secondary to sphincteric incompetence. Long-term followup in our initial 6 patients shows encouraging durability. Continued study is required to determine strategies that might decrease the complication rate of this approach.

Repeatability of innervation zone identification in the external anal sphincter muscle

Knowledge of the distribution of the innervation zones (IZs) of the external anal sphincter (EAS) may be useful for preventing anal sphincter incompetence during vaginal delivery. A method proposed for the automatic estimation of the distribution of IZs of EAS from high-density surface electromyography (EMG) was evaluated for repeatability in continent volunteers. In 13 healthy female subjects (age: 35 +/- 11 years) surface EMG signals were acquired using an anal probe with three circumferential electrode arrays (of 16 contacts each) at different depths within the anal canal (15 mm distance between the centers of adjacent arrays), during four independent experimental sessions. Three maximal voluntary contractions (MVCs) of 10 sec were performed for each session for a total of 12 contractions per subject. Repeatability of the estimation of the distribution of IZ was tested by evaluating the coefficient of multiple correlations (CMC) between the IZ distributions estimated from the signals recorded from each subject. A high repeatability (CMC > 0.8) was found comparing IZ distributions estimated from signals recorded by each array within the same session. A slightly lower value was obtained considering signals recorded during different sessions (CMC > 0.7), but a higher value (CMC > 0.8) was obtained after aligning the estimated IZ distributions. The realignment compensates for the operator's error in repositioning the probe in the same position during different sessions. This result justifies clinical studies using high-density surface EMG in routine examinations, providing information about IZs of EAS and assessing the possibilities of preventing neuronal trauma during vaginal delivery.

Outcome Of Patients Who Failed Endoscopic Treatment For Incontinence With Dextranomer Based Implants(Deflux®)

PURPOSE To evaluate the +results of bladder neck procedures after failed endoscopic injections of dextranomer based bulking agent (Deflux®) for incontinence in children. Endoscopic treatments of incontinence are unconstantly effective; a so far unanswered question is whether they compromise further treatment options or not. MATERIAL AND METHODS From October 1997, 89 children and adolescents (3-18years) suffering from severe sphincteric incompetence (exstrophy-epispadias 33, neuropathic bladder 45, bilateral ectopic ureters 6, miscellaneous 5) have received 144 endoscopic injections of dextranomer (Deflux®). A third had had a previous failed bladder neck procedure. 25 patients had two and 13 three treatment sessions. At each evaluation, the patient was classified as: cured (dryness interval of four hours), significantly improved (minimal incontinence requiring no more than one pad per day; no further treatment required) treatment failure when no significant improvement was observed. 84 have at least 6 months follow up and 33/84 (39%) are treatment failure. Further treatment was: Bladder neck plasties: 9/33, AMS 800 AUS : 7/33, Slings: 3/33, Further endoscopic treatment: 6/33 (including two after bladder neck plasty). Seeking for further treatment: 5/33; Lost to follow up: 5/33. At surgery Deflux paste was easily identified with minimal surrounding tissue inflammatory reaction. RESULTS Table 1: Results on continence of 25 treatments in 23 patients Procedure DRY IMPROVED FAILED Bladder neck plasty 6 2 1 AUS 7 0 0 SLING 2 1 0 Repeated endoscopic Treatment 1 1 4 TOTAL 16 4 5 Table 2: results on voiding ability of 25 treatments in 23 patients Procedure VOID CIC VOID/CIC Bladder neck plasty 5 3 0 AUS 2 2 3 SLING 0 3 0 Repeated endoscopic Treatment 2 2 2 TOTAL 9 10 5 CONCLUSIONS Endoscopic injections with dextranomer (Deflux) do not make further surgery at the bladder neck technically more challenging and do not seem to defavorably affect the outcome of these procedures. Repeated endoscopic treatments have a low success rate.

Hiatal Hernia, Lower Esophageal Sphincter Incompetence, and Effectiveness of Nissen Fundoplication in the Spectrum of Gastroesophageal Reflux Disease

Background and AimsGastroesophageal reflux disease (GERD) is a spectrum of disease that includes nonerosive reflux disease (NERD), erosive reflux disease (ERD), and Barrett’s esophagus (BE). Treatment outcomes for patients with different stages have differed in many studies. In particular, acid suppressant medication therapy is reported to be less effective for treating patients with NERD and Barrett’s esophagus. The aims of this study were to investigate (1) the role of mechanical factors including hiatal hernia and lower esophageal sphincter (LES) competence in the spectrum of GERD and (2) outcomes of Nissen fundoplication. MethodsFrom the records of patients who had undergone laparoscopic Nissen fundoplication after an abnormal pH study, we identified 50 symptomatic consecutive patients with each of the GERD stages: (1) NERD, (2) mild ERD, defined as esophagitis that was healed with acid suppression therapy, (3) severe ERD, defined as esophagitis that persisted despite medical therapy, and (4) BE. Exclusion criteria were normal distal esophageal acid exposure, esophageal pH monitoring performed elsewhere, antireflux surgery less than 1 year previously or previous fundoplication, and a named esophageal motility disorder or distal esophageal low amplitude hypomotility. Patients who could not be contacted for the study were also excluded. All patients completed a detailed preoperative questionnaire; underwent preoperative upper gastrointestinal endoscopy, stationary manometry, and distal esophageal pH monitoring; and were interviewed at least 1 year after operation. ResultsOne hundred sixty patients meeting the entry criteria were studied. The mean follow-up period was 36.7 months. The only significant preoperative symptom difference was that patients with BE had more moderately severe or severe dysphagia compared to patients with NERD. Patients with severe ERD or BE had a significantly higher prevalence of hiatal hernia, lower LES pressures, and more esophageal acid exposure. Hiatal hernia and hypotensive LES were present in most patients with severe ERD or BE but in only a minority of patients with NERD or mild ERD. Surgical therapy resulted in similarly excellent symptom outcomes for patients in all GERD categories. ConclusionsCompared to mild ERD and NERD, severe ERD and BE are associated with significantly greater loss of the mechanical antireflux barrier as reflected in the presence of hiatal hernia and LES measurements. Restoration of the antireflux barrier and hernia reduction by laparoscopic Nissen fundoplication provides similarly excellent symptom control in all patients.

Sling suspension of the bladder neck for pediatric urinary incontinence

Surgery for urinary incontinence in childhood is in the process of an ongoing search for better results because a procedure that guarantees dryness still does not exist. This study has been conducted to assess the overall results of the fascia sling procedure for incontinence in children. Eighty-nine patients with neurogenic lower urinary tract dysfunction and follow-up of more than 2 years have been included in the study (46 boys and 43 girls aged 2-17 years). All patients underwent U-type sling suspension of the bladder neck. In 59 patients detrusorectomy and in 11 patients bladder augmentation was performed. Sphincter incompetence was defined as low-pressure (<30 cm H(2)O) leakage observed during urodynamic studies. The results of surgery were assessed clinically (dryness intervals). Forty-two (47%) patients were completely dry, and 23 (26%) considerably improved. The success rate was higher in males (35) than in females (30) (76% vs 70%). Detrusorectomy did not improve the success rate of the sling procedure (68% vs 79% sling only), but bladder augmentation did (90%). Higher success rates have been observed in adolescents compared to prepubertal children (83% vs 56%). No serious complications were observed. Rectus fascia sling suspension is a safe procedure and could be considered a good option for the treatment of neurogenic sphincter incompetence in children.

Autologous muscle precursor cell Transplantation for the treatment of Urinary Incontinence in Children with Classic Bladder Extrophy: One year follow up

PURPOSE The application of muscle derived stem cells is an area of active research that may represent an improved alternative for the treatment of urinary incontinence. We investigated the effectiveness of autologous muscle precursor cell transplantation as a treatment option for urinary incontinence due to sphincter incompetence in children with the bladder exstrophy/epispadias complex (BEEC). MATERIAL AND METHODS Twelve patients with BEEC (11 boys and 1 girl) with persistent urinary incontinence entered the study. All patients had undergone staged bladder repair and bladder neck reconstruction and all of them (except 1) had received 1-3 transurethral injections of bulking agents with minimal effects. Muscle precursor cells were isolated from each patient's abdominal skeletal muscle, and cultured before endourethral injection. The effectiveness of treatment was evaluated with particular emphasis on clinical outcome (based on a 24-hour voiding diary), cystometric and urodynamic studies. RESULTS Eight Patients had a mean follow-up of 11.3 (from 8 to 14 months), The remaining 4 cases with less than 6 months follow-up are not presented in this data. There was a significant time-dependent improvement in patients' urinary continence. At the final follow-up, all 7 (88%) boys were socially dry (day-time dryness >3 hours) – including 3 (38%) completely dry. Urodynamic studies revealed an increase in mean bladder capacity (p < 0.001) and leak point pressure (p < 0.001). Six months after injection, all 7 boys (versus 2 cases preoperatively) had normal micturition with demonstrable voiding detrusor contraction in presence of compliant, stable bladders (p < 0.05). These changes were accompanied by an increment in the average maximum urinary flow (p < 0.01). CONCLUSIONS Autologous myoblast transplantation may be a safe, effective and attractive alternative treatment option for structural urinary incontinence, with possible ability for functional regeneration of urethral sphincter.

Update on detrusor hyperactivity with impaired contractility

Detrusor hyperactivity with impaired contractile function (DHIC) is a complex voiding dysfunction that is often misdiagnosed as incontinence resulting from benign prostatic hyperplasia with outlet obstruction, underactive detrusor with chronic retention, and stress urinary incontinence due to sphincter incompetence, particularly in women. Urodynamic assessments have shown that these subjects exhibit low pressure and almost unrecognizable involuntary detrusor contractions associated with reflex urethral relaxation accompanied with inefficient bladder emptying. These patients therefore tend to develop high residual volumes with a tendency towards chronic urinary retention. DHIC is a major cause of urinary incontinence in institutionalized elderly women. Accurate diagnosis requires awareness of this condition, careful video-urodynamic evaluation, and elimination of other disorders such as outlet obstruction and neurogenic bladder that confound DHIC. The exact causes are unclear, although some studies indicate that this entity may be a coincidental association of two separate etiologies, with each one independently contributing to the two different components of DHIC. Alternately, impaired detrusor function could emerge as a long-term sequelae of detrusor overactivity. Recent ultrastructural studies of the bladder in those with DHIC show distinct morphological patterns characteristic of both detrusor overactivity and impaired contractility. Management of this condition requires knowing that the condition potentially causes incontinence in women and lower urinary tract symptoms in men. Failure to diagnose DHIC in symptomatic patients may lead to inappropriate therapies including morbidity-prone surgical misadventures.

Wirksamkeit, Verträglichkeit und Akzeptanz von Incontex bei Hündinnen mit kastrationsbedingter Harninkontinenz

A clinical study about efficacy and acceptance of Incontex in spayed bitches with urinary incontinence was performed. In a randomised, double-blinded study the efficacy and acceptance of Incontex (Dr. E. Gräub AG, Bern, Schweiz) in bitches with urethral sphincter incompetence due to spaying was evaluated under field conditions. The active ingredient of the Incontex Syrup is phenylpropanolamine (PPA), an alpha1-adrenergic agonist. The study was performed using 24 spayed, incontinent bitches. Over a first period of treatment of 30 days the bitches received either Incontex, at 1.5 mg/kg twice per day, or a placebo. In the second period of 30 days all 24 bitches were treated with Incontex at the recommended dose. Any changes in the incontinence compared with the situation before the study were evaluated. Of 24 bitches 21 (88%) became continent and in 2 bitches (8%) urinary incontinence improved. In only 1 bitch (4%) the medication did have no effect. Five bitches (21%) showed side effects. The acceptance of Incontex was good. Incontex can be recommended as an efficient and well-tolerated medication for the treatment of bitches with urinary incontinence after spaying. The oral application of 1.5mg/kg BW phenylpropanolamine twice daily has been approved.

Mini-invasive collagen sling in the treatment of urinary incontinence due to sphincteric incompetence

To assess the technical feasibility of mini-invasive sling procedure and present preliminary results in the treatment of urinary incontinence due to sphincteric insufficiency. Thirteen patients (6 males, 7 females, 8 with myelomeningocele, 1 with tethered spinal cord, 3 with bladder exstrophy, 1 with epispadias) underwent sling procedure with porcine dermis acellular collagen matrix (Pelvilace, Bard medical, UK). The median age was 15.5 (range 8.9-27.5) years. A suprapubic catheter was inserted for the measurement of leak point pressure during the operation. In females vaginal and in males perineal incision was used for sling insertion. The sling was introduced under cystoscopic control. The sling was not fixed with sutures. The outcomes were reviewed at 1, 6 and 12 month after the operation. The median leak point pressure increased from 21.5 (range 5-25) cm H2O to 85 (range 70-100) cm H2O. At 1 month 8 and at 6 months 3 out of 13 patients were dry. At 12 months, none out of 11 patients was completely dry. However, at 12 months some improvement in incontinence was detected in 9 out of 11 patients. Two patients had primary failures. One patient got sling erosion to urethra after a tightening attempt. In one patient detrusor overactivity increased after the sling procedure. Pelvilace sling is safe and easy to introduce in both males and females if pelvic floor anatomy is normal. Although immediate results were promising in neuropathic incontinence, the results seem to deteriorate to unacceptable low level already during the first year. In exstrophy patients the results are generally poor.

Chapitre C-2 E - Chirurgie prothétique de l’incontinence urinaire d’effort par insuffisance sphinctérienne neurologique

Neurogenic sphincter incompetence, in the absence of detrusor dysfunction, results in stress urinary incontinence. Management is exclusively surgical. The available artificial sphincters ensure continence, provided intermittent self-catheterization is performed when necessary for neurogenic bladder. Artificial urinary sphincter is the reference treatment, historically and based on published cohort studies. However, it is associated with a higher morbidity in this population than in the non-neurological population. Although the surgical implantation technique is not modified in females as a result of the neurological disorder it is modified in males, as periprostatic implantation may be necessary, requiring specific training in this technique and rigorous patient selection. Other more recent prosthetic treatments are being developed, but are still at the stage of evaluation: periurethral fascia sling, periurethral injections and periurethral balloon implantation. These techniques eliminate the need to manipulate a pump to open the sphincter for self-catheterization. They appear to be promising, but their long-term results are unknown. In conclusion, operative indications for SUI due to neurogenic sphincter incompetence must be based on a multidisciplinary diagnostic assessment and explicit patient information.

Bladder neck sling and appendicovesicostomy without augmentation for neurogenic incontinence in children

Purpose Most children undergoing a sling for neurogenic urinary incontinence from sphincteric incompetence also have had bladder augmentation. However, complications from enterocystoplasty and uncertainty regarding its indications during bladder outlet enhancement led us to perform slings without augmentation, and we now report outcomes in consecutive patients. Material and methodsS 30 consecutive patients with a neurogenic bladder underwent tight 360 degree fascial sling wrap around the bladder neck and appendicovesicostomy without augmentation. Indications included a detrusor leak point pressure (DLPP) less than 50 cm water or stress urinary incontinence. Urodynamics were obtained in all patients before surgery, in 26 a mean of 6 months postoperatively, and in 16 a mean of 26 months after surgery. Results Preoperative bladder capacity was 37 – 175% predicted value for age; compliance was 2 – 53cc/cm. Postoperatively satisfactory continence was achieved in 83% of patients with follow-up 6 to 60 months (mean 22). The remaining 5 patients were not improved, 4 due to sling failure. In 8 children symptomatic hyperreflexia and/or loss of compliance developed postoperatively, but responded to anticholinergics in all but 1 who remained wet and underwent enterocystoplasty 18 months later for an augmentation rate of 3%. No patient developed hydronephrosis or reflux. Subsequent urodynamics in 16 patients at a mean of 26 months showed bladder capacity increased in 13, remained stable in 2 and decreased in 1. Conclusions We report the largest series of children with neurogenic incontinence undergoing sling without augmentation. Preoperative urodynamic parameters including bladder capacity and compliance did not predict the need for augmentation.

Interleukin-8 levels in esophageal mucosa and long-term clinical outcome of patients with reflux esophagitis

Reflux esophagitis (RE) is primarily attributable to gastric contents refluxing via an incompetent lower esophageal sphincter. Proton-pump inhibitors (PPIs) are currently the most effective modalit...

Significance of fibrosis around and/or at external urinary sphincter on pelvic magnetic resonance imaging in patients with postprostatectomy incontinence

Objectives To determine the clinical importance of fibrosis on pelvic magnetic resonance imaging in patients with postprostatectomy incontinence (PPI) due to sphincteric incompetence. Methods Urethral and periurethral fibrosis was determined by pelvic magnetic resonance imaging in patients who did (n = 22) or did not (n = 14) have urinary incontinence after transurethral resection, transvesical prostatectomy, or radical retropubic prostatectomy. The relation between fibrosis and the duration of incontinence, pad weight, symptom score, cystoscopy findings, and urodynamic findings was examined. Results Fibrosis was seen in all patients (22 of 22) in the study group and in 4 of 14 patients in the control group ( P <0.001). All the patients with severe fibrosis had undergone radical retropubic prostatectomy ( P <0.001). Similar to the etiology for incontinence, no relation was found between the severity of fibrosis and the duration of incontinence, pad weight, symptom score, cystoscopy findings, or urodynamic findings. However, the duration of incontinence was shorter in patients with mild fibrosis, clinically. Conclusions The results of our study have shown that the incidence of fibrosis is much greater in patients with PPI than in patients without PPI. Consequently, we believe that fibrosis plays an important role in the development of PPI because it may have a negative effect on external urethral sphincter function.