Sphincter Components Research Articles

Prediction of Postradical Prostatectomy Urinary Incontinence Through the Combination of the Urethral Pressure Profile With Electromyography of the Urethral Sphincter.

PurposeWe tested the hypothesis that the urethral pressure profile, in combination with electromyography of the urethral sphincter, may be useful as a predictor of urinary incontinence after radical prostatectomy (RP). The aim of this study was to assess whether the combination of these tests resulted in an improved tool for the prediction of post-RP urinary incontinence.MethodsPatients with indications for RP were included. The urethral pressure profile, including prostatic and sphincter components for maximum urethral closure pressure (MUCP) and functional urethral length, was recorded in combination with needle electromyography of the urethral sphincter. The mean and maximum amplitude of waves were measured twice: 1 month before RP and 6 months after the procedure. The 1-hour pad test was conducted in parallel with other tests. Patients completed the International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF). The relationship of the results of the tests with post-RP urinary incontinence was studied. Age, urodynamic parameters, pathologic stage, and surgical technique were recorded for analysis as potential confounding factors.ResultsNineteen patients were included within the 1-year study period. Their mean age was 63 years. According to the 1-hour pad test and ICIQ-SF, 42.1% of the sample had urinary incontinence after RP. Prostate MUCP with the mean and during-stress amplitude of waves predicted post-RP urinary incontinence with a sensitivity of 87.5% (P=0.002) in our model. Age, urodynamic parameters, pathological stage, and surgical technique were not related to incontinence after surgery.ConclusionsThe combination of the urethral pressure profile (prostatic MUCP) and electromyography of the urethral sphincter might be a useful prognostic predictor of post-RP urinary incontinence.

Chicago Classification update (v4.0): Technical review of high-resolution manometry metrics for EGJ barrier function.

Esophagogastric junction (EGJ) barrier function is of fundamental importance in the pathophysiology of gastroesophageal reflux disease. Impaired EGJ barrier function leads to excessive distal esophageal acid exposure or, in severe cases, esophagitis. Hence, proposed high-resolution manometry (HRM) metrics assessing EGJ integrity are clinically important and were a focus of the Chicago Classification (CC) working group for inclusion in CC v4.0. However, the EGJ is a complex sphincter comprised of both crural diaphragm (CD) and lower esophageal sphincter (LES) component, each of which is subject to independent physiological control mechanisms and pathophysiology. No single metric can capture all attributes of EGJ barrier function. The working group considered several potential metrics of EGJ integrity including LES-CD separation, the EGJ contractile integral (EGJ-CI), the respiratory inversion point (RIP), and intragastric pressure. Strong recommendations were made regarding LES-CD separation as indicative of hiatus hernia, although the numerical threshold for defining hiatal hernia was not agreed upon. There was no agreement on the significance of the RIP, only that it could localize either above the LES or between the LES and CD in cases of hiatus hernia. There was agreement on how to measure the EGJ-CI and that it should be referenced to gastric pressure in units of mmHgcm, but the numerical threshold indicative of a hypotensive EGJ varied widely among reports and was not agreed upon. Intragastric pressure was endorsed as an important metric worthy of further study but there was no agreement on a numerical threshold indicative of abdominal obesity.

Are there age-related changes in the measurements of the urethral sphincter complex in nulliparous women? A three-dimensional ultrasound assessment.

The objective was to determine age-related changes in measurements of urethral sphincter complex components in asymptomatic nulliparous women. Eighty nulliparous women ≥18years underwent 3D ultrasound of the anterior pelvic compartment in a cross-sectional study. Measurements of the urethral sphincter components (smooth muscle sphincter [SMS] andstriated urinary sphincter [SUS]) and urethra including area, length, width, and distance of the SUS and SMS from the urethrovesical junction were obtained. The women were grouped into four age groups: < 30years (group A), 30 to < 45 (group B), 45 to < 60 (group C), and ≥ 60years (group D). Age-related differences in the measurements were determined. Inter-rater and intra-rater agreement were performed for 20 nulliparous women. There were 24, 18, 26, and 12 women in groups A, B, C, and D respectively. None of the urethral sphincter complex measurements was significantly associated with age (p > 0.05). No differences were found between the groups for any measurements using one-way ANOVA and multiple comparison pairwise comparison (p > 0.05) other than width of SMS (C > A), urethral length (C > A), and distance of SUS from urethrovesical junction (C > D). Inter-rater and intra-rater agreement were moderate for area, length, and width of SUS (intraclass correlation 0.6) and good (intraclass correlation above 0.8) for the remaining measurements. Other than width of SMS, urethral length, and distance of SUS from urethrovesical junction, the dimensions of urethral sphincter complex components, as visualized by 3D endovaginal ultrasound, do not vary with age.

Bacterial Cultures at the Time of Artificial Urinary Sphincter Revision Surgery in Clinically Uninfected Devices: A Contemporary Series.

We evaluated the rate of bacterial colonization in artificial urinary sphincters during revision surgery for noninfectious etiologies. We evaluated bacterial culture swab data on all explanted artificial urinary sphincter components (cuff, pump and reservoir) in patients who underwent revision surgery between February 2016 and July 2018. Those treated with revision for infection or erosion were excluded from study. Patient demographic variables were assessed to identify factors associated with colonization. Cultures were obtained from 200 components, including 86 cuffs, 56 pumps and 58 reservoirs among the total of 80 patients. The etiology of revision included urethral atrophy in 31 cases (39%) and mechanical failure in 49 (52%). Median time after prior artificial urinary sphincter placement was 4.3 years (IQR 2-9). Median operative time was 37.5 minutes (IQR 32-46). All components were explanted and replaced in 55 patients (69%) and a single component was replaced in 23 (28%). Positive culture swabs were identified in 37 of the 200 components (19%), including 25 of 86 cuffs (29%), 7 of 56 pumps (13%) and 5 of 58 reservoirs (9%). Of the 80 patients 31 (39%) had at least 1 positive component culture and were more likely to have a history of radiation (65% vs 33%, p = 0.006). Identified organisms included Staphylococcus species in 57% of cases, Propionibacterium in 10% and Aerococcus in 5%. Positive artificial urinary sphincter component bacterial swab cultures were found in 39% of patients undergoing artificial urinary sphincter revision in the absence of clinical infection. Those with positive cultures were more likely to have a history of pelvic radiation. These results suggest that bacterial colonization of organisms with low virulence may not lead to device infection.

Re: Mechanical Failure Rates of Artificial Urinary Sphincter Components: Is the 3.5-cm Urethral Cuff at Higher Risk?

Re: Mechanical Failure Rates of Artificial Urinary Sphincter Components: Is the 3.5-cm Urethral Cuff at Higher Risk?

Mechanical failure rates of artificial urinary sphincter components: Is the 3.5-cm urethral cuff at higher risk?

We report the rates of artificial urinary sphincter (AUS) mechanical failure in a contemporary cohort of patients stratified by component type and size to determine if the 3.5-cm cuff is at higher risk of failure. From 2005-2016, a total of 486 male patients with stress incontinence underwent implantation or revision of an AUS. 993 individual cases were retrospectively reviewed (465 primary placements and 528 revisions). Components were separately tallied and cases of mechanical failure were identified. Multiple variables including duration until failure and follow-up interval were collected and analyzed for each malfunction. After median follow-up of 31.5 months, there were 48 distinct cases of mechanical failure. The urethral cuff was the most common component to fail (n = 27, 56.3%), followed by the pressure regulating balloon (PRB) (n = 6, 12.5%), tubing (n = 6, 12.5%), and the control pump, (n = 5, 10.4%). Four (8.3%) cases did not have the source of malfunction identifiable in available records though fluid loss was evident at the time of device interrogation. Sub-analyses of cuff failure events showed that the 3.5-cm cuff had a statistically significant higher risk of failure (HR: 7.313, (P < .0001) compared to larger cuff sizes. While each component is prone to malfunction, our study suggests that the 3.5-cm urethral cuff is more susceptible to failure and failure events occur earlier after placement than larger cuff sizes.

Can time to failure predict the faulty component in artificial urinary sphincter device malfunctions?

Artificial urinary sphincter malfunctions can occur in any of the individual components. Preoperative identification of the malfunctioning component can be valuable for patient counseling and surgical planning. The optimal strategy for repair of failed artificial urinary sphincter components is debated given the relative rarity of the situation. The aim of the present study was to evaluate the relationship of time to failure with failed artificial urinary sphincter component and to compare our outcomes of specific component versus complete device replacement. From 1983 to 2011, 1805 artificial urinary sphincter procedures were carried out at Mayo Clinic (Rochester, Minnesota, USA), of which 1072 patients underwent primary artificial urinary sphincter placement. Clinical variables, including time to failure, were evaluated for association with component failure. Bootstrap analysis was used to estimate the differences in time to reach a fixed percentage of component failure. A total of 115 patients experienced device failure at a median follow up of 4.2 years. Urethral cuff, abdominal reservoir, scrotal pump and tubing malfunction occurred in 53 (4.9%), 26 (2.4%), 11 (1%) and 25 (2.3%) patients, respectively. Increasing age at the time of primary surgery was protective of cuff malfunction (hazard ratio 0.97, P = 0.04). Time to 3% urethral cuff failure outpaced other component failures (P < 0.05). Secondary failure-free rates after whole device versus specific component revisions were comparable (P = 0.38). Clinical predictors for artificial urinary sphincter failure continue to be difficult to establish. Although single component versus entire device replacement have similar outcomes, if pursuing single component revision, we recommend cuff-first interrogation in devices in place for >3 years, as this represents the most likely component to fail.

Normative anatomy of the anal sphincter detected with 3D-endoanal ultrasonography

Background: Understanding anal sphincter anatomy is crucial in management of anorectal disorders, including anorectal sepsis and fecal incontinence. Three-dimensional endoanal ultrasound (EAUS) provides better resolution of the tissue layers. Previous normative studies were obtained in Western populations. Objective: We demonstrated the anal sphincter anatomy in normal East Asian subjects. Methods: Forty-six healthy subjects without anorectal symptoms (M:F = 15:31, mean age ± SD = 47 ± 13 years) were enrolled. High-frequency (16 MHz) EAUS was performed with a mechanically rotated probe. Thickness and length of anal sphincter components were measured. Differences between sexes were assessed using a Student t test. Results: We demonstrated 4 differentiable components: the anal sphincter; internal anal sphincter (IAS), subcutaneous external anal sphincter (Sc EAS), superficial external anal sphincter (Sp EAS), and puborectalis muscle (PRm). The mean length of anal sphincter components were obtained in mm (men vs. women), IAS (28.5vs. 25.3, p = 0.03), Sc EAS (13.2 vs. 11.2, p = 0.005), Sp EAS (24.1 vs. 19.6, p = 0.0001), and PRm (12.4 vs. 12.2, p = 0.84). The anal canal was significantly longer in men (38.6 vs. 34.0, p = 0.007). The mean thickness for IAS (1.7 vs. 1.8, p = 0.095), Sc EAS (7.5 vs. 7.6, p = 0.587), Sp EAS (8.1 vs. 6.9, p = 0.001), and PRm (8.7 vs. 9.0,p = 0.605) were measured. The PRm was the thickest and the Sp EAS was the longest voluntary sphincter. Conclusion: Normative details of anal sphincter components in an East Asian population are described. This data can be used for future consideration of diseased states. Keywords: Anal sphincter anatomy, anal ultrasound, endoanal ultrasonography, normal anal sphincter anatomy,normative data, transanal ultrasound

The esophagogastric junction.

The following discussion of the esophagogastric junctions includes commentaries on the three component structures of the sphincteric segment between the stomach and the esophagus; the pressure contributions from the three sphincteric components in normal subjects and in gastroesophageal reflux (GERD) patients; the mechanism of action of endoscopic plication to determine the underlying pathophysiology of GERD; and in vitro muscle strip studies of defects within the gastroesophageal sphincteric segment potentially leading to GERD.

A missing sphincteric component of the gastro‐oesophageal junction in patients with GORD

It was recently shown that the tonic pressure contribution to the high-pressure zone of the oesophago-gastric segment (OGS) contains the contributions from three distinct components, two of which are smooth muscle intrinsic sphincter components, a proximal and a distal component [J Physiol 2007; 580.3: 961]. The aim of this study was to compare the pressure contributions from the three sphincteric components in normal subjects with those in gastro-oesophageal reflux disease (GORD) patients. A simultaneous endoluminal ultrasound and manometry catheter was pulled through the OGS in 15 healthy volunteers and seven patients with symptomatic GORD, before and after administration of atropine. Pre-atropine (complete muscle tone), postatropine (non-muscarinic muscle tone plus residual muscarinic tone) and subtracted (pure muscarinic muscle tone) pressure contributions to the sphincter were averaged after referencing spatially to the right crural diaphragm and the pull-through start position. In the normal group, the atropine-resistant and atropine-attenuated pressures identified the crural and two smooth muscle sphincteric components respectively. The subtraction pressure curve contained proximal and distal peaks. The proximal component moved with the crural sling between full inspiration and full expiration and the distal component coincided with the gastric sling-clasp fibre muscle complex. The subtraction curve in the GORD patients contained only a single pressure peak that moved with the crural sphincter, while the distal pressure peak of the intrinsic muscle component, which was previously recognized in the normal subjects, was absent. We hypothesize that the distal muscarinic smooth muscle pressure component (gastric sling/clasp muscle fibre component) is defective in GORD patients.

The Anatomical Components of Urinary Continence

BackgroundThe levator ani muscle (LAM) plays an important role in urinary continence, but the anatomical relationship between this pelvic floor muscle and the external urethral sphincter (EUS) remains incompletely understood. ObjectiveTo investigate the topographical relationship between the EUS and the LAM. Design, setting, and participantsSerially sectioned and histochemically stained foetal pelves from eleven females and nine males (10–27 wk of gestation) were studied. Three foetal pelves (two female, 12 and 18 wk of gestation; one male, 12 wk of gestation) and three adult pelves (two females, 54 and 85 yr; one male, 75 yr) were stained immunohistochemically for the presence of striated and smooth muscle tissue. Three-dimensional reconstructions were prepared. MeasurementsAnatomy of the LAM and urethral sphincter components was evaluated qualitatively. Results and limitationsThe EUS has no direct bony attachment. In female foetuses, the inferior part of the EUS is firmly attached to the LAM by a tendinous connection. Contraction of this part of the EUS produces a force on the urethra in a posteroinferior direction. Contraction of the LAM compresses the rectum and moves the rectovaginal complex anteriorly and superiorly towards the urethra in a plane that lies parallel to, but superior of, that of the EUS. Simultaneous contraction of the LAM and EUS causes an anteriorly convex bend in the midurethra, which closes the midurethral lumen. A similar attachment of the EUS to the LAM is absent in the male. Our study is limited due to the absence of young adult study specimens. ConclusionsThe EUS in females is anchored to the levator ani muscle via a tendinous connection. Because of this attachment to the LAM, proper function of the EUS is dependent on the integrity of the LAM and its attachment to the pelvic wall.

Pharmacological dissection of the human gastro‐oesophageal segment into three sphincteric components

Quantifications of gastro-oesophageal anatomy in cadavers have led some to identify the lower oesophageal sphincter (LOS) with the anatomical gastric sling-clasp fibres at the oesophago-cardiac junction (OCJ). However, in vivo studies have led others to argue for two overlapping components proximally displaced from the OCJ: an extrinsic crural sphincter of skeletal muscle and an intrinsic physiological sphincter of circular smooth-muscle fibres within the abdominal oesophagus. Our aims were to separate and quantify in vivo the skeletal and smooth muscle sphincteric components pharmacologically and clarify the description of the LOS. In two protocols an endoluminal ultrasound-manometry assembly was drawn through the human gastro-oesophageal segment to correlate sphincteric pressure with the anatomic crus. In protocol I, fifteen normal subjects maintained the costal diaphragm at inferior/superior positions by full inspiration/expiration (FI/FE) during pull-throughs. These were repeated after administering atropine to suppress the cholinergic smooth-muscle sphincter. The cholinergic component was reconstructed by subtracting the atropine-resistant pressures from the full pressures, referenced to the anatomic crus. To evaluate the extent to which the cholinergic contribution approximated the full smooth-muscle sphincter, in protocol II seven patients undergoing general anaesthesia for non-oesophageal pathology were administered cisatracurium to paralyse the crus. The smooth-muscle sphincter pressures were measured after lung inflation to approximate FI. The cholinergic smooth-muscle pressure profile in protocol I (FI) matched closely the post-cisatracurium smooth-muscle pressure profile in protocol II, and the atropine-resistant pressure profiles correlated spatially with the crural sling during diaphragmatic displacement. Thus, the atropine-resistant and cholinergic pressure contributions in protocol I approximated the skeletal and smooth muscle sphincteric components. The smooth-muscle pressures had well-defined upper and lower peaks. The upper peak overlapped and displaced rigidly with the crural sling, while the distal peak separated from the crus/upper-peak by 1.1 cm between FI and FE. These results suggest the existence of separate upper and lower intrinsic smooth-muscle components. The 'upper LOS' overlaps and displaces with the crural sling consistent with a physiological LOS. The distal smooth-muscle pressure peak defines a 'lower LOS' that likely reflects the gastric sling/clasp muscle fibres at the OCJ. The distinct physiology of these three components may underlie aspects of normal sphincteric function, and complexity of sphincter dysfunction.

Editorial Comment on: Prospective Clinical Trial Comparing Obtape® and DUPS to TVT: One-year Safety and Efficacy Results

Suburethral sling procedures are specifically designed to address both urethral hypermobility and intrinsic sphincteric deficiency components of stress urinary incontinence (SUI) in women. Although further studies are needed to establish their long-term efficacy and safety, these procedures seem more efficient than the ones adopted in the era before the development of tension-free vaginal tape (TVT). In their paper, Andonian et al [1] report the outcomes of three types of suburethral sling to treat female SUI. In a prospective, randomised, controlled, clinical trial Obtape and DUPS were compared to the original TVT procedure. The DUPS arm of the randomised clinical trial (RCT) was discontinued after 32 patients because they observed a high postoperative retention rate (18.8%) combined with suprapubic discomfort. This study demonstrates that, at 1-yr follow-up, no statistically significant differences in cure rates were evident, but Obtape, DUPS, and TVT were associated with postoperativecomplications in 14%, 28%, and 8% of patients, respectively (p 0.025). TVT was the only procedure associated with bladder perforation, and this complication was higher in patients who had undergone previous surgery [1]. The perivesical tissue hydrodissection due to local anaesthesia could reduce the risk of bladder perforation, but I agree with the authors that regional anaesthesia is better tolerated by patients. A recurrent SUI is reported in 23 patients (12.1%), but the outcome after retropubic and trans-obturator procedures is not available, so I suppose that the authors do not find any significant differences [1]. The International Consultation on Incontinence underlines that TVT procedure on recurrent SUI has shown promising results, whereas few data on this issue regarding the other type of suburethral slings efficacy are available in literature [2]. Urinary incontinence and pelvic organ prolapse (POP) commonly coexist [3]. SUI is observed in up to 60% of women with POP and prolapse in up to 40% of women presenting with SUI [3–5]. In this study a concomitant prolapse surgery (anterior and posterior colporrhaphy and vaginal hysterectomy) was performed in 29 patients (15.2%) and was associated with postoperative retention only in the Obtape group (38% vs. 4%) [1]. There are no data in the literature, obtained from comparative RCTs, that could clarify whether POP surgery and antiincontinence surgery have to be performed at the same or different times and which anti-incontinence procedure is better. The authors report no statistically significant differences among the three groups in terms of persistent or de novo urgency, but the overall rate of the persistent urgency ranges from 19% to 23% [1]. Recently, Costantini et al [6] reported on the efficacy of the retropubic or trans-obturator approach in the treatment of mixed urinary incontinence (MUI). They compared TVT and trans-obturator tape procedures and found that at a mean follow-up of 24 mo the outcome after TVT seems slightly worse in patients with MUI. ‘‘Urgency remains a postoperative problem especially in the TVT group’’ [6]. IbelievethatmulticentreRCTswithlongerfollowup are needed to establish which suburethral sling procedure in the treatment of MUI or recurrent SUI is better. In addition, comparative RCTs are needed to determine whether POP surgery and the retropubic or trans-obturator anti-incontinence procedure should be performed simultaneously or not.

Magnetic Resonance Imaging and 3-Dimensional Analysis of External Anal Sphincter Anatomy

To use magnetic resonance images of living women and 3-dimensional modeling software to identify the component parts and characteristic features of the external anal sphincter (EAS) that have visible separation or varying origins and insertions. Detailed structural analysis of anal sphincter anatomy was performed on 3 pelvic magnetic resonance imaging (MRI) data sets selected for image clarity from ongoing studies involving nulliparous women. The relationships of anal sphincter structures seen in axial, sagittal, and coronal planes were examined using the 3-D Slicer 2.1b1 software program. The following were requirements for sphincter elements to be considered separate: 1) a clear and consistently visible separation or 2) a different origin or insertion. The characteristic features identified in this way were then evaluated in images from an additional 50 nulliparas for the frequency of feature visibility. There were 3 components of the EAS that met criteria as being "separate" structures. The main body (EAS-M) is separated from the subcutaneous external anal sphincter (SQ-EAS) by a clear division that could be observed in all (100%) of the MRI scans reviewed. The wing-shaped end (EAS-W) has fibers that do not cross the midline ventrally, but have lateral origins near the ischiopubic ramus. This EAS-W component was visible in 76% of the nulliparas reviewed. Three distinct external anal sphincter components can be identified by MRI in the majority of nulliparous women.

New surgical technique for sphincter urinary control system using upper transverse scrotal incision.

Traditional implantation of the AMS Sphincter 800 Urinary Control System (American Medical Systems, Minnetonka, Minnesota) requires 2 incisions. The cuff is placed via a perineal incision, and the pressure regulating balloon and pump are placed through a separate suprapubic incision. We describe a novel implantation of all the artificial urinary sphincter components using a single upper scrotal incision. The scrotal incision allows excellent access to the proximal bulbar urethra and retropubic and subdartos spaces, and leaves the bulbocavernosus muscle intact. A total of 37 patients have undergone artificial urinary sphincter implantation using the new operative technique for revisions or reimplantations of a sphincter previously removed for infection/erosion (12) or as an initial procedure (25). In 9 of the 25 patients and 2 of the 12 dual implantation of a 3-piece penile prosthesis through the same incision was performed. All patients are using the devices. Of the patients 66% are completely dry with no pad use and the remainder use 1 pad for accident prevention. Operative time was reduced due to easier exposure of the urethra and a second incision for placement of the pressure regulating balloon was not necessary. Followup at 1 year shows no difference in complication rate with the single incision technique compared to the traditional method. Artificial urinary sphincter implantation through a single scrotal incision is easier and faster than the traditional 2-incision technique. Success in achieving continence is similar to traditional methods. Long-term followup is necessary to ensure that complications remain low.

Endosonographic characteristics of the anal sphincter complex in primigravid Sri Lankan women

Objective To determine the endosonographic anatomy of the anal sphincter complex in primigravid Sri Lankan women. Method This is an observational study of 95 primigravid women admitted to an antenatal ward. They were examined using anal endosonography and data from subjects without sphincter injury were analyzed to describe anal sphincter morphology. Individual anal canal components were measured at defined levels, and the relationship of individual measurements with age and body mass index was calculated. Results Ninety-three of 95 women had no anal sphincter damage. The puborectalis sling (mean 5.5 mm, S.D. 0.77) forms the upper most border of the sphincter complex. The mean width of the deep external sphincter was 4.3 mm (S.D. 0.61); that of the superficial external sphincter was 4.5 mm (S.D. 0.56); and that of the internal anal sphincter at the mid anal canal was 2.1 mm (S.D. 0.21). The intersphincteric space (mean 2.1 mm, S.D. 0.26) could be distinguished sonographically in all subjects. The mean width of the anterior ring of the subcutaneous component was 3.8 mm (S.D. 1.01). The perineal body was sonographically identified in 60%. Conclusion A set of normal values for the anal sphincter components in Sri Lankan primigravid women was established.

New Surgical Technique for Sphincter Urinary Control System Using Upper Transverse Scrotal Incision

Traditional implantation of the AMS Sphincter 800 Urinary Control System (American Medical Systems, Minnetonka, Minnesota) requires 2 incisions. The cuff is placed via a perineal incision, and the pressure regulating balloon and pump are placed through a separate suprapubic incision. We describe a novel implantation of all the artificial urinary sphincter components using a single upper scrotal incision. The scrotal incision allows excellent access to the proximal bulbar urethra and retropubic and subdartos spaces, and leaves the bulbocavernosus muscle intact. A total of 37 patients have undergone artificial urinary sphincter implantation using the new operative technique for revisions or reimplantations of a sphincter previously removed for infection/erosion (12) or as an initial procedure (25). In 9 of the 25 patients and 2 of the 12 dual implantation of a 3-piece penile prosthesis through the same incision was performed. All patients are using the devices. Of the patients 66% are completely dry with no pad use and the remainder use 1 pad for accident prevention. Operative time was reduced due to easier exposure of the urethra and a second incision for placement of the pressure regulating balloon was not necessary. Followup at 1 year shows no difference in complication rate with the single incision technique compared to the traditional method. Artificial urinary sphincter implantation through a single scrotal incision is easier and faster than the traditional 2-incision technique. Success in achieving continence is similar to traditional methods. Long-term followup is necessary to ensure that complications remain low.

Alteration of anal sphincter morphology following vaginal delivery revealed by multiplanar anal endosonography.

To assess morphologic change in the anal sphincters in the absence of endosonographic evidence of trauma after vaginal delivery. Prospective observational study. District general hospital. Consecutively booked nulliparous pregnant women attending antenatal clinic. All women were examined using three-dimensional anal endosonography, simple manometry and had questionnaire assessment of incontinence before and after delivery. Components of the anal canal were measured in the axial, sagittal and coronal planes and paired pre- and post-delivery examinations were compared. Any changes were related to changes in continence and anal canal manometry. Twenty-two women had a vaginal delivery and no endosonographic evidence of perineal trauma after delivery. After delivery, there was significant shortening of the length of the anterior external anal sphincter [EAS] (mean 21.7 vs 20.5 mm, P = 0.02) when measured in the sagittal plane, which increased in anterior angulation with respect to the axis of the anal canal (10 degrees vs 13.8 degrees, P = 0.03). In the axial plane, no change was seen in the thickness of any of the sphincter components after delivery. None of these morphologic changes correlated with changes in manometry or continence score. Anal sphincter morphology changes after an otherwise atraumatic vaginal delivery. This change does not correlate with any functional symptoms.

Alteration of anal sphincter morphology following vaginal delivery revealed by multiplanar anal endosonography

Objective To assess morphologic change in the anal sphincters in the absence of endosonographic evidence of trauma after vaginal delivery. Design Prospective observational study. Setting District general hospital. Population Consecutively booked nulliparous pregnant women attending antenatal clinic. Methods All women were examined using three-dimensional anal endosonography, simple manometry and had questionnaire assessment of incontinence before and after delivery. Main outcome measures Components of the anal canal were measured in the axial, sagittal and coronal planes and paired pre- and post-delivery examinations were compared. Any changes were related to changes in continence and anal canal manometry. Results Twenty-two women had a vaginal delivery and no endosonographic evidence of perineal trauma after delivery. After delivery, there was significant shortening of the length of the anterior external anal sphincter [EAS] (mean 21.7 vs 20.5 mm, P = 0.02) when measured in the sagittal plane, which increased in anterior angulation with respect to the axis of the anal canal (10° vs 13.8°, P = 0.03). In the axial plane, no change was seen in the thickness of any of the sphincter components after delivery. None of these morphologic changes correlated with changes in manometry or continence score. Conclusions Anal sphincter morphology changes after an otherwise atraumatic vaginal delivery. This change does not correlate with any functional symptoms.

Assessment of the intrinsic urethral sphincter component function in postprostatectomy urinary incontinence.

Postprostatectomy incontinence remains a disabling condition. Sphincter injury, detrusor instability, and decreased bladder compliance have been previously reported as major factors. The aim of this study was to evaluate the urethral sphincter intrinsic component, which may provide passive continence. A urodynamic evaluation was performed in 20 patients undergoing a radical retropubic prostatectomy in the preoperative period and 3 months after surgery. Patients with disabled urinary incontinence underwent a new urodynamic evaluation 6 months later. The urethral pressure profile was measured just before, then 10, 20, and 30 minutes after the injection of 0.5 mg/kg moxisylyte chlorhydrate, an alpha adrenergic blocker. Three different pressure components were defined in urethral sphincter capacity: baseline, adrenergic, and voluntary. A postoperative intrinsic urethral sphincter pressure component was found in 17 patients and its value was under 6 cm H(2)O in five cases of severe incontinence. No significant difference was observed for these patients on urethral profile components 6 months later. In contrast, in cases of significant intrinsic component value, no incontinence was observed in most patients. Passive continence after radical prostatectomy should be a matter of concern and may also explain paradoxical incontinence, despite high voluntary urethral pressure obtained after reeducation. A follow-up evaluation of the intrinsic sphincter component is suggested, by using an alpha receptor blockage test during urodynamic studies in the management of patients with postprostatectomy incontinence.