Urethral Support Research Articles

Durability of Macroplastique volume and configuration in women with stress urinary incontinence secondary to intrinsic sphincter deficiency: A retrospective review.

To evaluate the durability of Macroplastique® (MPQ) volume and configuration in women with stress urinary incontinence (SUI) secondary to intrinsic sphincter deficiency (ISD) using serial three-dimensional ultrasound (3DUS) measurements. Following Institutional Review Board approval, charts of women with SUI and ISD (defined based on leak point pressure; lateral imaging of urethral support without hypermobility) who underwent MPQ were reviewed from a prospectively maintained database. All had at least two serial transperineal 3DUS measurements with no MPQ or other bulking agent injection between measurements. 3DUS was performed using the Philips IU22 ultrasound system with endovaginal 3D 9-3V end-fire probe typically at 6-8 weeks post-injection and yearly thereafter. The same imaging team blinded to clinical outcomes evaluated volume and configuration (circumferential/symmetric or asymmetric) at each 3DUS. Between 2011 and 2019, 62 of 174 women met study criteria. Those with prior other bulking agent injection or having ≤1 3DUS follow-up were excluded. Seventy-one percent of patients had one injection, while the remainder had two or more (29%). Median time between first and second 3DUS was 12 months. The mean change in MPQ volume between the first and last 3DUS measurement was -0.2cc (95% CI: -0.5 to 0.004; P=.054). A median of 5.0cc were injected in each patient. Forty-seven women had symmetric MPQ at first 3DUS, of whom only five (11%) had a follow-up 3DUS showing asymmetric MPQ distribution. At mid-term follow-up, repeat transperineal 3DUS after MPQ injection revealed minimal change in volume and configuration in the urethral wall.

The transvaginal tape surgery vs. trans-obturator tape for stress urinary incontinence

: Female urinary incontinence is a highly prevalent condition affecting women’s quality of life and is associated with considerable personal and societal stress. Stress urinary incontinence (SUI) is thought to be due to the loss of urethral support vs. a weakness of the urethra itself. Multiple treatment options exist for the SUI including conservative behavioral modifications, physical therapy, medications, and surgical options. Surgical options can be offered to patients who achieve unsatisfactory results from non-surgical options or who prefer to have surgery by choice. Numerous surgical options for SUI have been described and have evolved over time. This evolution of surgery for SUI has led to more minimally invasive surgical options. The gains in the knowledge of anatomy of the bladder and urethra has also shifted the focus of continence mechanism to be at the mid urethra and not just the bladder neck as previously thought. This has led the mid urethral sling (MUS) to be the surgical options of choice by most surgeons. Patient selection and knowledge of the anatomy associated with midurethral slings are critical as the outcomes and complications associated with surgery are the results of these factors. The retropubic [transvaginal tape (TVT)] and the transobturator [trans-obturator tape (TOT)] MUSs are the main surgical options for SUI. Between the TVT and TOT sling, there is no one sling better or worse than the other.

Architecture of female urethral supporting structures based on undeformed high-resolution sectional anatomical images.

Female urinary incontinence mainly relates to damage of female urethra supporting structures, while its anatomy and function specially in which the connective tissue part are still unclear and controversial. We study it based on 4 thin-sectional, high-resolution, transverse sectional anatomical images [Chinese Visible Human (CVH) images] and 10 high-resolution MRI images from volunteers. The female urethral supporting structures and its adjacent structures were segmented and three-dimensional (3D) reconstructed with Amira software. The urethral supporting structures include muscular and connective tissue supporting structures. Muscular supporting structures are composed of levator ani muslce and striated urethral sphincter, the connective tissue supporting structures are composed of anterior vaginal wall, pubovesical muscle, pubovesical ligament, lateral vesical ligament, and tendinous arch of pelvic fascia (TAPF). The anterior vaginal wall includes tight and loose connections between urethral, bladder, and vagina. The lateral vesical ligament connects the proximal part of the urethra to the TAPF. The pubovesical muscle is crescent shaped and continues with the detrusor of the bladder superior and directly connects the TAPF laterally. The TAPF is an obvious fibrous structure that originates at the middle-posterior surface of the pubis, travels onto the parietal pelvic fascia, and inserts posteriorly onto the ischial spine. The anterior vaginal wall, the pubovesical muscle, the lateral vesical ligament, and the TAPF create the "hammock" structure and supplement DeLancey's theory. Its support to the proximal urethra and neck of bladder is crucial to maintain stability and urinary continence during increased abdominal pressure.

Spatial distribution of smooth muscle tissue in the female pelvic floor and surrounding the urethra and vagina.

Data regarding urethral supporting structures are insufficient for understanding the mechanism of stress urinary incontinence. Whether smooth muscle fibers contribute to urethral support and pelvic floor support structures is unclear. This study aimed to clarify the histological structures and spatial distributions of smooth muscle tissues surrounding the urethra and vagina. Using cadaveric specimens, macroscopic anatomical and histological evaluations were conducted. Six female cadavers were used for macroscopic observations. Ten female cadavers were used for histological observations. Three pelvises were cut in a plane vertical to the urethra, and the other pelvises were cut in a plane parallel to the urethra and vagina to observe tissues surrounding the urethra and vagina. The major tissue component around the proper muscle layer of the urethra was smooth muscle tissue, which mediated among the urethra, pubis, and levator ani. Smooth muscle tissues laterally extended the smooth muscle fibers, both superiorly and inferiorly toward the levator ani, with a few fibers inserted in the levator ani. Smooth muscle was found between the urethral walls and pubic bones. Smooth muscle may contribute to the mechanism of pelvic floor support.

Female urethral reconstruction: dorsal buccal mucosa graft onlay.

Female urethral stricture (FUS) is an infrequent entity, but may cause significant morbidity. Despite a rising interest in recent years, there is still scarce published information. In this article, we review FUS with a special attention to the use of dorsal buccal mucosa grafts (DBMG). A literature search was conducted summarizing information about etiology, anatomy, diagnosis, and management. A detailed description of our technique for DBMG urethroplasty is given, with a summary report of our experience and results. FUS accounts for about 1% of all women consulting for lower urinary tract symptoms (LUTS). Diagnosis is suspected in front of persistent LUTS suggestive of obstruction. Confirmatory tests are uroflowmetry, endoscopy, and urethrography; true anatomic strictures must be differentiated from functional or physiological obstructions. Initial management may include dilations, but recurrence is frequent. On the contrary, reconstructive surgery is highly efficient, with overall curative rates around 90%. For reconstruction, DBMG has gained popularity, because it would maintain intact the ventro-lateral urethral supporting structures, important for continence. The pathology of female strictures is unknown and neither the pre nor the intraoperative assessment allows determining the precise location and extent or the urethral damage; therefore, we advise extensive grafting of the entire urethra. Collected success of DBMG is 86% at a mean follow-up of 21 months. Morbidity is very low and de novo stress incontinence has not been reported. Because of its many advantages, DMBG currently represents a prime choice for FUS reconstruction.

Clinical characteristics and treatment of female stress urinary incontinence combined with bladder neck obstruction

Objective: To analyze the clinical characteristics and treatment of female stress urinary incontinence (SUI) combined with bladder neck obstruction (BNO). Methods: The clinical data of 17 cases of female SUI patients with BNO, who was admitted to the Urology department, Beijing Chaoyang hospital from November 2011 to April 2018, were retrospectively analyzed. The mean age was (60.3±2.6) years old and the mean body mass index was (23.8±0.5) kg/m(2). All patients had the first stage bladder neck incision with the second stage suprapubic urethral support sling. The clinical characteristics, curative effects and outcomes were analyzed. Results: The maximum flow rate was increased significantly after the bladder neck incision compared with preoperative [(9.3±0.5) vs (25.6±0.8) ml/s, P<0.001]. The postvoid residual urine volume and PdetQmax were decreased significantly than that preoperative [(167.5±4.4) vs (4.1±0.5) ml, P<0.001; (49.4±1.3) vs (24.9±0.7) cmH(2)O, P<0.001]. The incontinence questionnaire-short form score was significantly lower after the second stage suprapubic urethral support sling [(2.4±0.4) vs (14.9±0.3), P<0.001]. The number of subjective and objective case of suprapubic urethral support sling was 13, and the treatment effect of other patients was improved. The hospitalization and operation time of the bladder neck incision and the suprapubic urethral support sling were short. All patients had no intraoperative complications, two cases had dysuria and one case had groin pain after the suprapubic urethral support sling operation. Conclusions: The patients of female SUI combined with BNO are most elderly and obese population. The effectiveness and safety of the first stage bladder neck incision and the second stage suprapubic urethral support sling are high, and the surgeries can effectively relieve the obstruction and improve the quality of patients' life.

Preservation of continence in radical prostatectomy patients: a laparoscopic surgeon's perspective.

IntroductionPreserving continence in patients who underwent radical prostatectomy is of utmost importance. Therefore, modification of surgical technique that would contribute to the regaining of continence with a shortest possible delay after the procedure and adequate evaluation of chances of continence recovery should be considered.Material and methodsA PubMed database search was performed to review the current literature concerning the physiology and anatomy of sphincter mechanisms, perioperative risk factors, the effects of surgical techniques on post-prostatectomy continence and post-operative management.ResultsModifications of surgical approach with an aim to minimize damage to the sphincter complex, maintenance of maximal urethral length to enable safe anastomosis, and the reconstruction of the urethral support system appears necessary. The patient should also be informed about the chances of regaining continence after surgery.ConclusionsThere is a need to develop a predictive model to stratify patients according to risk of incontinence and implement adequate action to minimize those risks including preoperative pelvic floor muscle training and/or surgical technique modification.

Pelvic floor function in women with stress urinary incontinence

Objective To evaluate any changes in overall pelvic floor function among women with stress urinary incontinence (SUI). Methods Twenty-five female SUI patients were recruited as the SUI group and twenty-three healthy female counterparts were selected as the control group. Pelvic organ prolapse quantification (POP-Q) was performed with both groups. Ultrasonography was used to measure the position of the bladder neck, the posterior angle of the urethra, the urethra′s inclination angle and the size of the diaphragmatic hiatus for both groups at rest, during the Valsalva maneuver, as well as during the transition from resting to the Valsalva maneuver. The strength and fatigue of type I and type II fibers in the pelvic muscles were evaluated electrophysiologically, and anorectal manometry was also performed with both groups. The significance of any relationship between these measurements and SUI was determined using multivariate logistic regression analysis. Results Eleven members of the SUI group showed phase I pelvic organ prolapse. Twelve were in phase II and 2 were in phase III. All of those incidences were significantly different from the control group. There were significant differences between the two groups in the average bladder neck position, urethral inclination angle, posterior urethra angle, descending distance of the bladder neck, and urethral rotation angle during the Valsalva maneuver. In the transition from resting to the Valsalva maneuver, significant differences were found only in the distance of the bladder neck′s descent and the rotation angle of the urethra. The severity of pelvic organ prolapse, the descending distance of the bladder neck and the urethral rotation angle, as well as the bladder neck position and urethral angle during the Valsalva maneuver were the major risk factors associated with female SUI, and the correlation was statistically significant. Conclusion The greater the mobility of the bladder neck and urethra in female SUI patients, the more serious the prolapse. Prolapse, bladder neck mobility and urethral support all affect the overall functionality of the pelvic floor. Key words: Stress; Urinary incontinence; Pelvic floor; Ultrasonography; Anorectal manometry

Midurethral support is also necessary for reflex closure of the urethra.

The pathophysiology of female stress urinary incontinence (SUI) is far from unraveled. Capturing all aspects of this bothersome condition in one theory remains challenging. The well-known Hammock and Integral theories, both from the early 90's, were successful in explaining a large proportion of the observations made in clinical practice. Nevertheless, some (pre)clinical observations cannot be explained by the current understanding. One of the issues concerns the pressure transmission. Is this process really a passive mechanical action, or is an additional active mechanism responsible for urethral closure? The finding that an increase in urethral pressure sometimes precedes and exceeds the increase in intravesical pressure suggests the latter. This concept has never been incorporated in one of the existing theories describing SUI. This is remarkable as a lot of evidence has been generated in recent years that proves involvement of active components. This review aims to provide an additional theory in which an active reflex closure mechanism of the urethra is incorporated. Recent as well as older publications from clinical and animal studies are included to support the hypothesis. The smooth muscles of the urethra, the vascular bed, and the estrogen-influenced urethral mucosa, combined with striated muscle tone, contribute to the intra-urethral pressure. A passive transmission of force to the urethra exists only in the abdominal proximal third of the urethra. In the distal two thirds of the urethra an active closure mechanism is present, dependent on sufficient urethral support in the proper anatomical position. This active closure mechanism is generated by reflex contraction of striated muscles of the urethra and the pelvic floor. Continence is a result of passive as well as active urethral closure mechanisms. The most important factor in female continence seems to be the proper functioning of an active reflex urethral closing mechanism.

Review of optimal techniques for robotic-assisted radical prostatectomy.

Robotic-assisted radical prostatectomy has been rapidly adopted and is now the standard of care in the surgical management of prostate cancer. Since the initial description in 2001, the technique has evolved to optimize oncological functional outcomes. Herein, we review key techniques for the robotic-assisted radical prostatectomy. With the current influx of new technology such as focal therapy, stereotactic body radiation therapy and prostate-sparing treatments, there is greater emphasis on maximizing outcomes of robotic-assisted radical prostatectomy. The evidence-based techniques of optimizing oncological outcomes including the lymph node dissection and improving cancer control through minimizing positive surgical margins are reviewed. Improvements in functional recovery has also been seen with technical modifications such as nerve sparing, preservation of the urethral support structures and the bladder neck and the urethra-vesical reconstruction. Robotic prostatectomy has demonstrated adequate long-term oncologic success and satisfactory functional recovery. As technology and techniques in robotic-assisted surgery evolve, surgeons will continue to optimize techniques to maximize functional outcome recovery and cancer control. Further studies are actively being conducted to provide level one evidence in multiple aspects of the robotic-assisted radical prostatectomy.

The Association of Serum Testosterone Levels and Urinary Incontinence in Women

Pelvic floor integrity is an important predictor of stress urinary incontinence. Androgen receptors have been found in the pelvic floor musculature and fascia, and testosterone administration has been shown to increase levator ani hypertrophy and improve stress incontinence in a rodent model. We examined the relationship between serum total testosterone levels and self-reported urinary incontinence in women. We included women older than 20 years in the 2012 NHANES (National Health and Nutrition Examination Survey) cycle who underwent serum total testosterone measurement and answered self-reported urinary incontinence questions. A weighted, multivariate logistic regression model was used to determine the association between incontinence and serum testosterone levels after adjusting for age, body mass index, diabetes, race, parity, menopause and time of venipuncture. A total of 2,321 women were included in analysis, of whom 37.5% had stress incontinence, 29.8% had urge incontinence and 16.4% had mixed incontinence. Women in the lowest quartile of serum testosterone were more likely to complain of stress and mixed incontinence (OR 1.45, 95% CI 1.03-2.12 and OR 1.68, 95% CI 1.23-2.22, respectively). No association was noted between serum testosterone levels and urge incontinence. Low serum testosterone is associated with an increased likelihood of stress and mixed incontinence in women. Given the role of pelvic musculature in maintaining urethral support and the anabolic effect of androgens on skeletal muscle, a physiological mechanism for this relationship can be proposed and further evaluated in prospective and translational studies.

Urethral Closure Pressure at Stress: A Predictive Measure for the Diagnosis and Severity of Urinary Incontinence in Women.

PurposeMaintaining urinary continence at stress requires a competent urethral sphincter and good suburethral support. Sphincter competence is estimated by measuring the maximal urethral closure pressure at rest. We aimed to study the value of a new urodynamic measure, the urethral closure pressure at stress (s-UCP), in the diagnosis and severity of female stress urinary incontinence (SUI).MethodsA total of 400 women without neurological disorders were included in this observational study. SUI was diagnosed using the International Continence Society definition, and severity was assessed using a validated French questionnaire, the Mesure du Handicap Urinaire. The perineal examination consisted of rating the strength of the levator ani muscle (0–5) and an assessment of bladder neck mobility using point Aa (cm). The urodynamic parameters were maximal urethral closure pressure at rest, s-UCP, Valsalva leak point pressure (cm H2O), and pressure transmission ratio (%).ResultsOf the women, 358 (89.5%) were diagnosed with SUI. The risk of SUI significantly increased as s-UCP decreased (odds ratio [OR], 0.92; 95% confidence interval, 0.88–0.98). The discriminative value of the measure was good for the diagnosis of SUI (area under curve>0.80). s-UCP values less than or equal to 20 cm H2O had a sensitivity of 73.1% and a specificity of 93.0% for predicting SUI. The association between s-UCP and SUI severity was also significant.Conclusionss-UCP is the most discriminative measure that has been identified for the diagnosis of SUI. It is strongly inversely correlated with the severity of SUI. It appears to be a specific SUI biomarker reflecting both urethral sphincter competence and urethral support.

Female pelvic floor biomechanics

The pelvic floor is a complex assembly of connective tissues and striated muscles that simultaneously counteracts gravitational forces, inertial forces, and intra-abdominal pressures while maintaining the position of the pelvic organs. In 30% of women, injury or failure of the pelvic floor results in pelvic organ prolapse. Surgical treatments have high recurrence rates, due, in part, to a limited understanding of physiologic loading conditions. It is critical to apply biomechanics to help elucidate how altered loading conditions of the pelvis contribute to the development of pelvic organ prolapse and to define surgeries to restore normal support. Evidence suggests the ewe is a potential animal model for studying vaginal properties and that uterosacral and cardinal ligaments experience significant creep, which may be affecting surgical outcomes. A new method of measuring ligament displacements in vivo was developed, and finite element models that simulate urethral support, pelvic floor dynamics, and the impact of episiotomies on the pelvic floor were studied. The current review highlights some contributions over the past year, including mechanical testing and the creation of models, which are used to understand pelvic floor changes with loading and the impact of surgical procedures, to illustrate how biomechanics is being utilized.

Three-dimensional translabial ultrasound assessment of urethral supports and the urethral sphincter complex in stress urinary incontinence.

The pathophysiological mechanism of incontinence is multifactorial. We evaluated the role of 3D-4D ultrasound in the assessment of the fascial supports of the urethra and the urethral sphincter complex (USC) for diagnosing stress urinary incontinence. Observational case-control study in women with and without stress urinary incontinence attending a urogynecology service and a general gynecology service. All women were interviewed, examined, and classified according to the Pelvic Organ Prolapse Quantification (POP-Q) and underwent a 3D-4D translabial ultrasound. Fascial supports of the urethra were assessed by tomographic ultrasound and were considered to be intact or absent if it was possible to identify them at eight levels on each side, urethral mobility was assessed on maximal Valsalva in sagittal section and the length and volume of the USC at rest and on maximal Valsalva were determined using the Virtual Organ Computer-aided Analysis (VOCAL) program. Variables were compared between continent and incontinent women. A total of 173 women were examined, 78 continent and 95 incontinent. There was a significant difference in urethral mobility between continent and incontinent women (12.82 mm vs. 21.85 mm, P < 0.001), but there was no significant difference in the percentage of supports affected (43.27% vs. 35.94%, P < 0.070). The length of the USC at rest was significantly shorter (P < 0.001) ​​in incontinent patients. Ultrasound evaluation of urethral supports does not discriminate between continent and incontinent women. However, the length of the USC at rest was shorter and urethral mobility was higher in incontinent women. Neurourol. Urodynam. 9999:XX-XX, 2016. © 2016 Wiley Periodicals, Inc.

V2 - Robot-assisted radical prostatectomy: Experience with new ARVUS technique of reconstruction of urethral support

V2 - Robot-assisted radical prostatectomy: Experience with new ARVUS technique of reconstruction of urethral support

VE39 - New technique of reconstruction of urethral support during robot-assisted radical prostatectomy reducing time to complete continence

VE39 - New technique of reconstruction of urethral support during robot-assisted radical prostatectomy reducing time to complete continence

Mean echogenicity and area of puborectalis muscle in women with stress urinary incontinence during pregnancy and after delivery.

Introduction and hypothesisPregnancy and childbirth are risk factors for the development of stress urinary incontinence (SUI). Urinary continence depends on normal urethral support, which is provided by normal levator ani muscle function. Our objective was to compare mean echogenicity and the area of the puborectalis muscle between women with and those without SUI during and after their first pregnancy.MethodsWe examined 280 nulliparous women at a gestational age of 12 weeks, 36 weeks, and 6 months after delivery. They filled out the validated Urogenital Distress Inventory and underwent perineal ultrasounds. SUI was considered present if the woman answered positively to the question “do you experience urine leakage related to physical activity, coughing, or sneezing?” Mean echogenicity of the puborectalis muscle (MEP) and puborectalis muscle area (PMA) were calculated. The MEP and PMA during pregnancy and after delivery in women with and without SUI were compared using independent Student’s t test.ResultsAfter delivery the MEP was higher in women with SUI if the pelvic floor was at rest or in contraction, with effect sizes of 0.30 and 0.31 respectively. No difference was found in the area of the puborectalis muscle between women with and those without SUI.ConclusionsWomen with SUI after delivery had a statistically significant higher mean echogenicity of the puborectalis muscle compared with non-SUI women when the pelvic floor was at rest and in contraction; the effect sizes were small. This higher MEP is indicative of a relatively higher intramuscular extracellular matrix component and could represent diminished contractile function.

Restoration of the pubourethral ligament with platelet rich plasma for the treatment of stress urinary incontinence

Stress urinary incontinence (SUI) is a major health problem, which affects nearly 20% of adult women and has a detrimental impact on their daily activities and quality of life. Several surgical techniques have been proposed for the treatment of SUI including the Burch colposuspension, retropubic mid-urethral slings (TVT), trans-obturator tapes (TOT), trans-obturator tapes inside out (TVT-O), bladder neck injections and the insertion of an artificial urethral sphincter. All of these treatments aim to either restore the urethral support, which is naturally preserved by the pubourethral ligament (PUL) or to increase the urethral resistance at rest. Most surgical techniques are associated with a variety of intraoperative and postoperative complications. Platelet rich plasma (PRP) is extremely rich in growth factors and cytokines, which regulate tissue reconstruction and has been studied extensively among trauma patients and trauma experimental models. To date, however, there is no evidence to support or oppose its use in women who suffer from SUI due to PUL damage. PRP is an easily produced and relatively inexpensive biologic material. It is produced directly from the patient’s blood and is, thus, superior to synthetic materials in terms of potential adverse effects such as from foreign body reaction. In the present article we summarize the existing evidence in the field, which supports the conduct of animal experimental and clinical studies to elucidate the potential role of PRP in treating SUI.

V21 Robot-assisted functional reconstruction of urethral support during radical prostatectomy

V21 Robot-assisted functional reconstruction of urethral support during radical prostatectomy

Functional reconstruction of urethral support during robot-assisted radical prostatectomy

Functional reconstruction of urethral support during robot-assisted radical prostatectomy