Urodynamic Examination Research Articles

Conservative management of overactive bladder in children: Evaluation of clinical and urodynamic results

Objective Overactive bladder in children may indicate serious anatomic as well as functional changes in both the lower and upper urinary tracts. In order to prevent such problems, these patients should be diagnosed quickly and treated appropriately. In this study, children with diurnal and nocturnal enuresis symptoms (without any underlying neurological pathology) were evaluated and the long-term follow-up results are discussed. Material and methods Between 2001 and 2004, 95 children with an average age of 8.1 years (1–13 years), referring with complaints of diurnal incontinence, nocturnal enuresis and recurrent urinary tract infections, were included in the study. Apart from conventional evaluation and ultrasonographic and urodynamic examinations, voiding cysto-urethrography was performed in children with upper tract changes. Results Seventy-three children (76.8%) completely responded to medical treatment, in 12 children (12.6%) the clinical status has been significantly improved, and in the remaining 10 children (10.5%) conservative management was unsuccessful. Of the children demonstrating complete response or significant improvement, 18 children (18.9%) continued to be under medication during 3–22 months of follow up with a mean maintenance period of 7.4 months. Average time to resolution in all groups was 2.6 years (0.2–3.8 years). Conclusion Conservative therapy (especially oral anticholinergic agents) in children with overactive bladder is effective when applied appropriately (especially in patients with evident detrusor instability) with adequate follow up. Taking the effect of behavioural factors into account, biofeedback training programs in addition to medical treatment should solve the problem in the majority of cases.

Botulinum-A Toxin Detrusor and Sphincter Injection in Treatment of Overactive Bladder Syndrome: Objective Outcome and Patient Satisfaction

ObjectiveWe investigated the effect of botulinum-a toxin injections into the detrusor and external sphincter muscle in patients with overactive bladder (OAB) symptoms. MethodsWe included 44 patients - 41 women and three men with a mean age of 66.1 years - who were suffering from OAB symptoms that were refractory to anticholinergic treatment. We injected 200–300U of BTX-A (Botox®) into the detrusor muscle; 22 patients also received external sphincter injections. For outcome analysis, we used a bladder diary, a urodynamic examination, and a questionnaire that consisted of 27 validated questions. ResultsChanges in the bladder diary 4 weeks and 3, 6, and 9 months after BTX-A injection were as follows: Micturition frequency was reduced by 12%, 16%, 13% and 9%, respectively. Average pad use decreased from 4.2 pads per day to at most 2.4 pads per day after 6 months. Urodynamic changes were most distinct after 4 weeks: the volume when the first uninhibited detrusor contraction occurred increased from 149±18.2mL to 263±24.2mL, and maximum cystometric bladder capacity increased from 228±19.2mL to 305±19.0mL. Subjectively, 86% of the patients would choose this procedure for their bladder condition again. Residua 4 weeks after additional injection into the sphincter muscle were distinctly smaller than in the “only detrusor” group. ConclusionsBTX-A detrusor and sphincter injection is very effective in treating OAB symptoms. For patients who might be expected to have residual urine after injection only into the detrusor, additional injection of low doses of BTX-A into the external sphincter muscle could be one option to reduce that risk.

Botulinum-A toxin for treatment of overactive bladder without detrusor overactivity: Urodynamic outcome and patient satisfaction

Objectives To investigate the effect of botulinum toxin type A bladder injections in the treatment of overactive bladder syndrome in the absence of detrusor overactivity. Methods The subjects were 7 women (average age 61.1 years, range 51 to 79) who presented with overactive bladder symptoms. Their disorder had been refractory to several classic treatment options. Urodynamic examination excluded detrusor overactivity. A total of 300 U BTX-A (Botox) was injected, of which 50 to 75 U was injected as quadrant injections into the external sphincter muscle to avoid the postoperative need for catheterization in the case of high postvoid residual urine volume. For follow-up, complete urodynamic studies were performed, and a bladder diary and validated incontinence questionnaires were given to patients at all visits at 1, 3, and 6 months. Results The bladder diaries indicated a clear reduction in daytime frequency and nocturia and a reduction in pad use. The maximal voiding volume increased significantly. The urodynamic examinations showed a significant increase in volume when the first and the strong desire to void were expressed. The maximal bladder capacity increased by 20% in 3 months. In the questionnaires, 5 of the 7 patients reported better urine control after therapy, and 6 would have chosen this therapy again for their condition. The overall satisfaction score (on a scale of 0 to 10) averaged 6.8. No side effects, such as urine retention, occurred. Conclusions Botulinum-A toxin injection has positive effects in treating overactive bladder symptoms without detrusor overactivity. The effects were seen not only in urodynamic measures but also in patient satisfaction.

Concomitant pelvic organ prolapse surgery with TVT procedure

The aim of this study is to evaluate the efficacy and feasibility of concomitant pelvic reconstructive surgery with tension-free vaginal tape (TVT) procedure to treat pelvic organ prolapse women with urodynamic stress incontinence (USI) or occult USI. Seventy-five women with pelvic organ prolapse and diagnosed as USI or occult USI were enrolled in this study. All patients with USI or occult USI underwent TVT treatment under general anesthesia, combined with transvaginal total hysterectomy (VTH), anterior-posterior colporrhaphy (APC), and/or right sacrospinous ligament suspension (SSS) reconstructive surgeries. The subjective assessment was evaluated by using a visual analog scale (VAS) score and a urinary symptomatic questionnaire. The objective assessment was carried out with a 1-h pad test, cough stress test, and urodynamic examination. Of the 75 patients, 35 patients with grade III uterine prolapse underwent VTH and APC, 30 patients with grade IV uterine prolapse underwent VTH, SSS, and APC, and the other 10 patients who had previous hysterectomy with total vaginal vault prolapse underwent SSS and APC. The mean follow-up interval was 25 months (12-42 months). The mean hospitalization was 5.9 days and the mean catheterization time was 3.8 days. The subjective success rate for the treatment of urine incontinence was 88%, and the objective complete cure rate was 84%. The rate of postoperative complications with persistent urinary urgency, de novo detrusor overactivity, dysfunctional voiding, and tape erosion were 50, 8, 12, and 1.3%, respectively. There were no bladder perforations during the TVT procedure and no perioperative complications requiring conversion to laparotomy. Pelvic organ prolapse women with USI or occult USI can be treated by reconstructive surgeries combined with a TVT procedure to treat and prevent postoperative USI.

Myogenic bladder decompensation in boys with a history of posterior urethral valves is caused by secondary bladder neck obstruction?

To investigate whether myogenic bladder decompensation in patients treated for congenital posterior urethral valves (PUV, the most serious cause of infravesical obstruction in male neonates and infants) may be secondary to bladder neck obstruction, as despite prompt ablation of PUV these patients can have dysfunctional voiding during later childhood or adolescence, the so-called 'valve bladder syndrome'. The study comprised 18 boys (mean age 14 years, range 6.2-18.5) who had had successful transurethral ablation of PUV between 1982 and 1996, and had completed a follow-up which included serial assessment of serum creatinine, completion of a standard voiding diary, ultrasonography with measurement of urine before and after voiding, a urodynamic examination with simultaneous multichannel recording of pressure, volume and flow relationships during the filling and voiding phases, coupled with video-cystoscopy at least twice. The mean (range) follow-up was 9.3 (6-17) years. Urodynamic investigation showed myogenic failure with inadequate bladder emptying in 10 patients; five with myogenic failure also had unstable bladder contractions. On video-cystoscopy the posterior bladder neck lip appeared elevated in all patients but in those with myogenic failure it was strongly suggestive of hypertrophy, with evidence of obstruction. At the last follow-up one patient with myogenic failure who had had bladder neck incision and four others who were being treated with alpha-adrenergic antagonists had a significant reduction of their postvoid residual urine. Despite early valve ablation, a large proportion of boys treated for PUV have gradual detrusor decompensation, which may be caused by secondary bladder neck obstruction leading to obstructive voiding and finally detrusor failure. Surgical or pharmacological intervention to improve bladder neck obstruction may possibly avert this course, but further studies are needed to validate this hypothesis.

TVT versus TOT - Eine prospektiv randomisierte Studie zur operativen Behandlung der weiblichen Stressinkontinenz

Fragestellung: Ziel der prospektiv randomisierten Studie ist die Evaluation der Erfolgs- und Komplikationsrate von zwei Bandoperationen mit retropubischer TVT versus transobturatorischer Schlingenführung TOT zur operativen Therapie der weiblichen Stressharninkontinenz. Material und Methodik: 110 Frauen mit einem Alter von 37 bis 75 Jahren wurden nach präoperativer klinischer, urodynamischer und sonographischer Abklärung wegen einer Stressharninkontinenz operativ behandelt. Ausschlusskriterien waren Detrusorinstabilität, Genitalprolaps und frühere Inkontinenzoperationen. Nach einem Randomisierungsschema unterzogen sich 54 Frauen einer TVT-Operation und 56 Frauen einer TOT-Operation in Regional- oder Allgemeinanästhesie. Bei beiden Operationsverfahren wurde das Band zwischen dem distalen und mittleren Urethradrittel spannungsfrei positioniert. Nach einem Jahr (Median 15 Monate) unterzogen sich 105 Frauen einer klinischen und urodynamischen Nachuntersuchung. Ergebnisse: Die Kontinenzrate erreichte beim TVT-Verfahren 86 % und beim TOT-Verfahren 84 %. Der Depressionsquotient zeigte in beiden Operationsgruppen eine signifikante Verbesserung von 0,9 auf 0,3 in der TVT-Gruppe und von 1,1 auf 0,4 in der TOT-Gruppe (p < 0,05). Die durchschnittliche Operationszeit betrug bei der TVT-Gruppe 25 Minuten und in der TOT-Gruppe 15 Minuten (p < 0,05). In beiden Gruppen beobachteten wir keine prolongierten Schmerzen oder Schlingen-Abstoßungen, jedoch trat in jeder Patientinnengruppe eine Banderosion auf. Bei insgesamt 7 Patientinnen der TVT-Gruppe (13 %) kam es zum Auftreten von 3 (5,7 %) revisionsbedürftigen Hämatomen im retropubischen Bereich und bei 4 (7,6 %) Patientinnen zu Blasenperforationen. In der TOT-Gruppe traten keine Hämatome oder Blasenverletzungen auf. In beiden Patientinnengruppen wurde das Auftreten einer De-novo-Urgeinkontinenz in 12 % in der TVT- und in 10 % in der TOT-Gruppe beobachtet. Schlussfolgerung: Die objektive Erfolgsrate von TVT und TOT als Erstinkontinenzoperation zeigte nach 15 Monaten klinisch keinen signifikanten Unterschied in der operativen Therapie der weiblichen Stressharninkontinenz. Bei der Komplikationsrate ergab sich ein klarer Vorteil für den transobturatorischen Zugang im Gegensatz zum retropubischen Zugang. Die transobturatorische Schlingenführung führt bei identischer klinischer Erfolgsrate zu einer Reduzierung der Komplikationsrate in der weiblichen Inkontinenzchirurgie.

Can neurologic examination predict type of detrusor sphincter-dyssynergia in patients with spinal cord injury?

To assess the correlations in males with spinal cord injury (SCI) between the neurologic status and type of detrusor-sphincter dyssynergia (DSD) observed during urodynamic examinations and to evaluate the change in the DSD pattern over time. A total of 105 male patients with chronic SCI were neurologically examined according to the American Spinal Cord Injury Association protocol and underwent video-urodynamic examinations. DSD observed during urodynamic studies was classified according to the Blaivas classification. To assess the stability of the DSD over time, patients who had been recently injured were clinically and urodynamically controlled after 1 year and thereafter. A statistically significant positive correlation was found between the DSD type and completeness or incompleteness of the SCI lesion. Patients with an incomplete sensory and motor SCI lesion presented with DSD type 1 compared with patients with complete sensory and motor SCI lesion, who had DSD type 2 to type 3. A correlation was also found between the American Spinal Cord Injury Association scores and the DSD type. No correlation was found between the DSD type and lesion level. At medium to long-term follow-up, a significant change was found in the DSD type. The neurologic status and DSD type after SCI showed significant correlations. Therefore, neurologic examination and determination of the DSD type might be helpful to complete the neurourologic diagnosis and to assist in confirming completeness of the lesion after acute injury. Because DSD seems to become aggravated with time, regular urodynamic follow-up examinations are mandatory in patients with DSD to adjust their treatment, if necessary.

Transurethral incision of bladder neck in treatment of bladder neck obstruction in women

To report our preliminary experience with transurethral incision of the bladder neck in the treatment of female voiding dysfunction due to bladder neck obstruction. Bladder neck obstruction in women is an infrequently diagnosed urologic condition. Bladder neck obstruction was diagnosed in 11 women 41 to 80 years of age, who presented with difficult micturition or urinary retention. Preoperative investigations included a full urodynamic examination and urethrocystoscopy. Transurethral bladder neck incision was performed in all patients. Urodynamic results and clinical improvement in voiding symptoms were assessed. Of the 11 patients, 5 had chronic urinary retention and 6 had difficult micturition; 3 also had recurrent urinary tract infection or upper urinary tract deterioration. The most frequent findings on video-urodynamic study were a high voiding pressure plus low flow rate and a narrow bladder neck during voiding on cinefluoroscopy. After treatment, the lower urinary tract symptoms were resolved or improved in all patients. Ten patients resumed spontaneous voiding with a small postvoid residual urine volume; the remaining patient was able to void by abdominal straining after adjuvant urethral botulinum A toxin injection. Urodynamic study revealed a decreased voiding pressure and postvoid residual urine volume and an increased maximal flow rate. The overall satisfactory rate was 91%. Transurethral incision of the bladder neck is effective in relieving voiding difficulty owing to anatomic or functional bladder neck obstruction in women. A full video-urodynamic evaluation is essential in making the correct diagnosis and formulating a treatment plan.

BLADDER CONTRACTION STRENGTH PARAMETERS POORLY PREDICT THE NECESSITY OF LONG-TERM CATHETERIZATION AFTER A PUBOVAGINAL RECTUS FASCIAL SLING PROCEDURE

We verified if the necessity of long-term catheterization after a pubovaginal rectus fascial sling procedure can be predicted by preoperatively determined bladder contraction strength. We analyzed the files of 58 consecutive nonneurogenic women who underwent a sling procedure for severe or refractory stress urinary incontinence. Preoperative urodynamic measurements in these patients were re-analyzed using the power factor WF and the bladder contractility index as bladder contraction strength parameters. Catheterization was considered necessary if the patient self-catheterized at least once daily. One patient was lost to followup. Three and 6 months after surgery 24 (42%) of 57 and 18 (33%) of 54 patients were on catheterization. On average patients who were not on catheterization had a stronger bladder but the results were not consistently statistically significant. A trend toward higher bladder contraction strength in patients not on catheterization was found. However, preoperative urodynamic examination can only poorly predict the necessity of long-term catheterization after sling surgery.

VOIDING DYSFUNCTION IN X-LINKED ADRENOLEUKODYSTROPHY: SYMPTOM SCORE AND URODYNAMIC FINDINGS

Adrenoleukodystrophy is an x-linked genetic disorder characterized by the breakdown of the myelin sheath surrounding nerve cells in the brain and progressive dysfunction of the adrenal gland with 6 possible phenotypes. Lower urinary tract symptoms affect the quality of life of these patients but only sporadic cases have been previously studied by urodynamics. We report to our knowledge the first series in the literature looking at the prevalent pattern. A total of 14 children and adults 8 to 53 years old (average age 30) with different phenotypes were referred for evaluation. Of the patients 6 had adrenomyeloneuropathy without cerebral involvement (C-) 3 had the adult cerebral form, 3 had the childhood cerebral form, 1 had cerebral involvement (C+) and 1 was asymptomatic. All patients were submitted to a screening protocol, consisting of the self-administered short form questionnaire International Conference on Incontinence Questionnaire-Short Form (ICIQ-SF) and a 3-day voiding diary. Patients were divided in group 1-no urinary symptoms, ICIQ-SF score 0 and no further investigation (3); group 2-frequency/urgency, ICIQ-SF score 1 to 5, uroflowmetry and post-voiding residual urine (4); and group 3-voiding symptoms and incontinence, ICIQ-SF score greater than 5, standard urodynamic examination (7). A neurogenic overactive bladder was the prevalent urodynamic finding (6 of 7 patients), while hypocontractility was found in 1 case. Vesicosphincteric dysfunction can be explained by spinal and/or cerebral involvement in the different neurological forms of adrenoleukodystrophy. Attempts at treatment with anticholinergics and neuromodulation in 4 of our patients provided temporary benefit with clear subjective amelioration of symptoms and improved quality of life.

Long-term urinary dysfunction after rectal cancer surgery.

Urinary dysfunction is a well-known complication of rectal surgery, secondary to injury to the autonomic nervous plexus. The object of this study was to evaluate the incidence, prevalence and type of micturition disorders following rectal cancer surgery and their reversibility during long-term follow-up. A prospective study of 45 patients who underwent surgery for rectal cancer between 1993 and 1998 was undertaken. Those with pre-operative urinary dysfunction were excluded after sequential uroflowmetry and clinical interview. Ten of the surgical interventions were high anterior resections, 18 low anterior resections, and 17 abdominoperineal amputations. Pre-operative radiotherapy was performed in 47.9% of patients. All patients underwent sequential uroflowmetry and a clinical interview 3 and 12 months after the intervention. Subjects who presented micturition disorders underwent urodynamic examination The follow up period was three years. Three months after surgery alterations were found in 14 (31.3%) patients; the most frequent were stress incontinence, urinary tenesmus and the urge to urinate. At the 12-month assessment only 6 (13.3%) patients had urinary symptomatology or uroflowmetry abnormalities. After three years, micturition disorders persisted in 3 (6.6%) patients. Urinary dysfunction after rectal cancer excision is associated with a high degree of reversibility. Seventy-eight percent of the alterations detected after three months and 50% of those that persisted after a year disappeared during follow up.

The role of capsaicin-sensitive afferent fibers in the lower urinary tract dysfunction induced by chronic spinal cord injury in rats

The role of capsaicin-sensitive afferents in neurogenic voiding dysfunction was studied in chronic spinal cord injured rats (SCI). Cystometry and external urethral sphincter (EUS) electromyography were performed on 2 consecutive days after induction of urethane anesthesia in SCI rats 6–8 weeks after spinal cord injury. SCI rats exhibited voiding abnormalities including: non-voiding contractions (NVCs) before micturition, increased volume threshold (VT) for initiating voiding, increased amplitude and duration of voiding contractions, decreased voiding efficiency, increased residual urine, and changes in the pattern of the EUS-EMG. In SCI rats, the EUS electromyogram (EUS-EMG) consisted of more prominent tonic activity, shorter periods of bursting activity, and a reduction in the ratio of silent to active periods during bursting. These changes were more prominent during deeper levels of anesthesia on day 1. Capsaicin (125 mg/kg, s.c., 4 days before urodynamic examination) reduced VT and the number of NVCs, decreased the amplitude and duration of voiding contractions, partially normalized the pattern of EUS-EMG activity, and improved the voiding efficiency on day 1 after induction of anesthesia but not on day 2. Capsaicin treatment increased the percentage of animals (from 55% to 80%) that voided on day 1. The results indicate that capsaicin-sensitive C-fiber bladder afferents are not essential for reflex micturition in SCI rats. However, these afferents do contribute to overactivity of the bladder and detrusor sphincter dyssynergia in deeply anesthetized SCI rats.

Nocturnal penile tumescence and rigidity (NPTR) findings in spinal cord injured men with erectile dysfunction.

This prospective study aimed at determining whether nocturnal penile tumescence and rigidity (NPTR) findings correlate to the neurologic disorders in spinal cord injured (SCI) patients suffering from erectile dysfunction (ED). A total of 25 acute SCI male patients with post-traumatic ED underwent neurological, electrophysiological and urodynamic examinations, respectively, as well as NPTR recordings. The mean value for rigidity (R), tumescence (T) and duration (D) during NTPR tests were 83.3%, 3.3 cm, 6.4 min in patients with a complete lesion above the sacral (S2-S4) spinal cord (n=10), 46.1%, 1.6 cm, 5.5 min in patients with a complete lesion involving the sacral metameres (n=5) and 89.8%, 3.8 cm, 29 min in patients with an incomplete suprasacral lesion (n=7). The differences among these groups were statistically significant (P<0.05). Patients with lesions involving both sacral and thoracolumbar spinal cord showed no erections (n=3). We found four NTPR patterns: (1) normal R and T, short D; (2) weak R and T, short D; (3) normal R, T and D; and (4) no erections, which can be assigned to different levels and completeness of spinal cord lesions. Nocturnal erections of normal quality need preservation of thoracolumbar and sacral neuronal control as well as partially intact connections of the spinal erection centres with brain areas responsible for sexual arousal.

Urethral Evoked Sympathetic Skin Responses and Viscerosensory Evoked Potentials as Diagnostic Tools to Evaluate Urogenital Autonomic Afferent Innervation in Spinal Cord Injured Patients

In most spinal cord injured (SCI) patients the objective assessment of afferent neuronal pathways from the lower urinary tract and the recording of a disturbed urethral sensation and/or desire to void are still difficult. Viscerosensory evoked potentials (VSEPs) might be helpful, but they remain technically difficult to obtain and interpretation is delicate. As a new approach, sympathetic skin response (SSR) of the hand and foot were recorded after electrical stimulation of the posterior urethral mucosa. This technique should allow assessment of the integrity or deterioration of the autonomic afferent pathway. A total of 20 males and 8 females with SCI somatosensory incomplete 15, somatosensory complete 13 and 6 healthy male volunteers were prospectively examined. During urodynamic examination electrical stimulation (single square pulses of 0.2 ms, 2 to 3-fold sensory threshold, 60 mA in complete SCI patients) of the posterior urethra/bladder neck was performed using a bipolar electrode inserted into a microtip pressure catheter. SSR recordings of the right palm and sole were simultaneously taken using surface electrodes and were analyzed by an electromyography unit. Patient reports on evoked urethral sensations at individual sensory thresholds were simultaneously noted. Additionally, well-known electrophysiological measurements such as pudendal sensory evoked potential and urethral VSEP were recorded to check clinical assessed somatosensory and viscerosensory status, and to compare SSR results with these conventional methods. Electrical stimulation of the posterior urethra evoked clear urethral sensation and SSRs in normal subjects. In 14 of 15 sensory incomplete SCI patients with disturbed urethral sensation SSRs could be recorded as well. Electrically evoked urethral sensations resembled the subjective desire to void at full bladder reported by controls and patients. In 13 sensory complete SCI patients with loss of any urethral sensation SSRs could not be recorded even at maximal electrical stimulation strength. All subjects with electrically induced urethral sensation had positive evoked (supralesional) SSRs of the hand. However, none of the patients with absent urethral sensation presented SSRs. Simultaneously recorded VSEPs could not be recorded clearly in 5 patients and 2 control subjects, whereas SSRs delivered clear results in all controls and patients, matching their reports. SSR recordings above a spinal lesion level after urethral electrostimulation might provide a useful and technically simple objective diagnostic tool to assess integrity of autonomic (visceral) afferent nerves from the lower urinary tract. Somatosensory deficits are not always paralleled by viscerosensory loss and vice versa. In this study SSRs were superior to VSEPs, the latter being more difficult to record. The subjective sensations reported by subjects during stimulation could be confirmed in an objective way in 100% of cases by positive/negative SSR findings.

Primary nocturnal enuresis persistent to adulthood, functional evaluation.

The incidence of nocturnal enuresis (NE) in adults (over 18 years of age) ranges from 0.5 to 2% for most authors. NE is a multifactorial disease. Lack of circadian rhythm of antidiuretic hormone (ADH) is one of the commonly accepted causes, however, disorders affecting bladder function is another important pathophysiologic factor that has not been settled. The target of the present study is to define bladder function in adults having persistent NE. Fifty two adult patients were included. Mean age was 23.6 +/- 6.9 years. All of them had primary NE persistent to adulthood. No treatment was received within 2-7 days prior to the urodynamic examination. All of them had intact neuro-urological examination. Filling (in all patients) and voiding cystometry (in 29 patients) were carried out, using 8 F urodynamic and 8 F rectal catheters. Pressure flow analysis was interpreted using Schafer's nomogram. Overall mean maximum cystometric capacity was 419.2 +/- 142 ml, mean bladder compliance was 51.3 +/- 39.7 ml/cmH2O. In males (n=25), mean maximum cystometric capacity was 453 +/- 173 ml and compliance was 56 +/- 42 ml/cmH2O, while in females (n=27), mean capacity was 388 +/- 98 ml and compliance was 46.7 +/- 36.7 ml/cmH2O. Twenty patients had detrusor instability (38.5%). Twelve out of 27 (44.4%) females had instability while only 8 out of 25 (32%) males had the same finding. Differences relevant to maximum bladder capacity and compliance between the patients with and without instability were significant (P<0.0001). Mean detrusor opening pressure was 55.3 +/- 25 cmH2O, mean detrusor pressure at maximum flow and maximum detrusor pressure, were 53.5 +/- 21 and 78.9 +/- 35 cmH2O respectively. Urodynamic studies in adults with persistent NE reveals a relatively high incidence of instability, normal capacity and compliance. The presence of instability was associated with smaller bladder and poorer compliance and with diurnal urgency. Voiding bladder function in adult enuretics was found to be normal.

Transobturator tape (Uratape): a new minimally-invasive procedure to treat female urinary incontinence.

Assessment of one-year results of a new technique of transobturator suburethral tape in the treatment of female stress urinary incontinence. UraTape, a non-woven, non-elastic polypropylene tape with a 15 mm long central (suburethral) silicone-coated section was inserted via the transobturator route. The tape is inserted tension-free in a horizontal plane underneath the middle of the urethra between the two obturator foramens. The ends of the tape are tunnelled percutaneously with a tunneller. As the retropubic space is preserved intact, cystoscopy is not required. From May 2000 to February 2002, 150 patients with stress urinary incontinence without associated prolapse were operated and a minimum of 1 year follow-up was available for 32 patients (mean follow-up 17 months; range 13-29). The mean age was 64 years (range 50-81). All patients were assessed before surgery by clinical and urodynamic examination: 5 patients presented sphincter incompetence (maximum closure pressure <20 cm H(2)O); 5 patients presented with recurrent urinary incontinence after Burch procedure or TVT; 18 patients presented with mixed incontinence, six of them with detrusor instability confirmed by cystometry. The results were evaluated by two independent investigators (clinical examination, uroflowmetry, cough test). Voiding disorders suggesting bladder outflow obstruction were defined as the presence of the following two criteria: Q(max)<15 ml/s, residual urine volume >20%. 29/32 patients (90.6%) were cured and 3/32 (9.4%) were improved. Mean operating time was 15minutes. No intra-operative complications were recorded. One patient had complete postoperative bladder retention which resolved after 4 weeks of self-catheterization. There were no problems with urethral erosion, residual pain or functional impairment related to the tape. 5/32 patients had voiding disorders suggesting bladder outflow obstruction. Two patients developed de novo urge incontinence. Uratape transobturator tape is a simple and effective procedure with follow-up of one year for the treatment of female stress urinary incontinence confirmed after 1 year of follow-up. The transobturator approach avoids the risk of bladder, bowel or vascular injuries. Evaluation of the results after a longer follow-up period is needed to validate this technique.

Bladder dysfunction and surgery in the small pelvis. Therapeutic possibilities

The more extensive a surgical procedure in a small pelvis, the higher the risk for the lower urinary tract with its nerve supply and nerve plexus. This concerns mainly the sympathetic chains, the parasympathetic structures and, rarely, the visceral supply of the pelvic floor. Direct trauma to the bladder and its vascular supply as well as indirect injury by displacement of the bladder need to be seriously considered. Problems with micturition and impaired storage capacity of the bladder are the result. Complete urodynamic examination and follow-up can help in differentiating between temporary and persisting disturbances and in taking therapeutical decisions. The most evident postoperative complication is disturbed micturition, managed initially by suprapubic urinary diversion, followed as soon as possible by intermittent self-catheterisation. This is the only way to avoid overstretching of the bladder, recurring urinary tract infection and damage to the upper urinary tract. Restoration of spontaneous micturition can be supported by drug treatment with parasympatholytics and/or alpha-blockers if the measured bladder pressure and residual urine are within tolerable limits. For electrostimulation of micturition, intravesical therapy, although timeconsuming, is best suited because it can easily be done on an outpatient basis. More promising seems bilateral sacral neuromodulation, which, however, is a rather complicated and expensive procedure. Surgical procedures to reduce the voiding resistance of the bladder involve the risk of postoperative incontinence because the sphincter function in those patients is often disturbed too. Persisting problems with bladder storage capacity as a result of tumor surgery in the small pelvis are frequently secondary to retention of urine (overflow incontinence). In these cases, regular evacuation of the bladder by intermittent self-catheterisation can lead to social acceptance. Reduced bladder compliance and lowering of the urethral leak pressure point may result in stress and urge incontinence, which, according to the established rules, should be managed by physiotherapy and behaviour therapy as well as drug therapy and only in exceptional cases by surgical measures. Prevention of postoperative bladder dysfunction can be tried by tissue- and nerve-sparing surgical techniques, but is always determined by oncological aspects.

The axial location of structural regions in the urethra: a magnetic resonance study in nulliparous women

Objective To define and quantify the appearance and location of distinct regions of the bladder neck and urethra by using axial magnetic resonance images from healthy, continent, nulliparous women. Methods Seventy-eight asymptomatic, healthy, nulliparous women (mean age 29.2 ± 5.4 years) volunteered for this study. All women were proven continent on urodynamic examination. Axial proton density magnetic resonance images of the pelvic floor were analyzed at 5-mm intervals. A geometric origin was established at the internal urethral meatus. The presence or absence of each of six structural regions—the bladder base, bladder neck, striated urethral sphincter, compressor urethrae and urethrovaginal sphincter, perineal membrane, and distal urethra—was then noted in each more distal image. The proportion of women in whom a structural region was seen at each 5-mm interval was recorded. Results The striated urogenital sphincter was observed at 5–25 mm distal to the bladder base. It was observed 10 and 15 mm below the bladder base in 91% (95% confidence interval [CI] 85%, 98%) and 99% (95% CI 97%, 100%), respectively, of all women. The perineal membrane, marking the distal end of the muscular urethra, was located 20–35 mm distal to the bladder base. The length of the muscular region of the urethra ranged from 20 to 35 mm (mean 24 mm, 95% CI 24, 25 mm). Conclusion Magnetic resonance images allow the normal appearance and location of urethral and bladder neck structures to be quantified in healthy, continent, nulliparous women.

Concomitant surgery with tension‐free vaginal tape

To evaluate the efficacy and feasibility of tension-free vaginal tape (TVT) surgery combined with gynecologic surgery using general anesthesia. One hundred and six women with genuine stress incontinence (GSI) diagnosed with a traditional urodynamic examination were prospectively enrolled into this study. All of the 106 women underwent TVT surgery for the treatment of GSI, along with a concomitant hysterectomy procedure, under general anesthesia. We estimated the severity of incontinence symptoms on a visual analog scale (VAS), and used a questionnaire for subjective assessment before and after TVT surgery. The objective assessment of urinary incontinence was carried out with a 1-h pad test and traditional urodynamic examination. Of the 106 patients, 50 had uterine prolapse and underwent transvaginal hysterectomy and anteroposterior colporrhaphy (APC), and another 50 had uterine myoma and underwent laparoscopic-assisted vaginal hysterectomy (LAVH). The follow-up mean interval was 18 months (range 12-36 months). The 50 women undergoing LAVH and TVT surgery had a mean hospitalization of 3.5 days. The subjective success rate was 90.5% and the objective success rate was 86.8%. The other group of 50 women undergoing vaginal total hysterectomy (VTH), APC and TVT surgery had a mean hospitalization of 4.8 days. The subjective success rate was 88.6% and the objective success rate was 84.9%. There were six patients lost to follow-up for several reasons. The rates of complications of bladder perforation, postoperative voiding difficulty and postoperative urinary urgency were 2%, 11% and 10%, respectively; neither pelvic hematoma requiring blood transfusion nor conversion to laparotomy occurred. The results of this study prove that the TVT procedure, performed under general anesthesia without the need for the intraoperative cough provocation test to treat GSI, and carried out concomitantly with other gynecologic surgeries, is safe and effective.

Follow-up in sacrococcygeal teratomas

Sacrococcygeal teratomas (SCT) are the most common type of childhood germ cell tumor in extragonadal locations, occurring at rate of approx. 1 in 38,000 live births. The objective of this study was to evaluate the results of surgical treatment in children with SCT with regard to urinary tract function. Between 1992 and 2000, 23 children underwent SCT resection, 20 with external and 3 with presacral/pelvic locations. Mortality rate was 13% (3 deaths). Histopathologic examination revealed mature SCT in 22 specimens and malignant foci in one. Children were seen 6 months to 6 years after operation. Urinalysis and culture, ultrasound examination, voiding cystouretherography, and IVP were performed. There were no pathologic findings in the results of these examinations. Bladder capacity, pressure, and urethral function were evaluated during urodynamic examination in 8 children showing normal values of measured parameters. The maximum intrabladder pressure was 11.28 cm H2O (±6.1), and detrussor pressure was 10.45 cm H2O (±4.24) during collecting and 44.29 cm H2O (±0.66) and 43,75 cm H2O (±11.29), respectively during voiding phase. The authors recommend urinary tract evaluation (including urodynamics) as a routine in postoperative assessment of children with SCT to exclude associated anomalies.—Jerzy K. Niedzielski Sacrococcygeal teratomas (SCT) are the most common type of childhood germ cell tumor in extragonadal locations, occurring at rate of approx. 1 in 38,000 live births. The objective of this study was to evaluate the results of surgical treatment in children with SCT with regard to urinary tract function. Between 1992 and 2000, 23 children underwent SCT resection, 20 with external and 3 with presacral/pelvic locations. Mortality rate was 13% (3 deaths). Histopathologic examination revealed mature SCT in 22 specimens and malignant foci in one. Children were seen 6 months to 6 years after operation. Urinalysis and culture, ultrasound examination, voiding cystouretherography, and IVP were performed. There were no pathologic findings in the results of these examinations. Bladder capacity, pressure, and urethral function were evaluated during urodynamic examination in 8 children showing normal values of measured parameters. The maximum intrabladder pressure was 11.28 cm H2O (±6.1), and detrussor pressure was 10.45 cm H2O (±4.24) during collecting and 44.29 cm H2O (±0.66) and 43,75 cm H2O (±11.29), respectively during voiding phase. The authors recommend urinary tract evaluation (including urodynamics) as a routine in postoperative assessment of children with SCT to exclude associated anomalies.—Jerzy K. Niedzielski