Reference urodynamic values for stress incontinent women

Pelvic Floor Pressures Differ Based on Location in the Pelvis and Body Position: A Cadaver Mode

Background: The pelvic floor is a bowl-shaped complex of multiple muscles and fascia, which functions to support the pelvic organs, and it aids in controlling continence. In pelvic floor disease, this complex becomes weakened or damaged leading to urinary, fecal incontinence, and pelvic organ prolapse. It is unclear whether the position of the body impacts the forces on the pelvic floor. Purpose: The primary objective of this work is to measure force applied to the pelvic floor of a cadaver in sitting, standing, supine, and control positions. The secondary objective is to map the forces across the pelvic floor. Methods: An un-embalmed female cadaver without pelvic floor dysfunction was prepared for pelvic floor pressure measurement using a pressure sensory array placed on top of the pelvic floor, and urodynamic catheters were placed in the hollow of the sacrum, the retropubic space, and at the vaginal apex. Pressure measurements were recorded with the cadaver in the supine position, sitting cushioned without external pelvic floor support, and standing. Pressure array data were analyzed along with imaging of the cadaver. Together, these data were mapped into a three-dimensional reconstruction of the pressure points in pelvic floor and corresponding pelvic organs. Results: pressures were higher at the symphysis than in the hollow of the sacrum in the standing position. Pressure array measurements were lowest in the standing position and highest in the sitting position. Three-dimensional reconstruction confirmed the location and accuracy of our measurements. Conclusions: The findings of increased pressures behind the symphysis are in line with the higher incidence of anterior compartment prolapse. Our findings support our hypothesis that the natural shape and orientation of the pelvis in the standing position shields the pelvic floor from downward forces of the viscera.

Is bladder outlet obstruction responsible for a successful surgical outcome in women with complicated stress urinary incontinence? Urodynamic results before and after a Remeex® readjustable sling

AIMS

To describe the changes in urodynamic parameters after Remeex® placement in women with recurrent stress urinary incontinence (rSUI) or intrinsic sphincteric deficiency (ISD) and to analyze a potential relationship between postoperative bladder outlet obstruction and a successful surgical outcome.

METHODS

Retrospective analysis of those women who had undergone Remeex® placement due to rSUI or ISD in our department between 2000 and 2017. All patients underwent urodynamic evaluation before and after the surgery. If tension readjustment was required, postoperative urodynamics was performed after the last regulation, once the final continence status had been achieved. The female Bladder Outlet Obstruction Index (BOOIf) was calculated for all patients postoperatively. Obstruction was considered present if BOOIf was >18. Pre- and postoperative urodynamic variables were compared. Postoperative urodynamic changes were also compared between cured and noncured patients.

RESULTS

A total of 205 women were included. After a follow-up of 89 ± 36 months, 165 women (80.5%) were continent. A significant impairment in the majority of the urodynamic parameters was observed. Mean postoperative BOOIf was -11.8 ± 21.5 in cured patients and -15.3 ± 23.1 in noncured patients (p = 0.365); 15 (9.1%) patients in the cured group had a postoperative BOOIf >18, whereas all (100%) patients in the noncured group had a postoperative BOOIf <18.

CONCLUSIONS

Most urodynamic parameters may worsen after the Remeex® system placement. Postoperative urodynamic parameters may not differ substantially between cured and noncured patients, although a certain grade of bladder outlet obstruction could be related to postoperative continence status in some patients.

Traditional suburethral sling operations for urinary incontinence in women

BACKGROUND

Stress urinary incontinence constitutes a significant health and economic burden to society. Traditional suburethral slings are surgical operations used to treat women with symptoms of stress urinary incontinence.

OBJECTIVES

To assess the effectiveness of traditional suburethral sling procedures for treating stress urinary incontinence in women; and summarise the principal findings of relevant economic evaluations.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), as well as MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP); we handsearched journals and conference proceedings (searched 27 February 2017) and the reference lists of relevant articles. On 23 January 2019, we updated this search; as a result, several additional reports of studies are awaiting classification.

SELECTION CRITERIA

Randomised or quasi-randomised trials that assessed traditional suburethral slings for treating stress or mixed urinary incontinence.

DATA COLLECTION AND ANALYSIS

At least two review authors independently extracted data from included trials and assessed risk of bias. When appropriate, a summary statistic was calculated: risk ratio (RR) for dichotomous data, odds ratio (OR) for continence and cure rates that were expected to be high, and mean difference (MD) for continuous data. We adopted the GRADE approach to assess the quality of evidence.

MAIN RESULTS

A total of 34 trials involving 3244 women were included. Traditional slings were compared with 10 other treatments and with each other. We did not identify any trials comparing suburethral slings with no treatment or sham treatment, conservative management, anterior repair, or laparoscopic retropubic colposuspension. Most trials did not distinguish between women having surgery for primary or recurrent incontinence. One trial compared traditional slings with bladder neck needle suspension, and another trial compared traditional slings with single-incision slings. Both trials were too small to be informative. Traditional suburethral sling operation versus drugs One small trial compared traditional suburethral sling operations with oxybutynin to treat women with mixed urinary incontinence. This trial did not report any of our GRADE-specific outcomes. It is uncertain whether surgery compared with oxybutynin leads to more women being dry (83% vs 0%; OR 195.89, 95% confidence interval (CI) 9.91 to 3871.03) or having less urgency urinary incontinence (13% vs 43%; RR 0.29, 95% CI 0.09 to 0.94) because the quality of this evidence is very low. Traditional suburethral sling versus injectables One small trial compared traditional slings with suburethral injectable treatment. The impact of surgery versus injectables is uncertain in terms of the number of continent women (100% were dry with a traditional sling versus 71% with the injectable after the first year; OR 11.57, 95% CI 0.56 to 239.74), the need for repeat surgery for urinary incontinence (RR 0.52, 95% CI 0.05 to 5.36) or the occurrence of perioperative complications (RR 1.57, 95% CI 0.29 to 8.49), as the quality of evidence is very low. Traditional suburethral sling versus open abdominal retropubic colposuspension Eight trials compared slings with open abdominal retropubic colposuspension. Moderate-quality evidence shows that the traditional suburethral sling probably leads to more continent women in the medium term (one to five years) (69% vs 59% after colposuspension: OR 1.70, 95% CI 1.22 to 2.37). High-quality evidence shows that women were less likely to need repeat continence surgery after a traditional sling operation than after colposuspension (RR 0.15, 95% CI 0.05 to 0.42). We found no evidence of a difference in perioperative complications between the two groups, but the CI was very wide and the quality of evidence was very low (RR 1.24, 95% CI 0.83 to 1.86). Traditional suburethral sling operation versus mid-urethral slings Fourteen trials compared traditional sling operations and mid-urethral sling operations. Depending on judgements about what constitutes a clinically important difference between interventions with regard to continence, traditional suburethral slings are probably no better, and may be less effective, than mid-urethral slings in terms of number of women continent in the medium term (one to five years) (67% vs 74%; OR 0.67, 95% CI 0.44 to 1.02; n = 458; moderate-quality evidence). One trial reported more continent women with the traditional sling after 10 years (51% vs 32%: OR 2.22, 95% CI 1.07 to 4.61). Mid-urethral slings may be associated with fewer perioperative complications (RR 1.74, 95% CI 1.16 to 2.60; low-quality evidence). One type of traditional sling operation versus another type of traditional sling operation Nine trials compared one type of traditional sling operation with another. The different types of traditional slings, along with the number of different materials used, mean that trial results could not be pooled due to clinical heterogeneity. Complications were reported by two trials - one comparing non-absorbable Goretex with a rectus fascia sling, and the second comparing Pelvicol with a rectus fascial sling. The impact was uncertain due to the very low quality of evidence.

AUTHORS' CONCLUSIONS

Low-quality evidence suggests that women may be more likely to be continent in the medium term (one to five years) after a traditional suburethral sling operation than after colposuspension. It is very uncertain whether there is a difference in urinary incontinence after a traditional suburethral sling compared with a mid-urethral sling in the medium term. However, these findings should be interpreted with caution, as long-term follow-up data were not available from most trials. Long-term follow-up of randomised controlled trials (RCTs) comparing traditional slings with colposuspension and mid-urethral slings is essential. Evidence is insufficient to suggest whether traditional suburethral slings may be better or worse than other management techniques. This review is confined to RCTs and therefore may not identify all of the adverse effects that may be associated with these procedures. A brief economic commentary (BEC) identified three eligible economic evaluations, which are not directly comparable due to differences in methods, time horizons, and settings. End users of this review will need to assess the extent to which methods and results of identified economic evaluations may be applicable (or transferable) to their own setting.

The role of urodynamics in the management of female stress urinary incontinence

AIM

The role of urodynamic study (UDS) in the management of female stress urinary incontinence (SUI) is one of the most controversial and debated topic in urogynecology. Here, we aimed to systematically assess the most relevant available evidence on urodynamics' value in the management of women with stress urinary incontinence.

METHODS

A systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement was performed in May 2018. Only randomized clinical trials, prospective studies, or retrospective studies articles evaluating the use of urodynamic studies in women with stress urinary incontinence were included.

RESULTS

After screening a total of 3055 records, 39 studies published from 1996 to 2018 were included.

CONCLUSIONS

In an uncomplicated population of women with SUI, it is not demonstrated that preoperative urodynamic evaluation can improve the outcome of continence surgery; however, UDS provides additional information regarding lower urinary tract function that could guide the physician to make the right therapeutic choice. UDS should be considered mandatory before surgery in complicated patients, but its use should also be evaluated in index patients when the results may help counseling and management of these women.

Is ureteral stent an effective way to deliver drugs such as bacillus Calmette-Guérin to the upper urinary tract? An experimental study

Background:

We aim to evaluate the distribution in the upper urinary tract of intravesical-delivered fluids, after inducing vesicoureteral reflux (VUR) with a double J stent.

Methods:

In group 1 (n = 35) patients were maintained in a 20° Trendelenburg position and were evaluated after immediate insertion of ureteral stent, while in group 2 (n = 16) patients were evaluated after several days with ureteral stent placement. Patients in both groups were submitted to a cystogram with progressive volumes of iodine contrast and were evaluated according to VUR of contrast medium to the renal pelvis. Additionally, in group 2 visual confirmation was performed by endoscopic inspection of upper tract mucosal impregnation with methylene blue.

Results:

In group 1, after immediate insertion of ureteral stent reflux occurred in 51.4% (n = 18/35), and after several days with ureteral stent placement reflux was observed in 87.5% (n = 14/16) of patients. Reflux was progressively more frequent according to increasing bladder volume (p < 0.001). At 60 ml bladder volume no reflux was observed, while at 120 ml, 180 ml, 240 ml, 300 ml and 360 ml bladder volume reflux was observed in 14%, 25%, 41%, 55% and 63% of patients, respectively.

Conclusion:

Retrograde delivery of fluids such as bacillus Calmette-Guérin to the upper urinary tract through double J stents can be effective; however, it is mainly effective after several days with ureteral stent and relatively large volumes might be instilled into the bladder.

Does assessing urethral function allow the selection of the optimal therapy for recurrent SUI? Report from the ICI-RS 2017

AIMS

The management of recurrent stress urinary incontinence following failed previous continence surgery remains challenging. Whilst the role of urodynamic investigations has been questioned in the management of primary stress incontinence there is a widely held view that women with recurrent symptoms require further investigation although there is no agreement regarding which tests are required. We sought to understand what testing is recommended prior to managing this difficult cohort of patients.

METHOD

This research proposal was presented at the International Consultation on Incontinence Research Society (ICI-RS) in order to clarify our current knowledge regarding the assessment of urethral function and to set research priorities for the future.

RESULTS

Whilst the majority of clinicians would advocate urodynamic evaluation of women with recurrent stress incontinence following previous surgery there is no consensus of opinion as to which tests should be performed, on whom or where. The available evidence to date suggests that urethral function tests do have a role with regard to prognosis following surgery and also in planning the most appropriate surgical intervention.

CONCLUSION

The ICI-RS developed a list of research questions which may be able to assist in improving the investigation and management of women with recurrent SUI. Questions included whether patients felt the information gained via urethral function tests had an important role in their counseling regarding outcome of repeat SUI surgery.

A comparison of normal and high post-void residual urine and urodynamic parameters in women with overactive bladder

Objective

To investigate voiding functions and assess the relationships of voiding parameters to overactive bladder symptoms and postvoiding residue volumes.

Materials and Methods

This is a retrospective study analyzing urodynamic parameters in patients who were diagnosed as having overactive in our urogynecology clinic between April 2014 and April 2016. A total of 290 women who met the selection criteria were included in the study. The patients were divided into two groups according to postvoiding residue volumes: group 1, postvoiding residue volumes <100 mL (n=135); group 2, postvoiding residue volumes ≥100 mL (n=155).

Results

A total of 290 women were included in the study; the mean age was 71.4 years. A total of 158 (54.5%) patients had detrusor over-activity during urodynamic testing. The mean maximum bladder capacity in elevated group 2 (postvoiding residue volumes ≥100 mL) was significantly higher than in group 1 (postvoiding residue volumes <100 mL) (p<0.01). Additionally, there was a significant difference between detrusor pressure at Q_max in both study groups (p<0.05). There were no significant differences in the first-sensation volume between the normal and elevated postvoiding residue volumes groups.

Conclusion

In conclusion, patients with overactive with elevated postvoiding residue volumes showed increased maximum bladder capacity, but detrusor over-activity was not more prevalent in these women compared with women with normal postvoiding residue volumes.

Traditional suburethral sling operations for urinary incontinence in women

BACKGROUND

Stress urinary incontinence constitutes a significant health and economic burden to society. Traditional suburethral slings are one of the surgical operations used to treat women with symptoms of stress urinary incontinence.

OBJECTIVES

To determine the effects of traditional suburethral slings on stress or mixed incontinence in comparison with other management options.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register (searched 3 June 2010) and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised trials that included traditional suburethral slings for the treatment of stress or mixed urinary incontinence.

DATA COLLECTION AND ANALYSIS

At least three reviewers independently extracted data from included trials onto a standard form and assessed trial methodological quality. The data abstracted were relevant to predetermined outcome measures. Where appropriate, we calculated a summary statistic: a relative risk for dichotomous data and a weighted mean difference for continuous data.

MAIN RESULTS

We included 26 trials involving 2284 women. The quality of evidence was moderate for most trials and there was generally short follow-up ranging from 6 to 24 months.One medium-sized trial compared traditional suburethral sling operations with oxybutynin in the treatment of women with mixed urinary incontinence. Surgery appeared to be more effective than drugs in treating participant-reported incontinence (n = 75, risk ratio (RR) 0.18, 95% confidence interval (CI) 0.08 to 0.43).One trial found that traditional slings were more effective than transurethral injectable treatment (RR for clinician-assessed incontinence within a year 0.21, 95% CI 0.09 to 0.21)Seven trials compared slings with open abdominal retropubic colposuspension. Participant-reported incontinence was lower with the slings after one year (RR 0.75, 95% CI 0.62 to 0.90), but not when assessed by clinicians. Colposuspension, however, was associated with fewer peri-operative complications, shorter duration of use of indwelling catheter and less long-term voiding dysfunction. One study showed there was a 20% lower risk of bladder perforation with the sling procedure but a 50% increase in urinary tract infection with the sling procedure compared with colposuspension. Fewer women developed prolapse after slings (compared with after colposuspension) in two small trials but this did not reach statistical significance.Twelve trials addressed the comparison between traditional sling operations and minimally invasive sling operations. These seemed to be equally effective in the short term (RR for incontinence within first year 0.97, 95% CI 0.78 to 1.20) but minimally invasive slings had a shorter operating time, fewer peri-operative complications (other than bladder perforation) and some evidence of less post-operative voiding dysfunction and detrusor symptoms.Six trials compared one type of traditional sling with another. Materials included porcine dermis, lyophilised dura mater, fascia lata, vaginal wall, autologous dermis and rectus fascia. Participant-reported improvement rates within the first year favoured the traditional autologous material rectus fascia over other biological materials (RR 0.45, 95% CI 0.21 to 0.98). There were more complications with the use of non-absorbable Gore-Tex in one trial.Data for comparison of bladder neck needle suspension with suburethral slings were inconclusive because they came from a single trial with a small specialised population.No trials compared traditional suburethral slings with anterior repair, laparoscopic retropubic colposuspension or artificial sphincters. Most trials did not distinguish between women having surgery for primary or recurrent incontinence when reporting participant characteristics.For most of the comparisons, clinically important differences could not be ruled out.

AUTHORS' CONCLUSIONS

Traditional slings seem to be as effective as minimally invasive slings, but had higher rates of adverse effects. This should be interpreted with some caution however, as the quality of evidence for the studies was variable, follow-up short and populations small, particularly for identifying complication rates. Tradional sling procedures appeared to confer a similar cure rate in comparison to open retropubic colposuspension, but the long-term adverse event profile is still unclear. A brief economic commentary (BEC) identified two studies suggesting that traditional slings may be more cost-effective compared with collagen injection but not cost-effective when compared with minimally invasive sling operations. Reliable evidence to clarify whether or not traditional suburethral slings may be better or worse than other surgical or conservative management options is lacking.

Open retropubic colposuspension for urinary incontinence in women

BACKGROUND

Urinary incontinence is a common and potentially debilitating problem. Stress urinary, incontinence as the most common type of incontinence, imposes significant health and economic burdens on society and the women affected. Open retropubic colposuspension is a surgical treatment which involves lifting the tissues near the bladder neck and proximal urethra in the area behind the anterior pubic bones to correct deficient urethral closure to correct stress urinary incontinence.

OBJECTIVES

The review aimed to determine the effects of open retropubic colposuspension for the treatment of urinary incontinence in women. A secondary aim was to assess the safety of open retropubic colposuspension in terms of adverse events caused by the procedure.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 5 May 2015), and the reference lists of relevant articles. We contacted investigators to locate extra studies.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in women with symptoms or urodynamic diagnoses of stress or mixed urinary incontinence that included open retropubic colposuspension surgery in at least one trial group.

DATA COLLECTION AND ANALYSIS

Studies were evaluated for methodological quality or susceptibility to bias and appropriateness for inclusion and data extracted by two of the review authors. Trial data were analysed by intervention. Where appropriate, a summary statistic was calculated.

MAIN RESULTS

This review included 55 trials involving a total of 5417 women.Overall cure rates were 68.9% to 88.0% for open retropubic colposuspension. Two small studies suggested lower incontinence rates after open retropubic colposuspension compared with conservative treatment. Similarly, one trial suggested lower incontinence rates after open retropubic colposuspension compared to anticholinergic treatment. Evidence from six trials showed a lower incontinence rate after open retropubic colposuspension than after anterior colporrhaphy. Such benefit was maintained over time (risk ratio (RR) for incontinence 0.46; 95% CI 0.30 to 0.72 before the first year, RR 0.37; 95% CI 0.27 to 0.51 at one to five years, RR 0.49; 95% CI 0.32 to 0.75 in periods beyond five years).Evidence from 22 trials in comparison with suburethral slings (traditional slings or trans-vaginal tape or transobturator tape) found no overall significant difference in incontinence rates in all time periods evaluated (as assessed subjectively RR 0.90; 95% CI 0.69 to 1.18, within one year of treatment, RR 1.18; 95%CI 1.01 to 1.39 between one and five years, RR 1.11; 95% CI 0.97 to 1.27 at five years and more, and as assessed objectively RR 1.24; 95% CI 0.93 to 1.67 within one year of treatment, RR 1.12; 95% CI 0.82 to 1.54 for one to five years follow up, RR 0.70; 95% CI 0.30 to 1.64 at more than five years). However, subgroup analysis of studies comparing traditional slings and open colposuspension showed better effectiveness with traditional slings in the medium and long term (RR 1.35; 95% CI 1.11 to 1.64 from one to five years follow up, RR 1.19; 95% CI 1.03 to 1.37).In comparison with needle suspension, there was a lower incontinence rate after colposuspension in the first year after surgery (RR 0.66; 95% CI 0.42 to 1.03), after the first year (RR 0.56; 95% CI 0.39 to 0.81), and beyond five years (RR 0.32; 95% CI 15 to 0.71).Patient-reported incontinence rates at short, medium and long-term follow-up showed no significant differences between open and laparoscopic retropubic colposuspension, but with wide confidence intervals. In two trials incontinence was less common after the Burch (RR 0.38; 95% CI 0.18 to 0.76) than after the Marshall Marchetti Krantz procedure at one to five year follow-up. There were few data at any other follow-up times.In general, the evidence available does not show a higher morbidity or complication rate with open retropubic colposuspension compared to the other open surgical techniques, although pelvic organ prolapse is more common than after anterior colporrhaphy and sling procedures. Voiding problems are also more common after sling procedures compared to open colposuspension.

AUTHORS' CONCLUSIONS

Open retropubic colposuspension is an effective treatment modality for stress urinary incontinence especially in the long term. Within the first year of treatment, the overall continence rate is approximately 85% to 90%. After five years, approximately 70% of women can expect to be dry. Newer minimal access sling procedures look promising in comparison with open colposuspension but their long-term performance is limited and closer monitoring of their adverse event profile must be carried out. Open colposuspension is associated with a higher risk of pelvic organ prolapse compared to sling operations and anterior colporrhaphy, but with a lower risk of voiding dysfunction compared to traditional sling surgery. Laparoscopic colposuspension should allow speedier recovery but its relative safety and long-term effectiveness is not yet known. A Brief Economic Commentary (BEC) identified five studies suggesting that tension-free vaginal tape (TVT) and laparoscopic colposuspension may be more cost-effective compared with open retropubic colposuspension.

Correlation of Xiphopubic Distance, Body Weight, Height and Body Mass Index with Intravesical and Abdominal Initial Resting Pressures in Urodynamic Testing in the Sitting Position

OBJECTIVES

To compare the initial resting intravesical pressure (p_ves ) and abdominal pressure (p_abd ) in the sitting position with the typical range of values, to assess the correlation between such pressures and patient xipho-pubic distance, body weight, height and body mass index (BMI), and to estimate if xipho-pubic distance can be a guide to interpret initial resting pressures in urodynamic testing.

METHODS

Women with lower urinary tract symptomatology referred for urodynamic testing were consecutively enrolled in a prospective study. Conventional cystometry was done following "good urodynamic practices". The correlation between initial resting p_ves and p_abd and xipho-pubic distance, body weight, height and BMI were studied using simple and multiple linear regression analysis. Statistical significance was defined as P < 0.05.

RESULTS

One hundred women aged (mean ± SD) 59.2 ± 13.3 were studied. There was a significant correlation between both p_ves and p_abd , and xipho-pubic distance, body weight and BMI and no correlation with height. Over the multiple analysis, xipho-pubic distance and body weight correlated independently with p_ves ; body weight correlated independently with p_abd . Three patients had p_ves and/or p_abd out of typical range, with BMIs values of 18.48, 18.72 and 35.81 kg/m² . There was a wide range of difference between xipho-pubic distance and initial resting pressures.

CONCLUSIONS

Out of range initial resting pressures occur in underweight (or close to) or severely obese patients. Xipho-pubic distance and body weight correlated independently with p_ves . Body weight correlated independently with p_abd . Xipho-pubic distance cannot be a guide to interpret the initial resting pressures.

Typical Value Ranges and Typical Signal Patterns in the Initial Cough in Patients With Neurogenic Bladder: Quality Control in Urodynamic Studies

Purpose

The goal of this study was to establish typical value ranges (TVRs) and to analyze typical signal patterns (TSPs) of the initial cough (cough before bladder filling) for quality control in urodynamic studies.

Methods

A total of 539 urodynamic traces from patients with neurogenic bladder obtained over the course of a year were retrospectively reviewed. The TVRs for cough amplitude in measurements of the intravesical pressure (P_ves), abdominal pressure (P_abd), and detrusor pressure (P_det) during the initial cough were established. We used the 95% range as a reference range for all parameters. Cough spikes in P_det were described and classified, and the reasons for different patterns of cough spikes were established. The quality of all the cystometry traces was checked, and we also present remedial actions for inappropriate cough spikes.

Results

The cough amplitudes in the measurements of P_ves and P_abd were similar, with 95% of measurements falling within the following ranges: 4–62 cm H₂O and 3–70 cm H₂O, respectively, in supine position and 9–95 cm H₂O and 8–98 cm H₂O, respectively, in sitting position. For P_det, the cough amplitude ranged from −38 to 25 cm H₂O in supine position and from −44 to 41 cm H₂O in sitting position. The cough spikes for P_det were classified as follows: type I, P_det pressure exhibited a minimal change (<5 cm H₂O) during the cough; type II, a monophasic spike (>5 cm H₂O) was observed for P_det; and type III, biphasic spikes were observed for P_det. Type I coughs were found to have more high-quality traces (P<0.01).

Conclusions

TVRs for the initial cough test among neurogenic patients were established in order to provide guidelines for quantitative quality control. The TSPs for the initial cough signal were described, and the presence of a high-quality cough signal may be recommended as a component of quality control in urodynamic measurements.

Comparison of Effectiveness between Tension-Free Vaginal Tape (TVT) and Trans-Obturator Tape (TOT) in Patients with Stress Urinary Incontinence and Intrinsic Sphincter Deficiency

Background

The aim of this study was to compare the two types of mid-urethral slings for stress urinary incontinence (SUI) with intrinsic sphincter deficiency (ISD).

Methods

This retrospective study included patients who underwent tension-free vaginal tape (TVT) procedure or transobturator tape (TOT) procedure by a single surgeon for SUI with ISD, defined as Valsalva leak point pressure (VLPP) < 60 cmH₂O in a urodynamic study. Cases of neurogenic bladder, previous SUI surgery, and concomitant cystocele repair were excluded. The primary outcome was treatment success at 12 months, defined by self-reported absence of symptoms, no leakage episodes recorded, and no retreatment.

Results

Among the 157 women who were included in the final analysis, 105 patients received TVT and 52 patients received TOT. Age, underlying diseases, Stamey grade, cystocele grade, and presence of urge incontinence were not significantly different between the two groups. Urodynamic parameters including maximal urethral closing pressure, detrusor overactivity, VLPP, urethral hypermobility (Q-tip ≥ 30°), were also comparable between the two groups. Success rate was significantly higher in the TVT group than in the TOT group (95.2% vs. 82.7%, p = 0.009). On multivariate analysis, only TOT surgery (OR = 3.922, 95%CI = 1.223–12.582, p = 0.022) was a risk factor for failure following surgical treatment.

Conclusion

TVT is more effective than TOT in treatment of female SUI with ISD.

Open retropubic colposuspension for urinary incontinence in women

BACKGROUND

Urinary incontinence is a common and potentially debilitating problem. Open retropubic colposuspension is a surgical treatment which involves lifting the tissues near the bladder neck and proximal urethra in the area behind the anterior pubic bones to correct deficient urethral closure to correct stress urinary incontinence.

OBJECTIVES

The review aimed to determine the effects of open retropubic colposuspension for the treatment of urinary incontinence in women. A secondary aim was to assess the safety of open retropubic colposuspension in terms of adverse events caused by the procedure.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 5 May 2015), and the reference lists of relevant articles. We contacted investigators to locate extra studies.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in women with symptoms or urodynamic diagnoses of stress or mixed urinary incontinence that included open retropubic colposuspension surgery in at least one trial group.

DATA COLLECTION AND ANALYSIS

Studies were evaluated for methodological quality or susceptibility to bias and appropriateness for inclusion and data extracted by two of the review authors. Trial data were analysed by intervention. Where appropriate, a summary statistic was calculated.

MAIN RESULTS

This review included 55 trials involving a total of 5417 women.Overall cure rates were 68.9% to 88.0% for open retropubic colposuspension. Two small studies suggested lower incontinence rates after open retropubic colposuspension compared with conservative treatment. Similarly, one trial suggested lower incontinence rates after open retropubic colposuspension compared to anticholinergic treatment. Evidence from six trials showed a lower incontinence rate after open retropubic colposuspension than after anterior colporrhaphy. Such benefit was maintained over time (risk ratio (RR) for incontinence 0.46; 95% CI 0.30 to 0.72 before the first year, RR 0.37; 95% CI 0.27 to 0.51 at one to five years, RR 0.49; 95% CI 0.32 to 0.75 in periods beyond five years).Evidence from 22 trials in comparison with suburethral slings (traditional slings or trans-vaginal tape or transobturator tape) found no overall significant difference in incontinence rates in all time periods evaluated (as assessed subjectively RR 0.90; 95% CI 0.69 to 1.18, within one year of treatment, RR 1.18; 95%CI 1.01 to 1.39 between one and five years, RR 1.11; 95% CI 0.97 to 1.27 at five years and more, and as assessed objectively RR 1.24; 95% CI 0.93 to 1.67 within one year of treatment, RR 1.12; 95% CI 0.82 to 1.54 for one to five years follow up, RR 0.70; 95% CI 0.30 to 1.64 at more than five years). However, subgroup analysis of studies comparing traditional slings and open colposuspension showed better effectiveness with traditional slings in the medium and long term (RR 1.35; 95% CI 1.11 to 1.64 from one to five years follow up, RR 1.19; 95% CI 1.03 to 1.37).In comparison with needle suspension, there was a lower incontinence rate after colposuspension in the first year after surgery (RR 0.66; 95% CI 0.42 to 1.03), after the first year (RR 0.56; 95% CI 0.39 to 0.81), and beyond five years (RR 0.32; 95% CI 15 to 0.71).Patient-reported incontinence rates at short, medium and long-term follow-up showed no significant differences between open and laparoscopic retropubic colposuspension, but with wide confidence intervals. In two trials incontinence was less common after the Burch (RR 0.38; 95% CI 0.18 to 0.76) than after the Marshall Marchetti Krantz procedure at one to five year follow-up. There were few data at any other follow-up times.In general, the evidence available does not show a higher morbidity or complication rate with open retropubic colposuspension compared to the other open surgical techniques, although pelvic organ prolapse is more common than after anterior colporrhaphy and sling procedures. Voiding problems are also more common after sling procedures compared to open colposuspension.

AUTHORS' CONCLUSIONS

Open retropubic colposuspension is an effective treatment modality for stress urinary incontinence especially in the long term. Within the first year of treatment, the overall continence rate is approximately 85% to 90%. After five years, approximately 70% of women can expect to be dry. Newer minimal access sling procedures look promising in comparison with open colposuspension but their long-term performance is limited and closer monitoring of their adverse event profile must be carried out. Open colposuspension is associated with a higher risk of pelvic organ prolapse compared to sling operations and anterior colporrhaphy, but with a lower risk of voiding dysfunction compared to traditional sling surgery. Laparoscopic colposuspension should allow speedier recovery but its relative safety and long-term effectiveness is not yet known.

Medication effects on periurethral sensation and urethral sphincter activity

AIM

The aim of this study was to characterize urethral neuromuscular function before and 2 weeks after medication therapy.

METHODS

Premenopausal women without lower urinary tract symptoms were randomly allocated to 1 of the 6 medications for 2 weeks (pseudoephedrine ER of 120 mg, imipramine of 25 mg, cyclobenzaprine of 10 mg, tamsulosin of 0.4 mg, solifenacin of 5 mg, or placebo). At baseline and after medication, participants underwent testing: quantitative concentric needle electromyography (CNE) of the urethral sphincter using automated multimotor unit action potential software, current perception threshold (CPT) testing to measure periurethral sensation, and standard urodynamic pressure flow studies (PFS). Nonparametric tests were used to compare pre-post differences.

RESULTS

Fifty-six women had baseline testing, 48 (85.7%) completed follow-up CNE, and 49 (87.5%) completed follow-up CPT and PFS testing. Demographics showed no significant differences among medication groups with respect to age (mean, 34.3; SD, 10.1), body mass index (mean, 31.8; SD, 7.5), parity (median, 1; range, 0-7), or race (14% Caucasian, 80% African American). The PFS parameters were not significantly different within medication groups. No significant pre-post changes in CNE values were noted; however, trends in amplitudes were in a direction consistent with the expected physiologic effect of the medications. With CPT testing, a trend toward increased urethral sensation at the 5-Hz stimulation level was observed after treatment with pseudoephedrine (0.15-0.09 mA at 5 Hz, P = 0.03).

CONCLUSIONS

In women without lower urinary tract symptoms, pseudoephedrine improved urethral sensation but not urethral neuromuscular function on CNE or PFS. Imipramine, cyclobenzaprine, tamsulosin, solifenacin, and placebo did not change urethral sensation or neuromuscular function.

Evaluation of obstructed voiding in the female: how close are we to a definition?

PURPOSE OF REVIEW

The difficulties of defining and evaluating bladder outlet obstruction (BOO) in the female patient have been described for several years. This review aims to examine recent literature to summarize progress in the area.

RECENT FINDINGS

Within the last 2 years, functional causes of female BOO have been summarized, new nomograms proposed, several case reports of different causes of BOO have been published and work on surgical outcomes and possible diagnostics reported.

SUMMARY

Women complain of voiding dysfunction because of different reasons. For clinical decision-making, and to evaluate different surgical procedures, finding a way of detecting and quantifying infravesical obstruction is immensely helpful. This review aims to clarify questions concerning definitions of BOO in women and provide an update on recent advances.

Urodynamic study in women with pure stress urinary incontinence

OBJECTIVE

To describe the results of urodynamic study in women with pure stress urinary incontinence symptoms, including the characteristics of the overactive detrusor. No other clinical assessments were taken into account.

MATERIAL AND METHODS

A retrospective study in women with urinary incontinence consecutively evaluated by urodynamic study. From a total of 710 women, only 108 (15%) with pure stress urinary incontinence symptoms were selected. Women with prior urinary incontinence surgery, pelvic organ prolapse (stage ≥iii), pelvic radiotherapy, using medication active on the lower urinary tract and neurological diseases were excluded. Infusion rate was 70 ml/min. Detrusor overactivity was induced only by cough. A standardized cough stress test with progressive cough intensity was carried out.

RESULTS

Reference urodynamic values for stress incontinent women are described. Urodynamic stress incontinence was observed in 79 women (73.1%), detrusor overactivity in 4 (3.7%) and mixed urodynamic diagnosis in 15 (13.8%). Test was inconclusive in 10 patients (9.2%). Two women had detrusor overactivity incontinence (1.9%). One patient had detrusor overactivity induced by cough without urodynamic stress incontinence (0.9%). There was an association between detrusor overactivity and nocturia ≥2 (P=.002; odds ratio: 3.74; 95% confidence interval: 1.22-11.39). One woman had a bladder outlet obstruction (0.9%).

CONCLUSIONS

In women with pure stress urinary incontinence, without knowing the outcome of other clinical assessments, urodynamic study can provide useful information to define the proper therapy.

Comparison of flowrates and voided volumes during non-instrumented uroflowmetry and pressure-flow studies in women with stress incontinence

AIMS

The Blaivas-Groutz nomogram defines voiding obstruction in women using Qmax from the NIF and the maximum detrusor pressure (Pdetmax ) from the PFS. The aim of this study was to understand the relationship between NIF and PFS maximum flow rates in women with stress incontinence.

METHODS

We analyzed the UDS of 597 women with stress-dominant urinary incontinence. Each subject underwent a NIF and then a PFS. Mixed model was used to test the hypothesis that the relationship between flow rates and voided volume (VV) were similar for NIF and PFS.

RESULTS

There were 452 subjects with both NIF and PFS studies that met the inclusion criteria and had max flow rate (Qmax ) for both NIF and PFS. The mean age was 53. Overall, higher VV were observed during PFS compared to NIF and subjects had higher Qmax with NIF compared to PFS. The relationship between Qmax and VV was significantly different between NIF and PFS (P < 0.004). At 200 ml, NIF Qmax was 14% higher than PFS Qmax and this difference increased to 30% at 700 ml.

CONCLUSION

The difference between PFS Qmax and NIF Qmax increases as VV increase. As a result, values from PFS and NIF cannot be used interchangeably as has been suggested in the Blaivas-Groutz nomogram for obstruction in women.

Quantitative quality control during urodynamic studies with TVRs for cystometry in men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia

OBJECTIVE

To establish typical value ranges (TVRs) and to outline their role in urodynamic quality control.

METHODS

Five hundred and eighty-two data sets of free flow, filling cystometry, and voiding from 181 males in a strictly quality-controlled study were analyzed for intravesical pressure (Pves), abdominal pressure (Pabd), and detrusor pressure (Pdet) before, at the beginning and end of filling, and after voiding. Cystometric capacity, maximum flow rate (Qmax), voided volume (Vvoid), and compliance were determined. Mean value, standard deviation, median, and various TVRs were calculated. Technical errors related to the TVRs are classified and examples given.

RESULTS

TVRs for initial resting Pves, Pabd, and Pdet were 31-42, 28-39, and 0-4 cmH₂O, respectively. Various technical errors are classified as type I: normal initial Pdet, both Pves and Pabd are incorrect; type II: negative initial Pdet; and type III: initial Pdet too high. The incidences of I, II, and III errors were 9.8, 4.5, and 1.4%, respectively. The TVRs for maximum cystometric capacity and compliance were 157-345 mL and 26.7-70.8 mL/cmH₂O; Qmax, Pdet, and Vvoid were 5.5-9 mL/s, 57-92 cmH₂O, and 167-315 mL, respectively; Qmax and Vvoid in free flow were 8-9.2 mL/s and 167-301 mL, respectively. After voiding, two errors were found: type V (Pves and Pdet after voiding still high) and type VI (Pves and Pdet negative).

CONCLUSIONS

TVRs in urodynamics are indispensable and effective tools for quantitative plausibility checks and quality control. They are sensitive and reliable indicators for correct measurement and a relevant contribution to a collection of normal values.

Qualitative quality control during urodynamic studies with TSPs for cystometry in men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia

The aim of this study was to describe typical signal patterns (TSPs) by amplitude and pressure gradients and indicate the role and significance of them in quality control. A total of 582 measurements from a multicenter urodynamic study on males (mean age, 65.3 years) were re-analyzed. Using manual graphical analysis, we identified signal patterns by typical amplitude (A) and typical pressure gradient (PG). TSPs were classified into four types: I: fine structure (A < 3 cm H2O); II: minor dynamic changes (A < 5 cm H2O); III: major changes due to cough tests (A > 50 cm H2O, PG > 100 cm H2O/s); IV: typical major changes due to muscular activity: detrusor overactivity (A > 3 cm H2O, PG > 1-5 cm H2O/s), rectal contractions (A = 5-10 cm H2O, PG = 5-10 cm H2O/s), and straining (A > 5 cm H2O, PG ≥ 30 cm H2O/s). At beginning of and during filling, 91.8 and 98.3 % of traces showed the identical fine structure and minor changes between P ves and P abd tracings, and P det tracing was quiet. 92.3 % of P ves and P abd traces had equal pressure changes at test coughs. During filling, 8.3 % traces showed straining, 17.4 % showed rectal contractions, and 33.7 % showed detrusor overactivity. Before voiding, 94 % of P ves and P abd traces had equal cough response. During voiding, 91.2 % of traces showed the same fine structure, 53.3 % of traces showed straining, and 15.3 % showed relaxation of the pelvic floor. After voiding, 91.2 % of traces had the same fine structure, and 87.5 % had an equal cough response. TSPs are a powerful tool for qualitative plausibility and quality control and are an indispensable pre-condition for good urodynamic practice.

Risk factors for incomplete bladder emptying after midurethral sling

OBJECTIVE

To describe the prevalence and risk factors for incomplete bladder emptying after midurethral slings (MUS) in a large multicenter trial.

METHODS

Five hundred ninety-seven women were randomized to retropubic (RMUS) or transobturator midurethral slings as part of the Trial of MidUrethral Slings study. Demographic data and voiding symptoms were obtained preoperatively along with urodynamics. Patients underwent a standardized voiding trial at discharge after continence surgery. Incomplete bladder emptying was defined as a postvoid residual of >150 mL.

RESULTS

Three-quarters of patients (454 of 597) were self-voiding at discharge, whereas 114 of 597 (19%) were managed with an indwelling urethral catheter and 29 of 597 (5%) with intermittent catheterization. At 2 weeks, only 38 of 586 (6%) reported any catheter use, and by 6 weeks, only 9 of 587 (2%) reported any catheter use. Women with incomplete bladder emptying at discharge were more likely to have had a RMUS (odds ratio 1.79; 95% confidence interval 1.22-2.62) and to report preoperative voiding accommodations such as straining to void (odds ratio 1.75; 95% confidence interval 1.04-2.96). Urodynamic and clinicodemographic parameters were not predictive of incomplete bladder emptying.

CONCLUSION

Incomplete bladder emptying at discharge after MUS is common, especially after RMUS, but of short duration. Risk factors include preoperative voiding accommodations such as straining or bending over to void, but other variables including urodynamics did not predict incomplete bladder emptying after MUS.

The effect of a 6 Fr catheter in women: Are they obstructive?

OBJECTIVES

Our objective was to evaluate the effect of a 6 Fr transurethral catheter on the uroflowmetry and to assess whether it potentially contributes to the bladder outlet obstruction (BOO) in women.

METHODS

We reviewed the charts of 1367 women who underwent an urodynamic study. We included patients with a non-invasive free-flow study (NIFFS) and pressure flow study (PFS) performed through a 6 Fr double lumen transurethral catheter.

RESULTS

In total, 120 women met the inclusion/exclusion criteria. Mean maximal flow rate (Qmax) was significantly higher (p < 0.001) in the NIFFS (27.2±11.1 mL/s) than in the PFS (19.3±10.6 mL/s). The mean difference between both Qmax was 7.9±12.0 mL/s. Of these women, 92.3% (24/26) with a Qmax <12 mL/s during PFS were found to have a Qmax ≥12 mL/s during the NIFFS. Ten of the 72 women with an available Pdet.Qmax were deemed to have a BOO according to the PFS and all of them had a Qmax >12 mL/s during the NIFFS. Of the 10 patients, only 2 reported obstructive symptoms.

CONCLUSION

The presence of 6 Fr transurethral catheters alters the PFS and results in a significant reduction of the Qmax in patients who voided more than 250 mL. We believe that NIFFS should be performed in all patients before any urethral manipulation to lower a possible overdiagnosis of BOO and findings should always be correlated to clinical symptoms.

When are urodynamics indicated in patients with stress urinary incontinence?

Despite technical and procedural advances in urodynamics over the past decade, the role of urodynamics in women with stress urinary incontinence (SUI) remains controversial. Many of these advancements have been the result of multicentric studies in the United States, such as the UITN and PFDN, which will be highlighted in this article. It appears to be the consensus that urodynamics may not be needed in pure stress incontinence. Urodynamics can be valuable in unmasking stress urinary incontinence in prolapse, although its impact on the ultimate management of occult incontinence remains debated. This article reviews the indications for urodynamic testing in women with SUI but will exclude more complex conditions such as mixed or recurrent incontinence which are outside the scope of this review.

Open retropubic colposuspension for urinary incontinence in women

BACKGROUND

Urinary incontinence is a common and potentially debilitating problem. Open retropubic colposuspension is a surgical treatment which involves lifting the tissues near the bladder neck and proximal urethra in the area behind the anterior pubic bones to correct deficient urethral closure.

OBJECTIVES

To assess the effects of open retropubic colposuspension for the treatment of urinary incontinence.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register (searched 13 March 2012), which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and CINAHL, and handsearching of journals and conference proceedings, and the reference lists of relevant articles. We contacted investigators to locate extra studies.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in women with symptoms or urodynamic diagnoses of stress or mixed urinary incontinence that included open retropubic colposuspension surgery in at least one trial group.

DATA COLLECTION AND ANALYSIS

Studies were evaluated for methodological quality or susceptibility to bias and appropriateness for inclusion and data extracted by two of the review authors. Trial data were analysed by intervention. Where appropriate, a summary statistic was calculated.

MAIN RESULTS

This review included 53 trials involving a total of 5244 women.Overall cure rates were 68.9% to 88.0% for open retropubic colposuspension. Two small studies suggested lower incontinence rates after open retropubic colposuspension compared with conservative treatment. Similarly, one trial suggested lower incontinence rates after open retropubic colposuspension compared to anticholinergic treatment. Evidence from six trials showed a lower incontinence rate after open retropubic colposuspension than after anterior colporrhaphy. Such benefit was maintained over time (risk ratio (RR) for incontinence 0.51; 95% CI 0.34 to 0.76 before the first year, RR 0.43; 95% CI 0.32 to 0.57 at one to five years, RR 0.49; 95% CI 0.32 to 0.75 in periods beyond five years).Evidence from 20 trials in comparison with suburethral slings (trans-vaginal tape or transobturator tape) found no significant difference in incontinence rates in all time periods assessed.In comparison with needle suspension, there was a lower incontinence rate after colposuspension in the first year after surgery (RR 0.66; 95% CI 0.42 to 1.03), after the first year (RR 0.48; 95% CI 0.33 to 0.71), and beyond five years (RR 0.32; 95% CI 15 to 0.71).Patient-reported incontinence rates at short, medium and long-term follow-up showed no significant differences between open and laparoscopic retropubic colposuspension, but with wide confidence intervals. In two trials incontinence was less common after the Burch (RR 0.38; 95% CI 0.18 to 0.76) than after the Marshall Marchetti Krantz procedure at one to five year follow-up. There were few data at any other follow-up times.In general, the evidence available does not show a higher morbidity or complication rate with open retropubic colposuspension compared to the other open surgical techniques, although pelvic organ prolapse is more common than after anterior colporrhaphy and sling procedures.

AUTHORS' CONCLUSIONS

Open retropubic colposuspension is an effective treatment modality for stress urinary incontinence especially in the long term. Within the first year of treatment, the overall continence rate is approximately 85% to 90%. After five years, approximately 70% of patients can expect to be dry. Newer minimal access procedures such as tension-free vaginal tape look promising in comparison with open colposuspension but their long-term performance is not known and closer monitoring of their adverse event profile must be carried out. Laparoscopic colposuspension should allow speedier recovery but its relative safety and long-term effectiveness is not known yet.

Association of baseline urodynamic measures of urethral function with clinical, demographic, and other urodynamic variables in women prior to undergoing midurethral sling surgery

AIMS

To explore how baseline demographic, clinical, and urodynamic (UDS) variables correlate with measures of urethral function in women planning midurethral sling surgery.

METHODS

Women with predominant stress urinary incontinence (SUI) as part of the trial of mid-urethral slings (TOMUS) were characterized preoperatively including: demographics, body mass index (BMI), responses to the Medical and Epidemiologic Social Aspects of Aging (MESA) and Urogenital Distress Inventory (UDI) questionnaires, pad weight (PW), incontinence duration, prior SUI surgery, prolapse, strength of pelvic contraction, Q-tip test, uroflow, cystometrogram, and detrusor pressures at maximum flow (Pdet at Qmax). Multivariate regression analysis and modeling confirmed variables with significant correlations with maximal urethral closure pressure (MUCP), functional urethral length (FUL), and Valsalva leak point pressure (VLPP).

RESULTS

Five-hundred thirty-nine women were included in the analysis. In multivariable analyses, PW (P =  0.045) and age (P < 0.0001) were negatively correlated with MUCP (as PW and age increased, MUCP decreased); BMI (P = 0.02) and Pdet at Qmax (P < 0.0001) were positively correlated with MUCP (as BMI and Pdet at Qmax increased, MUCP increased). Age (P = 0.002) was negatively correlated with FUL; Qtip delta (P = 0.006), pelvic organ prolapse quantification examination (POPQ) stage (P = 0.002) and strength of pelvic contraction (P = 0.03) were positively correlated with FUL. Duration of incontinence (P = 0.01) was negatively correlated with VLPP; Qtip delta (P = 0.02), BMI (P = 0.0005) and Pdet at Qmax (P = 0.0005) were positively correlated with VLPP.

CONCLUSIONS

Age, BMI, Qtip delta, and Pdet at Qmax were variables that correlated with two or more measures of urethral function. These correlations may help direct future research in female urethral function.

Baseline urodynamic predictors of treatment failure 1 year after mid urethral sling surgery

PURPOSE

We determined whether baseline urodynamic study variables predict failure after mid urethral sling surgery.

MATERIALS AND METHODS

Preoperative urodynamic study variables and postoperative continence status were analyzed in women participating in a randomized trial comparing retropubic to transobturator mid urethral sling. Objective failure was defined by positive standardized stress test, 15 ml or greater on 24-hour pad test, or re-treatment for stress urinary incontinence. Subjective failure criteria were self-reported stress symptoms, leakage on 3-day diary or re-treatment for stress urinary incontinence. Logistic regression was used to assess associations between covariates and failure controlling for treatment group and clinical variables. Receiver operator curves were constructed for relationships between objective failure and measures of urethral function.

RESULTS

Objective continence outcomes were available at 12 months for 565 of 597 (95%) women. Treatment failed in 260 women (245 by subjective criteria, 124 by objective criteria). No urodynamic variable was significantly associated with subjective failure on multivariate analysis. Valsalva leak point pressure, maximum urethral closure pressure and urodynamic stress incontinence were the only urodynamic variables consistently associated with objective failure on multivariate analysis. No specific cut point was determined for predicting failure for Valsalva leak point pressure or maximum urethral closure pressure by ROC. The lowest quartile (Valsalva leak point pressure less than 86 cm H2O, maximum urethral closure pressure less than 45 cm H2O) conferred an almost 2-fold increased odds of objective failure regardless of sling route (OR 2.23, 1.20-4.14 for Valsalva leak point pressure and OR 1.88, 1.04-3.41 for maximum urethral closure pressure).

CONCLUSIONS

Women with a Valsalva leak point pressure or maximum urethral closure pressure in the lowest quartile are nearly 2-fold more likely to experience stress urinary incontinence 1 year after transobturator or retropubic mid urethral sling.

Perineal surface electromyography does not typically demonstrate expected relaxation during normal voiding

AIMS

To describe perineal surface patch electromyography (EMG) activity during urodynamics (UDS) and compare activity between filling and voiding phases and to assess for a relationship between preoperative EMG activity and postoperative voiding symptoms.

METHODS

655 women underwent standardized preoperative UDS that included perineal surface EMG prior to undergoing surgery for stress urinary incontinence. Pressure-flow studies were evaluated for abdominal straining and interrupted flow. Quantitative EMG values were extracted from 10 predetermined time-points and compared between fill and void. Qualitative EMG activity was assessed for the percent of time EMG was active during fill and void and for the average amplitude of EMG during fill compared to void. Postoperative voiding dysfunction was defined as surgical revision or catheterization more than 6 weeks after surgery. Fisher's exact test with a 5% two-sided significance level was used to assess differences in EMG activity and postoperative voiding dysfunction.

RESULTS

321 UDS had interpretable EMG studies, of which 131 (41%) had EMG values at all 10 predetermined and annotated time-points. Quantitative and qualitative EMG signals during flow were usually greater than during fill. The prevalence of postoperative voiding dysfunction in subjects with higher preoperative EMG activity during void was not significantly different. Results were similar in the 42 subjects who had neither abdominal straining during void nor interrupted flow.

CONCLUSIONS

Perineal surface patch EMG did not measure expected pelvic floor and urethral sphincter relaxation during voiding. Preoperative EMG did not predict patients at risk for postoperative voiding dysfunction.

Urodynamics, the supine empty bladder stress test, and incontinence severity

AIMS

Determine whether urodynamic measures of urethral function [(valsalva leak point pressure (VLPP), maximum urethral closure pressure (MUCP), functional urethral length (FUL)] and the results of the supine empty bladder stress test (SEBST) correlate with each other and with subjective and objective measures of urinary incontinence (UI).

METHODS

Data were collected preoperatively from subjects enrolled in a multicenter surgical trial of mid-urethral slings. Subjective measures included questionnaire scores from the Medical Epidemiological and Social Aspects of Aging Questionnaire, Urogenital Distress Inventory, and Incontinence Impact Questionnaire. Objective measures included a 24-hr pad weight test, incontinence episode frequency on a 3-day voiding diary, and a SEBST.

RESULTS

Five hundred ninety-seven women enrolled. Three hundred seventy-two women had valid VLPP values; 539 had valid MUCP/FUL values. Subjective measures of severity had weak to moderate correlation with each other (r = 0.25-0.43) and with objective measures of severity (r = -0.06 to 0.45). VLPP and MUCP had moderate correlation with each other (r = 0.36,  P< 0.001). Urodynamic measures of urethral function had little or no correlation with subjective or objective measures of severity. Subjects with a positive SEBST had more subjective and objective severity measures compared to the negative SEBST group, but they did not have significantly different VLPP and MUCP values.

CONCLUSIONS

VLPP and MUCP have moderate correlation with each other, but each had little or no correlation with subjective or objective measures of severity or with the results of the SEBST. This data suggests that the urodynamic measures of urethral function are not related to subjective or objective measures of UI severity.

Traditional suburethral sling operations for urinary incontinence in women

BACKGROUND

Traditional suburethral slings are surgical operations used to treat women with symptoms of stress urinary incontinence.

OBJECTIVES

To determine the effects of traditional suburethral slings on stress or mixed incontinence in comparison with other management options.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Register (searched 3 June 2010) and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised trials that included traditional suburethral slings for the treatment of stress or mixed urinary incontinence.

DATA COLLECTION AND ANALYSIS

At least three reviewers independently extracted data from included trials onto a standard form and assessed trial methodological quality. The data abstracted were relevant to predetermined outcome measures. Where appropriate, a summary statistic was calculated: a relative risk for dichotomous data and a weighted mean difference for continuous data.

MAIN RESULTS

Twenty six trials involving 2284 women were included. The quality of evidence was moderate for most trials and there was generally short follow-up ranging from 6-24 months.One medium sized trial compared traditional suburethral sling operations with oxybutynin in the treatment of mixed urinary incontinence patients. Surgery appeared to be more effective than drugs in treating patient-reported incontinence (n = 75, Risk Ratio (RR) 0.18, 95% Confidence Interval (CI) 0.08 to 0.43).One trial found that traditional slings were more effective than transurethral injectable treatment (RR for clinician-assessed incontinence within a year 0.21; 95% CI 0.09 to 0.21), and also cheaper on average cost.Seven trials compared slings with open abdominal retropubic colposuspension. Patient-reported incontinence was lower with the slings after one year (RR 0.75; 95% CI 0.62 to 0.90), but not when assessed by clinicians. Colposuspension, however, was associated with fewer peri-operative complications, shorter duration of use of indwelling catheter and less long term voiding dysfunction. One study showed there was a 20% lower risk of bladder perforation with the sling procedure but a 50% increase in urinary tract infection with the sling procedure compared with colposuspension. Fewer women developed prolapse after slings (compared with after colposuspension) in two small trials but this did not reach statistical significance.Twelve trials addressed the comparison between traditional sling operations and minimally invasive sling operations.These seemed to be equally effective in the short term (RR for incontinence within first year 0.97; 95% CI 0.78 to 1.20) but minimally invasive slings had a shorter operating time, fewer peri-operative complications (other than bladder perforation) and some evidence of less post-operative voiding dysfunction and detrusor symptoms.Six trials compared one type of traditional sling with another. Materials included porcine dermis, lyophilised dura mater, fascia lata, vaginal wall, autologous dermis and rectus fascia. Patient-reported improvement rates within the first year favoured the traditional autologous material rectus fascia over other biological materials (RR 0.45; 95% CI 0.21 to 0.98). There were more complications with the use of non-absorbable Goretex in one trial.Data for comparison of bladder neck needle suspension with suburethral slings were inconclusive because they came from a single trial with a small specialised population.No trials compared traditional suburethral slings with anterior repair, laparoscopic retropubic colposuspension or artificial sphincters. Most trials did not distinguish between women having surgery for primary or recurrent incontinence when reporting patient characteristics.For most of the comparisons, clinically important differences could not be ruled out.

AUTHORS' CONCLUSIONS

Traditional slings seem to be as effective as minimally invasive slings, but had higher rates of adverse effects. This should be interpreted with some caution however, as the quality of evidence for the studies was variable, follow-up short and populations small, particularly for identifying complication rates. Tradional sling procedures appeared to confer a similar cure rate in comparison to open retropubic colposuspension, but the long term adverse event profile is still unclear. Reliable evidence to clarify whether or not traditional suburethral slings may be better or worse than other surgical or conservative management options is lacking.

Preoperative voiding detrusor pressures do not predict stress incontinence surgery outcomes

Introduction and hypothesis

The aim of this study was to determine whether preoperative voiding detrusor pressures were associated with postoperative outcomes after stress incontinence surgery.

Methods

Opening detrusor pressure, detrusor pressure at maximum flow (p_det Q_max), and closing detrusor pressure were assessed from 280 valid preoperative urodynamic studies in subjects without advanced prolapse from a multicenter randomized trial comparing Burch and autologous fascia sling procedures. These pressures were compared between subjects with and without overall success, stress-specific success, postoperative detrusor overactivity, and postoperative urge incontinence using independent sample t tests.

Results

There were no clinically or statistically significant differences in mean preoperative voiding detrusor pressures in any comparison of postoperative outcomes.

Conclusions

We found no evidence that preoperative voiding detrusor pressures predict outcomes in women with stress predominant urinary incontinence undergoing Burch or autologous fascial sling procedures.

Uroflow measurements in healthy female volunteers

OBJECTIVE

: There is not currently a standard definition of "normal" for uroflowmetry parameters, particularly with respect to spontaneous voids or multiple repeated measurements within an individual. Our study aimed to describe uroflow parameters for "normal" in a group of healthy women based on repeated measurements.

METHODS

: Spontaneous voids of twelve healthy women were recorded over two weeks. Additionally, one prompted void per subject was recorded. Prompted voids were compared to the subjects' spontaneous voids. These voids were also compared to those of patients evaluated for urinary incontinence. Groups were compared using paired t tests.

RESULTS

: The mean voided volume was 306 ml and the mean maximum flow rate was 49 ml/s. The prompted voids were lower in volume, maximum flow, and duration than spontaneous voids. When corrected for volume, these differences were not significant. Maximum flow rates in patients evaluated for urinary incontinence were lower than those of volunteers.

CONCLUSIONS

: Uroflowmetry parameters vary widely between and within healthy volunteers. Prompted voids are representative of spontaneous voids. Maximum flow rates of patients evaluated for urinary incontinence were lower than those of volunteers. In a group of healthy volunteers voiding in a private, spontaneous setting, a maximum flow rate of lower than 17 ml/s (2 SDs below the mean) might be considered abnormally low.

Edward McGuire's influence in the field of stress urinary incontinence and bladder storage symptoms

AIMS

Dr. Edward McGuire's academic career spans four decades. His impact in our field of female urology and urodynamics is reflected by the many residents and fellows he has trained that are now academic leaders in our subspecialty. For this festschrift, my goals are to: (1) review the history of the surgical approaches to alleviate stress urinary incontinence (SUI) (2) discuss recent research in SUI and bladder storage symptoms and the influence of Dr. McGuire in these areas and (3) propose a paradigm shift in the understanding of the function of the bladder urothelium from providing barrier function to providing afferent input that affects bladder storage function.

METHODS

A literature review of the publications related to SUI and bladder storage symptoms was performed. Using Thompson Reuters ISI Web of Knowledge, the two most cited papers by Dr. McGuire are discussed.

RESULTS

Dr. McGuire's two most cited publications are related to valsalva leak point pressure (VLPP) and the utility of the American Urologic Association Symptom Index (AUASI). These two instruments, one objective and one subjective, address two canonical areas in our subspecialty: 1. role of urethral function in continence and 2. pathophysiology of lower urinary tract symptoms. These two areas continue today to be fertile areas for research and creativity. Recent investigations have proposed that bladder urothelium may play a role in bladder afferent function; thus mediating bladder storage.

CONCLUSIONS

Dr. McGuire helped establish the scientific foundation for our subspecialty. His influence remains pertinent today as it ever has.

Open retropubic colposuspension for urinary incontinence in women

BACKGROUND

Urinary incontinence is a common and potentially debilitating problem. Open retropubic colposuspension is a surgical treatment which involves lifting the tissues near the bladder neck and proximal urethra in the area behind the anterior pubic bones to correct deficient urethral closure.

OBJECTIVES

To assess the effects of open retropubic colposuspension for the treatment of urinary incontinence.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Register (searched 30 June 2008) and reference lists of relevant articles. We contacted investigators to locate extra studies.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in women with symptoms or urodynamic diagnoses of stress or mixed urinary incontinence that included open retropubic colposuspension surgery in at least one trial group.

DATA COLLECTION AND ANALYSIS

Studies were evaluated for methodological quality/susceptibility to bias and appropriateness for inclusion and data extracted by two of the reviewers. Trial data were analysed by intervention. Where appropriate, a summary statistic was calculated.

MAIN RESULTS

This review included 46 trials involving a total of 4738 women.Overall cure rates were 68.9% to 88.0% for open retropubic colposuspension. Two small studies suggest lower failure rates after open retropubic colposuspension compared with conservative treatment. Similarly, one trial suggests lower failure rates after open retropubic colposuspension compared to anticholinergic treatment. Evidence from six trials showed a lower failure rate for subjective cure after open retropubic colposuspension than after anterior colporrhaphy. Such benefit was maintained over time (RR of failure 0.51; 95% CI 0.34 to 0.76 before the first year, RR 0.43; 95% CI 0.32 to 0.57 at one to five years, RR 0.49; 95% CI 0.32 to 0.75 in periods beyond 5 years). In comparison with needle suspensions there was a lower failure rate after colposuspension in the first year after surgery (RR 0.66; 95% CI 0.42 to 1.03), after the first year (RR 0.48; 95% CI 0.33 to 0.71), and beyond five years (RR 0.32; 95% CI 15 to 0.71). Evidence from twelve trials in comparison with suburethral slings found no significant difference in failure rates in all time periods assessed. Patient-reported failure rates in short, medium and long-term follow-up showed no significant difference between open and laparoscopic retropubic colposuspension, but with wide confidence intervals. In two trials failure was less common after Burch (RR 0.38 95% CI 0.18 to 0.76) than after the Marshall Marchetti Krantz procedure at one to five year follow-up. There were few data at any other follow-up time.In general, the evidence available does not show a higher morbidity or complication rate with open retropubic colposuspension, compared to the other open surgical techniques, although pelvic organ prolapse is more common than after anterior colporrhaphy and sling procedures.

AUTHORS' CONCLUSIONS

The evidence available indicates that open retropubic colposuspension is an effective treatment modality for stress urinary incontinence especially in the long term. Within the first year of treatment, the overall continence rate is approximately 85 to 90%. After five years, approximately 70% of patients can expect to be dry. Newer minimal access procedures like tension free vaginal tape look promising in comparison with open colposuspension but their long-term performance is not known and closer monitoring of its adverse event profile must be done. Laparoscopic colposuspension should allow speedier recovery but its relative safety and effectiveness is not known yet.

Design of the Value of Urodynamic Evaluation (ValUE) trial: A non-inferiority randomized trial of preoperative urodynamic investigations

BACKGROUND AND PURPOSE

Urodynamic studies (UDS) are routinely obtained prior to surgery for stress urinary incontinence (SUI) despite a lack of evidence that UDS information has an actual impact on outcome. The primary aim of this non-inferiority randomized clinical trial is to determine whether women with symptomatic, uncomplicated SUI who undergo only a basic office evaluation (BOE) prior to SUI surgery (No UDS arm) have non-inferior treatment outcomes compared to women who have BOE and UDS (UDS arm). Secondary aims are: 1) to determine how often physicians use preoperative UDS results to alter clinical and surgical decision-making, 2) to compare the amount of improvement in incontinence outcomes, and 3) to determine the incremental cost and utility of performing UDS compared with not performing UDS.

METHODS

After an initial basic office evaluation, women planning surgery for uncomplicated SUI who consent to study participation will be randomized to receive preoperative UDS or No UDS. Treatment will be planned and performed by the surgeon utilizing all the data available to them. We will compare results from the basic office evaluation (No UDS) with results from the basic office evaluation and preoperative UDS.

RESULTS

The primary outcome will be measured at 12 months using responses to the Urogenital Distress Inventory and the Patient Global Index-Improvement.

CONCLUSIONS

Randomized trials comparing the effects of different diagnostic alternatives on treatment outcomes pose study design challenges. A non-inferiority design is appropriate when comparing a less invasive and less expensive alternative with a standard of care approach.

Mixed incontinence: comparing definitions in women having stress incontinence surgery

OBJECTIVE

To develop an empirically derived definition of mixed urinary incontinence (MUI) for use in incontinence outcomes research.

METHODS

Participants in a randomized trial comparing the fascial sling and. Burch colposuspension were assessed using standardized measures including the Medical, Epidemiologic and Social Aspects of Aging (MESA), UI questionnaire, the Urogenital Distress Inventory (UDI), 3-day urinary diary and urodynamic studies (UDS). Participants were required to have stress incontinence with a MESA stress subscale score > MESA urge subscale score. Several definitions of MUI were considered. Logistic and linear regression analysis methods were used to predict clinical outcomes based on the different MUI definitions. Analyses were carried out using SAS (SAS Institute, Inc., Cary, NC, Version 9.1). Statistical significance was defined at P-value <0.05.

RESULTS

In 655 participants, the proportion of women with MUI varied from 8.3% to 93.3% depending on the MUI definition All definitions were associated with severity as measured by the frequency of incontinence episodes at baseline; however little of the variability was explained by any single definition. No strict cut-off value for these baseline measures was identified to predict clinical outcomes.

CONCLUSIONS

These MUI definitions do not adequately categorize clinically relevant UI subgroups. For research reporting, MUI subcomponents of stress and urge UI should be described separately rather than as a single dimension.