Role of bladder neck mobility and urethral closure pressure in predicting outcome of tension-free vaginal tape (TVT) procedure

Which parameters, related to the female urethra and pelvic floor, determine therapy selection for recurrent female stress urinary incontinence: ICI-RS 2023?

INTRODUCTION

The evidence basis for therapy selection in women who have failed primary stress urinary incontinence (SUI) surgery is limited. The ICI-RS group discussed the available data at its meeting in June 2023, particularly the anatomical characteristics as assessed using magnetic resonance imaging (MRI) and ultrasound (US) modalities, functional characteristics associated with storage and voiding urodynamic assessment, as well as the patient characteristics that might influence outcomes. This paper summarizes the evidence base that supported these discussions and offers the basis for research proposals for future groups.

METHODS

A literature search of MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials was performed, and the data is presented. Research questions are based on the knowledge gaps highlighted.

RESULTS

Possible MRI parameters that may influence outcomes were striated urethral sphincter volume, bladder and proximal urethral funneling, pubo-urethral ligament integrity, distance of the bladder neck below the pubococcygeal line, posterior urethra-vesical angle, and bladder neck to levator ani distance. US parameters included sling distance to the urethral lumen and pubis, sling position, bladder neck mobility, and lateral arm asymmetry, twisting, or curling. Urodynamic parameters included detrusor overactivity, Valsalva leak point pressure, maximum urethral closure pressure, and bladder outlet obstruction. Important patient parameters included body mass index, age, and previous interventions.

CONCLUSIONS

Identifying and quantifying causative factors in patients with recurrent SUI, that allow clinicians to modify subsequent treatment choices and techniques may help reduce treatment failure and complications. Formulating algorithms is the next step in optimizing patient counseling, surgical selection, and healthcare allocation.

Role of puboperinealis and rectourethralis muscles as a urethral support system to maintain urinary continence after robot-assisted radical prostatectomy

The present study investigated the role of a urethral support system to maintain urinary continence after robot-assisted radical prostatectomy (RARP), with a focus on pelvic floor muscles, such as the puboperinealis muscle (PPM) and rectourethralis muscle (RUM). Finally, 323 patients who underwent RARP were analyzed in this study. All patients performed a one-hour pad test 1, 3, 6, 9, and 12 months after RARP to assess urinary incontinence and MRI before and 9 months after RARP to evaluate the pelvic anatomical structure. The preoperative cross-sectional area of PPM (2.21 ± 0.69 cm2) was significantly reduced by 19% after RARP (1.79 ± 0.60 cm2; p < 0.01). Positive correlations were observed between the amount of urinary leakage according to the 1-h pad test 1, 3, 6, 9, and 12 months after RARP and the change in the cross-sectional area of PPM by RARP (p < 0.01, < 0.001, < 0.001, < 0.001, and < 0.001, respectively). A positive correlation was also noted between the amount of urinary leakage 6 and 12 months after RARP and the preoperative RUM diameter (p < 0.05). The amount of urinary leakage 1, 3, 6, 9, and 12 months after RARP negatively correlated with the change in the antero-posterior diameter of the membranous urethra (MU diameter) from the static to dynamic phases during the Valsalva maneuver by cine MRI. Furthermore, the change in the MU diameter negatively correlated with the change in the cross-sectional area of PPM (p < 0.05). PPM and RUM play significant roles as a supportive mechanism to maintain urinary continence by functioning as a urethral support.

Readjustable Sling in Women With Stress Urinary Incontinence and Hypomobile Urethra: Understanding the Mechanisms of Closure by Transperineal Ultrasound

OBJECTIVES

To assess the postsurgical sonographic parameters of a readjustable sling (RAS) according to urinary incontinence (UI) symptoms after surgery and compare this RAS sonographic pattern with mid-urethral slings (MUS).

METHODS

Observational, prospective multicenter study, including women undergoing stress urinary incontinence (SUI) surgery with RAS (Remeex®). The primary outcome was the association between UI symptoms and sonographic parameters measured by two-dimensional transperineal and high-frequency endovaginal ultrasound. We measured static parameters (bladder neck funneling, RAS position, symmetry, distance to the urethral lumen), and the movement of the sling on Valsalva. UI symptoms were measured with the postsurgical Incontinence Questionnaire-Short Form (ICIQ-UI-SF) questionnaire. We created two control groups including patients with transobturator-MUS (TOT-MUS) and retropubic-MUS (RT-MUS) to compare postsurgical sonographic parameters of RAS with MUS.

RESULTS

Among the 55 women with RAS included, the postoperative ICIQ-UI-SF scores were significantly higher in patients with bladder neck funneling (15.0 (3.9) vs 10.6 (6.7); P = .020) and in those with discordant movement of RAS on Valsalva (14.6 (5.7) vs 10.3 (6.7); P = .045). Compared with the 109 women with TOT-MUS and the 55 with RT-MUS, RAS was more often located in the proximal urethra and farther from the urethral lumen.

CONCLUSIONS

Postsurgical pelvic floor ultrasound demonstrated that in women with complex SUI and hypomobile urethra who underwent RAS (Remeex®) surgery, the presence of bladder neck funneling and discordant movement on Valsalva correlate with the persistence of UI symptoms. In these women, RAS is more often located in the proximal urethra and farther from the urethral lumen at rest in comparison with MUS.

Midterm postoperative results of mid-urethral slings. Role of ultrasound in explaining surgical failures

INTRODUCTION

Surgical treatment for stress urinary incontinence (SUI) with mid-urethral sling (MUS) is considered to have a high success rate. However, between 5% and 20% of MUS fail, with inadequate surgical implantation being a possible cause of SUI persistence or recurrence. Misplacement of a MUS can be determined by pelvic floor ultrasound (PF-US). The aim of this study was to investigate the role of PF-US in patients with persistent or recurrent urinary incontinence (UI) symptoms after MUS surgery for SUI with a midterm follow-up.

MATERIALS AND METHODS

A historical cohort study including women undergoing MUS surgery for SUI between 2013 and 2015 was designed. The primary outcome was to correlate the sonographic parameters of MUS with SUI cure (negative International Continence Society-Uniform Cough Stress Test, Incontinence Questionnaire-Short Form < 5 points and no symptoms of SUI), at 5 years postsurgery. Secondary outcomes were changes of maximum urethral closure pressure (MUCP) and symptoms of urgency urinary incontinence (UUI) at 1 and 5 years after surgery.

RESULTS

Eighty-seven patients (80 transobturator-MUS, 7 retropubic-MUS) were included. At 5 years all patients referred improvement of UI and objective cure of SUI was demonstrated in 81.2%. The MUS was sonographically correct in 67 (98.5%) of the 68 patients with cure of SUI. The MUS was considered incorrectly placed in only 4 (28.6%) of the 14 patients with noncured SUI. MUCP decreased from 61.9 to 48.8 cmH₂ O at 5 years of follow-up (p < 0.01) and up to 53% of women had UUI symptoms after surgery, with a nonsignificant decrease compared to baseline.

CONCLUSION

Patients cured of SUI had sonographically correct MUS by PF-US. Less than one-third of cases of SUI persistence or recurrence after MUS surgery could be explained by a sonographically incorrect sling. Low urethral resistance and/or UUI symptoms could help to explain the remaining failures. Complete functional and anatomic studies, including urodynamics and PF-US, should be performed before deciding on the next management strategy in patients with SUI persistence or recurrence after MUS.

Management and Follow-Up Practices of Women With Recurrent Stress Urinary Incontinence Following Transobturator Mid-urethral Synthetic Sling Procedure: A 6-Year Retrospective Monocentric University-Based Study

Purpose: The purpose of this study is to evaluate the efficacy of management and follow-up practices in repeat retropubic mid-urethral synthetic sling (MUS) procedure after transobturator tape/tension-free vaginal tape-obturator (TOT/TVT-O) failure, and to clarify the possible etiology of recurrent stress urinary incontinence.

Methods: The charts of all women patients who underwent tension-free vaginal tape (TVT) slings after previous failed transobturator MUS procedures between February 2012 and November 2018 at a single center were reviewed retrospectively. The transperineal ultrasound was performed to assess the pre-operative or post-operative urethral mobility and location of the slings. Furthermore, some essential evaluations were also made, mainly including medical history, physical examination, 1 h pad test, and urodynamic study. Finally, primary outcomes were evaluated according to the above items at 3, 6, and 12 months after the second operation, respectively.

Results: Thirty-five patients were included in the primary transobturator MUS sling procedure. At the 6 months follow-up, 32 (91.42%) patients were socially continent and negative in 1 h pad test. The transperineal ultrasound measurement results revealed that the bladder neck descent (BND) values were significantly decreased after the repeat sling operation, and better urinary continence function was observed according to the post-operative urodynamic study. Multifactorial etiologies resulted in recurrent stress urinary incontinence (SUI), including poor surgical technique, inadequate sling tension when treating ISD, and inappropriate sling position. Then the detail of the surgical procedure varied with the results of pre-operative evaluations, affecting the validity of the second sling.

Conclusion: Recurrent SUI has resulted from multi factors, pre-operative urodynamic study and transperineal ultrasound might be valuable tools to guide repeat sling operation and predict post-operative outcomes. A repeat TVT procedure may be regarded as a remedial measure for a failed transobturator MUS operation.

Ultrasound evaluation of anterior transvaginal mesh for pelvic organ prolapse: correlation to 5-year clinical outcomes

Introduction and hypothesis

Vaginal prolapse mesh may effectively restore vaginal anatomy. The aim of this study was to investigate how the in vivo mesh position correlates to clinical outcomes.

Methods

Seventy-one women operated on using Uphold mesh for apical pelvic organ prolapse (POP-Q, C ≥ stage II) were examined 5 years after surgery by introital-perineal 2D ultrasound in a midsagittal plane at rest and Valsalva. The horizontal line and pubis symphysis were considered the reference for all measures. Ultrasound measures were statistically compared to clinical outcomes: POP-Q, Pelvic Floor Distress Inventory (PFDI-20) and subscales [Pelvic Organ Distress Inventory (PODI-6), and Urinary Distress Inventory (UDI-6)] and the VAS scale for pain.

Results

Original mesh length was preserved by 86% and correlated to improved pain as estimated by VAS scale (r 0.321). Valsalva was associated with a lowering of the superior and inferior mesh margins by 7.3 and 6.1 mm, respectively (p < 0.001) but a reduction of total mesh length by only 1 mm (30.2 ± 5.2 to 29.2 ± 4.7 mm, p < 0.001). Mobility of the anterior vaginal wall (bladder neck and midurethra) at Valsalva was parallel to downward movement of the mesh inferior margin (r 0.346 and 0.314) but inversely correlated to total UDI-6 (r − 0.254 and − 0.263). Mobility of the midurethra was inversely correlated to bladder emptying (PFDI-20 Question 19, r − 0.245).

Conclusions

Five years after surgery, preserved original length of the mesh with apical support was correlated to improved anatomical and patient-reported outcomes. Mesh support to the vaginal apex was associated with improved bladder emptying and total urinary distress outcomes but not stress urinary incontinence.

Modelling of Soft Connective Tissues to Investigate Female Pelvic Floor Dysfunctions

After menopause, decreased levels of estrogen and progesterone remodel the collagen of the soft tissues thereby reducing their stiffness. Stress urinary incontinence is associated with involuntary urine leakage due to pathological movement of the pelvic organs resulting from lax suspension system, fasciae, and ligaments. This study compares the changes in the orientation and position of the female pelvic organs due to weakened fasciae, ligaments, and their combined laxity. A mixture theory weighted by respective volume fraction of elastin-collagen fibre compound (5%), adipose tissue (85%), and smooth muscle (5%) is adopted to characterize the mechanical behaviour of the fascia. The load carrying response (other than the functional response to the pelvic organs) of each fascia component, pelvic organs, muscles, and ligaments are assumed to be isotropic, hyperelastic, and incompressible. Finite element simulations are conducted during Valsalva manoeuvre with weakened tissues modelled by reduced tissue stiffness. A significant dislocation of the urethrovesical junction is observed due to weakness of the fascia (13.89 mm) compared to the ligaments (5.47 mm). The dynamics of the pelvic floor observed in this study during Valsalva manoeuvre is associated with urethral-bladder hypermobility, greater levator plate angulation, and positive Q-tip test which are observed in incontinent females.

Role of intrinsic sphincter deficiency with and without urethral hypomobility on the outcome of tape insertion

AIMS

Intrinsic sphincter deficiency (ISD) is a known risk factor for therapy failure after tension-free vaginal tape (TVT) insertion. The purpose of this study was to investigate if the severity of ISD alone or other factors such as urethral mobility and tape localization influence outcomes.

METHODS

One hundred and nine women with urodynamically determined ISD, a TVT insertion, and a 6-month follow-up visit were included. Urethral length, mobility, and tape localization were evaluated by pelvic floor sonography. Patients were classified into three urethral mobility groups (hypomobile, normomobile, hypermobile). Surgical outcome was assessed by a combination of objective and subjective criteria.

RESULTS

Therapeutic success rate after TVT insertion was 81.6%. The severity of ISD did not associate with therapy failure. But urethral mobility (P < 0.0001), relative tape position (P = 0.0003), and tape-urethra distance (P < 0.0001) differed between cured and not cured patient groups. Patients with a relative tape position toward 1/2 of urethral length had a higher cure rate. Significantly different cure rates (P = 0.0003) were found for hypomobile (67%), normomobile (76%), and hypermobile (100%) urethras. For ISD patients with a hypomobile urethra, highest cure rates were obtained for tape-urethra distances between 2.5 and 3.5 mm.

CONCLUSIONS

The reduced cure rate for ISD patients was due to the subgroup with a hypomobile urethra. A prospective study is needed to confirm that slightly shorter tape-urethra distances and a relative tape position more toward the mid-urethra will lead to better outcomes for this patient group.

Ultrasound imaging in urogynecology - state of the art 2016

The role of ultrasound imaging in urogynecology is not clearly defined. Despite significant developments in visualization techniques and interpretation of images, pelvic ultrasound is still more a tool for research than for clinical practice. Structures of the lower genitourinary tract and pelvic floor can be visualized from different approaches: transperineal, introital, transvaginal, abdominal or endoanal. According to contemporary guidelines and recommendations, the role of ultrasound in urogynecology is limited to the measurement of post-void residue. However, in many instances, including planning and audit of surgical procedures, management of recurrences or complications, ultrasound may be proposed as the initial examination of choice. Ultrasound may be used for assessment of bladder neck mobility before anti-incontinence procedures. On rare occasions it is helpful in recognition of pathologies mimicking vaginal prolapse such as vaginal cyst, urethral diverticula or rectal intussusception. In patients subjected to suburethral slings, causes of surgery failure or postsurgical voiding dysfunctions can be revealed by imaging. Many reports link the location of a tape close to the bladder neck to unfavorable outcomes of sling surgery. Some postoperative complications, such as urinary retention, mesh malposition, hematoma, or urinary tract injury, can be diagnosed by ultrasound. On the other hand, the clinical value of some applications of ultrasound in urogynecology, for example measurement of the bladder wall thickness as a marker of detrusor overactivity, has not been proved.

Outcome of TVT operations in women with low maximum urethral closure pressure

AIMS

(i) To establish whether low maximal urethral closure pressure (MUCP) is associated with a poorer prognosis after TVT-surgery, and if so to establish an MUCP cut-off value for poor outcome. (ii) To characterize the population with a low MUCP.

METHODS

Retrospective analysis of data from 6,646 women with stress/mixed urinary incontinence included in the Norwegian Female Incontinence Registry. Postoperative subjective (degree of satisfaction), objective (leakage on stress test) and composite cure according to preoperative MUCP were analyzed in unadjusted and adjusted analysis. Preoperative variables were compared between women having a low or normal MUCP. Non-parametric tests were used on continuous variables and χ² tests on categorical variables. Logistic regression was used for the adjusted analysis. Level of significance: P < 0.05.

RESULTS

An analysis of centiles of preoperative MUCP showed that a cut-off at 20 cm H₂ O did best identify women at risk of not being cured. In unadjusted analysis MUCP ≤20 cm H₂ O (n = 422) was associated with objective (OR: 2.48), subjective (OR: 1.60), and composite failure (OR: 1.95) compared to MUCP >20 cm H₂ O. In adjusted analysis MUCP ≤20 cm H₂ O was associated with neither objective, subjective, nor composite failure. Women with MUCP <20 cm H₂ O were preoperatively significantly older, had larger leakage on stress and 24 h pad test, lower mean voided volume and maximum flow rate and higher stress and urge indices.

CONCLUSIONS

Women with MUCP ≤20 cm H₂ O have similar objective, subjective, and composite outcomes after TVT-surgery compared to women with MUCP >20 cm H₂ O after adjusting for preoperative variables. Neurourol. Urodynam. 36:1320-1324, 2017. © 2016 Wiley Periodicals, Inc.

Ultrasound Evaluation of Midurethral Sling Position and Correlation to Physical Examination and Patient Symptoms

OBJECTIVE

The primary objective was to evaluate the position and angle variation between 3 different midurethral slings (MUSs) using 3-dimensional ultrasound (US) technology. The secondary objective was to compare differences in findings on physical examination and symptoms of incontinence and sexual dysfunction between subjects.

METHODS

This was a cross-sectional study of 61 subjects who had undergone MUS placement without concomitant anterior or apical compartment prolapse surgery (21 retropubic [RP], 19 out-to-in transobturator [TOT], 21 in-to-out transobturator [TVT-O]). Subjects completed validated questionnaires (Sandvik Incontinence Severity Index, Urogenital Distress Inventory 6) and underwent a pelvic examination and standardized 2-dimensional and 3-dimensional ultrasonography evaluation.

RESULTS

On translabial US, the median RP sling angle was 108.2 degrees (72.6-135.9), significantly more acute than the angle of TOT and TVT-O slings (119.3 degrees [72.3-140.4, P = 0.02] and 118.5 degrees [99.0-154.7, P = 0.004]). There was no difference in the sling angles between the TOT and TVT-O slings (P = 0.86). No difference was noted in the position of the sling along the urethra (P = 0.82). The TOT sling was more often palpable (57.8%, P = 0.02) compared with the RP or TVT-O groups.Fifteen patients (4 RP, 5 TOT, 6 TVT-O) reported discomfort during intercourse that they attributed to the MUS. Three of 19 TOT subjects reported that their partner experienced pain with intercourse because of the sling. However, sexual function and urinary symptoms were not statistically different between the 3 groups.

CONCLUSIONS

On 3-dimensional US, RP sling angle was found to be significantly more acute than the angles of the TOT and TVT-O slings, and there was no difference between the 2 transobturator slings. The TOT sling was more often palpable on examination, but this finding did not correlate with increased pain on palpation.

The impact of tension-free vaginal tape on the urethral closure function: mechanism of action

AIM

To investigate if the tension-free vaginal tape (TVT) works by increasing the abdominal to urethral pressure impact ratio (APIR).

METHODS

Twenty one women with urodynamically proven stress urinary incontinence (SUI) were assessed by ICIQ-SF, pad-weighing test, incontinence diary and Urethral Pressure Reflectometry (UPR) before and after TVT. UPR was conducted during resting and increased intra-abdominal pressure (P(Abd)) by straining. Related values of P(Abd) and urethral opening pressure (P(o)) were plotted into an abdomino-urethral pressuregram. Linear regression of the values was conducted, and the slope of the line was found. The slope expresses the ratio of pressure increase in the urethra compared to the pressure increase in the abdomen and was called APIR.

RESULTS

The urethral opening pressure at rest (P(o-rest)) was unchanged after TVT, while APIR increased in all women (from 0.7 to 1.4, P < 0.0001).

CONCLUSIONS

The TVT seems to strengthen the urethral closure function by increasing the APIR while P(o-rest) is unchanged regardless of the type of pre-operative dysfunction. This confirms the theory of TVT's mechanism of action being mid-urethral support.

Functional and morphological differences following Monarc and TVT-O procedures

OBJECTIVE

To explore function of the lower urinary tract and morphology of tape and urethra following Monarc or TVT-O suburethral tape placement for urodynamic stress incontinence (USI).

METHODS

We recruited prospectively women undergoing either Monarc or TVT-O placement for USI. Before and 3 months after the procedure, participants were evaluated by a question-directed interview, the measures of Sandvik Incontinence Severity Index (SISI), Incontinence Bother Scale (IBS), Ingelman-Sundberg Score (ISS) and short forms of Urogenital Distress Inventory (UDI-6) and Incontinence Impact Questionnaire (IIQ-7), physical examination, a cough stress test and 4D ultrasound investigation. The primary outcome was participants' responses to clinical assessments and the secondary outcome was ultrasound findings.

RESULTS

A total of 67 women with Monarc procedures and 60 women with TVT-O procedures completed the survey both preoperatively and 3 months postoperatively. There were significant improvements in scores of SISI, IBS, ISS, UDI-6 and IIQ-7 after both Monarc and TVT-O procedures. At the 3-month follow-up, both procedures had similar success rates, SISI scores, IBS scores, ISS scores, UDI-6 scores and IIQ-7 scores, and similar incidences of postoperative voiding difficulty and overactive bladder symptoms. After Bonferroni correction, all ultrasound parameters representing tape location, tape tension and urethral mobility were similar between the two procedures.

CONCLUSIONS

At short-term follow-up, Monarc and TVT-O procedures are comparable in both functional outcome of the lower urinary tract and morphology on ultrasound as assessed by parameters representing tape location, tape tension and urethral mobility.

Correlation of tape location and tension with surgical outcome after transobturator suburethral tape procedures

OBJECTIVE

To explore, using 4D ultrasound, the importance of location and tension of transobturator sub- urethral tape (TOT) with respect to surgical outcome.

METHODS

Enrolled into the study were 56 women who had undergone TOT placement in the treatment of urodynamic stress incontinence. Tape location and tension were assessed by 4D ultrasound with the women at rest, during straining and during coughing. Ultrasound parameters representing tape location included the sagittal tape-symphysis pubis distance (sTSD), sagittal tape-symphysis pubis angle (sTSA) and tape percentile (an indication of tape position along the urethra with respect to urethral length), while those representing tape tension included urethral encroachment, sagittal tape-urethra distances at the upper end (sTUDu), center (sTUDc) and lower end (sTUDl) of the tape and axial urethral central echolucent area at the tape center (aUCEAc).

RESULTS

In women in whom the tape procedure had been successful, during increased intra-abdominal pressure sTSA and the incidence of urethral encroachment increased, while sTUDu, sTUDc, sTUDl and aUCEAc decreased. Compared with those reporting no stress urinary incontinence (SUI) symptoms, women who reported SUI postoperatively had lower tape percentile. Women with SUI postoperatively demonstrated no manifestation on ultrasound of urethral encroachment at rest or during increased intra-abdominal pressure. Women with postoperative overactive bladder (OAB) symptoms had shorter resting sTSD and larger resting sTSA than did women without OAB symptoms. Women reporting postoperative de novo or worsening voiding difficulty had larger resting sTSA and higher incidence of urethral encroachment at rest than did women without this difficulty.

CONCLUSIONS

Both tape location and tape tension are associated with surgical outcome of TOT procedures. Assessment of tape location and tension can be achieved using 4D ultrasound.

Do urodynamic parameters predict persistent postoperative stress incontinence after midurethral sling? A systematic review

INTRODUCTION AND HYPOTHESIS

It is unclear whether preoperative urodynamic study (UDS) values are predictive of outcomes after midurethral sling.

MATERIALS AND METHODS

We systematically reviewed multiple databases from January 1989 to October 2011 for English-language studies correlating UDS data with postoperative outcomes after midurethral slings. We performed random effects model meta-analyses, as indicated. Relative risk (RR) ratios for the outcome of stress urinary incontinence (SUI) cure were calculated using high maximum urethral closure pressure (MUCP) and Valsalva leak point pressure (VLPP) values as the reference group.

RESULTS

High preoperative MUCP was associated with cure after retropubic [RR 0.67; 95% confidence interval (CI) 0.47-0.97)] and transobturator slings (RR 0.65; 95% CI 0.49-0.90). High preoperative VLPP was also associated with cure after retropubic sling (RR 0.89; 95% CI 0.82-0.96), but this relationship did not achieve statistical significance for cure after transobturator sling (RR 0.86; 95% CI 0.74-1.00).

CONCLUSIONS

Preoperative MUCP and VLPP values may add insight into postoperative outcomes after surgical treatment for SUI.

Can we place tension-free vaginal tape where it should be? The one-third rule

OBJECTIVES

The tension-free vaginal tape (TVT) insertion technique generally does not take into account individual urethral length. In this study we investigated whether preoperative sonographic measurement of individual urethral length allows for reliable TVT positioning under the midurethra, which is a critical segment for the continence mechanism.

METHODS

Urethral length was measured by preoperative introital ultrasonography in 102 consecutive female patients with stress urinary incontinence. TVT procedures were performed as recommended by the manufacturer. The suburethral incisions were initiated at one-third of the sonographically measured urethral length. TVT position and tape-urethra distance were followed up 6 months postoperatively.

RESULTS

At 6-month examination of the 102 study participants, 93.1% were cured and 6.9% showed improved continence. TVTs were found in the target range of 50-70% of the urethral length in 88.2% of the cohort. Women with the TVT in the 50-70% urethral length range and a 3-5-mm tape-longitudinal smooth muscle distance had a greater likelihood of being cured without complications (P < 0.001).

CONCLUSIONS

Preoperative sonographic measurement of urethral length, combined with the one-third rule, may aid in reliable midurethral TVT positioning.

Reliability of a new method for assessing urethral compression following midurethral tape procedures using four-dimensional ultrasound

OBJECTIVES

To evaluate the intra- and interobserver reliability of a new method of assessing resting and dynamic urethral compression after midurethral tape procedures using three- and four-dimensional (3D and 4D) ultrasound.

METHODS

Thirty-one women who had undergone transobturator midurethral tape procedures at Cathay General Hospital were enrolled in the study and 4D ultrasound was performed pre- and postoperatively. Preoperative ultrasound assessment included measurement of the urethral central echolucent area (UCEA) in the axial plane. Postoperative ultrasound assessment included measurement of the tape-urethral distance (TUD) in the sagittal plane as well as UCEA and tape angle in the axial plane (ATA). The TUD was measured at the upper end (TUDu), central point (TUDc) and lower end (TUDl) of the tape. All pre- and postoperative ultrasound assessments were performed in women at rest, on maximum straining and during strong coughing. 4D ultrasound volume datasets were stored digitally and analyzed offline by two independent investigators blinded to clinical data and to each others' measurements. Intra- and interobserver reliability were evaluated using the intraclass correlation coefficient (ICC).

RESULTS

There were significant reductions in TUDc, TUDl and UCEA during increased intra-abdominal pressure. ICC values for the measurement of TUD at rest, on straining and during coughing demonstrated very good reliability. ICC values for the pre- and postoperative measurement of UCEA at rest, on straining and during coughing demonstrated good to very good reliability. ICC values for the measurement of ATA at rest, on straining and during coughing demonstrated fair to good reliability.

CONCLUSIONS

4D ultrasound can be used to obtain measurements with good reliability in the assessment of urethral compression.

An adjustable sling in the management of recurrent urodynamic stress incontinence after previous failed midurethral tape

OBJECTIVE

The aim of this prospective study was to evaluate the feasibility and outcome of an adjustable sling system AMI in patients with recurrent urinary stress incontinence after failed suburethral sling insertion.

PATIENTS AND METHODS

Twenty-five patients with recurrent urinary stress incontinence treated with an adjustable sling system AMI were analyzed for feasibility and outcome. Patients' incontinence bother was quantified using the Visual Analogue Scale (VAS) from 0 to 10. Multichannel urodynamics and pad tests were pre- and postoperatively performed. Time of adjustment, time of the surgical intervention, and clinical outcome were also recorded.

RESULTS

Twenty-five patients were treated with the adjustable sling system AMI. Median time of adjustment was 3 days (range 1-8) and a median follow up time of 12 months. Twenty-one out of 25 patients were continent, four patients suffered from persisting incontinence. One patient was put on clean intermittent self-catheterization (CISC). Detrusor pressure at maximum flow rate (pdet/Qmax) increased significantly as did the maximum urethral closure pressure (MUCP). Patient satisfaction improved significantly.

CONCLUSION

Adjustable slings in women with stress urinary incontinence might be indicated in difficult situations after surgical failure. As we present a selective group of patients these findings may not apply to other patients with recurrent stress incontinence.

Tape functionality: position, change in shape, and outcome after TVT procedure--mid-term results

INTRODUCTION AND HYPOTHESIS

This study evaluates the relevance of the tape position and change in shape (tape functionality) under in vivo conditions for mid-term outcome.

METHODS

Changes in the sonographic tension-free vaginal tape (TVT) position relative to the percentage urethral length and the tape-urethra distance were determined after 6 and 48 months in 41 women with stress urinary incontinence.

RESULTS

At 48 months, 76% (31/41) of women were cured, 17% (7/41) were improved, and 7% (3/41) were failures. Disturbed bladder voiding was present in 12% (5/41), de novo urge incontinence in 7% (3/41). The median TVT position was at 63% of urethral length. Median tape-urethra distance was 2.7 mm, ranging from 2.9 mm in continent patients without complications to 1.1 mm in those with obstructive complications. Patients with postoperative urine loss had a median distance of 3.9 mm. The tape was stretched at rest and C-shaped during straining in 15 of 41 women (37%) at 48 months (all continent). Patients with this tape functionality at 6 months were also cured at 48 months in 86% of cases (19/22), and only 14% (3/22) showed recurrent incontinence.

CONCLUSIONS

Mid-term data suggest an optimal outcome if the tape is positioned at least 2 mm from the urethra at the junction of the middle and distal thirds. Patients with optimal tape functionality at 6 months are likely to show mid-term therapeutic success.

Bladder neck evaluation by perineal ultrasound before and after reconstructive surgery for pelvic organ prolapse

PURPOSE

To study the correlation between stress urinary incontinence (SUI) and the mobility and funneling of the bladder neck (BN) by observation of pre- and postoperative course by perineal ultrasound (PUS).

METHODS

We investigated 123 cases that underwent reconstructive surgery for pelvic organ prolapse (POP). We prospectively checked bladder neck mobility (BNM) during the Valsalva maneuver and funneling of the BN at rest by PUS. We defined the width multiplied by the depth of the funnel-like profile of the BN as the funneling index (FI). We checked BNM, FI, and the presence of SUI just before the operation, and we checked the postoperative course of BNM and SUI.

RESULTS

When BNM was ≥10 mm before surgery, the odds ratio for accompanying SUI was 2.68 relative to BNM <10 mm (p = 0.031). When FI was ≥150 before surgery, the odds ratio for accompanying SUI was 4.12 relative to FI <150 (p = 0.004). Although postoperative BNM values were significantly improved immediately after surgery, they gradually increased within 2 years. Among the cases with preoperative SUI, the recurrence rate was significantly higher in the patients whose FI was <150 (p = 0.019).

CONCLUSIONS

Our results yielded by PUS suggested that larger BNM and FI values were the causative factors of SUI. PUS may be beneficial for selecting a suitable surgical procedure for POP, and it may also be helpful for assessing surgical efficacy.

[Role of ultrasound in the evaluation of patients after laparoscopic sacropexy: preliminary study]

OBJECTIVES

To evaluate results of laparoscopic sacropexy with introital and vaginal ultrasonography, that is to observe dynamic behavior of the mesh, to measure precisely its position and to conclude on the feasibility of this exam.

PATIENTS AND METHODS

The surgery was a laparoscopic subtotal hysterectomy and a suspension of the cervix with an anterior vesicovaginal mesh and a posterior rectovaginal mesh. These meshes are joined together and fixed on the sacrum. Ultrasound was performed in fifteen patients to see in the sagital plane the position of the mesh. The distance anterior mesh-bladder neck and the distance posterior mesh-anal sphincter were measured at rest, during straining and during retaining. The spreading out and the dynamic behavior of the mesh were studied.

RESULTS

The distance anterior mesh-bladder neck is 12 mm at rest, 15 mm during straining and 13 mm during retaining. The distance posterior mesh-anal sphincter is 30 mm at rest, 26 mm during straining and 31 mm during retaining. The mesh is always seen as spread out, or folded, but never strained. Video recording shows that sacropexy does not block pelvic dynamics.

DISCUSSION AND CONCLUSION

Ultrasound imaging appears in this study as a simple and efficient exam to study and measure prosthesis. It could be a good help for clinical examination to explain failure or complication of surgery.

Monarc transobturator sling system for the treatment of female urinary stress incontinence: results of a post-operative transvaginal ultrasonography

The aim of the study was to determine Monarc (American Medical Systems) sling position after surgical treatment of stress urinary incontinence (SUI) through the transobturator approach. A total of 54 consecutive women with SUI were evaluated post-operatively with transvaginal ultrasound. A concomitant hysterectomy was performed in ten cases and a concomitant prolapse surgery in six cases. Ultrasound measurements include urethral length, the distance between the upper edge of the sling and the bladder neck (BN-S) and the BN-S/U ratio. The mean distance between the transobturator tape and the bladder neck was found to be 12.6 +/- 3.2 mm in the group of patients who underwent the transobturator procedure alone, 13 +/- 3.1 mm in the transobturator plus hysterectomy group and 12 +/- 2.8 mm in the transobturator plus prolapse group. The superior tape margin was at the mid-urethra in 81.5% of patients and always at a distance greater than 7 mm from the bladder neck. Eight patients did not have satisfactory results after the surgery. Only in one out of these eight patients was the transobturator sling not found to be at the mid-urethra. The superior tape margin of the Monarc sling remained at the level of mid-urethra in the majority of cases. It was never located too proximally beneath the bladder neck.