COMPARATIVE OUTCOME ANALYSIS OF LAPAROSCOPIC COLPOSUSPENSION, ABDOMINAL COLPOSUSPENSION AND VAGINAL NEEDLE SUSPENSION FOR FEMALE URINARY INCONTINENCE

Urinary incontinence in women treated by ischemic compression over the bladder area: a pilot study

OBJECTIVE

The purpose of this study was to determine if ischemic compression therapy over the bladder area results in clinically important changes among female patients with stress and mixed (stress and urge) incontinence.

METHODS

One group of patients (n = 24) received ischemic compression therapy directed over the bladder area (experimental group). The control group (n = 9) received ischemic compression therapy directed toward structures of the hip joint. Changes in urinary incontinence symptoms were monitored using a 2-part questionnaire: the urogenital distress inventory and the incontinence impact questionnaire. Patients' perceived amelioration (improvement) was quantified using a scale divided from 0% to 100%.

RESULTS

Mean scores for the first questionnaire (urogenital distress inventory + incontinence impact questionnaire, 19 questions) were 23.3 vs 25.3 at baseline and 10.2 vs 22.2 after 15 treatments for the experimental and control group, respectively. The experimental group scores were 6.9 at 30 days after the last treatment and 11.3 at the 6-month follow-up. The perceived percentages of amelioration after 15 treatments were 69% vs 32% for the experimental and control group, respectively. The experimental group scores were 73% at 30 days after the last treatment and 60% at the 6-month follow-up.

CONCLUSIONS

In this study, ischemic compression directed toward elicited trigger points over bladder area was found to be an effective treatment of patients presenting symptoms of urinary incontinence. Improvement in symptoms was still present in follow-up at 6 months.

Reconstruction of the lower urinary tract by laparoscopic and robotic surgery

PURPOSE OF REVIEW

Minimally invasive techniques are being developed at a rapid rate, although not all of these stand up to close peer-review and scrutiny. We describe the current state of laparoscopy and robotic-assisted reconstructive urological surgery on the lower urinary tract. These procedures are technically demanding and require advanced laparoscopic skills, including suturing.

RECENT FINDINGS

Techniques for urethra-vesical anastomosis following radical prostatectomy and reconstruction after radical cystectomy are discussed. In addition, minimally invasive techniques for bladder augmentation, colposuspension and ureteric reimplantation are reviewed.

SUMMARY

We indicate both the reconstructive procedures supported by sound evidence and those with little hard data backing them up.

Quality of life in women with urinary stress incontinence and evaluation of tension-free vaginal tape treatment

OBJECTIVES

Assessment of quality of life in women stress urinary incontinence (USI) and evaluation of tension-free vaginal tape (TVT) treatment.

MATERIAL AND METHODS

The research included a group of 112 women aged 33-78 years. Before as well as 3 and 6 months after the TVT operation, patients were asked to fill in quality of life questionnaires.

RESULTS

After 3 months 87.25% of the women reported full regression of USI symptoms, 7.8% an insignificant improvement, and 4.9% did not observe any change. After 6 months 85.71% reported full regression, 9.18% an insignificant improvement, and 5.1% did not observe any change. USI is responsible for a decrease in physical activity. The most uncomfortable symptom is involuntary urine leakage occurring mainly during an effort or sleep. After the TVT procedure, the majority of women confirmed a significant improvement in quality of life.

CONCLUSIONS

The TVT procedure is an effective method of treating USI in women: it significantly improves quality of life, with a recovery rate of 85-87%, and a low rate of complications.

Laparoscopic Burch surgery: is there any advantage in relation to open approach?

INTRODUCTION

Surgery represents the main therapeutic modality for stress urinary incontinence. In incontinent patients with urethral hypermobility, the retropubic colposuspension by Burch technique is one of the surgeries that present better long-term results. Current trends towards performing minimally invasive techniques led proposing the Burch surgery through videolaparoscopy. The laparoscopic technique's long-term efficacy is a highly controversial issue. However, even if late results turn out to be satisfactory, the assumed advantages of laparoscopy (faster recovery, less pain, early return to daily activities, etc.) must be evident, in order to justify the use of this minimally invasive surgical access.

MATERIALS AND METHODS

We reviewed our records and analyzed the medical charts of 26 female patients who underwent Burch surgery by open approach and 36 female patients by laparoscopic approach, between May 1999 and February 2001. The satisfaction level, surgical complication rates, surgery length, hospital stay and return to daily activities were analyzed.

RESULTS

Mean age was 42 years, ranging from 27 to 68 years. Epidemiological data from both groups were not statistically different. Patients operated by laparoscopic route had a shorter hospital stay (p = 0.002) and a faster return to their daily activities (p < 0.001). However, there were no statistical differences in the following parameters: surgical time (p = 0.11), surgical complications (p = 0.98), patient satisfaction immediately (p = 0.77) and 90 days following surgery (p = 0.84), surgery acceptance (p = 0.85), indication of this surgery to a friend (p = 0.93) and score given to the procedure (p = 0.68).

CONCLUSIONS

Even if the efficacy of both methods is similar, we did not observe significant advantages of laparoscopic surgery over open surgery, concerning the recovery in recent post-operative period.

Laparoscopic artificial urinary sphincter in women for type III incontinence: preliminary results

PURPOSE

To evaluate the feasibility by laparoscopy of the AMS 800 (American Medical Systems, Inc., Minnetonka, Minnesota) artificial urinary sphincter in women with type III incontinence.

MATERIALS AND METHODS

Four women with genuine stress incontinence due to intrinsic sphincter deficiency were operated by laparoscopy. Primary criterion was negative Marshall test. One patient had not undergone surgery, and we performed laparoscopic promonto-fixation in the same procedure. Two of the three remaining patients had previous TVT (tension-free vaginal tape) with complications regarding the perforation and erosion of bladder mucosa and urethra. Laparoscopic explantation of TVT was performed 3 months previously. In the last case, previous urethropexy and laparoscopic promonto-fixation in association with TVT were performed 10 years and 1 year ago respectively. A modified surgical procedure was used to implant the AMS 800 through laparoscopic transperitoneal approach, with placement of the cuff around the bladder neck between the periurethral fascia and the vagina.

RESULTS

Mean age was 68.5 (50-79) years. Mean closure pressure was 24.5 (20-28) cm. Water. There was no erosion or extrusion. The only significant risk factor was previous surgery. The operative time was less than 3 hours. The hospital stay was 8 days. The mean follow-up was 6 (3-13) months. Activation was done 6 to 8 weeks after implantation. Social continence (1 pad use with moderate leakage) and improvement of quality of life was reported in one patient. In this case the balloon was changed in order to obtain more pressure in the cuff. Resolution of incontinence was achieved in 3 patients.

CONCLUSIONS

The AMS 800 can be successfully implanted by laparoscopy to treat women with genuine stress incontinence, a low urethral closure pressure and negative Marshall test indicating severe intrinsic sphincter deficiency. A long term follow-up is warranted to determine the efficacy and durability of this procedure.

Pubo-fascial versus vaginal sling operation for the treatment of stress urinary incontinence: a prospective study

AIMS

To compare the long-term results of stress urinary incontinence (SUI) treatment involving the fascial or vaginal sling operations.

MATERIAL AND METHODS

Two-hundred-thirty-two women were consecutively submitted to fascial or vaginal sling operations due to urodynamic proven SUI. The fascial group had a median age of 47.3 years with a parity of 2.2 and 1.8 surgeries/patient, while the vaginal group demonstrated a median age of 48.5 years with a median parity of 3.1 and 2.2 anterior surgeries/patient. The results were subjectively classified as cured--no further pads, greatly improved--very rare dribbling, improved--eventual dribbling necessitating one pad, no cure--with no urine loss change and worse. The number of pads/day, the presence of urgency or urge-incontinence episodes were all measured. Statistical analysis using Fisher's exact test was employed.

RESULTS

The patients were followed up for an average time of 70.3 and 44.9 months, in the fascial and vaginal sling group respectively. Subjective clinical success rate was 93.7% for the fascial sling group and 79.8% for the vaginal one, however, the stratification of the results favored the fascial sling group mostly with 74.4% (94 cases) of the cases with total urinary control and no voiding dysfunctions. Only two cases (1.6%) in this group classified themselves as worsened. On the other hand, the vaginal sling subset revealed cure with total clinical satisfaction and no urinary complaint in 61.5% (62 females) (P > 0.05). Thirteen cases (12.5%) reported recurrence of the urine loss under stress and these constituted the failure group. The average number of pads diminished from 3.3 (+/- 0.8) to 0.2 (+/- 0.2) and from 3.2 (+/- 0.7) to 0.6 (+/- 0.5) after the surgery, for the fascial and vaginal sling operations respectively. Return to daily activities occurred after 9.3 days (+/- 1.2, max: 33, min: 2) for the fascial slings and 5.3 days (+/- 0.2, max: 17, min: 2) in the vaginal group. Surgical complications were compared between the groups. Time to urethral voiding varied according to expertise, demonstrating a diminishing tendency after the initial 20 cases. Female obstruction was observed in 11.1% of the fascial slings and 8.6% after vaginal approach, but none in the vaginal group required urethrolysis. Looking individually, the FS group migrated to the worse results while the VWS group started to lose the efficiency after 6 months.

CONCLUSIONS

Sling operations are a safe and efficacious option to treat SUI, however, the results can vary according to the technique employed. Shorter efficacy and fewer complications are observed in vaginal wall sling operations, while durable results, but with a higher rate of voiding dysfunctions compromising the long-term clinical satisfaction may be observed after excessive urethral suspensions, as in fascial sling suspension.

Compliance with recommendations of the urodynamic society for standards of efficacy for evaluation of treatment outcomes in urinary incontinence

The Urodynamic Society (US) published (1997) minimal standards to assess the efficacy of therapy for urinary incontinence (UI). The standards were developed by a US committee and were approved by the American Urological Society. The objective of our study was to evaluate compliance with these standards in recent UI research studies. A MEDLINE search was conducted for all articles in which outcomes of treatment for UI were reported (November, 1997-October, 1999). Reported data were compared with the recommended minimum standards including pre- and posttreatment data. Compliance rates for each data field were calculated by percentages for (1) the individual article and (2) overall compliance rate among all articles. A total of 39 articles that reported treatment for UI were selected. The treatments included various surgical procedures, injectables, pharmacologic treatments, and mechanical valves. Overall compliance for each article varied between 0% and 100%. Only one article met all 100% of the recommendations and one met none. The overall mean compliance rate for each article was 29%. We conclude that there is far less than optimal reporting of outcomes for treatment of UI per the recommendations of the Urodynamic Society. This low compliance makes standardized evaluation of treatment outcomes of UI difficult if not impossible. We suggest that initiation of funded cooperative clinical trials may improve the standardization in UI.

Retropubic surgery for stress urinary incontinence

More than 150 surgical techniques have been proposed in the literature for treating stress urinary incontinence. Many of the original published approaches were vaginal, but through the years the literature has expanded to include needle suspension, pubovaginal slings, and retropubic procedures. In this chapter, we focus on retropubic approaches for the treatment of SUI and discuss the physiology, indications, technical details and the complications of these procedures.

Is diminished pubocervical fascia collagen content a risk factor for failure of surgical management of genuine stress urinary incontinence in women?

OBJECTIVE

The assessment of relationship between pubocervical collagen content and clinical results of surgical treatment of genuine stress urinary incontinence (GSUI) in women.

METHODS

Twenty-four women treated for genuine stress urinary incontinence were included into the study. All women underwent the same surgical procedure. The samples of pubocervical fascia were taken at the time of surgery. The contents of acid soluble, pepsin soluble, insoluble fraction of collagen, total collagen and collagen crosslinks were measured. The study of pubocervical fascia collagen metabolism included also estimation of collagenase activity. At follow-up done 5 years following surgery, 20 patients reported symptoms of GSUI (study group). Four women were still without symptoms of urine leakage (control group).

RESULTS

The biochemical parameters of pubocervical fascia did not show, statistically significant differences between compared groups.

CONCLUSION

The pubocervical fascia collagen metabolism does not have impact on the results of anti-incontinence surgery.

Laparoscopic versus open Burch retropubic urethropexy: comparison of morbidity and costs when performed with concurrent vaginal prolapse repairs

OBJECTIVE

The purpose of this study was to determine the morbidity and cost that are associated with laparoscopic and open Burch retropubic urethropexy when they are performed with concurrent vaginal prolapse repairs.

STUDY DESIGN

We conducted a retrospective study of all patients who had undergone laparoscopic (n = 76) or open (n = 143) Burch retropubic urethropexy with at least 1 concurrent vaginal repair for symptomatic prolapse. We compared demographic data, level of prolapse, operative and postoperative details, medical and surgical histories, complications, and hospital charges.

RESULTS

The group with open retropubic urethropexy had an older age, greater degree of prolapse, fewer concurrent hysterectomies, and a greater number of vaginal procedures than the group with laparoscopic retropubic urethropexy. There were minimal differences in complications and no differences in the estimated blood loss, operative time, hemoglobin change, hospitalization, or hospital charges between the 2 groups.

CONCLUSION

Traditional benefits of laparoscopic retropubic urethropexy were not apparent when vaginal prolapse repairs were performed.

Laparoscopic management of female urinary incontinence

Recent technologic developments in laparoscopic reconstructive surgery have generated an interest in the laparoscopic approach to bladder neck suspension. There have been numerous descriptions of a variety of techniques for the laparoscopic approach to bladder neck suspension. Initial reports seemed to suggest satisfactory rates of improvement in the stress urinary incontinence of these patients. Long-term follow-up has shown that although this minimally invasive approach to the management of stress urinary incontinence is associated with a short duration of urinary diversion, minimal postoperative discomfort, and a quick return to a productive life, the durability of the cure has failed the test of time. The laparoscopic bladder neck suspension in 3 and 4 years follow-up has achieved a success rate of only 30%, with a mean time to failure of 18 months. Any new surgical technique applied to the management of stress urinary incontinence must have a minimum of 2 years mean follow-up to determine its true clinical efficacy and durability.

Pubovaginal sling: 4-YEAR outcome analysis and quality of life assessment

PURPOSE

Stress urinary incontinence is a common disease with a devastating impact on patient quality of life. Needle suspension procedures, which produce disappointing long-term results for type II stress incontinence, are being replaced by pubovaginal slings which previously were reserved solely for the treatment of type III stress incontinence. We report the long-term outcomes of pubovaginal slings for the treatment of types II and III stress urinary incontinence, and assess its quality of life impact.

MATERIALS AND METHODS

From January 1993 until December 1996, 247 females 10 to 84 years old (mean age 54.5) with type II (54%) or III (46%) stress urinary incontinence diagnosed by fluoroscopic urodynamics received a pubovaginal sling. Concomitant urge incontinence was present in 109 patients (44%). Quality of life was assessed with the Urogenital Distress Inventory short form.

RESULTS

At a mean followup of 51 months (range 22 to 68) the continence rates were 88% overall, 91% for type II and 84% for type III. Preoperative urge incontinence resolved in 81 of 109 patients (74%), while de novo urge incontinence developed in 10 (7%). Intermittent urethral catheterization duration averaged 8.4 days, with 5 women undergoing urethrolysis for a hypersuspended urethra. Secondary procedures were required in 9 patients with type II and 5 with type III incontinence, and included transurethral collagen injections in 6 and repeat pubovaginal slings in 8. There was a 4% complication rate due to pelvic hematoma in 2 cases, incisional hernia in 2, deep venous thrombosis in 1 and pulmonary embolus in 1. Of the 247 patients 235 (95%) completed the quality of life questionnaire with 92% reporting a high degree of satisfaction with low (less than 20 of 100 points) symptom distress scores.

CONCLUSIONS

Pubovaginal slings are effective and durable, and significantly improve quality of life in patients with types II and III stress urinary incontinence.

Laparoscopic bladder neck suspension fails the test of time

PURPOSE

Initial reports on laparoscopic bladder neck suspension have suggested success rates similar to those of traditional bladder neck suspension. We compare long-term success rates of laparoscopic and transvaginal Raz bladder neck suspension.

MATERIALS AND METHODS

A total of 100 patients with anatomical stress urinary incontinence underwent extraperitoneal laparoscopic bladder neck suspension with securing of the endopelvic fascia to Cooper's ligament (58, laparoscopy group) or transvaginal Raz bladder neck suspension (42, transvaginal group). Patients were evaluated by chart review and telephone questionnaire to determine whether they had urinary incontinence.

RESULTS

The 2 groups were similar in terms of age, mean body mass index, preoperative bladder capacity and post-void residual. Mean followup was 45 months (range 14 to 71) in 50 laparoscopy group (86%) and 59 months (range 35 to 72) in 29 transvaginal group (70%) patients. Only 15 of 50 laparoscopy group (30%) and 10 of 29 transvaginal group (35%) patients were completely continent at followup. There was no statistically significant difference in the success rates for the 2 groups. Mean time to failure for both groups was 18 to 24 months.

CONCLUSIONS

With long-term followup laparoscopic bladder neck suspension demonstrated poor success rates similar to other minimally invasive surgical therapies for stress urinary incontinence. Any new surgical technique for treatment of stress urinary incontinence should have a mean followup of more than 2 years to determine true clinical efficacy.

The surgical management of recurrent stress urinary incontinence

Recurrent stress urinary incontinence is a distressing problem. Its causes are multifactorial and the literature continually provides suggestions for changes to the surgical approach. Over 200 surgical procedures exist for the treatment of stress urinary incontinence, and this leaves the practising surgeon with an overwhelming range of choice. This article will review current available techniques for the surgical treatment of recurrent stress urinary incontinence.