Incontinence and voiding difficulties associated with prolapse

Outcomes of bladder outlet obstruction following extensive vaginal pelvic reconstruction surgery on patient with advanced pelvic organ prolapse

OBJECTIVE

To evaluate the impact of extensive vaginal pelvic reconstruction surgery (PRS) on advanced pelvic organ prolapse (POP) patients with bladder outlet obstruction (BOO).

METHODS

We conducted a single-center, retrospective analysis of women who received extensive vaginal pelvic reconstruction surgery for advanced POP (POP-Q ≥3) with BOO from January 2006 to January 2016. Data regarding preoperative evaluation, surgical procedure, and postoperative management were abstracted from medical records. Patients were considered to have BOO when detrusor pressure at maximum flow (Dmax) was ≥20 cm H2O and peak flow rate (Qmax) was ≤15 mL/s. Patients with postoperative value of Dmax lower than 20 cm H2O or Qmax higher than 15 mL/s were regarded as objectively cured.

RESULTS

A total of 1894 patients with POP stages III or IV were assessed. The incidence of BOO was 22.8% (431/1894) within this patient population of advanced POP. One year after the vaginal PRS, the objective cure rate of BOO was 98.1%. Urodynamic parameters showed a significant increase in Qmax (P < 0.001), while Dmax (P < 0.001) and postvoid residual urine (PVR) (P < 0.001) were significantly decreased. Previous POP surgery, native tissue repair (NTR), PVR ≥200 mL, and maximal cystometric capacity (MCC) ≥500 mL increase the likelihood of persistent BOO in patients.

CONCLUSION

Vaginal PRS demonstrated effectiveness in treating BOO in patients with advanced POP. Irrespective of the types of transvaginal mesh (TVM), using TVM achieved better outcome than did NTR. Previous POP surgery, preoperative PVR ≥200 mL, and MCC ≥500 mL were the risk factors predicting the failure of PRS in improving BOO.

Bidirectional Relationships between Sarcopenia and Pelvic Floor Disorders

Sarcopenia and pelvic floor disorders (PFDs) are prevalent and often cooccurring conditions in the aging population. However, their bidirectional relationship and underlying mechanisms remain underexplored. This narrative review aims to elucidate this relationship by exploring potential causative interplays, shared pathophysiological mechanisms, and common risk factors. A comprehensive literature search was conducted to identify relevant studies focusing on epidemiological associations, interaction mechanisms, and implications for patient care. While epidemiological studies demonstrate associations between sarcopenia and PFDs, our findings reveal a cyclical relationship where sarcopenia may exacerbate PFDs through mechanisms such as decreased muscle strength and mobility. Conversely, the presence of PFDs often leads to reduced physical activity due to discomfort and mobility issues, which in turn exacerbate the muscle atrophy associated with sarcopenia. Additionally, shared risk factors such as physical inactivity, nutritional deficiencies, metabolic syndrome, and menopausal hormonal changes likely contribute to the onset and progression of both conditions. These interactions underscore the importance of concurrently integrated care approaches that address both conditions. Effective management requires comprehensive screening, the recognition of contributing factors, and tailored exercise regimens supported by a multidisciplinary approach. Future research should focus on longitudinal studies tracking disease progression and evaluating the efficacy of multidisciplinary care models in optimizing patient outcomes.

How Old Is Too Old? Outcomes of Prolapse Native-Tissue Repair through Uterosacral Suspension in Octogenarians

INTRODUCTION

Medical advancements are expected to lead to a substantial increase in the population of women aged 80 and older by 2050. Consequently, a significant number of individuals undergoing corrective prolapse surgery will fall into the elderly-patient category. The research indicates a notable rise in complications associated with prolapse surgery in patients older than 80, irrespective of frailty and other risk factors. Despite these challenges, the vaginal approach has been identified as the safest surgical method for pelvic organ prolapse (POP) repair in the elderly population. For this reason, we aimed to investigate the efficacy, complication rate, and functional outcomes associated with vaginal hysterectomy and an apical suspension/high uterosacral ligaments suspension as a primary technique for prolapse repair, both within a cohort of elderly patients.

METHODS

We retrospectively analyzed patients who underwent transvaginal hysterectomy plus an apical suspension procedure for stage ≥ II and symptomatic genital prolapse between January 2006 and December 2013. Anatomical and functional outcomes were evaluated. The Patient Global Impression of Improvement (PGI-I) score was used to evaluate subjective satisfaction after surgery.

RESULTS

Sixty-five patients were included in the analysis. The median age was 81.3 years. All individuals exhibited an anterior compartment prolapse stage II or higher, and the majority also a central prolapse stage II or higher. Notably, all participants reported symptoms of vaginal bulging. Over half of the population (58.6%) complained of incomplete bladder emptying. The intervention for all participants involved a vaginal hysterectomy with an apical suspension. Sixty-three patients (96.9%) and forty-four patients (67.6%) underwent a simultaneous anterior or posterior repair, respectively. Long-term complications (>30 days from surgery) were observed during follow-up, with a median duration of 23 ± 20 months. Seven (10.7%) anatomical recurrences were recorded, five (7.69%) concerning the anterior compartment, one (1.5%) the central, and three (4.6%) the posterior. Nevertheless, none of them necessitated further surgical intervention due to symptoms. Significant anatomical improvements for the anterior, central, and posterior compartments were noticed, compared to preoperative assessment (p < 0.001 for Aa and Ba, p < 0.001 for Ap and Bp, and p < 0.001 for C). PGI-I values established that 100% of patients were satisfied (PGI-I ≥ 2), with a median score of 1.12. Consequently, objective and subjective cure rates were 89.5% and 100%, respectively.

CONCLUSION

Vaginal hysterectomy combined with apical suspension, particularly high uterosacral ligaments suspension, is a safe and effective primary surgical approach, even in elderly patients.

Analysis of the anatomical and biomechanical characteristics of the pelvic floor in cystocele

INTRODUCTION

Stress urinary incontinence (SUI) occurs due to disruption of the pelvic floor anatomy; however, the complexity of the pelvic floor support structures and individual patient differences make it difficult to identify the weak points in the pelvic floor support that cause SUI to occur, develop, and recur. This study aimed to analyze the pelvic floor anatomy, structural features, and biomechanics of cystoceles to develop more effective treatment plans with individualized and precise healthcare.

MATERIAL AND METHODS

In this observational case-controlled study (clinical trial identifier BOJI201855L), 102 women with normal pelvic floor function and 273 patients diagnosed with cystocele degrees I-III were identified at Shanghai General Hospital from October 2016 to December 2019. We combined ultrasound and vaginal tactile imaging (VTI) to assess the anatomy and biomechanical functions of the anterior and posterior vaginal walls. Both examinations included relaxation and muscle tension tests.

RESULTS

Of the 42 VTI parameters, 13 were associated with the degree of cystocele, six with an increase in the urethral rotation angle (pointing to the mobility of the urethra), and six with a decrease in the retrovesical angle (pointing to hypsokinesis and decrease in bladder position). According to these data, the strength of tissues, especially the muscles in both the anterior and posterior compartments, contributes to the stability of the pelvic floor structure. The strength of the levator ani muscle (LAM) is important for the degree of cystocele, mobility of the urethra, hypsokinesis, and decrease in bladder position.

CONCLUSIONS

In general, the biomechanical status of the pelvic floor in patients with cystocele is complex and involves various muscles, ligaments, tendons, and fascia. Of these, repair and exercise of the LAM have not received much attention in the treatment of patients with cystoceles, which may be an important risk factor for the high recurrence rate.

Investigation of predictive factors for the presence of voiding dysfunction after transvaginal mesh surgery-Can the flow curve shape on uroflowmetry be a predictor?

PURPOSE

This study established the prognostic significance of the uroflowmetry flow curve shape in the presence of voiding dysfunction following transvaginal mesh surgery.

METHODS

This is a retrospective study of 439 symptomatic cystocele patients who underwent anterior wall repair with transvaginal mesh surgery. Uroflowmetry and postvoid residual were used to evaluate voiding function both preoperatively and 12 months postoperatively. The patients were divided into two groups: those with and without postoperative voiding dysfunction, and the predictors of postoperative voiding dysfunction were analyzed. The shape of the urine flow curve was analyzed for its influence on the presence of postoperative voiding dysfunction.

RESULTS

Thirty-five participants were in the voiding dysfunction group, while 404 were in the nonvoiding dysfunction group. Multivariate analysis was conducted by adding an interrupted-shaped curve to age, Qmax, and postvoid residual, which showed significant differences in univariate analysis, found that age 68 years or older (odds ratio [OR]: 7.68, 95%CI 1.02-58, p = 0.048), postvoid residual ≥110 mL (OR: 2.8, 95%CI 1.25-6.29, p = 0.013) and interrupted-shaped curve (OR: 2.47, 95%CI 1.07-5.69, p = 0.034) were discovered to be independent risk factors for the presence of voiding dysfunction after transvaginal mesh surgery.

CONCLUSIONS

Following transvaginal mesh surgery for cystocele, three variables were found to be predictive of voiding dysfunction: the old age, excessive postvoid residual, and an interrupted-shaped flow curve. The uroflowmetry flow curve shape has the potential to be a new predictor of postoperative voiding dysfunction.

Permanent Compared With Absorbable Suture in Apical Prolapse Surgery: A Systematic Review and Meta-analysis

OBJECTIVE

To explore how permanent compared with absorbable suture affects anatomic success in native tissue vaginal suspension (uterosacral ligament suspension and sacrospinous ligament suspension) and sacrocolpopexy with mesh.

DATA SOURCES

MEDLINE, EMBASE, and ClinicalTrials.gov were searched through March 29, 2022.

METHODS OF STUDY SELECTION

Our population included women undergoing apical prolapse surgery (uterosacral ligament suspension and sacrospinous ligament suspension and abdominal sacrocolpopexy). Our intervention was permanent suture for apical prolapse surgery, and our comparator was absorbable suture. We determined a single anatomic success proportion per study. Adverse events collected included suture and mesh exposure, surgery for suture and mesh complication, dyspareunia, and granulation tissue. Abstracts were doubly screened, full-text articles were doubly screened, and accepted articles were doubly extracted. Quality of studies was assessed using GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria. In single-arm studies using either permanent or absorbable suture, random effects meta-analyses of pooled proportions were used to assess anatomic success. In comparative studies investigating both suture types, random effects meta-analyses of pooled risk ratios were used.

TABULATION, INTEGRATION, AND RESULTS

Of 4,658 abstracts screened, 398 full-text articles were assessed and 63 studies were included (24 vaginal suspension [13 uterosacral ligament suspension and 11 sacrospinous ligament suspension] and 39 sacrocolpopexy). At 2-year follow-up, there was no difference in permanent compared with absorbable suture in uterosacral ligament suspension and sacrospinous ligament suspension (proportional anatomic success rate 88% [95% CI 0.81-0.93] vs 88% [95% CI 0.82-0.92]). Similarly, at 18-month follow-up, there was no difference in permanent compared with absorbable suture in sacrocolpopexy (proportional anatomic success rate 92% [95% CI 0.88-0.95] vs 96% [95% CI 0.92-0.99]). On meta-analysis, there was no difference in relative risk (RR) of success for permanent compared with absorbable suture for uterosacral ligament suspension and sacrospinous ligament suspension (RR 1.11, 95% CI 0.93-1.33) or sacrocolpopexy (RR 1.00, 95% CI0.98-1.03).

CONCLUSION

Success rates were similarly high for absorbable and permanent suture after uterosacral ligament suspension, sacrospinous ligament suspension, and sacrocolpopexy, with medium-term follow-up.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021265848.

Novel insight into the correlation between hernia orifice of cystocele and lower urinary tract function: a pilot study

BACKGROUND

It has been hypothesized that women with significant pelvic organ prolapse (POP), particularly of the anterior vaginal wall, may have voiding dysfunction (VD). Although the VD mechanism due to cystocele is not fully understood, different vaginal compartments have rarely been closely examined. This study attempted to further elucidate the correlation between POP and VD through a new subgroup classification using cystoscopy.

METHODS

This study reviewed clinical records of 49 women who underwent cystocele repair. All patients were scheduled for laparoscopic sacrocolpopexy, preoperatively underwent uroflowmetry and postvoid residual urine volume (PVR) measurement, and completed pelvic floor function questionnaires. Bladder examination by cystoscopy was additionally performed using the lithotomy position with the Valsalva maneuver.

RESULTS

Subjects were divided into four groups according to hernia orifice presence determined by cystoscopy, which included the trigone type, posterior wall type, trigone and urethra type, and trigone and posterior wall type. The posterior wall type had statistically higher PVR values versus the trigone and posterior wall type (P = 0.013). The posterior wall type had statistically lower values for average urine flow rate versus the urethra and trigone type (P = 0.020). There were no significant differences noted in the pelvic floor function questionnaires among the four groups.

CONCLUSIONS

A new bladder defect classification based upon hernia orifice location was associated with lower urinary tract function. Posterior wall hernia presence caused significant voiding function deterioration. This new subgroup classification, which can more clearly identify and indicate bladder function, is also comparable among patients.

Association between overactive bladder and pelvic organ mobility as evaluated by dynamic magnetic resonance imaging

Overactive bladder (OAB) is a prevalent condition, which negatively impacts patients’ quality of life. Pelvic organ prolapse (POP), also prevalent in women, has been recognized as an important etiology of female OAB, although the pathophysiological mechanisms remain controversial. In this study, we reviewed findings of dynamic magnetic resonance imaging (dMRI) in 118 patients with POP and investigated the association between dMRI findings, including positions and mobilities of pelvic organs as well as parameters of pelvic organ support and bladder outlet obstruction (urethral kinking), and OAB in order to elucidate the pathophysiology of OAB in patients with POP. Our results showed that compared with non-OAB patients, OAB patients had a significantly higher body mass index, more severe pelvic floor muscle impairment, and more profound supportive defects in the uterine cervix (apical compartment). On the other hand, dMRI parameters showed hardly any significant difference between patients with mild and moderate to severe OAB. These findings may imply that levator ani impairment and defective supports of the apical compartment could be associated with the presence of OAB and that the severity of OAB could be affected by factors other than those related to pelvic organ mobility and support or urethral kinking.

Conservative Management of Pelvic Organ Prolapse: Indian Contribution

Pelvic organ prolapse (POP) is a very common condition which can greatly impact a woman's quality of life. Treatment options are individualized and typically involve a combination of physiotherapy, pessary insertion and surgical treatments. It is well known that nulliparous prolapse in India constitutes 1.5-2% of genital prolapse, while the incidence is even higher (5-8%) for young women who have delivered one or two children, thus making it one of the highest rates in the world. This has necessitated the development of numerous conservative surgical treatment options for POP, which allows women to retain their sexual and reproductive function and therefore allows for subsequent pregnancies. With the controversy surrounding the use of mesh, a variety of surgical treatment options should be considered. Such alternative treatments include the use of surgical sling procedures, which have been used widely in Indian practice for the treatment of POP for over 60 years. This review outlines some of the well-established conservative treatment options for POP. It also highlights the unique contribution of Indian Obstetricians in the development of these conservative surgical treatment options, from prominent Indian Gynecologists including Dr VN Shirodkar, Dr BN Purandare, VN Purandare, RP Soonawala, Brigadier SD Khanna and Dr RM Nadkarni.

Symptoms of voiding dysfunction and other coexisting pelvic floor dysfunctions: the impact of transvaginal, mesh-augmented sacrospinous ligament fixation

INTRODUCTION AND HYPOTHESIS

The objective was to investigate the prevalence for voiding dysfunction and if symptom improvement can be achieved by adequate pelvic floor surgery.

METHODS

We evaluated the Propel Study data from 281 women with pelvic organ prolapse (POP) stage 2-4. Bother caused by obstructive micturition, voiding dysfunction, and coexisting pelvic floor symptoms were assessed using the Pelvic Floor Distress Inventory (PFDI) preoperatively and 6, 12, and 24 months after vaginal prolapse repair. Successful reconstruction (Pelvic Organ Prolapse Quantification [POP-Q] stage 0-I throughout the 2-year follow-up at all compartments, "responders"), was compared with all others ("non-responders").

RESULTS

Prevalence of voiding dysfunction was significantly reduced after surgery for all patients with "moderate" to "quite a bit" of bother ("R2") regarding all examined PFDI questions. Defects of the posterior/apical compartment and lower stage defects were found to cause obstructive micturition, which improved significantly after POP surgery. Six months after surgery, the prevalence of R2 for voiding dysfunction symptoms was reduced significantly for responders compared with non-responders. Significant reduction of R2 in patients with rectoceles could be shown for some PFDI questions, whereas the rate was lower in patients with cystoceles. Other pelvic floor symptoms often coexisted in patients with voiding dysfunction symptoms and improved significantly after surgery as well.

CONCLUSIONS

Symptoms of voiding dysfunction are frequent in female patients with POP and can significantly improve after vaginal mesh-augmented prolapse repair even for posterior and minor defects. Before counseling patients to undergo POP surgery because of their obstructive symptoms, other causes of voiding dysfunction must first have been ruled out.

Changes in urethral mobility and configuration after prolapse repair

OBJECTIVE

To evaluate changes in urethral mobility and configuration after prolapse repair.

METHODS

This was a retrospective study of 92 patients who were examined between 2005 and 2016 before and after surgery for pelvic organ prolapse (POP) without concomitant anti-incontinence surgery. All patients were assessed with an interview, POP quantification and translabial four-dimensional ultrasound. Urethral mobility was evaluated using semi-automated urethral motion profile software in which x- and y-coordinates of six equidistant points along the length of the urethra were determined both at rest and on Valsalva, relative to the posteroinferior margin of the pubic symphysis. Urethral kinking was measured by placing tangents distal and proximal to any visually identified change in the urethral axis. Imaging data obtained before and after prolapse surgery were compared.

RESULTS

Mean age was 58 years and mean follow-up was 5.8 months. Prolapse symptoms had resolved in 85% of patients. Highly significant reductions in urethral mobility and urethral kinking were seen after surgery (all P ≤ 0.001). Similar changes were observed after anterior vaginal repair with or without apical repair, without concomitant posterior repair (n = 23; all P < 0.05).

CONCLUSIONS

POP surgery was associated significantly with 'straightening' of the urethra and reduction in urethral mobility. The effect seems to be due largely to cystocele repair. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Management of Urinary Incontinence before and after Total Pelvic Reconstruction for Advanced Pelvic Organ Prolapse with and without Incontinence

Background:

The effectiveness of an anti-incontinence procedure concomitant with prolapse reconstruction for pelvic organ prolapse (POP) in preventing urinary incontinence (UI) after surgery remains controversial. Our study aimed to describe the incidence of pre- and postoperative UI for pelvic reconstructive surgery and evaluate the management of POP associated with UI.

Methods:

A total of 329 patients who underwent total pelvic reconstruction between June 2009 and February 2015 at a single institution were identified. These patients were divided into two groups (Group A [Prolift reconstruction]: n = 190 and Group B [modified total pelvic reconstruction]: n = 139). Data regarding surgical procedures and patient demographic variables were recorded. Chi-square and Student's t-tests were used for two independent samples.

Results:

A total of 115 patients presented with UI preoperatively. The average follow-up time was 46.5 months, with 20 patients lost to follow-up (6.1%). The cure rates of stress UI (SUI), urgency UI (UUI), and mixed UI (MUI) were 51% (30/59), 80% (16/20), and 48% (14/29), respectively. The cure rate of UUI after total pelvic reconstruction (80% [16/20]) was higher than that of SUI (50.8% [30/59], χ²= 5.219, P = 0.03), and the cure rate of MUI (48%, 14/29) was the lowest. The cure rate of patients with UI symptoms postoperatively was lower than that of those with symptoms preoperatively (9.1% [28/309] vs. 16.2% [50/309], χ²= 7.101, P = 0.01). There was no difference in the incidence of UI postoperatively between Groups A and B (P > 0.05). The cure rate of SUI in patients undergoing tension-free vaginal tape-obturator was not higher than that in those who did not undergo the procedure (42.9% [6/14] vs. 53.3% [24/45], χ²= 0.469, P = 0.49). There were no differences in the cure rate for POP or UI between these two types of reconstructions (P > 0.05).

Conclusions:

No correlation between the incidence of UI and POP was identified. The results suggest that UI treatment should be performed after POP surgery for patients with both conditions.

Does videourodynamic classification depend on patient positioning in patients with stress urinary incontinence?

INTRODUCTION AND AIMS

Videocystometrogram (VCMG) is used to assess patients with SUI. A common classification system of SUI is the Blaivas and Olsson classification. The position this grading is performed in has never been established.

MATERIALS AND METHODS

One hundred twenty-one women complaining of SUI refractory to conservative measures had video-urodynamic assessment prior to operative intervention. Grading of stored video SUI image traces was assessed as per Blaivas and Olsson criteria by two independent investigators whilst women were both lying and standing with bladder at maximum cystometric capacity.

RESULTS

Seventy-two (56.7%) patients' grading remained the same in both lying and standing positions. 49(40.5%) patients' grading altered on standing. twenty had non-demonstrable incontinence converted to demonstrable incontinence and 29 had demonstrable incontinence on lying that changed grading on standing; 22 of these by one grade and seven by two grades (from I to IIb). A Fisher's exact test demonstrated a statistically significant difference in the distribution of SUI grading between supine and standing positions (P < 0.01).

CONCLUSION

40.5% of women have a changed Blaivas and Olsson grade of SUI when assessed standing as opposed to lying. This has implications for surgical treatment options and patient counselling. While the Blaivas and Olsson grading system for SUI is simple and reproducible there is little standardisation as to which position this grading is to be performed. We recommend that an international consensus is agreed upon in order for results to be comparable and to help with future outcome studies.

The urethral closure mechanism is deteriorated after anterior colporrhaphy

INTRODUCTION AND HYPOTHESIS

Urethral pressure reflectometry (UPR) has proven highly reproducible in women with pelvic organ prolapse. We hypothesized that urethral parameters would decrease after anterior colporrhaphy.

METHODS

A prospective, observational study where women with anterior vaginal wall prolapse ≥stage II were assessed before and after anterior colporrhaphy. Assessments consisted of prolapse staging according to the Pelvic Organ Prolapse Quantification system, UPR measurements at rest, during squeezing and straining (at a standardized abdominal pressure of 50 cmH₂O, P_{O-Abd 50}), standardized stress tests with 300 ml saline, and answering the International Consultation on Incontinence - Urinary incontinence short form. Stress urinary incontinence (SUI) was defined as a positive stress test and a questionnaire with symptoms of SUI and a bother score > 1. Sample size was 30, power was 100% and the level of significance was 5%. We analyzed data with paired t-tests or non-parametric Wilcoxon signed rank tests; p-values <0.05 were considered statistically significant.

RESULTS

Twenty-eight women who underwent anterior colporrhaphy completed the study. P_{O-Abd 50} decreased 12 cmH₂O after surgery (p < 0.0001). Five women developed postoperative SUI and one had persistent SUI; the six women's preoperative P_{O-Abd 50} was lower than the rest (p < 0.01). If preoperative P_{O-Abd 50} was ≤65 cmH₂O, the positive predictive value for postoperative SUI was 50%, and if P_{O-Abd 50} was ≥85 cmH₂O, the negative predictive value was 100%.

CONCLUSIONS

The urethral closure mechanism deteriorates after anterior colporrhaphy. Using UPR, we can calculate a woman's risk of SUI after anterior colporrhaphy.

Treatment of urethral obstruction secondary to caudal bladder displacement, trigonal invagination, and urethral kinking in a dog

CASE DESCRIPTION A 15-year-old spayed female mixed-breed dog was evaluated for a 7-week history of stranguria, pollakiuria, and intermittent urethral obstruction. CLINICAL FINDINGS On initial evaluation, the patient had persistent stranguria with lack of urine production; after multiple unsuccessful attempts to urinate, a large volume of urine was produced. Prior to voiding the large volume, the urinary bladder was not palpable during examination. Abdominal ultrasonography confirmed caudal displacement of the urinary bladder, and the urethra and trigone could not be located ultrasonographically. Positive-contrast cystourethrography and CT confirmed caudal displacement of the urinary bladder and also revealed trigonal invagination and urethral kinking; dysuria was attributed to these findings. TREATMENT AND OUTCOME Surgical repositioning of the lower urinary tract was performed. The urinary bladder was moved cranially and was fixed in place along the left lateral aspect of the body wall by cystopexy. After surgery, positive-contrast cystourethrography revealed a more cranial positioning of the urinary bladder and straightening of the urethra with no urethral kinking or trigonal invagination. Immediately after surgery, stranguria had resolved and the patient was able to void normally. Two years after surgery, the dog was reported to be urinating normally. CLINICAL RELEVANCE Surgical correction of caudal urinary bladder displacement with cystopexy led to resolution of trigonal invagination, urethral kinking, and urethral obstruction in the dog of the present report. Trigonal invagination and urethral kinking, although uncommon findings, should be considered as possible causes of dysuria in dogs.

Posterior colporrhaphy does not affect the urethral closure mechanism

INTRODUCTION AND HYPOTHESIS

Studies have suggested that a posterior vaginal wall prolapse might compress the urethra and mask stress urinary incontinence (SUI), much like an anterior vaginal wall prolapse. A recent study with urethral pressure reflectometry (UPR) has shown that the urethral closure mechanism deteriorates after anterior colporrhaphy; this could explain the occurrence of postoperative de novo SUI. We hypothesized that urethral pressure would also decrease after posterior colporrhaphy.

METHODS

This was a prospective, observational study where women with posterior vaginal wall prolapse ≥stage II were examined before and after posterior colporrhaphy. We performed prolapse staging according to the Pelvic Organ Prolapse Quantification system, UPR measurements at rest, during squeezing and straining, and standardized stress tests with 300 ml saline. The women filled out International Consultation on Incontinence-Urinary incontinence (ICIQ-UI) short forms. The sample size was 18, with a power of 99.9% and a level of significance of 5%. Parameters were compared using paired t tests or Fisher's exact test, where appropriate; p values <0.05 were considered statistically significant.

RESULTS

Eighteen women with posterior vaginal wall prolapse ≥stage II were recruited. One woman did not undergo surgery. There were no changes in urethral pressure at rest (p = 0.4), during squeezing (p = 0.2) or straining (p = 0.2), before and after surgery. The results of the stress tests and ICIQ-UI short forms were the same after surgery.

CONCLUSIONS

The urethral closure mechanism is not affected by posterior colporrhaphy. Our study does not support the theory that the posterior vaginal wall prolapse compresses the urethra and masks SUI.

Prevalence and factors associated with urinary incontinence in climacteric

OBJECTIVE

To estimate the prevalence and identify associated factors to urinary incontinence (UI) in climacteric women.

METHOD

In a cross-sectional study with a stratified random sample, 1,200 women aged between 35 and 72 years were studied, enrolled in the Family Health Strategy in the city of Pindamonhangaba, São Paulo. Urinary incontinence was investigated using the International Consultation of Incontinence Questionnaire - Short Form, while associated factors were assessed based on a self-reported questionnaire with socio-demographic, obstetric and gynecological history, morbidities and drug use. The prevalence of urinary incontinence was estimated with a 95% confidence interval (95CI) and the associated factors were identified through multiple logistic regression model performed using Stata software, version 11.0.

RESULTS

Women had a mean age of 51.9 years, most were in menopause (59.4%), married (87.5%), Catholic (48.9%), and declared themselves black or brown (47.2%). The mean age of menopause of women with UI was 47.3 years. The prevalence of UI was 20.4% (95CI: 17.8-23.1%). The factors associated with UI were urinary loss during pregnancy (p=0.000) and after delivery (p=0.000), genital prolapse (p=0.000), stress (p=0.001), depression (p=0.002), and obesity (p=0.006).

CONCLUSION

The prevalence of UI was lower but similar to that found in most similar studies. Factors associated with the genesis of UI were urinary loss during pregnancy and after delivery, genital prolapse and obesity.

Urethral pressure reflectometry in women with pelvic organ prolapse: a study of reproducibility

INTRODUCTION AND HYPOTHESIS

The mechanism of continence in women with pelvic organ prolapse (POP) before and after surgery remains unknown. Urethral pressure reflectometry (UPR) separates women with stress urinary incontinence (SUI) from continent women by measuring urethral opening pressure at an abdominal pressure of 50 cmH₂O (P _{O-Abd 50}). UPR can help identify women with POP at risk of postoperative de novo SUI. The aim of this study was to investigate the reproducibility of UPR in women with POP.

METHODS

Women with anterior or posterior vaginal wall prolapse were recruited for this prospective, observational study from our outpatient clinic. The women were examined with UPR on two occasions. Measurements were done at rest, and during squeezing and straining. Statistical analyses were performed using SAS 9.4. A Bland-Altman analysis with limits of agreement and coefficients of variation was used to determine the level of agreement between measurements. Paired t tests were used to estimate the difference; a two-tailed P value of <0.05 was considered significant.

RESULTS

We recruited 19 women with anterior vaginal wall prolapse and 11 women with posterior vaginal wall prolapse. There were no significant differences in the opening pressures at rest or during squeezing or in the values of P _{O-Abd 50}. P _{O-Abd 50} showed limits of agreement of 15.3 cmH₂O and a coefficient of variation of 9.9 %.

CONCLUSIONS

UPR was found to be a highly reproducible method in women with POP. UPR may be used in future studies to help reveal urodynamic features predictive of postoperative de novo SUI in women with POP.

The significance and factors related to bladder outlet obstruction in pelvic floor dysfunction in preoperative urodynamic studies: A retrospective cohort study

Objective

To demonstrate the significance of bladder outlet obstruction (BOO) in preoperative urodynamic studies (UDS) in women who have been diagnosed with pelvic floor dysfunction including pelvic organ prolapsed (POP) and stress urinary incontinence (SUI).

Methods

The medical records of 150 patients with pelvic floor dysfunction who underwent preoperative UDS at Yonsei University Health System from 2006 to 2012 were reviewed. Under the criteria of BOO, as a maximal flow rate in free-flow study (Q_max) less than 12 mL/sec and a detrusor pressure at Q_max in pressure-flow study (P_detQ_max) higher than 20 cmH₂O in UDS, they were divided into two groups: a group of 50 patients with BOO and a group of 100 patients without BOO. Comparisons were made between the patients with and without BOO in preoperative UDS.

Results

In the POP-with-SUI group, 25 patients with BOO had lower mean Q_max (10.0 vs. 25.4 mL/sec, P < 0.001), higher P_detQ_max (49.6 vs. 21.5 cmH₂O, P < 0.001), lower maximum cystometric capacity (422.7 vs. 454.0 mL, P = 0.007), and higher postvoidal residual volume (44.3 vs. 21.1 mL, P = 0.021) than the patients without BOO. In the SUI-only group, the mean Q_max was significantly lower in the 25 patients with BOO (9.4 vs. 25.4 mL/sec, P < 0.001). The mean P_detQ_max was significantly higher with BOO (39.6 vs. 25.4 cmH₂O, P = 0.004). In the univariate analyses, menopause, maximum cystometric capacity, and cystoscopic bladder trabeculation were associated with BOO.

Conclusion

In the univariate analysis, menopause, MCC and cystoscopic bladder trabeculation were associated with BOO. In the multivariate model, however, no significant association with BOO was found.

Utilizing preoperative 20-minute pad testing with vaginal gauze packing for indicating concomitant midurethral sling during cystocele repair

OBJECTIVE

To investigate the feasibility of using preoperative 20-minute pad testing with vaginal gauze packing for cystocele reduction to indicate a concomitant midurethral sling during cystocele repair.

STUDY DESIGN

Retrospective review of the records of consecutive women with pelvic organ prolapse quantification≥stage II symptomatic cystocele who visited the urogynecologic outpatient clinics and underwent cystocele repair between July 2005 and December 2010. Only patients who underwent preoperative urodynamic studies and 20-minute pad testing with vaginal gauze packing for cystocele reduction were enrolled.

RESULTS

Twenty-one patients did not demonstrate any stress urinary incontinence. For evident stress urinary incontinence (>1g pad weight before reduction), the criterion of ≥8g pad weight before reduction was chosen for concomitant midurethral sling. For patients with occult stress urinary incontinence (≤1g pad weight before reduction), the criterion of ≥8g pad weight after reduction was chosen as an indication for concomitant midurethral sling. Among 22 patients with evident stress urinary incontinence (<8g) without concomitant midurethral sling, only one patient (4.5%) received a midurethral sling during the follow-up period (median follow-up interval: 30.5 months). Among 21 patients with occult stress incontinence but <8g after reduction without concomitant midurethral sling, only one patient (4.8%) received midurethral sling during the follow-up period (median follow-up interval: 38 months).

CONCLUSIONS

A preoperative 20-minute pad test with vaginal gauze packing for cystocele reduction is a feasible and practical method to decide for a concomitant midurethral sling.

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.

Doppler ureteric jet in urogenital prolapse

INTRODUCTION AND HYPOTHESIS

This work was conducted to study the Doppler ureteric jets in the assessment of pelvic organ prolapse (POP) patients.

METHODS

Forty POP-Q stage ≧ III patients and 20 without POP were assessed with color Doppler ultrasonography.

RESULTS

Among 40 POP, 28 had bladder outlet obstruction (BOO) and 4 had hydronephrosis. Comparing POP and controls, the difference in mean frequency, mean duration, and mean maximum velocity of ureteric jets was not statistically significant. The ureteric jets of POP with BOO are of longer duration and lower velocity. The frequency of ureteric jets was lower in POP with hydronephrosis. Plateau-type waveforms were much more common among POP associated with voiding and ureteric dysfunction.

CONCLUSIONS

The longer duration and lower velocity of the ureteric jet are strongly correlated with prolapse-associated BOO. The plateau-type waveform and decrease in frequency of ureteric jets indicate possible hydronephrosis. Further investigation is needed to confirm the consistency of this study.

Procidentia-induced perinephric and subcutaneous abscesses

Total uterine prolapse, or procidentia, rarely causes obstructive uropathy. Procidentia-induced perinephric abscess has not been reported to date. We present a case of perinephric and subcutaneous abscesses secondary to procidentia-induced hydronephrosis and forniceal rupture of Staphylococcus aureus-infected urine.

Incontinence and detrusor dysfunction associated with pelvic organ prolapse: clinical value of preoperative urodynamic evaluation

INTRODUCTION AND HYPOTHESIS

We examined how preoperative urodynamic findings are related to the urinary problems following surgical repair of pelvic organ prolapse (POP).

METHODS

The clinical records of 87 women who underwent surgery for POP were reviewed retrospectively. Preoperatively, cough stress test and urodynamic testing, including pressure-flow study, were performed with prolapse reduction. Postoperative evaluation included uroflowmetry, postvoid residuals, and symptom assessment using questionnaires.

RESULTS

A cough stress test with simple filling was sufficient for diagnosis of occult stress urinary incontinence (SUI). The presence of detrusor overactivity was a good predictor of postoperative persistence of urgency and urge urinary incontinence. Postvoid residuals (PVR) largely increased immediately after surgery, but usually recovered within 1 month. Poor detrusor contractility was the best predictor of large PVR occurrence.

CONCLUSIONS

Preoperative urodynamic evaluation of SUI and detrusor function was useful for predicting postoperative urinary conditions in POP patients. Its cost-effectiveness remains to be examined.

Outcomes of vaginal hysterectomy for uterovaginal prolapse: a population-based, retrospective, cross-sectional study of patient perceptions of results including sexual activity, urinary symptoms, and provided care

Background

Vaginal hysterectomy is often used to correct uterovaginal prolapse, however, there is little information regarding outcomes after surgery in routine clinical practice. The objective of this study was to investigate complications, sexual activity, urinary symptoms, and satisfaction with health care after vaginal hysterectomy due to prolapse.

Methods

We analyzed data from the Swedish National Register for Gynecological Surgery (SNRGS) from January 1997 to August 2005. Women participating in the SNRGS were asked to complete surveys at two and six months postoperatively. Of 941 women who underwent vaginal hysterectomy for uterovaginal prolapse, 791 responded to questionnaires at two months and 682 at six months. Complications during surgery and hospital stay were investigated. The two-month questionnaire investigated complications after discharge, and patients' satisfaction with their health care. Sexual activity and urinary symptoms were reported and compared in preoperative and six-month postoperative questionnaires.

Results

Almost 60% of women reported normal activity of daily life (ADL) within one week of surgery, irrespective of their age. Severe complications occurred in 3% and were mainly intra-abdominal bleeding and vaginal vault hematomas. Six months postoperative, sexual activity had increased for 20% (p = 0.006) of women and urinary urgency was reduced for 50% (p = 0.001); however, 14% (n = 76) of women developed urinary incontinence, 76% (n = 58) of whom reported urinary stress incontinence. Patients were satisfied with the postoperative result in 93% of cases and 94% recommended the surgery.

Conclusion

Vaginal hysterectomy is a patient-evaluated efficient treatment for uterovaginal prolapse with swift recovery and a low rate of complication. Sexual activity and symptoms of urinary urgency were improved. However, 14% developed incontinence, mainly urinary stress incontinence (11%). Therefore efforts to disclose latent stress incontinence should be undertaken preoperatively.

The correlation of voiding variables between non-instrumented uroflowmetery and pressure-flow studies in women with pelvic organ prolapse

AIMS

To (1) correlate peak and maximum flow rates from non-instrumented flow (NIF) and pressure-flow studies (PFS) in women with pelvic organ prolapse (POP); (2) measure the impact of voided volume and degree of prolapse on correlations.

METHODS

We compared four groups of women with stages II-IV POP. Groups 1 and 2 were symptomatically stress continent women participating in the colpopexy and urinary reduction efforts (CARE) trial; during prolapse reduction before sacrocolpopexy, Group 1 (n = 67) did not have and Group 2 (n = 84) had urodynamic stress incontinence (USI). Group 3 (n = 74) and Group 4 participants (n = 73), recruited specifically for this study, had stress urinary incontinence (SUI) symptoms. Group 3 planned sacrocolpopexy. Group 4 planned a different treatment option. Participants completed standardized uroflowmetry and pressure voiding studies.

RESULTS

Subjects' median age was 61 years; median parity 3% and 80% had stage III or IV POP. Based on the Blaivas-Groutz nomogram, 49% of all women were obstructed. NIF and PFS peak and average flow rates had low correlations with one another (0.31, P < 0.001 and 0.35, P < 0.001, respectively). When NIF and PFS voided volumes were within 25% of each other, the peak and average flow rate correlations improved (0.52, P < 0.001 and 0.57, P < 0.001, respectively). As vaginal prolapse increased, correlations between NIF and PFS peak and average flow rates decreased.

CONCLUSION

Peak and average flow rates are highly dependent on voided volume in women with prolapse. As the prolapse stage increases, correlations between NIF and PFS variables decrease.

Abnormal spinal curvature as a risk factor for pelvic organ prolapse

To determine the relationship between pelvic organ prolapse and spinal curvature changes, a cross-sectional study was done in Gynecologic and Obstetrics educational hospitals and clinics in North West of Iran. One hundred patients were classified as cases based on the presence of abnormality at the spinal curvature and 100 patients classified as controls with no abnormality. The POP-Q (pelvic organ prolapse quantitation) staging system was used for assessment of prolapse stage and a flexi-curve malleable rod for measurement of thoracic and lumbar length and width, respectively. Main outcome was the stage of prolapses. The stage of prolapse was higher in cases compared to controls. There was a significant statistical difference between prolapse stage in two groups (p-value = 0.035). Among cases, grade II prolapse was the most prevalent abnormally (56%) and the grade III, I and IV were observed in 32, 5 and 7%, respectively. These observations underline the importance of taking into account the abnormal changes in spine curvature of patients when investigating risk factors for development of pelvic organs prolapse.

Bladder symptoms 1 year after abdominal sacrocolpopexy with and without Burch colposuspension in women without preoperative stress incontinence symptoms

OBJECTIVE

The objective of the study was to examine changes in bladder symptoms 1 year after abdominal sacrocolpopexy (ASC) with vs without Burch colposuspension.

STUDY DESIGN

Women without stress urinary incontinence (SUI) symptoms undergoing ASC were randomized to receive or not receive Burch. One year later, irritative, obstructive, and SUI symptoms were assessed in 305 women using Urogenital Distress Inventory subscales. A composite "stress endpoint" combined SUI symptoms, positive stress test, and retreatment.

RESULTS

In all women, the mean irritative score decreased from 19.6 +/- 16.3 (mean +/- SD) to 9.1 +/- 10.6; for obstructive symptoms, from 34.8 +/- 21.0 to 6.3 +/- 10.4 (both P < .001). Preoperative bothersome irritative symptoms resolved in 74.6% (126 of 169) and obstructive symptoms in 85.1% (212 of 249), independent of Burch. Fewer women with Burch had urge incontinence (14.5% vs 26.8%, P = .048) and fulfilled the stress endpoint (25.0% vs 40.1%, P = .012).

CONCLUSION

ASC reduced bothersome irritative and obstructive symptoms. Prophylactic Burch reduced stress and urge incontinence.

Lower Urinary Tract Symptoms, Quality of Life and Pelvic Organ Prolapse: Irritative Bladder and Obstructive Voiding Symptoms in Women Planning to Undergo Abdominal Sacrocolpopexy for Advanced Pelvic Organ Prolapse

PURPOSE

We compared lower urinary tract and voiding symptoms in women with and without symptoms of stress urinary incontinence who were planning to undergo abdominal sacrocolpopexy for pelvic organ prolapse.

MATERIALS AND METHODS

Subjects without stress urinary incontinence included 293 women in the Colpopexy and Urinary Reduction Efforts Trial. Subjects with stress urinary incontinence included 82 women who met trial inclusion criteria except for having stress urinary incontinence symptoms. We assessed symptoms and quality of life using validated measures.

RESULTS

After adjusting for age, race and site subjects with stress urinary incontinence had higher irritative and obstructive symptom subscale scores and reported greater symptom bother, greater impact of colorectal and prolapse symptoms, and poorer physical and mental health.

CONCLUSIONS

Women with prolapse and stress urinary incontinence had more lower urinary tract symptoms and reported more functional impact. This is contrary to our hypothesis that women with prolapse and stress urinary incontinence would have fewer irritative, obstructive and voiding symptoms because of the relief valve effect of the less resistant urethra.

Posterior intra-vaginal slingplasty for the treatment of vaginal apex prolapse: Medium-term results of 140 operations with a novel procedure

OBJECTIVES

Urogynecologists are constantly looking for simple, safe and effective ways to cure vaginal apex prolapse. A novel surgical technique, posterior intra-vaginal slingplasty (PIVS), was reported recently to include both a high therapeutic rate and a low complication rate. The present study was aimed at evaluating the preliminary data of a series of PIVS-treated patients.

STUDY DESIGN

A total of 140 patients with vaginal apex prolapse underwent the PIVS operation in a daycare setting. Pre-operative demographics, operative details and post-operative follow-up data were prospectively collected for all patients.

RESULTS

The PIVS procedure dose requires neither laparotomy nor deep transvaginal dissection as previously required for operative intervention. No intra-operative complications were recorded. The hospitalization period was relatively short. Three patients (2.1%) presented with surgical failure, whereas 137 (97.8%) of the operated patients reported satisfaction with the therapeutic results. One patient had post-operative unilateral gluteal skin infection. She was treated by surgical removal of the infected hemi-tape. Twelve (8.6%) patients had vaginal tape protrusion, of which 11 underwent segmental tape resection at the outpatient clinic. Two patients had spontaneous rejection of the tape while the vaginal apex remained well suspended. One patient suffered from post-operative fever of unknown origin, which was effectively treated with oral antibiotics.

CONCLUSIONS

The novel PIVS operation reduces the complication rate and shortens the rehabilitation period previously reported for the types of operation designed in the past to cure vaginal apex prolapse. The current list of results supports the previously reported efficacy, safety and simplicity of this procedure. However, more long-term data are required to be able to draw solid conclusions concerning the superiority of the discussed operative technique.

Postvoid residual urine in women with stress incontinence

AIMS

To confirm the idea that women with stress incontinence can have elevated postvoid residual urine (PVR) and to examine the correlation between PVR obtained with catheterization versus that with BladderScan (BS).

MATERIALS AND METHODS

This is a prospective study involving 902 women referred to our urogynecology clinics because of symptoms of lower urinary tract dysfunction. Women were selected if they met all of the following conditions: (1) A main complaint of stress urinary incontinence; (2) A diagnosis of urodynamic stress incontinence; and (3) No previous pelvic surgery, advanced pelvic prolapse or neurological deficit. One hundred and seven women met all criteria and formed the basis for this study. All women in the study group underwent three-part urodynamic testing including uroflowmetry, filling (provocative) and voiding cystometry. After uroflowmetry they were scanned by a BS, and then catheterized for PVR volume before the procedure of cystometry.

RESULTS

The mean PVR volume was 62.8 ml by BS and 38.5 ml by catheterization. 35.5% women had PVR urine higher than 50 ml and 15.9% had PVR urine greater than 100 ml. The PVR volume obtained by BS correlated significantly with catheterized volume (r = 0.625, P = 0.001) and offered a sensitivity of 64.7% and a specificity of 94.3% in detecting PVR greater than 100. The mean maximum flow rate was 22.1 ml/sec and mean detrusor contraction pressure during voiding was 21 cm H(2)O.

CONCLUSIONS

Women in our study had low maximum flow rate (22.1 ml/sec), elevated PVR (38.5 ml) and high detrusor contraction pressure during voiding (21 cm H(2)O) indicating that women with stress incontinence have some degree of voiding dysfunction. The bladder behavior in women with stress incontinence may be more complex than we had previously considered and special care should be taken if a woman with elevated PVR is scheduled for anti-incontinence surgery. BS appears to be reasonably sensitive and specific for the detection of elevated PVR and is reliable in clinical use.

Conservation of the prolapsed uterus is a valid option: medium term results of a prospective comparative study with the posterior intravaginal slingoplasty operation

It has been reported that, by the age of 80, the risk of women to undergo surgery for the treatment of pelvic organ prolapse (POP) exceeds 10%, a percentage expected to increase with the rise in life expectancy. The vaginal approach for POP reconstructive operations is associated with fewer complications and results in a shorter rehabilitation period than the abdominal route, whereas hysterectomy is widely performed concomitantly whenever the uterus is significantly prolapsed. However, there is no clear evidence supporting the role of hysterectomy in improving surgery outcome. We present our experience with a new minimally invasive procedure--the posterior intravaginal slingplasty (PIVS) for correction of advanced uterine prolapse--at the same time, comparing additive vaginal hysterectomy to uterine preservation, to evaluate the therapeutic significance of hysterectomy when vaginal apical prolapse is reconstructed with PIVS. Seventy-nine women presenting with moderate to severe uterine prolapse were enrolled into the current PIVS study. Vaginal hysterectomy was concomitantly performed upon patient's request (44 patients), whereas those wishing to preserve their uterus underwent reconstructive surgery only (35 patients). No intraoperative or postoperative major complications were recorded during an average follow-up of 29.8 months: One patient (1.3%) presented with surgical failure, whereas 71 (89.9%) of the operated patients reported satisfaction with the therapeutic results. Bladder overactivity symptoms declined from three thirds of the patients preoperatively to below 10% postoperatively. Ten (12.7%) patients had vaginal tape protrusion; all underwent segmental tape resection at the out-patient clinic. Because the PIVS procedure does not require either laparotomy or deep transvaginal dissection, as previously required for operative intervention, the hospitalization period was relatively short: 4.2 days for the hysterectomy group and 1.5 for the non-hysterectomy group. Other statistically significant differences between the hysterectomy and non-hysterectomy groups were the average ages (63.5 vs 51.0 years, respectively) and concomitant surgery (87% vs 69%, respectively, the higher percentage due to additive amputation of elongated uterine cervices). No other significant differences were recorded. The current results support the previously reported efficacy, safety, and simplicity of the PIVS procedure as well as the legitimacy of uterine preservation. Moreover, unstable bladder symptoms were found to be improved after this operation. However, long-term data are required to be able to draw solid conclusions concerning the superiority of the discussed operation.

Recommendations for urodynamic assessment in the evaluation of women with stress urinary incontinence

Urinary incontinence is a common problem that is experienced by women of all ages. The overall evaluation and treatment of incontinence has increased in sophistication, both as a result of the introduction of urodynamic testing in the assessment of patients, and because there are increasing numbers of medical and surgical treatments available for incontinence. What was previously considered a personal problem for women, and which was rarely discussed, has become a more open and acceptable complaint for female patients to bring to their physicians. This Review aims to clarify when urodynamic testing is clearly indicated for patients with symptoms of stress urinary incontinence, and describes the current recommendations from three national and international governing bodies. This Review will also highlight some of the ongoing debates over the performance, interpretation, and utility of urodynamic testing, and provide references for further reading on these topics.

Evaluation and management of refractory overactive bladder

The refractory overactive bladder patient is a complex new entity for the urologic community. We present the most current review of this difficult subject matter with an emphasis on evaluation and new treatment options such as sacral neuromodulation and botulinum toxin injection. It is hoped that in this new era of medical innovation, extirpation and reconstruction of the bladder will become historic in nature and refractory therapy can be transitioned to the office and outpatient operation rooms.

Management of pelvic abscess after Le Fort colpocleisis

We report the case of a 75-year-old woman who developed pelvic abscess following Le Fort colpocleisis. After drainage and completion of treatment with intravenous antibiotherapy, the patient returned with persistent signs of infection, which responded to outpatient gentamicin irrigation through Le Fort vaginal tunnels.

Reduction of moderate-to-large cystocele during urodynamic evaluation using a vaginal gauze pack: 8-year experience

OBJECTIVE

To determine the effect of cystocele reduction by a vaginal gauze pack on urodynamic studies (UDS).

PATIENTS AND METHODS

UDS from consecutive women with symptomatic pelvic organ prolapse were reviewed. The protocol included a 'fill-void' study with a vaginal gauze pack, and then repeated without the pack. Tracings were categorized based on filling cystometrograms (CMGs) and pressure-flow studies (PFS).

RESULTS

Of 202 women, 121 with a mean (sd) age of 67 (9.4) years contributed 221 interpretable 'pack, then no-pack' UDS (111 CMGs and 110 PFS); 77 of the women had a moderate cystocele and 44 had a large cystocele. Eighty-five women had urethral hypermobility (UH), and 36 had a well-supported urethra (WSU). The pack unmasked stress urinary incontinence (SUI) in 6% of women, with a mean (sd, range) Valsalva leak-point pressure of 54 (22, 23-90) cmH(2)O. SUI occurred more often in women with UH than WSU. Detrusor overactivity occurred similarly in pack (15%) and no-pack (14%) tracings. Bladder outlet obstruction (BOO) was relieved by the pack in 25 studies and caused by the pack in four. Women with WSU had BOO more often than those with UH (43% vs 22%, P < 0.05), regardless of the presence or absence of the pack.

CONCLUSION

Unmasked SUI by pack reduction was uncommon, presumably due to anterior vaginal wall stabilization, as the pack rarely caused BOO. Those with SUI had Valsalva leak-point pressures suggestive of intrinsic sphincter deficiency. The pack did not significantly influence the presence of detrusor overactivity.

Classification and evaluation of prolapse

Pelvic organ prolapse is prevalent among older women. Milder stages of prolapse, cranial to the hymen, are common and usually symptomless. A specific symptom is a bulge outside the vagina. Functional symptoms from the bladder, bowel and sexual life frequently coexist without a known cause/effect relationship to prolapse. Prolapse should be measured by the validated internationally approved pelvic organ prolapse quantification (POPQ) system that can measure prolapse in the three compartments and three levels of the vagina. We should work on a common classification system and agreement in which symptoms should be recorded as related to prolapse and expected to improve by prolapse surgery.

Associated pelvic organ prolapse in women with stress urinary incontinence: when to operate?

PURPOSE OF REVIEW

This review discusses recently published data concerning the indications for pelvic organ prolapse (POP) surgery in women who present with stress urinary incontinence (SUI).

RECENT FINDINGS

POP can functionally mask SUI. Surgery for POP may unmask occult SUI in many women. Clinically continent women undergoing POP surgery are at risk for developing symptomatic SUI postoperatively. Preoperative identification of occult (and overt) SUI will facilitate the use of an appropriate prophylactic anti-incontinence procedure at the time of prolapse repair. Numerous studies on the preoperative prediction of SUI following repair of POP have been conducted in an effort to determine whether concomitant prophylactic measures should be taken at the time of POP repair to prevent the postoperative unmasking of SUI in women who do not have SUI preoperatively (with or without prolapse reduction). Although the literary evidence available is not sufficient for POP with occult SUI, there is some information available to guide clinicians in deciding when to perform concurrent POP surgery in women who are undergoing primary surgery for SUI.

SUMMARY

The intended goal of surgical correction of SUI and POP is durable restoration of normal anatomy and function, with symptomatic relief and avoidance of morbidity. Recommendations regarding when to surgically intervene for POP in women who present with SUI are based on the available literature although contemporary studies are few and include small numbers of patients with no controls. Long-term, randomized, controlled prospective studies of large numbers of patients are indicated.

Laparoscopic sacral colpopexy approach for genito-urinary prolapse: experience with 363 cases

OBJECTIVE

To evaluate the surgical outcome, complications and benefits of laparoscopic double promonto-fixation for patients with pelvic prolapse.

METHODS

Women with genito-urinary prolapse underwent a transperitoneal placement of a 100% polyester mesh on the anterior vaginal wall and a posterior mesh on the levator ani muscle. Both of these were anchored to the sacral promontory. A TVT was placed simultaneously in patients who had concurrent stress urinary incontinence.

RESULTS

A total of 363 patients were operated upon between 1996 and 2002. Their mean age was 63 (range 35-78), average follow-up was 14.6 months, the mean operating time was 97 minutes. There were 8 conversions due to anesthetic or surgical difficulties. Follow up was done by a postal questionnaire and physical examination at 6 months and then yearly. 96% were satisfied with the results of their operation and no patients complained of sexual dysfunction. There was a 4% recurrence rate of prolapse, 3 vaginal erosions, 2 urinary retentions that required TVT section, 1 bowel incarcerations, 1 spondylitis and 2 mesh infection.

CONCLUSIONS

Laparoscopic promonto-fixation is feasible and highly effective technique that offers good long-term results with complication rates similar to open surgery, with the added benefits of minimally invasive surgery.

The role of urodynamics in the treatment of lower urinary tract symptoms in women

PURPOSE OF REVIEW

Urodynamic investigation was developed as an extension of patient history and physical examination in order to reveal the pathology of a patient's complaints. Much progress in standardizing definitions and procedures has been made in recent years. In particular, stress urinary incontinence and overactive bladder can be differentiated with urodynamics. The developed parameters, however, cannot distinguish the various types of stress urinary incontinence. Moreover the definition and diagnosis of voiding dysfunction is not clear. Finally our understanding of bladder sensations and the impact on voiding behaviour has only started to emerge. This review is about last year's publications that focus on urodynamics and lower urinary tract symptoms in women.

RECENT FINDINGS

Defining bladder outlet obstruction is based on voiding pressure, urinary flow speed and residual urine but standardization is lacking. Urodynamics to reveal occult stress urinary incontinence in patients with pelvic organ prolapse needs standardization of the reducing manoeuvres. The quest for urodynamic tools for distinguishing intrinsic sphincter deficiency from urethral hypermobility continues. Urodynamics are still not good enough to discriminate between treatment options for stress urinary incontinence. The use of urodynamics in overactive bladder is developing and has elicited new findings. Voiding habit seems to be independent from bladder sensations. Also bladder sensations appear to be imperfectly correlated with bladder filling. Even bladder volumes do not predict entirely bladder fullness sensations.

SUMMARY

In order to use urodynamics as a proper clinical tool, defining subtypes of stress urinary incontinence and standardization of urodynamics in pelvic organ prolapse and bladder outlet obstruction in women is needed.