Intra-operative introital ultrasound in Burch colposuspension reduces post-operative complications

Current Treatment of Stress Urinary Incontinence by Bulking Agents and Laser Therapy-An Update

Stress urinary incontinence (SUI) affects around 20% of women. In addition to the established suburethral sling insertion, two less invasive approaches are of interest today: urethral bulking agents and vaginal laser therapy. This review discusses articles through December 2023 identified by a PubMed literature search using the keywords "incontinence" and "bulking" or "laser". Although the two approaches are less effective than sling insertions, there are specific conditions in which one or the other technique is more advantageous. Injecting bulking agents into the urethra only takes some minutes and works without general anesthesia. The method is particularly suited for elderly, frail, or obese patients with multiple comorbidities, but is also applicable for all patients and in combination with other therapies. Generally, the safety profile is good but differs between bulking materials. Two laser types-the Erbium:YAG laser with SMOOTH-mode and the fractional ablative CO2 laser-deliver heat into the tissue to induce tissue tightening and regeneration. Intravaginal laser therapy improves mild to moderate SUI, while studies describe how intraurethral laser therapy is also beneficial for severe SUI. Young women between childbirths, as well as postmenopausal women, may benefit from laser therapy. The method is safe, can be performed on an outpatient basis, and does not require any artificial material.

Use of intraoperative ultrasound to improve tension-free vaginal tape-obturator placement: A pilot study

OBJECTIVE

To evaluate the use of intraoperative ultrasound (IUS) to achieve a postoperative optimal placement of the tension-free vaginal tape-obturator (TVT-O).

METHODS

A cohort study was performed among women who underwent TVT-O placement. In 25 women, ultrasound was used for the placement, and based on current evidence, the optimal intraoperative and postoperative ultrasound pattern was selected. They were compared with 25 women where IUS was not used.

RESULTS

IUS increased operative time (by 7.5 min), and in 36% (9/25) of cases it was necessary to perform some corrections based on the ultrasound findings. After 1 month, in patients of the IUS group, the tapes were more frequently placed at a distance of 3-5 mm (P = 0.01), and it was more common for it to be placed between 40% and 70% relative to the urethral length (P = 0.011). Of tapes placed with IUS, 76% (met the optimal postoperative ultrasound pattern, as opposed to only 48% placed without IUS (P = 0.041). No differences were found in the complications or the functional results at 1 month post-surgery.

CONCLUSION

The use of IUS for the placement of TVT-O allows us to position them optimally and avoid erroneous placements, although IUS increases the operative time without improving the functional results and the rate of complications.

Hand-held, clinical dual mode ultrasound - photoacoustic imaging of rat urinary bladder and its applications

Urinary bladder imaging is critical to diagnose urinary tract disorders, and bladder cancer. There is a great need for safe, non-invasive, and sensitive imaging technique which enables bladder imaging. Photoacoustic imaging is a rapidly growing imaging technique for various biological applications. It can be combined with clinical ultrasound imaging system for hand-held, dual modal ultrasound-photoacoustic real-time imaging. Structural (bladder wall) and functional (accretion of nanoparticles) bladder imaging is shown here with combined ultrasound and photoacoustic imaging in rats. Photoacoustic images of bladder wall is shown using black ink as the contrast agent. Chicken tissues were stacked on the abdomen of the animal to demonstrate the feasibility of photoacoustic imaging till a depth of 2 cm. Also, the feasibility of photoacoustic imaging for a common bladder disorder, vesicoureteral reflux is studied using urinary tract mimicking phantom. It is also shown that a clinical ultrasound system can be used for photoacoustic imaging of non-invasive clearance study of gold nanorods from circulation by monitoring the gradual accumulation of the gold nanorods in the bladder. The time taken for accumulation of nanorods in the bladder can be used as an indicator of the clearance rate of the nanoparticle circulation from the body.

Size Does Not Make the Difference: 3D/4D Transperineal Sonographic Measurements of the Female Urethra in the Assessment of Urinary Incontinence Subtypes

Purpose. The objective was to evaluate the usefulness of transperineal ultrasound in the assessment of the urethral length and urethral lumen by 3D/4D transperineal sonography to discriminate between female patients with subtypes of urinary incontinence. Methods. A total of 150 female patients underwent an examination because of urinary incontinence. 41 patients were diagnosed with urgency urinary incontinence (OAB), 67 patients were diagnosed with stress urinary incontinence (SUI), and 42 patients were in the control group (CTRL). Three diameters of the urethral lumen (proximal (U1), medial (U2), and distal (U3)) and the urethral length were measured. By the assessment of the urethral lumen, the presence of the urethral funneling was evaluated. Results. We found a significant difference in the urethral length and urethral lumen U2 of OAB and SUI versus CTRL. The urethral length was significantly greater (P < 0.05) and the urethral lumen was significantly wider (P < 0.05) in the patients with urinary incontinence. The incidence of the urethral funneling was significantly higher (P < 0.05) in the study groups with urinary incontinence than in the control group. Conclusions. Our results have shown the urethral changes obtained by ultrasound in patients with urinary incontinence, but they are still insufficient to distinguish between subtypes of urinary incontinence.

Complications following Tension-Free Vaginal Tapes: Accurate Diagnosis and Complications Management

The sling procedures are the gold standard for SUI treatment. They are highly effective but not free from complications. The most common adverse effect for the surgery with the implant insertion is: overactive bladder occurring de novo after the surgery, voiding dysfunctions, urine retention, and unsatisfactory treatment outcome. The most important question that arises after 20 years of sling procedures is how to manage the complications and what can be offered to complicated patients. The above review summarises the ultrasound findings in complicated cases and shows the scheme of management of the clinical problems concerning the tape location in suburethral region.

Intraoperative imaging

Intraoperative image is a rapidly expanding field encompassing many applications that use a multitude of technologies. Some of the these applications have been in use for many years and are firmly embedded in, and indispensable to, clinical practice (e.g. the use of X-ray to locate foreign bodies during surgery or oocyte retrieval under ultrasound guidance. In others, the application may have been in use in one discipline but not yet fully explored in another. Examples include the use of intraoperative ultrasound with or without contrast enhancement for the detection of hepatic metastases not identified preoperatively, and the effect of such additional information on the ultimate operative procedure. Intraoperative identification of sentinel lymph nodes has been explored in many specialties to a varying extent, with the aim of fine tuning and avoiding unnecessary surgery. In both these instances, we do not know the long-term effect of these interventions on patient survival or quality of life. In this chapter, we will explore the available evidence on these applications and current advances in the new technology in general, with a specific focus on gynaecology.

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.

The association of changes in opening detrusor pressure with the resolution of overactive bladder symptoms after repair of pelvic organ prolapse

AIMS

To evaluate whether changes in opening detrusor pressure (ODP) are associated with resolution of overactive bladder symptoms in women undergoing surgical correction of pelvic organ prolapse.

METHODS

Forty women with DO and OAB together with anterior wall prolapse who underwent a repair between 2003 and 2007 were studied. Each woman was assessed pre- and post-operatively with a clinical assessment and cystometry. Opening pressures were recorded pre- and post-operatively for each patient by retrospective review of the pressure flow traces. Patients were divided into those who experienced resolution of OAB symptoms and those with persistent OAB symptoms. Wilcoxon matched pairs signed rank test was used to assess any change in opening pressures between these groups.

RESULTS

Resolution of urgency with an anterior repair was associated with a significant fall in ODP from a mean of 27.9 to 11.7 cmH(2)O (P = 0.01). There was no significant pre-operative difference in ODP between women in whom urgency resolved and those in whom it did not.

CONCLUSION

These results suggest that a fall in ODP is associated with resolution of urgency in women undergoing prolapse surgery. This may imply that decreased urethral resistance is of importance in symptom resolution.

Transperineal ultrasound to assess the effect of tension-free vaginal tape position on flow rates

OBJECTIVE

To determine whether the position of the tension-free vaginal tape (TVT) has an effect on postoperative flow rates and voiding function in women successfully cured of urodynamic stress incontinence.

METHODS

Postoperatively 72 women who had undergone TVT surgery had a transperineal ultrasound examination to assess the position of the TVT on the urethra. The tape was categorized as proximal, mid or distal urethral. The effect on voiding was assessed using the maximum flow rate (MFR) centiles corrected for voided volume and detrusor pressure at maximum flow.

RESULTS

Forty-six women had distal tapes and 26 mid-urethral tapes. A tape lying on the mid urethra was associated with a fall in MFR centile (P = 0.04) while a tape lying on the distal urethra did not cause a fall in the MFR centile (P = 0.52). There was no significant change in the detrusor pressure at maximum flow between mid and distally placed tapes.

CONCLUSIONS

Distally placed tapes cause less alteration in flow rates than do mid-urethrally placed tapes. This may be beneficial in certain patient groups.

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.