The Michigan Incontinence Symptom Index (M-ISI): a clinical measure for type, severity, and bother related to urinary incontinence

AIMS

To develop a clinically relevant, easy to use, and validated instrument for assessing severity and bother related to urinary incontinence.

METHODS

Survey items were piloted and refined following psychometric principles in five separate patient cohorts. Patient and expert endorsement of items, factor analyses, Spearman rank correlations and response distributions were employed for item selection. Formal reliability and validity evaluation were conducted for the final questionnaire items.

RESULTS

Expert physicians and patient focus groups confirmed face and content validity for the measure. A 10-item measure called the Michigan Incontinence Symptom Index (M-ISI) was developed with two domains: a Total M-ISI Domain consisting of subdomains for stress urinary incontinence, urgency urinary incontinence, and pad use, and a Bother Domain. High construct validity was demonstrated with a Cronbach's alpha for the Total M-ISI Domain (items 1-8) of 0.90 and for the Bother Domain (items 9-10) of 0.82. Cronbach's alpha for the subdomains were all > 0.85. Construct validity, convergent and divergent validity, internal discriminant validity, and predictive validity were all robust. The minimally important difference for the measure was determined to be 4 points (out of 32) for the Total M-ISI Severity Domain, and 1-2 points (out of 8-12) for the individual subdomains.

CONCLUSIONS

The M-ISI is a parsimonious measure that has established reliability and validity on several levels and complements current clinical evaluative methods for patients with urinary incontinence.

Management of difficult cases in female urology and neurourology at the Reed M. Nesbit society meeting. Festschrift in honor of Edward J. McGuire, MD

This is a panel discussion of seven complex urologic cases in female urology and neurourology. Differences in diagnosis and management are discussed by this international panel of experts.

The association of Incontinence Symptom Index scores with urethral function and support

OBJECTIVE

The objective of this study was to establish categories of symptom severity based on Incontinence Symptom Index (ISI) scores and to show how these categories are associated with urethral function and support.

STUDY DESIGN

Women with stress incontinence (n = 97) and asymptomatic controls (n = 98) completed the ISI. Asymptomatic women's scores were between 0 and 6; this range was designated as absent/mild (n = 104). The median score for symptomatic women was 16; scores from 7 to 16 (n = 50) were designated as moderate, and scores of 17 or greater (n = 40) were designated as severe.

RESULTS

Urethral function differed in women with mild, moderate, and severe scores: Valsalva leak point pressure (162.3 vs 123.5 vs 101.9 cm H(2)O; P = .001), cough leak point pressure (202.0 vs 163.0 vs 134.3 cm H(2)O; P = .001), and maximum urethral closure pressure (69.1 vs 44.1 vs 35.3 cm H(2)O; P = .001). Loss of urethrovesical support (point Aa: -1.0 vs -0.6 vs -0.5 cm; P = .004) was found in women with moderate and severe symptoms, compared with those with mild symptoms.

CONCLUSION

Categories of symptom severity assessed by the ISI are associated with urethral function and support.

Complications requiring reoperation following vaginal mesh kit procedures for prolapse

OBJECTIVE

The objective of the study was to the characterize the symptoms and management of vaginal mesh-related complications requiring operative intervention.

STUDY DESIGN

This was a case series of patients undergoing excision of vaginal graft material. Only women who had vaginal mesh placement for the correction of pelvic organ prolapse (POP) were included. We describe the symptoms, complications, and management of women treated surgically for vaginal mesh-related complications.

RESULTS

Thirteen referred women underwent surgery for vaginal mesh-related complications. All meshes were Apogee and/or Perigee. Ten had symptomatic mesh exposures, 1 had an exposure with pelvic abscess, and 2 had pain syndromes without mesh exposure. Patients also had rectovaginal fistula, vesicovaginal fistula, recurrent POP, and persistent discharge. Five women had prior surgery for this problem. All patients underwent transvaginal mesh excision and other indicated procedures at our institution, and 6 women required a second surgery at our institution, with a median of 2 surgeries per patient.

CONCLUSION

Vaginal mesh placement for POP can be associated with pain, exposure, and fistula formation, requiring multiple operative interventions.

Ileovesicostomy for adults with neurogenic bladders: complications and potential risk factors for adverse outcomes

AIMS

Risk factors for complications following ileovesicostomy have not been well defined. This study's purpose was to examine outcomes following ileovesicostomy in adults and identify possible risk factors that may contribute to post-operative complications.

METHODS

Retrospective database review identified ileovesicostomy procedures from August 1999 to September 2003. Demographic, pre-operative, and post-operative data were extracted. Statistical analysis determined whether risk factors influenced outcomes of urethral continence, re-operation, and post-operative complications. Factors included age, tobacco use, diabetes, neurogenic bladder etiology, body mass index, pre-operative indwelling catheterization, or simultaneous procedures including pubovaginal sling/urethral closure.

RESULTS

50 adults status-post ileovesicostomy were identified. At last follow-up, 36 patients (72%) were continent per urethra. The incidence of complications decreased significantly from 3.38 per patient to 1.16 post-operatively (P < 0.0001). Twenty-seven averaged 1.52 inflammatory or infectious post-operative complications per patient, 19 averaged 1.47 stomal complications, and 11 averaged 2.09 ileovesicostomy mechanical obstructions. Overall, 27 required 2.85 re-operations or additional procedures following ileovesicostomy. Sub-group analysis identified BMI (P = 0.0569) as a possible risk factor. Differences in outcomes based on age, tobacco use, diabetes, neurogenic bladder etiology, pre-operative indwelling catheterization, or urethral closure were not significant.

CONCLUSIONS

Ileovesicostomy is a valuable management option for adults with neurogenic bladder unable to perform intermittent catheterization. The incidence of urinary tract comorbid events significantly decreased following ileovesicostomy though the onset of other complications should be considered. The morbidity associated with ileovesicostomy requires careful patient selection, close long-term follow-up, and potential subsequent interventions to address post-operative complications.

Long-term durability and functional outcomes among patients with artificial urinary sphincters: a 10-year retrospective review from the University of Michigan

PURPOSE

The artificial urinary sphincter continues to be one of the most effective and commonly used surgical treatments for severe urinary incontinence. The long-term durability and functional outcome remains unclear. This study sought to report the artificial urinary sphincter complication rates, associated risk factors with complications, and long-term quality of life and durability.

MATERIALS AND METHODS

This single institution study reports the outcomes of 124 consecutive index cases of artificial urinary sphincter from 1996 to 2006 for complications (infection, erosion, and mechanical failure). Bivariate statistics and multivariable logistic models were used to identify patient and artificial urinary sphincter characteristics associated with complications. Functional outcomes and long-term durability were assessed using a cross sectional analysis of a validated health related quality of life survey and a product limit estimates, respectively.

RESULTS

Among the 124 male patients median followup was 6.8 years. The overall complication rate for patients undergoing an artificial urinary sphincter was 37.0%, with mechanical failure the most common cause (29), followed by erosion (10) and then infection (7). Significant differences between complications and specific patient and artificial urinary sphincter characteristics risk factors were not found. Functional outcomes appeared stable with similar mild-moderate urinary incontinence severity and 0 to 1 daily pad use at intervals of 0 to 4 years, 4 to 8 years and more than 8 years. Long-term durability was notable with 36% having complications (requiring surgical revision or removal) within 10 years and most events occurring within the first 48 months.

CONCLUSIONS

Long-term durability and functional outcomes are achievable for the AMS 800, but there are appreciable complication rates for erosion, mechanical failure and infection in the first 48 months from implantation.

Transcutaneous Mechanical Nerve Stimulation Using Perineal Vibration: A Novel Method for the Treatment of Female Stress Urinary Incontinence

PURPOSE

We defined basic guidelines for transcutaneous mechanical nerve stimulation in modifying pelvic floor responses in women and determined the efficacy of transcutaneous mechanical nerve stimulation in treating stress urinary incontinence.

MATERIALS AND METHODS

Perineal and clitoral transcutaneous mechanical nerve stimulation was performed in healthy volunteers while measuring changes in peak urethral pressure to determine optimal vibration amplitude and site of stimulation. Perineal transcutaneous mechanical nerve stimulation was then performed weekly for 6 weeks in a cohort of women with stress urinary incontinence (33). Reduction in incontinence episodes and pad use on voiding diary were compared from baseline to 6 weeks. Global efficacy was determined at 6 weeks and 3 months after the completion of the program.

RESULTS

In healthy subjects a vibration amplitude of 2.0 mm resulted in the highest urethral pressure increase. Although the increase with perineal transcutaneous mechanical nerve stimulation was lower than that seen with clitoral stimulation (80 vs 115 cm H(2)O), perineal transcutaneous mechanical nerve stimulation was more acceptable to the patient and resulted in a better subjective response. Urethral pressure increases with transcutaneous mechanical nerve stimulation at either site were greater than with voluntary contraction (60 cm H(2)O). After 6 weeks of transcutaneous mechanical nerve stimulation in the subjects with stress urinary incontinence, there was a significant reduction in daily incontinence episodes (2.6 +/- 1.1 vs 0.5 +/- 1.1, paired t test p <0.001) and pad use (3.5 +/- 0.9 vs 0.6 +/- 1.3, paired t test p <0.001). At 6 weeks the cure rate (no incontinence episodes) was 73%, with durability through 3 months with 67% still reporting persistent resolution.

CONCLUSIONS

Perineal transcutaneous mechanical nerve stimulation has promise as a noninvasive and well tolerated method of treating stress urinary incontinence.

Comparative Analysis of Urinary Incontinence Severity After Autologous Fascia Pubovaginal Sling, Pubovaginal Sling and Tension-Free Vaginal Tape

PURPOSE

Autologous fascia, Pelvicol implant and polypropylene are common materials used in suburethral anti-incontinence procedures. We explored the relative effectiveness of the autologous fascia pubovaginal sling, Pelvicol pubovaginal sling and Gynecare TVT on self-reported postoperative urinary incontinence.

MATERIALS AND METHODS

The study was a mailed cross-sectional survey of health related quality of life 1 to 3 years after suburethral anti-incontinence surgery performed at our institution. The Incontinence Symptom Index was used to assess the presence and severity of urinary incontinence symptoms and the Incontinence Impact Questionnaire-7 was used to assess impairment. Regression models were developed to identify factors with an independent effect on the presence, severity and impairment of urinary incontinence symptoms.

RESULTS

The questionnaire was returned by 69% of eligible respondents (173 of 250). Those with previous incontinence surgery (OR 11.0, 95% CI 2.3-51.4) and medical comorbidities (OR 1.6, 95% CI 1.1-2.2) were more likely to report urinary incontinence symptoms, ie incontinence symptom index greater than 0. Symptom severity, which was analyzed only in respondents with urinary incontinence symptoms, was greater in the Pelvicol than in the autologous fascia pubovaginal sling and TVT groups (each p <0.01). No significant difference was observed between the TVT and autologous fascia pubovaginal sling groups (p = 0.15). Also associated with higher urinary incontinence symptom severity scores were body mass index (p = 0.03), a history of incontinence surgery (p = 0.01) and lower education (p <0.01). Impairment from urinary incontinence, as assessed by the Incontinence Impact Questionnaire-7, was associated with body mass index, severe depression and current smoking (each p = 0.01) but not with surgical treatment group.

CONCLUSIONS

Women who received an autologous fascia pubovaginal sling or TVT reported lower symptom severity scores than those who had a Pelvicol pubovaginal sling. Impairment was not associated with procedure type. These findings suggest better outcomes with autologous fascia pubovaginal sling and TVT. Randomized, controlled trials are needed to confirm these findings.

TRANSURETHRAL COLLAGEN INJECTIONS FOR MALE INTRINSIC SPHINCTER DEFICIENCY: THE UNIVERSITY OF TEXAS-HOUSTON EXPERIENCE

PURPOSE

Injectable agents are used to increase urethral coaptation for the treatment of intrinsic sphincter deficiency. We evaluated the long-term results and complications of transurethral collagen injections in males.

MATERIALS AND METHODS

We reviewed the charts of 322 men (mean age 67.2 years, range 40 to 91) with intrinsic sphincter deficiency after therapy for prostate carcinoma (307) or benign prostatic hyperplasia (15) who received transurethral collagen injections. The analysis included types and combinations of treatment for prostate cancer or benign prostatic hyperplasia, pre-procedure voiding symptoms, total collagen received, maximal percentage improvement and durability of effect.

RESULTS

The mean length of followup was 40.1 (+/-13.2) months. Overall, the mean number of injections was 4.37 (+/-2.09). Mean percent improvement after a series of injections was 44.59 (+/-38.26). Mean pad use before and after injection was statistically different (5.15 vs 2.98, p=0.0001). Mean duration of response was 6.3 (+/-8.14) months. In those who achieved complete continence (17%), the mean duration of response was 11.1 (+/-8.87) months. Within this group the mean number of injections and ml of collagen injected were 3.83 and 29.27, respectively. Five patients (1.5%) complained of a quantitative increase in leakage after their series of collagen injections.

CONCLUSIONS

Transurethral collagen injections are a good option for short-term therapy in men with post-prostatectomy incontinence. The mean number of injections to achieve a plateau is 3 to 4, regardless of initial severity of incontinence. Those in the radical prostatectomy only treatment group are statistically more likely to achieve continence than all other treatment groups.

Technique for removal of symptomatic bone anchors placed during stress incontinence surgery

INTRODUCTION

To present an uncomplicated, reliable technique for bone anchor removal in patients with anchor-related infections or chronic pain.

TECHNICAL CONSIDERATIONS

We removed 17 anchors from 9 patients between 1999 and 2004. The surgical technique used fluoroscopy for localization of the anchors and an orthopedic broken screw removal instrument for resection of the anchor and surrounding bone. Nine patients with bone anchors had been symptomatic with chronic pain and/or wound drainage for a mean of 23.7 months before surgery. After removal, 10 anchors grew positive bacterial cultures. The most common organism was coagulase-negative Staphylococcus. During a mean follow-up period of 6.8 months after hardware removal, 8 of the 9 patients had symptomatic improvement.

CONCLUSIONS

Fluoroscopic localization and en bloc resection with a broken screw removal instrument is an effective method of removing symptomatic bone anchors.

Outcome of urethral closure in patients with neurologic impairment and complete urethral destruction

AIMS

The purpose of this study is to describe the problems associated with prolonged urethral catheterization in 12 patients with neurological problems and to report the results of surgical treatment.

METHODS

A retrospective study of patients with neurogenic bladder and urethral dysfunction treated with prolonged catheterization resulting in incontinence associated with loss of urethral tissue and or function selected 12 patients. All had video urodynamics. Twelve were continuously incontinent despite a catheter. Bladder compliance, where that could be measured, was low is 10, and there were multiple and serious co-morbidities including sepsis, hypoalbuminemia, skin breakdown, osteomyelitis, respiratory insuffiency, etc. There were 4 males and 8 females, 9 had a spinal cord injury and 3 progressive multiple sclerosis.

RESULTS

Male patients underwent transperineal closure of the membranous urethra; females transvaginal closure of the urethra. All patients had a urinary diversion, either an ileovesicostomy, or an augmentation cystoplasty and construction of a neourethra. Continence was ultimately achieved in 11 of 12 patients at a median 20 months. Four patients had one additional procedure to gain continence, but five patients required 3.8 procedures/patient to achieve continence. Closure of the male urethra was more easily accomplished than closure of an extensively damaged eroded female urethra.

CONCLUSIONS

Patients with urethral damage and erosion related to prolonged catheter present a formidable challenge in surgical reconstruction. Most have serious co-mobidities and a single operation does not usually solve all the problems. Persistence does almost always result in continence.

Complications following surgical intervention for stress urinary incontinence: A national perspective

AIMS

Stress urinary incontinence (SUI) impacts many women. Treatment is primarily surgical. Post-operative morbidity considerably affects individuals and the health care system. Our objective is to describe complications following surgery for SUI and how they affect resource utilization.

METHODS

Utilizing the Nationwide Inpatient Sample (a nationally representative dataset), 147,473 patients who underwent surgery for SUI from 1988 to 2000 were identified by ICD-9 codes. Comorbid conditions/complications were extracted using ICD-9 codes, including complication rates, length of stay (LOS), hospital charges, and discharge status.

RESULTS

Overall complication rate was 13.0% (not equal to sum of complication sub-types, as each woman may have had = 1 complication), with 2.8% bleeding, 1.4% surgical injury, 4.3% urinary/renal, 4.4% infectious, 0.1% wound, 1.1% pulmonary insufficiency, 0.5% myocardial infarction, 0.2% thromboembolic. The "gold standard" surgical technique for SUI, the pubovaginal sling, had the lowest morbidity at 12.5%. Mean LOS increased with morbidity: from 2.9 to 4.1 to 6.1 days for those with 0, 1, and =2 complications respectively (P < 0.001). Similarly, inflation-adjusted hospital charges increased with morbidity: from 7,918 dollars to 9,828 dollars to 15,181 dollars for those with 0, 1, and =2 complications respectively (P < 0.001). The percentage of patients requiring post-discharge subacute or home care increased with morbidity: from 4.4% to 8.4% to 14.3% for those with 0, 1, and =2 complications (P < 0.001).

CONCLUSIONS

A substantial percentage of women experience complications following surgery for SUI. Post-operative morbidity leads to dramatically increased resource utilization. Prospective studies are needed to identify pre-operative risk factors and intraoperative process measures to optimize the quality of care.

Pathophysiology of stress urinary incontinence

All cases of stress urinary incontinence (SUI) are not the same; urethral pressures, prolapse conditions, and congenital and acquired sphincteric dysfunction all contribute to SUI pathophysiology. In order to optimally manage SUI, a thorough understanding of the pathophysiology behind the condition is necessary. Unsuccessful treatment of incontinence can result from the procedure itself or from a poor fit between the patient's condition and the treatment chosen. Proper patient evaluation, including videourodynamics and measurement of Valsalva leak point pressure, is key to making the best treatment decisions and obtaining optimal patient outcomes.

Temporary Perineal Urethrostomy for External Sphincter Dilation in a Male Patient With High Risk Myelomeningocele

PURPOSE

We describe our use of perineal urethrostomy to facilitate serial external sphincter dilations in a male child with high risk myelomeningocele.

MATERIALS AND METHODS

A 5-month-old boy with lumbar myelomeningocele presented with poor bladder compliance, increased detrusor leak point pressure and high grade vesicoureteral reflux. Urodynamic parameters failed to improve with clean intermittent catheterization and anticholinergic therapy. Given the persistent risk to the upper urinary tract, perineal urethrostomy was performed to facilitate external sphincter dilation in a serial fashion.

RESULTS

The patient underwent 2 aggressive external sphincter dilations (30Fr) under direct vision. The second dilation was performed in the outpatient clinic without anesthesia. Subsequent cystometrographic evaluation revealed dramatic improvement in bladder storage properties with improved compliance and a safe detrusor leak point pressure. Moreover, followup imaging demonstrated complete resolution of vesicoureteral reflux.

CONCLUSIONS

Creation and maintenance of perineal urethrostomy is a valuable innovation in the treatment of some boys with high risk myelomeningocele. This easily reversible diversion allows aggressive, sequential external sphincter dilation and produces substantial improvements in bladder storage properties.

Effects of ejaculation by penile vibratory stimulation on bladder capacity in men with spinal cord lesions

PURPOSE

We examined the effects of ejaculation by penile vibratory stimulation on bladder capacity in men with spinal cord lesions.

MATERIAL AND METHODS

Included in our study were 14 men with spinal cord lesions from C4 to T7 with detrusor hyperreflexia. Cystometry was performed before and immediately after ejaculation by penile vibratory stimulation to establish baseline conditions and repeated after 1 month of ejaculation by penile vibratory stimulation every third day. The third cystometry study was done after 1 month of ejaculation by penile vibratory stimulation every third day at home to determine any long-term effects of treatment. This third cystometry was performed 72 hours after the last ejaculation to exclude any acute effects of ejaculation by penile vibratory stimulation on detrusor hyperreflexia. In addition, 1 to 3 days later ejaculation was induced by penile vibratory stimulation and immediately followed by cystometry to examine whether it was possible to achieve an acute effect as well as a potential long-term effect.

RESULTS

Baseline urodynamic investigations revealed bladder hyperreflexia and external sphincter dyssynergia in all individuals. There was no statistically significant difference in bladder capacity at leak point before and immediately after ejaculation by penile vibratory stimulation. However, after 4 weeks of frequent penile vibratory stimulation treatment bladder capacity at leak point increased significantly from a median of 190 ml. (range 17 to 700) at baseline to 293 (range 30 to 700) (Wilcoxon signed rank test p = 0.03). Furthermore, there was a trend toward decreased intravesical pressure during the filling phase.

CONCLUSIONS

Ejaculation by penile vibratory stimulation was associated with a significant increase in bladder capacity at leak point after 4 weeks of frequent treatment. This finding may have implications in the management of incontinence in men with spinal cord lesions.

Intraoperative nerve stimulation with measurement of urethral sphincter pressure changes during radical retropubic prostatectomy: a feasibility study

PURPOSE

We evaluated the feasibility of using intraoperative nerve stimulation and real-time urodynamic monitoring to identify the intrapelvic innervation of the urethral sphincter during radical retropubic prostatectomy.

MATERIALS AND METHODS

Using an intraurethral balloon pressure transducer and nerve stimulator changes in urethral pressure were measured in response to stimulation of the neurovascular bundles, pelvic side wall, bladder neck, rectus muscle and other structures in 8 patients undergoing nerve sparing radical retropubic prostatectomy. Intraurethral pressure changes were charted on an urodynamic monitor and correlated with the anatomical location of stimulation.

RESULTS

Stimulation of the neurovascular bundles resulted in measurable and significant (greater than 10 cm. H(2)O) increases in intraurethral pressure in all 8 patients. The mean pressure increase was 22 cm. H(2)O. Neither control structure, that is the bladder neck or rectus, resulted in pressure changes with stimulation. In 60% of the subjects pelvic side wall stimulation resulted in urethral pressure increases, while in 40% this stimulation caused pelvic contraction floor but no pressure increase. The mean pressure changes with side wall stimulation was 14 cm. H(2)O.

CONCLUSIONS

Intraoperative stimulation of pelvic neural structures and measurement of changes in urethral pressure in response to stimulation are feasible during radical retropubic prostatectomy. Stimulating the neurovascular bundle consistently results in significant increases in urethral pressure. The finding of an intrapelvic urethral innervation supports the previously published observation that nerve sparing radical retropubic prostatectomy may result in improved continence postoperatively.

Obstructive uropathy induced bladder dysfunction can be reversible: bladder compliance measures before and after treatment

PURPOSE

We demonstrated that abnormal bladder compliance in the setting of obstructive uropathy can be improved by relief of bladder outlet obstruction.

MATERIALS AND METHODS

A cohort of 9 men with nonneurogenic lower urinary tract symptoms and videourodynamics proven bladder outlet obstruction were identified prospectively from a university urology practice. Study exclusion criteria ensured absence of active urinary infection, hematuria and neurourological pathology. Testing specifically focused on assessment of the bladder compliance curve, and a compliance value was calculated (ml./cm. H2O). Treatment intervention consisted of transurethral incisions or resection of the prostate in 8 cases and transurethral balloon dilation of a urethral stricture in 1. Followup videourodynamics testing was performed 1 month after treatment to confirm relief of outlet obstruction and reassess bladder compliance.

RESULTS

Mean patient age was 75.2 +/- 6.16 years. Pretreatment mean bladder compliance +/- SE was 3.06 +/- 0.45 ml./cm. H2O. At 1 month after treatment videourodynamics testing confirmed relief of obstruction in the cohort. Posttreatment mean bladder compliance +/- SE was 13.53 +/- 0.45 ml./cm. H2O. Nonparametric paired t test analysis determined that the difference between pretreatment and posttreatment bladder compliance was statistically significant at p = 0.0117.

CONCLUSIONS

This pilot study suggests that relief of obstructive uropathy even in elderly patients with long-standing lower urinary tract symptoms, can significantly improve bladder compliance.

Long-term results of Ingelman-Sundberg denervation procedure for urge incontinence refractory to medical therapy

PURPOSE

Urge incontinence refractory to anticholinergic medication and behavioral techniques is a therapeutic challenge. We evaluated the durability of the modified Ingelman-Sundberg detrusor denervation procedure as minimally invasive surgical therapy for intractable urge incontinence.

MATERIALS AND METHODS

Patients presenting with severe urge incontinence unresponsive to medical and/or behavioral therapy were injected subtrigonally with 10 ml. 0.25% bupivacaine. The patients were contacted 24 hours later to determine whether they experienced a decrease in urgency and urge incontinent episodes. The 28 patients with temporary resolution of symptoms were offered operative management. All patients were evaluated with history, physical examination and fluoroscopic urodynamics. The procedure consists of transvaginal dissection of the perivesical fascia from the area of the trigone, including sharp division of the terminal branches of the pelvic nerve.

RESULTS

A total of 28 patients 28 to 83 years old (mean age 54.6) underwent the Ingelman-Sundberg procedure from April 1993 to September 1997. All patients presented with a history of urge incontinence, 10 reported concomitant stress incontinence and 10 had documented unstable detrusor contractions on urodynamic evaluation. Needle suspension and the pubovaginal sling procedure were performed with the Ingelman-Sundberg procedure in 1 case each. Mean followup was 44.1 months (range 14 to 67). Of the patients 15 (54%) achieved the complete durable resolution of urge incontinence, 4 (14%) were improved and 9 (32%) were unchanged.

CONCLUSIONS

Ingelman-Sundberg bladder denervation resulted in a 68% long-term cure or improved rate in a difficult patient population, namely those with intractable urge incontinence. This brief, minimally invasive procedure is an excellent alternative to more aggressive surgical options.

Long-term results of Ingelman-Sundberg denervation procedure for urge incontinence refractory to medical therapy

PURPOSE

Urge incontinence refractory to anticholinergic medication and behavioral techniques is a therapeutic challenge. We evaluated the durability of the modified Ingelman-Sundberg detrusor denervation procedure as minimally invasive surgical therapy for intractable urge incontinence.

MATERIALS AND METHODS

Patients presenting with severe urge incontinence unresponsive to medical and/or behavioral therapy were injected subtrigonally with 10 ml. 0.25% bupivacaine. The patients were contacted 24 hours later to determine whether they experienced a decrease in urgency and urge incontinent episodes. The 28 patients with temporary resolution of symptoms were offered operative management. All patients were evaluated with history, physical examination and fluoroscopic urodynamics. The procedure consists of transvaginal dissection of the perivesical fascia from the area of the trigone, including sharp division of the terminal branches of the pelvic nerve.

RESULTS

A total of 28 patients 28 to 83 years old (mean age 54.6) underwent the Ingelman-Sundberg procedure from April 1993 to September 1997. All patients presented with a history of urge incontinence, 10 reported concomitant stress incontinence and 10 had documented unstable detrusor contractions on urodynamic evaluation. Needle suspension and the pubovaginal sling procedure were performed with the Ingelman-Sundberg procedure in 1 case each. Mean followup was 44.1 months (range 14 to 67). Of the patients 15 (54%) achieved the complete durable resolution of urge incontinence, 4 (14%) were improved and 9 (32%) were unchanged.

CONCLUSIONS

Ingelman-Sundberg bladder denervation resulted in a 68% long-term cure or improved rate in a difficult patient population, namely those with intractable urge incontinence. This brief, minimally invasive procedure is an excellent alternative to more aggressive surgical options.

Polypropylene mesh tape for stress urinary incontinence: complications of urethral erosion and outlet obstruction

PURPOSE

Gynecare tension-free vaginal tape (Ethicon, Inc., New Brunswick, New Jersey) is a propylene mesh tape recently introduced in the United States as minimally invasive treatment for stress urinary incontinence. We report the combined experience at 3 tertiary care institutions with graft erosion and bladder outlet obstruction after procedures performed elsewhere.

MATERIALS AND METHODS

We reviewed the records of 5 patients with complications who presented to 1 of 3 institutions after polypropylene mesh tape placement. All pertinent information was obtained from the medical records and the operating surgeon at the referring institution.

RESULTS

Treatment was required in 2 patients with urethral erosion, 1 with vaginal and bladder erosion, and 2 with bladder outlet obstruction. Common presenting symptoms included urge, urge incontinence and gross hematuria. Cystoscopy showed polypropylene graft erosion at the urethra or through the bladder wall. Each patient required explantation of the polypropylene mesh tape and further surgery to restore continence. The graft was divided transvaginally in the 2 patients presenting with outlet obstruction. Urge incontinence resolved and they returned to complete spontaneous voiding.

CONCLUSIONS

High clinical suspicion is necessary when evaluating patients presenting with urinary symptoms after polypropylene mesh tape placement. Bladder outlet obstruction and possible graft erosion should be considered.

Rodent carcinogenicity with the thiazolidinedione antidiabetic agent troglitazone

Carcinogenic potential of the thiazolidinedione antidiabetic troglitazone was assessed in 104-week studies in mice and rats. Mice were given 50, 400, or 800 mg/kg, male rats 100, 400, or 800 mg/kg, and female rats 25, 50, or 200 mg/kg. Vehicle and placebo controls were included. Survival was significantly decreased in both sexes of both species at high doses, but was adequate for valid evaluation of carcinogenicity. Hypertrophy and hyperplasia of brown adipose tissue was observed in both species at all doses, and fatty change and hypocellularity of bone marrow was noted in mice at all doses and in female rats at 50 and 200 mg/kg. Hepatocellular vacuolation was observed in mice at 400 and 800 mg/kg, and centrilobular hepatocellular hypertrophy occurred in rats at > or = 200 mg/kg. Ventricular dilatation, myocardial fibrosis, and atrial myocyte karyomegaly in male rats at 400 and 800 mg/kg and female rats at all doses were morphologically similar to spontaneous lesions, but incidence and severity were increased compared with controls. In mice, the incidence of hemangiosarcoma was increased in females at 400 mg/kg and in both sexes at 800 mg/kg. The incidence of hepatocellular carcinoma was increased in female mice at 800 mg/kg. Troglitazone exposure [AUC((0-24))] at the lowest dose associated with increased tumor incidence in mice was 16 times human therapeutic exposure at 400 mg daily. No tumors of any type were increased in rats at exposures up to 47 times therapeutic exposure.

Polypropylene mesh tape for stress urinary incontinence: complications of urethral erosion and outlet obstruction

PURPOSE

Gynecare tension-free vaginal tape (Ethicon, Inc., New Brunswick, New Jersey) is a propylene mesh tape recently introduced in the United States as minimally invasive treatment for stress urinary incontinence. We report the combined experience at 3 tertiary care institutions with graft erosion and bladder outlet obstruction after procedures performed elsewhere.

MATERIALS AND METHODS

We reviewed the records of 5 patients with complications who presented to 1 of 3 institutions after polypropylene mesh tape placement. All pertinent information was obtained from the medical records and the operating surgeon at the referring institution.

RESULTS

Treatment was required in 2 patients with urethral erosion, 1 with vaginal and bladder erosion, and 2 with bladder outlet obstruction. Common presenting symptoms included urge, urge incontinence and gross hematuria. Cystoscopy showed polypropylene graft erosion at the urethra or through the bladder wall. Each patient required explantation of the polypropylene mesh tape and further surgery to restore continence. The graft was divided transvaginally in the 2 patients presenting with outlet obstruction. Urge incontinence resolved and they returned to complete spontaneous voiding.

CONCLUSIONS

High clinical suspicion is necessary when evaluating patients presenting with urinary symptoms after polypropylene mesh tape placement. Bladder outlet obstruction and possible graft erosion should be considered.

Salvage cryotherapy for recurrent prostate cancer after radiotherapy: variables affecting patient outcome

PURPOSE

To determine the long-term disease-specific survival (DSS) and disease-free survival (DFS) rates after salvage cryotherapy for locally recurrent adenocarcinoma of the prostate and to identify pretreatment factors that have an impact on DSS and DFS.

PATIENTS AND METHODS

Between July 1992 and January 1995, 131 patients who had received definitive radiation therapy (XRT) underwent salvage cryotherapy for locally recurrent adenocarcinoma of the prostate. Cryotherapy failure was defined as an increasing postcryotherapy prostate-specific antigen (PSA) level of > or = 2 ng/mL above the postcryotherapy nadir, a positive prostate biopsy, or radiographic evidence of metastatic disease. Clinical variables were studied to determine whether there was an association with the DSS and DFS.

RESULTS

The median follow-up was 4.8 years. The 5-year DSS rates were 87% for patients with a precryotherapy Gleason score < or = 8 and 63% for those with Gleason scores of 9 and 10 (P =.012). The 5-year DFS rates were 57% for patients with a precryotherapy PSA level of < or = 10 ng/mL and 23% for those with a PSA level greater than 10 ng/mL (P =.0004). The 5-year DSS rates for patients with a pre-XRT clinical stage of T1 to T2 and those with a clinical stage of T3 to T4 were 94% and 72%, respectively (P =.0041). The 5-year DFS rates for these groups were 90% and 69%, respectively (P =.0057).

CONCLUSION

Androgen-independent local recurrences, Gleason score, and pre-XRT clinical stage were important factors that had an impact on DSS and DFS. The subset of patients cured by salvage cryotherapy seems to be small, and patient selection is important.

Chronic toxicity in monkeys with the thiazolidinedione antidiabetic agent troglitazone

The antidiabetic agent troglitazone was given to groups of 4 cynomolgus monkeys per sex at 300, 600, or 1200 mg/kg daily by gavage for 52 weeks. A group of 4 monkeys per sex received vehicle alone and served as controls. Emesis and soft stool or diarrhea occurred sporadically in all troglitazone-treated groups, but did not compromise animal health. There were no effects on body weight or food consumption, or ophthalmologic, electrocardiographic, or echocardiographic parameters. Erythrocyte count, hemoglobin, and hematocrit decreased 8% to 16% in males at all doses and serum cholesterol decreased 30% to 46% in both sexes at all doses. Urinary ketones were increased in several animals at 600 and 1200 mg/kg. Absolute and relative liver weights increased at all doses in both sexes by 40% to 71%. The only microscopic change attributable to troglitazone treatment was minimal to mild bile duct hyperplasia in males at all doses and in females at 600 and 1200 mg/kg. No differences in systemic exposure were apparent between sexes. Over the dose range tested, AUC(0-24) values were 27 to 102 micrograms.hr/ml of troglitazone, 401 to 2060 micrograms.hr/ml of its sulfate conjugate, and 34 to 312 micrograms.hr/ml of its quinone metabolite. Therefore, oral administration of troglitazone to monkeys at 300, 600, and 1200 mg/kg for 52 weeks resulted in significant systemic exposure, with only minimal gastrointestinal, hematologic, and hepatic effects.