Female Stress Urinary Incontinence Clinical Guidelines Panel summary report on surgical management of female stress urinary incontinence. The American Urological Association

PURPOSE

The American Urological Association convened the Female Stress Urinary Incontinence Clinical Guidelines Panel to analyze the literature regarding surgical procedures for treating stress urinary incontinence in the otherwise healthy female subject and to make practice recommendations based on the treatment outcomes data.

MATERIALS AND METHODS

The panel searched the MEDLINE data base for all articles through 1993 on surgical treatment of female stress urinary incontinence. Outcomes data were extracted from articles accepted after panel review. The data were then meta-analyzed to produce outcome estimates for alternative surgical procedures.

RESULTS

The data indicate that after 48 months retropubic suspensions and slings appear to be more efficacious than transvaginal suspensions, and also more efficacious than anterior repairs. The literature suggests higher complication rates when synthetic materials are used for slings.

CONCLUSIONS

The panel found sufficient acceptable long-term outcomes data (longer than 48 months) to conclude that surgical treatment of female stress urinary incontinence is effective, offering a long-term cure in a significant percentage of women. The evidence supports surgery as initial therapy and as a secondary form of therapy after failure of other treatments for stress urinary incontinence. Retropubic suspensions and slings are the most efficacious procedures for long-term success (based on cure/dry rates). However, in the panel's opinion retropubic suspensions and sling procedures are associated with slightly higher complication rates, including longer convalescence and postoperative voiding dysfunction.

The standardization of terminology for researchers in female pelvic floor disorders

The lack of standardized terminology in pelvic floor disorders (pelvic organ prolapse, urinary incontinence, and fecal incontinence) is a major obstacle to performing and interpreting research. The National Institutes of Health convened the Terminology Workshop for Researchers in Female Pelvic Floor Disorders to: (1) agree on standard terms for defining conditions and outcomes; (2) make recommendations for minimum data collection for research; and (3) identify high priority issues for future research. Pelvic organ prolapse was defined by physical examination staging using the International Continence Society system. Stress urinary incontinence was defined by symptoms and testing; 'cure' was defined as no stress incontinence symptoms, negative testing, and no new problems due to intervention. Overactive bladder was defined as urinary frequency and urgency, with and without urge incontinence. Detrusor instability was defined by cystometry. For all urinary symptoms, defining 'improvement' after intervention was identified as a high priority. For fecal incontinence, more research is needed before recommendations can be made. A standard terminology for research on pelvic floor disorders is presented and areas of high priority for future research are identified.

Persistence and adherence in the treatment of overactive bladder syndrome with anticholinergic therapy: a systematic review of the literature

Overactive bladder syndrome (OAB) is a chronic condition that has an impact on patients' daily activities and health-related quality of life (HRQL). Anticholinergic therapy is often prescribed following insufficient results with behaviour modification alone; however, rates of treatment discontinuation are consistently high. This study systematically reviewed persistence and adherence data in patients with OAB treated with anticholinergic therapy. A search focused on the intersection of OAB, persistence/adherence, and anticholinergic therapy was conducted in MEDLINE and EMBASE. Articles published after 1998 were reviewed and selected for inclusion based on prespecified criteria. A total of 147 articles and two abstracts were included in the review. Results from 12-week clinical trials showed high rates of discontinuation, ranging from 4% to 31% and 5% to 20% in treatment and placebo groups, respectively. Unsurprisingly, rates of discontinuation found in medical claims studies were substantially higher, with 43% to 83% of patients discontinuing medication within the first 30 days and rates continuing to rise over time. Findings from medical claims studies also suggest that over half of patients never refill their initial prescription and that adherence levels tend to be low, with mean/median medication possession ratio (MPR) values ranging from 0.30 to 0.83. The low levels of persistence and adherence documented in this review reveal cause for concern about the balance between the efficacy and tolerability of anticholinergic agents. Strategies should be identified to increase persistence and adherence. New agents and non-pharmacologic alternatives with good efficacy and minimal side effects should be explored.

Neuroanatomy of the male rhabdosphincter

OBJECTIVES

The external striated urethral sphincter (rhabdosphincter) is a tubular muscle sleeve that extends from the prostato-membranous urethra and perineal membrane to the bladder neck. The male rhabdosphincter neuroanatomy remains unclear, and a better understanding of its innervation may provide insight into potential modifications of radical pelvic surgery to improve urinary continence.

METHODS

Fresh cadaveric dissections of 12 male hemipelves were undertaken to investigate the neuroanatomy of the urinary rhabdosphincter.

RESULTS

Neuroanatomic courses of the nerve supply to the rhabdosphincter revealed that, in the perineum, the perineal nerve (a terminal branch of the pudendal nerve) provided branches directly to the bulbospongiosus muscle and the urinary rhabdosphincter. In the pelvis, the course of the pelvic nerve was as follows: (1) arising from the inferior hypogastric plexus, it had a weblike course beneath the muscle fascia of the levator ani muscle; (2) traveling posterolateral to the rectum, it gave many branches that perforated into the lateral rectum; and (3) at the level of the prostatic apex, still beneath the levator ani muscle fascia (superior fascia), it sent multiple direct branches to the inferolateral aspect of urinary rhabdosphincter. The pudendal nerve traversed the pelvis in the pudendal canal, and, before leaving the pelvis to enter the perineum, it gave an intrapelvic branch that courses with the pelvic nerve to innervate the rhabdosphincter.

CONCLUSIONS

Our understanding of the neuroanatomy of what may be the continence nerves has been improved by fresh cadaveric dissection. The rhabdosphincter receives nerve fibers from the pelvic nerve and dual innervation from an intrapelvic branch and a perineal branch of the pudendal nerve. Better understanding of these anatomic findings may have potential surgical significance with respect to improvement in postoperative urinary continence.

Erosion of woven polyester pubovaginal sling

PURPOSE

Various materials have been used for pubovaginal slings to correct female stress urinary incontinence. Use of synthetic materials provides a theoretical advantage in that no graft harvesting is necessary. Major risks of synthetic material use are erosion and infection of the sling. We report on erosion of woven polyester slings treated with pressure injected bovine collagen (ProteGen) which required removal.

MATERIALS AND METHODS

Office records of patients who had ProteGen slings removed at 5 centers during the last 24 months were retrospectively reviewed. Presenting symptoms, interval between sling placement and removal, subsequent procedures and continence status following sling removal were evaluated.

RESULTS

A total of 34 women required removal of the polyester sling secondary to erosion, infection or pain. The most common presenting complaints were delayed vaginal discharge in 21 patients (62%), vaginal pain or pressure in 21 (62%), suprapubic pain in 11 (32%) and recurrent urinary tract infection in 5 (15%) at a mean of 7.95 months (range 1 to 22) after sling placement. Of the patients 17 (50%) had vaginal erosion only, 7 (20%) isolated urethral erosion and 6 (17%) urethrovaginal fistulas. In 4 patients no erosion was obvious but slings were removed secondary to vaginal pain. Before sling removal 16 patients (47%) were totally dry, 13 (38%) had some degree of urinary incontinence and 3 (8%) had retention. Following sling removal 7 patients (20%) remained dry, 25 (74%) had mild to severe stress urinary incontinence with or without urgency and urge incontinence, and 2 (6%) are pending followup.

CONCLUSIONS

Woven polyester slings treated with pressure injected bovine collagen are prone to erosion. Although the ProteGen sling was recalled in January 1999, patients who have had the sling placed must be followed closely.

Association of level of injury and bladder behavior in patients with post-traumatic spinal cord injury

OBJECTIVES

The expected urodynamic findings of patients with suprasacral and sacral spinal cord injury have previously been reported. However, the associations between the radiographically determined level or levels of injury and urodynamic findings are ill defined. This study investigated these relationships, specifically the bladder behavior of patients with post-traumatic spinal cord injury with combined suprasacral and sacral injuries.

METHODS

A retrospective review of the patient records, spinal imaging studies, and video-urodynamic studies of 316 patients with post-traumatic spinal cord injury was performed. Of these patients, 243 had complete spinal computed tomography or magnetic resonance imaging studies and constitute the study population. Patients were categorized by the radiographically determined level or levels of injury, clinical neurologic level and completeness of injury, and urodynamic findings.

RESULTS

Of the 196 patients with suprasacral injuries, 186 (94.9%) demonstrated hyperreflexia and/or detrusor sphincter dyssynergia, 82 (41.8%) had low bladder compliance (less than 12.5 mL/cm H(2)O), and 79 (40.3%) had high detrusor leak point pressures (greater than 40 cm H(2)O). Of the 14 patients with sacral injuries, 12 (85.7%) manifested areflexia, 11 (78.6%) had low compliance, and 12 (85.7%) had high leak point pressures. Of the 33 patients with combined suprasacral and sacral injuries, urodynamic studies showed 23 with hyperreflexia and/or detrusor sphincter dyssynergia (67.7%), 9 with areflexia (27.3%), 19 (57.6%) with low compliance, and 20 (60.6%) with high leak point pressures.

CONCLUSIONS

In patients with a single level of spinal cord injury, this study revealed a significant association between the level of injury and the type of voiding dysfunction. Patients with combined suprasacral and sacral injuries, as identified with precise spinal imaging techniques, had relatively unpredictable urodynamic findings. Management of the urinary tract in patients with spinal cord injury must be based on urodynamic findings rather than inferences from the neurologic evaluation.

Preservation of putative continence nerves during radical retropubic prostatectomy leads to more rapid return of urinary continence

OBJECTIVES

Urinary incontinence is a significant complication of radical pelvic surgery. A better understanding of the neuroanatomy of the rhabdosphincter has led to the modification of the radical retropubic prostatectomy to optimize the recovery of postoperative urinary control.

METHODS

Mock radical retropubic prostatectomy was performed on fresh cadavers to determine which surgical maneuvers could injure what may be the continence nerves. To assess the clinical significance of modifying the radical retropubic prostatectomy based on these anatomic studies, a contemporary series of 60 consecutive patients who underwent radical retropubic prostatectomy with continence nerve preservation was compared with a control group of 38 consecutive patients who had a standard anatomic radical retropubic prostatectomy.

RESULTS

At the level of the prostatic apex, both the pelvic and pudendal nerves gave intrapelvic branches that bilaterally coursed to the external urinary sphincter to enter at the 5 and 7 o'clock positions. The mock radical prostatectomy revealed that the nerves to the external urinary sphincter were most prone to injury when a right angle clamp was used to develop a plane between the posterior rhabdosphincter and anterior rectum and if the urethral anastomotic sutures were placed at the 5 and 7 o'clock positions. In addition, blunt dissection of the tips of the seminal vesicles injured the inferior hypogastric plexus. Modifications to preserve the continence nerves were incorporated in the anatomic radical prostatectomy. Although overall continence rates were similar for the two groups (98.3% for continence nerve-preserving radical prostatectomy versus 92. 1% for standard prostatectomy), continence nerve preservation decreased the time to achieve continence.

CONCLUSIONS

During radical retropubic prostatectomy, surgical maneuvers that avoid injury to the continence nerves resulted in the more rapid return of urinary control.

Experience with the management of urethral diverticulum in 63 women

The presentation and management are reviewed of 63 women with urethral diverticulum seen at a single institution in 10 years. Of the women 36 (61.9%) had urinary incontinence as a presenting symptom and 20 (31.7%) had incontinence as the only presenting complaint. Diverticula were suspected in 57 cases (90.5%) based on the presence of a periurethral mass during pelvic examination. Investigations included voiding cystourethrogram, excretory urogram, urodynamic studies and recently transvaginal ultrasound. Voiding cystourethrography adequately demonstrated the diverticulum in 60 of the 63 women (95.2%). Urodynamic studies performed in 58 women revealed abnormal findings in 36 (62%), including genuine stress urinary incontinence in 28 (48.3%). The location/number/size/configuration, communication, continence classification was used to define the characteristics of the diverticula. Seven women either refused operation or had small asymptomatic diverticula not requiring treatment. Transvaginal diverticulectomy was performed using a 3-layer closure in 56 women. Concomitant bladder neck suspension was performed in 27 women with documented stress urinary incontinence and/or urethral hypermobility. With a mean followup of 70 months (range 6 to 136) 48 women (85.7%) were completely relieved of the presenting complaint. Complications of diverticulectomy included 2 small distal recurrent diverticula, 1 urethrovaginal fistula and 6 transient early urinary tract infections. None of the women had urethral stricture or recurrent urinary tract infection. Six women (22.2%) who underwent diverticulectomy and bladder neck suspension, and 3 (10.3%) treated with diverticulectomy alone had minimal urinary incontinence requiring less than 2 pads a day.

Female Stress Urinary Incontinence Clinical Guidelines Panel summary report on surgical management of female stress urinary incontinence. The American Urological Association

PURPOSE

The American Urological Association convened the Female Stress Urinary Incontinence Clinical Guidelines Panel to analyze the literature regarding surgical procedures for treating stress urinary incontinence in the otherwise healthy female subject and to make practice recommendations based on the treatment outcomes data.

MATERIALS AND METHODS

The panel searched the MEDLINE data base for all articles through 1993 on surgical treatment of female stress urinary incontinence. Outcomes data were extracted from articles accepted after panel review. The data were then meta-analyzed to produce outcome estimates for alternative surgical procedures.

RESULTS

The data indicate that after 48 months retropubic suspensions and slings appear to be more efficacious than transvaginal suspensions, and also more efficacious than anterior repairs. The literature suggests higher complication rates when synthetic materials are used for slings.

CONCLUSIONS

The panel found sufficient acceptable long-term outcomes data (longer than 48 months) to conclude that surgical treatment of female stress urinary incontinence is effective, offering a long-term cure in a significant percentage of women. The evidence supports surgery as initial therapy and as a secondary form of therapy after failure of other treatments for stress urinary incontinence. Retropubic suspensions and slings are the most efficacious procedures for long-term success (based on cure/dry rates). However, in the panel's opinion retropubic suspensions and sling procedures are associated with slightly higher complication rates, including longer convalescence and postoperative voiding dysfunction.

Fournier's gangrene: therapeutic impact of hyperbaric oxygen

Many controversial issues exist surrounding the disease pathogenesis and optimal management of Fournier's gangrene. In Fournier's original descriptions, the disease arose in healthy subjects without an obvious cause. Most contemporary studies, however, are able to identify definite urologic or colorectal etiologies in a majority of cases. To investigate disease presentation, treatment modalities, and overall mortality, a retrospective analysis of Fournier's gangrene from a single institution is presented. Since 1990, 26 cases of Fournier's gangrene have been diagnosed at the University of Tennessee. An evaluation of intercurrent disease revealed that 38 percent of the patients had diabetes mellitus, 35 percent manifested ethanol abuse, and 12 percent were systemically immunosuppressed. Fifteen patients (58 percent) presented with identifiable etiologies for their disease: 31 percent (8) urethral disease or trauma, 19 percent (5) colorectal disease, and 8 percent (2) penile prostheses. Management in all cases involved prompt surgical debridement with initiation of broad-spectrum antibiotics. Multiple debridements, orchiectomy, urinary diversion, and fecal diversion were performed as clinically indicated. Fourteen patients received hyperbaric oxygen as adjuvant therapy. Statistically significant results were noted with mortality rates of 7 percent in the group receiving hyperbaric oxygen (n = 14) versus 42 percent in the group not receiving hyperbaric oxygen (n = 12). Overall mortality was 23 percent. Controversy still surrounds disease pathogenesis in Fournier's gangrene, particularly in regard to etiology. Our study corroborates current trends in that a clear focus or origin was identified in a majority of the cases. Although a grim prognosis usually accompanies the diagnosis, this study shows significant improvement combining traditional surgical and antibiotic regimens with hyperbaric oxygen therapy.

Injectable agents in the treatment of stress urinary incontinence in women: where are we now?

Periurethral bulking agents have been used for decades. The only currently available agents (in the United States) include glutaraldehyde cross-linked collagen, autologous fat, and carbon bead technology. Initial subjective cure rates with collagen are acceptable, but with the majority of women requiring reinjection. The risk of allergic phenomena complicates collagen use. Autologous fat injection is initially effective in >50% of women, but resorption and fibrous replacement hamper the stability of the transplanted graft. Polytetrafluoroethylene and silicone are not currently approved by the US Food and Drug Administration because of particle migration. Materials in development include biologic agents such as allogeneic human collagen and autologous cartilage. Developmental synthetic agents include microballoon technology, hyaluronic acid with or without microsphere technology, hydroxylapatite, and a variety of polymeric technologies. Patient selection and material characteristics influence the optimal choice for injectable agent.

Clinical significance of detrusor sphincter dyssynergia type in patients with post-traumatic spinal cord injury

OBJECTIVES

To investigate the significance of categorizing detrusor sphincter dyssynergia (DSD) by type in patients with chronic spinal cord injury.

METHODS

A retrospective review of the charts, video-urodynamic studies, and upper tract radiographic studies of 269 patients with post-traumatic, suprasacral spinal cord injuries was performed. The patients were categorized according to the DSD type (intermittent or continuous), level and completeness of injury, intravesical pressure at leak, upper tract complications, and interval since injury.

RESULTS

Of the 269 patients, 20 (7.4%), 216 (80.3%), and 33 (12.3%) had no DSD, intermittent DSD, and continuous DSD, respectively. No significant association between the specific level of injury and the DSD type was found (P = 0.71). The presence of DSD was associated with complete injuries, elevated intravesical pressures, and upper tract complications (P <0.01); these associations were more prominent with continuous DSD than with intermittent DSD. The proportion of patients with no DSD, intermittent DSD, and continuous DSD was unchanged during the chronic follow-up period.

CONCLUSIONS

The clinical significance of DSD type is not crucial, since patients with both intermittent and continuous DSD require urodynamic surveillance and expedient treatment to minimize urologic complications. However, the presence of continuous DSD is one of several factors that may require earlier urodynamic follow-up.

Outpatient visual laser-assisted prostatectomy under local anesthesia

OBJECTIVE

Visual laser-assisted prostatectomy (VLAP) with a noncontact right-angle delivery system recently has been introduced as a new treatment option for symptomatic outlet obstruction secondary to benign prostatic hyperplasia. The right-angle laser technology has numerous potential advantages over traditional transurethral resection of the prostate. These advantages include the feasibility of performing the VLAP procedure under local anesthesia without bleeding. We summarize our experience with VLAP performed with local anesthesia administered with periprostatic block.

METHODS

This technique was employed in 46 men with symptomatic BPH as an outpatient procedure. All men were evaluated prior to surgery with flow rates, residual volume determinations, and AUA-6 symptom score analyses. Follow-up occurred at three and six months and included repeat measures of flow rates, residual volumes, and symptom scores.

RESULTS

Mean AUA symptom scores and uroflow parameters significantly improved with six months' follow-up. No significant complications were encountered.

CONCLUSIONS

VLAP under local anesthesia as an outpatient procedure is a promising treatment alternative for men with symptomatic benign prostatic hyperplasia.

Multicenter prospective randomized 52-week trial of calcium hydroxylapatite versus bovine dermal collagen for treatment of stress urinary incontinence

OBJECTIVES

To evaluate the safety and effectiveness of soft-tissue augmentation of the urethral sphincter with calcium hydroxylapatite (CaHA; Coaptite) compared with glutaraldehyde cross-linked bovine collagen (Contigen) in female patients with stress urinary incontinence due to intrinsic sphincter deficiency and without associated urethral hypermobility.

METHODS

This 12-month prospective, randomized, comparative, multicenter, single-blind, parallel, clinical trial of CaHA and collagen for soft-tissue augmentation of the urethral sphincter in the treatment of stress urinary incontinence enrolled 296 women. Up to five injections were performed in the first 6 months of the trial. Twelve-month postinjection efficacy data were available for 231 patients.

RESULTS

The results indicated that CaHA and collagen were both well tolerated in this study. No systemic adverse events were observed with either product. We used the Stamey Urinary Incontinence Scale to grade the improvement, which was the primary endpoint of the study. At 12 months, 83 (63.4%) of 131 CaHA patients compared with 57 (57.0%) of 100 collagen patients showed improvement of one Stamey grade or more (P = 0.34). More CaHA patients required only one injection (n = 60; 38.0%) during the study compared with the Contigen patients (n = 36; 26.1%; P = 0.034). Also, the average total volume of material injected during the course of the study was less for CaHA than for collagen (4.0 mL versus 6.6 mL, respectively; P <0.0001).

CONCLUSIONS

The results of the study have demonstrated that Coaptite is an appropriate and well-tolerated treatment for patients with incontinence due to intrinsic sphincter deficiency. This new soft-tissue augmentation material has a good safety profile and appears to provide durable improvement.

Systematic review of the relationship between bladder and bowel function: implications for patient management

BACKGROUND

The complex relationship between bladder and bowel function has implications for treating pelvic disorders. In this systematic review, we discuss the relationship between bladder and bowel function and its implications for managing coexisting constipation and overactive bladder (OAB) symptoms.

METHODS

Multiple PubMed searches of articles published in English from January 1990 through March 2011 were conducted using combinations of terms including bladder, bowel, crosstalk, lower urinary tract symptoms, OAB, incontinence, constipation, hypermotility, pathophysiology, prevalence, management and quality of life. Articles were selected for inclusion in the review based on their relevance to the topic.

RESULTS

Animal studies and clinical data support bladder-bowel cross-sensitization, or crosstalk. In the rat, convergent neurons in the bladder and bowel as well as some superficial and deeper lumbosacral spinal neurons receive afferent signals from both bladder and bowel. On a functional level, in animals and humans, bowel distention affects bladder activity and vice versa. Clinically, the bladder-bowel relationship is evident through the presence of urinary symptoms in patients with irritable bowel syndrome and bowel symptoms in patients with acute cystitis. Functional gastrointestinal disorders, such as constipation, can contribute to the development of lower urinary tract symptoms, including OAB symptoms, and treatment of OAB with antimuscarinics can worsen constipation, a common antimuscarinic adverse effect. The initial approach to treating coexisting constipation and OAB should be to relieve constipation, which may resolve urinary symptoms.

CONCLUSIONS

The relationship between bladder and bowel function should be considered when treating patients with urinary symptoms, bowel symptoms, or both.

Primary bladder neck obstruction: urodynamic findings and treatment results in 36 men

PURPOSE

We reviewed the urodynamic findings and treatment outcomes of a large series of men with primary bladder neck obstruction.

MATERIALS AND METHODS

A retrospective review was done of the presenting symptoms and urodynamic findings of 36 men with primary bladder neck obstruction. Outcomes after treatment with alpha-blockers, transurethral incision of the bladder neck and prostate, or no long-term therapy were determined by chart review and patient survey in the majority of cases.

RESULTS

Mean age of the men was 41 years. Patients had significant lower urinary tract symptoms, decreased peak urinary flow rates, elevated post-void residual, markedly elevated peak voiding pressures and poor funneling of the bladder neck during voiding. Although most patients initially chose alpha-blocker therapy, only 30% of those beginning alpha-blockers continued them long term, usually due to inadequate symptomatic improvement. A total of 18 men underwent transurethral incision, which resulted in significant improvements in symptom scores, peak urinary flow rates, post-void residual and peak voiding pressures. Patients reported a mean 87% overall improvement in symptoms after transurethral incision.

CONCLUSIONS

Video urodynamics facilitate diagnosis of primary bladder neck obstruction. Transurethral incision is the most effective therapy for primary bladder neck obstruction.

Advancements in pharmacologic management of the overactive bladder

Continued developments in the understanding of lower urinary tract function have led to improvements in the pharmacologic manipulation of bladder dysfunction. Drug delivery changes have produced drugs that provide better efficacy and tolerability, thus improving patient compliance. Improvements in drug delivery systems have altered drug bioavailability and pharmacokinetics. Active current investigation in new agents and delivery systems for intravesical delivery has yielded intriguing early results that may substantially add to the armamentarium for the management of the overactive bladder (urgency, frequency, urge incontinence). New developments in the understanding of the neuropharmacology of the bladder, peripheral pelvic nerves, and sacral cord may provide agents with entirely new drug effects, either as primary agents or agents to be used in combination with currently available drugs. We herein review newer agents and drug delivery systems.

Neuroanatomy of the pelvis: implications for colonic and rectal resection

PURPOSE

Urinary dysfunction remains a common complication of radical pelvic surgery, particularly after abdominoperineal resection. In treating rectal carcinoma, the extent of primary resection and lymphadenectomy are major determinants in the degree of postoperative urologic morbidity.

METHODS

Twelve male and eight female hemipelves from fresh cadavers were dissected with reference to the neuroanatomy of the lower genitourinary tract. These cadavers were dissected within twelve hours of thaw from frozen state. The cadavers were hemisected at the level of the sacral promontory for better exposure of neural trunks and vascular structures leading into the pelvis. These structures were followed down sequentially into the true pelvis, using magnified dissection under operating microscope or loupe dissection or both.

RESULTS

Coordinated lower urinary tract function relies on both autonomic and somatic nerve activity. Emanating from the inferior hypogastric plexus, the pelvic nerve supplies sympathetic and parasympathetic innervation to the pelvic viscera. The course of the pelvic nerve is as follows: 1) from the inferior hypogastric plexus, it has multiple branches forming a web-like complex within the endopelvic fascial sleeve, some of which innervate the bladder detrusor; 2) a main branch traveling inferolateral to the rectum remains deep to the fascia of the levator ani muscle and courses to the external urinary sphincter; 3) at the level of the prostatic apex (or bladder neck in females), this pelvic nerve branch sends direct branches to the urinary sphincter. The pudendal nerve traverses the pelvis in the pudendal canal, and before leaving the pelvis to enter the perineum, it gives an intrapelvic branch that courses alongside the ischium to enter the external urinary sphincter. In the ischiorectal fossa, terminal branches of the pudendal nerve (i. e., perineal nerve) can be seen inserting into the urinary sphincter.

CONCLUSIONS

Urinary retention and urinary incontinence represent two distinct urologic complications after abdominoperineal resection. Injury to detrusor branches of the pelvic nerve can cause detrusor denervation and urinary retention. In addition, injury to intrapelvic branches of the pelvic and pudendal nerves to the urinary sphincter can result in intrinsic sphincter deficiency and urinary incontinence. A better understanding of the neuroanatomy of the lower genitourinary tract can give a physiologic basis for clinical findings of postoperative voiding dysfunction and may help the surgeon refine surgical technique by more precisely determining resection limits to minimize urologic complications.

Role of the four-corner bladder neck suspension to correct stress incontinence with a mild to moderate cystocele

OBJECTIVES

Women undergoing four-corner bladder neck suspension were evaluated for subjective and objective results of the procedure. Patients were evaluated for continence, prolapse, and symptomatic status postoperatively.

METHODS

Forty-seven women underwent four-corner bladder neck suspension for moderate cystocele with (44) or without (3) stress urinary incontinence. Mean and median follow-up were 37 months (range 15 to 80). To assess results of the four-corner bladder neck suspension, two sets of outcome measures were used (subjective questionnaire, including patient satisfaction, and objective physical examination, with standing voiding cystourethrogram) to compare pre- and postoperative data.

RESULTS

At the time of follow-up, 25 patients (53%) reported no incontinence, 14 (30%) reported one incontinent episode per week, and 8 (17%) reported daily loss of urine. Twenty-seven (57%) had grade I or grade II cystoceles on follow-up examination and voiding cystourethrogram; however, only 12 (26%) experienced recurrent prolapse symptomatology. Overall patient acceptance of the procedure was high (70%).

CONCLUSIONS

The four-corner bladder neck suspension is an effective option in the management of moderate cystocele.

The risk of rhabdomyolysis and acute renal failure with the patient in the exaggerated lithotomy position

Rhabdomyolysis with subsequent renal failure has been well documented as a complication of major trauma. However, this complication from elective urological procedures is less well recognized. In 10 patients who underwent elective urethroplasty serum levels of creatine kinase and urinary myoglobin were examined preoperatively and postoperatively. These patients were placed in the lithotomy position for several hours and had minimal muscle dissection. Serum creatine kinase was noted to increase significantly postoperatively to greater than 1,000 units and in 1 patient myoglobin was detected in the urine. This finding indicates that there is, indeed, a risk of muscle injury and potential rhabdomyolysis in these patients from the use of the exaggerated lithotomy position.

Pelvic recurrence after radical cystectomy without preoperative radiation

Between March 1, 1983 and December 31, 1985, 178 patients underwent radical cystectomy without preoperative radiation on the urology service at our university hospital and tumor institute. Of the patients 33 per cent received postoperative adjuvant chemotherapy. Over-all, the pelvic recurrence rate was 6 per cent. The recurrence rate by stage was stage O/A 2 per cent, stage B 5 per cent, stage C 6 per cent and stage D 15 per cent. The results demonstrate that adequate local control can be achieved without routine use of preoperative radiation.

Vesica percutaneous bladder neck stabilization

The Vesica percutaneous bladder neck stabilization (PBNS) represents a minimally invasive surgical procedure for the treatment of stress incontinence caused by hypermobility of the proximal urethra and bladder neck. Since the initial description of the procedure, technique and instrumentation modifications have added to the reproducibility of this operation. Three specific modifications have been incorporated: strong attachment of the stabilization suture to the pubic bone utilizing a bone anchor; incorporation of a full-thickness broad segment of tissue including the endopelvic, pubocervical, and subvaginal fascia as well as vaginal wall in a Z suture; and loose resuspension of the proximal urethra to stabilize the continence mechanism. Cystoscopic verification of suture location precludes bladder entry or distal suture placement. This procedure has been utilized in 71 women with an overall cure rate (no stress incontinence) of 94% at follow-up of 12 months. One retropubic abscess required drainage, and a second patient required excision of a skin sinus tract caused by an infected bone anchor. Urinary retention longer than 3 weeks has not been encountered. Overall morbidity has been minimal. Long-term follow-up of continence status and other procedure-related complications is ongoing. The PBNS provides continence results and complication rates equivalent to those of other retropubic and transvaginal procedures using a minimally invasive outpatient technique.

Segmental infarction of the testicle: atypical presentation of a testicular mass

Segmental infarction of the testis represents a rare entity. To our knowledge 11 cases have been reported in the literature. We report 4 additional cases of segmental testicular infarction masquerading as testis tumors. Inability to distinguish these benign lesions from malignant testis tumors resulted in orchiectomy in all 4 cases.