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Summary Aims Standardise the injection technique with botulinum toxin type A (BoNT A) in the bladder of patients with overactive bladder (OAB) [idiopathic overactive bladder (iOAB) or neurogenic overactive bladder (nOAB) with urinary incontinence], using a literature review and a survey of an International expert panel. Methods PubMed literature searches of BoNT A in adults with iOAB/nOAB together with a survey of 13 experts from 10 countries. Results Data from 21 articles and completed questionnaires were collated. The procedure can be carried out in an out-/inpatient setting. Dose used in clinical studies vs. clinical practice was 300 and 200 U for nOAB and 200 and 100 U for iOAB. Recent studies have also demonstrated that there are no clinically relevant benefits between 100 and 150 U in iOAB or between 300 and 200 U in nOAB, though adverse effects are increased with higher doses. Usually, 30 sites for nOAB (range: 6.7–10 U/ml) and 20–30 sites for iOAB (range: 5–10 U/ml) are injected in clinical studies vs. 20–30 sites of 1 ml/injection for 200 U in nOAB and 10–20 sites of 0.5–1 ml/injection for 100 U in iOAB in clinical practice. BoNT A is usually injected directly into the detrusor, sparing the trigone. Flexible or rigid cystoscopes are used. The needle should be typically 22–27 gauge and 4 mm in length and should have a stopper to avoid any leakage or perforation of the bladder wall while ensuring a targeted injection. Conclusion Based on the literature and survey analysis, recommendations are proposed for the standardisation of the injection procedure.

Purpose of review The surgical armamentarium for stress urinary incontinence in men ranges from minimally invasive endoscopic procedures to artificial urinary sphincter implantation. In this rapidly moving field, respective indications of surgical options are also evolving, as evidence for the use of innovative devices is growing. This review is focused on recent data about injectables, stem cells and periurethral balloons implantation. Recent findings Periurethral injections are probably the most minimally invasive options, but are considered of low efficacy, with a high recurrence rate in the short term. Reinjections are often needed. However, the market share of periurethral bulking is decreasing relatively slowly. Innovative, so-called regenerative therapies, including injection of biological material, stem cells, myoblasts and muscle strings implantation have shown promising results but did not yet reach maturity for daily use in the clinic. Periurethral balloons implantation shows an acceptable success rate at mid-term follow-up, but are associated with a high rate of complications and reoperations. Summary Indications of periurethral bulking are decreasing. Regenerative therapies are still under investigation in men, and long-term studies are still required. Comparative studies against male slings and other compression devices are still awaited to accurately determine the role of periurethral balloons implantation.

Mesh erosion is one of the major complications of prolapse surgery conducted by transvaginal approach. Following the extensive use of meshes and warning about potential complications, a new classification of mesh-related adverse events has been proposed. Due to the wide scope of clinical features, no standardized approach has been proposed. Surgery is required after failure of conservative management, mostly based on mesh partial or total excision by transvaginal route, following the classic rules of re-do vaginal surgery. Complex cases are best managed in tertiary reference centers.

Data on the Ajust, a new single-incision sling procedure for female stress urinary incontinence (SUI) management, remain scarce and limited to a 1-year follow-up. Our goal was to assess the efficacy of this procedure after a 1-year follow-up.This prospective evaluation involved 95 consecutive patients implanted with Ajust at a single centre. All patients had SUI on urodynamics due to urethral hypermobility, 33 % had preoperative overactive bladder (OAB) symptoms and none had detrusor overactivity. Ninety-two patients were treated on an outpatient basis, and 3 patients had general anaesthesia. Postoperative assessment was conducted at 1, 6, 12 months, and yearly thereafter. The main outcome measure was pad usage. Secondary parameters were self-reported SUI episodes, OAB symptoms, data of clinical examination, satisfaction using the Patient Global Impression of Improvement (PGI-I) scale, postoperative pain, and adverse events.After a mean follow-up of 21 ± 6 months (12-32), 76 out of 95 patients used no pads or one dry security pad, showing a success rate of 80 %. Seventy-nine out of 95 patients had no more SUI-related leakage. Only 6 patients experienced late recurrence of SUI after 6 months' follow-up. Perioperative complications included 1 case of vaginal hematoma, 1 case of acute urinary retention, 2 cases of urinary tract infection, all managed conservatively. Half of the patients had no pain after day 1, free of medications. Late complications were vaginal erosion in 1 case, and pain during exertion in 2 cases.The Ajust single incision transobturator sling is a safe and effective procedure, with durable results after 1 year.

Les traitements chirurgicaux des hyperactivites vesicales neurologiques sont reserves aux echecs des traitements medicaux, conservateurs. Le but de ces interventions est d’obtenir un reservoir vesical de bonne capacite qui se remplit a basse pression. Cela permet de diminuer les symptomes, de preserver le haut appareil urinaire et de diminuer les complications des vessies neurologiques. Plusieurs options therapeutiques sont a decrire : les methodes chirurgicales de denervation vesicale, la detrusoromyomectomie, les enterocystoplasties avec ou sans derivation urinaire continente et enfin les derivations urinaires non continentes. Nous ne parlerons pas de la neuromodulation sacree qui fera l’objet specifiquement d’un article.

Background Transobturator male slings have been proposed to manage stress urinary incontinence (SUI) after prostatic surgery, but data are still lacking. Objective To determine the safety and prospectively evaluate the clinical outcome after management of SUI after prostatic surgery by placement of a transobturator male sling. Design, setting, and participants We conducted a prospective evaluation on 102 patients treated in a single center between 2007 and 2009 for mild to moderate SUI following prostatic surgery. Interventions Placement of a suburethral transobturator sling and clinical follow-up. Measurements Patients were evaluated by medical history, preoperative urodynamics, maximum flow rate measurement, 24-h pad test, and daily pad use. During follow-up, data on patients' pad use, complications, and answers to the Patient Global Impression of Improvement (PGI-I) questionnaire were collected. Cure was defined as no pad usage or one pad for security reasons and improvement as reduction of pads ≥50%. Median follow-up was 13 mo (range: 6–26). Results and limitations Most patients (95%) presented post–radical prostatectomy incontinence (PRPI). Hospital stay was 2 d in 97 cases, and all patients were catheterized for 24h except two (48h). Of 102 patients, 64 were cured, 18 were improved, and 20 were not improved. According to the PGI-I questionnaire, 85%, 11%, and 4% of patients described a respectively better, unchanged, and worse urinary tract condition, respectively. Previous radiation was associated with higher rate of failure ( p =0.039). Neither severe complication nor postoperative urinary obstruction was noted during follow-up. Conclusions Placement of a transobturator sling is a safe and effective procedure, giving durable results after >1 yr of follow-up. Further evaluation and high-quality controlled, randomized studies are needed to assess long-term efficacy and precise indications of this procedure for post–prostatic-surgery SUI management.

Nous avons evalue l’eventuel caractere predictif d’une disparition des contractions non inhibees du detrusor sous stimulation aigue du sciatique poplite interne (SPI) a la cheville et de la racine S3 sur l’efficacite ulterieure d’une neuromodulation chronique des racines sacrees. Il s’agit d’une etude retrospective effectuee a partir de 150 patients ayant beneficie d’un test aigu de neuromodulation. Cinquante et un ont ete implantes, dont 30 pour un syndrome clinique d’hyperactivite vesicale. Parmi ces 30, 11 avaient une hyperactivite du detrusor. Dans ce groupe, l’âge moyen de ces 10 femmes et 1 homme etait de 57,2 ans. Le recul moyen pour juger de l’efficacite de la stimulation chronique etait de 9,45 mois. Une cystomanometrie etait realisee a l’etat basal, puis sous stimulation aigue de la racine S3 et du SPI, suivant un ordre randomise. Les parametres etudies etaient le volume de la premiere contraction non inhibee du detrusor et la capacite cystomanometrique maximale. Le test etait positif (doublement du volume d’apparition de la premiere contraction desinhibee, doublement de la capacite cystomanometrique maximale), 5/11 sous stimulation S3 et 4/11 sous stimulation du SPI. Il n’existait aucune correlation entre la positivite du test urodynamique et le devenir des patients sous neuromodulation chronique (6/11 gueris, 5/11 ameliores). La disparition d’une hyperactivite detrusorienne sous stimulation de S3 ou du SPI n’est pas un facteur predictif de l’efficacite ulterieure d’une neuromodulation chronique des racines sacrees. Les criteres d’implantation restent cliniques, principalement fondes sur le catalogue mictionnel.

TVT-Secur has been described as a new minimally invasive sling for women's stress urinary incontinence (SUI) management, showing promising results in short-term studies.Our goal was to evaluate the outcome of this procedure after a midterm follow-up.A prospective evaluation involved 45 consecutive patients presenting SUI associated with urethral hypermobility. Fourteen patients preoperatively reported overactive bladder (OAB) symptoms, but none had objective detrusor overactivity. Eight patients had low maximal urethral closure pressure (MUCP). Four patients had pelvic organ prolapse (POP).Patients with POP were treated under general anesthesia by Prolift and TVT-Secur procedure. The 41 other patients received TVT-Secur under local anesthesia on an outpatient basis. All interventions were made by the same surgeon.Postoperative assessment included pad count, bladder diary, clinical examination with stress test, evaluation of satisfaction with the Patient Global Impression of Improvement (PGI-I) scale, and evaluation of side effects. Patients were classified as cured if they used no pads, had no leakage, and had a PGI-I scoreor = 2; as improved in case of reduction of SUI symptoms50% and PGI-I scoreor = 3; and as failure otherwise.Mean postoperative follow-up was 30.2 +/- 9.8 mo (range: 11-40 mo). Short-term evaluation showed a 93.5% success rate, but, at last follow-up, only 18 (40%) patients were cured, while 8 (18%) were improved, and 19 (42%) failed. Twelve patients underwent implantation of TVT or transobturator tape during follow-up. Age, MUCP, or OAB were not associated with failure. Side effects were limited to five cases of de novo OAB and three cases of urinary tract infection. This work is limited by the absence of a comparison group.Our experience shows that despite its good short-term efficacy, TVT-Secur is associated with a high recurrence rate of SUI. Therefore, TVT-Secur does not seem appropriate for SUI first-line management in women.

Objective To assess the prevalence of and risk factors for urinary incontinence (UI) in young and middle-aged women. Subjects and methods During 1998 the prevalence of overall, stress, urge and mixed UI was assessed in women working in a French academic hospital. Women (2800) received a questionnaire at the same time as their yearly interview with a staff physician in occupational medicine. The usual risk factors for constitutional events, i.e. increasing age, obesity (defined as a body mass index ofor = 25), obstetric events (pregnancy, previous Caesarean delivery, previous vaginal delivery, postpartum incontinence) and gynaecological events (hysterectomy) were evaluated. Results Of the 1700 women (mean age 40.0 years) who returned the questionnaire, 467 (27.5%, 95% confidence interval, CI, 25.4-29.7) reported UI, comprising 210 (12.4%, 10.8-14.0) with stress UI, 28 (1.6%, 1.1-2.4) with urge UI and 229 (13.5%, 11.9-15.2) with mixed UI. Thirty-eight women (8.1%) had frequent urinary leakage, comprising one (0.5%), four (14.3%) and 33 (14.4%) with stress, urge and mixed UI. The prevalence of UI increased significantly with ageor = 40 years, with a relative risk (95% CI) of 2.16 (1.86-2.57), and with pregnancy (2.22, 1.71-2.87), previous vaginal delivery (2.15, 1.72-2.69), postpartum incontinence (2.57, 2.22-2.97), and hysterectomy (1.52, 1.11-2.08). Obesity (1.14, 0.99-1.32) and previous Caesarean delivery (2.15, 1.72-2.69) did not significantly increase the risk of UI. The risk factors for stress UI were ageor = 40 years, pregnancy, previous vaginal delivery, postpartum incontinence and hysterectomy, but there was no relationship between stress UI and obesity or previous Caesarean delivery. Conclusion There was a high prevalence of UI among young adult and middle-aged women hospital workers who had easy access to medical resources. Gynaecological and obstetric events (pregnancy, particularly previous vaginal delivery and hysterectomy) were the most prominent risk factors, especially for stress UI.

La toxine botulique represente, apres echec des traitements habituels, un traitement peu invasif et efficace [1-3] de l’hyperactivite du detrusor rebelle chez le patient neurologique. Il s’agit de realiser plusieurs injections de toxine dans le muscle vesical. Ces injections sont effectuees par voie endo-vesicale lors d’une cystoscopie. Tous les patients pris en charge sont prevenus de la necessite de realiser des autosondages apres le traitement par toxine dans le detrusor. Les traitements sont effectues en ambulatoire. Les patients sont tous munis a leur arrivee d’un ECBU sterile (ou sont traites si l’ECBU est positif) et d’un bilan sanguin preoperatoire (TP, TCA, plaquettes). L’intervention debute systematiquement par une anesthesie locale. Une application de gel de xylocaine introduit dans l’uretre est realisee, puis un sondage vesical permettant, apres vidange vesicale, l’instillation intravesicale d’une solution melangeant 20 ml de xylocaine 1 % non adrenalinee et 10 ml de bicarbonate a 1,4 %. Cette anesthesie locale est effectuee 15 minutes avant le debut du geste. Les injections sont faites par voie endoscopique en utilisant un endoscope rigide et une aiguille flexible qui est introduit dans le cystoscope. Il est propose de facon systematique une analgesie par inhalation de protoxyde d’azote. L’inhalation debute si elle est realisee 3 minutes avant le debut de l’intervention et se poursuit jusqu’au retrait du cystoscope. Cette inhalation permet de reduire de facon significative la douleur induite par les injections. La toxine botulique, Botox a la dose de 300 UI, est diluee dans 30 ml de serum physiologique. Avant de debuter les injections, l’endoscopie permet de verifier l’integrite de la vessie. Puis les injections de toxine botulique sont debutees en repletion vesicale faible (environ 100/150 ml). Vingt injections de 1,5 ml chacune sont ainsi faites. Elles sont reparties uniformement dans le muscle vesical, en dehors du trigone et desmeats ureteraux, en injectant de preference les travees musculaires, les diverticules sont evites. A l’issue du geste, on verifie l’absence de saignement, en general on effectue un lavage vesical par l’intermediaire de l’endoscope, ce qui permet d’evacuer d’eventuels petits caillots qui ont pu se former lors des injections. La vessie est ensuite videe. Des que la vidange vesicale est effectuee et le cystoscope retire, l’inhalation de protoxyde d’azote est suspendue. Les patients sont gardes 1 a 2 heures, ils effectuent de facon systematique un sondage vesical, ce qui permet de verifier l’absence d’hematurie significative. Ils sont bien sur prevenus des complications eventuelles (qu’elles soient liees a la toxine elle-meme ou au geste realise), de l’effet retarde et transitoire de la toxine. La necessite de realiser les autosondages leur est rappelee. Ils sont tous revus en consultation d’urodynamique a 3 mois.