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Burch urethropexy is one of the earliest and most effective surgeries for stress urinary incontinence. Minimally invasive robotic surgery is becoming more popular in the field of urogynecology. Herein, we present the safety and efficacy of a large case series of robotic-assisted Burch urethropexy. A retrospective chart review was performed on robotic-assisted Burch urethropexy cases performed between 2013 and 2019. Patient characteristics, perioperative data and follow-up outcomes were collected at a single teaching institution. A total of 76 women underwent robotic-assisted Burch urethropexy for pure stress urinary incontinence. Fifty of them had concomitant robotic procedures at the time of the Burch. We performed the robotic-assisted Burch urethropexy alone on 26 patients. The mean age was 55 years old. The overall treatment success rate was 85% with a mean follow-up time of 134 (±157.8) days. Complications included cystotomy (3%), urinary tract infection (16%) and postoperative voiding dysfunction (10%). Our study reveals that robotic-assisted Burch urethropexy is a feasible option in the treatment of stress urinary incontinence in terms of operative outcomes and short-term efficacy.Impact statement

To investigate the short- and medium-term effect of vaginal antetheca submucosal-retropubic space with mesh repair through the implantation of organic patch (shortly as new-style vaginal mesh repair) in the treatment of patients with stress urinary incontinence (SUI).This was a clinical prospective single arm study in a tertiary grade hospital (General Hospital of Jinan Military Region, Jinan, China). From January 2009 to December 2014, 316 female patients were enrolled. 316 female patients with stress urinary incontinence (SUI) underwent the surgery. The treatment effect was evaluated using the urinary incontinence questionnaire (ICIQ-SF), urine pad test and coughing test. The perioperative and postoperative complications were also evaluated. The results were compared with 1-year cure rates of Burch retropubic urethropexy (Burch) and tension-free vaginal tape (TVT) procedure.The mean follow-up period was 25 ± 12 months. The success rate of the new surgical technique was 94.0% (297/316) at 1 month, and 91.5% (289/316) at 1-year postoperation. The ICIQ-SF score significantly decreased at the 1-year follow-up (P 0.01). There was no significant difference in the 1-year cure rate when compared with the Burch and TVT procedures (P 0.05). The rates of perioperative urinary tract irritation and mesh exposure were 9.5% (30/316) and 5.38% (17/316), respectively, and no serious complications were found.The surgery demonstrated favorable short-term and medium-term treatment effects. Given its advantages of being minimally invasive, cost efficient and requiring only local anesthesia, this new surgical technique has a potential for broader clinical application. CLINICALTRIALS.NCT02934490.

Objective To evaluate 1- and 2-year urinary continence rates after Burch retropubic urethropexy compared with a retropubic midurethral sling for women with urinary incontinence undergoing sacrocolpopexy. Methods We conducted a planned secondary analysis of a multicenter, randomized, single-blind trial comparing Burch with a sling that enrolled participants from June 2009 to August 2013. Objective outcome measures of continence were assessed at 1- and 2-year follow-up through office visits and validated questionnaires. Overall continence was defined as a negative stress test, no retreatment for stress incontinence, and no self-reported urinary incontinence (International Consultation on Incontinence Questionnaire, Short Form, score, 0). Stress-specific continence was defined as fulfillment of the first two criteria and no self-reported stress-related incontinence. Primary outcomes were assessed with intention-to-treat and within-protocol analyses. Comparisons between groups were evaluated using χ or Fisher exact test. Results The two groups were similar in all measured baseline features. Outcome assessments at 2 years were available for 48 of 57 patients (84%) in the sling group and 45 of 56 patients (80%) in the Burch group. With intention-to-treat analysis, the sling group had significantly higher rates of overall continence than the Burch group (49% [28/57] vs 29% [16/56]; 95% CI for absolute risk difference 3.0-38.1; P=.03) at 1- but not 2-year follow-up (47% [27/57] vs 32% [18/56]; 95% CI for absolute risk difference -2.6 to 33.1; P=.10). The sling group had significantly higher rates of stress-specific continence than the Burch group at 1-year (70% [40/57] vs 46% [26/56]; 95% CI for absolute risk difference 6.1-41.4; P=.01) and 2-year (70% [40/57] vs 45% [25/56]; 95% CI for absolute risk difference 7.9-43.2; P=.006) follow-up. No difference was detected in prolapse recurrence, voiding dysfunction, antimuscarinic medication use, urgency incontinence, or patient satisfaction. Conclusion Among women with baseline urinary incontinence undergoing sacrocolpopexy, the retropubic midurethral sling resulted in higher stress-specific continence rates than Burch retropubic urethropexy at 1- and 2-year follow-up.

OBJECTIVE To compare efficacy and safety of retropubic Burch urethropexy and a midurethral sling in women with stress urinary incontinence (SUI) undergoing concomitant pelvic floor repair with sacrocolpopexy. METHODS Women were randomly assigned to Burch retropubic urethropexy (n=56) or retropubic midurethral sling (n=57) through dynamic allocation balancing age, body mass index, history of prior incontinence surgery, intrinsic sphincter deficiency, preoperative incontinence diagnosis, and prolapse stage. Overall and stress-specific continence primary outcomes were ascertained with validated questionnaires and a blinded cough stress test. RESULTS Enrollment was June 1, 2009, through August 31, 2013. At 6 months, no difference was found in overall (29 midurethral sling [51%] compared with 23 Burch [41%]; P=.30) (odds ratio [OR] 1.49, 95% confidence interval [CI] 0.71-3.13) or stress-specific continence rates (42 midurethral sling [74%] compared with 32 Burch [57%]; P=.06) (OR 2.10, 95% CI 0.95-4.64) between groups. However, the midurethral sling group reported greater satisfaction (78% compared with 57%; P=.04) and were more likely to report successful surgery for SUI (71% compared with 50%; P=.04) and to resolve pre-existing urgency incontinence (72% compared with 41%; P=.03). No difference was found in patient global impression of severity or symptom improvement, complication rates, or mesh exposures. CONCLUSION There was no difference in overall or stress-specific continence rates between midurethral sling and Burch urethropexy groups at 6 months. However, the midurethral sling group reported better patient-centered secondary outcomes.

OBJECTIVE The aim of this study was to evaluate reasons and factors associated with patient calls in the postoperative period after female pelvic medicine and reconstructive surgery. METHODS A retrospective review using electronic medical records was performed on consecutive patients who underwent surgery within our academic female pelvic medicine and reconstructive surgery practice during a 6-month period. Calls after postoperative discharge until first scheduled postoperative visit were included. Reasons and number of calls were tabulated. Clinical and surgical factors were extracted. Continuous data were evaluated with a Student t test or analysis of variance; categorical data were evaluated with a χ test. P < 0.05 was considered significant. RESULTS During the designated period, 302 patients underwent surgery, and 173 (57.3%) patients made 345 calls (mean ± SD, 2.0 ± 1.5 calls). Reasons were categorized under 6 distinct domains: bowel, pain, activity, medication regimen, urinary, and bleeding. The most frequent concern within each domain was constipation (11.6%), abdominal pain (6.4%), physical activity (8.7%), pain regimen (14.5%), urinary catheter related (13.3%), and vaginal bleeding (12.1%), respectively. A greater number of phone calls were recorded among patients discharged home with catheters (P = 0.015), and patients who underwent posterior colporrhaphy (P = 0.005) and retropubic urethropexy (P = 0.014). Patients discharged with home nursing (11, 6.4%) demonstrated a significantly higher number of phone calls (3.8 ± 2.5, P < 0.001). Evaluations were required for 37% of callers. Twelve patients were seen in the emergency department, of whom 3 (1.7%) were readmitted to the hospital. CONCLUSIONS Postoperative patient-initiated telephone calls after pelvic reconstructive surgery are common. Bowel-, urinary-, and medication-based phone calls account for the highest frequency and volume.

Both LigaSure (LS) and Harmonic Scalpel (HS) are new surgical technologies that have been used to secure hemostasis in various fields of surgery. There is little information in the literature about the use of LS and HS in thyroid surgery. The aim of this study was to report our experience with LS and HS in thyroid surgery. Materials and methods: In this nonrandomized retrospective study 326 consecutive patients who underwent primary thyroid surgery were reviewed. HS was used in 136 patients and LS was used in 126 patients. A conventional technique was used in 64 patients. The were 42 male patients (12.9%) and 284 female patients (87.1%); their ages varied between 19 and 72 years (mean 42.8 ± 12.4). Data regarding each patient's demographics, thyroid pathology, operation time, and complications were collected throughout the study. Results: The 3 study groups had similar demographics (age, female/male ratio) and thyroid pathology. Permanent hypocalcemia developed in 2 (1.6%) patients in the patient group operated on through LS, of which 1 was male and the other was female. In the HS group, postoperative hematoma developed in 2 (1.5%) patients. Conclusion: The results of this retrospective clinical study showed that LS and HS thyroidectomy can be a useful and fast alternative for conventional thyroidectomy. The main advantage of these devices is that they simplify the procedure and eliminate the need for clips and suture ligations while achieving efficient hemostasis.

Objective To provide general gynaecologists and urogynaecologists with clinical guidelines for the management of recurrent urinary incontinence after pelvic floor surgery. Options Evaluation includes history and physical examination, multichannel urodynamics, and possibly cystourethroscopy. Management includes conservative, pharmacological, and surgical interventions. Outcomes These guidelines provide a comprehensive approach to the complicated issue of recurrent incontinence that is based on the underlying pathophysiological mechanisms. Evidence Published opinions of experts, and evidence from clinical trials where available. Values The quality of the evidence is rated using the criteria described by the Canadian Task Force on Preventive Health Care (Table). Recommendations 1.Thorough evaluation of each patient should be performed to determine the underlying etiology of recurrent urinary incontinence and to guide management (II-3B). 2.Conservative management options should be used as the first line of therapy (III-C). 3.Patients with a hypermobile urethra, without evidence of intrinsic sphincter deficiency, may be managed with a retropubic urethropexy (e.g., Burch procedure) or a sling procedure (e.g., mid-urethral sling, pubovaginal sling) (II-2B). 4.Patients with evidence of intrinsic sphincter deficiency may be managed with a sling procedure (e.g., mid-urethral sling, pubovaginal sling) (II-3B). 5.In cases of surgical treatment of intrinsic sphincter deficiency, retropubic tension-free vaginal tape should be considered rather than transobturator tape (I-B). 6.Patients with significantly decreased urethral mobility may be managed with periurethral bulking injections, a retropubic sling procedure, use of an artificial sphincter, urinary diversion, or chronic catheterization (III-C). 7.Overactive bladder should be treated using medical and/or behavioural therapy (II-2B). 8.Urinary frequency with moderate elevation of post-void residual volume may be managed with conservative measures such as drugs to relax the urethral sphincter, timed toileting, and double voiding. Intermittent self-catheterization may also be used (III-C). 9.Complete inability to void with or without overflow incontinence may be managed by intermittent self-catheterization or urethrolysis (III-C). 10.Fistulae should be managed by an experienced physician (III-C).

Minimally invasive procedures for urinary incontinence and pelvic organ prolapse have gained increasing popularity in the past decade. The advantages of minimal access through laparoscopic and vaginal routes include smaller incisions, shortened hospital stay, decreased analgesia, rapid recovery and rapid return to work. The laparoscopic Burch colposuspension and the tension-free vaginal tape procedure were at the forefront of minimal access antiincontinence procedures. The most recent and significant publications regarding laparoscopic Burch colposuspension and tension-free vaginal tape procedure are highlighted in this article.The laparoscopic Burch is time-consuming and requires a steep learning curve in laparoscopic suturing, thwarting its adoption and staying power. The advantages and success of the retropubic midurethral sling procedures such as tension-free vaginal tape have largely replaced all other antiincontinence procedures and have ignited the development and adoption of transobturator midurethral sling procedures and vaginal 'kit' procedures for pelvic organ prolapse.Clinical trials show that laparoscopic Burch cure rates are equal or inferior to tension-free vaginal tape cure rates. Publications regarding laparoscopic Burch colposuspension have tapered significantly in the past year, which may represent the ebb of its utilization. Tension-free vaginal tape and other midurethral sling procedures may become the new 'gold standard' antiincontinence therapy.

Stamey bladder neck suspension is thought to be an excellent procedure for stress urinary incontinence in selected groups of patients. However we must not ignore the complications of this procedure. We report a case of a patient who developed a delayed reaction with bladder wall erosion to the Dacron buttress used in Stamey urethropexy 19 years before. She was presented with pelvic pain and persisting irritative bladder symptoms. The treatment of choice was cystoscopic removal of suture and buttress. Tissue intolerance is a common problem with the use of different kinds of biomaterials in incontinence surgery. Careful cystourethroscopy is essential for early diagnosis and treatment if pain, infections and severe irritative symptoms occur postoperatively.

Objective More than 20,000 women, aged 70 years or older, undergo surgery for stress urinary incontinence each year. Our objective was to review the published randomized trials of the surgical treatment of stress urinary incontinence and estimate the proportion of women 70 years or older enrolled in those trials. Data sources MEDLINE and Cochrane Databases of Clinical Trials were searched from January 1966 through December 2003 with the terms "urinary incontinence," "stress incontinence," "urethropexy," "needle suspension," "pubovaginal sling," "tension-free vaginal tape," "urethral injection," "collagen injection," "anterior colporrhaphy," and "clinical trial," "controlled trial," or "randomized trial" as both subject headings and words contained in article titles. We supplemented this search with manual searches of meta-analyses and review articles from 2000 to 2003. Methods of study selection All studies that included at least one group undergoing an invasive treatment for stress incontinence (including urethral bulking injections) were reviewed. We excluded reports without sufficient data to estimate the number of women aged 70 and older who participated, those published only in abstract form, and those studies in languages other than English, French, German, Italian, or Spanish. Twenty studies met our inclusion criteria. Tabulation, integration, and results The number of women aged 70 or older in each study was estimated using the demographic data provided. The median percentage of subjects aged 70 or older was 3.8% (interquartile range 0.37-15%). There was no significant difference in the proportion of subjects 70 years of age or older based on the year of publication. Conclusion Our review of the published literature suggests that elderly women are underrepresented in clinical trials of stress incontinence surgery. Efforts should be made to include more elderly women in clinical trials of stress incontinence surgery.

Laparoscopic colposuspension (LC) was first described in the early 1990s as a technique distinct from open Burch colposuspension. Subsequently, however, LC was closely modelled along the lines of the Burch technique, and the distinct features of the original urethropexy (UP) were largely disregarded. In this case-control series the authors aimed to compare symptoms and anatomical outcomes after standard LC and urethropexy +/- paravaginal repair. The design was a clinical retrospective case-control trial. The setting was the urogynaecology and endogynaecology services of tertiary hospitals. Fifty patients after LC and 50 women after UP surgery, matched for age, body mass index, previous surgery, pre-existing urge incontinence and length of follow-up (1.01 year, range 0.02-3.54 years) for LC and 0.98 years (range 0.06-3.55 years) for UP). Intervention consisted of standardised interview and translabial ultrasound imaging. There were no significant differences for subjective cure of stress incontinence (80% for UP vs. 74% for LC), postoperative urge incontinence, frequency and nocturia. Significantly more UP patients complained of voiding dysfunction (p=0.01). Significant differences were found for urethral rotation, position of the bladder neck on Valsalva and bladder neck descent on Valsalva (all p0.001). Both procedures were shown to be effective in curing stress incontinence. The incidence of bladder symptoms was comparable, with the exception of voiding difficulty. Significant differences were observed regarding anatomical appearances, with urethropexies showing more recurrent bladder neck hypermobility and cystocele.

A case-control study was performed in two departments performing tension-free urethropexy for the treatment of stress urinary incontinence. During a period of 4.5 years, 127 cases of tension-free vaginal tape operations (TVT) and 42 cases of intravaginal slingplasty (IVS) were performed. In the TVT group one case of urethral erosion was observed, but in the IVS group six cases of defective healing, erosion or extrusion were observed. It is considered that the complications might be due to the multifilamentous nature of the IVS tape in contrast to the monofilamentous nature of the TVT tape.

The goal of this study was to determine the efficacy of retropubic urethrolysis without resuspension for the surgical treatment of postoperative urinary retention.A retrospective chart review was done of six women with posturethropexy urinary retention or voiding dysfunction who underwent retropubic urethrolysis between July 1999 and June 2000.An average of 27.0 (+/- 19.6) months elapsed between obstructive incontinence procedure and urethrolysis. The mean maximum detrusor pressure during voiding was elevated at 52.7 (+/- 31.7) cm H2O. The mean maximum flow rate during voiding was decreased at 16.3 (+/- 10.8) cm H2O. The average postvoid residual volume was 152.9 +/- 71.6 mL, significantly decreased postoperatively to 36.9 +/- 40.0 mL (t = 3.37, p = 0.043). Postoperative cystourethroscopy showed a completely free and mobile urethra. In the short-term, all patients had resolution of their symptoms. No patient had return of stress incontinence in a mean clinical follow-up of 3.3 +/- 2.3 months.Our results are comparable to other series of urethrolyses, despite omission of resuspension. Retropubic urethrolysis offers favorable relief of persistent postoperative urinary retention and voiding dysfunction, particularly after retropubic urethropexy.

The aim of this study was to compare the long-term results of a modified Burch procedure with a sling procedure for the treatment of stress incontinence with a low-pressure urethra. Thirty-six women with urodynamic stress incontinence, low-pressure urethra, urethral hypermobility and no significant pelvic organ prolapse were randomly assigned to undergo either a modified Burch procedure ( n=19) or a sling placement ( n=17). Cure of the stress incontinence (defined as a negative stress test and negative pad-weight test) was the primary long-term endpoint. Secondary endpoints included subjective cure of stress incontinence (defined as no incontinence episodes on a 1-week voiding diary) and voiding function studies. Comparisons of group means were performed with the Mann-Whitney U-test, pooled variance t-tests and separate variance t-tests. Proportions were compared with Fisher's exact test. A logistic regression analysis was performed to control for covariates that differed in our two groups despite randomization. Long-term follow-up (mean=72.6 months) was available for 82% (28/34) of the original study group. The objective cure rates for the Burch and sling groups were 84.6% and 100%, respectively ( P=0.17). Mean uroflowmetry rates for the Burch and sling groups were 7.38 and 6.8 ml/s, respectively ( P=0.58, 95%CI -2.5, 4.4). Mean postvoid residual volumes for both groups were 35 ml ( P=0.97, 95% CI -23.8, 65.9). Two sling patients (12%) required partial resection of their slings because of erosion. Both patients remained continent. In terms of voiding function and stress incontinence cure, there were no differences between groups undergoing modified Burch or sling procedures for treatment of urodynamic stress incontinence with low-pressure urethra.

Objective : To describe the results after colpourethropexy with a REMEEX prosthesis in the treatment of stress urinary incontinence with associated genital prolapse. Materials and methods : A prospective analysis of all patients treated in our Urogynaecology Unit between November 2000 and March 2001. Results : There were 29 patients with mean age of 62 and mean body mass index of 28. All but one patients had stress incontinence (genuine or mixed) associated with a genital prolapse. The other patient was a failed past technique (Marshall–Burch). Cystometry was performed in 80% of the patients. Of these 93% had genuine stress incontinence and 7% mixed incontinence. The average operating time was 119min (CI: 60–310), and the mean hospital stay 5 days (CI: 3–13). There was one case of severe haemorrhage during surgery, four cases of wall seroma and one postoperative urinary infection. Concerning patient satisfaction, 90% of our patients felt they were cured, 8% were much better and 2% had a slight improvement. No patient had a worsening of symptoms after surgery. Conclusion : We propose colpourethropexy by suburethral sling with a REMEEX prosthesis as suitable treatment for stress incontinence with associated genital prolapse.

The purpose of our study was to describe the surgical trends for female stress urinary incontinence (SUI) during 2006–2010, and a time-frame comparison with 1997–2005, based upon the National Health Insurance (NHI) claims data in Taiwan. Women who underwent various primary surgeries for SUI during 2006–2010 were identified, with a total of 15,099 inpatients. The variables included surgical types, patient age, surgeon age and gender, specialty, and hospital accreditation levels. Chi-squared tests and SAS version 9.3.1 were used for statistical analysis. During the follow-up study, midurethral sling (MUS) application increased significantly from 53.09 % in 2006 to 78.74 % in 2010. It was associated concomitantly with a decrease in retropubic urethropexy (RPU) from 29.68 % to 12.99 %, and pubovaginal sling treatment (PVS) from 9.33 % to 3.46 %. MUS was most commonly used among all patients’ and surgeons’ age groups, and different accreditation hospital levels. MUS was more commonly used by gynecologists (71.38 %) than urologists (57.91 %); while PVS and periurethral injection were more commonly performed by urologists than gynecologists. Similar surgical trends were found during time-frame comparison, 2006–2010 vs 1997–2005. SUI surgeries increased in patients aged ≥60, surgeons aged ≥ 50, and in regional hospitals. This follow-up study depicts the increase in popularity of MUS and offers evidence of surgical trends and a paradigm shift for female SUI surgery. More older women were willing to seek healthcare and undergo surgery. The surgical skills and knowledge spread from medical centers into regional hospitals. The time-frame shift may have a profound impact on patients, as well as the healthcare providers.

OBJECTIVE: To describe trends in the management of prolonged voiding dysfunction and urinary retention after anti-incontinence procedures. METHODS: Physician members of the American Urogynecologic Society were queried by means of a two-page questionnaire regarding the management of prolonged voiding dysfunction and urinary retention after anti-incontinence procedures. RESULTS: A total of 344 (42%) of 825 questionnaires were completed and returned. Of the 344 respondents, 61% identified themselves as urogynecologists, 50% worked in a university-affiliated practice, and 26% had been in practice for 11–20 years. Respondents rarely encountered prolonged urinary retention after anti-incontinence procedures. Among the respondents, 30% allowed 3–6 months for resumption of spontaneous voiding before performing surgical revision, and 90% performed multichannel urodynamic studies before surgical revision. However, 66% performed surgical revision transabdominally when urinary retention occurred after retropubic urethropexy, and 61–81% of respondents performed surgical revision transvaginally when urinary retention followed needle suspension, pubovaginal sling, or tension-free vaginal tape procedures. A total of 90–96% did not perform an anti-incontinence procedure concomitantly with surgical revision. The majority of respondents reported spontaneous voiding in greater than 80% of patients, and recurrent stress urinary incontinence in less than 10% of patients after surgical revision. CONCLUSION: Although certain trends in the management of prolonged urinary retention after anti-incontinence procedures were identified, there was no clear consensus on the method of surgical revision used, nor the management of recurrent stress urinary incontinence after surgical revision. Randomized clinical trials are required to determine the optimal management of prolonged urinary retention after anti-incontinence procedures.

Objective: The purpose of this study was to evaluate the independent effect of suburethral sling placement on the risk of cystocele recurrence after pelvic reconstructive operation. Study Design: One hundred forty-eight women with cystoceles to or beyond the hymenal ring underwent pelvic reconstructive operation, with or without incontinence procedures, and were evaluated at 12 and 52 weeks after operation with a standardized pelvic examination. Rates of recurrent prolapse, at all sites, were statistically compared between subjects with and without suburethral slings. A multiple regression analysis was used to determine the independent effect of sling placement on the risk of recurrent cystoceles. Results: Suburethral sling placement was associated with a 54.8% reduction in the mean rate of postoperative cystocele recurrence ( P =.004). This protective effect was observed as early as 12 weeks and remained significant at 1-year follow up (42% vs 19%). A markedly reduced risk of cystocele recurrence was observed when women with sling procedures were compared with all other women, with those women who underwent other incontinence operations, and even with those women who had undergone prolapse repair with no incontinence procedure. The protective effect of the sling procedure remained highly significant (odds ratio, 0.29; P =.0003), even after controlling for potentially confounding variables in a multiple logistic regression model. Conclusion: Suburethral sling procedures appear to significantly reduce the risk of cystocele recurrence after pelvic reconstructive operation, in contrast with the effect of retropubic urethropexy and needle suspensions. These findings should be considered when the surgical treatment of stress incontinence that accompanies pelvic organ prolapse is being planned. (Am J Obstet Gynecol 2001;185:1307–13.)

OBJECTIVE: To assess the difference in measured urethral function before and after tension-free vaginal tape procedure (TVT). METHODS: Women who underwent TVT for genuine stress incontinence with or without intrinsic sphincter deficiency completed this study. Multichannel urodynamic testing was performed preoperatively and 6 weeks postoperatively. Maximum urethral closure pressure and pressure transmission ratio were recorded. Valsalva leak point pressures were determined at 150 mL and at full bladder capacity. Resting and straining urethral angles were measured using the cotton swab technique. Subjects completed both the Incontinence Impact Questionnaire and Urodynamic Distress Inventory preoperatively and postoperatively. RESULTS: Thirty-five consecutive women were studied. Twenty-three (65.7%) had a preoperative diagnosis of intrinsic sphincter deficiency as defined by maximum urethral closure pressure less than 20 cm H2O and/or Valsalva leak point pressure less than 60 cm H2O. Subjective and objective success rates were 91% and 83%, respectively. Subjects showed an 86.8% (95% CI 71.9%, 100.0%) improvement in their Incontinence Impact Questionnaire score and a 72.9% (95% CI 62.6%, 83.1%) improvement in their Urodynamic Distress Inventory score. The mean change in maximum urethral closure pressure was −1.3 cm H2O (95% CI −5.9, 3.3), whereas the pressure transmission ratio increased 15.7% (95% CI 5.0%, 26.3%). The mean decrease in straining urethral angle was 16.3° (95% CI −23.9°, −8.7°). Cured subjects demonstrating hypermobility preoperatively continued to do so postoperatively. CONCLUSION: There was a significant increase in pressure transmission ratio, but not maximum urethral closure pressure, after TVT. These changes are similar to those reported after retropubic urethropexy and traditional sling procedures. The effectiveness of the TVT sling does not appear to depend on a clinically significant change in the straining urethral angle.

Numerous surgeries have been proposed for the treatment of genuine stress incontinence, with the goals to improve functional outcome and decrease complications and their associated morbidity. Two new, minimally invasive procedures, transvaginal retropubic urethropexy and transvaginal Cooper’s ligament sling, are reviewed in this article. These procedures provide a completely transvaginal approach, without the use of abdominal incisions or bone anchors. The anterior point of suspension is Cooper’s ligament. The transvaginal retropubic urethropexy is used for the treatment of genuine stress incontinence with urethral hyper-mobility, and the transvaginal sling also may be used in the presence of intrinsic sphincteric deficiency. The procedures are described and the recent outcomes discussed.

We sought to determine the long-term efficacy, safety, and urodynamic effects of the Mersilene mesh suburethral sling in treating complicated forms of genuine stress incontinence.Two hundred women diagnosed with genuine stress incontinence, complicated by recurrence, intrinsic sphincter deficiency, or chronically increased intraabdominal pressure underwent a suburethral mesh sling procedure (Mersilene; Ethicon Inc, Somerville, NJ). They were monitored with yearly clinical examinations plus short- and long-term postoperative urodynamic evaluations; statistical analysis was carried out by use of the Friedman 2-way analysis by rank, Fischer-Freeman-Halton exact testing, analysis of variance for repeated measures, Wilcoxon, exact Mann-Whitney U test, and Bonferroni paired t test. Of 176 patients who were 5 months or more postop, 127 (72%) had preoperative and short-term postoperative urodynamic evaluations (range 5 to 23 months, mean 12.6 months). Fifty-two of 117 women who were more than 19 months postop (44%) completed preoperative and long-term postoperative urodynamic evaluations at a mean of 63 months (range 20 to 107). One hundred thirty-six of 176 patients (77%) who were more than 4 months postop had a short- and/or long- term postoperative urodynamic evaluation (range 5 to 107 months, mean 30 months).Objective cure rate by stress test was 93% (126 of 136 patients) at a mean of 30 months follow-up. The long-term objective cure rate was 94% (49 of 52). Subjectively, the short- and long-term cure rates were 95.3% and 90.4%, respectively. The cotton swab angle deflection decreased by a mean of 54 degrees at 1 year and 50 degrees at 5 years. Of the 10 failures, the mean preoperative cotton swab straining angle was 19.6 degrees, with 6 being30 degrees. Nineteen patients had a negative preoperative cotton swab angle test result (mean straining angle 15 degrees before operation, -6 degrees after operation) and a long-term cure rate of 67%. The objective cure rate in patients with positive cotton swab angle results monitored long term (mean 62 months) was 100% (41 of 41). The postvoid residual increased by a mean of 25 mL short term and 10 mL long term. Thirty-eight patients (19%) had a total of 43 complications. Seven patients (3.5%) had long-term retention. De novo detrusor instability occurred in 12 patients (8.8%), although it was cured in 6 (4.4%). Eight patients (4%) had vaginal or inguinal sling erosion and were healed after revision. Delayed healing at the vaginal sling site responded completely to estrogen cream in two (1%) patients. Five women had treatable vaginal stenosis, 5 had a local inguinal collection/infection unrelated to the mesh, and 3 required a 2-unit transfusion of packed red blood cells. One patient each had an entrapped nerve released, a cystotomy repaired, or experienced thigh numbness or groin pain.The suburethral Mersilene mesh sling has a very high long-term objective and subjective cure rate in the treatment of complicated forms of genuine stress incontinence. Frequent complications do occur but are remediable. The 33% failure rate among patients with a preoperative negative cotton swab angle test result and the very low cotton swab straining angle among the 7% who had sling failures further confirms the widely held belief that sling urethropexy in the absence of hypermobility lacks efficacy.

Objectives: We describe a series of patients with rectal prolapse who had other pelvic floor defects. Study Design: Patients with rectal prolapse that we examined between 1990 and 2000 were reviewed. Results: During this time frame 55 patients with rectal prolapse were seen by one of us. Fifty-two of these patients had other defects of pelvic floor support and are the subject of this report. The diagnosis was established in all patients with video defecography. Thirty-nine of the patients had internal (occult) prolapse that simulated either a rectocele or an enterocele. The mean number of surgical procedures for pelvic floor support before the diagnosis of rectal prolapse was 1.5. Thirty-one patients underwent a sigmoid resection with rectopexy, 12 underwent a rectopexy alone, 3 underwent a Ripstein procedure, 2 elderly patients had physical therapy alone, and the other 4 patients had surgical correction of the rectal prolapse before being referred for repair of vaginal vault prolapse. Other procedures performed simultaneously included sacral colpopexy, sacrospinous suspension, rectopubic urethropexy, and abdominal fixation of the vagina to the uterosacral ligaments. Conclusions: Rectal prolapse frequently coexists with other pelvic floor defects. Internal rectal prolapse may simulate a rectocele or enterocele and requires defecography to establish the diagnosis. Rectopexy (with or without sigmoid resection) is a satisfactory technique for correction and may be combined with other reconstructive procedures on the pelvic floor. (Am J Obstet Gynecol 2001;184:1488-95.)

A prospective follow-up study was performed to evaluate the effect of a concomitant abdominal hysterectomy with Burch colposuspension. Sixty-five women underwent Burch colposuspension (the Burch group) and 78 women colposuspension with concomitant abdominal hysterectomy (the hysterectomy group) during a 1-year period in Turku University Hospital. Subjective outcome was assessed with three questionnaires: at 6 weeks, 1 year, and a mean of 4.9 years after the operation. Complications related to the operation occurred in 19 patients (29.2%) in the Burch group and in 36 (46.2%) in the hysterectomy group (P = 0.038). No statistically significant difference in the frequency of any subgroup of complications was found. Instead, complications cumulated to fewer patients in the Burch group. During postoperative care in the hospital intermittent catheterization to treat transient urinary retention was needed more frequently in the Burch group than in the hysterectomy group (10.8% vs. 1.3%, P = 0.046). No significant difference was found in subjective short- and long-term outcome. In the long-term follow-up 79% were subjectively cured or improved, 77% in the Burch group and 81% in the hysterectomy group.

Study Objective To report long-term follow-up of 300 patients undergoing extraperitoneal retropubic bladder suspension using balloon distention and mesh suspension. Design Observational study (Canadian Task Force classification II-2). Setting Private practice. Patients Three hundred women with urinary incontinence. Intervention Extraperitoneal retropubic bladder neck suspension with mesh, after balloon distention of the space of Retzius performed under general anesthesia in 162 (54%) and epidural anesthesia in 138 (46%). Measurements and Main Results Eight procedures were converted to open urethropexy, resulting in 259 laparoscopic urethropexies. Spontaneous voiding resumed within 24 hours in 235 patients (90.4%). Follow-up was available for 267 patients and ranged from 1.5 to 5.5 years (mean 3.28 yrs). Of these, 173 women (67%) reported that they were cured and 64 (24.5%) were satisfied with the result; 22 (8.5%) were considered failures. Conclusion Extraperitoneal retropubic bladder neck suspension with mesh results in a durable repair and is associated with relatively short operating time, low morbidity, and excellent patient satisfaction.

The objective of this article was to review the available literature on laparoscopic Burch urethropexy cure rates and describe the authors' laparoscopic technique and experience with Burch urethropexy and paravaginal repair. A MEDLINE search (1991 to 1999) was performed for articles describing the laparoscopic Burch urethropexy using suture to elevate and stabilize the paraurethral tissue. Also a retrospective chart review of the authors' 171 consecutive patients between January 1997 and December 1999 was done. The laparoscopic Burch urethropexy and paravaginal repair is described using an open laparoscopic technique with 3 accessory ports for access. A transperitoneal approach is taken to gain access to the space of Retzius. The anterior vaginal wall and its paravaginal defects, if present, are identified. Nonabsorbable sutures are placed in a conventional fashion. The paravaginal repair is used for support of the anterior vaginal wall proximal to the urethral vesical junction and the Burch urethropexy distal to the vesical neck. An average of 6 sutures are used for the paravaginal repair and 4 sutures for the Burch urethropexy. Cystoscopy is performed to ensure no breech of lower urinary tract integrity. In all, 20 articles describing a laparoscopic Burch urethropexy and postoperative cure rate were identified. Cure rates ranged from 69% to 100%. A review of our experience revealed 130 of 171 patients had a Burch urethropexy and paravaginal repair, 23 of 171 patients a Burch urethropexy alone, and 18 of 171 patients a paravaginal repair alone. Of the authors' 171 patients, 4 (2.3%) had injury to the lower urinary tract during laparoscopic Burch urethropexy or paravaginal repair. All 4 injuries were cystotomies, 2 in patients with previous open retropubic urethropexies. No ureteral ligations or intravesical placement of suture was diagnosed. Other surgical parameters for the laparoscopic Burch uethropexy and paravaginal repair include an estimated blood loss of 50 mL, average hospital stay of less than 23 hours, and an average operative time of 70 minutes. All patients had their surgery completed via laparoscopy. The literature review and our personal experience suggests that the laparoscopic Burch urethropexy and paravaginal repair are safe and effective alternatives to traditional laparotomy for the treatment of genuine anatomic stress urine incontinence and cystourethrocele resulting from lateral vaginal wall defects.

The aim of the study was to determine whether urodynamic testing improves the outcome of retropubic surgery in women aged 50 or younger. A retrospective study was undertaken of 212 women aged 50 or younger who underwent retropubic surgery at a medical school-affiliated hospital between February 1991 and July 1997. Excluded were patients with prior retropubic urethropexy and known low urethral closure pressures. The surgery was performed by one urogynecologist and two urologists. The minimal evaluation by the urogynecologist was a focused incontinence questionnaire, pelvic neurologic examination, pelvic floor grading, cough stress test, urinalysis, postvoid residual, cotton swab test and supine empty stress test. Full urodynamics consisted of uroflowmetry, subtracted cystometry, urethral closure pressure, cough leak-point pressure and cystourethroscopy. Subjective postoperative follow-up at 14 years was by annual questionnaire. The urogynecologist's patients were in group I (95 women with full urodynamic studies) and group II (36 women with minimal testing). The urologists' patients were in group III (81 women with a very minimal workup and cystourethroscopy). A review of seven variables revealed no difference between the groups. In terms of cured, improved and failed, there was also no difference in outcome. There was a difference in postoperative voiding problems (though not stress incontinence) in group III compared to group I (P= 0.005) and group II (P=0.002). Our conclusion was that all women with stress incontinence should undergo a careful minimal evaluation. In women aged 50 or younger urodynamic studies may be avoided unless there is significant stress incontinence, complex symptoms, a positive supine empty stress test, marked prolapse, or a history of prior retropubic urethropexy.

Objective: The aim of this study was to compare a modified Burch procedure with a suburethral sling for the treatment of stress incontinence complicated by a low-pressure urethra. Study Design: Thirty-six women with stress incontinence, low-pressure urethra, and urethral hypermobility (straining cotton swab angle ≥30°) were randomly assigned to undergo either a modified Burch procedure (n = 19) or a suburethral sling (n = 17). Objective and subjective cure rates at 3 months after the operation were the primary outcome measures. Comparisons of group means were performed with the Student t test for independent groups, and proportions were compared with the Fisher exact test. Results: After the operation the 2 groups had statistically similar cure rates and voiding function. Urethral closure pressure, pressure transmission ratios, and maximum detrusor pressure during voiding were significantly higher in the sling group. Conclusion: At 3 months there were no clinically significant differences between the groups treated with suburethral sling and modified Burch procedures. (Am J Obstet Gynecol 2000;182:30-4.)

We evaluate objectively the results of a modified in situ vaginal wall sling operation for recurrent genuine stress incontinence and whether it is a substitute for the traditional sling procedure.A total of 23 patients with urodynamically proved recurrent genuine stress urinary incontinence were recruited in this study. Patients were treated with a modified needle urethropexy technique using an island of in situ vaginal skin as a sling to support the bladder neck and urethra. Surgical outcome was evaluated subjectively and objectively at a median of 15 months. A total of 42 patients who underwent a traditional polytetrafluoroethylene sling operation served as controls.The cure rate of the vaginal wall sling operation was 34.8% by objective assessment, which was lower than that of the traditional sling procedure (88.1%, p0.05). The subjective success rate demonstrated the same results (vaginal sling 60.9% versus traditional sling 92.9%, p0.05). The risk factors for operation failure were lower maximal urethral pressure, lower urethral closing pressure, narrow vaginal capacity and previous anterior colporrhaphy or a Stamey operation (all p0.05). In 3 cases suburethral epithelial inclusion cysts were specific complications of the operation. There was no prolonged urinary retention or urethral erosion.Based on our results, we do not believe that the vaginal wall sling operation should be recommended for all recurrent genuine stress urinary incontinence cases and especially not for those with factors predictive of surgical failure. Further studies are needed to investigate and clarify the possible causes of failure.

Objective: This study was undertaken to evaluate the use of intraoperative cystoscopy for the detection of incidental bladder or ureteral injuries during abdominal urethropexy procedures and to determine whether the incidence of injuries warrants the routine use of cystoscopy. Methods: We reviewed the medical records of 109 consecutive patients who underwent abdominal urethropexy procedures between November 1990 and February 1996 at a teaching institution. Each underwent intraoperative cystoscopy. We determined the incidence of cystotomy and ureteral obstruction and attempted to determine surgical factors that might be associated with an increased risk of injury. Results: Ten of 109 patients (9%) had bladder or ureteral injury, including 1 cystotomy during retropubic dissection, 6 cases of a transvesical suture noted during cystoscopy, 1 cystotomy recognized before closure, 1 case of ureteral obstruction found during cystoscopy, and 1 case of ureteral obstruction not recognized at cystoscopy. Cystoscopy allowed detection of 7 of 9 (78%) otherwise unrecognized events. The only injury that resulted in significant postoperative morbidity was the unrecognized ureteral obstruction. There was no association between incidence of lower urinary tract injuries and surgical risk factors. Conclusion: Intraoperative bladder or ureteral injuries during urethropexy procedures are not uncommon, with an incidence of 9% in our series. There is minimal morbidity if these injuries are detected and corrected during the operation, whereas morbidity may be significant if they remain unrecognized. With a potential for unrecognized injury in 8% of Burch procedures without the use of cystoscopy, routine use of cystoscopy during urethropexy procedures appears to be warranted. (Am J Obstet Gynecol 1999;181:35-8.)

Objective: The objective of this study was to determine the accuracy of clinical assessment of paravaginal defects in women with anterior vaginal wall prolapse. Study Design: A retrospective chart review of all women undergoing surgery for anterior vaginal wall prolapse during the years of 1994 to 1996 identified operative notes that described the surgical assessment of paravaginal support. These surgical findings were compared with the preoperative clinical assessment. Clinical parameters that predicted poor correlation were identified. Statistical analysis used the χ 2 test. Results: One hundred seventeen patients had surgery for anterior vaginal prolapse. Seventy had documentation of an intraoperative paravaginal support evaluation. Of these, 44 patients had vaginal procedures, and 26 had abdominal procedures. All patients had at least stage 2 prolapse before surgery, and all were noted to have excellent pelvic support 4 to 6 weeks after surgery. The prevalence of paravaginal defects at surgery was 47% on the right and 41% on the left. The sensitivity and negative predictive value for the clinical assessment for paravaginal defects were good on both the right and left sides, whereas the specificity and positive predictive values were poor. Stage of prolapse, previous hysterectomy, or previous anterior colporrhaphy did not significantly affect the accuracy of the clinical examination in predicting fascial defects. However, previous retropubic urethropexy did significantly decrease the accuracy of the clinical examination in predicting right paravaginal defects ( P Conclusion: Although preoperative clinical assessment for paravaginal defects is useful, it does not substitute for careful intraoperative evaluation for endopelvic fascial defects. (Am J Obstet Gynecol 1999;181:87-90.)

Objective: To determine the screening value of febrile morbidity for detecting infections after vaginal surgery. Methods: A cohort of 431 consecutive women had vaginal surgery at the M. S. Hershey Medical Center from September 1988 through June 1995. Outcomes of febrile morbidity and infection were analyzed. Results: Fifty-four of 431 patients (12.5%) had febrile morbidity. Thirty-five infections (8.1%) were identified, of which only 13 were accompanied by febrile morbidity. Forty-one patients (9.5%) had unexplained fevers. The sensitivity of febrile morbidity for postoperative infection was 40%, specificity was 98%, positive predictive value was 26%, and negative predictive value was 94%. Stepwise logistic regression found blood loss (odds ratio 1.001/mL; confidence interval 1.0001–1.0035), uterine weight (0.987/g; 0.976–0.999), and parity (1.570; 1.146–2.050) as significant independent variables for developing fever. Patient weight (0.984/lb; 0.971–0.998) and type of procedure (2.16; 2.12–6.38) were confirmed as significant independent variables for postsurgical infections. Conclusion: Febrile morbidity had limited value as a screening test for postoperative infection, with poor sensitivity and positive predictive value after vaginal surgery.

A 58-year-old G3, P0 woman presented for management of severe urinary incontinence. She reported urgency as well as stress-provoked symptoms. She voided hourly during the day and had bothersome nocturia. She used adult diapers lined with pads which she changed several times daily. Past surgical history included what the patient called a Bbladder tie^ in 2002 and MarshallMarchetti-Krantz urethropexy in 2004. She reported no relief after either of these procedures. Subsequent urethral bulking procedures were ineffective. She had not benefited from several anticholinergic agents. Pelvic examination revealed no prolapse and a fixed, immobile urethra. Office cystoscopy revealed a 2-cmwide bandlike structure vertically spanning the bladder from the anterior to the posterior wall (Fig. 1). The band appeared epithelialized and vascular, but was without calcification or evidence of exposed mesh. Urodynamics revealed stress urinary incontinence with a Valsalva leak point pressure of 30 cm of water, severe detrusor overactivity, and a reduced cystometric capacity of only 160 ml. The patient underwent cystoscopic resection of the bladder septum using electrocautery with simultaneous rectus fascia pubovaginal sling. Pathologic analysis of the bladder septum revealed fibrosis, without evidence of foreign bodies. Five months postoperatively the stress incontinence symptoms had entirely resolved. Her urgency incontinence, frequency, and nocturia had dramatically improved, and were now responsive to fesoterodine. Though the etiology of the bladder septum was not entirely clear, it was presumably related to Bscarring^ from prior surgical intervention. As pathologic review Fig. 1 Cystoscopic view of bladder septum. The septum vertically spans the bladder from the 12 o’clock to the 6 o’clock position. It is approximately 2 cm in thickness and 5 cm in depth, and is adherent to the anterior and posterior walls of the bladder but not to the dome. An air bubble is seen at the 8 o’clock position in the figure; the trigone is not in view

Retrospective, subjective evaluation of results of suprapubic vesicourethropexy (Marshall-Marchetti-Krantz procedure) for stress urinary incontinence.A total number of 81 patient records operated between 1980 and 1994 at our institution were reviewed and questionnaires were mailed to them to estimate the success rate, period of continence, current complaints and patient satisfaction. Patients with primary incontinence constituted 73% of this group, the remainder of 27% being recurrent or persistent incontinence.The response rate was 75% (60 cases) and this group was evaluated. Mean postoperative time was 9.9 (2-15) years at the time of assessment. Mean duration of continence was 78.5 months and was not influenced by prior hysterectomy or parity. Weak correlation was found between patients' age and continence period. It was similar in patients operated in their 5th and 6th decades of life and was shorter in the 7th decade. Additional sutures placed between the anterior bladder wall and rectus fascia (Lapides modification) resulted in a longer continence period. Cure rates decreased with time and were 81, 77, 57 and 28% after 6, 12, 60 and 120 months respectively. In the incontinent group, 34% of patients described leakage degree as lesser than preoperatively and 65% required protection. As many as 90% of continent and 62% of incontinent women evaluated their urinary system status as better than preoperatively. 90% of continent and 69% of incontinent women would repeat surgery again.This procedure is characterized by a high 81% early postoperative success rate that decreases with time. Despite recurrence of stress incontinence, one third of patients declare lesser incontinence degree and do not require protection.

BACKGROUND: The Burch retropubic urethropexy for the repair of stress urinary incontinence can be performed laparoscopically. Advances in laparoscopic technique have led some surgeons to perform this procedure with hernia mesh and surgical tacks. CASE: A postmenopausal woman presented with complaints of lower abdominal pain, dyspareunia, dysuria, and urinary urgency and frequency after a laparoscopic Burch and paravaginal repair. Bimanual examination revealed tenderness over the pelvic floor muscles and anterior vaginal wall. Exploratory laparotomy revealed dense fibrous adhesions in the space of Retzius along with mesh, permanent suture, and 13 helical tacks. CONCLUSION: Laparoscopic procedures that use hernia mesh fastened with surgical tacks should not be used in the vagina or surrounding structures.

Intraoperative cystoscopy is a useful adjunct to surgical procedures that may compromise the integrity of the lower urinary tract. Ureteral injury and the placement of intravesical sutures are risks, especially at teaching facilities, during operations such as retropubic urethropexy, paravaginal repair, or even simple hysterectomy. The conventional use of transurethral cystoscopy during open surgical cases may require repositioning of the patient if not previously placed in Allen stirrups. Alternative practices of bladder examination include placement of a standard cystoscope via an intentional cystotomy through the dome of the bladder. The authors have implemented the direct insertion of a 2 mm microlaparoscope through the bladder dome to verify an intact lower urinary system and found this method to be both efficacious and safe. Visualization is not compromised by the slightly smaller visual field compared to the standard 0 degrees or 30 degrees cystoscope. The perspective of the bladder neck region may be more easily oriented from the superior viewing angle. The authors prefer transvesical cystoscopy with the microlaparoscope for its ease of use, compared to their experience of performing a small cystotomy or routine transurethral cystoscopy.

We sought to establish whether colpocystourethropexy creates bladder outlet obstruction, as evaluated by pressure-flow studies.We retrospectively analyzed the records of 50 women. Preoperative evaluation included a detailed questionnaire, physical examination, urine culture, cystourethroscopy and multichannel urodynamic testing. Every patient underwent retropubic colpocystourethropexy according to the Tanagho modification of the original Burch technique. An average of 3 months after the operation clinical evaluation and identical multichannel urodynamic testing were repeated. Preoperative and postoperative urodynamic parameters were compared for each patient and statistical differences were established using Student's 2-tailed t test.No statistically significant difference was demonstrated in static urethral pressure profile parameters and in parameters during the filling phase of the cystometrogram except for cystometric capacity, which decreased after surgery (p = 0.02). In contrast, all 5 pressure-flow parameters analyzed (minimum urethral opening pressure, detrusor pressure at maximum flow, maximum flow, theoretical cross-sectional area and theoretical diameter of the flow rate controlling zone) showed statistically significant differences induced by surgery. Pressure-flow data reported on Schäfer's diagram and on the Abrams-Griffiths nomogram failed to demonstrate urodynamically significant obstruction created by surgery.Our data suggest that colpocystourethropexy does not create obstruction but, rather, restores pressure-flow conditions to a normal or nearly normal level.

Commentary on: Nygaard I, Brubaker L, Zyczynski HM, et al. Long-term outcomes following abdominal sacrocolpopexy for pelvic organ prolapse. JAMA 2013;309:2016–24.[OpenUrl][1][CrossRef][2][PubMed][3][Web of Science][4] The challenge of pelvic organ prolapse (POP) is to develop durable surgeries, including sacrocolpopexy. One must consider concomitant anti-incontinence procedures. This study by Nygaard and colleagues addresses the durability of sacrocolopexy, and also provides valuable data on the long-term efficacy of concurrent anti-incontinence surgery. The extended colpopexy and urinary reduction efforts (eCARE) trial provides follow-up of the CARE trial.1 Women with advanced POP without baseline incontinence were randomised to receive abdominal sacrocolpopexy with or without urethropexy. The majority (215/231) were enrolled and 121 women (56%) completed a 7-year assessment. The outcomes included anatomic and symptomatic … [1]: {openurl}?query=rft.jtitle%253DJAMA%26rft.volume%253D309%26rft.spage%253D2016%26rft_id%253Dinfo%253Adoi%252F10.1001%252Fjama.2013.4919%26rft_id%253Dinfo%253Apmid%252F23677313%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10.1001/jama.2013.4919&link_type=DOI [3]: /lookup/external-ref?access_num=23677313&link_type=MED&atom=%2Febmed%2F19%2F2%2F55.atom [4]: /lookup/external-ref?access_num=000318855500024&link_type=ISI

The options available to correct stress urinary incontinence are numerous. We reviewed the current literature on transperitoneal laparoscopic surgery as a new minimally invasive alternative for the correction of this problem. Transperitoneal laparoscopic colposuspension is technically feasible and has a success rate comparable to that of the traditional open retropubic urethropexy and transvaginal needle suspension techniques. Laparoscopic repair takes longer to complete but minimizes postoperative discomfort, hospital stay, and the time to return of normal activities. There is little blood loss, and the duration of urinary diversion averages 24 to 48 hours, with suprapubic urinary drainage unnecessary. Laparoscopic colposuspension by the transperitoneal approach is a reasonable alternative in treating stress urinary incontinence. Early results are similar to those of open and needle suspension techniques, although longer follow-up is necessary to determine long-term efficacy.

Our purpose was to compared the efficacy of anterior colporrhaphy and retropubic urethropexy performed for genuine stress urinary incontinence.A retrospective analysis was performed on women who underwent either anterior colporrhaphy or retropubic urethropexy for genuine stress urinary incontinence. Patients were identified by a computer-assisted search, and these women were contacted by telephone. The interview was used to assess current continence status. Variables reviewed included demographic data, medications, hormonal status, current smoking history, significant medical and surgical history, and time to recurrence of incontinence. Operative procedure, prior or concomitant hysterectomy, history of previous incontinence procedures, concomitant surgery for repair of other pelvic floor defects, experience level of the primary surgeon, and duration of postoperative catheterization were also documented.Seventy-six women who had undergone surgery for genuine stress incontinence during a 4-year period were identified and evaluated by telephone interview. Fifty-six had undergone anterior colporrhaphy and 20 retropubic urethropexy. Both groups of patients were comparable in age, social status, race, parity, and weight. The duration of follow-up (mean +/- SD) was 66.6 +/- 14.2 months (range 48 to 96 months). Concurrent surgery to repair other pelvic floor defects was more common in patients undergoing anterior colporrhaphy than in patients undergoing retropubic urethropexy (p0.05). Of the 56 patients treated with anterior colporrhaphy, 26 (46%) were continent at the time of interview versus 15 of 20 (75%) treated with retropubic urethropexy (p0.05). Times to recurrence for anterior colporrhaphy and retropubic urethropexy were not significantly different. History of previous incontinence procedures, concomitant hysterectomy, previous hysterectomy, duration of postoperative catheterization, obesity, chronic lung disease, and smoking were not correlated with success for either procedure. Experience of the primary surgeon did have a significant effect on success, with attending staff having a better cure rate than resident surgeons (p0.05).Retropubic urethropexy was significantly more effective than anterior colporrhaphy for long-term cure of genuine stress urinary incontinence. We believe these conclusions should be tempered because of the complex nature of genuine stress incontinence. Patients having anterior colporrhaphy may represent a high-risk group because nearly all of them had associated pelvic floor defects. Experience of the surgeon seems to enhance the likelihood of success and may reflect subtle modifications of technique.

OBJECTIVE: Our purpose was to evaluate and compare the long-term results of the Kelly plication, modified Pereyra needle suspension, and Burch urethropexy for the treatment of stress urinary incontinence in women. STUDY DESIGN: One hundred twenty-seven consecutive women underwent surgery at the gynecologic urology division at Women's Hospital, Los Angeles county—University of Southern California Medical Center between January 1986 and June 1987. The only indication for surgery was stress urinary incontinence. Women with previously failed antiincontinence procedures were excluded. Fifty-three patients were premenopausal and 74 postmenopausal. History, physical examination, urethocystoscopy, cotton swab test, filling cystometry, urethral pressure profile at rest and on cough, and uroflowmetry were performed preoperatively, 3 months, 1 year, and 5 years postoperatively. The subjects and surgeons were randomly allocated to one of three surgical procedures: group 1 had anterior colporrhaphy with Kelly plication, group 2 had modified Pereyra needle urethropexy, and group 3 had Burch urethropexy. One hundred seven women were available after 1 year, and 93 were the subjects of the 5-year evaluation. Fisher exact text, χ 2 , t test, and paired t test were used for statistical analysis. RESULTS: The results of the 1-year postoperative evaluation has been previously published. The objective success rate for groups 1, 2, and 3 after 5 years was 37%, 43%, and 82%, respectively, and the difference was statistically significant. The drop in the success rate in 4 years was 26%, 22%, and 7% for groups 1, 2, and 3, respectively. Urodynamically all three procedures significantly increased the abdominal pressure transmission to the urethra, when successful. Ninety-one percent of women after the Burch procedure had a negative cotton swab test after 5 years compared with 46% for the Pereyra and 30% for the Kelly procedures. CONCLUSIONS: In our hands the Burch urethropexy has a higher cure rate that holds over time when compared with the modified Pereyra needle suspension and the Kelly plication. The lower incidence of the position cotton swab test in women after Burch urethropexy may be proof of a better anatomic suspension of the bladder neck.

Osteitis pubis is a painful, noninfectious inflammatory condition that involves the pubic bone, symphysis, and surrounding structures. Initially associated with urologic procedures, osteitis pubis has been described as a complication of various obstetrical and gynecological procedures including vaginal deliveries. An incidence of approximately 2 to 3 percent has been observed after the Marshall-Marchetti-Krantz urethropexy. Although the pathogenesis of osteitis pubis is not clear, periosteal trauma seems to be an important initiating event. Pain is the primary symptom associated typically with difficulty in ambulation and the characteristic "waddling gait." A low grade fever, elevated sedimentation rate, and mild leukocytosis may be observed. Radiographic findings which include reactive sclerosis, rarefaction, and osteolytic changes lag behind the symptoms by about 4 weeks. The major differential diagnosis is osteomyelitis; however, the self-limiting nature and its response to nonantibiotic therapy indicates that osteitis pubis is a separate clinical entity. Treatment is directed at the associated inflammation with most minor cases responding to antiinflammatory agents and bedrest. Other more recalcitrant cases require more involved therapy including systemic steroids and rarely surgical resection. The diagnosis of osteitis pubis should be considered when pelvic pain is present in association with potential trauma to the symphysis pubis. Also, with more women participating in sporting activities patients may present to the physician with osteitis pubis related to athletic injury.

Laparoscopic retropubic urethropexy has recently been described as an alternative method to the surgical correction of pure stress urinary incontinence. This study compares the operative technique and results of laparoscopic colposuspension with traditional open Burch urethropexy to treat women with stress urinary incontinence.We assessed the short-term results of 12 women who underwent a modified laparoscopic Burch urethropexy for the correction of stress urinary incontinence and compared these with a similar contemporary group of 10 women who underwent a traditional open Burch colposuspension procedure.Ten women (83%) who underwent the laparoscopic procedure are continent with a mean follow-up of 20.8 months, and 7 women (70%) who had an open Burch colposuspension are continent at a mean follow-up of 35.6 months. The laparoscopic procedure took an average of 1.5 hours longer than the open repair (P0.01). Patients who underwent the laparoscopic urethropexy required less postoperative analgesia (mean, 14.2 mg morphine equivalents versus 131.4 mg; P0.01), shorter length of hospitalization (mean, 1.9 days versus 4.9 days; P0.01), and a more expedient return to normal activity when compared with those who underwent open Burch colposuspension.Laparoscopic bladder neck suspension offers a less invasive approach to the surgical correction of stress urinary incontinence and can provide successful outcomes in properly selected patients.

Pelvic organ prolapse (POP) is a common accompaniment of advancing age. Current repair techniques incorporate transvaginal and transabdominal approaches with or without prosthetic mesh insertion. In this paper, we present the short- and medium-term results of a unit policy directed at patients with POP of combined abdominal rectopexy and Burch retropubic urethropexy without the use of prosthetic mesh assessing its safety profile in selected cases.Between January 2009 and January 2011, 16 women with tri-compartmental prolapse who had all undergone prior hysterectomy underwent combined surgical pelvic floor repair. Preoperative symptom assessment by validated questionnaires and clinical examination were pre- and postoperatively recorded. Cures were defined as either optimal or satisfactory outcomes based on combined clinical, radiological examinations and reported patient satisfaction.The mean age of the 16 patients was 57.2 years, and their mean BMI was 28.6 (±5 SD). Pelvic examination revealed a POP-Q stage III prolapse in 12 patients and stage IV in 4 patients. The mean operating time was 57.5 min (range 40-85), with a mean length of hospital stay of 4.5 days. Cystocele and enterocele resolution was noted in every case on dynamic magnetic resonance imaging (MRI).Our results in a small patient cohort employing a simple 'all-in-one' repair approach combining a retropubic colposuspension with an anterior rectopexy appear to be satisfactory. Further larger randomized studies are required, incorporating a laparoscopic arm in order to determine the longer-term effectiveness of this approach.

OBJECTIVE: Postoperative bladder complaints after incontinence procedures are well known to the pelvic surgeon, but there are few reports comparing subjective complaints with objective data. Thirty of 68 patients who underwent a modified Burch urethral suspension were interviewed and examined by the first author. Four-channel urodynamics were then performed. STUDY DESIGN: Of the 30 patients, eight (27%) complained of postoperative urinary leaking, and three of eight (10%) said they leaked worse than before surgery. Four patients (13%) had objective evidence of detrusor instability on cystometrogram. Two patients (6%) had recurrent genuine stress incontinence. No patients had bladder spams or symptoms of retention. Univariate and multivariate analyses were performed on the following preoperative patient factors in relation to surgical success: age, height, hormonal status, and concurrent pelvic relaxation. Only preoperative hormone use had statistical significance in relation to surgical success. RESULTS: The eight patients with leaking were treated on the basis of subjective complaints plus objective findings. The patients with detrusor instability had improvement with medication and bladder drills, but two of the four still had mild leakage. Of the other four patients, one required a urethral sling and is now dry. The other three patients had significant improvement or cure of symptoms after modifications were made in their voiding techniques. CONCLUSION: Our study suggests that preoperative and postoperative estrogen use is significantly correlated with surgical success of the Burch procedure, whereas age, weight, and postoperative pelvic relaxation have little influence. We also found that surgical success could be improved by close evaluation and individual management of patients with voiding complaints.

Recent advances in laparoscopic surgery have allowed urologists to perform laparoscopic bladder suspension; however, laparoscopic suturing techniques have a steep learning curve and make the procedure more difficult and time consuming. We describe a new technique that combines extraperitoneal laparoscopic bladder neck mobilization through a single port with the ease of a needle suspension urethropexy in order to avoid the need for vaginal incisions and the use of laparoscopic suturing techniques. The procedure has been performed in four patients, all of whom are continent and voiding with complete bladder emptying. Postoperative pain was minimal, allowing most patients to be discharged the day after surgery. In the future, the procedure may be performed on an outpatient basis.

Objective: To assess the effectiveness and perioperative morbidity of the modified Pereyra procedure in the treatment of recurrent stress urinary incontinence. Methods: Data of 54 patients who underwent a modified Pereyra procedure for the treatment of recurrent stress urinary incontinence between January 1, 1978, and August 1, 1992, were analyzed retrospectively regarding presenting symptoms, preoperative evaluation, surgical procedure, complications, and cure and failure rates. The patients were divided into two groups depending on the preoperative absence (group I) or presence (group II) of risk factors for repeated failure (detrusor instability, low-pressure urethra, fibrotic urethra, negative Q-tip test, and neurogenic incontinence). Results: After a mean follow-up of 36.3 months, the cure rate of 81.6% in group I (N= 38) was significantly (P= .005) higher than that in group II (N= 16; 43.8% cured). The mean time of occurrence of failure was 11.9 months for group I and 6.8 months for group II. The incidence of intraoperative complications (Pereyra suture in bladder, hemorrhage) for both groups was 7.4%. Immediate postoperative complications were found in 25.9% of all patients; these were mainly infectious processes. Late postoperative complications occurred in 33.3%, with the most prevalent being new-onset urge incontinence and de novo detrusor instability (11.1%) and obstructive voiding dysfunction (9.3%). The rates of perioperative morbidity were not significantly different between the groups. Conclusion: The modified Pereyra procedure is well suited for the treatment of uncomplicated recurrent stress urinary incontinence, with a long-term cure rate of over 80%. However, success rates are significantly lower for recurrent stress incontinence in association with persistent risk factors for failure. In either instance, the procedure is associated with appreciable perioperative morbidity.(Obstet Gynecol 1994;83:573-8)

To analyze the effectiveness of simplified urethropexy in the evolution of urinary incontinence after radical laparoscopic prostatectomy.Between January 2007 and December 2008, 104 patients were included in a randomized trial to assess the effectiveness of simplified urethropexy. The simplified urethropexy technique was performed on conclusion of a urethrovesical anastomosis with running suture and, before cutting the suture material, a suture was applied using the same material with a needle through the pubic tubercle, tightening it and securing it with a Hem-o-lok. Fifty-one patients qualified for the trial in the simplified urethropexy group (group 1) and another 51 in the control group without urethropexy (group 2). Incontinence was defined as the lack of the need for protection for normal life, and the degree of continence was compared at 3, 6, and 12 months after surgery.Surgery lasted 141 minutes in group 1 and 139 in group 2 (NS). There were no secondary complications such as urine retention, osteitis pubis, or bladder perforation. After 3 months, 47.1% of patients in each group declared continence (NS). After 6 months, 72.6% of patients in group 1 and 66.7% in group 2 (P0.05) declared continence. After 12 months, 92.2% of patients in group 1 and 84.3% in group 2 declared continence.In our experience, simplified urethropexy is a simple, nontime-consuming technique that shows a slight clinical improvement in continence within 6 and 12 months, without reaching significant differences with the Fisher Test. It would be necessary to perform a trial with a greater number of patients to confirm these data.

Pad test, cystometry and analysis of micturition were performed in 36 women with stress incontinence before and a year after operation with either retropubic urethrocystopexy (n = 22) or pubococcygeal repair (n = 14). There was no difference in the subjective cure rate between the two groups of women (77% and 79%, respectively). The pad test 1 year after operation showed that 59% of the women in the urethrocystopexy group and 43% of the women in the pubococcygeal repair group had stopped leaking urine. The bladder volume had increased in both groups and the intravesical pressure of the bladder filled to the maximum had increased in the pubococcygeal repair group. The functional length of the urethra, intravesical pressure at maximal urine flow, maximal urine flow rate and urethral conductance were not affected by either operation. Pad test was a more accurate test for an objective evaluation of urine leakage before operation than were the urodynamic investigation or continence tests.

Retropubic colpourethrocystopexy has been shown to be associated with good immediate cure rate in treating female urinary stress incontinence. Urodynamic data is often lacking in follow-up studies. This study presents long-term results 8-12 years after operation. Between 1979-1982, 72 women suffering from genuine stress incontinence underwent a colpourethrocystopexy. Follow-up was done 1989-1990. Each patient had a complete urodynamic evaluation preoperatively and at the follow-up. Mean age at operation was 46.2 years and follow-up was done on average 9.4 years later (8-12 years). 71% were postmenopausal at the time of follow-up. Surgical cure rate was 90.3%, 9.7% (seven patients) were considered failures. Five of the seven patients had experienced much improvement. A number of patients showed a decrease in one or more urodynamic parameter without a recurrence of stress incontinence. The bladder neck was incompetent in 38 (52.8%) of the patients, 31 of the 38 patients were still continent. Retropubic colpourethrocystopexy should be considered the primary operation for the treatment of female stress incontinence. Cure rate and postoperative evaluation cannot be judged by urodynamic parameters only, as some of the continent women showed a decrease in one or more urodynamic parameters that are considered important for continence. Bladder neck competence is not necessary for postoperative continence.