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The aim of this study was to assess the association between four-dimensional translabial ultrasound (4D-TLUS) features of the retropubic mid-urethral sling (MUS) and post-operative pelvic floor symptoms. A prospective cohort study was performed involving 100 women who had a solitary retropubic MUS (TVT Exact™) between Jan 2013 and Dec 2017 for urodynamic stress incontinence (SI) at a tertiary urogynaecological centre. All patients completed a standardised interview and had free flowmetry, prolapse evaluation and assessment for mesh exposure and tenderness. 4D-TLUS parameters measured included pelvic organ descent, levator ani status, sling–symphysis pubis (SP) gap at rest and Valsalva, angle formed by cranial and caudal ends of the sling, cranio-caudal and dorso-ventral sling–symphysis pubis distance at Valsalva. The primary outcome was treatment success as defined by patient report of cure or improvement and no objective demonstrable SI. Eighty-nine (89%) patients reported treatment success. Two patients (2%) had mesh exposure; one was symptomatic with pain, requiring complete sling removal. There was a significant association between treatment success and a SP gap at Valsalva of 10–12 mm (p = 0.001); and independently with a SP angle at Valsalva of 45°–80° (p = 0.007). A narrower SP gap at Valsalva closer to 10 mm was associated with voiding symptoms (p = 0.036). Sling–pubis gap and sling–pubis angle at Valsalva appear to be significantly associated with treatment success in retropubic MUS. There is a significant association between a narrower sling–pubis gap at Valsalva and voiding symptoms.

Objective To establish whether the infusion method trial of void (TOV) after a mid-urethral sling procedure, in contrast to the standard auto-fill TOV, permits discharge home from recovery, as these procedures are eminently suited to same day discharge, and the delay in achieving a successful TOV often keeps the patient in hospital overnight. Method A randomised controlled trial performed between December 2014 and April 2016 at the University Hospital, enrolling 40 women undergoing a mid-urethral sling procedure for stress urinary incontinence. The women were randomised to infusion method or auto-fill method TOV. The primary outcome was discharge home from the recovery area of theatre. Results Discharge from recovery was not different between the two groups (odds ratio (OR) 1.3 95% CI: 0.3-5.9, P = 0.71). The rate of TOV being successfully passed in recovery was higher in the infusion-fill group compared to the standard auto-fill group (OR 4.5 95% CI 1.2-17.4, P = 0.025). This means that three women will undergo the infusion-fill to achieve one more successful TOV in recovery. Conclusions The infusion method resulted in more women passing their TOV in recovery but this did not translate into more discharges from recovery.

To compare the safety and efficacy of the transobturator tape (Monarc®) with the retropubic tape (tension-free vaginal tape, TVT®) for the treatment of urodynamic stress incontinence (USI) a prospective, single-blinded, multi-centre randomised clinical controlled trial was undertaken in four urogynaecology units in Australia. One hundred and eighty-seven women with USI were randomly allocated to undergo surgery with either the Monarc sling (n = 80) or TVT (n = 107). Outcome measures were intra-operative complications (especially bladder injury), as well as peri-operative complications, symptomatology, quality of life and urodynamic outcomes. At 3 months, data were available on 140 women, 82 (59%) TVT and 58 (42%) Monarc. The TVT group was significantly more likely to be complicated by bladder injury (7 TVT, 0 Monarc, p

The most practical and accurate method to measure residual urine volumes in women is yet to be determined. The practicality of transvaginal ultrasound in measuring the range of residuals typically encountered in a group of 100 symptomatic women attending for urodynamic investigations was tested and compared with urethral catheterization. Transvaginal ultrasound was found to be more comfortable, less invasive and quicker. In ideal circumstances for both techniques, mean time from voiding until residual assessment was 47 seconds for transvaginal ultrasound and 270 seconds for urethral catheterization. Transvaginal ultrasound was applicable to 99% of women, with accurate assessment of residuals possible in 96% (100% for urethral catheterization). Eighty-five percent of women were found to have a residual under the level of likely clinical significance (30 ml). Transvaginal ultrasound permits the avoidance of catheterization in these women. Transvaginal ultrasound allows for immediate retesting of the residual, a feature not possible if there is bladder drainage by urethral catheterization. Of the 22 women with residuals initially over 30 ml, 11 (50%) were able to lower this by an average of 69%, 7 (32%) of these to under 30 ml, with an immediate further attempt at voiding. In terms of practicality, transvaginal ultrasound is the method of choice for residual determination in the vast majority of women attending for urodynamic investigations. While it is not possible to directly compare the accuracy of the two techniques, a theoretical comparison is possible by summation of their respective sources of error. This comparison showed that the two techniques, in ideal circumstances, have similar accuracies over the range 0–175 ml. In non-ideal circumstances, urethral catheterization has more potential sources of error.

Summary The sacrospinous ligament has been used for over 50 years as a convenient structure for treating vaginal vault and more recently, uterine prolapse. The procedure has evolved over the years and its efficacy has been hotly debated with invariable comparisons made to abdominal sacral colpopexy. Mesh surgery has introduced a newer dimension to the debate. This review is an attempt to clarify the anatomy, reflect on various techniques and offer a critique on the current ‘status’ of the sacrospinous ligament.

Background: The TVT-Secur (Ethicon, Somerville, NJ, USA) is a minimally invasive suburethral synthetic sling used in the treatment of female stress urinary incontinence. It claims to cause less postoperative pain and to enable performing in an office setting. However, this may be at the expense of a significant learning curve and a higher early failure rate. Aims: To assess objectively the success rate of the TVT-Secur procedure in the ‘U’ configuration at six months. Secondary outcomes focussed on subjective success rates, complications, patient satisfaction and quality-of-life (QOL). Methods: A prospective observational study was undertaken at two tertiary referral urogynaecology centres. A cohort of 42 consecutive patients with urodynamic stress incontinence who underwent the TVT-Secur procedure in the ‘U’ configuration between November 2006 and August 2007 were followed up for six months. Three standardised QOL questionnaires were completed preoperatively and at six months. A urogenital history, visual analogue score (VAS) for patient satisfaction, uroflow and urinary stress test were performed at six months. Results: Recruitment was ceased prematurely because of a high number of early failures. Objective and subjective success rates at six months were 58.3% and 51.3% respectively. Complications included urinary tract infections, voiding difficulty, groin discomfort, haematoma, vaginal pain, tape erosion and intra-operative dislodgement of tape. Prevalence of de novo urge incontinence was 10.3%. Only symptom-specific QOL scores improved and only 48.6% indicated a high level satisfaction (VAS ≥ 80%) with TVT-Secur. Conclusion: On the basis of this limited study, we are hesitant to recommend the ‘U’ configuration of the TVT-Secur over its more established counterparts, the TVT and TVT-O.

Twenty patients adjudged to require surgical management of genuine stress incontinence underwent the abdomino-perineal urethral suspension procedure between May, 1989 and February, 1990. Short-term subjective follow-up revealed a 94% cure and improved rate in 19 patients in whom the operation was completed. There was a striking absence of postoperative voiding morbidity. We believe this somewhat neglected procedure is worthy of further objective study and comparison with the more popular methods of surgical management of genuine stress incontinence.

SummaryCold knife cone biopsy using ornipressin and a cervical encircling suture is described. Case notes from 81 patients using this technique were studied retrospectively. The 3-7 per cent incidence of haemorrhage requiring hospital re-admission compared very favourably with other surgical techniques used.

Summary— The effectiveness of different types of urinary catheters in completely draining the bladder has not been tested. Transvaginal ultrasound, which is able to measure bladder volumes in women from 2 to 175 ml, provides a means of measuring any fluid volume remaining in the bladder following catheter drainage. Using transvaginal ultrasound, the post-catheterisation bladder volumes were measured in 26 female patients; 14 underwent urethral catheterisation using either a 14F short plastic female catheter or a Foley catheter of the same size (balloon not inflated); 12 had an indwelling 12F suprapublic catheter following bladder neck surgery. The mean post-catheterisation bladder volumes after using the short plastic female and Foley catheters were less than 1 ml and 77 ml respectively. A short plastic catheter should be used in women to collect the residual urine volume by urethral catheterisation. A Foley catheter is relatively ineffective in this task. A 12F suprapubic catheter was found to drain the bladder relatively well. The mean post-catheterisation bladder volume was 35 ml. Prior to removing a suprapubic catheter post-operatively, it is recommended that the residual urine volume (measured using the suprapubic catheter) be checked by measuring the post-catheterisation bladder volume (using either a short plastic catheter or transvaginal ultrasound).

Tests of the integrity of bladder sensation are a poorly understood and often neglected part of urodynamic investigations. The electrical techniques that have been described to test sensation involve the use of costly and complex equipment; electrical current also is not the natural stimulator of bladder nerves. Trigonal sensitivity testing held promise as a simple, effective and inexpensive test of bladder sensation. We evaluated a modified version of this technique in 89 women: 78 had urodynamically proved lower urinary tract dysfunction and 11 were control patients. The technique proved to be of no value in distinguishing among various urodynamic diagnoses. In particular, patients with detrusor instability or bladder hypersensitivity showed no characteristic patterns on trigonal sensitivity testing. Sensitivity values correlated neither with the first sensation to void nor the cystometric bladder capacity during urodynamic testing. It does not appear to contribute any clinically useful information in the evaluation of lower urinary tract dysfunction in women.

Two potential sources of error in the measurement of residual urine volumes in women were quantified. These were (i) whether a diuresis is operating at the time of measurement, and (ii) the time between voiding and residual urine volume collection. A regime is suggested for the accurate measurement of residual urine in women by urethral catheterisation.

The subjective assessment of urine loss in 84 incontinent women was quantified by using a 10-cm visual analogue scale. These results were compared with the results of a 2-h pad weighing test. We found no relationship between a patient's subjective impression of the severity of her incontinence and the corresponding objective assessment by a 2-h pad weighing test.