Search

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

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 describe the surgical treatment and short- and long-term outcome of young pot-bellied pigs with penile prolapse. Study design Short case series. Animals Five young castrated Vietnamese pot-bellied pigs. Methods Five Vietnamese pot-bellied pigs presented with penile prolapse of several weeks duration. No other abnormalities were found at physical examination. Under general anesthesia, phallopexy with or without combined urethropexy was performed successfully in all cases. Results All pigs were discharged from the hospital. One pig required a second urethropexy the day after the initial surgery to improve positioning of the penis in the prepuce. Long-term outcome was available in 4 cases. Penile prolapse resolved in the 4 cases available for follow-up, and the owners were satisfied with the cosmetic outcome of the procedure. Conclusion Penile prolapse was successfully corrected in 5 pot-bellied pigs by using 2 different phallopexy techniques. The procedure was combined with urethropexy in 3 pigs. Long-term outcome was excellent in the 4 cases available for follow-up. Clinical impact This is the first report describing the use of phallopexy with or without urethropexy for successful treatment of penile prolapse in young pot-bellied pigs. Two different phallopexy techniques were effectively used in this report. The etiology of penile prolapse in pot-bellied pigs remains unknown.

Stress urinary incontinence (SUI) is a major problem affecting more than 20% of the nation's female population, with increasing prevalence as our population continues to age. Incontinence places a great burden on individuals, and the economic effect is large. Stress urinary incontinence occurs when there is involuntary leakage of urine during coughing, laughing, sneezing, or physical activity. It can be diagnosed during physical examination and by using low-cost office diagnostics. Although nonsurgical treatments provide some benefit, surgical interventions have demonstrated superiority with respect to subjective and objective cure and better long-term improvement. Corrective surgeries for SUI can be grouped into four categories: 1) slings (midurethral slings and slings placed at the ureterovesical junction), 2) retropubic urethropexy, 3) urethral bulking agents, and 4) artificial sphincters. The success and failure of each approach needs to be assessed in the context of individual patients and their circumstances. Slings and retropubic urethropexy are considered first-line surgical options. Since the advent of minimally invasive retropubic midurethral slings such as the tension-free vaginal tape, transobturator tension-free vaginal tape, and single-incision sling, retropubic urethropexy have fallen out of favor. Warnings about mesh use may contribute to a resurgence of retropubic urethropexy procedures such as the Burch procedure. A Burch procedure should still be considered for patients who have an aversion to mesh or if they are undergoing concurrent abdominal approach surgery. Urethral bulking agents are usually reserved for patients with a fixed, nonmobile urethra who cannot tolerate an operative experience or have failed previous antiincontinence procedures. Artificial sphincters should be considered an operation of last resort.

Objective To report 1) a combined technique of urethropexy and colposuspension; 2) intra- and postoperative complications; and 3) medium term outcome. Study design Retrospective case series. Animals Female dogs (n = 30) with urinary incontinence associated with urethral sphincter mechanism incompetence (USMI) unresponsive to medical management. Methods Through a ventral median celiotomy, the bladder was positioned abdominally to permit the urethra to be anchored with single interrupted polypropylene sutures to the prepubic tendon and linea alba. The vagina was freed from the vesicovaginal and rectovaginal attachments and advanced cranially by traction before attachment to the prepubic tendon with polypropylene mattress sutures. Bitches were re-examined 2 weeks postoperatively; medium term outcome (>6 months) was evaluated by telephone interview of owners. Results At a median follow up of 39.5 months, 21 bitches (70%) were considered to have an “excellent” medium term outcome with complete resolution of their urinary signs; 8 (26.6%) had a “good” outcome, and 3 (10%) had mild transient dysuria postoperatively. Conclusion Combined urethropexy and colposuspension resulted in complete resolution of urinary incontinence in 70% of bitches with USMI and was not associated with major complications.

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).

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.

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.

SummaryThe development of a new operation for certain types of urinary incontinence has been described. A preoperative test, consisting essentially of temporary elevation and fLxation of the vesical neck and urethra, has permitted the selection of those candidates who have an excellent chance for improvement by the operation, and which at the same time seems to indicate those whose postoperative result will not be good. The operation is a simple elevation and immobilization of the vesical neck and urethra by suturing them to the pubis and rectus muscles. Of 44 suitable cases excellent results were obtained in 36 (82%), significant improvement in 3 (7%), and no improvement in 5 (11%). The causes of most of the failures seem evident and are discussed. The most significant group reported consisted of 25 patients with the common variety of female stress incontinence which had failed to be corrected by one or more standard gynecological procedures for incontinence. Of these 25 patients, 19 have normal control ...

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.

Objective To determine the effectiveness of a vaginal retropubic urethropexy with intraoperative cystometry in treating urinary stress incontinence. Patients and methods One hundred patients with genuine stress incontinence on urodynamic examination underwent the procedure and were followed up for 1 year; 96 completed the follow-up (four were lost to follow-up). Results At 1 year, 91 patients (95%) were cured of their stress incontinence and five (5%) failed, with recurrent stress incontinence developing. The complications were mainly of suture erosion (6%). Conclusion This method of urethropexy has produced excellent results to date, with low complication and morbidity rates, and continues to be our treatment of choice. A randomized control trial comparing it with standard established procedures would be welcomed.

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.

Background. To evaluate the results of retropubic urethrocystopexy (with sutures and fibrin sealant) and pubococcygeal repair five to seven years postoperatively. Material and methods. Thirty women with genuine stress urinary incontinence were subjected to retropubic urethrocystopexy (n=30) and 15 women to pubococcygeal repair (n=15). The preoperative assessment included both subjective and objective methods. The results evaluated three months, one year and five to seven years after the surgical treatment. Results. One year after surgery 71% of the women in the urethrocystopexy group reported that they were continent, compared with only 43% five to seven years after surgery. In the pubococcygeal repair group 80% were continent at one-year follow-up, compared with 60% at the long-term follow-up. According to pad test 79% of the women in the urethrocystopexy group had ceased leaking urine at minimal activity and 64% at maximal activity five to seven years after surgery. However, in the pubococcygeal repair group the corresponding percentage was 71% under both conditions. Intravesical pressure and Body Mass Index increased significantly in the whole group but urethra conductance and maximal urine flow decreased only in the urethrocystopexy group five to seven years after the surgical treatment. Conclusions. Accurate assessment of the results of any surgical treatment of stress urinary incontinence is difficult. During long term follow-up period significant changes may occur among the women, e.g. menopause and increase of Body Mass Index both predisposing to urinary incontinence.

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.

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

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.

Purpose: We compared 2 treatment modalities (sling cystourethropexy and periurethral collagen injection) in patients with intrinsic sphincter deficiency alone or with urethral hypermobility (combined stress urinary incontinence).Materials and Methods: We retrospectively reviewed a series of 50 consecutive patients treated surgically for intrinsic sphincter deficiency during a 2-year period. All patients were evaluated by history and physical examination to assess urethral hypermobility and urodynamic testing. Intrinsic sphincter deficiency was assessed by abdominal leak point pressure and video urodynamics. Of the 50 patients 28 underwent a pubovaginal sling operation and 22 received a periurethral injection of collagen.Results: Of the patients studied 40 percent had combined stress urinary incontinence. A pubovaginal sling procedure resulted in a cure rate of 81 percent in this group, compared to 25 percent for periurethral injection of collagen.Conclusions: A subgroup of women exists with combin...

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.

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.

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.

The treatment of intrinsic urethral weakness (Type III stress urinary incontinence) has traditionally been accomplished by the performance of a sling cystourethropexy or the placement of an artificial urinary sphincter. As experience with operative laparoscopy continues to increase, the possibility of performing these procedures from a laparoscopic approach becomes realistic. We report our experience with the laparoscopic performance of a sling cystourethropexy and placement of an artificial urinary sphincter in the canine model. On the basis of initial results, we believe these techniques are feasible in human subjects.

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.

We determined the effect of an anterior urethropexy (AU) stitch on postoperative urinary continence, irritative urinary symptoms, and sexual function after robotic radical prostatectomy (RP).Consecutive patients undergoing robotic RP for prostate cancer were prospectively evaluated. The Expanded Prostate Cancer Index Composite (EPIC) questionnaire was administered pre- and postoperatively to all patients. Patients were then grouped by AU status. A linear mixed model was used to compare the rate of recovery in incontinence (UIN), irritative (UIR), and sexual domain scores between the two groups. A t-test was used to compare UIN, UIR, and sexual domain scores at specific time points.A total of 229 patients underwent robotic RP and filled out a preoperative and at least one postoperative EPIC questionnaire. In this population, 87 did have and 142 did not have an AU performed. The mean EPIC-UIN score at 3 months was 68 in the AU group and 58 in the non-AU group (p = 0.015). Comparison of all other time points and overall urinary scores revealed no other statistically significant differences after surgery. Sexual domain scores were also improved at 3 months in the AU group (p = 0.002).AU during robotic RP leads to improved urinary continence and sexual functioning at 3 months of follow-up. An earlier return to continence may facilitate an earlier return to sexual activity. AU may offer a short-term quality-of-life advantage for patients undergoing robotic RP.

Submitted by Guilherme Lemeszenski (guilherme@nead.unesp.br) on 2013-08-22T19:00:11Z No. of bitstreams: 1 S0103-84782010000300038.pdf: 59979 bytes, checksum: ede78d329b9d3f24ffe3a26675ea944c (MD5) Made available in DSpace on 2013-08-22T19:00:11Z (GMT). No. of bitstreams: 1 S0103-84782010000300038.pdf: 59979 bytes, checksum: ede78d329b9d3f24ffe3a26675ea944c (MD5) Previous issue date: 2010-03-01 Made available in DSpace on 2013-09-30T19:58:16Z (GMT). No. of bitstreams: 2 S0103-84782010000300038.pdf: 59979 bytes, checksum: ede78d329b9d3f24ffe3a26675ea944c (MD5) S0103-84782010000300038.pdf.txt: 49993 bytes, checksum: a304e77c36c4501a2dea17234759fb63 (MD5) Previous issue date: 2010-03-01 Submitted by Vitor Silverio Rodrigues (vitorsrodrigues@reitoria.unesp.br) on 2014-05-20T13:15:14Z No. of bitstreams: 2 S0103-84782010000300038.pdf: 59979 bytes, checksum: ede78d329b9d3f24ffe3a26675ea944c (MD5) S0103-84782010000300038.pdf.txt: 49993 bytes, checksum: a304e77c36c4501a2dea17234759fb63 (MD5) Made available in DSpace on 2014-05-20T13:15:14Z (GMT). No. of bitstreams: 2 S0103-84782010000300038.pdf: 59979 bytes, checksum: ede78d329b9d3f24ffe3a26675ea944c (MD5) S0103-84782010000300038.pdf.txt: 49993 bytes, checksum: a304e77c36c4501a2dea17234759fb63 (MD5) Previous issue date: 2010-03-01 A incontinência urinária adquirida é uma condição debilitante e, muitas vezes, incurável que acomete fêmeas castradas e raramente fêmeas inteiras ou machos. A manifestação clínica pode ocorrer em qualquer momento após a gonadectomia e resulta em graves problemas no manejo do paciente. Os mecanismos que desencadeiam a incontinência após ovariectomia envolvem decréscimo na pressão de fechamento uretral, alterações hormonais, aumento na deposição de colágeno na musculatura lisa da bexiga, diminuição na contratilidade do músculo detrusor e redução na resposta aos estímulos elétricos e ao carbachol. O diagnóstico é realizado pelo histórico do animal, pelo exame físico, pelos exames laboratoriais, pelo perfil de pressão uretral, pela ultrassonografia e pelas radiografias abdominais. O tratamento clínico envolve utilização de fármacos -adrenérgicos, estrógenos, análogos de GnRH e agentes antidepressivos. As técnicas cirúrgicas recomendadas correspondem à uretropexia, cistouretropexia, aplicação de colágeno na uretra e colpossuspensão. Melhor compreensão da etiologia, da fisiopatologia, dos métodos de diagnóstico e tratamentos é fundamental em razão do pouco conhecimento e da identificação dessa condição no Brasil. Acquired urinary incontinence is a debilitating, incurable condition, prevalent in spayed bitches and rarely seen in entire bitches or males. In bitches, acquired urinary incontinence can occur anytime from one week after neutering and is associated with severe management problems. Incontinence in neutered bitches can be associated with a decrease in maximal urethral closure pressure, hormonal changes and increase in the percentage of collagen in the bladder wall. It's also associated to a reduced contractility of the detrusor muscle, decrease in the magnitude of response of the bladder wall to both carbachol and eletrical field stimulation, and there are risk factors involved. The diagnosis is established based on historical findings, physical examination, laboratorial exams, urethral pressure profilometry, ultrasonography and abdominal radiographs. The medical management involves the appliance of -adrenergics agonists, oestrogens, GnRH analogues and antidepressive agents. Surgical recommendation management corresponds to urethropexy, cistourethropexy, endoscopic periurethral injection and colposuspension. The better understanding A better comprehension of etiology, physiopathology, diagnosis methods and treatment could provide significant benefits considering the lack of knowledge and diagnoses of this clinical condition in Brazil. Universidade Estadual Paulista Faculdade de Ciências Agrárias e Veterinárias Universidade Estadual Paulista Faculdade de Ciências Agrárias e Veterinárias Departamento de Medicina Veterinária Preventiva e Reprodução Animal Universidade Estadual Paulista Faculdade de Ciências Agrárias e Veterinárias Universidade Estadual Paulista Faculdade de Ciências Agrárias e Veterinárias Departamento de Medicina Veterinária Preventiva e Reprodução Animal

Urethral sphincter mechanism incompetence (USMI) is the most common cause of urinary incontinence in dogs. Surgery may be recommended if the animal does not respond to medical treatment or becomes refractory. In this third part of a three-part review, surgical options for the treatment of USMI are described. Colposuspension is the most frequently described procedure and offers a fair prognosis, with about 50% of the dogs being continent after surgery and most of the reminder being improved or more responsive to medical treatment. Urethropexy offers a similar success rate, but with a higher rate of complications. Endoscopic injection of collagen is an attractive technique due to its minimally invasive nature and low risk of adverse effects. Initial results may however deteriorate with time. Other procedures have been reported, but involve a low number of cases and have resulted in variable success rates. In women, stress urinary incontinence is mainly treated by minimally invasive procedures involving vaginal placement of sub-urethral slings.

The management of stress urinary incontinence continues to be a perplexing problem for the gynecologist. The needle urethropexy procedures have undergone extensive revision with modifications of Pereyra, Stamey, Gittes, and Raz. In 16 patients with severe pelvic floor relaxation a modified needle urethropexy was performed along with vaginal surgery for correction of prolapse. Two small suprapubic incisions are made. No vaginal incision is required. The Pereyra needle is passed twice on each side of the urethra from the rectus fascia through the full thickness of the vaginal mucosa at the level of the urethrovesical junction. A 5-mm Mersilene strip is used in the suspension. At 2 months vaginal mucosa has epithelialized over the strips in all patients. There were 5 objective failures, but 4 of these patients were subjective cures. Two patients developed vesical instability. One patient postoperatively was unable to void, and 4 months later the sutures were cut. Only 1 patient developed suture rejection 11 months after surgery.

Armand J. Pereyra introduced a new approach in the treatment of female urinary stress incontinence which did not require abdominal retropubic dissection. This operation and subsequent modifications by Pereyra serve as the foundation for various needle suspension procedures. The reported cure rates for the Modified Pereyra Procedure and its variations have exceeded 85 per cent in several studies. There has been some suggestion of an increased late failure rate in the Modified Pereyra Procedure compared to abdominal retroubic urethropexy. Additional long-term studies are needed to answer this important question utilizing preoperative and postoperative urodynamic evaluation. Karram and Bhatia in their review of transvaginal needle bladder neck suspension procedures cited three studies which accomplished this in a total of 60 patients. It seems the popularity of needle suspension procedures continues to grow. Increasingly, needle suspension procedures have been used in the outpatient treatment of urinary stress incontinence. A continuing tribute to the operative contributions of Armand J. Pereyra in the treatment of urinary stress incontinence.

Sixty-one women with genuine stress incontinence undergoing preoperative and postoperative multichannel urodynamic investigation were tested with augmenting urethral closure pressure profiles during contraction of the pelvic floor muscles to assess voluntary control of the urethral “sphincter.” Increases of 20% or more above resting functional length and closure pressure were selected as indicators of augmentation. The presence or absence of augmentation of functional urethral length and/or closure pressure during pelvic floor contraction allowed for the grouping of these patients into six subgroups which were compared for urinary symptoms, prior anti-incontinence procedures and the presence of low urethral pressure, detrusor instability and genuine stress incontinence both pre- and postoperatively. Evaluation of the patient's ability to augment functional length and closure pressure did not affect surgical success nor did its presence or absence correspond to the presence of a low pressure urethra, detrusor instability, or specific urinary symptoms. Evaluation of augmentation of functional length and closure pressure was therefore felt to be of no prognostic value during the performance of multichannel urodynamic testing in incontinent females.

Nineteen women with stress urinary incontinence (SUI) and low urethral pressure were compared with 106 patients with SUI and normal urethral pressure. All underwent either a revised Pereyra procedure or Burch retropubic urethropexy, and all had detailed clinical and urodynamic evaluations before their operation and one year postoperatively. Surgical procedures effectively stabilized the bladder base and enabled adequate abdominal pressure transmission to the urethra in both groups of women. In spite of these urodynamic findings, the failure rate in women with stress urinary incontinence and low urethral pressure was significantly higher compared with women with good urethral pressure (50% vs 23% for the Pereyra procedure and 33% vs 12% for the Burch procedure [p less than 0.05]), indicating an etiology for their incontinence other than poor support to the urethrovesical junction; therefore, the need for another approach to cure stress incontinence.

A prospective follow-up study was performed to evaluate the effect of Burch colposuspension alone and a concomitant abdominal hysterectomy with Burch colposuspension. Twenty seven women underwent Burch colposuspension and 34 women colposuspension with abdomina hysterectomy. Subjective outcome was assessed with questionnaire at 4 weeks, 6 months and 1 year. In the 1 year follow-up 81,4% were subjectively cured or improved in the Burch group and 76,4% in the hysterectomy group. No statistically significant difference in the frequency of any subgroup of complications was found.

Background. Sling procedures performed for urinary stress incontinence can be complicated by urinary retention and flow problems. The aim of this study was to evaluate the flow and the residual urine before and after a tension-free vaginal urethropexy procedure performed for stress urinary incontinence. Methods. A total of 72 women were included in the study. For voiding phase assessment, patients had spontaneous flow and residual urine measurements performed before the operation and 3 months and 1, 2, 3, and 4 years after the operation. Results. The patients experienced an increase in residual urine 3 months postoperatively, but returned toward preoperative values in the following 4 years. A statistically significant decrease in maximum flow, average flow, and corrected maximum flow was observed 3 months after the operation, which was unchanged in time and thus did not increase over the years. Conclusion. The tension-free urethropexy operation had an influence on flow which did not deteriorate over the years. Whether this change in flow will have any influence on the detrusor function or create voiding problems in years to come is unknown.

The author reports a case of an abdominovaginal fistula caused by a Dacron buttress needle urethropexy. In one case this occurred 12 years after the original procedure. Inadequate identification and removal of the Dacron buttress 9 and 10 years after the original needle urethropexy may have predisposed to the development of the abdominovaginal fistula.

The surgical treatment of intrinsic sphincter deficiency, or Type III genuine stress urinary incontinence, has traditionally been accomplished by sling cystourethropexy, the placement of an artificial urinary sphincter, or periurethral injection. We developed a laparoscopic approach for the performance of a sling cystourethropexy as an alternative to the open approach and herein describe our experience. We have found that a laparoscopic sling cystourethropexy is feasible, but at the present time, we have been unable to demonstrate any significant advantages to the patient in terms of decreased cost or convalescence compared with the open vaginal sling cystourethropexy.

PURPOSE: To evaluate the feasibility by laparoscopy of the AMS 800 (American Medical Systems, Inc., Minnetonka, Minnesota) artificial urinary sphincter in women with type III incontinence. MATERIALS AND METHODS: Four women with genuine stress incontinence due to intrinsic sphincter deficiency were operated by laparoscopy. Primary criterion was negative Marshall test. One patient had not undergone surgery, and we performed laparoscopic promonto-fixation in the same procedure. Two of the three remaining patients had previous TVT (tension-free vaginal tape) with complications regarding the perforation and erosion of bladder mucosa and urethra. Laparoscopic explantation of TVT was performed 3 months previously. In the last case, previous urethropexy and laparoscopic promonto-fixation in association with TVT were performed 10 years and 1 year ago respectively. A modified surgical procedure was used to implant the AMS 800 through laparoscopic transperitoneal approach, with placement of the cuff around the bladder neck between the periurethral fascia and the vagina. RESULTS: Mean age was 68.5 (50-79) years. Mean closure pressure was 24.5 (20-28) cm. Water. There was no erosion or extrusion. The only significant risk factor was previous surgery. The operative time was less than 3 hours. The hospital stay was 8 days. The mean follow-up was 6 (3-13) months. Activation was done 6 to 8 weeks after implantation. Social continence (1 pad use with moderate leakage) and improvement of quality of life was reported in one patient. In this case the balloon was changed in order to obtain more pressure in the cuff. Resolution of incontinence was achieved in 3 patients. CONCLUSIONS: The AMS 800 can be successfully implanted by laparoscopy to treat women with genuine stress incontinence, a low urethral closure pressure and negative Marshall test indicating severe intrinsic sphincter deficiency. A long term follow-up is warranted to determine the efficacy and durability of this procedure.

We report a case of osteitis pubis after Marshall-Marchetti-Krantz urethropexy. There are several theories on the pathogenesis of the postoperative osteitis pubis and inconsistent results with a wide variety of treatments. Also, osteomyelitis and osteitis pubis can have identical symptoms. In our case, the use of a Mitek anchor system and its migration within the joint cavity might have induced a foreign-body reaction as the responsible mechanism of the joint destruction.

The purpose of our study was to examine the incidence of prolapse in a group of women who had had an isolated Tanagho modification of the Burch colposuspension performed without significant pelvic organ prolapse preoperatively. Sixty women were identified who underwent an isolated Burch procedure for genuine stress incontinence between 1991 and 1999. Thirty-four women returned for postoperative Pelvic Organ Prolapse Quantification (POP-Q) staging evaluation. Overall, 6 (17.6%) had stage II anterior prolapse. Eleven (32.4%) had stage II posterior prolapse. Three (8.8%) had stage II uterine prolapse. None of these patients with identified support defects was symptomatic. Two patients had subsequently undergone vaginal hysterectomy. One had this performed for dysfunctional uterine bleeding 3 years after her Burch procedure. One patient developed symptomatic uterine prolapse and underwent a vaginal hysterectomy 5 months after her Burch procedure. The majority of patients undergoing an isolated Tanagho modification Burch procedure without preoperative prolapse do not appear to be placed at increased risk for subsequent operative intervention.

There was a time when intrinsic sphincter deficiency (ISD) had a definition that was clinically relevant and guided the therapeutic decision-making process. However, over time the definition has become muddied and has somewhat morphed into a vague term defined in various ways with various tests. Currently, I doubt that any two clinicians use the same definition, and ISD has become more of a euphemism than a defined disease. So how did we get here? It may be the result of some technology introduced in the mid 1990s that has been described by my colleague T. Fleming Mattox as “The single most important practice altering technology in urogynecology in our lifetime,” the tensionfree vaginal tape (TVT). The term ISD was originally coined by McGuire et al. in the urology literature from the 1980s and was used to describe a severe form of stress urinary incontinence, equating it to an earlier term “type III urinary incontinence” (reported in Blavais and Olsson [1]). In the urogynecology literature ISD was equated with a concept introduced by Sand et al. in 1987 in an article describing the “low pressure urethra” [2]. These terms were urodynamically defined as a Valsalva leak point pressure (VLPP) of less than 60 mm H2O and a maximal urethral closure pressure (MUCP) of less than 20 cm H2O respectively. The disease ISD was a poor prognostic indicator and helped clinicians identify those patients at risk of failing our “gold standard” procedure for treating stress urinary incontinence, the Burch retropubic urethropexy. Subjects with ISD were felt to be better candidates for a pubovaginal sling. This literature contributed to ISD being formally defined in an Agency for Healthcare Research and Quality (AHRQ) 1996 manual on the evaluation and treatment of urinary incontinence in adults as follows

The aim of this paper is to report vaginal erosion of cadaveric fascia lata used for abdominal sacrocolpopexy and suburethral sling urethropexy. The charts of patients who underwent abdominal sacrocolpopexy or suburethral sling urethropexy between March 1994 and February 1999 were reviewed for perioperative data. In 47 cases of abdominal sacrocolpopexy or suburethral sling, 32 utilized cadaveric fascia lata, with 11 for sacrocolpopexy and 22 for suburethral sling. Vaginal erosion of cadaveric fascia lata graft was noted in 5 (23%) following sling procedure and 3 (27%) following sacrocolpopexy, diagnosed a mean of 36.8 days (þ 7.1, range 27–45) following surgery. These women were treated conservatively with estrogen vaginal cream, and both vaginal and oral antibiotics. Four of the 8 (50%) underwent excision of the exposed graft and reapproximation of the vaginal edges under local anesthesia, whereas the remainder responded to medical therapy alone. None of the patients experienced recurrence of vaginal vault prolapse or urinary incontinence following graft erosion. Comparison of women with vaginal erosion of cadaveric fascia lata to those without revealed an association with perioperative febrile morbidity (P = 0.04), but not with age, hormonal or insurance status, body mass index, history of diabetes mellitus or smoking, length of surgery, estimated blood loss, change in hematocrit, or other perioperative complications. Vaginal erosion of cadaveric fascia lata utilized for abdominal sacrocolpopexy and suburethral sling was noted in 25% of our patients and may have an infectious etiology. Conservative treatment with antibiotics and estrogen is effective, but removal of exposed graft with vaginal closure may be necessary.

Study Objective To compare two techniques of transperitoneal laparoscopic urethropexy. Design Prospective, randomized, open trial (Canadian Task Force classification I). Setting University-affiliated department of gynecology and obstetrics. Patients Sixty women with genuine stress incontinence. Interventions Transperitoneal laparoscopic retropubic urethropexy using nonabsorbable sutures (group A) and polypropylene mesh fixed with tacks or staples (group B). Measurements and Main Results Failure was assessed subjectively and objectively. Subjective evaluation was performed asking patients if they had urine loss and having them describe symptomatology on a visual analog scale before surgery and at each follow-up visit. Objective evaluation was by clinical examination and/or multichannel urodynamic studies. No significant differences in intraoperative and postoperative complications were observed between groups. The subjective failure rate was not significantly different between groups 3, 6, and 12 months after surgery. At 3 and 6 months the objective failure rate was not significantly different; however, at 12 months it was significantly lower in group A than in group B. Conclusion Transperitoneal laparoscopic retropubic urethropexy is more effective with sutures than with mesh.