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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

Two hundred and fifty consecutive women referred because of symptoms of lower urinary tract dysfunction underwent a full clinical and urodynamic assessment. Their urine flow rates and residual urine volumes were analyzed. The urine flow rates of the urogynecology patients were found to be significantly less than those of an asymptomatic population. There were significant declines in urine flow rates in the presence of a previous hysterectomy and with increasing grades of prolapse, particularly uterine prolapse, cystocele and enterocele. Unlike the normal female population, there was also deterioration with increasing parity and age, the latter largely due to the increasing incidence of hysterectomy and prolapse with age. The 10th centile of the Liverpool Nomogram for the maximum urine flow rate was found to be the most useful discriminant for a final urodynamic diagnosis of voiding difficulties. Most urogynecology patients have no or small residual urine volumes, 74%

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.

The sensory aspects of bladder function are not clearly defined, are poorly understood and imperfectly managed. Sensory urgency or bladder hypersensitivity often present with symptoms without an obvious cause (idiopathic sensory urgency). This article reviews the evidence that some of these symptomatic patients are actually suffering from early interstitial cystitis. The implications of such a possibility are discussed and the possible role of detrusor mast-cell infiltration in the genesis of bladder symptoms in women is examined.

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.

Choroid plexus cysts may be detected in the fetal choroid plexus on routine second trimester ultrasound scanning. The presence of these cysts is associated with trisomy 18 (Edward syndrome) in 3.47% of cases and with trisomy 21 (Down syndrome) in 0.46% of cases. The cysts themselves almost always disappear by 23 weeks and are thought to be a normal developmental variant. The world literature experience would indicate that the size of the choroid plexus cyst and the presence of bilateral cysts has no bearing on the magnitude of risk of chromosomal abnormality; 76% of babies with trisomy 18 also have other dysmorphic features which may be detectable by ultrasound. It is strongly advised that genetic counselling be undertaken and amniocentesis be considered when choroid plexus cysts are identified in the fetus.

The tension-free vaginal tape procedure is an increasingly popular choice for treating female urinary stress incontinence. This ongoing, prospective, open label study presents the results of tension-free vaginal tape surgery at 1 year in women who have previously undergone unsuccessful stress incontinence surgery.A total of 67 women with previous failed surgery for stress urinary incontinence underwent the tension-free vaginal tape procedure. Treatment outcome was categorized as cure, significant improvement or failure based on cystometry findings and urinary pad loss results at 3 months of followup, and on subjective questioning at 3 months and 1 year of followup.At 12 months 54 women (81%) were cured, 4 (6%) were significantly improved and 9 (13%) were no better. No serious morbidity was noted after the procedure.The tension-free vaginal tape procedure provides the prospect of a success rate similar to that of a conventional sling procedure in patients with previous failed surgery. It has a low rate of operative complications and postoperative morbidity.

Summary— Interstitial cystitis is rarely considered as a cause of urinary symptoms in referrals to gynaecology clinics. Recent concepts in the diagnosis of this condition mean that it is emerging as a much more common entity, with both early and late forms of the disease being described. Mast cell density in the detrusor muscle has been reported to be useful as a disease marker to substantiate the diagnosis of interstitial cystitis where no classical diagnostic features exist. We assessed mast cell counts in bladder biopsies from 27 women with idiopathic sensory urgency and 10 control patients about to undergo a colposuspension procedure for pure genuine stress incontinence; 30% of the study group had a clear increase in the detrusor muscle mast cell population (detrusor mastocytosis). No control patient showed such an increase. Early interstitial cystitis should be considered as a possible cause of lower urinary tract symptoms in patients with apparently idiopathic sensory urgency.

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).

Summary— The case histories of 494 women referred to a urodynamic clinic with the symptom of stress incontinence were studied. None had undergone previous incontinence surgery. In only 12 patients was stress incontinence the sole symptom. In the remainder, symptoms suggestive of detrusor instability were present in 417, of a voiding disorder in 261 and of an inflammatory disorder in 166. The sign of stress incontinence was present in only 168 patients and was not a reliable guide to the diagnosis of genuine stress incontinence. Urodynamic studies were necessary in 488 patients in order to obtain an accurate diagnosis.

Summary— Transvaginal linear array ultrasound is described as a method of measuring bladder volumes in the range 2 to 175 ml, overcoming the limitations of abdominal ultrasound at these smaller (though clinically important) volumes. The mean error over the range 10 to 175 ml was 23%. Statistical analysis of preliminary data obtained by this technique shows that bladder volume in ml can be calculated by the formula: Volume = 5.9 × (height × depth) - 14.6 ml (95% confidence limits=±37 ml)

Summary— The pattern of bladder filling in response to a 1-litre fluid load was assessed in 20 women with urinary incontinence. The period between 60 and 120 min after the fluid load was identified as best for pad testing because of consistently high bladder volumes and filling rates. A 2-h pad test is recommended as achieving effective and reproducible test conditions for the quantification of urine loss.

Etude sur 110 femmes presentant une incontinence urinaire. L'estimation subjective par analogue visuel est faite avant les examens objectifs. Les femmes presentant une instabilite du detrusor ont toutes un score superieur a 40 mm, ce qui est rare parmi celles presentant uns vraie incontinence de stress. L'epreuve peut etre utile dans les services ne disposant pas de tous les moyens d'exploration objective

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 study of voiding in men and women has been handicapped by the lack of a normal reference range covering urinary flow rates over a wide range of voided volumes. Normal volunteers (331 males and 249 females) were studied. Each voided once into a calibrated Dantec Urodyn 1000 mictiograph. On a second occasion 282 men and 46 women voided. The maximum and average urine flow rates of the first voids in both sexes were compared with the respective voided volumes. Nomogram charts, in centile form, for both the maximum and average urine flow rates were constructed using statistical transformations of the data. Males showed a significant decline in both urinary flow rates with age, although there was no statistically significant variation in either urine flow rate with respect to first versus repeated voiding. Females showed no statistically significant variation in either urine flow rate with respect to age, parity or first versus repeated voiding. The maximum and average urine flow rates in both sexes showed an equally strong relationship to voided volume. No artificial restriction of voided volume, e.g. minimum 200 ml, appeared appropriate. These nomograms offer reference ranges for both maximum and average urinary flow rates in both sexes covering a wide range of voided volumes (15-600 ml).

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.