Search

INTRODUCTION AND OBJECTIVE:It has been reported that urinary symptoms, especially stress urinary incontinence may worsen after pelvic organ prolapse repair surgery. In this study, we try to evaluat...

Aims: (i) To describe the displacement and recovery of the vesical neck position during pregnancy and after childbirth and (ii) to discriminate between compliance of the vesical neck supporting structures with and without pelvic floor contraction. Methods: We focussed on the biomechanical properties of the vesical neck supporting structures during pregnancy and after childbirth by calculating the compliance and the hysteresis as a result from of abdominal pressure measurements and simultaneous perineal ultrasound. Results: This study shows that compliance of the supporting structures remains relatively constant during pregnancy and returns to normal values 6 months after childbirth. Hysteresis, however, showed an increase after childbirth, persisting at least until 6 months post partum. Conclusions; Vaginal delivery may stretch and or load beyond the physiological properties of the pelvic floor tissue and in this way may lead to irreversible changes in tissue properties which play an important role in the urethral support continence mechanism.

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: We sought to develop a vector-based assessment to determine the magnitude and direction of bladder neck movements, as well as to assess whether probe movement relative to the pubis needs to be taken into account. Study Design: Ten nulliparous continent, 10 primiparous continent, and 10 primiparous stress-incontinent women were recruited. Perineal ultrasound scanning was performed in standing women while they were resting, performing the Valsalva maneuver, coughing, and performing Kegel exercises. A direct on-screen assessment of bladder neck displacement from rest to the peak of dynamic activity relative to the pubic axis was made. Transducer movement was assessed by measuring the displacement of the pubic bone. Results: The method was feasible because measurements were possible in all 30 subjects. Vesical neck and pubic point movement in millimeters (± SD) and the percentage error if pubic point movement is not accounted for are as follow: strain, vesical neck 16.9 ± 6.1 and pubic point 4.8 ± 3.9, 28%; cough, vesical neck 10.2 ± 5.4, pubic point 2.9 ± 3.4, 33%; Kegel exercise, vesical neck 7.0 ± 3.6 and pubic point 0.7 ± 1.4, 37%. Similar discrepancies in angle were found and are presented. Uncorrected direction of vesical neck and pubic point movement in degrees and the percentage error if pubic point movement is not accounted for are as follow: strain, vesical neck 169.4 ± 18.5 and pubic point 214.0 ± 56.7, 18%; cough, vesical neck 162.0 ± 12.8, pubic point 238.4 ± 27.4, 22%; Kegel exercise, vesical neck –0.9 ± 12.7 and pubic point –4.8 ± 20.6, 87%. Test-retest reliability correlations were more than an r value of 0.7 in all measures and 86% of the measurements greater than 0.8. Conclusion: The vector-based system provides a simple method for quantifying distance and direction of vesical neck motion, as well as localizing the resting vesical neck position. (Am J Obstet Gynecol 2001;185:65-70.)

Objective To evaluate the mobility of the vesical neck during coughing and valsalva in healthy nulliparous volunteers and to test the reliability of the technique applied. Design Clinical observational study. Setting Department of Obstetrics and Gynaecology, Cantonal Hospital Lucerne, Switzerland. Population Thirty-nine nulliparous volunteers. Methods Vesical neck motion was assessed with perineal ultrasound. Intra–abdominal pressure was controlled for with an intrarectal probe. Intra-rater reliability was evaluated. Results Vesical neck mobility was significantly lower during coughing (8 mm, SD 4 mm) than during valsalva (15 mm, SD 10 mm) (P < 0.005). Between individuals mobility varied from 4 mm to 32 mm during coughing and from 2 mm to 31 mm during valsalva. Test-retest-studies showed a maximum difference between to tests during coughing of 4 mm and during valsalva of 5 mm. Conclusion The bladder neck is mobile in normal continent women and bladder neck mobility is lower during coughing than during Valsalva.

The aim of this study was to describe normal characteristics of spontaneous and voluntary pelvic muscle function in nulliparous healthy continent women and to assess the reaction of the pelvic floor to stress and fatigue. Ten nulliparous volunteers were recruited. Pelvic muscle strength was evaluated by palpation and perineal ultrasound. Kinesiological EMG and perineal ultrasound were performed to test for possible fatigue and to assess bladder neck mobility during coughing with a pre-contraction of the pelvic floor muscles. Bladder neck mobility did not increase after attempts to fatigue the pelvic floor muscles. Bladder neck descent was significantly less when the women were instructed to contract the pelvic floor muscles before coughing. The contraction of the pelvic floor muscles stabilizes the vesical neck in nulliparous women. Neurourol. Urodynam. 20:269–275, 2001. © 2001 Wiley-Liss, Inc.

1. There is a type of urinary incontinence in women, with no manifest injury to the bladder, which is due to an impairment of the function of the sphincter muscle at the internal orifice of the urethra. It is most common among multiparae in the fourth decade. 2. The operation as performed by Kelly is the most satisfactory thus far suggested for this type of incontinence. Entire control is given in a large percentage of cases by means of a mechanical restoration of the sphincter area at the vesical neck. Operation may be under local or general anaesthesia.

Purpose: A retrospective study was done to evaluate the results of a 1-stage urethral reconstruction in women.Materials and Methods: Of 49 consecutive women who presented with anatomical damage to the urethra or vesical neck 48 underwent urethral and/or vesical neck reconstruction with vaginal flaps. A Martius labial fat pad flap was used in 47 patients, a gracilis flap in 1 and an anterior bladder tube in 1. In 41 patients the anti-incontinence procedure consisted of a fascial pubovaginal sling placed over the labial fat pad flap without tension. In 5 patients a modified Pereyra operation was done and 1 underwent a Kelly plication. Followup ranged from 1 to 11 years.Results: Postoperatively continence was obtained in 42 of 49 patients (87 percent). The initial procedure failed in 7 patients and a secondary procedure was successful in 6. Of the 5 initial patients who underwent a modified Pereyra operation 3 had postoperative stress incontinence and all were cured subsequently by a pubovaginal slin...

Objective To evaluate the outcome of the Stamey procedure for stress incontinence and to decide if it is an acceptable first-line option for the treatment of patients. Patients and methods Between June 1987 and March 1993 67 women had Stamey bladder neck suspension carried out for the treatment of stress incontinence. In September 1993 all patients received a detailed questionnaire to ascertain their present status. Results Immediately after surgery 70% of patients were dry and 15% were much improved. At 6 months 56% of patients were dry and 21% were much improved. More than 1 year following surgery, of 58 patients responding only 31% were dry and 28% were much improved. More than 5 years after surgery only 18% of the 28 women responding were dry. The factors which were significantly associated with failure were obesity (P< 0.005) and the number of pads used per day (P

Eighteen patients at University College Hospital in Ibadan, Nigeria, underwent urologic evaluation after repair of obstetrics-related vesicovaginal fistulas. This included a questionnaire, assessment of vaginal scarring, urodynamics and urethroscopy. Eight patients demonstrated stress urinary incontinence, with 4 revealing type III incontinence with either low maximum urethral closure pressure or open vesical neck on urethroscopy. This study documents some of the persistent problems that occur even after successful closure of vesicovaginal fistulas. Continued evaluation should lead to better surgical and medical techniques to diminish the incidence of continued bladder dysfunction after closure of fistulas.

MOST urologists are aware of the fact that vesical-neck obstruction in women exists, but not all, I believe, are aware of the fact that it is not an infrequent entity. Although no statistics are available regarding its incidence the condition undoubtedly occurs oftener than is ordinarily appreciated, and I have seen 4 advanced cases in the last two years. Caulk1 (1921), Nesbit2 (1933), Fite3 (1934), Thompson4 (1935) and van Houtum5 (1935) reported 1 or more cases, and Mirabile6 presented a case in 1942. The principal reason for the presentation of the following cases is not only to call attention to . . .

Excessive tension of the vesical neck sutures produces postoperative urinary retention or difficulties in urination after anti-stress urinary incontinence operations. We have demonstrated that these complications after the Stamey operation and its modifications can be resolved by readjusting the suspending loops to an adequate tension under local anesthesia, since these operations use non-absorbable monofilament loops for the suspension of the vesical neck. The technique was also applied for the correction of insufficient suspension which caused persistent or recurrent stress incontinence after these operations. The procedure was performed for 7 patients with postoperative difficulties in urination, and for 7 with postoperative recurrence of stress incontinence, and all of them recovered normal urination without stress incontinence. These procedures have been performed successfully even 27 months after a Stamey operation. These cases suggest that a recurrence of stress incontinence, even several years after the Stamey operation, can be cured with our procedure, as long as the supporting tissue of the suspending loops is not damaged.

Damage to the urethra may be functional or anatomic. In the former, to some extent, the urethra functions merely as a tube. Anatomic damage ranges from small urethrovaginal fistulas to total loss of the urethra, vesical neck, and trigone. For functional damage, the goal is compression of the proximal urethra, and the author favors a pubovaginal fascial sling, which is described. In the author's view, the best results in anatomic loss are obtained by performing an appropriate anti-incontinence procedure at the time of urethral reconstruction.

Recent studies suggest that clinical "prostatism" encompasses at least four conditions that may be present singly or in combination: prostatic urethral obstruction, impaired detrusor contractility, detrusor instability, and sensory urgency. In addition, primary vesical neck obstruction may be present in the absence of benign prostatic hyperplasia (BPH). Thus, the purpose of diagnostic evaluation in men with BPH is to identify precisely the pathophysiology of the patient's symptoms so that rational therapy can be selected.

Giant prostatic calculi are very rare. We present the case of a 45-year-old man with multiple prostatic urethral calculi that replaced the entire gland. He underwent an open "prostatolithotomy," a novel method of stone removal akin to a simple retropubic prostatectomy. Eight stones weighing a total of 59 g were removed from the prostate. For certain patients, adjunctive vesical neck revision and deliberate drainage of the prostatic fossa may be beneficial in addition to stone extraction.

Summary.- OBJECTIVE: Vesical perforation during transurethral resection of the prostate (TURP) is usually related to high increases in intravesical pressure. However, it may rarely be related to explosion precipitated by the contact of the electrocautery with some gases produced during the resections. The authors present a case of vesical explosion, discuss its mechanism and suggest some measures for prevention. METHODS/RESULTS: A 71-years-old male underwent TURP and hemostasy of bleeding from the bladder neck due to persistent hematuria. A wire loop electrode set at a cutting and coagulating current of 80 watts was used. During coagulation of a bleeding in the anterior aspect of the vesical neck when the bladder was empty, a loud pop was heard and a jolt was felt at the lower abdomen. Inspection revealed a hole in the dome of the bladder with loops of small bowel visible. A low midline incision was done, and the intraperitoneal bladder rupture was repaired. Resumen.- OBJETIVO: La perforacion vesical durante la reseccion transuretral de prostata (RTUP) esta relacionada generalmente con grandes elevaciones de la presion intravesical. Sin embargo, en raras ocasiones puede estar relacionada con la explosion de los gases producidos durante la reseccion al entrar en contacto con el asa de electrocauterio. Presentamos un caso de explosion vesical, discutimos su mecanismo y sugerimos algunas medidas para prevenirlo.

Purpose: We evaluated the factors critical in achieving urinary continence in patients with the exstrophy-epispadias complex.Materials and Methods: A total of 51 patients with epispadias and 33 with classic bladder exstrophy underwent vesical neck reconstruction. Patient records were reviewed to identify factors associated with the achievement of continence, including timing of bladder closure and urethroplasty, effect of bladder capacity before and after vesical neck reconstruction, and effect of enterocystoplasty.Results: Complete urinary continence was achieved in 42 of the 51 patients with epispadias (82 percent) and in 23 of the 33 with exstrophy (70 percent). Delayed bladder closure did not affect the ability to gain continence but increased the likelihood of subsequent enterocystoplasty (12 of 19 patients, 63 percent) compared to early bladder closure (5 of 14 patients, 36 percent).Conclusions: Preliminary urethroplasty did not enhance urinary control or reduce the need for enterocystoplast...

We evaluated recovery of urinary continence and incidence of vesical neck contractures following radical retropubic prostatectomy in a series of 120 patients with clinical stage A-B-C prostate cancer. 58 patients (group A) underwent radical retropubic prostatectomy with bladder neck preservation and 62 patients (group B) with bladder neck excision and reconstruction. In group A there were no anastomotic strictures and in group B, 6.4%. In the first group we noticed an earlier return of continence, but there were no statistically significant differences in urinary continence between the two groups. Bladder neck preservation does not compromise cancer control as assessed by local or PSA-only failure rates.

Objective: To test the hypothesis that a voluntary pelvic muscle contraction initiated in preparation for a cough, a maneuver we call the Knack, significantly reduces vesical neck displacement. Methods: A convenience sample of 22 women consisted of 11 young, continent nulliparas (mean age [± standard deviation] 24.8 ± 7.0 years) and 11 older, incontinent paras (mean age [±SD] 66.9 ± 3.9 years). With the use of perineal ultrasound, we quantified vesical neck displacement at rest and during coughs using caliper tracing and a coordinate system. The subjects coughed with and without voluntary pelvic floor muscle contraction. Results: Vesical neck mobility during coughs was significantly decreased when voluntary contraction was used: from a median (range) of 5.4 (20.0) mm without volitional contraction to 2.9 (18.3) mm with volitional contraction (P < .001). The younger women demonstrated a median (range) decrease in excursion from 4.6 (19.5) to 0.0 (17.0) mm (P = .007), and the older incontinent women demonstrated a median (range) decrease from 6.2 (10.0) to 3.5 (15.4) mm (P = .003). At rest, the median vesical neck position in the group of older incontinent women was significantly further dorsocaudal (P = .001) than in the younger women. Conclusion: A pelvic floor muscle contraction in preparation for, and throughout, a cough can augment proximal urethra support during stress, thereby reducing the amount of dorsocaudal displacement.

Objective: We tested the null hypothesis that vesical neck descent is the same during a cough and during a Valsalva maneuver. We also tested the secondary null hypothesis that differences in vesical neck mobility would be independent of parity and continence status. Methods: Three groups were included: 17 nulliparous continent (31.3 ± 5.6; range 22–42 years), 18 primiparous continent (30.4 ± 4.3; 24–43), and 23 primiparous stress-incontinent (31.9 ± 3.9; 25–38) women. Measures of vesical neck position at rest and during displacement were obtained by ultrasound. Abdominal pressures were recorded simultaneously using an intravaginal microtransducer catheter. To control for differing abdominal pressures, the stiffness of the vesical neck support was calculated by dividing the pressure exerted during a particular effort by the urethral descent during that effort. Results: The primiparous stress-incontinent women displayed similar vesical neck mobility during a cough effort and during a Valsalva maneuver (13.8 mm compared with 14.8 mm; P = .49). The nulliparous continent women (8.2 mm compared with 12.4 mm; P = .001) and the primiparous continent women (9.9 mm compared with 14.5 mm; P = .002) displayed less mobility during a cough than during a Valsalva maneuver despite greater abdominal pressure during cough. The nulliparas displayed greater pelvic floor stiffness during a cough compared with the continent and incontinent primiparas (22.7, 15.5, 12.2 cm H2O/mm, respectively; P = .001). Conclusion: There are quantifiable differences in vesical neck mobility during a cough and Valsalva maneuver in continent women. This difference is lost in the primiparous stress-incontinent women.

Hemangiomas of the bladder and prostate are rare. There haveonly been approximately 80 cases described in the literature, the majority of which were of bladder origin. Treatment has varied from partial cystectomy to use of the neodymium yttrium aluminum garnet (Nd-YAG) laser. Herein, we report a case of vesical neck and prostatic hemangiomas successfully treated with super-selective intra-arterial injections of polyvinyl alcohol.

A main complication of an anti-stress urinary incontinence operation in women is postoperative urinary retention or difficulty in urination caused by the urethrovesical junction being suspended too tightly. A total of 7 women who complained of the complication after a modified Stamey operation underwent our procedure in which the suspension loops were loosened to an adequate tension with the patient under local anesthesia. All patients recovered normal voiding without incontinence immediately after the procedure. The Stamey operation uses a nylon loop for suspension of the urethrovesical junction. Therefore, the tightness of the suspension loop can easily be readjusted postoperatively by the procedure, even though initially the suspension of the urethrovesical junction was too tight or too loose. We believe the procedure will enhance the value of the Stamey operation. (J. Urol, 144: 319-323, 1990)

The key to restoring urinary continence in the female is to raise the internal vesical neck of the bladder to a position behind the symphysis pubis. The operation which accomplishes this with the least morbidity, the most accuracy and the greatest permanency is endoscopic suspension; it is particularly applicable in patients with obesity, multiple operative failures, radiation incontinence, and severe pelvic fractures. Between December 1973 and May 1979, 203 patients underwent 211 operations with a minimum of six months of follow-up study at final review (November 1979). Twenty per cent of the patients were totally incontinent on referral, and 60 per cent lost urine with minimal activity; only 20 per cent of the patients had typical stress urinary incontinence, requiring coughing or sneezing to lose urine. Among the 203 patients, there were 188 previous operations for urinary incontinence, including 74 Marshall-Marchetti retropubic repairs. Forty-seven patients have been followed for over four years, and 156 patients have been followed for six months to four years. While 138 patients had a previous hysterectomy, 65 patients had not; the presence of the uterus did not affect the results. Urinary incontinence is not an indication for hysterectomy. Ninety-one per cent of the 203 patients were cured of their urinary incontinence by endoscopic suspension of the vesical neck. Technical advantages over the retropubic vesical neck suspensions include the use of monofilament heavy nylon (No. 2), a vaginally placed Dacron((R)) buttress to prevent tearing of the pubocervical fascia, less postoperative morbidity, minimal blood loss, functional measurements and anatomic visualization of a restored vesical neck during the operative procedure, easy access to a surgically difficult pelvis, and simultaneous repair of significant rectoceles or substantial cystoceles through the same operative field.

53 patients presenting with post-prostatectomy obstructive complications above the verumontanum were treated in a single session by means of guided dilatation of the stricture followed by transurethral resection of the stenosing fibrotic tissue. The results obtained in cases of vesical neck stenosis were very encouraging. Unsatisfactory results were observed in cases of cervicoprostatic fibrosclerosis where resection was insufficient for resolution of the obstruction. No failures or complications with the guided dilatation technique have been observed.

Vesical neck reconstruction was performed in 50 male and 12 female patients with the epispadias-exstrophy complex. Of these patients 45 had epispadias and 17 had classical exstrophy. Patient age ranged from 3 to 27 years, with a mean age of 12.6 years. Followup after vesical neck reconstruction averaged 11.6 years. Of the 45 patients with epispadias 35 (78 per cent) and of the 17 with bladder exstrophy 13 (76 per cent) are continent, for an over-all continence rate of 77 per cent. An adequate bladder capacity was one of the most important determinants of continence. In 11 patients with a small capacity or poorly compliant bladder augmentation cystoplasty was combined with vesical neck reconstruction to increase vesical capacity and to produce complete urinary continence.

The urethral pressure profile is influenced by the degree of patient relaxation, which explains marked variations in measured pressure values among normal subjects, as well as the frequent lack of reproducibility in a given subject. The quality of relaxation can be estimated by observing the difference between maximum resting and maximum holding pressures. The most reproducible parameters are 1) the total urethral length, 2) the length to the point of maximum pressure and 3) the ratio of area to the point of maximum pressure over total area. Changes in intravesical volume do not produce significant differences in peak pressure, total area or area to maximum pressure. When subjects were asked to strain the pressure in the proximal urethra increased by 60 per cent of the intravesical pressure observed, even in the absence of a vesical neck opening.

In order that ejaculation may take place correctly, it is necessary that the vesical neck and the smooth sphincter within it contract violently in order to establish resistance against the seminal liq