Incontinence Urology (Part II) :

Tension-Free Vaginal Tape (TVT) in Morbidly Obese Patients with Severe Urodynamic Stress Incontinence as Last Option Treatment.
Skriapas K, Poulakis V, Dillenburg W, de Vries R, Witzsch U, Melekos M, Becht E
Eur Urol. 2005 Dec 19;.

OBJECTIVES: To determine the safety and efficacy of tension-free vaginal tape (TVT) in morbidly obese women with severe urodynamic stress incontinence (USI) as last option treatment. METHODS: Thirty-one patients with body mass index (BMI) >40kg/m(2), who had undergone the TVT procedure for urodynamically-confirmed USI were matched with 52 patients with BMI <30kg/m(2) who underwent the same procedure. BMI was calculated at the time of the surgery. Patients' characteristics and surgical data, complications and cure rates were analyzed for both groups. RESULTS: After a mean follow-up of 18.5 (range: 12-24) months the continence rates were 87% and 92% for morbidly obese women and control group, respectively (p=0.103). No serious intraoperative complications were noted in both groups. However, the early postoperative complications were significantly higher (p<0.05) in morbidly obese patients. In 4 patients from both group long term postoperative catheterization was necessary for 4 weeks. In one patient (2%) from the control group dilatation of urethra took place. No defect in healing or rejection of the tape occurred. CONCLUSIONS: TVT is a minimal invasive and safe procedure for morbidly obese patients suffering from severe USI with good outcome. Preoperative morbid obesity does not seem to be a risk factor for failure of this procedure.

Transobturator vaginal tape inside-out A minimally invasive treatment of stress urinary incontinence: Surgical procedure and anatomical conditions.
Reisenauer C, Kirschniak A, Drews U, Wallwiener D
Eur J Obstet Gynecol Reprod Biol. 2005 Dec 26;.

OBJECTIVE: The aim of this study was to review the surgical transobturator vaginal tape inside-out (Gynecare TVT-O, Ethicon Inc., Somerville, NJ) technique as described by de Leval and to present the relevant anatomical conditions of the lower pelvis on the basis of corpse dissections after TVT-O placement. STUDY DESIGN: In order to visualize the anatomical structures through which the tape runs, anatomical dissections of five corpses after TVT-O placement were performed. Furthermore, the dissections made possible to give a detailed description of the neighbouring neurovascular structures. RESULTS: The anatomical dissections show that the transobturator tape does not reach into the retropubic space at any time during the procedure, so that injuries of the bladder, of the epigastric vein and the external iliac vessels are not to be expected. The distance between the tape and the major neighbouring neurovascular structures shows slight individual differences, however without the danger of neurovascular injuries if the surgical procedure is performed as recommended. CONCLUSION: Precise knowledge about the anatomy of the area of operation provides the surgeon with the possibility to safely conduct the operation and it contributes to a reduction of perioperative complications.

The puzzle of overactive bladder: controversies, inconsistencies, and insights.
Dmochowski RR
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Dec 14;:1-9.

Overactive bladder (OAB) affects millions of individuals and may severely impair the quality of life of those affected. The contribution of human behavior to manifestations of this symptom complex remains poorly understood. Continued evolution of our understanding of the pathophysiology of OAB has identified contributory mechanisms, which in turn may open new therapeutic avenues. Recent improvements in drug delivery systems represent advances in the management of OAB. However, more complete symptom control with greater tolerability is desirable; this awaits the development of agents specific for newly emerging and as yet unidentified pathophysiologic pathways. Importantly, as understanding of outcomes assessment in OAB matures, refined assessments of disease severity, response to intervention, and patient preference should be possible.

Design of the Stress Incontinence Surgical Treatment Efficacy Trial (SISTEr).
Tennstedt S
Urology. 2005 Dec;66(6):1213-7.

OBJECTIVES: To describe the methods and rationale for the first randomized controlled trial conducted by the Urinary Incontinence Treatment Network. METHODS: The primary objective of this clinical trial is to compare two commonly performed surgical procedures for stress urinary incontinence-the Burch colposuspension and the autologous rectus fascial sling-for overall treatment success for urinary incontinence and stress-type symptoms of incontinence at 24 months after surgery. Secondary aims include a comparison of complications, quality of life, sexual function, patient satisfaction, costs, and the need for additional treatments or surgery; and an evaluation of the prognostic value of preoperative urodynamic studies. The Stress Incontinence Surgical Treatment Efficacy Trial is being conducted on 655 women with predominant stress urinary incontinence, as determined by history and physical examination, urinary stress test with witnessed leakage, and voiding diary. Administration of all questionnaires and performance of examinations, tests, and both surgical procedures are standardized within and across the clinical centers. Assessments occur preoperatively and at 6 weeks and 3, 6, 12, 18, and 24 months postoperatively. A sample of 655 women ensures 80% power to detect a 12% difference (60% versus 72%) at the 5% significance level. The intent-to-treat analysis will use Fisher's exact test and time-to-failure analyses. RESULTS: Enrollment was completed in June 2004 with 24 months of follow-up to end in June 2006. CONCLUSIONS: This is the first large, multicenter randomized clinical trial comparing these two standard-of-care procedures for stress incontinence.

Tension-free vaginal tape exposure presenting as a recurrent sterile paraurethral abscess.
Tate SB, Franco AV, Fynes MM
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Sep-Oct;16(5):420-3. Epub 2005 Apr 22.

We report a case of tension-free vaginal tape (TVT) exposure presenting as a recurrent sterile paraurethral abscess at 25 months and 40 months following successful continence surgery and describe the management of this problem.

Urinary incontinence after multiple gestation and delivery: impact on quality of life.
Goldberg RP, Kwon C, Gandhi S, Atkuru LV, Sand PK
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Sep-Oct;16(5):334-6. Epub 2005 Feb 8.

An anonymous 77-item urogenital symptom questionnaire was administered to 769 women with a history of previous multifetal gestation and delivery, including long forms of the Incontinence Impact Questionnaire (IIQ) and Urogenital Distress Inventory (UDI). IIQ and UDI scores were analyzed using univariate and multivariate regression to determine the impact of incontinence on quality of life (QOL). Mean age was 37 years (22-75), and nearly half [49.8% (365)] reported at least one type of incontinence. Higher mean UDI scores were reported by women with stress incontinence (SI) (12.3 vs 4.7, p=0.0001), urge incontinence (UI) (14.9 vs 5.7, p=0.0001), and mixed incontinence (15.1 vs 6.2, p=0.0001) compared to continent women. Similarly, higher mean IIQ scores were associated with SI (6.9 vs 1.9, p=0.0001), UI (9.4 vs 2.2, p=0.0001), and mixed incontinence (9.3 vs 2.7, p=0.0001). In conclusion, among "mothers of multiples," stress and urge urinary incontinence were associated with strongly adverse effects on QOL at a young age.

Impact of duloxetine on quality of life for women with symptoms of urinary incontinence.
Kinchen KS, Obenchain R, Swindle R
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Sep-Oct;16(5):337-44. Epub 2005 Jan 21.

The objective of this study was to evaluate the effectiveness of duloxetine in improving quality of life among women with stress and mixed urinary incontinence. The study included 451 women with self-reported stress incontinence episodes (>or=1/week) who were randomized to duloxetine (40 mg BID) or placebo in a double-blind, usual care design. Patients and physicians were allowed to titrate, augment, and/or discontinue treatment. Concomitant treatments were permitted. The primary outcome was the Incontinence Quality of Life Questionnaire (I-QOL) score, with assessments at 3, 6, and 9 months. Other measures included the Patient Global Impression of Improvement (PGI-I) and adverse events. The adjusted mean change in I-QOL total score was greater in the duloxetine group than in the placebo group and at a level comparable to that found in previous clinical trials, but the difference between placebo and duloxetine was not statistically significant in the intent-to-treat, last observation carried forward (LOCF) analysis. The difference approached statistical significance in favor of duloxetine at 3 months (p=0.07). PGI-I ratings did not demonstrate significant superiority for duloxetine in LOCF analysis; however, study completers taking duloxetine were significantly more likely to rate themselves as "better" (70.2%) than completers taking placebo (50.8%, p<0.05). Women utilized a variety of treatment methods including pelvic floor muscle training, estrogen, anticholinergic medication, weight reduction, and smoking cessation. In this study, while mean I-QOL change scores were numerically higher for the duloxetine group than mean change scores for the placebo group, this difference was not statistically significant. Among women who completed the study on study drug, a significantly greater proportion of duloxetine women versus placebo women rated their condition to be better.

Massive prolapse of the urethral mucosa following periurethral injection of calcium hydroxylapatite for stress urinary incontinence.
Palma PC, Riccetto CL, Martins MH, Herrmann V, de Fraga R, Billis A, Netto NR Jr
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Dec 9;:1-2.

The injection of bulking agents into the urethral submucosa is designed to create artificial urethral cushions that can improve urethral coaptation and hence restore continence. Ideally, a urethral bulking agent should be non-immunogenic and biocompatible, leading to minimal inflammatory and fibrotic response. The authors present a case report of a granulomatous reaction leading to urethral prolapse, 3 months after the transurethral injection of calcium hydroxylapatite. To our knowledge, this is the first granulomatous reaction described after calcium hydroxylapatite injection.

The direct cost of stress urinary incontinence among women in a Medicaid population.
Kinchen KS, Long S, Chang S, Girts TK, Pantos B
Am J Obstet Gynecol 2005 Dec;193(6):1936-44.

OBJECTIVE: To describe health care utilization and costs for women diagnosed with stress urinary incontinence in a Medicaid population. STUDY DESIGN: We utilized a pooled database of claims for women enrolled in Medicaid in 1 of 3 states. Health care utilization and costs were compared for 12 months before and 12 months after a woman's urinary incontinence diagnosis. Additional analyses utilized data from a fourth state. RESULTS: Of 13,672 women with diagnosed stress urinary incontinence, average urinary incontinence-related costs were approximately 800 dollars in the 12-month study period, less than 0.1% of total Medicaid spending. Thirteen percent of women underwent a surgery for stress urinary incontinence in the study period, with sling procedures performed most commonly. CONCLUSION: Although population prevalence estimates of any stress urinary incontinence symptoms often are high, diagnosis and health care utilization in the Medicaid population is low. Overall costs of stress urinary incontinence treatment in Medicaid currently are minimal. Further efforts to understand the appropriate detection, diagnosis, and treatment of women with stress urinary incontinence are needed.

Bleeding complications with the tension-free vaginal tape operation.
Kolle D, Tamussino K, Hanzal E, Tammaa A, Preyer O, Bader A, Enzelsberger H, Ralph G, Riss P
Am J Obstet Gynecol 2005 Dec;193(6):2045-9.

OBJECTIVE: This study was undertaken to analyze bleeding problems with tension-free vaginal tape (TVT) operations in a national registry. STUDY DESIGN: We studied patients for whom increased intraoperative bleeding or reoperation for bleeding/hematoma with TVT operation were reported to the registry. RESULTS: Bleeding problems were reported for 151 of 5578 (2.7%) TVT operations. Increased intraoperative bleeding was reported for 106 (1.9%) and reoperation (or conversion) in 45 (0.8%) patients (both in 5 patients). Increased intraoperative bleeding was managed conservatively in 103 patients (95%). Overall, 45 (0.8%) patients required reintervention for bleeding or hematoma. The reinterventions comprised 34 laparotomies, 4 transvaginal evacuations of hematomas, 3 revisions for bleeding from a suprapubic catheter site, and 2 revisions of the vaginal incision (details unclear in 1 patient). Bleeding was considered arterial in 12% (including 1 external iliac artery injury and 1 obturator artery injury) and venous or unknown in 88%. Of reoperated patients, 39% were reoperated within 24 hours, 20% within 2 to 10 days, and 41% within 11 to 56 days after TVT placement. Overall, 19 patients received blood transfusions (range, 1-10 units). There were no deaths from bleeding complications. CONCLUSION: Bleeding complications were reported with less than 3% of 5578 TVT operations. Most cases of increased intraoperative bleeding were managed conservatively; 0.8% of patients required conversion or reoperation.

Outcomes of vaginal reconstructive surgery with and without graft material.
Vakili B, Huynh T, Loesch H, Franco N, Chesson RR
Am J Obstet Gynecol 2005 Dec;193(6):2126-32.

OBJECTIVE: This study was undertaken to evaluate the outcomes of vaginal surgery for pelvic organ prolapse, comparing cases implementing graft augmentation to those without graft augmentation. STUDY DESIGN: This was a retrospective cohort study of 312 patients who underwent vaginal surgery for prolapse from February 1998 to January 2004. RESULTS: Of the 312 patients, 98 (31.4%) had graft augmentation. The median follow-up was 9 months (3-67 months). Graft use was not associated with reduction in recurrent prolapse, recurrent stage 3 prolapse, recurrent incontinence, or additional surgery for prolapse. After controlling for confounders, there was still no difference in surgical outcomes. Complications such as vaginal/graft infection (18.4% vs 4.7%; P < .001) and granulation tissue (38.8% vs 17.3%; P < .001) were more common after cases in which graft was used. CONCLUSION: In the early postoperative period, there was no benefit in using graft for prolapse repair. Graft use leads to a higher rate of postoperative complications.

Factors associated with incontinence frequency in a surgical cohort of stress incontinent women.
Richter HE, Burgio KL, Brubaker L, Moalli PA, Markland AD, Mallet V, Menefee SA, Johnson HW, Boreham MK, Dandreo KJ, Stoddard AM
Am J Obstet Gynecol 2005 Dec;193(6):2088-93.

OBJECTIVE: The aim of this study was to identify factors associated with urinary incontinence severity at baseline in women undergoing surgery for stress incontinence. STUDY DESIGN: Baseline data were obtained from 650 women (age 28 to 81 years) with stress incontinence participating in a randomized surgical trial. Severity of incontinence was defined by the mean number of incontinence episodes per day recorded in a 3-day bladder diary. The relationships between severity and several baseline variables were examined, including demographics, medical, obstetric, and gynecologic history, body mass index, smoking status, Q-tip displacement, and Pelvic Organ Prolapse Quantification stage (POP-Q). RESULTS: In a multivariable model, severity of incontinence was positively associated with body mass index (P = .0003) and current smoking (P = .01), and negatively associated with prolapse stage (P < .0001) and Q-tip displacement (P = .042). CONCLUSION: Incontinence severity in a surgical population was independently associated with 2 modifiable factors, obesity and tobacco use, as well as pelvic support.

Sacral neuromodulation for the treatment of refractory urinary urge incontinence after stress incontinence surgery.
Sherman ND, Jamison MG, Webster GD, Amundsen CL
Am J Obstet Gynecol 2005 Dec;193(6):2083-7.

OBJECTIVE: This study was undertaken to evaluate the response to sacral neuromodulation in women with refractory, nonobstructive urinary urge incontinence after stress incontinence surgery. STUDY DESIGN: We reviewed the medical records of women in whom sacral neuromodulation was performed for worsening or de novo urinary urge incontinence after a stress incontinence procedure. All patients had undergone preliminary test stimulation. Demographics, surgical and urogynecologic history, including bladder diary and pad weight test, and urodynamic parameters were evaluated. RESULTS: Of 34 women, 22 (65%) responded to the test stimulation and underwent permanent lead implant. There was no difference between responders and nonresponders with respect to type of stress incontinence surgery. Incontinence or urodynamic parameters were not different between responders and nonresponders. Factors that were predictive of a positive response were women aged less than 55 years (P = .01), the test stimulation performed within 4 years of the stress incontinence procedure (P = .01), and evidence of pelvic floor muscle activity (P = .03). CONCLUSION: Sacral neuromodulation is a viable option for the treatment of refractory urinary urge incontinence that occurs after stress urinary incontinence surgery. Older women with no pelvic floor activity who are remote from their incontinence surgery may have a suboptimal response.

Suburethral sling materials: best outcome with autologous tissue.
Simsiman AJ, Powell CR, Stratford RR, Menefee SA
Am J Obstet Gynecol 2005 Dec;193(6):2112-6.

OBJECTIVE: This study was undertaken to assess the outcome of suburethral slings by type of sling material. STUDY DESIGN: A retrospective review of women who underwent a suburethral sling between January 1997 and January 2003 with autograft, allograft or xenograft materials. Objective failure was defined as urinary leakage with cough stress testing at any time after 3 months, postoperatively. Objective cure was defined as no leakage with a standing cough stress test with at least 200 mL bladder volume at a minimum of 12 months postoperatively. Data were analyzed using Student t, Wilcoxon rank sum, and Kaplan-Meier survival tests. RESULTS: A total of 241 women were included in this study: 78 received autograft, 80 received allograft, and 83 received xenograft. Objective failure was 36% and 46% for allograft and xenograft, respectively compared with 13% for autograft (P < .001). CONCLUSION: Autograft has a significantly higher cure rate when used for suburethral slings.

Delivery mode is a major environmental determinant of stress urinary incontinence: results of the Evanston-Northwestern Twin Sisters Study.
Goldberg RP, Abramov Y, Botros S, Miller JJ, Gandhi S, Nickolov A, Sherman W, Sand PK
Am J Obstet Gynecol 2005 Dec;193(6):2149-53.

OBJECTIVE: We studied a large cohort of identical twin sisters, utilizing the unique properties of a twin research design to explore the relationship between obstetrical delivery mode and stress urinary incontinence. STUDY DESIGN: An anonymous 67-item survey was completed by 271 identical twin pairs (n = 542) at the world's largest annual gathering of twins. Logistic regression for repeated binary measures was used to evaluate risk factors and accounting for shared genetics within pairs. RESULTS: The twins had a mean age of 47.1 years (range 15 to 85 years), and stress urinary incontinence was reported by 51.8%. Stress urinary incontinence was associated with age (P = .001), parity (P = .001), obesity (P = .002), and birth mode, with vaginal delivery conferring a considerable increase in stress urinary incontinence risk relative to cesarean section (odds ratio 2.28, 95% confidence interval 1.14 to 4.55, P = .019). CONCLUSION: Vaginal delivery mode represents a potent determinant of stress urinary incontinence, carrying more than twice the risk of cesarean section. This study of identical twins provides new insight into the epidemiology of female incontinence.

Peri-Operative Complications and Pain After the Suburethral Sling Procedure for Urinary Stress Incontinence: A French Prospective Randomised Multicentre Study Comparing the Retropubic and Transobturator Routes.
David-Montefiore E, Frobert JL, Grisard-Anaf M, Lienhart J, Bonnet K, Poncelet C, Darai E
Eur Urol 2005 Nov 2;.

OBJECTIVE: To compare peri-operative complications, pain, and the immediate functional results of the sub-urethral sling procedure for urinary stress incontinence by the retropublic and transobturator routes, using a non-elastic polypropylene sub-urethral sling. PATIENTS AND METHODS: This prospective, multicentre study involved 88 women undergoing the sub-urethral sling procedure for stress urinary incontinence (SUI). The retropubic route (RPR) and the transobturator route (TOR) were used in respectively 42 and 46 cases. The characteristics of the women in the RPR and TOR groups were as follows: mean age (+/-standard deviation) 56.8+/-12 years and 53.4+/-10 years, respectively; mean BMI: 25 +/- 4 and 26 +/- 4; mean parity: 2.1+/-0.9 and 2+/-1 children; post-menopausal status: 66.7% and 58.7%; prior surgery for SUI: 7.1% and 6.5%; and prior hysterectomy: 21.4% and 26.1%. None of these characteristics differed significantly between the groups. Likewise, pre-operative urinary functional status (SUI stage, and pollakiuria, nocturia and urgency rates) was similar in the two groups. RESULTS: Mean hospital stay and overall morbidity rate were not significantly different between the RPR and TOR groups. Mean operating time was longer in the RPR group. Bladder injury was significantly more frequent in the RPR group and vaginal injury was significantly more frequent in the TOR group. Pain scores were significantly lower in the TOR group. The objective functional results at one month did not differ between the groups. Quality of life, evaluated with questionnaires and numerical rating scales, was similarly improved in the two groups. DISCUSSION: The suburethral sling procedure was less painful by the TOR route than by the RPR route. Bladder injury, haematomas and abscesses were only observed in the RPR group, while vaginal injury only occurred in the TOR group. The immediate functional results of the two approaches were similar.

Re: Chapple CR, Martinez-Garcia R, Selvaggi L, Toozs-Hobson P, Warnack W, Drogendijk T, Wright DM, Bolodeoku J. A Comparison of the Efficacy and Tolerability of Solifenacin Succinate and Extended Release Tolterodine at Treating Overactive Bladder Syndrome
Jonas U, Rackley RR
Eur Urol 2005 Nov 15;.

Diabetes and urinary incontinence in 50- to 90-year-old women: a cross-sectional population-based study.
Lewis CM, Schrader R, Many A, Mackay M, Rogers RG
Am J Obstet Gynecol 2005 Dec;193(6):2154-8.

OBJECTIVE: The purpose of this study was to examine the association between urinary incontinence and diabetes in a large community-based population of women. STUDY DESIGN: The Health and Retirement Study is a large multistage area probability sample of households in the United States. Data were collected from 10,678 women aged 50 to 90 years. Dependent variables were no, mild, and severe incontinence. Independent variables consisted of demographic and health data. Diabetes was dichotomized into insulin-requiring (IRDM) and non-insulin-requiring disease (NIRDM). Survey-based ordered logistic regression was used to simultaneously analyze associations between incontinence groups. RESULTS: Urinary incontinence was reported by 22% (2319/10,678) of women. IRDM was associated with urinary incontinence (odds ratio [OR] 1.63; 95% CI 1.28-2.09), but NIRDM was not (OR 1.20; 95% CI 1.00-1.45). CONCLUSION: IRDM is independently associated with urinary incontinence in women ages 50 to 90 years, independent of patient body mass index, comorbidities, or age.

Following midurethral versus bladder sling procedures.
Botros SM, Abramov Y, Goldberg RP, Beaumont JL, Gandhi S, Miller JJ, Sand PK
Am J Obstet Gynecol 2005 Dec;193(6):2144-8.

OBJECTIVE: The objective of the study was to compare detrusor overactivity and urge urinary incontinence rates after midurethral slings versus bladder neck slings. STUDY DESIGN: Three hundred forty subjects underwent midurethral slings or bladder neck slings. Comparisons were made using Student's t test and chi2 test. Multivariate analysis was performed to detect confounding factors. RESULTS: More patients in the midurethral sling group resolved detrusor overactivity than in the bladder neck sling group (38% versus 15%, P < .001). In addition, subjects in the midurethral sling group had significantly lower rates of de novo detrusor overactivity than subjects in the bladder neck sling group (29% versus 62%, P = .002). The only significant predictors of postoperative detrusor overactivity were preoperative detrusor overactivity (P < .001) and sling type (P < .001). After adjusting for preoperative detrusor overactivity, bladder neck slings significantly increased the risk for persistent detrusor overactivity (odds ratio 3.9). CONCLUSION: Midurethral slings have increased rates of resolution of detrusor overactivity and lower rates of de novo detrusor overactivity than transvaginal bladder neck sling procedures.

Suburethral sling using the transobturator approach: a quality-of-life analysis.
Lukban JC
Am J Obstet Gynecol 2005 Dec;193(6):2138-43.

OBJECTIVE: The objective of the study was to determine the degree of benefit of a transobturator midurethral polypropylene sling in patients with stress urinary incontinence through a quality-of-life instrument and outcome analysis. STUDY DESIGN: Forty-seven patients completed the validated Individual Incontinence Impact Questionnaire both before and after treatment. Subjects also completed the validated Patient Satisfaction Questionnaire postoperatively to complete outcome analysis. Statistical analyses included a paired Student t test for intrapair comparisons and 2-sample t tests to compare mean differences between groups. RESULTS: Individual Incontinence Impact Questionnaire scores for the entire sample declined from a preoperative mean of 43.0 +/- 27.0% to a postoperative mean of 11.8 +/- 16.4 (P < .0001). On review of Patient Satisfaction Questionnaire responses, 45 patients (95.7%) were completely satisfied or somewhat satisfied, and 42 subjects (89.4%) stated their leakage was much better or better. CONCLUSION: The transobturator midurethral sling provides a significant improvement in quality-of-life and high postoperative patient satisfaction.

Urinary incontinence in nulliparous women and their parous sisters.
Buchsbaum GM, Duecy EE, Kerr LA, Huang LS, Guzick DS
Obstet Gynecol 2005 Dec;106(6):1253-8.

OBJECTIVE: To investigate the role of vaginal delivery and familial factors in the development of urinary incontinence by comparing the prevalence of this condition in nulliparous women and their parous sisters. METHODS: A sample of 143 pairs of nulliparous/parous postmenopausal sisters completed a comprehensive questionnaire regarding symptoms of pelvic floor disorders. Of these, 101 pairs underwent clinical evaluation of urinary incontinence and genital prolapse. RESULTS: Among this sample of biological sisters, urinary incontinence was reported by 47.6% of nulliparous women and by 49.7% of parous women (P = .782). We found no difference in the severity or type of urinary incontinence between these 2 groups. There was a high concordance in continence status, however, within biological sisters. CONCLUSION: Vaginal birth does not seem to be associated with urinary incontinence in postmenopausal women. Considering the high concordance in continence status between sister pairs, and considering that the majority of parous women are continent, an underlying familial predisposition toward the development of urinary incontinence may be present. LEVEL OF EVIDENCE: II-2.

Women's narratives of long-term urinary incontinence.
Bradway C
Urol Nurs 2005 Oct;25(5):337-44.

PURPOSE: The purpose of this study was to use narrative analysis as a method for examining the lived experience and meaning of long-term, female urinary incontinence (UI). METHOD: Cognitive anthropology and critical medical anthropology provided the overall framework for this study. Theoretical saturation (Strauss, 1987) was achieved after 17 community-dwelling women with long-term (greater than 5 year's duration) UI were interviewed. Informants participated in two face-to-face, audiotaped, interviews and a semi-structured, topical outline for each interview was used. A field journal was used to supplement and validate other data. Informant's narratives were analyzed to emphasize the overall plot type of their stories. FINDINGS: In this study, three dominant plot types emerged from women's narratives: the UI Quest Narrative, UI Restitution and Redemption Narratives, and the UI Victim Narrative. These plot types provide a beginning understanding of the lived experience and meaning of long-term female UI. CONCLUSIONS: Study findings suggest (a) long-term female UI is primarily conceptualized as a condition integrated into a larger life story, (b) women with long-term UI relate stories that follow a narrative format, and (c) long-term, female UI is heterogeneous. Findings go beyond existing literature by suggesting that women's UI narratives serve an important function in understanding the lived experience and the meaning of UI.

Self-monitoring and pelvic floor muscle exercises to treat urinary incontinence.
Kincade JE, Dougherty MC, Busby-Whitehead J, Carlson JR, Nix WB, Kelsey DT, Smith FC, Hunter GS, Rix AD
Urol Nurs 2005 Oct;25(5):353-63.

Urinary incontinence (UI) is a common chronic condition among women. Treatment of UI can involve behavioral techniques, pharmacological strategies, or surgical intervention. Clinically, treatment strategies should start with the simplest and least invasive measures. To overcome the deficiencies in previous research and provide definitive information for clinical practice, a randomized clinical trial is currently underway. This clinical trial uses a pretest-posttest design to first determine the effectiveness of self-monitoring techniques before subjects are randomized into one of two treatment groups or an attentional control group with a 1-year followup. The study design, sampling plan, and interventions used in an ongoing clinical trial to assess the effectiveness of self-monitoring and efficacy of biofeedback to treat UI in women are described. Innovative techniques to assess adherence to the pelvic muscle exercise protocol are addressed.

Vaginal mesh extrusion associated with use of Mentor transobturator sling.
Siegel AL
Urology 2005 Nov;66(5):995-9.

OBJECTIVES: To describe my experience of vaginal mesh extrusion using the monofilament polypropylene transobturator sling, the Mentor ObTape. The Mentor ObTape was the first transobturator sling developed as an alternative to the retropubic commercially available suburethral slings for providing mid-urethral support as treatment of female stress urinary incontinence. METHODS: Thirty patients underwent transobturator suburethral sling placement for anatomic stress urinary incontinence using the ObTape from October 2003 to January 2005. A retrospective chart review was performed to retrieve data on the safety, efficacy, complications, and outcomes using this product. RESULTS: Six patients (20%) to date have presented with defective vaginal healing manifested by extrusion of the sling material. Five patients required surgical removal of the sling material, and one underwent a trial of conservative management. No urethral erosions were noted. CONCLUSIONS: In my experience, the Mentor ObTape sling, which uses a nonwoven, minimally elastic, micropore, monofilament polypropylene mesh, incurs an unacceptably high rate of defective vaginal wound healing and mesh extrusion.

Lower urinary tract symptoms after total and subtotal hysterectomy: results of a randomized controlled trial.
Gimbel H, Zobbe V, Andersen BJ, Sorensen HC, Toftager-Larsen K, Sidenius K, Moller N, Madsen EM, Vejtorp M, Clausen H, Rosgaard A, Villumsen J, Gluud C, Ottesen BS, Tabor A
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jul-Aug;16(4):257-62.

The aim of this Danish multicenter trial was to compare the proportion of women with lower urinary tract symptoms after total abdominal hysterectomy (TAH) and subtotal abdominal hysterectomy (SAH) for benign uterine disorders. A total of 319 women were randomized to TAH (n = 158) or SAH (n = 161). Women were followed up for 1 year by strict data collection procedures, including postal questionnaires. Results were analyzed by intention-to-treat analyses. Urinary incontinence was found less often among TAH women than among SAH women. This was due to a larger reduction of the number of women with stress and urinary incontinence in the TAH group. No other differences were found between the two operation methods. The number of women with urinary incontinence and frequency was reduced from study entry for follow-up, while double/triple voiding was increased. Incontinent women had significantly lower quality of life scores than continent women

Concomitant resection of congenital vaginal septum during the tension-free vaginal tape procedure.
Long CY, Juan YS, Liu CM, Wu CH, Tsai EM
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jul-Aug;16(4):311-2. Epub 2004 Nov 9.

This case report illustrates how the tension-free vaginal tape (TVT) procedure can be successfully combined with another gynecological intervention. A 38-year-old patient had been diagnosed with didelphys uterus during cesarean section. She came to us for treatment of confirmed genuine stress incontinence. In conjunction with the TVT procedure, we resected the congenital vaginal septum. The patient has remained continent for over 1 year.

Minimally invasive surgical techniques for stress incontinence surgery.
Morley R, Nethercliffe J
Best Pract Res Clin Obstet Gynaecol 2005 Dec;19(6):925-40. Epub 2005 Nov 7.

Minimally invasive techniques for surgical correction of stress incontinence date back to the late 1950s. Since that time there have been many developments to attempt to emulate the good results achieved by open surgery with less surgical morbidity. Needle suspensions have attempted to reposition the bladder neck in the same way as a colposuspension. However, although numerous variations have been described, they do not have the long-term outcomes of colposuspension. These variations, their complications and long-term outcome are discussed. Sling surgery, especially the tension-free vaginal tape (TVT), has probably had the largest impact on incontinence surgery in recent years, offering a procedure with low morbidity and, thus far in the medium term, outcomes comparable with those of more invasive procedures. This has led the TVT procedure to become the most common procedure performed worldwide for stress incontinence. With the benefit of lessons learnt from the use of synthetic material in the genitourinary tract, some worries remain with regard to the long-term complications of TVT. Other non-synthetic material should not be forgotten, and the advantages and disadvantages of various sling materials are compared. Injectables have an established place in the treatment of sphincter deficiency, though long-term results are poor compared to those of other procedures. Various materials used and the technique for their injection are discussed.

Anatomical and functional significance of urogenital hiatus in primary urodynamic stress incontinence.
Huang WC, Yang SH, Yang JM
Ultrasound Obstet Gynecol 2005 Dec 1;.

OBJECTIVES: To explore the correlations of anatomical and functional sonographic parameters of urogenital hiatus in primary urodynamic stress incontinence. METHODS: We reviewed retrospectively our urodynamic database from July 1996 to June 2003 and identified subjects with primary urodynamic stress incontinence who had had anatomical assessment of the lower urinary tract and the central part of the pelvic floor by ultrasound. The morphological changes that had occurred in the central pelvic floor were determined by the measurement of genitohiatal angle, genitohiatal distance and anorectal angle. RESULTS: A total of 396 women with a mean age of 48.8 +/- 10.7 (range, 26-82) years were included in the study. One hundred and eighteen subjects (29.8%) were postmenopausal. Stage I pelvic organ prolapse was found in 345 (87.1%) of the women, stage II in 19 (4.8%) and stage III in 32 (8.1%). The genitohiatal angle and genitohiatal distance were significantly and positively associated with resting and straining bladder neck angles. The genitohiatal angle was associated with bladder neck funneling and dependent cystocele during stress (r = 0.144, P = 0.016 and r = 0.140, P = 0.02, respectively), and it was negatively associated with functional profile length (r = -0.157, P = 0.012). The genitohiatal distance was negatively associated with functional profile length and maximum urethral closure pressure (r = -0.148, P = 0.018 and r = -0.227, P = 0.009, respectively). Increased genitohiatal distance was also related to a low Valsalva leak-point pressure (r = -0.199, P = 0.02). Multivariate analysis revealed that resting bladder neck angle was the independent factor for genitohiatal angle and genitohiatal distance. CONCLUSIONS: In primary urodynamic stress incontinence, an increased resting genitohiatal distance or genitohiatal angle on sonographic imaging implies anterior vaginal wall prolapse. In addition, an increased genitohiatal distance is associated with functional impairment of urethral closure. Copyright (c) 2005 ISUOG. Published by John Wiley & Sons, Ltd.

Management of ureteral injuries associated with vaginal surgery for pelvic organ prolapse.
Kim JH, Moore C, Jones JS, Rackley R, Daneshgari F, Goldman H, Vasavada S
Int Urogynecol J Pelvic Floor Dysfunct 2005 Nov 30;:1-5.

Due to the anatomic proximity of the urinary and genital tracts, iatrogenic ureteral injury during pelvic organ prolapse repairs is a serious complication that we have managed in increasing number at our institution. However, few centers have reported on their experience with ureteric injuries associated with gynecologic reconstructive surgery. These ureteral injuries may lead to much morbidity, in particular the formation of ureterovaginal fistula, and the potential loss of renal function especially when diagnosed postoperatively. It is necessary, therefore, for surgeons to have a thorough knowledge of ureteral anatomy and to take precautions to prevent such injuries. The purpose of this article is to review this pertinent anatomy and the key principles of management of ureteric complications of transvaginal surgery for pelvic organ prolapse. The present study illustrates the application of our treatment algorithm based on the time of presentation and the patient condition.

Prospective randomized comparison of transobturator suburethral sling (Monarc) vs suprapubic arc (Sparc) sling procedures for female urodynamic stress incontinence.
Wang AC, Lin YH, Tseng LH, Chih SY, Lee CJ
Int Urogynecol J Pelvic Floor Dysfunct 2005 Dec 3;:1-5.

The aims of this trial were to compare the attendant complications and postoperative voiding function of the Monarc and suprapubic arc (Sparc) suburethral sling procedures. This is the first article in English literature to compare different suburethral sling procedures using prosthesis of the same material and the same weave. Sixty women with urodynamic stress incontinence alone or combined with pelvic prolapse less than International Continence Society stage II were randomly allocated to either the Monarc or Sparc group. A comparison of the peri- and postoperative results comprising complications and symptoms of voiding function revealed no significant differences between the two groups in a follow-up ranged from 6 to 14 months (median, 9 months). However, the nonsignificant increase in tendency of inadvertent vaginal perforation and disability/pain of thigh (Monarc 12.9 vs Sparc 0.0%, p=0.112 and Monarc 12.9 vs Sparc 0.0%, p=0.112, respectively) has clinical significance. Based on the analyses of the comparison of Blaivas obstruction nomograms, postoperative voiding function was not significantly different between the two surgical groups. We concluded that Monarc and Sparc suburethral taping proved to be equally safe and posed no remarkable impact on voiding function in a short term postoperative follow up. However, intraoperative urethrocystoscopy is recommended for safety in both the Monarc and Sparc procedures.

Multicenter experience with the Monarc transobturator sling system to treat stress urinary incontinence.
Davila GW, Johnson JD, Serels S
Int Urogynecol J Pelvic Floor Dysfunct 2005 Nov 29;:1-6.

This study was conducted to report on the safety and efficacy of a transobturator sling approach for treatment of urodynamic stress incontinence (USI). Women with urodynamic stress incontinence were offered a novel polypropylene mesh sling procedure, implanted beneath the lateral pubic rami rather than retropubically. Retrospective data were collected at three U.S. sites. Two hundred women with a mean age of 59 years (range 27-93) underwent the sling procedure. Mean follow-up was 21.5 weeks (range 3-43). Perioperative safety parameters are reported for all subjects and efficacy parameters for those who were followed up for 26 weeks or more. Among the subjects, 95.3% reported being continent or substantially continent (occasional leakage of small amounts, with protection not needed). Mean operative time was 13.8 min (range 7-34). Preoperatively, 75% wore pads, with 5.3% continuing to do so at 26 weeks. Pre-op urgency was reported by 62.7%, with 41.5% receiving medication. Urgency was reported postoperatively by 20.5% of patients, but only 13.6% were medicated for urgency. Urinary retention was identified in 0.9% at 26 weeks. Transobturator slings are highly effective for treatment of SUI, and may offer increased safety relative to traditional and tension-free retropubic slings.

Spontaneous delivery following tension-free vaginal tape procedure.
Seeger D, Truong ST, Kimmig R
Int Urogynecol J Pelvic Floor Dysfunct 2005 Nov 28;:1-3.

There has been no report in the international literature concerning vaginal delivery following tension-free vaginal tape (TVT) procedure. Most gynecologists recommend cesarean section after TVT procedure. We present the case of a 37-year-old (gravida 2, para 2) woman who had spontaneous delivery at 40 weeks' gestation after TVT procedure performed 10 months prior because of stress urinary incontinence. Five months after spontaneous delivery, the patient was shown to be continent, with no urinary leakage occurring following stress maneuver. Urodynamic evaluation showed normal urethral pressure profile and sufficient maximum urethral closure pressure. Introital ultrasound demonstrated the correct position of the Prolene tape. In cases of pregnancy following TVT procedure, a general recommendation of delivery by cesarean section may be questioned, since the function and correct suburethral position of the Prolene tape can also remain intact following vaginal delivery.

A transvaginal ultrasound study comparing transobturator tape and tension-free vaginal tape after surgical treatment of female stress urinary incontinence.
de Tayrac R, Deffieux X, Resten A, Doumerc S, Jouffroy C, Fernandez H
Int Urogynecol J Pelvic Floor Dysfunct 2005 Nov 26;:1-6.

This study was carried out to compare ultrasonographic findings on patients after transobturator tape (TOT) and tension-free vaginal tape (TVT) procedures to evaluate displacement of tapes up to a 2-year follow-up and to test the correlation between bladder outlet obstruction and the tape position. Forty-nine patients had a transvaginal ultrasonographic evaluation after TOT (n=31) or TVT (n=18) procedures. Twenty-one patients from the TOT group and 12 from the TVT group had ultrasonographic evaluation both at 1 and 2 years follow-up. Tape position was evaluated with a complete sagittal view, and the width of the tape and the distance between the middle of the tape and the bladder neck were measured. Statistical analysis was performed using a t test. After clinical evaluation, stress test, and uroflowmetry with residual measurement, the tapes were compared on ultrasound with regard to clinical and urodynamic results: success in stress incontinence vs failure, bladder outlet obstruction vs no obstruction, and de novo urgencies vs no urgencies. No difference was found between TOT and TVT in the midurethral tape placement. The distance between the middle of the tape and the bladder neck at rest was similar at both 1 and 2 years after both TOT and TVT and was unchanged after coughing or Valsalva. The width of the tape was similar after TOT and TVT at both 1 and 2 years after the procedure. There was no difference in the distance between the middle of the tape and the bladder neck between cured patients, failure, bladder outlet obstruction, and de novo urgencies after both TOT and TVT. Transvaginal ultrasound examination showed no significant difference in the tape position between TOT and TVT. No correlation was found between ultrasonographic findings and postoperative voiding troubles for both techniques.

Solifenacin: as effective in mixed urinary incontinence as in urge urinary incontinence.
Kelleher C, Cardozo L, Kobashi K, Lucente V
Int Urogynecol J Pelvic Floor Dysfunct 2005 Nov 8;:1-7.

Patients with mixed urinary incontinence (MUI) are frequently treated with antimuscarinic therapy, despite little data being previously published for this patient group. We present a subgroup analysis of patients with overactive bladder syndrome, assessing the efficacy of once-daily solifenacin succinate in patients with MUI (n=1041) or urge urinary incontinence (UUI; n=1648) only. A greater proportion of patients receiving solifenacin achieved resolution of incontinence in both the MUI and UUI groups (MUI: 5 mg=43%, 10 mg=49%; UUI: 5 mg=55%, 10 mg=54%) compared with patients receiving placebo (MUI 33%, UUI 35%). Baseline to endpoint improvements in all other symptoms were statistically significant vs placebo for both solifenacin doses in both cohorts. The incidence of adverse events was comparable between the MUI and UUI cohorts. This analysis shows that once-daily solifenacin was as effective and well tolerated in patients with MUI as in patients with UUI.

Sulfated glycosaminoglycans of the periurethral tissue in women with and without stress urinary incontinence, according to genital prolapse stage.
Feldner PC Jr, Kati LM, Sartori MG, Baracat EC, Rodrigues de Lima G, Nader HB, Dietrich CP, Girao MJ
Eur J Obstet Gynecol Reprod Biol 2005 Nov 25;.

OBJECTIVE: The objective was to determine sulfated glycosaminoglycans (GAG) of the extracellular matrix (ECM) in women with and without stress urinary incontinence according to genital prolapse stage. STUDY DESIGN: Periurethral tissue was obtained from 30 women who underwent surgery for urinary incontinence, for pelvic organ prolapse, or for other benign gynecologic conditions. Biopsy specimens were assessed by biochemical methods to characterize and quantify sulfated glycosaminoglycans. Measurements were made of total glycosaminoglycans, chondroitin sulfate, dermatan sulfate, and of heparan sulfate. Data were compared using the t-test. RESULTS: In two groups, dermatan sulfate was the most predominant glycosaminoglycan. Women with stress urinary incontinence had significantly more total sulfated glycosaminoglycans (p<0.05) and dermatan sulfate (p<0.05) than women without stress urinary incontinence. We did not observe any differences in chondroitin sulfate and heparan sulfate. CONCLUSIONS: Women with stress urinary incontinence showed quantitative and qualitative differences in the biochemical characteristics of the extracellular matrix in periurethral tissue by analysis of sulfated glycosaminoglycans, according to genital prolapse stage.

MRI morphology of the levator ani muscle, endopelvic fascia, and urethra in women with stress urinary incontinence.
Tunn R, Goldammer K, Neymeyer J, Gauruder-Burmester A, Hamm B, Beyersdorff D
Eur J Obstet Gynecol Reprod Biol 2005 Nov 16;.

OBJECTIVE: To evaluate pathomorphologic changes of the levator ani muscle, endopelvic fascia, and urethra in women with stress urinary incontinence (SUI) by MRI. STUDY DESIGN: Fifty-four women with SUI were examined by MRI (1.5T): body phased-array coil, axial and coronal proton-density-weighted sequences. RESULTS: The urethral sphincter muscle showed a reduced thickness of its posterior portion (37%), an omega shape (13%) or higher signal intensity (50%); its abnormal configuration was associated with an increased signal intensity in 70% (p=0.001). The levator ani muscle comprised an unilateral loss of substance in 30%, a higher signal intensity in 28%, and alterated origin in 19%. Central defects of the endopelvic fascia were present in 39% (n=21), lateral defects in 46%. There was a significant association between loss of the symphyseal concavity of the anterior vaginal wall and lateral fascial defects (p=0.001) and levator ani changes (p=0.016). CONCLUSION: MRI yields findings supporting current theories on the pathogenesis of SUI.

Lower urinary tract symptoms in middle-aged women--prevalence and attitude towards mild urinary incontinence: a community-based population study.
Teleman P, Lidfeldt J, Nerbrand C, Samsioe G, Mattiasson A
Acta Obstet Gynecol Scand 2005 Nov;84(11):1108-12.

OBJECTIVE. To investigate the prevalence and perceived bother of lower urinary tract symptoms (LUTS) in middle-aged women with and without self-reported urinary incontinence. PATIENTS AND METHODS. In the Women's Health In the Lund Area study (WHILA 1995--2000), 32% of the participating 6,917 women, 50--59 years, reported urinary incontinence defined as involuntary urinary leakage causing a social and/or hygienic problem. Out of these, 1,500 women with (INCONT) and 1,500 without incontinence (CONT) received the Bristol Female lower urinary tract symptoms (LUTS) questionnaire in January 2001. RESULTS. A total of 2,682 (89%) women were included. Most common LUTS in the INCONT and CONT groups, respectively, were any urinary leakage (93.8% vs. 53.3%, P<0.001), urgency (86.2% vs. 62.5%, P<0.001), stress incontinence (85.1% vs. 41%, P<0.001), and frequency (86.9% vs. 35.6%, P<0.001). The two groups differed significantly in the degree of reported bother by infrequently occurring stress and urge incontinence. Urinary leakage more than once a week was reported as bothersome by 97.5%. The prevalence of self-reported urinary incontinence increased from 32% to estimated 66% if the demand for social and/or hygienic bother was omitted from the definition. Conclusion. The prevalence of self-reported urinary incontinence increased from 32% to estimated 66%, if the demand for social and/or hygienic bother was omitted from the definition. LUTS other than incontinence are common in middle-aged women, with a significantly higher prevalence in women with self-reported incontinence than in continent women. The attitude towards stress- and urge incontinence varied widely when the symptoms occurred infrequently. Urinary leakage more than once a week was considered bothersome by 97.5%.

Efficacy and complications in the surgical treatment of stress urinary incontinence by insertion of a silicone-coated polyester tape (Lift((R))).
Girard JM, Deruelle P, Collinet P, Lucot JP, Therby D, Cosson M
Eur J Obstet Gynecol Reprod Biol 2005 Oct 24;.

OBJECTIVES: To evaluate the efficacy and safety of a surgical treatment for stress urinary incontinence by implantation of a silicone-coated polyester tape (Lift((R))). MATERIALS AND METHODS: This retrospective study included 72 female patients having had a suburethral silicone-coated polyester tape inserted as treatment for stress urinary incontinence, combined or not with pelvic surgery. We recorded the patient's characteristics, the surgical procedure, the short and long-term results and complications. RESULTS: Seventy-two patients were operated, 60 of whom were fully evaluated. The average follow-up was 17 months. On 48 patients (80%) the treatment was successful, 3 (5%) were improved, and 9 (15%) were regarded as a failure. Dysuria occurred in six (10%) patients, five were de novo, and one was persistent. Ten patients (16.6%) presented de novo urge incontinence. The main complication was a higher rate of severe infections, accompanied by defective healing (4, i.e. 6.7%). CONCLUSION: The procedure using a silicone-coated polyester tape seems to be efficient, but insufficiently secure. This higher rejection rate leads us to prefer other synthetic materials proved to be better tolerated.

Comparison between monofilament and multifilament polypropylene tapes in urinary incontinence.
Bafghi A, Valerio L, Benizri EI, Trastour C, Benizri EJ, Bongain A
Eur J Obstet Gynecol Reprod Biol 2005 Oct 1;122(2):232-236.

OBJECTIVE: We compare the efficacy and late complications between a polypropylene monofilament tape (TVT) and a polypropylene multifilament tape (IVS) in the surgical implant of sub-urethral, tension free tape for the treatment of stress urinary incontinence (SUI). METHODS: It is a non-randomised, monocentric retrospective study. Two questionnaires were sent to the patients. The first questionnaire determined the efficacy of the tape and the tolerance of the urinary process. The second questionnaire evaluated discomfort and consequences linked to urinary incontinence and associated urinary troubles. RESULTS: The study included 313 female patients and 256 (82%) responded to the questionnaire (137 TVT, 119 IVS). Patient satisfaction was 88.3% for the TVT tape and 73.5% for the IVS tape (p<0.005). The improvement of the quality of life was also higher for the polypropylene monofilament tapes. "De novo" urge incontinence was more common in the TVT group. However, the rates of dysuria and infection of tapes were more common in the IVS group. CONCLUSION: The type of tape appears to influence efficacy and the emergence of late complications. Our results point at the greater efficacy of the polypropylene monofilament tape.

Long-term urinary continence rates after simple sling incision for relief of urinary retention following fascia lata pubovaginal slings.
Thiel DD, Pettit PD, McClellan WT, Petrou SP
J Urol 2005 Nov;174(5):1878-81.

PURPOSE: We examined long-term urinary continence rates in patients after midline simple sling incision for urinary retention following suburethral fascia lata slings. MATERIALS AND METHODS: A retrospective review was completed of 13 women undergoing a simple sling incision for catheter dependent obstruction after suburethral sling surgery more than 4 years previously. Urinary continence was evaluated by use of the Groutz-Blaivas anti-incontinence surgery response score. The scores were statistically compared as binary categories at mean 111-day and 60.8-month followup. RESULTS: A total of 13 women underwent a simple sling incision for catheter dependent urinary retention after sling surgery, and 11 patients (mean age 73.4 years) were available for long-term followup (60.8 months). The simple sling incision procedure was completed an average of 65 days (range 36 to 235) after original sling placement. Mean post-void residual urine volume at least 1 month after sling surgery was 289 ml (range 75 to 500). At a mean followup of 60.8 months, no patient required catheterization. Of 11 patients 5 wore no pads. There was no statistical difference in leakage episodes per day (p = 1.0), pads per day (p = 0.3), or patient perceived condition (p = 0.3) during long-term followup. The mean Groutz-Blaivas score did not change statistically during the 5-year followup period (p = 0.6). CONCLUSIONS: Midline simple sling incision provides relief of catheter dependent obstruction following fascia lata sling surgery while preserving urinary continence in the majority of patients during a 5-year followup period.

Factors that distinguish continent from incontinent older adults with detrusor overactivity.
Rosenberg LJ, Griffiths DJ, Resnick NM
J Urol 2005 Nov;174(5):1868-72.

PURPOSE: In older adults detrusor overactivity (DO) is almost as common in continent individuals as in those with urge incontinence (UUI). Thus, UUI likely reflects the contribution of additional factors. We postulated that of functionally independent individuals in whom transient causes were excluded those in whom DO was accompanied by UUI would be more likely to have smaller functional bladder capacity, less warning and less ability to avert urine loss in the face of DO. MATERIALS AND METHODS: While blinded to continence status, we reviewed the records of all 52 cognitively intact and nonobstructed volunteers older than 65 years who had DO associated with urgency during urodynamic testing and had been asked to try to prevent leakage for 2 minutes. Of these individuals 31 were continent at home. RESULTS: In patients with UI mean functional bladder capacity +/- SD was smaller (313 +/- 153 vs 390 +/- 178 ml, p = 0.06) and warning was briefer (87 +/- 81 vs 120 +/- 116 ml), although the association with warning was less impressive (p = 0.14). The ability to forestall leakage for at least 2 minutes correlated strongly with being continent at home (p < 0.002). For continence detrusor suppression at the onset of DO was more important than sphincter contraction. CONCLUSIONS: Urge incontinence in older adults involves more than simply the presence of DO. Physical function, cognitive function and medications are already known to be important for continence. Our data suggest that functional bladder capacity and the ability to suppress involuntary contraction (and possibly warning) are also potentially important covariates. These factors may represent additional potential targets for behavioral and pharmacological therapy.

Brain control of normal and overactive bladder.
Griffiths D, Derbyshire S, Stenger A, Resnick N
J Urol 2005 Nov;174(5):1862-7.

PURPOSE: Bladder control problems are common but their cause is often unclear. Many investigators have sought causes in the lower urinary tract, but fewer in the supraspinal control system. We have used functional magnetic resonance imaging (fMRI) to determine brain responses to bladder filling in subjects with normal and with poor bladder control (detrusor overactivity). MATERIALS AND METHODS: Cerebral responses to bladder infusion were recorded in 1 male and 11 females without overt neurological abnormality, aged 26 to 83 years. Six had good bladder control and 6 had poor control on prior urodynamics. fMRI was performed while repeatedly infusing and withdrawing liquid into and out of the bladder, and monitoring intravesical pressure. Measurements were made at small and large bladder volumes. RESULTS: fMRI detected activation of many brain regions involved in bladder control, including periaqueductal gray, thalamus, insula, dorsal anterior cingulate, and ventromedial cerebellum. Orbitofrontal cortex, pontine micturition center and preoptic hypothalamus were visible in subgroup analyses. Activations outweighed deactivations and responses became stronger at large bladder volumes. Among subjects with good control, this strengthening of response was prominent in the orbitofrontal cortex. Among those with poor control cortical responses were exaggerated at larger bladder volumes, except in the orbitofrontal cortex, which remained weakly activated. This difference was not due to concurrent detrusor activity. CONCLUSIONS: Poor bladder control is specifically associated with inadequate activation of orbitofrontal cortex. Clinically, frontal cortical lesions cause bladder control problems. This study suggests a similar neurophysiological basis for poor bladder control in the absence of overt neurological lesion.

Bladder Perforation During Tension-Free Vaginal Tape Procedures: Analysis of Learning Curve and Risk Factors.
McLennan MT, Melick CF
Obstet Gynecol 2005 Nov;106(5):1000-1004.

OBJECTIVE: To estimate whether rates of bladder perforation decrease with increasing surgical experience. METHODS: We performed a review of all patients undergoing a tension-free vaginal tape procedure performed by senior resident physicians under the guidance of a single surgeon. Physician experience was assessed by sequentially assigning case numbers to each procedure for each resident. For analysis of learning curve, cases were grouped in fives (ie, first five representing cases 1 to 5, second five cases 6 to 10). RESULTS: Twenty-three residents performed 278 procedures. The median number of cases performed was 13 (range 3 - 22); mean number was 12.1 (sd = +/- 5.6). The rate of perforation was 34.2% (95/278, 95% confidence interval 28.8-39.9%). Age and weight were significantly associated with perforation. The cystotomy group was, on average 4.5 years younger (P = .007) and 7.86 kg (17.3 lb) lighter (P < .001). Rate of injury in the first five series was 40.9%, 30.7% in second series of five, and 25.9% in the third series of five and was statistically significant (linear-by-linear association chi(2) = 4.286, df = 1, P = .038). The relationship between the incidence of cystotomy and the cumulative number of cases performed was inversely correlated. As the number of cases a resident completed increased, there was a slight tendency for cystotomy to decrease (P.033). On cystoscopic examination, residents missed 35 of the 95 injuries (37%, 95% confidence interval 27.8-46.9%). CONCLUSION: A learning curve exists for tension-free vaginal tape procedures. Many injuries are missed on initial resident cystoscopic inspection, highlighting the need for comprehensive cystoscopic training during residency. LEVEL OF EVIDENCE: II-3.

The Effect of Ultralow-Dose Transdermal Estradiol on Urinary Incontinence in Postmenopausal Women.
Waetjen LE, Brown JS, Vittinghoff E, Ensrud KE, Pinkerton J, Wallace R, Macer JL, Grady D
Obstet Gynecol 2005 Nov;106(5):946-952.

OBJECTIVE: To estimate the effect of 2 years of treatment with ultralow-dose transdermal estradiol (E2) on incontinence in postmenopausal women. METHODS: Ultra Low Dose Transdermal estRogen Assessment (ULTRA) was a multicenter, randomized, double-blinded, placebo-controlled trial of unopposed ultralow-dose (0.014 mg/d) transdermal E2 for prevention of osteoporosis in 417 postmenopausal women aged 60 to 80 years. Frequency of incontinence episodes was assessed at baseline and after 4 months and 2 years of treatment using a self-reported questionnaire. We used an intention-to-treat analysis to compare change in incontinence frequency, improved (decreased 2 or more episodes per week), unchanged (increased or decreased no more than 1 episode per week), or worsened (increased 2 or more episodes per week) between the E2 and placebo groups among women with and without at least weekly incontinence at baseline. RESULTS: At baseline, the prevalence of at least weekly incontinence was similar between E2 and placebo groups (43%). After 2 years, there was no difference between groups in the proportions of women with incontinence at baseline whose incontinence improved, worsened, or was unchanged. The odds ratio for worsening incontinence in the E2 compared with placebo group was 1.35 (95% confidence interval 0.75-2.42. In women without incontinence at baseline, the odds of developing at least weekly incontinence after 2 years in the E2 compared with placebo group was not significant (odds ratio 1.2, 95% confidence interval 0.7-2.2). CONCLUSION: Two years of treatment with unopposed ultralow-dose transdermal E2 did not substantially change the frequency of incontinence symptoms or alter the risk of developing at least weekly incontinence. LEVEL OF EVIDENCE: I.

Postmenopausal hormone therapy: does it cause incontinence?
Steinauer JE, Waetjen LE, Vittinghoff E, Subak LL, Hulley SB, Grady D, Lin F, Brown JS
Obstet Gynecol 2005 Nov;106(5):940-5.

OBJECTIVE: To estimate the effect of hormone therapy on risk of stress and urge urinary incontinence. METHODS: The Heart Estrogen/progestin Replacement Study was a randomized, placebo-controlled, double-blinded trial to evaluate daily oral conjugated estrogen (0.625 mg) plus medroxyprogesterone acetate (2.5 mg) therapy for the prevention of heart disease events in women with established heart disease. The 1,208 participants in Heart Estrogen/progestin Replacement Study who reported no loss of urine in the previous 7 days at baseline are included in this analysis. RESULTS: During 4.2 years of treatment, 64% of women randomly assigned to hormone therapy compared with 49% of those assigned to placebo reported weekly incontinence (P < .001). The higher risk of incontinence in the hormone group was evident at 4 months, persisted throughout the treatment period, and was independent of the age of the women. The odds ratios for weekly incontinence among women on hormone therapy compared with placebo were 1.5 for urge incontinence (95% confidence interval [CI] 1.2-1.8; P < .001) and 1.7 for stress incontinence (95% CI 1.5-2.1; P < .001). Four years of treatment with hormone therapy caused an excess risk of 12% for weekly urge incontinence and 16% for weekly stress incontinence; the corresponding numbers needed to harm were 8.6 (95% CI 5.8-16.6) and 6.2 (95% CI 4.6-9.4). CONCLUSION: Estrogen plus progestin therapy increases risk of urge and stress incontinence within 4 months of beginning treatment. LEVEL OF EVIDENCE: I.

Retropubic Hematoma After Transobturator Sling Procedure.
Rajan S, Kohli N
Obstet Gynecol 2005 Nov;106(5):1199-1202.

BACKGROUND: The transobturator tape procedure is one of the newer minimally invasive sling procedures used for the surgical treatment of genuine stress urinary incontinence. CASES: Two cases of retropubic hematomas following transobturator tape procedure are reported. One patient was managed conservatively and did not require reoperation, and the other patient required computed tomography-guided drainage of the hematoma. In both cases the patients' hematomas resolved, and they remained continent 3-6 months after surgery. CONCLUSION: The transobturator tape procedure is a minimally invasive alternative to the tension-free vaginal tape operation for stress urinary incontinence, but it may be associated with vascular complications.

Treatment of stress incontinence with the SPARC sling: intraoperative and early complications of 445 patients.
Hodroff MA, Sutherland SE, Kesha JB, Siegel SW
Urology 2005 Oct;66(4):760-2.

OBJECTIVES: To review our series of 445 patients to obtain safety and early outcome information regarding use of the SPARC mid-urethral sling. The SPARC mid-urethral sling is commonly used to treat stress urinary incontinence. The SPARC technique involves passage of the trocars from an initial suprapubic approach. METHODS: We retrospectively reviewed the charts of all SPARC slings performed from the first procedure in August 2001 through December 2003. The Urogenital Distress Inventory and Incontinence Impact Questionnaire short-form surveys were mailed to the patients. All SPARC procedures were performed on an outpatient basis unless the patient was undergoing a concurrent procedure. RESULTS: The average patient age was 60 years. Concurrent prolapse repair and/or hysterectomy were performed in 97 patients (22%). The mean time from surgery to questionnaire response was 15 months. Ninety-one percent would undergo the procedure again, and 84% would recommend the SPARC to a friend. One patient was admitted postoperatively for a rectus hematoma. Another presented after 3 days with abdominal pain resulting from a small bowel perforation. Sling release was performed in 19 patients (4.3%) because of large postvoid residual urine volume or obstructive voiding symptoms. CONCLUSIONS: The SPARC mid-urethral sling is an effective outpatient surgical procedure to treat stress urinary incontinence.

Sacral neuromodulation for intractable urge incontinence: are there factors associated with cure?
Amundsen CL, Romero AA, Jamison MG, Webster GD
Urology 2005 Oct;66(4):746-50.

OBJECTIVES: To determine the variables that affect the cure rate in patients with urge incontinence treated with sacral neuromodulation. METHODS: This prospective analysis of patients with refractory urinary urge incontinence who underwent placement of a neuromodulator lead and generator was undertaken between October 2000 and December 2003. Quantitative assessment of the severity of their urinary leakage was assessed by preoperative and postoperative 3-day bladder diaries documenting leakage episodes, number of pads used per day, and a 24-hour pad weight assessment. Cure was defined as no daily leakage episodes after permanent implantation. Subjective outcome was assessed using the Incontinence Impact Questionnaire. Two-sample independent t tests, two-way chi-square tests, and tests of two proportions were performed when appropriate, with P < 0.05 considered significant. RESULTS: The mean postimplantation follow-up was 29 months, and the average age was 60 years (range 29 to 83). The cure rate was associated with age, with individuals younger than 55 years having a statistically significant greater cure rate (65% versus 37% for older individuals; P < 0.05). Having three or more chronic conditions was associated with a lower cure rate in both younger and older individuals. Patients with a neurologic condition also had a lower cure rate, but no specific neurologic condition was associated. CONCLUSIONS: Age older than 55 years and more than three chronic conditions were independent factors associated with a lower cure rate in patients implanted with a sacral neuromodulator for refractory urge incontinence. A neurologic condition may be associated with a decrease in the cure rate.

Complications of transvaginal silicone-coated polyester synthetic mesh sling.
Govier FE, Kobashi KC, Kuznetsov DD, Comiter C, Jones P, Dakil SE, James R Jr
Urology 2005 Oct;66(4):741-5.

OBJECTIVES: To report a premarket multicenter trial to test the feasibility of a transvaginal silicone-coated polyester synthetic mesh sling in women with anatomic incontinence. METHODS: Fifty-one patients in four centers underwent transvaginal placement of a silicone-coated polyester synthetic mesh sling (American Medical Systems) during an 8-month period. Of the 51 patients, 31 were part of a prospective institutional review board-approved feasibility trial in three centers funded by American Medical Systems (group 1) and 20 underwent implantation by a single surgeon and their data were retrospectively reviewed (group 2). The studies were done concomitantly, and all slings were fixed transvaginally with bone anchors. All patients in group 1 were followed up at 4 weeks, 6 months, and 1 year (as applicable) with repeat questionnaires, physical examinations, and pad tests. RESULTS: In group 1, 20 patients completed 6 months of follow-up. Ten patients (32%) required a second surgical procedure at an average of 183 days (range 68 to 343) postoperatively. Eight patients (26%) had vaginal extrusion of the mesh, one (3%) required sling lysis, and one (3%) required sling removal because of infection. In group 2, 8 patients (40%) underwent sling removal for vaginal extrusion at a mean of 160 days (range 83 to 214). CONCLUSIONS: Transvaginally placed silicone-coated mesh slings used for the treatment of urinary incontinence demonstrated an unacceptably high vaginal extrusion rate in this study. Once identified, this study was immediately terminated, and this product was not marketed for this application in the United States.

Urinary stress incontinence treatment with Remeex in a patient with epispadias: a case report.
Soligo M, Proietti F, Cortese M, Villa M, Maruccia S, Milani R
Int Urogynecol J Pelvic Floor Dysfunct 2005 Oct 26;:1-2.

Epispadias is a rare condition in women. A postmenopausal 53-year-old woman with a known problem of epispadias came to our outpatient clinic complaining of persistent severe urinary stress incontinence without overactive bladder symptoms. She had previously undergone an inefficacious tension-free vaginal tape (TVT) procedure in another institution. We implanted a Remeex (Mechanic External Regulation) device without applying any tension to the sling. Two tape regulations were performed the day after surgery and 2 months later to gain continence. At 13 months of follow up, this woman was asymptomatic and satisfied. As documented by this case here, the Remeex procedure is particularly suitable in selected high-risk patients where TVT and TVT live slings are less effective.

The efficacy of the tension-free vaginal tape in the treatment of five subtypes of stress urinary incontinence.
Segal JL, Vassallo BJ, Kleeman SD, Hungler M, Karram MM
Int Urogynecol J Pelvic Floor Dysfunct 2005 Oct 18;.

Purpose: To determine the efficacy of tension-free vaginal tape (TVT) for the treatment of five sub-types of stress urinary incontinence (SUI).Materials and methods: A retrospective review was performed from November 1998 to November 2001 on all patients with SUI who underwent a TVT procedure either alone or with other reconstructive pelvic procedures. The patients were subdivided into five categories. Intrinsic sphincter deficiency (ISD) was defined by a maximum urethral closure pressure <20 cm H(2)O or a mean Valsalva leak point pressure <60 cm H(2)O above baseline. Urethral hypermobility (UH) was defined by a straining Q-tip angle greater than 30 degrees from the horizontal. Cure was defined as the subjective resolution of SUI without the development of voiding dysfunction or de novo urge incontinence. Improvement was defined as the subjective improvement of SUI without complete resolution or the subjective resolution of SUI occurring with the development of prolonged voiding dysfunction lasting greater than 6 weeks or de novo urge incontinence. Failure was defined as the subjective lack of improvement of SUI, the need for an additional procedure to correct SUI or the need for revision or takedown of the TVT for persistent voiding dysfunction or mesh erosion.Results: The cure, improvement and failure rates for each of the following groups are respectively as follows: group 1 (+UH, -ISD) (n=121): 101 (83.5%), 13 (10.7%), 7 (5.8%); group 2 (-UH, +ISD) (n=22): 17 (77.3%), 3 (13.6%), 2 (9.1%); group 3 (+UH, +ISD) (n=32): 26 (81.3%), 4 (12.5%), 2 (6.2%); group 4 (-UH, -ISD) (n=25): 21 (84.0%), 3 (12.0%), 1 (4.0%); group 5 (occult SUI) (n=67): 57 (85.1%), 10 (14.9%), 0 (0%).Conclusion: This study shows that the TVT is effective in treating all five sub-types of SUI.

Learning outcomes of a group behavioral modification program to prevent urinary incontinence.
Sampselle CM, Messer KL, Seng JS, Raghunathan TE, Hines SH, Diokno AC
Int Urogynecol J Pelvic Floor Dysfunct 2005 Nov-Dec;16(6):441-6. Epub 2005 Mar 15.

This study describes acquisition of knowledge and motor skill in bladder training (BT) and pelvic floor muscle training (PFMT) and adherence following a behavioral modification program (BMP). Essentially continent (0-5 episodes in past year) community-dwelling older women (n=359) were randomized to treatment (n=164), a 2-h group education session supplemented by one brief individualized session of approximately 10 min, or control (n=195), no instruction, and followed for 12 months. Knowledge, motor skill, and adherence to the BMP were documented. Changes in pelvic muscle function and voiding interval were used to validate self-reported adherence. Following group instruction, mean BT and PFMT knowledge was 90 and 86%, respectively; 68% demonstrated correct PFMT technique without additional instruction, 29% required brief instruction, and 3% were unable to learn PFMT technique. Adherence ranged from 63 to 82% for PFMT and 58 to 67% for BT. Group instruction supplemented with brief individual instruction as needed is an effective teaching method for BT and PFMT.

Factors influencing the long-term success of periurethral collagen therapy in the office.
Koduri S, Goldberg RP, Kwon C, Dobrez DG, Sand PK
Int Urogynecol J Pelvic Floor Dysfunct 2005 Oct 14;:1-6.

INTRODUCTION: Glutaraldehyde crosslinked bovine collagen has been used for periurethral bulking for the treatment of urodynamic stress incontinence since 1989 with variable success. A retrospective study was undertaken to evaluate the factors involved in the long-term success of glutaraldehyde crosslinked bovine collagen used for periurethral bulking in the office. METHODS: Patients were followed objectively with stress testing after receiving periurethral collagen injection in the office under local anesthesia. Repeat injections were done as necessary during their follow-up appointments. The "success" group was defined as those women who demonstrated negative stress tests for over 1 year following their first injection. RESULTS: Nineteen of 184 women (10.3%) demonstrated negative stress tests for over 1 year following only one initial injection of glutaraldehyde crosslinked collagen. Their success lasted a mean of 829 days up to the time of follow-up. CONCLUSION: Prior anti-incontinence surgery was the one factor analyzed that showed a trend toward this long lasting success. No other factors were predictive of negative stress tests for over 1 year. Prior anti-incontinence surgery seems to represent a factor involved in the long-term success of periurethral bulking in the office with glutaraldehyde crosslinked bovine collagen for the treatment of urodynamic stress incontinence.

Evaluation of early pelvic floor physiotherapy on the duration and degree of urinary incontinence after radical retropubic prostatectomy in a non-teaching hospital.
Cornel EB, Wit RD, Witjes JA
World J Urol 2005 Oct 7;:1-3.

The objective of this study was to study the effect of early pelvic floor re-education on the degree and duration of incontinence and to evaluate the results of radical retropubic prostatectomy (RRP) performed in a non-teaching hospital. This is a non-randomised study. From March 2000 to November 2003, 57 consecutive men, who underwent RRP for localized prostate cancer, participated in a pelvic floor re-educating program. Continence was defined as a loss of no more than 2-g urine on the 24-h pad test and no use of pads. The 24-h pad test was performed once in every 4 weeks until the patient indicated that he was continent. Diurnal and nocturnal continence was achieved after 1, 2, 3, 6 and 12 months post catheter removal in 40, 49, 70, 86 and 88% of all men, respectively. Comparison of our results with current literature suggest that the time period towards continence after a RRP can be shortened relevantly if pelvic floor re-education is started directly after catheter removal.

New hammock hypothesis-based method for the treatment of stress urinary incontinence: the first 29 urethral supports with a small fascial patch.
Yamada T, Hayashi T, Kamata S, Ohno R, Horiuchi S
Int J Urol 2005 Sep;12(9):806-9.

Abstract Aim : We have developed a new method requiring no manipulations of the retropubic passages, and carried out a retrospective study to assess the effectiveness, safety and early results of this new procedure in the treatment of female stress urinary incontinence. Methods : From January 2001 to September 2003, 29 patients underwent our new surgery for the treatment of SUI. A 3 x 2 cm vertical rectangle was harvested from the rectus fascia. A convex horizontal incision was made over the mid urethra and bladder neck. The retropubic space was entered to the urethropelvic ligament spreading toward the junctions between urethropelvic ligament and tendinous arc. One suture was made at the point lateral to the bladder neck. Another suture was made behind the pubic bone. These two sutures were sutured again and tied with the short side end of the harvested fascia. The same procedure was performed on the other side. Results : Of 29 patients, 26 (89.7%) were cured of stress urinary incontinence and 3 were improved. None of the patients had difficulty in voiding after the operation. Maximum flow rates were almost the same before and after surgery. None of the patients had any adverse events. Conclusion : This procedure, which requires no manipulations of the retropubic passages, is safe and effective for the treatment of stress urinary incontinence.

Solvent-dehydrated cadaveric dermis: a new allograft for pubovaginal sling surgery.
Onur R, Singla A
Int J Urol 2005 Sep;12(9):801-5.

Abstract Aim : The aim of this study was to evaluate the efficacy of solvent-dehydrated cadaveric dermis in pubovaginal sling surgery for the first time in the literature. Methods : Twenty-five women with stress urinary incontinence underwent pubovaginal sling surgery using 2 x 12 cm allograft dermis. Preoperatively, all patients were evaluated by a detailed urogynecologic evaluation, voiding diary, pelvic examination and urodynamic investigation. Outcome was assessed by the Urogenital Distress Inventory short form and standardized follow-up questionnaires. Results : Twenty (80%) patients were cured of stress incontinence symptoms. Seventeen wore no pad and three reported occasional stress urinary incontinence and used no or one pad at a mean follow up of 12 months. Five (20%) patients in our series experienced the same amount of leakage as before the surgery. Seventy-six percent of the patients indicated that urinary incontinence was no longer negatively affecting their daily life and were satisfied with the procedure. Conclusions : Questionnaire-based assessment of outcome suggests that solvent-dehydrated cadaveric dermis is effective in the treatment of stress urinary incontinence. However, larger and comparative prospective studies with long-term results and randomized comparison of tissue preparation techniques are warranted.

Translevator posterior intravaginal slingplasty: anatomical landmarks and safety margins.
Smajda S, Vanormelingen L, Vandewalle G, Ombelet W, Jonge E, Hinoul P
Int Urogynecol J Pelvic Floor Dysfunct 2005 Sep-Oct;16(5):364-8. Epub 2005 Jan 27.

The posterior intravaginal sling is a new tension-free needle suspension technique. It is used for the treatment of middle compartment (vaginal vault or uterine) prolapse. The Prolene sling suspends the vagina at the upper border of level II support as described by DeLancey (Am J Obstet Gynecol 166:1717, 1992). Human cadaveric dissections were undertaken to explore the pertinent anatomy that is involved when using this blind needle technique. Pre-dissected cadaveric material was used to obtain didactic illustrations of the anatomy of the procedure. Description of the surgical technique using anatomical landmarks and relative distances of the needle to these landmarks will improve the surgeon's visual understanding of the procedure. The measurements obtained demonstrate that the needle stays at a minimal distance of 4 cm away from the major (pudendal) vessels that could potentially cause life-threatening haemorrhage.

Anatomical study of the obturator foramen and dorsal nerve of the clitoris and their relationship to minimally invasive slings.
Achtari C, McKenzie BJ, Hiscock R, Rosamilia A, Schierlitz L, Briggs CA, Dwyer PL
Int Urogynecol J Pelvic Floor Dysfunct 2005 Oct 7;:1-5.

OBJECTIVES: The objective of the study is to clarify potential risks to the dorsal nerve of the clitoris (DNC) and obturator canal using different minimally invasive slings. STUDY DESIGN: Ten embalmed hemipelves were dissected to demonstrate the course of the DNC and the obturator canal. On each cadaver, tension-free vaginal tape (TVT), transobturator in-out (TVT-O) and transobturator out-in (Monarc) procedures were performed. Distances between the DNC and the obturator canal to the different devices were measured. RESULTS: The DNC passes beneath the pubic bone at a distance of 14.3+/-4.7 mm of the midline. The distances of the different devices to the DNC were similar. The distance to the obturator canal was significantly different, with TVT being the furthest (40.1+/-3.7 mm) and TVT-O the closest (19.3+/-3.1 mm; p<0.0001). CONCLUSION: Given the course of the DNC along the medial aspect of the ischiopubic ramus, the out-in technique may be safer. The in-out technique is the closest to the obturator canal.

Tension-free vaginal tape for the treatment of urodynamic stress incontinence with intrinsic sphincteric deficiency.
Ghezzi F, Serati M, Cromi A, Uccella S, Salvatore S, Triacca P, Bolis P
Int Urogynecol J Pelvic Floor Dysfunct 2005 Oct 7;:1-5.

The purpose of this study was to evaluate the outcome of tension-free vaginal tape (TVT) procedure in women with urodynamic stress incontinence diagnosed as having intrinsic sphincteric deficiency (ISD). The combination of a maximal urethral closure pressure <20 cm H(2)O and a Valsalva leak point pressure <60 cm H(2)O was considered as diagnostic of ISD. Subjects with detrusor overactivity on preoperative urodynamics were excluded. A total of 35 patients with both low closure pressure and leak point pressure were enrolled. Bladder perforation occurred in three (8.6%) cases. Postoperative urinary voiding difficulties occurred in nine (25.7%) women. Two patients underwent surgical detension of the tape, with complete resolution of urinary retention and no relapse of incontinence. Women with postoperative voiding dysfunction had a significantly lower detrusorial pressure at the peak flow on preoperative urodynamics compared to those who voided efficiently after TVT. The mean (range) follow-up time was 12.5 months (3-36). The objective cure rate for stress incontinence was 91.4%. Two of the three (66%) patients in whom the TVT procedure failed had a fixed urethra. De novo urge incontinence was found in five (14.3%) patients.

Vaginal erosion, sinus formation, and ischiorectal abscess following transobturator tape: ObTape implantation.
Babalola EO, Famuyide AO, McGuire LJ, Gebhart JB, Klingele CJ
Int Urogynecol J Pelvic Floor Dysfunct 2005 Sep 27;:1-4.

A 50-year-old woman was referred for evaluation with an 8-month history of intermittent malodorous vaginal discharge initially noted 2 months after placement of a transobturator tape for stress urinary incontinence. Evaluation revealed erosion of the tape through the vaginal wall with a sinus tract associated with an ischiorectal abscess. Surgical removal of the tape with excision of the sinus tract, drain placement, and antibiotic therapy was needed for complete resolution of the symptoms. Infectious complications need to be considered when counseling women prior to synthetic sling placement. A high index of suspicion, meticulous sub- and periurethral inspection, along with aggressive surgical management are required to treat an infected draining abscess following synthetic transobturator sling placement.

Overactive bladder.
Freeman RM, Adekanmi OA
Best Pract Res Clin Obstet Gynaecol 2005 Sep 19;.

The overactive bladder is a common condition, which has significant effects on quality of life. The aetiology in most cases is unknown, and treatment outcomes have until recently been unsatisfactory. Management includes excluding pathology and implementing behavioural changes such as caffeine reduction, bladder and pelvic floor training, as well as antimuscarinic drug therapy. Compliance is often problematic, and this can be improved with some of the newer antimuscarinics with fewer side-effects, and a good therapist/patient relationship. In the majority of cases this 'treatment package' is successful, but in those where it is not, intravesical therapies have been introduced, e.g. neuromodulation, alternative drug therapies (e.g. vanilloids, botox) and surgery. With a better understanding of the aetiology and identification of risk factors better outcomes from treatment are likely.

Midurethral Tissue Fixation System sling - a 'micromethod' for cure of stress incontinence - preliminary report.
Petros PE, Richardson PA
Aust N Z J Obstet Gynaecol 2005 Oct;45(5):372-5.

Aims: To assess the effectiveness of the Tissue Fixation System (TFS) in patients with stress incontinence. The TFS uses two small plastic anchors to fix an (adjustable) midurethral polypropylene mesh sling into the soft tissues below the pubic bone. Patients and methods: Thirty-six patients with stress incontinence, mean age 55 (35-87), mean weight 76 kg (33-117 kg), mean 0.8 previous operations for stress incontinence, underwent a TFS midurethral sling operation. The patients were preoperatively assessed with a structured questionnaire, 24-h urinary diary, cough stress test, transperineal ultrasound, and urodynamics. Using the TFS delivery system, a midurethral mesh tape was attached to the fibromuscular tissues behind the perineal membrane. The suburethral vaginal fascia was also tightened. Post-operatively. the patients were reviewed at 6 weeks, and at 3-monthly intervals with ultrasound, and cough stress tests. Results: Primary symptomatic cure rate at mean 9 months (3-15 months) was 83.4% (n = 36). Pad test loss decreased from a mean 12.7 g to a mean of 0.2 g; mean operating time was 5 min, and mean hospital stay was 24 h (12-48 h). There were no cases of obstructed micturition, and minimal analgesia only was required postoperatively. Conclusion: The TFS is a promising new method. The results at this stage are similar to those achieved previously with the 'tension-free' tape operations, but with greater safety and shorter operating time. Testing by other surgeons will be required to evaluate this method further.

Transobturator tape for stress incontinence: The North Queensland experience.
Naidu A, Lim YN, Barry C, Goodwin S, Corstiaans A, Rane A
Aust N Z J Obstet Gynaecol 2005 Oct;45(5):446-9.

A prospective observational study of 96 patients undergoing insertion of the MONARC transobturator tape (American Medical Systems, Minnetonka, USA) for treatment of urodynamic stress incontinence was conducted to investigate its' the safety and efficacy. Although there were no major intraoperative complications, sling protrusion was observed in 11/91 patients (12.1%) at early follow up visits. At these visits, 80 women (87.9%) were either completely or substantially continent and 74 women (81.3%) were satisfied with the operation. Objectively, 74 women (81.3%) were cured on urodynamic assessment and only one woman (1.1%) was found to have voiding dysfunction. As a conclusion, it would appear that this new technique is effective for the treatment of stress incontinence; but further studies are needed to investigate its long-term results and complications.

Validation of a Two-Item Quantitative Questionnaire for the Triage of Women With Urinary Incontinence.
Bent AE, Gousse AE, Hendrix SL, Klutke CG, Monga AK, Yuen CK, Meadows ES, Yalcin I, Muram D
Obstet Gynecol 2005 Oct;106(4):767-773.

OBJECTIVE: To evaluate the reproducibility, construct validity, and preferences for the 2-item Stress/Urge Incontinence Questionnaire. METHODS: The questionnaire asks a patient to recall the number of stress urinary incontinence and urge urinary incontinence episodes she experienced during the preceding week. The 4-week prospective study included 3 office visits and enrolled women with stress, urge, or mixed urinary incontinence symptoms. The test-retest reproducibility was assessed after 3 days, and the construct validity of the questionnaire was evaluated against a diary and other measures of incontinence severity and effect. The bother associated with completing (patients) or analyzing (physicians) the diary was assessed. Both groups also reported their time requirements and preferences for the questionnaire or diary. RESULTS: Reproducibility for the classification of symptoms was moderately strong (kappa = .536). Test-retest agreement was good (64-80%) for all but balanced mixed incontinence (38%). Intraclass correlations revealed good reproducibility for the number of stress (.694), urge (.703), and total (.726) incontinence episodes. Significant (P < .01) correlations with other measures of incontinence established construct validity. Patients and physicians reported it took less time to complete the questionnaire than the diary, but the majority said the completion or analysis of the diary was of little or no bother and preferred the diary. CONCLUSION: The Stress/Urge Incontinence Questionnaire is a valid tool that can be used in clinical practice to differentiate between symptoms of stress and urge urinary incontinence to make an initial diagnosis, especially in primary care where incontinence is not a focus of the practice. LEVEL OF EVIDENCE: III.

Objective analysis of mechanical resistance of tension-free devices.
Boukerrou M, Lambaudie E, Collinet P, Rubod C, Boulanger L, Dubois P, Fasel J, Cosson M
Eur J Obstet Gynecol Reprod Biol 2005 Sep 14;.

INTRODUCTION: The "tension-free" procedures are widely used by surgeons for the treatment of urinary incontinence and prolapse. The clinical results are largely in favour of these procedures. The aim of our study is to determine objectively the mechanical tissue resistance when using these techniques, before healing begins. MATERIAL AND METHODS: We measured the mechanical resistance using four different routes: the retro-pubic space, the transobturator, the translevator ani muscle and the trans-sacrospinous ligament. We compared five different meshes, TVT((R)), IVS((R)), Lift((R)), Prolene((R)) and Prolene Soft((R)). In order to study the effect of increasing dimensions, we tested Prolene((R)) tapes measuring 1, 1.5 and 2cm in width. We performed traction tests on meshes implanted in cadavers. Measurements were made with a dynamometer and the results expressed in Newtons. RESULTS: This study shows that TVT((R)) offers a better resistance to traction via the retro-pubic space route. There was no significant difference among the four routes when the same type of mesh measuring 1cm was used. However, an increase in the dimensions of Prolene((R)) tapes improves their resistance in the tissues, thereby facilitating fixation before healing begins. Also, these increasing dimensions (in width) show that there is better resistance with the trans-sacrospinous ligament compared with the transmuscular one. DISCUSSION: The increasing size of prosthetic meshes does not show the superiority of certain routes with commercial meshes of 1cm in width. The higher resistance obtained with wider tapes is probably due to an increased surface area between the tissues and meshes. This increase in resistance does not seem to be important for the treatment of urinary incontinence. However, it should be of interest for the treatment of prolapse where traction and surface are more important. CONCLUSION: Two different recommendations can be deduced from our study. On one hand, the arms of prosthetic meshes for pelvic floor repair should measure more than 1cm in width in order to improve their maintenance in the tissues in the immediate post-operative period. On the other hand to improve fixation, the posterior arms of the transperineal mesh should be passed through the sacrospinous ligament rather than via the transmuscular route. The resistance of tissues is also influenced by the armature of the prosthetic mesh. They must therefore be developed commercially specifically for "tension-free" fixation. Our results need to be confirmed by further studies including more cadavers and younger patients.

Tension-free vaginal tape (TVT) for treatment of stress urinary incontinence in women with low-pressure urethra.
Meschia M, Pifarotti P, Buonaguidi A, Gattei U, Spennacchio M
Eur J Obstet Gynecol Reprod Biol 2005 Sep 1;122(1):118-21.

OBJECTIVE: To assess the results of TVT in patients with urinary stress incontinence, urethral hypermobility, and low-pressure urethra. STUDY DESIGN: We retrospectively analysed 265 consecutive women who underwent a TVT procedure for urodynamic stress urinary incontinence over a 31-month period. Women were divided into two groups depending on their preoperative maximum urethral closure pressure (MUCP). Group 1 (61 women with MUCP </=20cm H(2)O) were compared with 204 women (group 2) with a MUCP >20cm H(2)O. Subjective and objective outcome data were assessed from routine postoperative visits. Office and hospital records were reviewed to check patients' characteristics, intraoperative findings, and surgical outcomes. RESULTS: Women with low-pressure urethra were older than those with MUCP >20cm H(2)O; they were more likely to have had a hysterectomy or anti-incontinence surgery. The mean duration of follow-up was 31 (+/-11) months. Cure rates among patients with low- or normal-pressure urethra were similar (77% and 86%, P=0.70). Nevertheless, the former were more likely to complain of voiding dysfunction. Conclusion: TVT is a highly effective treatment even in women with intrinsic sphincter deficiency.

Duloxetine for the treatment of stress urinary incontinence in women: An integrated analysis of safety.
Hurley DJ, Turner CL, Yalcin I, Viktrup L, Baygani SK
Eur J Obstet Gynecol Reprod Biol 2005 Sep 24;.

OBJECTIVE: The objective was to characterize the safety of duloxetine for treatment of stress urinary incontinence (SUI) in women, using an integrated database generated from four published placebo-controlled clinical trials. METHODS: The database included 1913 women randomized to duloxetine (N=958) or placebo (N=955), examining adverse events (AEs), serious adverse events (SAEs), vital signs, electrocardiograms, and laboratory analytes. AEs occurring initially or worsening during the double-blind treatment period were considered treatment-emergent (TEAE). Differences between duloxetine-treated and placebo-treated groups were compared statistically. RESULTS: Common TEAEs included: nausea (23.2%), dry mouth (13.4%), fatigue (12.7%), insomnia (12.6%), constipation (11.0%), headache (9.7%), dizziness (9.5%), somnolence (6.8%), and diarrhea (5.1%). Most TEAEs that emerged early were mild to moderate, rarely worsened, and resolved quickly. Overall AE discontinuation rates were 20.5% for duloxetine and 3.9% for placebo (P<.001). Most discontinuations (83%) occurred within the first month of treatment. SAEs were uncommon and did not differ between treatments. Statistically significant, but clinically unimportant mean increases in heart rate (2.4bpm) and systolic and diastolic blood pressure (</=2mmHg) occurred. No arrhythmogenic potential was observed and any rare, transient, asymptomatic increases in hepatocellular enzymes normalized. CONCLUSIONS: Duloxetine was safe and tolerable, although transient AEs were not uncommon.

Trans-Obturator Vaginal Tape (TOT((R))) for Female Stress Incontinence: One Year Follow-Up in 120 Patients.
Roumeguere T, Quackels T, Bollens R, de Groote A, Zlotta A, Bossche MV, Schulman C
Eur Urol 2005 Sep 20;.

OBJECTIVES: The aim of this study was to evaluate the effectiveness of a new minimally invasive surgical procedure, the Trans-obturator Vaginal Tape (TOT((R))) in the treatment of female urodynamic stress incontinence (USI) and to analyse functional results and quality of life after one year of follow up. MATERIAL AND METHOD: 120 consecutive women with stress urinary incontinence underwent the procedure since February 2002 under general or loco-regional anesthesia. Minimum follow up was one year (range 12-30 months). Mean age was 58 years (range 31-86). 70% of the patients had pure USI. 5 patients were previously operated for USI. In 10 cases, concomitant repair of pelvic floor defects was mandatory. Collection of the data included operative time, pre- and post-operative complications. Patients were post-operatively assessed at one week, one month and one year. A validated urinary incontinence-specific measure of Quality of Life (QoL) questionnaire (Contilife((R))) was sent and completed 12 months after surgery. RESULTS: The mean operative time was 12min (range 6-30) with a catheterisation time of 0,9 day (range 0-2). No severe bleeding was observed. There were 13 minor lateral tears of the vagina without any sequelae. Three perforations of the urethra and one of the bladder occurred during the learning phase. In two cases a re-intervention was necessary for tape removal when the injury was not recognised during the procedure. Two transient urinary retention needed a supra pubic catheter and tape release. Eleven women presented transient voiding outflow obstruction. After one month, 93% patients were cured with no pad and a negative cough test with a full bladder. Uroflowmetry did not show any significant changes between pre- and post-operative time in all the population. De novo urgency occurred only in 2.5% and persistent dysuria (Q(max) <10ml/s and/or post-void residual volume >120cc) in 4%. 80% of patients were completely dry after one year and 12% were greatly improved. According to the pre-operative maximal urethral closure pressure, continence rate was 86% above 30cm H(2)O and 76% below 30cm H(2)O respectively. Global satisfaction of women at 1 year was 78% with good scores based on daily and effort activities, self-image, emotional and sexual activities. CONCLUSIONS: TOT((R)) is a safe and effective new minimal invasive procedure for USI with a low rate of complications. To confirm the success of TOT((R)), longer follow up in large population is mandatory to assess the reliability of this attractive technique.

Severe mesh complications following intravaginal slingplasty.
Baessler K, Hewson AD, Tunn R, Schuessler B, Maher CF
Obstet Gynecol 2005 Oct;106(4):713-6.

OBJECTIVE: Synthetic meshes are increasingly used in the management of stress urinary incontinence and pelvic organ prolapse. This report describes severe complications following anterior and/or posterior intravaginal slingplasties employing a multifilament polypropylene mesh. METHODS: We describe the symptoms, findings, subsequent management, and outcome of 19 consecutive women who have been referred with complications following anterior (n = 11) and/or posterior intravaginal slingplasty (n = 13) employing the multifilament polypropylene tape. RESULTS: The main indications for removal of the 11 anterior intravaginal slings were intractable mesh infection in 6 women, retropubic abscess with cutaneous sinus in one, and vesico-vaginal fistula in one, intravesical mesh and pain syndrome in one, and voiding difficulties and pain syndrome in two. The main indications for removal of the 13 posterior intravaginal slings were intractable mesh infection in three and pain syndrome and dyspareunia in 10 women. Removal of the slings was performed after a median time of 24 months post-slingplasty. At follow-up between 6 weeks and 6 months, in all women genital pain, chronic vaginal discharge and bleeding, voiding, and defecation difficulties had been markedly alleviated (5) or they had ceased (14). Twelve of 17 sexually active women (71%) resumed sexual intercourse without difficulties. Ten women required subsequent surgery for stress incontinence and pelvic organ prolapse. CONCLUSION: Surgeons should be aware of the potential complications of synthetic meshes. Until data on the safety and efficacy of the intravaginal slingplasties are available, these procedures cannot be recommended. LEVEL OF EVIDENCE: III.


Removal of a missed polypropylene tape by a combined transurethral and transabdominal endoscopic approach.
Cornel EB, Vervest HA
Int Urogynecol J Pelvic Floor Dysfunct 2005 May-Jun;16(3):247-9. Epub 2004 Oct 21.

Surgical intervention for bladder perforation caused by application of a transvaginally placed polypropylene tape is rare. Open as well as endoscopic procedures for removal from the bladder have been described earlier. In this case report we describe the removal of an intravesical polypropylene tape by a combined transurethral and transabdominal endoscopic approach 3 months after the initial surgical procedure.

[Intraurethral injections of Zuidex: evaluation of the morbidity of the technique in the treatment of female urinary incontinence]
Ferchaud J, Girard F, Ciofu C, Peyrat L, Haab F
Prog Urol 2005 Jun;15(3):494-7.

OBJECTIVE: To evaluate the feasibility and morbidity of intraurethral injections of dextranomer/hyaluronic acid (Zuidex), performed under local anaesthesia as an outpatient procedure in the treatment of female urinary incontinence. MATERIAL AND METHODS: Twenty one patients with a mean age of 67 years (range: 29-93 years) presenting urinary incontinence related to sphincter incompetence were treated by intraurethral injection of Zuidex. Injections were performed with the Implacer system provided with the product under local anaesthesia. RESULTS: For nine of these patients (43%), a second injection after 6 weeks was performed due to an insufficient result on incontinence. A total of 30 injections were therefore performed. No significant problem was observed during the injections. Three injections (10%) were difficult because of a short urethra. In 7 cases (23%), the patient reported pain during the injection. In 3 cases (10%), macroscopic haematuria was observed after treatment and another 4 cases (13%) developed lower urinary tract infection. Six patients (20%) developed transient acute urinary retention with resumption of micturition after 24 to 48 hours. CONCLUSION: Intraurethral injection of Zuidex has the advantage of being minimally invasive and can be performed under local anaesthesia, as an outpatient procedure, with good safety and a low complication rate. Resumption of spontaneous voiding must be monitored in view of the risk of urinary retention. The long-term results have not yet been evaluated.

[Artificial urinary sphincters in women: indications, techniques, results]
Roupret M, Chartier-Kastler E, Richard F
Prog Urol 2005 Jun;15(3):489-93.

Artificial urinary sphincter (AUS) is one of the last resort surgical treatments proposed to patients with stress urinary incontinence (SUI) due to severe sphincter incompetence. Despite convincing functional results, AUS implantation in women is a preferred treatment option only for certain teams. An abdominal approach for implantation of the prosthesis is often preferred to the transvaginal approach. The most recent data show that more than 84% of patients are continent at 5 years. The 5-year sphincter revision rate is about 20%. In 2005, AUS is still a valid treatment option in SUI and has a real place in the urologist's therapeutic armamentarium even in the age of synthetic suburethral tape.

A nationwide analysis of transvaginal tape release for urinary retention after tension-free vaginal tape procedure.
Laurikainen E, Kiilholma P
Int Urogynecol J Pelvic Floor Dysfunct 2005 Aug 24;.

The role of transvaginal release procedure (TRP) for the treatment of urinary retention after TVT operation in Finland by the end of the year 2002 was evaluated. Questionnaires regarding the TVTs and the TRPs were sent to 56 hospitals. A retrospective review of the records of 48 women undergoing the TRP was available for analysis. TVT was performed on 9040 patients under local (94%), spinal (4%) or general (2%) anesthesia. TRP was made under local (48%), light (48%) or spinal (4%) anesthesia. The number of TRPs was 50/9040 (0.6%) in the whole country. Forty-nine percent of the patients were completely cured of their retention and remained continent after TRP by subjective report and by stress test. The retention following a TVT did not resolve in four patients (12%) who underwent TRP. This nationwide analysis proved that half of the patients remained continent after TRP, which is in our opinion an important information for all proceduralists.

Does the MONARC transobturator suburethral sling cause post-operative voiding dysfunction? A prospective study.
Barry C, Naidu A, Lim Y, Corsitaans A, Muller R, Rane A
Int Urogynecol J Pelvic Floor Dysfunct 2005 Aug 11;.

The aim of this study was to compare pre-operative and post-operative voiding parameters following insertion of the MONARC transobturator tape (TOT), for treating women with urodynamic stress incontinence. This prospective observational study was conducted at a tertiary referral urogynaecology unit, in North Queensland, involving 83 women who were prospectively assessed pre-operatively and at 6-8 weeks following the procedure. Information collected included patient demographics, concomitant surgery, pre-operative and post-operative symptomatology (using validated questionnaires), and pre-operative and post-operative urodynamic parameters. Parameters used to assess voiding function included symptoms of voiding difficulty (incomplete emptying and irritative symptoms) as well as objective parameters including maximum flow rate (Q(max)), adjusted maximum flow rate (Q(maxadj)) using the Liverpool nomogram (LN), maximal urethral pressure, and post-void residual (PVR). Pre-operative average Q(max) was 23.7 ml/s compared to 21.1 ml/s post-operatively (p=0.064). When the Q(max) was adjusted for voided volume using the LN, Q(maxadj) was seen to decrease significantly from 26 ml/s to 18 ml/s (p<0.05). Women with PVR>50 ml did not differ significantly pre-operatively and post-operatively, 5/83(6%) vs 7/83 (8.4%) (p=0.75). The number of women with a flow rate <10th centile on LN was 22 (26.5%) pre-operatively vs 29 (34.9%) post-operatively (p=0.21). One (1.2%) post-operatively had voiding dysfunction diagnosed by an abnormal voiding pattern (p=0.728), which was not statistically significant. Objective voiding dysfunction as determined by adjusted flow rates <10th centile LN and >50 ml PVR was seen in four women (4.8%). Adjusted free flow rates are significantly reduced following insertion of the MONARC TOT, as are some symptoms related to voiding dysfunction. Despite this, satisfaction rates remain high with observed voiding dysfunction or objective measures of voiding dysfunction showing no statistical change in the short term. Long-term follow-up is planned at 1 year.

Twelve-month results of nonsurgical radiofrequency energy micro-remodeling for stress incontinence.
Sotomayor M, Bernal GF
Int Urogynecol J Pelvic Floor Dysfunct 2005 May-Jun;16(3):192-6; discussion 196. Epub 2004 Sep 17.

This pilot clinical trial was performed to evaluate the safety and impact on quality of life and incontinence episode frequency of nonsurgical radiofrequency energy (RF) tissue micro-remodeling in women with stress urinary incontinence (SUI). The palpation-guided treatment produces focal denaturation of submucosal collagen, resulting in reduced luminal wall compliance without luminal narrowing. Forty-one women suffering from SUI associated with urethral hypermobility were enrolled into four treatment groups which differed in total number and lower urinary tract location of micro-remodeling sites. No serious and only limited minor adverse events were associated with the treatment. Incidence of quality of life score improvement at 12 months ranged from 75 to 78%, and statistically significant incontinence episode frequency reduction was demonstrated by three of four treatment groups. RF micro-remodeling demonstrated 12-month safety, quality of life improvement, and incontinence episode frequency reduction. No one treatment group demonstrated clear superiority in efficacy outcomes.

Risk factors influencing the complication rates of tension-free vaginal tape-type procedures.
Cetinel B, Demirkesen O
Curr Opin Obstet Gynecol 2005 Oct;17(5):530-4.

PURPOSE OF REVIEW: Tension-free vaginal tape (TVT)-type procedures are gradually becoming the new gold-standard treatment for female stress urinary incontinence. Studies trying to determine the influence of possible risk factors on complications of TVT surgery are needed in order to achieve more favorable results in the future. This review attempts to summarize the current studies which address the possible risk factors influencing the complication rates of TVT-type procedures. RECENT FINDINGS: Articles published in 2004 and 2005 were included and focused, while the older articles were used for historical purposes and achieving the integrity. Risk factors stated in the literature for immediate, infectious, vaginal and urethral erosion complications are found to be mostly on anectodal and speculative bases. The role of concomitant surgery as a risk factor for complications is conflicting, while preoperative low urine flow and low detrusor contractility for urinary retention, and previous anti-incontinence surgery and old age for de-novo urgency seem to appear as possible risk factors. SUMMARY: Most of the risk factors stated were anecdotal and speculative. No consensus exists on concomitant surgery's being a risk factor for postoperative urinary retention and bladder perforation, while prior anti-incontinence surgery and old age were found to be possible risk factors for postoperative overactive bladder symptoms. Multicentric data collection with well designed parameters under the surveillance of a well known organization is needed in order to identify the risk factors influencing the complications of TVT-type procedures.

Intravesical injection of botulinum toxin for the treatment of overactive bladder.
Ho MH, Lin LL, Haessler AL, Bhatia NN
Curr Opin Obstet Gynecol 2005 Oct;17(5):512-8.

PURPOSE OF REVIEW: In recent years, botulinum toxin has been investigated for the treatment of various types of lower urinary tract dysfunctions. This review discusses recently published data related to the therapeutic applications of botulinum toxin in overactive bladder as well as the effects of repeated doses, cross-reactivity between different serotypes, and side effects of the toxin injection into the detrusor muscle. RECENT FINDINGS: Botulinum toxin A has been employed initially in the treatment of neurogenic detrusor overactivity in spinal cord injured patients. Since then, several reports, including a large multicenter study, have confirmed the therapeutic effects of this neurotoxin. The application of botulinum toxin A was extended to the treatment of idiopathic detrusor overactivity and similar results were obtained. Repeated injections of botulinum toxin A had the same sustained benefit. Recently, botulinum toxin B was investigated for the treatments of both neurogenic and idiopathic detrusor overactivity as well as for the management of botulinum toxin A resistant cases. SUMMARY: Although intradetrusal injection of botulinum toxin is not yet an approved treatment for overactive bladder, available data suggest that botulinum toxin can be a therapeutic option in patients with neurogenic and nonneurogenic detrusor overactivity who are refractory to anticholinergic medications. There is a need, however, for further investigation to determine the optimal conditions for these applications. A randomized, double-blinded, placebo-controlled trial to evaluate the therapeutic effects of botulinum toxin is under way.

Overactive bladder: epidemiology and social impact.
Tubaro A, Palleschi G
Curr Opin Obstet Gynecol 2005 Oct;17(5):507-511.

PURPOSE OF REVIEW: Overactive bladder epidemiology is a rapidly evolving field. The new terminology of lower urinary tract function, introduced in 2002, modified the definitions of all four components of overactive bladder. In the same year, the lack of specific information on overactive bladder prevalence was identified and consequently new studies were launched and recently published. RECENT FINDINGS: Following the new terminology, overactive bladder now includes both a purely sensory disorder and a condition related to an altered bladder behaviour. Studies conducted in selected countries and populations suggested comparable prevalence data worldwide, although the syndrome is considered to be underreported. 'Urge' is now considered the cornerstone symptom of overactive bladder. Recent epidemiological data confirm the increase in overactive bladder prevalence with age and suggest that most diet and lifestyle factors are not associated with the condition, with the exception of body mass index. Among the symptoms, urge and urinary incontinence were considered to be more significantly related to patients' quality of life compared with frequency and nocturia. The socioeconomic consequences of the overactive bladder syndrome were recently estimated in a large US study and a total cost of US$12.6 billion was calculated. SUMMARY: Specific data on overactive bladder epidemiology are now available, providing new evidence about its relevance as a clinical issue. Both wet and dry overactive bladder cause a significant reduction in quality of life. In our daily practice we have to consider that overactive bladder is frequently underreported as patients believe that no treatment is available and urinary incontinence is considered a natural consequence of aging.

Newer pharmacologic options in management of overactive bladder syndrome.
Le TH, Ostergard DR, Bhatia NN, Huggins ME
Curr Opin Obstet Gynecol 2005 Oct;17(5):495-506.

PURPOSE OF REVIEW: Urinary incontinence is an under-reported epidemic that currently affects an estimated 13 million people in the United States, of whom about 11 million are women, according to the National Institute of Diabetes and Digestive and Kidney Diseases (Publication No. 02-4132). Because many patients are unaware of curative options and perceive it to be an inevitable outcome of advancing age, they fail to report their symptoms and increase their risk of developing associated co-morbid disease. Failure to diagnose and treat this condition increases financial burdens on individuals, their families and health care organizations. RECENT FINDINGS: Pharmacologic therapy of urge incontinence previously had limited treatment success because efficacious drugs were poorly tolerated, resulting in low patient compliance. Tolerance and effectiveness continue to be improved due to innovative new drugs and alternative delivery systems. SUMMARY: The goal of this review is to update the clinician on the efficacy and the tolerability of established and investigational pharmacologic modalities of therapy.

Microarray analysis of differentially expressed genes in vaginal tissues from women with stress urinary incontinence compared with asymptomatic women.
Chen B, Wen Y, Zhang Z, Guo Y, A Warrington J, Lake Polan M
Hum Reprod 2005 Aug 26;.

BACKGROUND: The pathophysiology of pelvic floor dysfunction resulting in stress urinary incontinence (SUI) in women is complex. Evidence suggests that there is also a genetic predisposition towards SUI. We sought to identify differentially expressed genes involved in extracellular matrix (ECM) metabolism in vaginal tissues from women with SUI in the secretory phase of menses compared with asymptomatic women. METHODS: Tissue samples were taken from the periurethral vaginal wall of five pairs of premenopausal, age-matched SUI and continent women and subjected to microarray analysis using the GeneChip Human Genome U133 oligonucleotide chip set. RESULTS: Extensive statistical analyses generated a list of 79 differentially expressed genes. Elafin, keratin 16, collagen type XVII and plakophilin 1 were consistently identified as up-regulated ECM genes. Elafin, a serine protease inhibitor involved in the elastin degradation pathway and wound healing, was expressed in pelvic fibroblasts and confirmed by Western blot, quantitative competitive PCR and immunofluorescence cell staining. CONCLUSIONS: Genes involved in elas-tin metabolism were differentially expressed in vaginal tissue from women with SUI, suggesting that elastin remodelling may be important in the molecular aetiology of SUI.

First paediatric experience of a new device for "non-endoscopic" periurethral injection in urinary incontinence.
Capozza N, De Dominicis M, Collura G, Caione P
Pediatr Surg Int 2005 Sep 2;:1-3.

The results of endoscopic treatment for urinary incontinence (ETUI) depend on the condition of the urethral mucosa and on the length of the urethra. ETUI is quite difficult to perform in female patients, and, in general, in cases of scarred urethral mucosa. A new device (Zuidex, Q-Med, Uppsala, Sweden) has recently been designed for the "non-endoscopic" treatment of urinary stress incontinence in women. Three paediatric cases are described hereunder. Three patients were treated using Zuidex: two patients (two girls aged 8 and 18) on intermittent catheterization for neurogenic bladder, and one 11-year-old girl, with epispadias, who had already undergone bladder neck reconstruction (Young-Deese). Zuidex is a special implacer for dextranomer implants. It consists of four syringes filled with dextranomer, one implacer, and four needles (25 gauges). Once the device is positioned, the four injections are performed. At the end of this procedure, four implants are symmetrically positioned at four points of the urethral wall, increasing the outlet resistance. In the follow-up phase (5-13 months), the increase in the continent period was +56, 50 and 36%; the increase in bladder capacity (leak volume point) was 40, 28 and 27% in the three patients.Although the new device for "non-endoscopic" treatment of urinary incontinence has been designed for women, the size of the implacer virtually allows its use in any paediatric patient who is above the age of six. Our early experience indicates that this new device could play an important role in the treatment of urinary incontinence in paediatric age.

Immediate complications of tension-free vaginal tape (TVT): Results of a French Survey.
Agostini A, Bretelle F, Franchi F, Roger V, Cravello L, Blanc B
Eur J Obstet Gynecol Reprod Biol 2005 Aug 8;.

BACKGROUND: The aim was to evaluate morbidity following operation using tension-free vaginal tape (TVT). METHODS: Between June 2002 and June 2003, a questionnaire was sent to French gynecologists and urologists. Participants reported the number of TVT procedures performed before January 2002, number of minor or major pre- and post-operative complications. RESULTS: The questionnaire was returned by 92 participants (21 urologists and 71 gynecologists) who reported 12,280 TVT procedures (median: 100, minimum: 5, maximum: 2100). Overall, 901 preoperative bladder injuries were reported (7.34%). For 809 patients (6.59%), complete post-operative urinary retention requiring catheterization was noted. There were 26 cases of vaginal defect healing (0.21%). Retropubic or vulvovaginal hematoma was reported for 39 patients (0.32%). Ten major organ injuries were reported (0.08%): one obturator nerve injury, three bowel perforations, four vessel injuries and two ureteral injuries. CONCLUSION: The risk of major complications following the use of tension-free vaginal tape is low. However, these potential complications require experienced surgeons for the practice of tension-free vaginal tape.

Comparison of Retropubic and Outside-In Transoburator Sling Systems for the Cure of Female Genuine Stress Urinary Incontinence.
Fischer A, Fink T, Zachmann S, Eickenbusch U
Eur Urol 2005 Sep 1;.

OBJECTIVES: Retropubic tension-free slings are a well established procedure in the treatment of SUI. There were and still are relevant complications and side effects. The transobturator approach is said to be safer and equally effective. This paper compares our data of the first TVT- and TOT-procedures to share our experience. METHODS: In this study (from May 1998 to November 1999 for TVTtrade mark and from February 2003 to September 2003 for TOT) only patients (n=220 in each group) with genuine SUI due to urethral hypermobility and/or intrinsic sphincter deficiency not showing signs of vaginal prolapse were evaluated. The results of pre- and postoperatively conducted examinations, quality-of-life assessments and urodynamic studies are reported. RESULTS: TOT is equally effective with less intraoperative and postoperative complications (including induction of urge). The procedure is faster and does not necessarily need intraoperative cystoscopy (even though cystoscopy adds to the procedure's safety) - it is thereby cheaper. CONCLUSIONS: performed under the right indication the transobturator approach seems to be peferable when a low-tension midurethral sling procedure is the method of choice.

Re: Chapple C, Khullar V, Gabriel Z, Dooley JA. The effects of antimuscarinic treatments in overactive bladder: a systematic review and meta-analysis.
Okpara-Kamanu RI
Eur Urol 2005;48:5-26. Eur Urol 2005 Aug 29;.

Botulinum-A Toxin Detrusor and Sphincter Injection in Treatment of Overactive Bladder Syndrome: Objective Outcome and Patient Satisfaction.
Schulte-Baukloh H, Weiss C, Stolze T, Herholz J, Sturzebecher B, Miller K, Knispel HH
Eur Urol 2005 Aug 25;.

OBJECTIVE: We investigated the effect of botulinum-a toxin injections into the detrusor and external sphincter muscle in patients with overactive bladder (OAB) symptoms. METHODS: We included 44 patients - 41 women and three men with a mean age of 66.1 years - who were suffering from OAB symptoms that were refractory to anticholinergic treatment. We injected 200-300U of BTX-A (Botox((R))) into the detrusor muscle; 22 patients also received external sphincter injections. For outcome analysis, we used a bladder diary, a urodynamic examination, and a questionnaire that consisted of 27 validated questions. RESULTS: Changes in the bladder diary 4 weeks and 3, 6, and 9 months after BTX-A injection were as follows: Micturition frequency was reduced by 12%, 16%, 13% and 9%, respectively. Average pad use decreased from 4.2 pads per day to at most 2.4 pads per day after 6 months. Urodynamic changes were most distinct after 4 weeks: the volume when the first uninhibited detrusor contraction occurred increased from 149+/-18.2mL to 263+/-24.2mL, and maximum cystometric bladder capacity increased from 228+/-19.2mL to 305+/-19.0mL. Subjectively, 86% of the patients would choose this procedure for their bladder condition again. Residua 4 weeks after additional injection into the sphincter muscle were distinctly smaller than in the "only detrusor" group. CONCLUSIONS: BTX-A detrusor and sphincter injection is very effective in treating OAB symptoms. For patients who might be expected to have residual urine after injection only into the detrusor, additional injection of low doses of BTX-A into the external sphincter muscle could be one option to reduce that risk.

Stress Incontinence Injection Therapy: What is Best for Our Patients?
Chapple CR, Wein AJ, Brubaker L, Dmochowski R, Pons ME, Haab F, Hill S
Eur Urol 2005 Aug 20;.

OBJECTIVE: Urethral injection (periurethral/intraurethral bulking) is an established, minimally invasive therapy for stress urinary incontinence (SUI). This review aims to determine which women should potentially benefit from, and be considered as candidates for, injection therapy and to elucidate what we are trying to achieve. METHODS: Based on MEDLINE database searches, all aspects of urethral injection were examined, including patient selection, safety, injection technique, efficacy, quality of life, goals and cost. RESULTS: Such therapy has a low complication rate, improves or cures about 3 out of 4 women, as shown in mainly short-term studies, and improves patients' quality of life. It can be used in the majority of patients with uncomplicated SUI. Therefore, injection therapy may be considered as a first-line treatment option for patients who have failed conservative therapy such as pelvic floor exercises and who decline or have a contraindication for pharmacological treatment. However, the decision of whether to use this type of treatment must be based on an informed discussion between the physician and patient - this dialogue should incorporate questions about patients' own treatment goals. Injection therapy appears to have the profile required to meet patients' goals, based on the findings that a procedure with an improvement in incontinence, minimal short-term risk, no long-term risk, and performed in a clinic, would be acceptable. CONCLUSION: Investigating and trying to achieve patients' own treatment goals will ultimately enable us to do what is best for our patients, but current evidence suggests that injection therapy is a valid option worth discussing with many patients.

Transvaginal electrical stimulation in the treatment of urinary incontinence.
Wein AJ
J Urol 2005 Sep;174(3):1007.

Transurethral collagen injections for male intrinsic sphincter deficiency: the University of Texas-Houston experience.
Westney OL, Bevan-Thomas R, Palmer JL, Cespedes RD, McGuire EJ
J Urol 2005 Sep;174(3):994-7.

PURPOSE: Injectable agents are used to increase urethral coaptation for the treatment of intrinsic sphincter deficiency. We evaluated the long-term results and complications of transurethral collagen injections in males. MATERIALS AND METHODS: We reviewed the charts of 322 men (mean age 67.2 years, range 40 to 91) with intrinsic sphincter deficiency after therapy for prostate carcinoma (307) or benign prostatic hyperplasia (15) who received transurethral collagen injections. The analysis included types and combinations of treatment for prostate cancer or benign prostatic hyperplasia, pre-procedure voiding symptoms, total collagen received, maximal percentage improvement and durability of effect. RESULTS: The mean length of followup was 40.1 (+/-13.2) months. Overall, the mean number of injections was 4.37 (+/-2.09). Mean percent improvement after a series of injections was 44.59 (+/-38.26). Mean pad use before and after injection was statistically different (5.15 vs 2.98, p=0.0001). Mean duration of response was 6.3 (+/-8.14) months. In those who achieved complete continence (17%), the mean duration of response was 11.1 (+/-8.87) months. Within this group the mean number of injections and ml of collagen injected were 3.83 and 29.27, respectively. Five patients (1.5%) complained of a quantitative increase in leakage after their series of collagen injections. CONCLUSIONS: Transurethral collagen injections are a good option for short-term therapy in men with post-prostatectomy incontinence. The mean number of injections to achieve a plateau is 3 to 4, regardless of initial severity of incontinence. Those in the radical prostatectomy only treatment group are statistically more likely to achieve continence than all other treatment groups.

Autologous fascial sling vs polypropylene tape at short-term followup: a prospective randomized study.
Wadie BS, Edwan A, Nabeeh AM
J Urol 2005 Sep;174(3):990-3.

PURPOSE: The incidence of urinary incontinence in women of childbearing age is about 30%. Around half have stress incontinence. Many treatment modalities have been elucidated to treat stress incontinence, and among the most popular are rectus fascia sling and tension-free vaginal tape (TVT). The introduction of TVT to the urological armamentarium put a multiplicity of synthetic materials into use in the correction of stress urinary incontinence. A comparison of the impact of these 2 commonly used techniques is needed. MATERIALS AND METHODS: A total of 53 female patients older than 21 years (mean age 45.09) were randomized, using closed envelopes, to undergo TVT or rectus fascia sling. Randomization was performed after patients received spinal anesthesia. One surgeon performed the 2 types of treatment. Associated grade 2 cystocele was simultaneously corrected. Patients with bladder or urethral pathology, as well as those with cystocele greater than grade 2, were excluded from analysis. RESULTS: All 53 patients completed 6 months of followup and all had stress urinary incontinence. There were 15 patients who underwent sling surgery and 17 who underwent TVT who had concomitant grade 1 or 2 cystocele. No statistically significant difference was found between the 2 groups at baseline. Cure was accomplished in 23 of 25 (92%) with sling and in 26 of 28 (92.9%) with TVT at first followup visit (1 week). There were 7 patients who needed at least 1 extra week of catheterization in the sling group and 3 in the TVT group. No significant difference was detected in terms of post-void residual urine, symptom score, and filling and voiding parameters. At 6 months 1 patient had de novo detrusor overactivity and 7 had wound pain. Compared to those with TVT, 2 cases of sling were considered treatment failures, none had de novo overactivity and 2 had wound pain. None of the patients had symptoms suggestive of urethral erosion. CONCLUSIONS: Rectus fascia sling and TVT seem to be equally effective regarding primary outcome measure (ie cure of stress incontinence). Symptom score related to incontinence surgery as well as simultaneous correction of cystocele are comparable in the 2 groups. Fascial sling is a longer treatment process yet it is more economical. Longer followup is vital before rigorous conclusions can be drawn.

A comparison between the response of patients with idiopathic detrusor overactivity and neurogenic detrusor overactivity to the first intradetrusor injection of botulinum-A toxin.
Popat R, Apostolidis A, Kalsi V, Gonzales G, Fowler CJ, Dasgupta P
J Urol 2005 Sep;174(3):984-9.

PURPOSE: Several studies have shown that intradetrusor injections of botulinum neurotoxin type A (BoNT/A) may effectively treat intractable spinal neurogenic detrusor overactivity (NDO), but fewer reports exist on the use of BoNT/A in patients with idiopathic detrusor overactivity (IDO). The purpose of this study was to investigate whether comparable efficacy could be displayed in the response of patients with IDO to those with NDO. MATERIALS AND METHODS: In a prospective, open label study, patients with urgency, and/or urgency incontinence due to urodynamically proven intractable detrusor overactivity received 300 units (NDO) or 200 units (IDO) of Botox injected into the bladder with a minimally invasive outpatient technique. Urodynamic maximum cystometric capacity and maximum detrusor pressure during filling, frequency of voids (frequency), number of incontinence episodes (leak) and number of voids associated with urgency per 24 hours (urgency) from 4-day voiding diaries were compared between the 2 groups at baseline and for changes at 4 and 16 weeks after treatment. RESULTS: A total of 44 patients with spinal NDO and 31 with IDO were treated. At 16 weeks, mean +/- standard error maximum cystometric capacity increased from 229.1 +/- 24.8 to 427.0 +/- 26.9 ml, p <0.0001 in NDO and from 193.6 +/- 24.0 to 327.1 +/- 36.1 ml, p=0.0008 in IDO. Maximum detrusor pressure during filling decreased from 60.7 +/- 6.8 to 26.1 +/- 3.7 cm H2O, p <0.0001 in NDO and from 62.1 +/- 10.8 to 45.1 +/- 8.1 cm H2O, p=0.027 in IDO. Frequency decreased from 12.3 +/- 0.7 to 6.6 +/- 0.6 voids per 24 hours, p <0.0001 in NDO and from 13.6 +/- 1.1 to 8.3 +/- 0.7, p=0.0002 in IDO. Leak decreased from 3.9 +/- 0.5 to 0.7 +/- 0.2 incontinence episodes per 24 hours, p <0.0001 in NDO and from 3.2 +/- 0.8 to 0.6 +/- 0.3, p=0.0017 in IDO, and urgency decreased from 7.5 +/- 0.6 to 1.44 +/- 0.3 episodes per 24 hours, p <0.0001 in NDO and from 10.9 +/- 1.7 to 4.9 +/- 1.1, p <0.0001 in IDO. The 2 groups were comparable for baseline data, but percent improvement in urgency was greater in patients with NDO at 4 weeks (78.2% vs 56.3%, p=0.019) and 16 weeks (78.3% vs 50.7%, p=0.013). Of patients with NDO 69% required self-catheterization de novo posttreatment compared with 19.3% of those with IDO. CONCLUSIONS: Patients with intractable IDO respond to intradetrusor BoNT/A with equally significant improvements in urodynamic and lower urinary tract symptom parameters as those with spinal NDO, despite the lower dose of toxin used.

Decreased sensory receptors P2X3 and TRPV1 in suburothelial nerve fibers following intradetrusor injections of botulinum toxin for human detrusor overactivity.
Apostolidis A, Popat R, Yiangou Y, Cockayne D, Ford AP, Davis JB, Dasgupta P, Fowler CJ, Anand P
J Urol 2005 Sep;174(3):977-82; discussion 982-3.

PURPOSE: Botulinum neurotoxin type A (BoNT/A) is effective in the treatment of intractable detrusor overactivity (DO). In addition to its known inhibitory effect on presynaptic release of acetylcholine by motor terminals, there is increasing evidence that BoNT/A may affect sensory fibers. We investigated a possible effect of BoNT/A on human bladder afferent mechanisms by studying the sensory receptors P2X3 and TRPV1 in biopsies from patients with neurogenic or idiopathic DO. MATERIALS AND METHODS: A total of 38 patients (22 with neurogenic DO, 16 with idiopathic DO) with intractable DO were treated with intradetrusor BoNT/A, and bladder biopsies were taken at 4 and 16 weeks. Urodynamics and voiding diary were also recorded. Specimens were studied immunohistochemically for P2X3, TRPV1 and the pan-neuronal marker PGP9.5, in comparison with controls. RESULTS: P2X3-immunoreactive and TRPV1-immunoreactive (-IR) fibers were decreased at 4 weeks after BoNT/A, and more significantly at 16 weeks (paired t test p=0.0004 and p=0.0008, respectively), when significant improvements were observed in clinical and urodynamic parameters. P2X3-IR fiber decrease was significantly correlated with reduction of urgency episodes at 4 and 16 weeks (p=0.0013 at 4 weeks and p=0.02 at 16 weeks), but not maximum cystometric capacity or detrusor pressures. TRPV1-IR fiber decrease showed a similar trend. PGP9.5-IR suburothelial fibers remained unchanged after treatment at both followups (p=0.85 and p=0.21 at 4 and 16 weeks, respectively). Urothelial cell P2X3-IR and TRPV1-IR also appeared unchanged. CONCLUSIONS: Decreased levels of sensory receptors P2X3 and/or TRPV1 may contribute to the clinical effect of BoNT/A in detrusor overactivity.

Using the circumstances of symptom experience to assess the severity of urgency in the overactive bladder.
Ghei M, Malone-Lee J
J Urol 2005 Sep;174(3):972-6.

PURPOSE: We identified a method for quantifying the symptoms of the overactive bladder that addresses the assessment of urgency. MATERIALS AND METHODS: An observational study of a cohort was used. Data were collected prospectively from 5,423 consultations on 1,797 patients (158 males and 1,639 females) being assessed and treated for the overactive bladder. The study was conducted during 5 years. The reported frequencies and incontinence episodes were recorded. Using ranked ordinal scales (none, mild, moderate, severe) the symptoms of urgency and urge incontinence associated with waking and rising, hearing running water, arriving home ("latchkey"), cold weather and when feeling tired or worried were noted. The experiences of urgency and urge incontinence, without reference to the circumstances in which they were experienced were similarly assessed and if on treatment, they were asked to grade their overall response. RESULTS: Reported urinary frequency and incontinence episodes were strongly associated with patient grading of response to treatment. Therefore, the symptoms assessed on the scale of none, mild, moderate and severe were compared with disease severity by using reported frequency and incontinence episodes. The description of the symptoms with reference to the situations in which they were experienced showed clear associations with frequency and incontinence, falling along a progressive scale. An overall pattern could be detected in that at points on the scale of none, mild, moderate and severe, the least frequency and incontinence tended to be associated with waking, rising and latchkey symptoms. Next followed symptoms precipitated by running water and cold weather. Aggravation by fatigue or worry was associated with the greatest disease severity (ANOVA F = 8.9, p <0.001). This scale covered a wide range from frequencies of 7 to 15 times daily and incontinence episodes through 0 to 4 times daily. CONCLUSIONS: Qualifying the experience of urgency and urge incontinence, according to the circumstances in which these symptoms are experienced, seems to offer a promising new method for assessing the severity of urgency and urge incontinence.

Incontinence.
Lightner DJ
J Urol 2005 Oct;174(4 Pt 1):1175-6.

The effects of the tension-free vaginal tape on voiding function: a prospective evaluation.
Wein AJ
J Urol 2005 Sep;174(3):1010.

Transvaginal surgery in the octogenarian using cadaveric fascia for pelvic prolapse and stress incontinence: minimal one-year results compared to younger patients.
Wein AJ
J Urol 2005 Sep;174(3):1009.

Effects of estrogen with and without progestin on urinary incontinence.
Wein AJ
J Urol 2005 Oct;174(4 Pt 1):1350-1.

Collagen Synthesis is Not Altered in Women With Stress Urinary Incontinence.
J Urol 2005 Oct;174(4, Part 1 of 2):1349.

High incidence of vaginal mesh extrusion using the intravaginal slingplasty sling.
Siegel AL, Kim M, Goldstein M, Levey S, Ilbeigi P
J Urol 2005 Oct;174(4 Pt 1):1308-11.

PURPOSE: The intravaginal slingplasty (IVS) is a tension-free vaginal tape variant that uses a multifilament polypropylene tape to support the mid urethra for the treatment of female stress urinary incontinence. Numerous cases of defective vaginal wound healing have been described in the international urogynecological literature. We describe our experience of vaginal mesh extrusion using the IVS sling. MATERIALS AND METHODS: A total of 35 patients underwent suburethral sling procedures for anatomical stress urinary incontinence using the IVS system from November 2002 to September 2003. A retrospective chart review was performed to retrieve data on safety and efficacy, complications and outcomes using this product. RESULTS: Six patients (17%) to date have presented with defective vaginal healing manifested by extrusion of the sling material. Mean time to presenting symptoms was 9 months (range 2 to 15). All patients required surgical removal of the sling material. No urethral erosions were noted. CONCLUSIONS: Our experience suggests that the IVS sling system, which uses a multifilament polypropylene suburethral mesh, incurs an unacceptably high rate of defective vaginal wound healing and mesh extrusion.

Endoscopic holmium laser excision of intravesical tension-free vaginal tape and polypropylene suture after anti-incontinence procedures.
Giri SK, Drumm J, Flood HD
J Urol 2005 Oct;174(4 Pt 1):1306-7.

PURPOSE: We report on our technique of endoscopic excision of intravesical tension-free vaginal tape procedure and polypropylene sutures using the holmium laser following various anti-incontinence procedures. MATERIALS AND METHODS: Three patients who previously underwent the tension-free vaginal tape, Burch colposuspension and Stamey vesicopexy, respectively, presented with a range of symptoms including hematuria, recurrent urinary tract infection, frequency, urgency and urinary incontinence. Patients were evaluated with history and examination, and all 3 were found to have nonabsorbable intravesical material. RESULTS: There was obvious encrustation over the eroded polypropylene material within the bladder. A 365 mum tip firing holmium laser fiber was inserted through the working channel of the flexible cystoscope. The tape and sutures were successfully excised using a holmium laser output of 1.0 J per pulse at a rate of 10 Hz. Mean operative time was 15 minutes. CONCLUSIONS: Holmium laser excision of intravesical polypropylene tape or suture is a minimally invasive solution to the problem of intravesical perforation or erosion following anti-incontinence procedures.

Efficacy and safety of extended release oxybutynin for the treatment of urge incontinence: an analysis of data from 3 flexible dosing studies.
Macdiarmid SA, Anderson RU, Armstrong RB, Dmochowski RR
J Urol 2005 Oct;174(4, Part 1 of 2):1301-1305.

PURPOSE: We assessed the efficacy and safety of extended release (ER) oxybutynin at individualized doses for urge urinary incontinence. MATERIALS AND METHODS: Data were combined from 3 flexible dosing studies of a total of 420 patients with urge urinary incontinence or mixed incontinence in whom ER oxybutynin dose adjustments were made to achieve the optimal balance between efficacy and tolerability, as judged by each participant. Individual doses were adjusted in 5 mg increments across a dose range of 5 to 30 mg daily. Efficacy was assessed during maintenance therapy using a 7-day diary. RESULTS: Data on 368 patients who completed dose adjustment were included in the analysis. In 47% of patients the preferred dose was greater than 10 mg daily. Individualized doses of ER oxybutynin produced a 79.3% decrease from baseline in the total of all incontinence episodes and an 83.2% decrease in urge episodes. Of patients 81% achieved a decrease of at least 70% in all incontinence episodes and 43% achieved total dryness. Moderate or severe dry mouth was reported by 23% of patients and it was cited as the cause for early withdrawal by 1.4% who completed dose adjustment. Therapy was well tolerated. In the pooled sample overall 6.7% of patients cited adverse events as the reason for discontinuing. CONCLUSIONS: Individualized dosing with ER oxybutynin was associated with highly effective and well tolerated control of urinary incontinence with more than 40% of patients achieving total dryness.

Small intestinal submucosa bladder neck slings for incontinence associated with neuropathic bladder.
Misseri R, Cain MP, Casale AJ, Kaefer M, Meldrum KK, Rink RC
J Urol 2005 Oct;174(4 Pt 2):1680-2.

PURPOSE: We assess the results using small intestinal submucosa (SIS) for neuropathic urinary incontinence in a large single institutional experience. Ambulatory status was considered as a possible predictor of success. MATERIALS AND METHODS: We retrospectively reviewed the charts of patients treated with SIS bladder neck sling procedures for neuropathic urinary incontinence with a leak point pressure less than 25 cm H2O and a minimum of 6 months followup. Continence was defined as wet (requiring pads or diapers) or dry (requiring no pads and dry underwear). Patients were classified as ambulatory (able to ambulate without assistance or using braces, crawling at home) or nonambulatory (confined to a wheelchair). Results were analyzed with regard to patient sex, ambulatory status and simultaneous bladder neck repair. RESULTS: A total of 21 females and 15 males 3 to 10 years old (mean age 9 years) were treated with SIS bladder neck slings (sling alone 27, bladder neck repair with SIS sling 9). Slings were performed along with reconstructive surgery in all cases (all had creation of urinary catheterizable channels and simultaneous or prior bladder augmentations). Minimum followup was 6 months (mean 15, range 6 to 42). Overall, 27 of the 36 patients (75%) are dry following bladder neck sling. In patients treated with the sling procedure alone 6 of 8 (75%) nonambulatory females and 8 of 10 (80%) ambulatory females were continent, and 3 of 4 (75%) nonambulatory males and 2 of 5 (40%) ambulatory males were dry. CONCLUSIONS: SIS has equivalent rates of continence compared to series using rectus fascia in patients with neuropathic urinary incontinence. The ambulatory status of males should be considered when determining which treatment option is best for the patient with myelodysplasia and neuropathic sphincteric incontinence, as in our series ambulatory males undergoing sling placement alone had a poor outcome.

Incontinence severity and major depression in incontinent women.
Melville JL, Delaney K, Newton K, Katon W
Obstet Gynecol 2005 Sep;106(3):585-92.

Objective: Research has shown an association between urinary incontinence and depression. Studies that use community-based samples and major depressive disorder diagnostic criteria are needed. The objective of this study was to estimate the prevalence of and factors associated with major depression in women with urinary incontinence. Methods: We conducted an age-stratified postal survey of 6,000 women aged 30-90 years. Subjects were randomly selected from enrollees in a large health maintenance organization in Washington state. Main outcome measures were prevalence of current major depression and adjusted odds ratios for factors associated with major depression in women with urinary incontinence. Results: The response rate was 64% (n = 3,536) after applying exclusion criteria. The prevalence of urinary incontinence was 42% (n = 1,458). The prevalence of major depression was 3.7% (n = 129), with 2.2% in those without incontinence versus 6.1% in those with incontinence. Among women with incontinence, major depression prevalence rates differed by incontinence severity (2.1% in mild, 5.7% in moderate, and 8.3% in severe) and incontinence type (4.7% in stress, 6.6% in urge/mixed). Obesity (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.3-4.0), current smoking (OR 2.7, 95% CI 1.5-4.9), lower educational attainment (OR 2.0, 95% CI 1.2-3.3), moderate incontinence (OR 2.7, 95% CI 1.1-6.6), and severe incontinence (OR 3.8, 95% CI 1.6-9.1) were each associated with increased odds of major depression in women with urinary incontinence, controlling for age and medical comorbidity. Compared with women with incontinence alone, women with comorbid incontinence and major depression had significantly greater decrements in quality of life and functional status and increased incontinence symptom burden. Conclusion: Women with moderate-to-severe urinary incontinence should be screened for comorbid major depression and offered treatment if depression is present. Level of Evidence: II-2.

Alternative uses of dextranomer/hyaluronic Acid copolymer: the efficacy of bladder neck injection for urinary incontinence.
Misseri R, Casale AJ, Cain MP, Rink RC
J Urol 2005 Oct;174(4 Pt 2):1691-4.

PURPOSE: Urinary continence in children with neuropathic bladder and other urological disorders depends on a bladder with adequate low pressure storage capacity and a competent outlet. Various procedures are performed with the goal of achieving continence in these patients. Recently, dextranomer/hyaluronic acid copolymer (Dx/H) has been introduced for the correction of vesicoureteral reflux. We evaluated the efficacy of submucosal bladder neck (BN) injection of Dx/H for urethral incontinence in children. MATERIALS AND METHODS: We retrospectively reviewed continence status after Dx/H injection into the BN for incontinence. Parameters examined include gender, underlying disease, prior BN surgery and means of emptying the bladder. Continence was described by the patients and/or their parents as unchanged (no change in requirements for diapers or pads), improved (longer dry intervals or requiring fewer pads/diapers) or dry (requiring no pads and dry in underwear). RESULTS: A total of 6 males and 10 females underwent injections for treatment of incontinence. Mean followup was 9.5 months (range 3 to 24). Volumes injected ranged from 0.8 to 4.4 ml (mean 1.88). Of the patients 3 achieved dryness after injection, all of whom had catheterizable urinary stomas and two-thirds had undergone bladder augmentations. All 5 patients who improved had undergone augmentation and had catheterizable channels. No improvement was seen in 8 patients. CONCLUSIONS: Injection at the BN is well tolerated and relatively easy to perform. Success rates may be better in females and in patients with neuropathic incontinence. Despite limited success it remains an option for all patients who are poor surgical candidates and those who want to avoid extensive BN reconstruction.

Relationship between ankle position and pelvic floor muscle activity in female stress urinary incontinence.
Chen CH, Huang MH, Chen TW, Weng MC, Lee CL, Wang GJ
Urology 2005 Jul 22;.

OBJECTIVES: To assess the influence of ankle position on pelvic floor muscle (PFM) activity in women with stress urinary incontinence. METHODS: A total of 39 women, ranging in age from 38 to 72 years and clinically diagnosed with stress urinary incontinence, participated in testing of PFM activity changes during various pelvic tilt angles created by horizontal, dorsiflexed, and plantar flexed ankle positions. PFM activity was measured by an intravaginal probe with surface electromyographic electrodes. An adjustable angle platform was used to set the ankle in each of the positions to create the various pelvic tilt postures. RESULTS: Significant differences were found in resting PFM activity between horizontal standing with the ankle in the neutral position and standing with the ankle in plantar flexion (P = 0.01). Patients with ankle dorsiflexion also had greater resting PFM activity than with ankle plantar flexion (P <0.01). Subjects showed significant changes in mean maximal PFM activity when standing with the ankle dorsiflexed and horizontal or in plantar flexion. CONCLUSIONS: A standing posture that includes various ankle positions effectively facilitates PFM activity through enhanced pelvic tilt. We recommend these ankle positions as an adjunctive option combined with PFM training for stress urinary incontinence.

Long-term results of suprapubic bladder neck closure for treatment of the devastated outlet.
O'connor RC, Stapp EC, Donnellan SM, Hovey RM, Tse VW, Stone AR
Urology 2005 Jul 22;.

OBJECTIVES: To assess the long-term success of suprapubic bladder neck closure in patients with irreparably damaged bladder outlets. METHODS: A cohort of 35 patients with intractable urinary incontinence secondary to severe posterior urethral/bladder neck damage underwent suprapubic bladder neck closure. Patients were assessed with regard to the success of procedure, as well as early and late complications. RESULTS: With a mean follow-up of 79 months (range 12 to 164), suprapubic bladder neck closure was successful in 29 (83%) of 35 patients. One revision of the bladder neck improved the success rate to 94% (33 of 35). Early and late complications, excluding bladder neck fistula, were reported in 3 (9%) and 5 (14%) of 35 patients, respectively. CONCLUSIONS: High success and acceptable complication rates can be achieved with suprapubic bladder neck closure for the treatment of severe urinary incontinence secondary to a devastated bladder outlet.

Urgency: the cornerstone symptom of overactive bladder.
Meijlink JM
Urology 2005 Jul;66(1):230-1; author reply 231.

Comprehensive Urodynamics Evaluation of 146 Men with Incontinence After Radical Prostatectomy.
Kielb SJ, Clemens JQ
Urology 2005 Jul 22;.

OBJECTIVES: To assess the filling, storage, and voiding urodynamic parameters in a large group of men with urinary incontinence after radical prostatectomy. METHODS: We reviewed the videourodynamics testing results for 146 consecutive men referred for urinary incontinence after radical prostatectomy. RESULTS: The mean patient age was 69.0 years (range 48 to 85), and the mean interval since radical prostatectomy was 4 years (range 4 months to 19 years). All but four tests were performed more than 12 months postoperatively. Stress urinary incontinence (SUI) was demonstrated in 139 men (95%), with a mean abdominal leak point pressure of 59 cm H(2)O. A statistically significant correlation was found between the leak point pressure and static urethral pressure profilometry measurements (r = 0.46, P <0.0001). The mean urethral pressure profilometry measurements in those with SUI were significantly lower than in those without (46.6 versus 69 cm H(2)O, P = 0.001). A total of 34 patients had diminished compliance or detrusor instability, but this was the sole finding in only 3. A hypocontractile detrusor response was seen in 49 patients, and 35 of these augmented voiding by abdominal straining. Patients with previous radiotherapy (n = 24) were more likely to have bladder outlet obstruction; the other parameters were similar to those in patients without radiotherapy. CONCLUSIONS: Incontinence after radical prostatectomy is caused by intrinsic sphincter deficiency in the vast majority of patients. Urethral pressure profilometry measurements correlated with the severity of SUI, as measured by abdominal leak point pressure. Bladder outlet obstruction may coexist with SUI in a significant portion of patients. During voiding, a hypocontractile detrusor response may be seen, but the clinical significance of this finding is unclear.

Long-term results of suprapubic bladder neck closure for treatment of the devastated outlet.
O'connor RC, Stapp EC, Donnellan SM, Hovey RM, Tse VW, Stone AR
Urology 2005 Jul 22;.

OBJECTIVES: To assess the long-term success of suprapubic bladder neck closure in patients with irreparably damaged bladder outlets. METHODS: A cohort of 35 patients with intractable urinary incontinence secondary to severe posterior urethral/bladder neck damage underwent suprapubic bladder neck closure. Patients were assessed with regard to the success of procedure, as well as early and late complications. RESULTS: With a mean follow-up of 79 months (range 12 to 164), suprapubic bladder neck closure was successful in 29 (83%) of 35 patients. One revision of the bladder neck improved the success rate to 94% (33 of 35). Early and late complications, excluding bladder neck fistula, were reported in 3 (9%) and 5 (14%) of 35 patients, respectively. CONCLUSIONS: High success and acceptable complication rates can be achieved with suprapubic bladder neck closure for the treatment of severe urinary incontinence secondary to a devastated bladder outlet.

The current role of the artificial urinary sphincter for the treatment of urinary incontinence.
Hussain M, Greenwell TJ, Venn SN, Mundy AR
J Urol 2005 Aug;174(2):418-24.

PURPOSE: The introduction of the artificial urinary sphincter (AUS) in 1972 was heralded as a revolution for the treatment of genuine stress incontinence. Initial enthusiasm was tempered by disappointment as complications occurred. The device has now been in routine clinical use for more than 30 years, and the indications and surgical principles involved in its use along with short-term and long-term outcomes are more clearly defined. Hence, we reviewed the literature to clarify the role of the AUS and offer a possible solution to its problems in the guise of a new sphincter. MATERIALS AND METHODS: A MEDLINE search was performed and all articles relating to the role of the AUS for the treatment of urinary incontinence were reviewed. RESULTS: The AMS 800 (American Medical Systems, Minnetonka, Minnesota) provides urinary continence in 73% of cases (range 61% to 96%) and it has a complication rate of 12% (range 3% to 33%) for mechanical failure, 4.5% to 67% for early infection/erosion, 15% for late erosion and 7% for delayed recurrent incontinence. The literature supports the role of the AUS as an important and reliable treatment modality for stress urinary incontinence and intrinsic sphincter deficiency. However, it is not suitable in all patients and its use for the management of hypermobility is controversial. Hence, careful patient selection according to indication is required with full preoperative counseling. CONCLUSIONS: Despite its reliability for achieving urinary continence the AMS 800 is not perfect. Newer devices, such as that being developed at our institution, may offer improved outcomes and decreased complication rates.

Is Urinary Incontinence a Barrier to Exercise in Women?
Nygaard I, Girts T, Fultz NH, Kinchen K, Pohl G, Sternfeld B
Obstet Gynecol 2005 Aug;106(2):307-314.

Objective: To describe the prevalence of urinary incontinence during exercise in women, estimate whether exercise intensity is related to leakage severity, and report women's assessments of incontinence as a barrier to exercise. Methods: Questionnaires were mailed to 5,130 women aged 18-60 years drawn from National Family Opinion research panels. Physical activity levels were assessed by the International Physical Activity Questionnaire. Urinary incontinence, defined as involuntary leakage in the last 30 days, was assessed with the Sandvik Severity Index and a global measure of bother. Prevalence estimates were adjusted via post-stratification weighting. Results: A total of 3,364 eligible women responded (68%), of whom 34.6% were insufficiently active (95% confidence interval [CI] 32.7-36.5%), 29.7% were sufficiently active (95% CI 27.9-31.5%), and 35.7% were highly active (95% CI 33.8-37.6%). Urinary incontinence prevalence was 34.3% (95% CI 32.5-36.1%). One in seven women experienced urinary leakage during physical activity; this was more common among highly active (15.9%) than less active women (11.8%) (P = .01). After adjusting for age, comorbidities, education, and race, women with very severe incontinence were 2.64 times (95% CI 1.25-5.55) more likely to be insufficiently active than continent women. Incontinence was a moderate or substantial barrier to exercise for 9.8% (95% CI 8.8-10.9%) of women. Of incontinent women, the proportion for whom incontinence was a moderate or substantial barrier to exercise increased with each severity category: 9.2%, slight; 37.8%, moderate; 64.6%, severe; and 85.3%, very severe (P < .01). Conclusion: Urinary incontinence is perceived as a barrier to exercise, particularly by women with more severe leakage. Level of Evidence: II-3.

Response of external urethral sphincter to high frequency biphasic electrical stimulation of pudendal nerve.
Tai C, Roppolo JR, de Groat WC
J Urol 2005 Aug;174(2):782-6.

PURPOSE: We optimized the axonal blocking effect of high frequency, biphasic stimulation on neurally evoked contractions of the external urethral sphincter (EUS) and further investigated the repeatability of the blocking effect during relatively long periods to evaluate any acute nerve damage. MATERIALS AND METHODS: Two stainless steel electrodes were positioned 5 to 10 mm apart on the decentralized pudendal nerve in alpha-chloralose anesthetized cats. The distal electrode was first tested at different frequencies (1 to 10 kHz) to search for the effective blocking frequency. At a fixed frequency (4, 6, 8 or 10 kHz) different stimulation intensities were then tested to evaluate their blocking effect. Sine waveform or biphasic pulses of a fixed pulse width were also tested. Finally, the proximal electrode was stimulated at 40 Hz for more than 40 minutes and during the same period the distal electrode (6 to 10 kHz) was repeatedly activated for 1-minute intervals in an attempt to block the EUS contraction induced by the proximal electrode. RESULTS: High frequency, biphasic stimulation (6 to 10 kHz) with a pulse width dependent on frequency is optimal to block EUS contractions compared with sine waveform or biphasic pulses of a fixed pulse width. Acute nerve damage caused by blocking stimulation was not observed on neurally evoked urethral pressure. CONCLUSIONS: Reversible block of EUS contractions by high frequency, biphasic stimulation of pudendal nerves is a potential method for suppressing detrusor-sphincter dyssynergia and improving voiding in spinal cord injured patients.

Role of sling integrity in the restoration of leak point pressure in the rat vaginal sling model.
Hijaz A, Daneshgari F, Huang X, Bena J, Liu G, Saffore L, Damaser M
J Urol 2005 Aug;174(2):771-5.

PURPOSE: We tested the hypothesis that cutting the sling at its suburethral section does not cancel its anti-incontinence effect. We also examined the long-term effects of the sling on bladder function in a recently validated rat model of vaginal sling. MATERIALS AND METHODS: Stress urinary incontinence was created in 60 female Sprague-Dawley rats by the previously established method of bilateral pudendal nerve transection. Under anesthesia 20 animals received a vaginal sling, 20 received a vaginal sling in which the suburethral portion of the sling was cut immediately after placement and 20 received a sham vaginal sling. Six weeks after the procedures leak point pressure was determined and a cystometrogram was done using anesthesia in each animal via a previously implanted suprapubic catheter. Kruskal-Wallis and pairwise separate rank multiple comparison tests were performed with a significance level of 0.05. RESULTS: The cut and intact slings increased leak point pressure similarly and these values were significantly higher than that of the sham sling (24.9 and 27.9 cm H2O, respectively, vs 20.7, p <0.0001). Peak micturition pressure was not significantly different among the 3 groups, indicating absent bladder outlet obstruction in the sling groups. Bladder compliance was significantly decreased 6 weeks after placement of a cut or intact sling compared with the sham sling (p = 0.007 and 0.05, respectively). CONCLUSIONS: An intact suburethral portion is not a requirement for sling effectiveness in the rat model of stress urinary incontinence. However, the sling procedure decreases bladder compliance. This may explain the observed voiding dysfunction associated with sling procedures.

The prevalence of urinary incontinence in community-dwelling married women: a matter of definition.
Albertsen PC
J Urol 2005 Aug;174(2):613; discussion 613.

Laparoscopic treatment of tension free vaginal tape erosion.
Siow A, Morris AR, Lam A
Aust N Z J Obstet Gynaecol 2005 Aug;45(4):333.

Tension-free vaginal tape: a prospective subjective and objective outcome analysis.
Richter HE, Norman AM, Burgio KL, Goode PS, Wright KC, Benton J, Varner RE
Int Urogynecol J Pelvic Floor Dysfunct 2005 Mar-Apr;16(2):109-13. Epub 2004 Oct 23.

The purpose of this prospective study was to describe the effects of the tension-free vaginal tape (TVT) procedure on subjective and objective outcomes. Eighty-seven women (aged 31-95 years) underwent a TVT procedure and were followed for up to 24 months using the Incontinence Impact Questionnaire (IIQ-7), Urogenital Distress Inventory (UDI-6), and a Patient Satisfaction Questionnaire. IIQ-7 scores improved from a mean 51.1 before surgery to 12.7 at 1 month (p<0.001) indicating reduced impact of incontinence on quality of life. UDI-6 scores declined from a mean 61.8 to 21.9 (p<0.001) indicating improvement in urinary symptoms. At 1 month, 91.2% of patients were satisfied. Improvements on all measures were maintained throughout follow-up. Urodynamic evaluation of 57 patients (mean: 15.0 months) showed that 91.2% had a negative stress test. Results indicate significant immediate and sustained improvement in incontinence impact and urinary symptoms, and a high rate of patient satisfaction and objective cure.

How urgent is urgency? A review of current methods of assessment.
Freeman RM
Int Urogynecol J Pelvic Floor Dysfunct 2005 Mar-Apr;16(2):93-5. Epub 2004 Nov 18.

The tension-free vaginal tape operation: a Swedish connection and Taiwan experience.
Wang AC
Int Urogynecol J Pelvic Floor Dysfunct 2005 Mar-Apr;16(2):91-2.

TVT erosion secondary to a twist in tape.
Dell JR, O'Kelley KR
Int Urogynecol J Pelvic Floor Dysfunct 2005 Mar-Apr;16(2):168-9. Epub 2004 Oct 20.

Mesh erosions through vaginal mucosa as well as the urethra following TVT procedures have been reported but are rare. We report a case of a 50-year-old woman who was found to have mesh erosion through vaginal mucosa 8 weeks after her TVT procedure, apparently secondary to a twist in the tape. Excision of approximately 5 mm of tape encompassing the twist was accomplished without difficulty, and allowed for complete healing of the vaginal mucosa and resolution of the patient's pain and irritative voiding symptoms.

Complications of synthetic graft materials used in suburethral sling procedures.
Tsui KP, Ng SC, Tee YT, Yeh GP, Chen GD
Int Urogynecol J Pelvic Floor Dysfunct 2005 Mar-Apr;16(2):165-7. Epub 2004 Oct 19.

Problems relating to the erosion of sling material, through either the vagina or the urethra, have been encountered with almost all kinds of synthetic sling materials. We present four unusual cases of women using different synthetic materials and the complications that occurred. The biopsies were examined histologically and analyzed for collagen and inflammatory reactions. Four patients who underwent suburethral slingplasty previously with different sling materials required surgical management for complications, including one intravesical Ethibond migration, vaginal mucosal mesh erosion in two patients, and one proximal urethral overcorrection with intravesical erosion. We reviewed the literature regarding the amount of mesh erosion and connective tissue reaction with synthetic materials. The efficiency of mesh removal was assessed. The four patients maintained urinary continence after urethrolysis and removal of the mesh. Fibrosis and severe inflammatory reactions were found in the connective tissue adjacent to the mesh as well as the Prolene mesh. Technically, it would be easier to remove the graft of patch sling if rejection or erosion occurs.

Assessing outcome after a modified vaginal wall sling for stress incontinence with intrinsic sphincter deficiency.
Costantini E, Mearini L, Mearini E, Pajoncini C, Guercini F, Bini V, Porena M
Int Urogynecol J Pelvic Floor Dysfunct 2005 Mar-Apr;16(2):138-46; discussion 146. Epub 2004 Oct 22.

Forty women with stress incontinence, intrinsic sphincter deficiency (ISD), associated or not with urethral hypermobility, a Valsalva leak point pressure (VLLP)<60 cmH(2)0 and a maximum urethral closure pressure<30 cmH(2)0 underwent in situ vaginal wall sling. The main modification to the technique was the use of two small Marlex meshes placed at the lateral edges of the sling. Outcome was assessed by pad use, surgical results and patients' satisfaction. Data of 39/40 patients were analyzed after a minimum follow-up of 1 year. After surgery 30/39 patients were completely dry (no pads), stress incontinence disappeared in 22/39, and 30/39 patients were satisfied with outcome. Reasons for dissatisfaction included recurrence of stress incontinence in three, infections in one and urge incontinence in five. Overall results are good given this category of patients. The vaginal wall sling can be recommended for patients with ISD because the results are promising, it corrects urethral hypermobility and, in our experience, it does not cause obstruction if correctly performed.

Prevalence, impact on the quality of life and pathophysiological determinants of nocturia in urinary incontinent women.
Massolt ET, Wooning MM, Stijnen T, Vierhout ME
Int Urogynecol J Pelvic Floor Dysfunct 2005 Mar-Apr;16(2):132-7. Epub 2004 Oct 21.

The objective of this study was to estimate the prevalence of nocturia in incontinent women in a urogynaecologic practice and its association with the quality of life and to estimate the prevalences of the pathophysiological categories among nocturics. From 1 January 2002, all patients with complaints of urinary incontinence were analysed according to a specific protocol: multichannel urodynamic testing, a 1-h International Incontinence Society (ICS) pad test and a 3-day frequency-volume (FV) chart. From 1 June 2002, subjects had to fill in a standardised quality of life questionnaire as well. Nocturia was defined as two or more micturitions per night calculated from the FV chart. Evaluable FV charts were received from 111 patients, and 72 patients completed the questionnaires correctly. The overall prevalence of nocturia was 48.6% (confidence interval: 43.9-53.3%). Nocturia had a negative impact on several aspects of the quality of life. The maximum voided volume was significantly (p=0.005) less in nocturics. The 24-h frequency was higher in nocturics (p=0.001). Nocturics lost more urine during the pad test (p=0.039). The multivariate logistic regression analysis showed that the greater the proportion of 24-h urine excreted at night, the greater the odds of having nocturia and that the lesser the maximum voided volume, the greater the odds of having nocturia. The majority (92.7%) of the nocturics can be classified into one of the responsible pathophysiologic categories: nocturnal polyuria in 51.2%, a low functional bladder capacity in 14.6%, a combination of both in 9.8%, polyuria in 4.9% and a combination of polyuria and nocturnal polyuria in 12.2% of the cases. Nocturia is a frequent symptom among urinary incontinent patients, with a negative impact on several aspects of the quality of life. With a FV chart, nocturics can be classified into one of the responsible pathophysiologic categories in the majority (92.7%) of the cases.

Incontinence-specific quality of life measures used in trials of treatments for female urinary incontinence: a systematic review.
Ross S, Soroka D, Karahalios A, Glazener CM, Hay-Smith EJ, Drutz HP
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jul 16;.

This systematic review examined the use of incontinence-specific quality of life (QOL) measures in clinical trials of female incontinence treatments, and systematically evaluated their quality using a standard checklist. Of 61 trials included in the review, 58 (95.1%) used an incontinence-specific QOL measure. The most commonly used were IIQ (19 papers), I-QoL (12 papers) and UDI (9 papers). Eleven papers (18.0%) used measures which were not referenced or were developed specifically for the study. The eight QOL measures identified had good clinical face validity and measurement properties. We advise researchers to evaluate carefully the needs of their specific study, and select the QOL measure that is most appropriate in terms of validity, utility and relevance, and discourage the development of new measures. Until better evidence is available on the validity and comparability of measures, we recommend that researchers consider using IIQ or I-QOL with or without UDI in trials of incontinence treatments.

Abdominal obesity is associated with stress urinary incontinence in Korean women.
Han MO, Lee NY, Park HS
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jul 15;.

This study investigated the relationship between abdominal obesity and stress urinary incontinence in Korean women. Women aged 30 and over, who visited the Department of Family Medicine of Asan Medical Center were recruited to participate in this study. Anthropometric measurements including body mass index (BMI) and waist circumference were taken, and associated factors of stress urinary incontinence was assessed by questionnaire. Stress urinary incontinence was significantly associated with physical work, vaginal delivery, and high waist circumference. In comparison with women in the lowest quartile of waist circumference, the odds ratios (OR) for stress urinary incontinence in women in the second, third, and fourth quartiles were increased significantly (1.79, 95% CI 1.07-2.98; 3.50, 95% CI 2.02-6.07; and 6.07, 95% CI 3.23-11.40, respectively). Our results indicate that high waist circumference may be a risk factor associated with stress urinary incontinence in women.

Prevalence and correlates of stress urinary incontinence during pregnancy: a survey at UNICAMP Medical School, Sao Paulo, Brazil.
Scarpa KP, Herrmann V, Palma PC, Riccetto CL, Morais SS
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jul 15;.

The aim of this study was to evaluate the prevalence of stress urinary incontinence (SUI) in women in the third trimester of pregnancy. In total, 340 patients attending the Antenatal Clinic at the State University of Campinas (UNICAMP) were interviewed. Overall, 170 women (50%) presented SUI. Stress urinary incontinence did not correlate to either body mass index (BMI) or race. There was no correlation between parity and SUI, but when considering distinct types of effort, urine leakage on coughing (P=0.0478) and laughing (P=0.0046) were highly more frequent in multiparous women. One hundred eleven women had had only vaginal deliveries and 68 delivered by cesarean section. There was no difference between the two groups concerning incontinence, but multiparous women (>/=4) who delivered exclusively vaginally demonstrated 2.0 times more chances to leak urine when compared to nulliparous women. This fact strongly suggests parity to be more relevant than delivery route as a risk factor to stress urinary incontinence. Nulliparous women presented with a high percentage (45.5%) of the symptom, emphasizing the elevated risk of SUI during first pregnancy.

Quality of life assessments in women operated on by tension-free vaginal tape (TVT).
Tomoe H, Kondo A, Takei M, Nakata M, Toma H
Int Urogynecol J Pelvic Floor Dysfunct 2005 Mar-Apr;16(2):114-8; discussion 108. Epub 2004 Sep 21.

The aim of the study was to evaluate quality of life (QOL) prospectively in women who undergo tension-free vaginal tape (TVT) operation for stress urinary incontinence. Sixty-six women who completed QOL questionnaires and a 2-year follow-up examination were included. Improvement of health-related QOL was assessed by the Incontinence Impact Questionnaire-7 (IIQ-7), the Urogenital Distress Inventory-6 (UDI-6), and two questions regarding patient satisfaction and de novo urge incontinence. Prior to surgery, patients complained most of stress symptoms followed by physical activities and emotional health. Postoperatively IIQ-7 and UDI-6 as a whole and all seven domains improved significantly (p<0.001). Scores of IIQ-7, UDI-6, and seven domains did not differ between the adult and the elderly groups. Of the patients 88% were much satisfied or satisfied with surgical outcomes. Incidence of de novo urge incontinence was 12%. It is concluded that the TVT procedure significantly improved health-related quality of life.

Comparison between porcine dermal implant (Permacol) and silicone injection (Macroplastique) for urodynamic stress incontinence.
Bano F, Barrington JW, Dyer R
Int Urogynecol J Pelvic Floor Dysfunct 2005 Mar-Apr;16(2):147-50; discussion 150. Epub 2004 Sep 18.

The objective of this study was to compare the efficacy of porcine dermal implant injection (Permacol) and silicone injection (Macroplastique) in the treatment of female urodynamic stress incontinence (USI) in a prospective randomized trial. Fifty women with urodynamically proven stress incontinence were recruited and randomised to receive either Permacol or Macroplastique injection. Twenty-five patients were enrolled in each case. An International Continence Society (ICS) standard 1-h pad test was carried out prior to the injection and a subjective analysis of incontinence made using a Stamey scoring system. In addition, a Kings College Hospital Quality of Health Questionnaire (KCQ) was completed. The women were followed up at 6 weeks and 6 months and the same methods used to gauge the success or failure of the operation. Preoperatively there were no significant differences in pad losses, Stamey score or King's score between the two groups. The mean age of the women was 61 years (range 28-80 years). At 6 weeks there were significant reductions in the mean and median values in pad losses, Stamey score and King's score in both Permacol and Macroplastique patients but the effects were more pronounced in Permacol patients than Macroplastique patients. Of the Permacol patients, 64% were improved on quantified pad losses out of which 60% were dry whereas 54% of Macroplastique patients were improved on pad losses of which 41.6% were dry. Of the Permacol patients, 64% and 60% had reduction in Stamey and KCQ score, respectively, whereas Macroplastique patients had 46% reduction in one or more grades of Stamey scores and 42% reduction in KCQ scores. At 6 months the results in the Permacol patients appeared to be sustained but not for Macroplastique patients. This study has shown that Permacol injection when used as a urethral bulking agent appears to have a higher cure rate for urodynamic stress incontinence than Macroplastique and these results persist until the follow-up period of 6 months. The use of Permacol injection is an attractive alternative in the treatment of urodynamic stress incontinence.

Stoller afferent nerve stimulation in woman with therapy resistant over active bladder; a 1-year follow up.
Nuhoglu B, Fidan V, Ayyildiz A, Ersoy E, Germiyanoglu C
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jul 28;.

Aim: In this prospective observational study, we investigated the efficacy of Stoller afferent nerve stimulation (SANS) in subjects with overactive bladder who failed anticholinergic treatment.Methods: Thirty-five subjects with overactive bladder who failed therapy with oxybutynin participated in this study. Treatment (n=35) was given once a week for 30 minutes for overall 10 weeks. In treatment, SANS device (Urosurge((R))) was used. Subjects were assessed with 3-day voiding diary, SEAPI quality of life questionnaires and cystometry before therapy after completion of therapy and at one-year follow-up.Results: In 54% (n=19) of subjects complete recovery was obtained after treatment. Urgency and SEAPI were reduced significantly whereas urine volume increased significantly (p<0.01). Complete recovery was maintained in eight of the 19 subjects at one year.Conclusions: SANS treatment has a short-term positive effect in patients with resistant overactive bladder. However, it was also established that efficacy was maintained at 1 year in only 23% of subjects.

Perineal ultrasound evaluation of the urethrovesical junction angle and urethral mobility in nulliparous women and women following vaginal delivery.
Costantini S, Nadalini C, Esposito F, Valenzano MM, Risso D, Lantieri P, Mistrangelo E
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jul 26;.

The objective of this study was to demonstrate the differences in the urethrovesical junction angle and urethral mobility by means of perineal ultrasounds in women following vaginal delivery with respect to nulliparous women. We have enrolled 34 women, 12 nulliparous (Group A) and 22 women in the post-partum period (Group B). The ultrasounds were employed to measure the urethrovesical junction angle ("urethro-pelvic" angle) and the urethral mobility. Data obtained show that the urethro-pelvic angle is narrower in Group A (97.3 degrees ) with respect to Group B (112.5 degrees ). Urethral mobility while coughing was significantly higher in Group B (30.4 degrees ) with respect to Group A (-2 degrees ). This study demonstrates the difference in the urethral support at rest and during cough in nulliparous versus recently delivered parous women.

Reasons for and treatment of surgical complications with alloplastic slings.
Petri E, Niemeyer R, Martan A, Tunn R, Naumann G, Koelbl H
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jun 18;.

Suburethral slings with tension-free vaginal tapes have become a popular treatment for stress urinary incontinence. Case reports on singleton complications are numerous and of clinical interest. Four European centers for urogynecology report on 328 surgical reinterventions after tension-free slings. Poor surgical technique is the most frequent cause of problems (45%), followed by incorrect indication (38%). The most frequent symptom is functional or anatomical outlet obstruction; perforation or penetration and defect healing are rare, but, apparently more frequent than described in studies or follow-up series previously.

Changes in urethral resistance in the presence of detrusor activity.
Chaliha C, Digesu GA, Salvatore S, Khullar V
Int Urogynecol J Pelvic Floor Dysfunct 2005 Aug 3;.

This was a prospective study performed at two tertiary referral teaching hospitals. The aim of our study was to investigate changes in urethral resistance with the bladder full compared to empty in women with different urodynamic diagnoses. Consecutive women attending the urodynamic clinics were asked to undergo urethral retro-resistance pressure (URP) measurement with the bladder empty and then full. 106 women were recruited - 25 had normal urodynamic studies, 17 had detrusor overactivity, 57 had urodynamic stress incontinence and 7 had mixed incontinence. Women with urodynamic stress incontinence have lower URP values than women with normal urodynamic studies or those with detrusor overactivity with the bladder empty (p = 0.01). Women with normal urodynamic studies and urodynamic stress incontinence showed a statistically significant rise in URP with the bladder full (p = 0.013 and p = 0.003, respectively). In women with detrusor overactivity, the converse was seen - URP was significantly lower with the bladder full compared to empty (p = 0.004). Our study has shown that bladder filling alters URP measurement and bladder volume should be standardised for reporting URP.

TVT versus SPARC: comparison of outcomes for two midurethral tape procedures.
Gandhi S, Abramov Y, Kwon C, Beaumont JL, Botros S, Sand PK, Goldberg RP
Int Urogynecol J Pelvic Floor Dysfunct 2005 Aug 4;.

To compare the subjective and objective cure rates in women who underwent either the SPARC or the TVT midurethral sling for the treatment of stress urinary incontinence. This retrospective study included all 122 consecutive women undergoing a TVT or SPARC midurethral sling procedure for objective stress urinary incontinence between January 2000 and March 2003 at the Evanston Continence Center. Primary outcomes were subjective and objective stress incontinence cure rates. Subjects underwent multichannel urodynamics preoperatively and 14 weeks postoperatively, and stress testing at last follow-up. The two groups were compared using univariate and multivariate analyses. Seventy-three subjects underwent a TVT and 49 subjects had a SPARC procedure. There were no statistical differences in demographic factors between the two groups. Subjects undergoing SPARC were more likely to void by Valsalva effort. One hundred and seven women returned for objective postoperative evaluation after surgery. The TVT procedure was associated with higher subjective (86 vs. 60%, P=0.001) and objective (95 vs. 70%, P<0.001) stress incontinence cure rates. There was no difference between the TVT and SPARC groups in the resolution of subjective and objective urge urinary incontinence. TVT was associated with a higher stress urinary incontinence cure rate than SPARC in this retrospective study. As new midurethral sling products are introduced, prospective randomized controlled trials should be conducted to evaluate their relative efficacy and safety.

Urinary incontinence in cystic fibrosis.
Dodd ME, Langman H
J R Soc Med 2005;98 Suppl 45:28-36.

Pathogenesis of urethral funneling in women with stress urinary incontinence assessed by introital ultrasound.
Tunn R, Goldammer K, Gauruder-Burmester A, Wildt B, Beyersdorff D
Ultrasound Obstet Gynecol 2005 Aug 5;.

OBJECTIVE: The incidence of urethral funneling (UF) seen in women with stress urinary incontinence (SUI) during straining is reported to range from 18.6% to 97.4%. Its morphologic basis is unknown. The aim of the present study was to determine whether SUI patients with and without UF differ in terms of history, urodynamic results and magnetic resonance imaging (MRI) findings. PATIENTS AND METHODS: Fifty-four women (mean age 52 +/- 11 years) with a history of SUI confirmed by clinical and urodynamic findings were included in the study. UF was demonstrated by introital ultrasound performed at a bladder filling volume of 300 mL during maximal straining. MRI for assessment of the urethra, levator ani muscle and endopelvic fascia was performed using axial proton-density-weighted sequences. RESULTS: UF was demonstrated by introital ultrasound in 59% of the patients with SUI (Group 1) and was absent in 41% (Group 2). There were no differences between the two groups in mean age (P = 0.208), the incidence of mild prolapse of the anterior vaginal wall (Aa, Ba; stage I; P = 0.741), and urodynamic parameters (urethral closure pressure at rest; P = 0.507). The percentages of nulliparous and parous women were 22% and 78% in Group 1 and 54% and 46% in Group 2 (P = 0.013). The two groups did not differ in the MRI demonstration of morphologic defects of the urethra, levator ani muscle and endopelvic fascia or of combined defects. CONCLUSIONS: The results of the present study did not elucidate the pathogenesis of UF. The demonstration of UF crucially depends on the examination technique employed. Copyright (c) 2005 ISUOG. Published by John Wiley & Sons, Ltd.

Questionnaire survey on female urinary frequency and incontinence.
Tomoe H, Sekiguchi Y, Horiguchi M, Toma H
Int J Urol 2005 Jul;12(7):621-30.

Background : Urinary incontinence is a well-known bothersome symptom in women, which may cause physical and psychological problems. We conducted a questionnaire survey on female urinary incontinence to investigate the disease's impact on the quality of life (QoL), the reasons women don't seek medical attention and the information they wished to obtain. Patients and methods : From March to October 2002, a member of the Professional Women's Coalition for Sexuality and Health distributed a questionnaire about urinary frequency and urinary incontinence to women who were attending the lectures hosted by the group. Results : We analysed 262 questionnaires: 158 people belonged to the Stress Urinary Incontinence (SUI) Group, 36 to the Overactive Bladder (OAB) Group, 22 to the Urinary Frequency (UF) Group and 18 to the Normal Group. 'Going out' was most influenced in all three groups with symptoms in their daily life. Compared with the Normal or SUI Group, the QoL in those belonging to the OAB and UF Groups was more deteriorated. The medical institution check-up rate in the SUI Group was the lowest at 7.1%, bringing down the overall consultation rate to 13.5%. More than 70% of respondents who didn't have a check-up said that they did not think it was a problem serious enough to require consultation. Conclusions : Urinary incontinence and frequency impairs women's QoL. It is important to provide information on these diseases and to provide medical treatments that cater to the needs of individual patients.

Surgical management of vaginal wound healing defects after tension-free vaginal tape placement.
Lee T, Kim JS, Jung JK, Lee HJ
Int J Urol 2005 Jul;12(7):699-701.

The use of tension-free vaginal tape (TVT) made of polypropylene mesh carries the risk of causing vaginal wound healing defects, which are usually detected within 4 weeks of operation. We present three cases of vaginal wound healing defects after TVT procedures. These defects were managed using surgical techniques aimed at preserving the mesh, but all failed. There are many options for dealing with the problems of vaginal wounds following TVT. These include further observation, mesh removal, suturing the wound, or using tissue flaps to cover it. However, the latter two options cannot be recommended as they usually fail.

Intravesical tape erosion following the tension-free vaginal tape procedure for stress urinary incontinence.
Negoro H, Kawakita M, Imai Y
Int J Urol 2005 Jul;12(7):696-8.

We report a case of intravesical tape erosion which occurred 6 months after the tension-free vaginal tape (TVT) procedure, which was successfully treated by partial tape removal. A 75-year-old woman, who had complained of recurrent cystitis after TVT procedure, was referred to Kobe City General Hospital in August 2003. The intravesical tape erosion was revealed by cystoscopy and computed tomography, and the tape was removed with a retropubic approach. The recurrent cystitis has been cured and the stress urinary incontinence has not recurred. The intravesical tape erosion was rare, with only seven reported cases including the present case.

Overactive bladder.
Thacker HL, Paraiso M
Cleve Clin J Med 2005 Jul;72(7):544; author reply 544-5.

Persistence with antimuscarinic therapy in patients with overactive bladder.
Haab F, Castro-Diaz D
Int J Clin Pract 2005 Aug;59(8):931-7.

Overactive bladder (OAB) is a chronic condition, which impacts patients' health and quality of life. The primary symptoms of OAB are distressing and may interfere with work, psychosocial and sexual functioning. OAB also is associated with increased risk of urinary tract infections, fractures from falls, skin infections and depression. Patient's concerns about the effects of incontinence on lifestyle highlight the need to restore continence. The mainstay of treatment is antimuscarinic drug therapy, which may often produce only modest reductions in OAB symptoms and may be accompanied by bothersome adverse effects, leading to poor adherence to prescribed medications. Successful treatment of OAB depends on persistence with the prescribed medication, and efficacy and tolerability are key influencers of persistence. New antimuscarinic agents are now available for treating OAB that significantly improve symptoms of incontinence, urgency and frequency with few adverse effects. An improved efficacy and tolerability profile should result in greater patient satisfaction and persistence with therapy during long-term therapy.

Contemporary therapy for overactive bladder.
Chapple C
Int J Clin Pract 2005 Aug;59(8):872-3.

Leaking urine prior to pregnancy: a risk factor for postnatal incontinence.
Stainton MC, Strahle A, Fethney J
Aust N Z J Obstet Gynaecol 2005 Aug;45(4):295-9.

Abstract Background: The prevalence of 30% for postnatal urinary incontinence is a major women's health issue. The majority of studies to date are retrospective, and evidence about contributing factors is inconsistent. Aims: To identify women at risk for postnatal urinary incontinence following the first pregnancy and birth. Study population and methods: One hundred and twenty four women participated in a longitudinal study. Questionnaires and interviews were conducted at 14, 24 and 38 weeks' gestation and 24-72 h, 6-8 weeks and 6-18 months postnatal. These, along with chart audits for pregnancy, labour and delivery factors and demographics, formed the database for logistic regression. Results: The only variable to emerge as a key indicator for predicting those women most at risk for developing postnatal urine leakage was a history of urinary leaking prior to the first pregnancy. Women with this history were 4.14 times more at risk of leaking urine 1 year after giving birth than women without previous urine leakage (P = 0.02). There was a pattern of leaking urine across the childbearing experience that suggests some resolution by 12 months regardless of parity. Length of second stage labour and method of delivery were the only labour and delivery variables to show significant differences between leaking and not leaking urine at 12 months postnatal. Conclusion: Women who leak urine before their first pregnancy can be identified during early antenatal care as those at risk for postnatal urinary incontinence. Further research to test preventive measures is needed.

Concomitant tension-free vaginal tape for urinary incontinence during laparoscopic hysterectomy.
Lin YH, Liang CC, Lo TS, Soong YK, Chang SD, Chang YL
Aust N Z J Obstet Gynaecol 2005 Aug;45(4):304-7.

Abstract Objective: To evaluate the effectiveness and safety of placing tension-free vaginal tape (TVT) during a laparoscopically assisted vaginal hysterectomy (LAVH) in women with stress urinary incontinence and coexistent benign gynaecological disease. Design: Retrospective clinical study (Canadian Task Force classification II-2). Sample: Thirty patients diagnosed with genuine stress incontinence and benign gynaecological disease were studied. Methods: All the patients underwent LAVH and concomitant TVT procedure. Results: There was no significant difference in urodynamic parameters before and after surgery. All patients were followed postoperatively for a mean duration of 24.6 +/- 11.5 months (range 12-40). The cure rate of stress urinary incontinence was 96.7%. Conclusions: Concomitant placement of tension-free vaginal tape during a laparoscopically assisted vaginal hysterectomy proved to be an efficacious and safe procedure for women with benign gynaecological disease and coexistent stress urinary incontinence.

A Comparison of the Efficacy and Tolerability of Solifenacin Succinate and Extended Release Tolterodine at Treating Overactive Bladder Syndrome: Results of the STAR Trial.
Chapple CR, Martinez-Garcia R, Selvaggi L, Toozs-Hobson P, Warnack W, Drogendijk T, Wright DM, Bolodeoku J
Eur Urol 2005 Jun 27;.

OBJECTIVE: To compare two new generation antimuscarinics at their recommended doses for treatment of overactive bladder syndrome (OAB). METHODS: A prospective, double blind, double-dummy, two-arm, parallel-group, 12-week study was conducted to compare the efficacy and safety of solifenacin 5 or 10mg and tolterodine extended release (ER) 4mg once daily in OAB patients. After 4 weeks of treatment patients had the option to request a dose increase but were dummied throughout as approved product labelling only allowed an increase for those on solifenacin. RESULTS: Solifenacin, with a flexible dosing regimen, showed greater efficacy to tolterodine in decreasing urgency episodes, incontinence, urge incontinence and pad usage and increasing the volume voided per micturition. More solifenacin treated patients became continent and reported improvements in perception of bladder condition assessments. The majority of side effects were mild to moderate in nature, and discontinuations were comparable and low in both groups. CONCLUSIONS: Solifenacin, with a flexible dosing regimen, was found to be superior to tolterodine ER with respect to the majority of the efficacy variables.

Treatment of Overactive Bladder in the Older Patient: Pooled Analysis of Three Phase III Studies of Darifenacin, an M(3) Selective Receptor Antagonist.
Foote J, Glavind K, Kralidis G, Wyndaele JJ
Eur Urol 2005 Jun 27;.

AIM: To evaluate the efficacy, tolerability and safety of darifenacin, an M(3) selective receptor antagonist, in the subgroup of older patients from a pooled analysis of three phase III, multicentre, randomized, double-blind clinical trials in patients with overactive bladder (OAB). PATIENTS AND METHODS: 317 patients aged >/=65 years with OAB symptoms (urge incontinence, urgency and frequency) received up to 12 weeks' oral treatment with darifenacin 7.5mg or 15mg once daily or matching placebo. Efficacy was evaluated from daily electronic diary records. Safety endpoints included withdrawal rates and treatment-related adverse events. RESULTS: Darifenacin treatment of patients aged >/=65 years was associated with a dose-related, significant improvement of all the major symptoms of OAB. At week 12, the median reduction in incontinence episodes/week was greater with darifenacin 7.5mg or 15mg than in the corresponding placebo arms (66.7% vs. 34.8% and 75.9% vs. 44.8%, respectively, both p<0.001). Both doses were also significantly superior to placebo in improving micturition frequency (both p<0.001), bladder capacity (volume voided) (darifenacin 7.5mg, p=0.018, darifenacin 15mg, p<0.001), and the frequency of urgency episodes (both p<0.001). Darifenacin was well tolerated. The most common treatment-related adverse events were dry mouth (7.5mg, 20.6%; 15mg, 30.9%; placebo, 4.5%) and constipation (7.5mg, 18.6%; 15mg, 23.6%; placebo, 6.4%), typically mild or moderate. Use of constipation remedies (laxatives, stool softeners or fibre supplements) was low and similar between groups (7.5mg, 10.3%; 15mg, 16.4%; placebo, 10.0%). There were few withdrawals due to treatment-related adverse events (7.5mg, 1.0%; 15mg, 9.1%; placebo, 2.7%), and no nervous system or cardiovascular safety concerns. CONCLUSIONS: The results demonstrate excellent efficacy, tolerability and safety with darifenacin 7.5mg and 15mg once-daily treatment for OAB in older patients.

An Open, Multicentre Study of NASHA/Dx Gel (Zuidextrade mark) for the Treatment of Stress Urinary Incontinence.
Chapple CR, Haab F, Cervigni M, Dannecker C, Fianu-Jonasson A, Sultan AH
Eur Urol 2005 Jun 17;.

OBJECTIVE: The Zuidextrade mark system facilitates non-endoscopic urethral injection for stress urinary incontinence (SUI). It comprises four pre-filled syringes of non-animal stabilised hyaluronic acid/dextranomer (NASHA/Dx) gel and an Implacertrade mark device. This open, 12-month study was performed to evaluate the safety and efficacy of this system in women with SUI. METHODS: Patients were aged >/=18 years with a history of SUI for >/=12 months (hypermobility and/or intrinsic sphincter deficiency), had failed prior non-invasive therapy and were invasive-therapy naive. Up to two treatments with NASHA/Dx gel were permissible (re-treatment was offered at week 8). Positive response to treatment was defined as a reduction in provocation test leakage of >/=50% compared with baseline. Efficacy was also measured by 24-hour pad weight test leakage, and number of incontinence episodes/24hours. RESULTS: A total of 142 patients were enrolled, with a mean age of 55.7 years. The response rate was 78% at week 12, and 77% at month 12. Significant reductions in median provocation test leakage, 24-hour pad-weight test leakage and number of incontinence episodes/24hours were observed at all time-points. At month 12, the median decreases from baseline in these three variables were 93%, 89% and 67%, respectively. Treatment-related adverse events were of a nature expected with urethral injection - most were transient, and of mild or moderate intensity. CONCLUSIONS: Treatment with NASHA/Dx gel produced large, statistically significant reductions in urinary leakage sustained over 12 months and was well tolerated. These findings suggest that NASHA/Dx gel could be considered as an early intervention in treatment-naive cases of SUI.

Propiverine versus Tolterodine: Efficacy and Tolerability in Patients with Overactive Bladder.
Junemann KP, Halaska M, Rittstein T, Murtz G, Schnabel F, Brunjes R, Nurkiewicz W
Eur Urol 2005 Jun 17;.

OBJECTIVES: Propiverine and tolterodine were compared with respect to efficacy, tolerability and impact on the quality of life in the treatment of patients with idiopathic detrusor overactivity. METHODS: In a randomised, double-blind, multicentre clinical trial, patients with idiopathic detrusor overactivity were treated with 15mg propiverine twice daily or 2mg tolterodine twice daily over a period of 28 days. The maximum cystometric capacity was determined at baseline and after 4 weeks of therapy. The difference of both values was used as the primary endpoint. Secondary endpoints were voided volume per micturition, evaluation of efficacy (by the investigator), tolerability, post void residual urine, and quality of life. RESULTS: The mean maximum cystometric capacity increased significantly (p<0.01) in both groups. The volume at first urge and the frequency/volume chart parameters also showed relevant improvements during treatment. 42/100 patients in the propiverine group and 43/102 in the tolterodine group experienced adverse events. The most common adverse event, dry mouth, occurred in 20 patients in the propiverine group and in 19 patients in the tolterodine group. The scores for the quality of life improved comparably in both groups. CONCLUSION: The study demonstrates comparable efficacy, tolerability, and improvement in the quality of life of 15mg propiverine twice-daily and 2mg tolterodine twice-daily in the treatment of the symptoms of idiopathic detrusor overactivity.

Luminal nitric oxide in ileal reservoirs for continent cutaneous diversion or orthotopic bladder reconstruction.
Pazooki D, Kilander A, Lindholm E, Olin AC, Tornqvist H, Ung KA, Jonsson O
Eur Urol 2005 Jul;48(1):140-4. Epub 2004 Dec 27.

OBJECTIVES: To measure mucosal inflammation as reflected in nitric oxide (NO) production in ileal reservoirs for the storage of urine and to correlate it with the growth of bacteria as well as CRP. METHODS: Intraluminal gas NO concentrations were determined using the chemoluminescence technique in 25 patients with continent cutaneous ileal reservoirs (Kock pouch) and 12 patients with orthotopic bladders (hemi-Kock or T-pouch). NO concentrations were determined in both intestinal reservoir gas and silicon catheter balloon gas. Urinary culture and blood CRP determinations were performed. RESULTS: NO concentrations in reservoir gas were higher than in silicon catheter balloons. Bacteriuria was associated with approximately 20 times higher NO concentrations than sterile urine. NO concentrations did not differ between continent cutaneous reservoirs or orthotopic bladders when due attention was paid to variance in the rate of bacteriuria. Elevated CRP was associated with higher NO concentrations. Bacteriuria with acinetobacter, enterococci and pseudomonas appeared to cause comparatively lower NO concentrations. The inflammatory response of reservoir walls to bacteriuria did not decrease with time. CONCLUSIONS: Urine in itself causes much less intestinal wall inflammation than bacteriuria, as reflected in NO production. High CRP values are associated with high NO concentrations. The inflammatory response varies with the bacterial specimens.

Urethral sensitivity in incontinent women.
Kinn AC, Nilsson BY
Eur Urol 2005 Jul;48(1):116-20. Epub 2005 Mar 8.

OBJECTIVES: The aim of this study was to ascertain whether frequent voiding and urge incontinence are associated with supersensitivity to electrical stimulation in the posterior urethra. METHODS: Current perception thresholds (CPT) were tested at four stimulus frequencies (1, 3, 20, and 100Hz; duration 0.5ms) using a square-wave constant current electrical stimulator connected to ring electrodes on a urethral catheter. The strength of the current at the first tingling sensation was regarded as the CPT. CPT analysis and cystometry were performed on 61 women (ages 28-89 years). RESULTS: CPTs were significantly higher at lower than at elevated stimulus frequencies, and they were also generally higher in old than in younger patients. Seven women repeated the CPT test after two months, and the thresholds were unchanged. There were no significant differences in sensitivity between patient groups with stress incontinence, urge, or mixed symptoms. Moreover, CPT was not significantly related to bladder volume at first sensation of filling. CONCLUSION: Measuring CPT is an easy and reproducible method of testing urethral sensibility, but our results do not support the suspicion that urethral hypersensitivity is involved in increased voiding frequency and urge incontinence.

Comparison of symptom severity and treatment response in patients with incontinent and continent overactive bladder.
Michel MC, de la Rosette JJ, Piro M, Schneider T
Eur Urol 2005 Jul;48(1):110-5. Epub 2004 Dec 15.

PURPOSE: Two thirds of patients with overactive bladder (OAB) are continent, but our knowledge on the treatment of the syndrome is largely based on studies with incontinent patients. Therefore, we have explored baseline symptoms and treatment responses to tolterodine in continent relative to incontinent OAB patients. MATERIALS AND METHODS: Data from an open-label, observational study involving 3824 patients with OAB symptoms were analyzed for baseline symptoms and alterations thereof upon a 9 months treatment with 4mg q.d. tolterodine ER. RESULTS: Baseline symptoms (number of urgency episodes, total urination frequency, daytime frequency, nocturia, and three scales of OAB severity) were similar in 1147 continent and 2571 incontinent patients, the latter having 4.8+/-3.7 incontinence episodes per 24h. Tolterodine ER-induced reduction of OAB symptoms was very similar in both groups of patients. CONCLUSIONS: The severity of OAB in continent patients can be similar to that in incontinent ones. Symptom improvement upon treatment with tolterodine ER is very similar in both groups. We propose that continent patients may similarly deserve treatment with a muscarinic receptor antagonist as incontinent ones.

Prevalence of the Overactive Bladder Syndrome by Applying the International Continence Society Definition.
Temml C, Heidler S, Ponholzer A, Madersbacher S
Eur Urol 2005 Jun 15;.

PURPOSE: To determine the prevalence of the overactive bladder (OAB) syndrome in an urban population by using the International Continence Society (ICS) definition and to determine its impact on quality of life and sexual function. METHODS: Women and men participating in a health screening project in the area of Vienna completed the Bristol Lower Urinary Tract Symptoms (LUTS) questionnaire. To assess the prevalence of OAB the 2002 ICS definition was applied. In addition, all participants underwent a detailed health examination, including physical assessment, evaluation of life style factors, laboratory study and urinalysis. RESULTS: A total of 1199 men and 1219 women aged 20-91 years were analysed. The prevalence of OAB in men (48.5+/-13.1 years) was 10.2% (OAB(dry): 8.4%; OAB(wet): 1.8%) and 16.8% in women (49.5+/-13.5 years; OAB(dry):10.3%; OAB(wet): 6.5%). In women, the prevalence of OAB(dry) remained fairly stable over 6 life decades, while OAB(wet) increased substantially after the age of 40 years. In men OAB(wet) and OAB(dry) increased after the third life decade. In men with OAB, 48% did not report a negative impact on quality of life, 36% had minimal, 9.8% moderate and 2.5% severe impairment; the respective percentages for women were 53%, 33%, 7.3% and 6.3%. OAB(wet) had a more profound impact on quality of life. A negative impact of OAB on sexuality was reported by 24% of men and 31% of women. CONCLUSION: The high prevalence of OAB in this population, its negative impact of quality of life and sexuality underline the importance of this syndrome.

Female Urinary Incontinence in the West of Turkey: Prevalence, Risk Factors and Impact on Quality of Life.
Kocak I, Okyay P, Dundar M, Erol H, Beser E
Eur Urol 2005 Jun 14;.

OBJECTIVES: To determine the prevalence and risk factors of urinary incontinence (UI), and to assess its impact on quality of life (QOL) in Turkish women. METHODS: In this cross-sectional study, 1012 women aged over 18 years were interviewed through a questionnaire including 'International Consultation on Incontinence Questionnaire Short Form'. RESULTS: The overall prevalence of UI was 23.9% (n=242). Among these women, 62 (25.6%) had urge, 80 (33.1%) stress and 100 (41.3%) mixed type UI. The prevalence rate increased with advancing age. Eighty-nine women (36.8%) stated to have urinary leakage at least once a day or more, while 153 (63.2%) women were experiencing less than twice a week. UI was significantly associated with fecal incontinence, hypertension, history of nocturnal enuresis, and recurrent urinary tract infections. Overall, 211 (87.2%) women stated that UI have negative impact on the QOL. This effect remained mostly at the mild or moderate level. Although many (87.2%) had intention for medical assistance, only a few (14.9%) had realized it. Women with urge UI and aged 40 to 50 years looked for more assistance than others. CONCLUSIONS: UI affect approximately one of four Turkish women. The results emphasize the need for taking preventive measures and policy development for UI.

Urodynamic Effect of Intravesical Resiniferatoxin in Patients with Neurogenic Detrusor Overactivity of Spinal Origin: Results of a Double-Blind Randomized Placebo-Controlled Trial.
Silva C, Silva J, Ribeiro MJ, Avelino A, Cruz F
Eur Urol 2005 Jun 13;.

OBJECTIVES: To access by a placebo-controlled randomized clinical trial the effect of intravesical resiniferatoxin on the urodynamic parameters of patients with neurogenic detrusor overactivity (NDO) of spinal origin. METHODS: Twenty eight patients with spinal NDO were randomised to receive intravesically 50nM resiniferatoxin dissolved in 10% ethanol in saline (RTX group) or only the vehicle solution (placebo group). Filling cystometries were obtained in each patient at 1 month and 1 week before and at 1 and 3 months after treatment. In a visual analog scale patients were asked to estimate the discomfort induced by treatment. Patients were also persuaded to fill a micturition chart during the 3 days preceding each cystometry. RESULTS: The RTX and placebo groups were homogeneous in what respects the volume to first involuntary detrusor contraction (FDC, 143+/-95ml and 115+/-58ml, respectively, p=0.3) and maximal cystometric capacity (MCC, 189+/-99ml and 198+/-111ml, respectively, p=0.8). At the end of the study, mean FDC and MCC in the RTX group, 184+/-93ml and 314+/-135ml, respectively were significantly higher than in the placebo group, 115+/-61ml (p=0.03) and 204+/-92ml (p=0.02). In the visual analogue scale discomfort caused by treatment was similar. Only 10 patients in the RTX group and 6 patients in the placebo group completed adequately the micturition chart. Mean frequency and urinary incontinence decreased significantly only in the RTX group. CONCLUSIONS: Intravesical RTX is effective in increasing bladder capacity in spinal NDO patients. Such increment might contribute to decrease urinary frequency and incontinence of these patients.

Overactive bladder: achieving a differential diagnosis from other lower urinary tract conditions.
Nitti V, Taneja S
Int J Clin Pract 2005 Jul;59(7):825-30.

Summary Overactive bladder (OAB) is a debilitating condition characterised by an urgent need to urinate (urgency), often with urinary frequency and, in some cases, urgency incontinence and nocturnal frequency. Patients often adopt complex adaptive behaviours to cope with their symptoms as OAB can compromise all dimensions of a patient's quality of life. Most OAB patients present initially to their primary care physician. Diagnosis is based on presenting symptomatology and does not require any invasive tests. Direct questioning about symptoms is important in achieving a differential diagnosis. The most common condition to be considered when working towards a differential diagnosis is a urinary tract infection (UTI). However, some physicians have expressed concerns about identifying the small number of cases where bladder cancer is a potential underlying aetiology for the symptoms of OAB. In this review, we examine the prevalence and patient profiles for these bladder conditions and their presenting symptomatology. We also review tests that may be recommended to exclude a diagnosis of UTI or bladder cancer and present a diagnostic algorithm suitable for office-based primary care practice.

Changes in overactive bladder symptoms after discontinuation of successful 3-month treatment with an antimuscarinic agent: a prospective trial.
Choo MS, Song C, Kim JH, Choi JB, Lee JY, Chung BS, Lee KS
J Urol 2005 Jul;174(1):201-4.

PURPOSE: We measured changes in overactive bladder (OAB) symptoms after the discontinuation of successful 3-month treatment with an antimuscarinic agent and the pretreatment factors that contributed to re-treatment. MATERIALS AND METHODS: A total of 68 women who reported improvement in OAB symptoms after 4 weeks of treatment with 20 mg propiverine hydrochloride daily were prospectively enrolled in a protocol consisting of 8 more weeks of medication and a 4-week discontinuation period. Frequency-volume charts were assessed before treatment, after 12 weeks of therapy and 4 weeks after discontinuation along with a questionnaire assessing satisfaction with treatment and desire for further treatment. The Indevus Urgency Severity Score was used to quantify the degree of urgency and changes during treatment. Changes in frequency, nocturia, and urgency score at 12 and 16 weeks were evaluated. Pretreatment factors leading to re-treatment were determined, including patient characteristics, voiding symptom parameters and urodynamic indexes. RESULTS: OAB symptoms at 16 weeks (4 weeks after the cessation of antimuscarinic medication) were improved compared with baseline but worse than after 12 weeks. At baseline, and 12 and 16 weeks mean daily frequency was 11.2, 7.3 and 8.3, mean nocturia frequency was 1.6, 0.4 and 0.8, and the urgency score was 1.7, 0.6 and 1.2, respectively. The re-treatment rate was 35.3%. Patients in the re-treatment group were significantly older (58.8 vs 47.3 years, p <0.001) and had higher initial urgency scores (1.9 vs 1.6, p = 0.034) than those requiring no further treatment. Of 23 patients who underwent a urodynamic study those without detrusor overactivity (DO) maintained significant improvement regarding frequency after cessation of medication, whereas those with DO did not, although their frequency was improved compared with baseline (p = 0.02). The re-treatment rate was higher in patients with DO but the difference was not statistically significant (60.9% vs 39.1%, p = 0.45). CONCLUSIONS: Of patients 35% sought re-treatment 1 month after the discontinuation of antimuscarinic therapy. Patients older than 55 years or those with severe urgency may more frequently receive re-treatment and patients with DO may experience more rapid symptom recurrence after medication discontinuation.

Botulinum toxin type a is a safe and effective treatment for neurogenic urinary incontinence: results of a single treatment, randomized, placebo controlled 6-month study.
Schurch B, de Seze M, Denys P, Chartier-Kastler E, Haab F, Everaert K, Plante P, Perrouin-Verbe B, Kumar C, Fraczek S, Brin MF
J Urol 2005 Jul;174(1):196-200.

PURPOSE: We determined the safety and efficacy of each of 2 doses of botulinum toxin type A (BTX-A) (200 or 300 U BOTOX) injected into the detrusor for urinary incontinence caused by neurogenic detrusor overactivity of predominantly spinal cord origin. MATERIALS AND METHODS: A total of 59 patients with urinary incontinence caused by neurogenic detrusor overactivity (due to spinal cord injury in 53 and multiple sclerosis in 6) requiring clean intermittent self-catheterization were randomized to receive a single dose into the detrusor of BTX-A (200 U or 300 U) or placebo. Changes in daily frequency of urinary incontinence episodes were monitored via a patient bladder diary during 24 weeks. Key urodynamic assessments (maximum cystometric capacity, reflex detrusor volume and maximum detrusor pressure during bladder contraction) were used to provide objective measures of the treatment effect on bladder function. The impact of treatment on quality of life was assessed using the Incontinence Quality of Life questionnaire. RESULTS: There were significant posttreatment decreases in incontinence episodes from baseline in the 2 BTX-A groups (p </=0.05) but not in the placebo group. In addition, more patients who received BTX-A reported no incontinence episodes during at least 1 posttreatment evaluation period. Positive treatment effects were also reflected by significant improvements in bladder function in the BTX-A groups, as assessed by urodynamics and in patient quality of life. Benefits were observed from the first evaluation at week 2 to the end of the 24-week study. No safety concerns were raised. CONCLUSIONS: Intramuscular injections of BTX-A into the detrusor can provide rapid, well tolerated, clinically significant decreases in the signs and symptoms of urinary incontinence caused by neurogenic detrusor overactivity during a 24-week study period.

Weight loss: a novel and effective treatment for urinary incontinence.
Subak LL, Whitcomb E, Shen H, Saxton J, Vittinghoff E, Brown JS
J Urol 2005 Jul;174(1):190-5.

PURPOSE: We evaluated the effect of weight loss on urinary incontinence (UI) in overweight and obese women. MATERIALS AND METHODS: A randomized, controlled clinical trial was conducted among overweight and obese women experiencing at least 4 UI episodes per week. Women were randomly assigned to a 3-month liquid diet weight reduction program (24 in the immediate intervention group) or a wait-list delayed intervention group (24 in the wait-list control group). Participants in the wait-list control group began the weight reduction program in month 3 of the study. All women were followed for 6 months after completing the weight reduction program. Wilcoxon tests were used to compare intergroup differences in change in weekly UI episodes and quality of life scores. RESULTS: A total of 48 women were randomized and 40 were assessed 3 months after randomization. Median (with 25% to 75% interquartile range [IQR]) baseline age was 52 years (IQR 47 to 59), weight was 97 kg (IQR 87 to 106) and UI episodes were 21 weekly (IQR 11 to 33). Women in the immediate intervention group had a 16 kg (IQR 9 to 20) weight reduction compared with 0 kg (IQR -2 to 2) in the wait-list control group (p <0.0001). The immediate intervention group experienced a 60% reduction (IQR 30% to 89%) in weekly UI episodes compared with 15% (IQR -9% to 25%) in the wait-list control group (p <0.0005) and had greater improvement in quality of life scores. Stress (p =0.003) and urge (p =0.03) incontinent episodes decreased in the immediate intervention vs wait-list control group. Following the weight reduction program the wait-list control group experienced a similar median reduction in weekly UI episodes (71%). Among all 40 women mean weekly UI episodes decreased 54% (95% CI 40% to 69%) after weight reduction and the improvement was maintained for 6 months. CONCLUSIONS: Weight reduction is an effective treatment for overweight and obese women with UI. Weight loss of 5% to 10% has an efficacy similar to that of other nonsurgical treatments and should be considered a first line therapy for incontinence.

A prospective multicenter randomized trial of tension-free vaginal tape and colposuspension for primary urodynamic stress incontinence: two-year follow-up.
Wein AJ
J Urol 2005 Jul;174(1):215-6.

Urinary complications and sexual function after the tension-free vaginal tape procedure.
Albertsen PC
J Urol 2005 Jul;174(1):273.

Predictors of treatment response to behavioral therapy and pharmacotherapy for urinary incontinence.
Wein AJ
J Urol 2005 Jul;174(1):219.

The prevalence of urinary incontinence in women in four European countries.
Wein AJ
J Urol 2005 Jul;174(1):218.

Behavioral treatment options for urinary incontinence.
Wein AJ
J Urol 2005 Jul;174(1):218-9.

The prevalence of urinary incontinence in community-dwelling married women: a matter of definition.
Wein AJ
J Urol 2005 Jul;174(1):217-8.

Long-Term Results With Tension-Free Vaginal Tape on Mixed and Stress Urinary Incontinence.
Holmgren C, Nilsson S, Lanner L, Hellberg D
Obstet Gynecol 2005 Jul;106(1):38-43.

Objective: To compare outcome of the tension-free vaginal tape (TVT) procedure in women with urinary mixed and stress incontinence. Methods: A mailed questionnaire was answered by 760 of 970 women who had undergone TVT surgery 2-8 years ago (78% response rate). Seventeen women had unclassified incontinence, and 51 women who developed de novo urgency were excluded, giving 580 (83.8%) with stress incontinence and 112 (16.2%) women with mixed incontinence eligible for analysis. Demographic, reproductive factors, and medical history were obtained. The questionnaire included detailed questions about urinary symptoms. Analysis of outcome was done for cohorts by number of years since the operation. Results: The women with stress incontinence had a persistent cure rate of 85% from 2 to 8 years after the TVT procedure. The women with mixed incontinence had a persistent cure rate of 60% up to 4 years postoperatively, but the cure rate then steadily declined to 30% from 4 to 8 years after surgery. The increased rate of incontinence was due to urgency symptoms. Conclusion: The results of this study indicate that initial good cure rates of TVT for mixed incontinence do not persist after 4 years. Level of Evidence: III.

Botulinum-A Toxin for Treatment of Overactive Bladder Without Detrusor Overactivity: Urodynamic Outcome and Patient Satisfaction.
Schulte-Baukloh H, Weiss C, Stolze T, Sturzebecher B, Knispel HH
Urology 2005 Jun 29;.

OBJECTIVES: To investigate the effect of botulinum toxin type A bladder injections in the treatment of overactive bladder syndrome in the absence of detrusor overactivity. METHODS: The subjects were 7 women (average age 61.1 years, range 51 to 79) who presented with overactive bladder symptoms. Their disorder had been refractory to several classic treatment options. Urodynamic examination excluded detrusor overactivity. A total of 300 U BTX-A (Botox) was injected, of which 50 to 75 U was injected as quadrant injections into the external sphincter muscle to avoid the postoperative need for catheterization in the case of high postvoid residual urine volume. For follow-up, complete urodynamic studies were performed, and a bladder diary and validated incontinence questionnaires were given to patients at all visits at 1, 3, and 6 months. RESULTS: The bladder diaries indicated a clear reduction in daytime frequency and nocturia and a reduction in pad use. The maximal voiding volume increased significantly. The urodynamic examinations showed a significant increase in volume when the first and the strong desire to void were expressed. The maximal bladder capacity increased by 20% in 3 months. In the questionnaires, 5 of the 7 patients reported better urine control after therapy, and 6 would have chosen this therapy again for their condition. The overall satisfaction score (on a scale of 0 to 10) averaged 6.8. No side effects, such as urine retention, occurred. CONCLUSIONS: Botulinum-A toxin injection has positive effects in treating overactive bladder symptoms without detrusor overactivity. The effects were seen not only in urodynamic measures but also in patient satisfaction.

Prevalence and impact on generic quality of life of urinary incontinence in japanese working women: assessment by ici questionnaire and sf-36 health survey.
Araki I, Beppu M, Kajiwara M, Mikami Y, Zakoji H, Fukasawa M, Takeda M
Urology 2005 Jun 29;.

OBJECTIVES: To examine the prevalence of urinary incontinence (UI) and the relationship between UI and generic quality of life (QOL) in working women. METHODS: Of 7229 female hospital nurses in Japan, 3734 (51.7%) responded to a self-administered postal questionnaire that included the Rand Medical Outcomes Study 36-item Health Survey (SF-36) and the International Consultation on Incontinence questionnaire (ICIQ) for evaluating symptoms and health-related QOL. RESULTS: The overall prevalence of UI in Japanese working women aged 20 to 64 years (mean 35.2) was 16.7%. The main type of incontinence was stress UI (73%). Its prevalence increased with age and reached a plateau at age 45 to 49 years (34.7%). The ICIQ score also correlated significantly with age. Generic QOL, especially physical functioning, role-physical, social functioning, and role-emotional, was significantly impaired by UI. A comparison of subjects with and without UI revealed that the differences in the physical and mental component summary scores of the SF-36 were largest in the age groups of 25 to 29 and 55 to 59 years, respectively. The correlations of the ICIQ score with the physical and mental component scores were most significant in the age groups of 25 to 29 and 45 to 49 years, respectively. The impact of mixed UI on QOL showed a greater tendency than that of stress or urge UI. CONCLUSIONS: The prevalence of UI showed an age-related increase, with a peak at 45 to 49 years old. The impact of UI on physical health was great in individuals in their 20s, but its impact on mental health increased in the older age groups.

Clinical Effects of Suburothelial Injection of Botulinum A Toxin on Patients with Nonneurogenic Detrusor Overactivity Refractory to Anticholinergics.
Kuo HC
Urology 2005 Jun 29;.

OBJECTIVES: To investigate the clinical and urodynamic effects of suburothelial injection of botulinum A toxin on patients with nonneurogenic detrusor overactivity. Intradetrusor injection of botulinum A toxin has been used to treat patients with detrusor overactivity. Suburothelial injection of botulinum A toxin might effectively inhibit the occurrence of detrusor overactivity mediated by sensory nerves. METHODS: Twenty patients with nonneurogenic detrusor overactivity refractory to anticholinergics were enrolled and treated with injection of 200 U botulinum A toxin into the suburothelial space. The clinical effects on the lower urinary tract symptoms and urodynamic parameters were assessed. RESULTS: At 3 months after treatment, 9 patients had regained continence (45%), 8 had improvement (40%), and treatment had failed in 3 (15%). At 6 months after treatment, 7 patients remained continent, but treatment had failed in 5. Hematuria developed in 1 patient, urinary tract infection in 7 (35%), and a large postvoid residual urine volume requiring catheterization in 6 (30%). Hesitancy in initiation and difficult urination was also noted in 15 patients (75%). The volume of the first sensation of bladder filling and bladder capacity increased about two times; however, the voiding efficiency was reduced by 50% at 2 weeks after treatment. The postvoid residual urine volume was increased by seven times the baseline value at 2 weeks and had decreased to three times greater at 3 and 6 months after treatment. CONCLUSIONS: The results of this study have shown that suburothelial injection of 200 U botulinum A toxin impairs bladder sensation and voiding efficiency, but is effective in the treatment of nonneurogenic detrusor overactivity. Transient urinary retention and the development of urinary tract infection should be carefully monitored.

Which factors predict upper urinary tract deterioration in overactive neurogenic bladder dysfunction?
Ozkan B, Demirkesen O, Durak H, Uygun N, Ismailoglu V, Cetinel B
Urology 2005 Jun 29;.

OBJECTIVES: To determine whether bladder histopathologic changes, detrusor leak point pressure (DLPP), disease duration, and preoperative catheterization time can predict for upper urinary tract (UUT) deterioration in patients with overactive neurogenic bladder dysfunction (ONBD). METHODS: A total of 39 patients (7 women and 32 men) with ONBD who were treated with augmentation cystoplasty were included in the study. The patients had undergone perioperative full-thickness bladder biopsies during augmentation cystoplasty. Routine evaluation using light microscopy to investigate for inflammation, fibrosis, and mast cell count was done. Statistical analysis was done using the chi-square and Mann-Whitney U tests. RESULTS: The mean duration of the disease was 8.7 years. Of the 39 patients, 18 (46%) had had indwelling catheters preoperatively. UUT deterioration was found in 16 (41%) of 39 patients. The mean DLPP was 105 cm H(2)O. The severity of detrusor fibrosis was a significant risk factor for UUT deterioration (P = 0.036). However, the degree of inflammation and the severity of fibrosis did not affect UUT deterioration. A DLPP of more than 75 cm H(2)O was a statistically significant risk factor (P = 0.04), but the disease duration and preoperative catheterization time were not. CONCLUSIONS: The results of our study have shown that moderate to severe fibrosis in the detrusor and a DLPP of more than 75 cm H(2)O are the risk factors for UUT deterioration in patients with ONBD. However, additional studies, including ones with more patients, are needed to determine the relationship between the histopathologic changes and UUT deterioration in ONBD.

A new technique combining both polypropylene and vaginal wall sling procedures: can it minimize the risk of urethral and vaginal erosion occurring with synthetic materials?
Emir L, Erol D, Ak H, Sunay M
World J Urol 2005 Jul 5;.

We describe a new technique combining in situ vaginal wall and polypropylene mesh slings that may decrease potential erosive complications caused by synthetic materials. A folded mucosal patch harboring the polypropylene mesh was placed between mid-urethra and bladder neck. Using this technique, 12 consecutive women (age range 44-66 years) were operated. Preoperative evaluation included a detailed history, pelvic examination, stress test, cystourethroscopy, basic urodynamic evaluation (cystometry, Valsalva leak point pressure measurement), and urine culture. Based on these evaluations, three, seven, and two patients had type I, II, and III stress urinary incontinence, respectively. A paraurethral cyst excision was carried out in one patient and anterior colporrhaphy in four patients during the same operation. No ischemia or sloughing at the operation site occurred in any case. Pelvic examination was repeated in all patients after 3 and 6 months of follow-up and symptoms were determined after 12 months of follow-up in eight patients by telephone interview. Average follow-up was 10 months (range: 6-14 months). None of the patients were incontinent, or complained of sexual dysfunction or erosive complications after 1 year. Since there are two distinct barriers between the sling and both urethra and vagina, our technique covers all advantages of a sling procedure with synthetic materials and avoids the risk of urethral and vaginal erosion. The other advantage of this technique is the concomitant utilization of the vaginal wall as sling material.

New tined lead electrode in sacral neuromodulation: experience from a multicentre European study.
Spinelli M, Weil E, Ostardo E, Del Popolo G, Ruiz-Cerda JL, Kiss G, Heesakkers J
World J Urol 2005 Jun 30;.

The use of a new tined lead electrode for sacral neuromodulation (SNS) was evaluated in a European study including 127 patients with chronic voiding dysfunction. The tined lead can be implanted during the first stage of the SNS procedure, which makes a longer test period possible before implanting the pulse generator in a second stage. Implantation of the tined lead was performed under local anaesthesia in 89% of patients. Screening lasted on average 30 days. Screening with the tined lead was considered successful by the physicians in 77% of patients (n=72). In 74% of first stage patients (n=70), at least 50% improvement in the main symptoms versus baseline was obtained. This was sustained for up to 6 weeks. All of these patients received the pulse generator in a second stage. The outcome of this study supports the use of the tined lead electrode as a screening tool in SNS therapy.

Female urinary incontinence: what the epidemiologic data tell us.
Mallett VT
Int J Fertil Womens Med 2005 Jan-Feb;50(1):12-7.

The prevalence of urinary incontinence (UI) in women has been the subject of many epidemiologic studies. Since 1968 the field has accumulated sufficient data that we now know how stress UI and urge UI appear in populations categorized by race, age, parity, body mass index and other demographic factors. The first comprehensive study in the U.S., the MESA study, was done in 1983. For community-dwelling women 60 years or older, it came up with the now familiar figure of 38% in this age-group. Very similar figures have been found in other national populations, but there are great differences in sub-populations and also by type--stress, urge, or mixed UI. However, with all differences in prevalence acknowledged, no type of UI is unusual in a population of older women. This article delineates, with detailed discussion of individual studies, prevalence by type, age, race, obstetric and gynecologic-surgery history, and anatomic dysfunction, plus consideration of the effects of obesity and menopause on UI. The conclusion is that a problem so widespread is a candidate for prevention, and that the few trials in this direction should be augmented.

Overactive bladder: treatment options for the aging woman.
Park SH, Davila GW
Int J Fertil Womens Med 2005 Jan-Feb;50(1):37-44.

Overactive bladder (OAB) is a common, chronic, and debilitating condition that is most often observed in the elderly population. It has a profound impact on the quality of life of patients, affecting many aspects of daily living, social interaction, and self-perception of health status. Possible neurological, muscular, and metabolic causes have been proposed, but in most cases the exact pathophysiology remains unclear. The management of OAB can be initiated conservatively with behavioral modification and antimuscarinics. For refractory cases, neuromodulation, denervation techniques, and bladder augmentation may be indicated. Not all patients are cured, but most may be improved with appropriate individualized therapy.

The overactive bladder and quality of life.
Epstein LB, Goldberg RP
Int J Fertil Womens Med 2005 Jan-Feb;50(1):30-6.

Overactive bladder (OAB) affects 16.6% of the U.S. population, or 33 million adults, in some form. Despite the prevalence of OAB, almost 60% of those affected seek no medical assistance for the condition either because of embarrassment or the misconception that it represents an inevitable function of aging. A recent surge of interest on the subject has uncovered the dramatic effect that OAB can have on social interactions, sleep, depression, sexual health, and overall health-related quality of life (HRQoL). The introduction of validated, condition-specific QOL questionnaires has enhanced our ability to measure these subjective dimensions of OAB, and to assess their response to therapeutic interventions.

Stress incontinence: alternatives to surgery.
Kielb SJ
Int J Fertil Womens Med 2005 Jan-Feb;50(1):24-9.

Although surgery is commonly performed to alleviate or cure stress incontinence, there are non-surgical options that might well be explored and tried before a woman undergoes surgery, for which many are poor candidates. The least drastic treatments are behavioral therapies, chiefly pelvic floor muscle training (Kegel exercises), alone or with biofeedback. This method is effective but has the drawback of poor patient compliance. Another therapy, almost noninvasive, is electrical stimulation via needle or surface electrodes of the pudendal nerve and the pelvic plexus in order to treat detrusor instability. Some studies show good results for many patients; and there is no need for long-term compliance. Medical management has included hormone replacement therapy and alpha-adrenergic agonists, but questionable results and intolerable risks have shifted this mode to serotonin-norepinephrine reuptake inhibitors, which have CNS action. Finally, there are urethral occlusive devices, which have poor acceptance owing to side effects and difficulty of use, and vaginal pessaries, theoretically attractive but inexplicably poor performers in the marketplace.

Letter to "Prolene tape in the bladder wall after TVT procedure-intramural tape placement or secondary tape migration?" and "Vaginal wall erosion after transobutrator tape procedure"
Wang AC
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jun 23;.

Bladder wall abscess following midurethral sling procedure.
Madjar S, Frischer Z, Nieder AM, Waltzer WC
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jun 18;.

Midurethal sling procedures are gaining popularity as the treatment of choice for stress urinary incontinence. Complications that were described include bladder perforation, urinary retention, pelvic hematoma and suprapubic wound infection. Sling erosion and pelvic abscess are rare complications of midurethral slings. We report the first case of an abscess formed within the wall of the urinary bladder, 7 months following a midurethral sling procedure.

Transobturator tape erosion associated with leg pain.
Mahajan ST, Kenton K, Bova DA, Brubaker L
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jun 18;.

A 39 year-old vaginal multipara status postpubovaginal sling in 2002 and a transobturator tape procedure in 2004 presented with persistent stress incontinence and vaginal polypropylene mesh erosion. Ten days later, she presented to the emergency room with severe right groin pain, difficulty walking, fever, and chills. She described shooting pain originating from the right inguinal ligament radiating down her right leg anteriorly. Although her neurologic examination was normal, palpation of the right obturator internus muscle reproduced her pain. MRI clearly revealed the course of the mesh tape through the obturator muscles and marked increase in the size of the right adductor and obturator internus muscles, apparently compressing the adjacent neurovascular fascicle. The patient was taken to the operating room where the polypropylene tape was easily removed through the vaginal erosion. Mesh cultures were positive for bacteroides fragilis. She experienced complete symptom resolution within 1 week of tape removal.

Long-term chronic complications from Stamey endoscopic bladder neck suspension: a case series.
Smith A, Rovner E
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jun 18;.

Purpose/objective Long-term complications from anti-incontinence surgical procedures are rarely reported. We report on delayed presentation of complications relating to the synthetic bolster placed for the Stamey bladder neck suspension. Materials and methods: Patients undergoing re-operative surgery following prior Stamey endoscopic bladder neck suspension were selected from a surgical database. Four women with lower urinary tract and/or vaginal symptoms following prior Stamey endoscopic bladder neck suspension were identified. All patients had undergone removal of the bolster material by a single surgeon (ESR) at re-operation. Preoperative, operative, and postoperative inpatient and outpatient records were reviewed. Results: Patients presented with a variety of symptoms including urinary incontinence, recurrent cystitis, vaginitis, and urinary frequency at 9, 11, 11, and 12 years after Stamey bladder neck suspension. In addition, two patients presented with recurrent, intermittent bloody vaginal discharge and two patients complained of recurrent urinary tract infections and irritative voiding symptoms. All patients underwent transvaginal excision of the Dacron bolster. Three patients also underwent placement of an autologous pubovaginal sling for symptomatic recurrent stress urinary incontinence. At a mean follow-up of 30 months all four patients were improved. There was no recurrence of vaginal discharge or urinary tract infections. Irritative voiding symptoms resolved. Conclusions: Delayed complications from surgically implanted synthetic materials can present many years after initial implantation. The clinical findings are often subtle and require a high degree of suspicion. Vaginal discharge and irritative urinary symptoms in patients with even a remote history of Stamey bladder neck suspension should prompt a thorough vaginal exam and cystoscopy. Excision of the bolsters can be performed and is usually followed by symptomatic improvement.

Concomitant pelvic organ prolapse surgery with TVT procedure.
Huang KH, Kung FT, Liang HM, Chen CW, Chang SY, Hwang LL
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jun 18;.

The aim of this study is to evaluate the efficacy and feasibility of concomitant pelvic reconstructive surgery with tension-free vaginal tape (TVT) procedure to treat pelvic organ prolapse women with urodynamic stress incontinence (USI) or occult USI. Seventy-five women with pelvic organ prolapse and diagnosed as USI or occult USI were enrolled in this study. All patients with USI or occult USI underwent TVT treatment under general anesthesia, combined with transvaginal total hysterectomy (VTH), anterior-posterior colporrhaphy (APC), and/or right sacrospinous ligament suspension (SSS) reconstructive surgeries. The subjective assessment was evaluated by using a visual analog scale (VAS) score and a urinary symptomatic questionnaire. The objective assessment was carried out with a 1-h pad test, cough stress test, and urodynamic examination. Of the 75 patients, 35 patients with grade III uterine prolapse underwent VTH and APC, 30 patients with grade IV uterine prolapse underwent VTH, SSS, and APC, and the other 10 patients who had previous hysterectomy with total vaginal vault prolapse underwent SSS and APC. The mean follow-up interval was 25 months (12-42 months). The mean hospitalization was 5.9 days and the mean catheterization time was 3.8 days. The subjective success rate for the treatment of urine incontinence was 88%, and the objective complete cure rate was 84%. The rate of postoperative complications with persistent urinary urgency, de novo detrusor overactivity, dysfunctional voiding, and tape erosion were 50, 8, 12, and 1.3%, respectively. There were no bladder perforations during the TVT procedure and no perioperative complications requiring conversion to laparotomy. Pelvic organ prolapse women with USI or occult USI can be treated by reconstructive surgeries combined with a TVT procedure to treat and prevent postoperative USI.

Large thigh abscess after placement of synthetic transobturator sling.
Goldman HB
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jun 29;.

Purpose: To report a unique complication associated with transobturator slings. Materials and methods: The evaluation and treatment of a unique infectious complication of transobturator slings is reviewed. Results: A large thigh abscess associated with a transobturator sling was diagnosed and treated. Conclusion: New techniques of sling placement may be associated with unique infectious complications. Slings passing through the obturator foramen and thigh can lead to a significant abscess within the adductor muscles of the thigh.

Urethral prolapse after durasphere injection.
Ghoniem GM, Khater U
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jun 29;.

Urethral prolapse is an uncommon condition among adult patients. We report a case of adult female patient with urethral prolapse after Durasphere injection. The patient was successfully treated with excision of the prolapsed urethra and Durasphere mass, and fibrin glue injection to support the remaining part of urethra.

In vivo comparison of suburethral sling materials.
Slack M, Sandhu JS, Staskin DR, Grant RC
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jul 2;.

In vivo tissue responses were compared for three commercially available polypropylene suburethral slings that differ markedly in fabric structure and in size of resulting interstices and pores. All three elicited the same basic inflammatory response; however, individual fabric structures produced distinct differences in tissue formation within each mesh. The presence of numerous, closely spaced, small diameter filaments prevented formation of extensive fibrous connective tissue within two slings (ObTape and IVS Tunneller mesh). The much larger diameter monofilament and open knit structure of the Monarc sling permitted the most extensive fibrous tissue integration. These differences may be of interest to physicians considering clinical use.

Dose response with darifenacin, a novel once-daily M(3) selective receptor antagonist for the treatment of overactive bladder: results of a fixed dose study.
Hill S, Khullar V, Wyndaele JJ, Lheritier K
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jul 6;.

This study evaluated the efficacy, tolerability, and safety of darifenacin, an M(3) selective receptor antagonist (M(3) SRA), in patients with overactive bladder (OAB). In a multicenter, double-blind, placebo-controlled dose-ranging study, 439 adult OAB patients (85.4% female) were randomized to darifenacin controlled-release tablets 7.5 mg (n = 108), 15 mg (n = 107) or 30 mg (n = 115) qd, or placebo (n = 109) for 12 weeks. Darifenacin significantly reduced the median number of incontinence episodes/week (-68.7, -76.5, and -77.3% from baseline at 7.5, 15, and 30 mg, respectively, vs -46% with placebo, all p< 0.01) and dose relatedly improved micturition frequency, frequency and severity of urgency, nocturia, and bladder capacity. Darifenacin was well tolerated. Adverse events were commonly mild to moderate dry mouth and constipation. There were no safety concerns. Darifenacin is effective and well tolerated in the treatment of OAB, with 7.5 and 15 mg doses offering flexibility of dosing for optimal treatment outcome.

Continence pads: have we got it right?
Uchil D, Thakar R, Sultan AH, Seymour J, Addison R
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jul 6;.

Women listed in the Croydon Community Continence database were contacted with a self-assessment questionnaire regarding continence pad usage and quality of life. Completed questionnaires were received from 763 of 1509 (51%) participants. Pads were used for bladder dysfunction (88.1%) and bowel dysfunction (44%). The majority (82.5%) had concurrent medical disorders and problems with mobility with 77.5% being on one or more types of medication. Nearly 39% of women claimed that they would be happy to continue pad use indefinitely and only 28% expressed interest in seeking further help. Compared to bowel dysfunction, bladder dysfunction appeared to have a greater impact on women's quality of life (P < 0.001). Containment products make a substantial contribution in improving the quality of lives of women with bowel and bladder dysfunction. The financial burden of containment products has a major impact on the health budget and therefore, comprehensive clinical evaluation should be mandatory before relegating women to pads as a final resort.

Bladder augmentation using Pelvicol(TM) implant for intractable overactive bladder syndrome.
Barrington JW, Dyer R, Bano F
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jul 7;.

The objective of the study was to evaluate the effectiveness of an implant of porcine dermis to augment the bladder in women with refractory overactive bladder syndrome (OAB). Twelve women underwent a Pelvicol(TM) bladder augmentation. A visual analogue score for severity of incontinence and a quality of life questionnaire was carried out pre-operatively and at 12 months post-operatively. Follow up cystoscopy was carried out in three women in addition. Three women were dry and cured; five women were significantly improved; two women were slightly improved and the procedure was unsuccessful in the remaining two women. There were no significant complications and voiding was spontaneous in every case. A bladder augmentation using porcine dermis may have a role in the surgical management of non-neuropathic women with OAB that has failed to respond to conservative therapy.

[Results of the AMS 800 artificial urinary sphincter in men, based on a series of 47 patients]
Simon P, Zerbib M, Debre B, Peyromaure M
Prog Urol 2005 Apr;15(2):244-9.

INTRODUCTION: Male urinary incontinence due to sphincter incompetence is usually secondary to prostate surgery. After failure of other treatments, severe sphincter incompetence requires placement of an artificial urinary sphincter The authors present the results of the AMS 800 artificial urinary sphincter based on a series of 47 consecutively operated patients. PATIENTS AND METHODS: From 1990 to 2003, 47 AMS 800 were inserted by the same operator and according to the same technique. The aetiologies of urinary incontinence were: radical prostatectomy (45% of cases), transurethral resection of the prostate (36%), open prostatectomy (10.5%), and others (8.5%). RESULTS: The mean age of the patients was 65 years. The mean follow-up was 36 months. The mean time to insertion was 3 years and 10 months (range: 5 months-15 years). 23.4% of patients presented one or several complications (mechanical failure: 19%; infection; 10.6%; erosion: 4%; bladder stones: 2%), 21% of patients required one or several surgical revisions after a mean interval of 25.5 months (range: 2-80 months). The actuarial 5-year revision rate was 25.5%. With a mean follow-up of 36 months, 98% of patients had a functioning artificial urinary sphincter and 83% still had their original artificial urinary sphincter Social continence and patient satisfaction rates were 87% and 95.7%, respectively. CONCLUSION: These results are comparable to those of similar published series. The AMS 800 is associated with high continence and patient satisfaction rates and currently remains the reference treatment for refractory sphincter incompetence in men.

Two-dimensional and three-dimensional ultrasound imaging of suburethral slings.
Dietz HP, Barry C, Lim YN, Rane A
Ultrasound Obstet Gynecol 2005 Jun 30;.

OBJECTIVE: Suburethral slings have become the most commonly performed anti-incontinence procedures in many developed countries. Three types of implant account for the majority of such surgery in Australia: tensionless vaginal tape (TVT), suprapubic arc procedure (SPARC) and intravaginal slingplasty (IVS). The aim of this study was to determine differences in position and mobility of these implants, and to determine whether such differences explain variations in clinical outcome. METHODS: In a prospective randomized controlled trial, 195 women were randomized to TVT (n = 67), IVS (n = 64) or SPARC (n = 64). Thirteen women were excluded from the study due to incomplete preoperative data. Of the remaining 182 women, 146 (50 TVT, 48 IVS, 48 SPARC) were seen between 2 and 23 months after their procedure (80%). After an interview, two-dimensional (2D) and three-dimensional (3D) pelvic floor ultrasound was performed. 3D-volume analysis was carried out on a computer with the help of proprietary software (GE Kretz 4D View). Assessors of ultrasound data were blinded against group allocation. RESULTS: There were no significant differences in subjective cure/improvement of stress or urge incontinence or overall subjective cure/improvement. Symptoms, including those of voiding dysfunction, did not vary between groups. All tapes could be imaged by ultrasound. TVT and SPARC were highly echogenic, with the SPARC generally flatter and of wider weave. The IVS seemed narrower and less echogenic. Tape position and mobility were similar, with a trend towards greater distances between tape and symphysis pubis and greater horizontal tape mobility in the SPARC group. CONCLUSIONS: The three types of suburethral sling, namely TVT, SPARC and IVS, investigated using 2D and 3D ultrasound, have comparable short-term clinical and anatomical outcomes. Copyright (c) 2005 ISUOG. Published by John Wiley & Sons, Ltd.


Histopathologic changes of porcine dermis xenografts for transvaginal suburethral slings.
Gandhi S, Kubba LM, Abramov Y, Botros SM, Goldberg RP, Victor TA, Sand PK.
Am J Obstet Gynecol 2005 May;192(5):1643-8.

OBJECTIVE: The purpose of this study was to examine the histopathologic changes of HMDI (Hexamethylene di-isocyanate) cross-linked porcine dermis grafts used for suburethral sling surgery. STUDY DESIGN: Twelve patients underwent reoperation with graft removal for urinary retention or recurrent stress urinary incontinence after transvaginal sling surgery. Tissue specimens were available for pathologic evaluation in 7 patients. Graft specimens underwent histologic preparation including hematoxylin and eosin staining. A single pathologist reviewed the slides blinded to clinical outcomes. RESULTS: Histopathologic analyses revealed only limited collagen remodeling, and evidence of a foreign body type reaction was present in some specimens. In cases of recurrent stress incontinence, implants appeared to be completely replaced by dense fibroconnective tissue and moderate neovascularization without evidence of inflammation or graft remnants. CONCLUSION: HMDI cross-linked porcine dermal collagen implants result in variable tissue reactions that may have unpredictable clinical outcomes in different patients, raising questions about the overall tolerability and efficacy of these grafts in pelvic reconstructive surgery.

Anal incontinence in women presenting for gynecologic care: prevalence, risk factors, and impact upon quality of life.
Boreham MK, Richter HE, Kenton KS, Nager CW, Gregory WT, Aronson MP, Vogt VY, McIntire DD, Schaffer JI.
Am J Obstet Gynecol 2005 May;192(5):1637-42.

The purpose of this study was to estimate the prevalence and impact upon quality of life of anal incontinence (AI) in women aged 18 to 65. STUDY DESIGN: Consecutive women presenting for general gynecologic care were given a bowel function questionnaire. Women with AI were prompted to complete the Fecal Incontinence Severity Index (FISI) and Fecal Incontinence Quality of Life Scale (FIQL). RESULTS: The cohort was composed of 457 women with a mean age of 39.9 +/- 11 years. AI prevalence was 28.4% (95% CI 24.4-32.8). After logistic regression, IBS (OR 3.22, 1.75-5.93), constipation (OR 2.11, 1.22-3.63), age (OR 1.05, 1.03-1.07), and BMI (OR 1.04, 1.01-1.08) remained significant risk factors. The mean FISI score was 20.4 +/- 12.4. Women with only flatal incontinence scored higher, and women with liquid loss scored lower on all 4 scales of the FIQL. CONCLUSION: AI is prevalent in women seeking benign gynecologic care, and liquid stool incontinence has the greatest impact upon quality of life.

Nocturnal polyuria in women with overactive bladder symptoms and nocturia.
Drake NL, Flynn MK, Romero AA, Weidner AC, Amundsen CL.
Am J Obstet Gynecol 2005 May;192(5):1682-6.

This study was undertaken to determine the prevalence of nocturnal polyuria in women complaining of nocturia and overactive bladder (OAB) symptoms and to identify clinical and health characteristics associated with nocturnal polyuria. STUDY DESIGN: Women presenting to a urogynecology clinic with complaints of nocturia and OAB symptoms were asked to participate. They completed a health characteristic summary, 3-day voiding diary, Nordic sleep questionnaire, urinary distress inventory (UDI), and a nocturia distress visual log (NDVL). The 24-hour urine production, nighttime urine volume, and maximum bladder capacity were calculated from the bladder diary. Nocturnal polyuria was defined as production of greater than 33% of the 24-hour urine volume during an 8-hour sleep period. A histogram was performed to analyze at what age the prevalence of nocturnal polyuria increased. Women were then divided by presence or absence of nocturnal polyuria and compared by the health and clinical characteristics. RESULTS: Fifty-five women met the qualifications and participated in the study. Average age of the cohort was 65.8 +/- 13.5 years. The risk of nocturnal polyuria increased with age 65 years or older (prevalence for age 65-74 = 0.86 [0.62-1.00]) and with white race. On the basis of the mean population values for UDI, NDVL, sleepiness scores, and insomnia scores, all women were bothered by their nocturia. Median number of nighttime voids, 24-hour urine production, maximum bladder capacity, nocturnal index, UDI, NDVL, sleepiness scores, and insomnia scores did not differ, based on presence or absence of nocturnal polyuria. CONCLUSION: Among women complaining of nocturia and overactive bladder symptoms, age 65 years or older and white race appear to be risk factors for nocturnal polyuria.

Comparison of long-term outcomes of autologous fascia lata slings with Suspend Tutoplast fascia lata allograft slings for stress incontinence.
McBride AW, Ellerkmann RM, Bent AE, Melick CF.
Am J Obstet Gynecol 2005 May;192(5):1677-81.

OBJECTIVE: This study was undertaken to compare the objective and subjective long-term surgical outcomes in patients receiving Tutoplast fascia lata allograft slings with those receiving autograft slings for the treatment of stress urinary incontinence (SUI). STUDY DESIGN: We reviewed all patients (n = 71) undergoing suburethral sling with either autologous fascia lata (n = 39) or Tutoplast fascia lata (n = 32) for urodynamic stress incontinence (USI) from October 1, 1998, to August 1, 2001. RESULTS: Of the original 71 patients, 47 were evaluated by objective and/or subjective means at a minimum of 2 years after surgery. Subjective quality of life measures, subjective continence, maximum urethral closure pressure, and bladder neck mobility were not different between the 2 groups. USI was demonstrated in 41.7% of allograft patients compared with no autograft patients (P = .007). CONCLUSION: Although patient reported cure of SUI is high for both sling types, USI recurs at a significantly higher rate in Tutoplast slings compared with autologous slings.

Efficacy of botulinum-A toxin in the treatment of detrusor overactivity incontinence: a prospective nonrandomized study.
Werner M, Schmid DM, Schussler B.
Am J Obstet Gynecol 2005 May;192(5):1735-40.

OBJECTIVE: This study was undertaken to investigate the efficacy and safety of botulinum-A toxin (BTX-A) treatment for non-neurogenic detrusor overactivity incontinence. STUDY DESIGN: This prospective nonrandomized ongoing study was performed in a tertiary referral urogynecology department. In 26 women with urge incontinence and urodynamically demonstrated detrusor overactivity incontinence resistant to conventional treatment 100 units of BTX-A were injected into the detrusor muscle at 30 sites. Clinical and urodynamic evaluations and a quality of life assessment were performed at baseline and 4, 12, and 36 weeks after BTX-A treatment. RESULTS: Of 26 women, 14 were dry after 4 weeks, 13 of 20 women after 12 weeks, and 3 of 5 women after 36 weeks. Two women failed to respond. Two women were on self-catheterization temporarily. There were no other complications besides 9 urinary tract infections within the 51 follow-up visits. CONCLUSION: BTX-A treatment seems to be a safe and efficacious new treatment option for patients with detrusor overactivity incontinence.

[The treatment of urinary incontinence by injectables. Analysis of our series].
Rodriguez Faba O, San Martin Blanco A, Jalon Monzon A, Gonzalez Alvarez RC, Alvarez Mujica M, Fernandez Gomez JM, Martin Benito JL, Escaf Barmadah S, Regaderas Sejas
J. Arch Esp Urol 2005 Apr;58(3):227-31.

OBJECTIVES: To determine the efficacy of endoscopical injections for the treatment of stress urinary incontinence (SUI), evaluating its low invasiveness and positive impact on quality of life. METHODS/RESULTS: Belween 1997--2003 30 procedures of periurethral injection of various substances for urinary incontinence were performed at our department in women between 47-80 years. All patients were evaluated before surgery, clinically and urodynamically, in accordance to international standardized parameters (filling pressure/flow studies, maximum urethral closure pressure, LPP-leak point pressure). The kind of material employed for injection, surgical technique and satisfaction degree were also evaluated. RESULTS: The indication for surgery was SUI in 17 cases (56.6%), and mixed urinary incontinence in 73 cases (43.3%). 16 cases (53.3%) had history of previous surgery for SUI. Regarding urodynamic parameters, 19 patients (63.3%) have a maximum urethral closure pressure below 25 H2O cm, and 22 patients (73.3%) had a leak point pressure below 60 H2O cm. Collagen was employed in six cases (20%) and macroplastic in 24 (80%) (14 of them with the MIS system). 22 patients had three injection sites (73.3%). Mean follow-up was 38 months. Continence outcomes were evaluated in relation to complete continence (12 cases, 40%), mild incontinence and patient satisfaction (11 cases, 36.6%), and severe incontinence (7 cases, 23.3%). CONCLUSIONS: 1-To achieve acceptable results it is mandatory to do the best possible indication (Mc Guire type III SUI). 2.-There is an excellent relationship between minimal invasiveness and good results.

Multicenter randomized clinical trial comparing surgery and collagen injections for treatment of female stress urinary incontinence.
Corcos J, Collet JP, Shapiro S, Herschorn S, Radomski SB, Schick E, Gajewski JB, Benedetti A, MacRamallah E, Hyams B.
Urology 2005 May;65(5):898-904.

OBJECTIVES: To compare, in a multicenter, randomized clinical trial, collagen injections versus surgery with regard to efficacy, quality of life, satisfaction, and complications. METHODS: Of 133 women with stress urinary incontinence, 66 were randomized to collagen injection and 67 to surgery (6 needle bladder neck suspensions, 19 Burch, and 29 slings). After randomization, 15 women refused their allocated treatment. "Intent-to-treat" and "per protocol" analyses were applied. Women assigned to collagen injection could receive up to three injections before it was considered a failure. A "top-up" injection was allowed within 3 months after cure. Success as the primary outcome at 12 months was defined as a dry 24-hour pad test (2.5 g or less of urine) after having received only the allocated intervention. RESULTS: The per protocol analysis showed that the success rate 12 months after collagen injections (53.1%) was much lower than that after surgery (72.2%). The difference was 19.1% (95% confidence interval -36.2% to -2%). The general and disease-specific quality-of-life scores measured by the Rand Medical Outcomes Study 36-item Health Survey and Incontinence Impact Questionnaire were similar in the two groups (P = 0.306). Women treated by surgery were, on average, more satisfied (79.6%) than those treated by collagen injection (67.2%), but the difference was not significant (P = 0.228). Finally, complications were less frequent and severe with collagen injection: 36 events in 23 subjects for collagen injection versus 84 events in 34 subjects for surgery (P = 0.03). CONCLUSIONS: One year after intervention, the success rate of collagen injection as a treatment for stress urinary incontinence was about 19% lower than that after surgery. This has to be tempered by the similar changes in quality of life and satisfaction in both groups and that the number and severity of complications were much greater after surgery than after collagen injection. The results of this study indicate that collagen injections might be a worthwhile alternative to surgery for the treatment of stress urinary incontinence.

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