[Low obstruction tract by system Reemex]. / Obstrucción infravesical tras cabestrillo tipo Remeex.

The Remeex system it's a sling with regulable tension created for the surgical correction of the female urinary incontinente. The system contains a varitensor central part of the protesis that regulates the tension of the uretra. The screwdriver that acts against the varitensor to the modify the tension under the uretra in the postop inmediately or time after also. We present a clinic case of a patient with diagnostic of urinary stress incontinence and the surgical treatment with advantages against others kind of systems used for incontinence treatment at this time.

Obstrucción infravesical tras cabestrillo tipo Remeex / Low obstruction tract by system reemex

La colocación de un cabestrillo de tensión regulable tipo Remeex, es un procedimiento quirúrgico destinado a corregir la incontinencia urinaria femenina. Contiene un varitensor que regula la tensión del sistema sobre la uretra, elemento central de la prótesis que quedará en la paciente y un manipulador, elemento que actúa sobre el varitensor y modificar la tensión bajo la uretra en el postoperatorio inmediato o incluso tiempo después. Presentamos el caso clínico de una paciente diagnosticada de incontinencia urinaria de esfuerzo y el tratamiento quirúrgico realizado con sus ventajas respecto a otros sistemas de corrección antiincontinencia que se realizan en la actualidad

The Remeex system it’s a sling with regulable tension created for the surgical correction of the female urinary incontinente. The system contains a varitensor central parto f the protesis that regulates the tension of the uretra. The screwdriver that acts against the varitensor to the modify the tension under the uretra in the postop inmediately or time after also. We present a clinic case of a patient with diagnostic of urinary stress incontinence and the surgical treatment with advantages against others kind of systems used for incontinence treatment at this time

Falso residuo postmiccional diagnosticado por videourodinamia / False postvoid residual volume diagnosed by videourodynamics

Presentamos un caso de un paciente varón joven diagnosticado de reflujo vésico ureteral bilateral. En el estudio urodinámico se objetiva una posible disinergia vesico-esfinteriana no neurógena, con gran residuo postmiccional. Tras tratamiento con biofeedback se soluciona la disinergia, persistiendo el gran residuo. El estudio con videourodinamia permitió diagnosticar la presencia de un falso residuo postmiccional causado por el vaciamiento ureteral del reflujo bilateral masivo

We present a case report of a young male patient, with a bilateral vesico renal reflux. The urodynamic study findings suggested the possibility of a non-neurogenic bladder-external spincter dissinergya producing a valuable residual volume. After biofeedback treatment, the dissinergia disappeaed, but residual volume persisted. The videourodynamic assessment allowed us the accurate diagnosis of a false residual volume, produced by the voiding of the refluxed urine from the ureters into the bladder

[False postvoid residual volume diagnosed by videourodynamics]. / Falso residuo postmiccional diagnosticado por videourodinamia

We present a case report of a young male patient, with a bilateral vesico renal reflux. The urodynamic study findings suggested the possibility of a non-neurogenic bladder-external spincter dissinergya producing a valuable residual volume. After biofeedback treatment, the dissinergia disappeaed, but residual volume persisted. The videourodynamic assessment allowed us the accurate diagnosis of a false residual volume, produced by the voiding of the refluxed urine from the ureters into the bladder.

[Vesico-scrotal hernia with hypocontractile detrusor]. / Hernia vesico escrotal con detrusor hipocontráctil.

OBJECTIVE: To present a case of massive inguinoscrotal hernia associated with low detrusor contractility. METHODS/RESULTS: A 70-year-old male patient with a history of diabetes and a previous diagnosis of low contractile bladder presented with urinary retention. Acute renal failure secondary to ureteral obstruction and inguinal bladder herniation was diagnosed. The direct bilateral hernia was repaired. Postoperative urodynamic evaluation showed an acontractile bladder. Intermittent catheterization was started, with satisfactory functional result and improvement of renal function. CONCLUSIONS: Massive bladder hernia can present as acute renal failure without lower urinary tract obstruction. The underlying impaired detrusor contractility can be diagnosed by urodynamic evaluation. Surgical treatment, with self-catheterization if required, achieves good results with preservation of renal function.

[Artificial sphincter in severe urinary incontinence: 9 years of experience]. / Esfínter artificial en incontinencia urinaria severa: nueve años de experiencia.

OBJECTIVE: To present the results achieved with the artificial urinary sphincter in the treatment of 44 patients with severe urinary incontinence. METHODS: From April 1990 to December 1998, an artificial urinary sphincter was implanted in 44 patients with severe urinary incontinence, aged 21 to 82 years (mean 56). These patients were categorized into the following groups: Group A comprised 24 males, aged 37 to 82 years (mean 66), who had undergone previous prostatic procedures. Four of them had undergone radical retropubic prostatectomy. The remaining 20 had undergone a total of 34 de-obstructive procedures (mean 1.7 procedures/patient; range 1-3); 28 were endoscopic procedures and 6 open prostatectomy. One of them had a previous ileocystoplasty due to severely low compliance. Ten were completely incontinent and were using a condom catheter (7), penile clamp (2) or permanent indwelling Foley catheter (1). The rest used a mean of 3.7 pads per day. Group B comprised 11 males with a complex urologic history: 9 had neurogenic dysfunction, 1 had bladder exstrophy and 1 had a previous cystectomy and Studer neobladder. Eight were using a condom catheter. The cuff was placed in the bulbar urethra in 8 (4-4.5 cm) and in the bladder neck in 4 (9-10 cm). Group C comprised 9 women with type III stress incontinence after failed previous interventions (range 1-4, mean 2.7). All of these patients required at least 3 pads per day (mean 4.5). The cuff was placed in the bladder neck with diameters ranging from 5 to 10 cm. RESULTS: The mean follow-up was 28.5 months (range 8-96). One patient died two years after implantation of the artificial sphincter which was never activated. In group A, 83% are socially continent and 17 do not require pads. Three of the 20 patients with the artificial sphincter have undergone a total of 4 surgical revisions. In group B, the social continence rate was 63% with a 36% revision rate. Four patients required a complete change of the system. In group C, The continence rate with revision was 66%. One patient underwent two successive successful revisions and 3 required removal of the device, accounting for a failure rate of 33%. Definitive removal of the artificial sphincter was required in 3 females and 5 males. Aside from one male who refused a new implant, the rest were considered unsuitable for a new device. Six patients underwent at least one reoperation to change one or more parts of the system. Continence was recovered in 66% after the revision. CONCLUSIONS: The artificial urinary sphincter achieves a good continence rate in patients with severe incontinence, although careful patient follow-up is required.

[Artificial sphincter implantation in women with urinary incontinence using a combined abdomino-vaginal approach]. / Implantación del esfínter urinario artificial en la mujer con incontinencia urinaria por vía combinada abdomino vaginal.

OBJECTIVE: The artificial sphincter has been utilized for urinary incontinence due to intrinsic sphincteric insufficiency, with good fixation of the urethra and a maximum urethral closing pressure of 20-30 cms H2O, or after failed attempts at correction using other techniques. This procedure is difficult to perform since the patients have generally undergone several operations and it is necessity to prepare the cleavage between the urethra and vagina. We propose a modified combined vaginal and suprapubic approach of the technique described by Appell and Abbassian in 1988 for enhanced exposure of the urethra and bladder neck and easy access. METHODS: The modified combined abdominovaginal approach has been utilized in 18 females aged 16-62 years since 1995. RESULTS: 16 patients were continent (88%). One patient (5.5%) required removal of the artificial sphincter due to infection. Another patient (5.5%) has mild incontinence and requires 2 pads a day. Four patients (22%) with detrusor instability are receiving anticholinergics. Three patients (16%) with an underlying neurogenic incontinence require intermittent catheterization. Fourteen patients (77.7%) have type III stress urinary incontinence. We performed the Kelly procedure in 10 patients (55.5%), the Marshall-Marcetti-Kranz in 7 (38.8%), Gittes in 3 (16.6%), and 2 patients (11.1%) had a sling procedure. Two techniques were simultaneously performed in some patients. CONCLUSIONS: Although the number of patients in this series is small, the fact that only one case required removal of the artificial spincter due to infection indicates that this is a useful alternative approach that significantly facilitates implantation of the artificial sphincter in these patients.

Outcome of colposuspension in patients with stress urinary incontinence and abnormal cystometry.

OBJECTIVE: To analyze the prognostic value of preoperative cystometric alterations in the outcome of women undergoing colposuspension for stress incontinence. PATIENTS AND METHODS: Over a 5 year period, 220 women were operated on for stress urinary incontinence using the Burch or Marshall colposuspension techniques. An abnormal cystometry was found pre-operatively in 44 (20%), which was associated with urge incontinence in 11 (25%). Cystometric abnormalities comprised 3 subgroups: detrusor instability (DI), low bladder compliance (LBC) and small detrusor contractions (SDC). Women with an abnormal cystometry had responded partially to anticholinergic therapy. Detailed postoperative questioning was undertaken to differentiate stress from urge incontinence, as well as storage symptoms. Results of patients with cystometric abnormalities were compared to an age-matched group of 44 patients with a stable bladder on the preoperative study. RESULTS: Bladder compliance was statistically lower in the preoperative CMG of patients with abnormal cystometry (p < 0.005). Groups were followed for a mean of 39 (abnormal CMG) and 36 months (stable bladder), respectively. The presence of the aforementioned cystometric alterations was not associated with lower cure rates of the stress incontinence. However, the group with DI referred more postoperative storage symptoms. "De novo" DI was found in 20% of patients with a previously stable bladder who referred storage symptoms postoperatively. CONCLUSIONS: Small detrusor contractions are not a contraindication for colposuspension. Patients with DI and low bladder compliance who also have stress incontinence showed more storage symptoms on postoperative evaluation.

[Percutaneous urethral suspension with bone anchorage (Vesica) in the treatment of stress urinary incontinence. Results after a year of follow-up]. / Suspensión uretral percutánea con anclaje óseo (vesica) en el tratamiento de la incontinencia urinaria de esfuerzo. Resultados tras un año de seguimiento.

OBJECTIVES: Evaluation of efficacy of percutaneous bladder neck suspension with bone anchors in women with stress incontinence with no previous treatment. PATIENTS AND METHODS: Fourteen women (mean age 48, range 37-74) were operated. All had a stable bladder and objective leakage, either by pad test of by physical examination. Ten were evaluated by a incontinence questionnaire. Mean incontinence time before the procedure was 3.9 years. All needed pads (mean 3.3 pads/day). The surgical technique is described. RESULTS: Mean surgical time was 80 minutes. In three patients there was bladder perforation during the procedure, that was solved by delaying the catheter withdraw. Mean postoperative stay was 4.2 days, with good tolerance, and one patient was discharged with a cystostomy. After a minimum follow-up of one year (mean 17.5 months), eleven patients have improved their continence (6 dry, 5 socially acceptable incontinence < pads/day) and 3 have recurrence. Postoperative pad test was < or = 10 g in patients without improvement and over 20 g in patients who failed. Mean postoperative total score in the questionnaire decreased from 10.1 to 2.5 in patients who improved and didn't change in patients who failed. CONCLUSION: Percutaneous bladder neck suspension is a useful alternative to open interventions, due to its low morbidity and lower postoperative stay.

[Complete urodynamic office evaluation; a method for the delivery of health care]. / Visita completa de urodinamia; una modalidad asistencial.

INTRODUCTION: The goal of the study was to evaluate the usefulness of the complete urodynamic office evaluation. This assistance modality consists on the realisation in the same moment of the clinical chart, physical examination, urodynamic study, report, therapeutic indications, program of other complementary studies, hospitalisation or discharge from the outpatient office. PATIENTS AND METHODS: During 1 year complete urodynamic office evaluation was performed to 100 patients (87 female, 13 male) All patients were directed to our department to perform a urodynamic test, most of them due to incontinence. Different kinds of urodynamic tests were performed in 91 patients, with a medium of 2 studies per test. Abnormalities were detected in 59 cases. RESULTS: After the complete urodynamic office evaluation, 16 patients were programmed for surgery, 26 were discharged from outpatient office, 37 were directed to follow up in the outpatient setting, 2 were hospitalised, and 19 were lost of follow up. CONCLUSIONS: The complete urodynamic office evaluation allowed us to get the diagnostic and therapeutic approach in 98% of patients, employing a standard of 90 minutes. Twenty six percent of patients could be discharged from our center. Sixteen patients were operated on following this unique visit, that means an important reduction in the usual assistance delay.

[Urinary stress incontinence in women under 40 years of age]. / Incontinencia urinaria de esfuerzo en mujeres menores de 40 años.

OBJECTIVE: To analyze the therapeutic approach in young females with stress urinary incontinence. METHODS: A retrospective study was conducted on 35 females less than 40 years of age who had undergone surgery for stress urinary incontinence. These patients had a mean follow-up of 3.5 years (range one month to 18 years) and a previous history of 3.9 years mean duration. Retropubic urethral suspension according to the MMK or Burch procedure was performed in all patients. RESULTS: 65.7% became completely continent, 20% were continent for at least two months, and 1.43% continued to be incontinent after surgery. The postoperative complication rate was 31%; of these complications, 4 referred inguinal pain and there were 3 cases of wound infection. Those who had a failed procedure showed no changes with respect to their preoperative urodynamic status, although two patients presented clinical features of urgency. The best surgical results were achieved in the older patients, although the differences were not statistically significant. However, statistically significant differences were found for the time to surgery; i.e., the patients with a shorter history of urinary incontinence remained incontinent after surgery. CONCLUSION: Surgical treatment of stress urinary incontinence in females less than 40 years of age achieves satisfactory results, with a success rate similar to that of the general population regardless of the age, and appears to be closely related with the period of time the patient has been incontinent before undergoing surgery.

[Quantification of urine leaks: standardized one-hour pad test]. / Cuantificación del escape de orina: prueba del pañal estandarizada de una hora ("pad test").

OBJECTIVE: To assess the feasibility and diagnostic performance of the one hour pad test proposed by ICS. PATIENTS AND METHODS: The pad test was performed in 20 women referred for incontinence. Five were included in a surgical protocol and 15 had inconsistent medical history. Their mean age was 52.5 years, the mean time of incontinence was 3.4 years and they used a mean of 3.5 pads/day. Six showed leakage on physical examination (PE) and 2 during previous cystometry. RESULTS: The test is well tolerated and lasts one hour and 15 minutes. The test was positive in 17 (mean leakage = 168 g). Leakage was not related to duration of incontinence, number of pads or cystometric capacity. A weak negative correlation (r = -0.52) was found between leakage and voided volume on uroflowmetry performed after the test. All patients who leaked on PE had a positive test and a significantly higher leakage compared to patients who didn't leak on PE. CONCLUSION: The pad test is a feasible outpatient procedure in the context of a Urodynamics Unit, providing objective information on leakage in most patients.

[Diagnosis of bladder neck obstruction in women]. / Diagnostic de l'obstruction sous vésicale chez la femme.

Bladder outlet obstruction in women is a rare entity, and difficult to diagnose. In our series most of the patients had previous history of gyneco-obstetric or urological procedures. Cystometry enabled us to diagnose the coexistence of bladder instability and obstruction in 48% of the patients. We did not find statistically significant differences between the patients with and without BI in terms of degree of obstruction measured by uroflowmetry and pressure/flow studies. Pressure/flow studies and Uroflowmetry had been the essential key in the diagnosis of obstruction in our series. Cysto-urethrography and urethroscopy were normal in over 50% of patients. The urethral calibration was abnormal in 16% of the cases.

[Retropubic urethral suspension. A surgery "without complications"?]. / Suspensión uretral retropúbica. Una cirugía "sin complicaciones"?

OBJECTIVE: To describe a case of bladder neck suspensión with special reference to the complications associated with this procedure. METHODS/RESULTS: Herein we describe a patient who developed most of the reported associated complications following two bladder neck suspension procedures: bilateral ureteral ligation, osteitis pubis, retropubic hematoma, eventration and recurrence of urinary stress incontinence. Finally, after two reoperations, the complications were resolved and the patient is continent. CONCLUSIONS: Bladder neck suspension is usually associated with a low complication rate. However, associated complications may appear in the same patient, accounting for a significant morbidity.

[Vesico-ureteral reflux associated with detrusor instability]. / Reflujo vesicoureteral asociado a inestabilidad del detrusor.

OBJECTIVE: The aim of this study was to determine the urodynamic characteristics of patients with vesico-ureteral reflux (VUR) and detrusor instability (DI) followed by medical treatment. PATIENTS AND METHODS: The urodynamic and cystographic findings in a group of 24 patients between 4 and 18 years of age (mean 7.6 years) with a simultaneous diagnosis of VUR and DI were reviewed. All of them presented with recurrent urinary tract infections. Twenty were female of whom eight also had enuresis and daytime symptoms. Mean follow-up was 40 months (range 18-97 months). VUR was diagnosed by voiding cystourethrogram and classified according to the grades proposed by the "International reflux study on children". RESULTS: All but 6 patients had at least a 15% reduction in age-adjusted capacity. No relationship was observed between the severity of VUR (measured as the addition of reflux grades in both units of each patient) and reduction in bladder capacity or compliance. Seven patients had upper tract damage (either scars or a decrease in size or function on the renogram). Upper tract damage was significantly more frequent in patients with bilateral reflux (regardless of the type of DI). Patients with unilateral reflux and sustained instability had significantly less upper tract damage. Results of treatment are reported separately. CONCLUSIONS: In these patients, the severity of VUR did not seem to have an impact on bladder capacity or compliance. The risk factors for upper tract damage in this series differ from those found by other authors.

[Efficacy of oxybutynin chloride in children with vesico-ureteral reflux and detrusor instability]. / Eficacia del cloruro de oxibutinina en niños con inestabilidad del detrusor y reflujo vesicoureteral.

OBJECTIVE: The purpose of this study was to assess the urodynamic (UD), radiological (VCUG) and clinical outcome in patients with detrusor instability (DI) and vesico-ureteral reflux (VUR). PATIENTS AND METHODS: UD and VCUG findings in 24 patients between 4 and 18 years of age (mean 7.6 years) with a simultaneous diagnosis of VUR and DI were reviewed. All presented with recurrent urinary tract infections (UTI). Twenty were female of whom 8 also had enuresis and daytime symptoms. Ten had bilateral VUR, making a total of 34 units. Mean follow-up was 40 months (range 18-97 months) and at least 2 UD studies were done. Treatment consisted of oxybutinin chloride (OC) and chemoprophylaxis. RESULTS: Treatment lasted an average of 31 months with an average dose of 11 mg/day. There was a statistically significant improvement in UTI rate, enuresis score and UD parameters [CysCap, volume at 1st contraction, maximum contraction and compliance (comp)]. Thirteen patients achieved stable bladders and 9 had some UD improvement (3 with low compliance and 2 with less severe DI), leaving 2 with unchanged DI. Reflux disappeared in 20 units and was downgraded in 6. VUR improvement coincided with the cases of UD improvement. Persistence of DI was always associated with persistent VUR. CONCLUSIONS: Oxybutinin treatment can be long, but UD and VUR improvement run parallel in most cases. The rare discrepant cases point towards a multifactorial ethology in this condition.

[The use of the IPSS questionnaire in surgical patients. International Prostatic Symptom Score]. / Uso del cuestionario IPSS en pacientes operados.

Some feasibility problems were detected during the evaluation of the IPSS questionnaire in Spanish that might limit its application. Our initial experience with the IPSS in patients undergoing surgery had 3 aims: 1) assess if changes in format and wording will improve feasibility; 2) evaluate symptoms before and after surgery according to the patients' point of view and 3) determine possible predictive factors of bad outcome in patients undergoing surgery for BPH. 50 patients were included and 35 completed symptom and urolow evaluation before and after the intervention. First objective: a modified format improved feasibility up to 92% (from 49% with the original format). Second objective: 7 patients had a poor symptomatic outcome (either worsened or had an unsignificant improvement), but only one of them had a low postoperative Qmax. Third objective: patients with preoperative urinary retention had a worse urodynamic outcome, but most improved in their symptoms. Worse symptomatic results occurred in: a) patients with a IPSS score smaller than 13 and b) patients undergoing transurethral incision of the prostate. The results are presented both in global (comparison of mean values) and in an individualized manner to call upon the pitfalls in their interpretation.

[The IPPS questionnaire in patients and controls. Psychometric validation]. / Cuestionario IPSS en pacientes y controles. Validación psicométrica.

The translation into Spanish of the AUA/International Prostatic Symptom (AUA/IPS) Score hadn't been validated in spanish. METHODS. AUA/IPS questionnaire was self administered by 103 consecutive patients and by 24 healthy volunteers. An alternative formulation to question 4 (ALT-4) was added. RESULTS. 51 patients (49%) and 17 controls (79%) completed al questions (Feasibility). Reliability was measured by: a) Crohnbach's alpha (0.68 and 0.70 with ALT-4) b) Kendall's coefficient of concordance (0.097, significance < 0.001) and c) retesting 17 patients within 2 months. The relation of the AUA/IPS scores with quality of life (Construct validity) showed a Spearman's correlation coefficient of 0.57 (confidence = 0.0001), and 0.52/0.0004 with ALT-4. The relation with uroflowmetry (Concurrent empirical validity) was poor as shown in ROC curves. CONCLUSIONS. The Spanish version of the AUA/IPS questionnaire given in an easy format improves feasibility without alteration of reliability or validity. The relation of the AUA/IPS score with uroflowmetry is poor, although the questionnaire can be considered valid and reliable.