Effects of menstrual cycle and urinary tract instrumentation on uroflowmetry.

We sought to compare bladder emptying function in normal women during the proliferative and secretory phases of the menstrual cycle and to evaluate whether urethral catheterization affected uroflowmetry parameters. Forty-nine normal volunteers (ages 19-42 years) were recruited and underwent uroflowmetry in the proliferative and secretory phases of the menstrual cycle. A serum progesterone level of <3.0 ng/mL defined the proliferative phase. During the proliferative phase, volunteers underwent uroflowmetry analysis when a sensation of fullness was appreciated. A post-void residual volume was determined, and the bladder was filled with 400 mL of normal saline. Repeat uroflowmetry analysis was then performed. This two-step procedure was repeated at a separate visit during the secretory phase. Voided volume, residual volume, maximum and average flow rates, time-to-maximum flow, and duration of flow were recorded. Wilcoxon signed-rank tests were used for statistical analysis. A two-tailed alpha value of <0.05 defined statistical significance. Our analysis was limited to the 33 patients whose predicted menstrual dating correlated with the obtained progesterone levels. During the follicular phase, we found significantly faster maximum (P < 0.0001) and average flow rates (P = 0.01), along with a shorter time-to-maximum flow (P < 0.0001) and shorter duration of flow (P < 0.0001), during the pre-catheterized void than the post-catheterized void. Similar results were observed in the secretory phase with the exception of a slightly higher residual volume (P = 0.05). No difference was seen in any measured uroflowmetry parameter when comparing similar voids between phases of the menstrual cycle. We conclude that when evaluating pre-menopausal patients, uroflowmetry may be scheduled and performed during either phase of the menstrual cycle. Neurourol. Urodynam. 19:147-152.

Lower urinary tract injury during the Burch procedure: is there a role for routine cystoscopy?

OBJECTIVE: This study was undertaken to evaluate the use of intraoperative cystoscopy for the detection of incidental bladder or ureteral injuries during abdominal urethropexy procedures and to determine whether the incidence of injuries warrants the routine use of cystoscopy. METHODS: We reviewed the medical records of 109 consecutive patients who underwent abdominal urethropexy procedures between November 1990 and February 1996 at a teaching institution. Each underwent intraoperative cystoscopy. We determined the incidence of cystotomy and ureteral obstruction and attempted to determine surgical factors that might be associated with an increased risk of injury. RESULTS: Ten of 109 patients (9%) had bladder or ureteral injury, including 1 cystotomy during retropubic dissection, 6 cases of a transvesical suture noted during cystoscopy, 1 cystotomy recognized before closure, 1 case of ureteral obstruction found during cystoscopy, and 1 case of ureteral obstruction not recognized at cystoscopy. Cystoscopy allowed detection of 7 of 9 (78%) otherwise unrecognized events. The only injury that resulted in significant postoperative morbidity was the unrecognized ureteral obstruction. There was no association between incidence of lower urinary tract injuries and surgical risk factors. CONCLUSION: Intraoperative bladder or ureteral injuries during urethropexy procedures are not uncommon, with an incidence of 9% in our series. There is minimal morbidity if these injuries are detected and corrected during the operation, whereas morbidity may be significant if they remain unrecognized. With a potential for unrecognized injury in 8% of Burch procedures without the use of cystoscopy, routine use of cystoscopy during urethropexy procedures appears to be warranted.

Sling transection of urethra: a rare complication.

Common postoperative complications associated with suburethral sling procedures include voiding disorders and urinary retention, de novo development of detrusor instability, sling graft rejection and, rarely, erosion of the graft into the urethra. The authors present a case of a late postoperative complication of polytetrafluoroethylene graft erosion and partial transection of the urethra, with resultant acute urinary retention. A 50-year-old patient presented with acute urethral outflow obstruction due to sling graft erosion into the urethra nearly 2 years after she underwent a curative sling procedure for recurrent genuine stress incontinence. After relieving the acute urinary retention by inserting a suprapubic catheter under ultrasound guidance, the sling graft was accessed and removed. The urethral defect was repaired successfully. At follow-up 5 months later, the patient was continent subjectively and by urodynamic criteria, with no voiding abnormalities. Although erosion of the sling graft into the urethra and transection of this structure is a rare complication after a sling procedure, it should be considered in the patient who experiences progressive voiding difficulties, has transvaginal urinary leakage, and/or cannot be catheterized transurethrally. Expedient relief of the urinary retention and outflow obstruction is necessary, as well as careful surgical reconstruction of the urethra. To minimize the development of this complication we recommend plication of paraurethral connective tissue in the midline beneath the sling graft, and placement of minimal tension on the sling.

Suburethral paraganglioma.

Masses presenting beneath the urethra are not uncommon. Besides ureteral diverticula, which account for the vast majority of these masses, a multiplicity of heterogeneous benign and malignant tumors have been encountered in this region. To the best of our knowledge, we report the first case of a neuroendocrine tumor, a paraganglioma, discovered in the anatomical compartment between the urethra and vagina. When evaluating a patient with a suburethral mass, it is important to consider paraganglioma as part of the differential diagnosis because unwitting surgical removal of a functional catecholamine-secreting tumor may precipitate a severe hypotensive episode and/or death.