Transvaginal bladder neck closure with posterior urethral flap for devastated urethra.

OBJECTIVES: To present a modified transvaginal bladder neck closure (TV BNC) technique using a posterior urethral flap to minimize the potential risk of ureteral injury and fistula formation. Urethral and bladder neck destruction owing to chronic indwelling urethral catheters in female neurogenic patients is a devastating complication. METHODS: A retrospective review was performed of all patients undergoing TV BNC at a single institution during a 3-year period. All patients had had a nonfunctional or destroyed urethra because of a long-term indwelling urethral catheter. In brief, the devastated outlet was closed using the dorsally bivalved urethra as a flap that was rotated cephalad onto the incised anterior bladder wall for closure, thereby rotating the suture line high into the retropubic space. A postoperative cystogram was obtained at 2-3 weeks. RESULTS: A total of 11 consecutive female patients with a devastated outlet underwent TV BNC, as described, with placement of a suprapubic tube. One patient experienced failure at 6 weeks postoperatively. The mean follow-up for the entire cohort was 9.6 months (range 1-36). Serial upper tract imaging at the last follow-up visit revealed no new hydroureteronephrosis. CONCLUSIONS: The results of our study have shown that TV BNC with a posterior urethral flap provides satisfactory early results. This technique creates a suture line far removed from the ureteral orifices, minimizing the risk of upper tract injury during closure. Also, the rotation of the posterior urethra onto the anterior bladder wall secures the suture line high into the retropubic space, minimizing the risk of failure and postoperative fistula formation.

Urodynamics in the evaluation of overactive bladder.

Overactive bladder (OAB) is a clinical syndrome characterized by urinary urgency, frequency, and nocturia with or without accompanying urinary incontinence. Thus, using this operational definition based on symptoms at presentation, urodynamic testing is not required for an initial diagnosis of OAB. An increasing body of evidence suggests that, although there is a relationship between the urodynamic finding of detrusor overactivity and OAB, these are quite separate findings, and successful response to nonsurgical and surgical interventions for OAB does not depend on finding detrusor overactivity on urodynamic testing. The role of urodynamics in the setting of OAB is not well defined at present, but there are several clinical scenarios where such testing may be useful. However, at this time, the evidence to support their routine use in patients with OAB is limited.

Which injectable to use in the treatment of intrinsic sphincter deficiency?

PURPOSE OF REVIEW: Injectable agents are frequently used in the treatment of stress urinary incontinence in a variety of patients. Materials and techniques used in this therapy have evolved over time, with the relatively recent introduction of several novel therapies. The publication of recent evidence regarding these newer agents as well as older materials has provided fuel for the debate over which therapy is best. RECENT FINDINGS: Each of the agents discussed in this paper has variable biophysical properties that affect its efficacy and safety. Despite increasing evidence evaluating the various injectable materials for the treatment of stress incontinence, there is no clear data to establish any agent as superior or inferior in the various subgroups in which they are used. SUMMARY: The ideal periurethral injectable agent has not yet been identified though many of the currently used agents have acceptable efficacy in selected populations. There is active research into novel therapies that may prove effective.