Biomechanics of urinary stress incontinence surgery--theory of the non-permanently acting suburethral supportive structure.

This biochemical study of the lower urinary tract as it relates to urinary continence and incontinence is based on the morphotopographic results of radiological, autopsy and surgical investigations in the period 1966-1968. The process of urinary continence is simply explained by the application of universal hydromechanical laws, which demonstrated that continence during straining results from compression of the urethra over a suburethral resistant structure. Compression occurs during dorsocaudal physiologic displacement of the urethrovesical complex in conditions of increased intra-abdominal pressure. The theory of a non-permanently acting suburethral support is based on these results and represents the essential principle of urinary stress incontinence surgery, namely, that surgery should create a suburethral resistance over which the proximal urethra is compressed during increased intra-abdominal pressure. Such suburethral resistance may be created via the vaginal or the abdominal routes, using autogenous or heterogeneous tissue. A critical analysis of different surgical techniques and how they achieve the demands of this theory is presented. In this context two orginal surgical procedures incorporating the best biomechanical features are elaborated: slinglike colposuspension via the abdominal route, and suburethral duplication of the anterior vaginal wall by the vaginal route. The aim of this paper is to present the biomechanical study of urethrovesical phenomena playing a role in urinary continence and the pathogenesis and surgery of stress incontinence in light of our theory. Our personal experience with 1,836 surgical procedures between 1968 and the end of 1997, encompassing 1,056 slinglike colposuspensions and 780 suburethral duplications of the vagina, gives practical support to our concepts.

The gamma-globin gene rearrangements in newborns from the Republic of Macedonia.

Cord blood samples of 3,232 newborns of different ethnic origins living in the Republic of Macedonia were analyzed by starch gel electrophoresis, polyacrylamide gel electrophoresis and reversed phase high performance liquid chromatography. Hb Bart's was detected in 26 newborns (0.8%) indicating the low incidence of alpha-thalassemia in the Republic of Macedonia. Five different hemoglobin variants (Hb O-Arab, Hb Hamilton, Hb Strumica, Hb F-Macedonia-I, and Hb F-Macedonia-II) were also detected. The levels of the G gamma chains fell into three categories; normal range with G gamma between 50 and 80% (3,143 newborns or 97.2%), low range with G gamma levels of < 50% (35 newborns or 1.1%), and high range with G gamma levels of > 80% (54 newborns or 1.7%). The overall incidence of the A gamma T variant was 20.8%, similar to that found in several Mediterranean populations. DNA analyses showed that the molecular basis of high and low G gamma determinants are heterogeneous in our population. gamma-Gene triplications and the G gamma G gamma arrangements were detected in newborns with high G gamma levels, while gamma gene deletions and A gamma A gamma arrangements were found in newborns with low G gamma levels. All but one of the 135 samples with G gamma between 50 and 80% had the normal G gamma A gamma arrangement on both chromosomes; the only exception was an Albanian newborn (G gamma = 63%) with an-A gamma/G gamma G gamma A gamma arrangement.

Obstetric ureterouterine fistula: a case report.

A fistula between the ureter and uterus is a rare disorder in obstetric practice. After reviewing available literature, we found only 27 published cases. We add our own case to this interesting surgical entity. Diagnostic and therapeutic approaches are presented.

Hb F-Macedonia-II [G gamma 104(G6)Lys-->Asn]: a new gamma chain variant.

In the course of our newborn screening program for the presence of hemoglobinopathies in the Republic of Macedonia, we have detected a new G gamma chain variant with a Lys-->Asn or AAG-->AAC substitution at codon 104. The variant was found in a blood sample from a healthy baby boy of Macedonian nationality. The abnormal chain was quantitated at 32.4% of the total gamma chains by reversed phase high performance liquid chromatography. The characterization of the variant was by sequence analysis of polymerase chain reaction-amplified DNA. The presence of the mutation in the mother was confirmed by Hph I restriction enzyme digestion of the polymerase chain reaction-amplified DNA fragment. Although the mutated G is the last nucleotide of exon 2 and part of the donor splice site sequence of the second intervening sequence of the G gamma gene, it appears that the splicing of the mRNA in this variant is not altered.

[Leiomyoma of the round ligament of the uterus]. / Leiomyoma ligamenti rotundi uteri.

A 53-year-old patient was surgically treated for a tumour the size of a female fist, located on the left of the uterus and appeared to be either a uterine myoma or an ovarian tumour, and also for urine incontinence. Laparotomy revealed a solid tumour on the uterine round ligament, about 2 cm from the uterine horn, and histologically diagnosed as leiomyoma. In the differential diagnosis the authors refer to Kleinwachter's sign having been known for a long time.

[Case report of clear cell carcinoma of the ovary (paramesonephric carcinoma of the ovary)]. / Povodom jednog slucaja karcinoma jajnika sa svetlim celijama (paramezonefricki karcinom jajnika).

A rare case of a clear cell carcinoma of the ovary (paramesonephric carcinoma of the ovary) is presented. Besides clinical implications, the authors discuss controversies concerning the histogenesis of these tumors.

[Pathogenesis of urinary stress incontinence and principles of its surgical treatment]. / Nasa shvatanja patogeneze urinarne stres inkontinencije i principi njenog operativnog lecenja.

As in different types of stress incontinence the mechanism of the destroyed urethral support is not the same, the principles of their surgical treatment are bound to differ. Generally speaking, the surgical intervention in stress incontinence aims at securing adequate mobility of the lower urinary organs, forming an effective suburethral support, and correcting the elements of the prolapse. Applying these principles in 508 women with stress incontinence having been surgically treated at the University Hospital Department of Gynecology and Obstetrics in Skopje from 1968 to 1976 and followed up at least two years afterwards, the global rate of relapses was 6.1%, by which the best results were obtained by Burch's modified method (2.1%), while after operations after Bonney or Barnett the frequency of relapses was relatively higher (7.1%). Analysing technical details in the carrying out of the above mentioned procedures, the authors plead for a most adequate preoperative preparation of patients, so as to determine and categorize the type of stress incontinence in question and allow the choice of the most appropriate surgical intervention in any given case.

[Results of an inquiry on stress urinary incontinence in women]. / Rezultati jedne ankete o stres inkontinenciji mokrace kod zena

The authors present the results of an inquiry into urinary stress incontinence in 415 women chosen at random, in whom the genital prolapse or stress incontinence were not complaints for hospitalization. The analysis also excluded all states of pregnancy or puerperium. As in other statistics, the frequency of urinary stress incontinence proved very high (39.2%). It is particularly interesting that 52.8% of the women questioned considered it as a completely normal event. A progressive increase in the frequency of stress incontinence related to aging. Stress incontinence was also twice as frequent in manual workers and housewives as in office workers, school girls, and students. In relation to obstetric traumatism, the disease is more frequent in parous women, showing a progressive increase with parity and the delivery of higher-weight newborns, whereas, quite unexpectedly, it proved rare in women with deliveries in intervals shorter than three years. A high incidence was recorded of stress incontinence having appeared in pregnancy for the first time (23.9%); in 59.0% of these women it persisted also after childbirth, which is very significant. Although the trouble is more frequent in menopausal patients, the effect of this period can hardly be separated from the effects related to senile involution. Besides emphasizing the role of the gynecologist, urologist, and general practitioner in the diagnosis of urinary stress incontinence in women, the data obtained raise the question of the revision of the existing views on the physiology of this disorder.

[New radiologico-clinical classification of changes in stress incontinence in women]. / Nova radiolosko-klinicka klasifikacija promena kod stres inkontinencije mokrace u zena

Setting forth their experience in over 800 colpocystographies applied in genital prolapse and stress incontinence, the authors propose an original classification of changes in urinary stress incontinence with a view to unifying clinical and radiological findings. Along with classical, wellknown radiological aspects (urethral vesicalization and the prolapse of the urinary bladder) one new type of changes is described. It is named the slipping prolapse of the urinary bladder and is determined by the deterioration of the urethro-vaginal septum leading to a completely isolated dislocation of the lower urinary organs and the frontal vaginal wall. The combination of these aspects gives the three types and six variants of stress incontinence which, from the clinical point of view, may be manifest, masked, and potential. The pathogenesis of different types of the disease is analysed, as well as the principles of their therapy. The authors plead for the widest possible use of colpocystography in the preoperative preparation on patients, especially in relapses, since the method is simple and harmless, yielding extremely useful informations in the study of the morphotopography of pelvic organs.

Colpocystography in cases of genital prolapse and urinary stress incontinence in women.

Experience with colpocystography used routinely in 586 cases of genital prolapse and urinary stress incontinence is described. Radiologic aspects are discussed and related to clinical findings by means of an original classification. The technique is described in detail. Systematic opacification of the urethra permits the study of changes in the urethrovaginal region. Contrary to prevailing opinion, the lower urinary system and the anterior vaginal wall do not participate concomitantly in the process of prolapse but sliding bladder prolapse, which may cause urinary stress incontinence, is often seen. Colpocystography is simple, easy, inexpensive, and safe. Its use in surgical gynecology assits in evaluation the tactical and technical indications, assessing the effectiveness of the operation, and studying recurrences and postoperative complications.