¿Es eficaz a largo plazo la malla ajustable TVA en el tratamiento de la incontinencia de esfuerzo femenina? / Is the adjustable TVA mesh effective for the long-term treatment of female stress incontinence?

Objetivos: Valorar a largo plazo la eficacia y seguridad de la malla ajustable TVA en el tratamiento de la incontinencia urinaria de esfuerzo. Material y métodos: Estudio seudoexperimental, antes y después, realizado en un servicio universitario de urología. Ochenta y dos pacientes fueron invitadas a participar desde enero de 2002 a marzo de 2005. Treinta y dos accedieron a participar y se les implantó una malla ajustable TVA. El estudio preoperatorio incluyó historia médica, examen físico con vejiga llena, flujometría, residuo, estudio urodinámico completo y los cuestionarios autoadministrados I-QoL, ICIQ-SF. En la evaluación postoperatoria se añadió el cuestionario PGI-I, no realizándose el estudio urodinámico completo. Resultados: Veintinueve pacientes (90,6%) eran continentes en la prueba de esfuerzo al año. Veintiocho (87,5%) a los diez años. Veinte pacientes (62,5%) nunca tenían escape al año. Dieciséis (50%) a los diez años. Veintiocho pacientes (87,5%) estaban satisfechos al año de la cirugía. Veinticinco (78%) a los diez años. Veintiocho (87,5%) tenían buena calidad de vida al año y veintiuno (62,5%) a los diez años. No hubo complicaciones importantes al final del periodo de estudio. Conclusiones: El tratamiento de la incontinencia urinaria de esfuerzo con malla TVA presenta un alto grado de cura objetiva y satisfacción a los diez años, sin efectos adversos graves. El estudio muestra que la satisfacción no siempre significa continencia total sino que expresa la mejoría de los síntomas y la consiguiente calidad de vida

Objectives: To assess the long-term safety and efficacy of the adjustable TVA mesh in treating stress urinary incontinence. Material and methods: Pseudoexperimental study, before and after, conducted in a university urology department. Eighty-two patients were invited to participate from January 2002 to March 2005. Thirty-two patients agreed to participate and were implanted an adjustable TVA mesh. The preoperative study included a medical history review, physical examination with full bladder, flowmetry, residue study, complete urodynamic study and the self-administered questionnaires I-QoL and ICIQ-SF. In the postoperative assessment, the PGI-I questionnaire was added, but a complete urodynamic study was not performed. Results: Twenty-nine (90.6%) and 28 (87.5%) patients were continent in the stress test at 1 and 10 years, respectively. Twenty (62.5%) and 16 (50%) patients had no urine escape at 1 and 10 years, respectively. Twenty-eight (87.5%) and 25 (78%) patients were satisfied 1 and 10 years after the surgery, respectively. Twenty-eight (87.5%) and 21 (62.5%) patients had a good quality of life at 1 year and at 10 years, respectively. There were no significant complications at the end of the study period. Conclusions: Treatment of stress urinary incontinence with the TVA mesh presented a high degree of objective healing and satisfaction at 10 years, with no severe adverse effects. The study showed that satisfaction does not always mean total continence but rather it reflects the improvement of symptoms and consequent quality of life

Is the adjustable TVA mesh effective for the long-term treatment of female stress incontinence? / ¿Es eficaz a largo plazo la malla ajustable TVA en el tratamiento de la incontinencia de esfuerzo femenina?

OBJECTIVES: To assess the long-term safety and efficacy of the adjustable TVA mesh in treating stress urinary incontinence. MATERIAL AND METHODS: Pseudoexperimental study, before and after, conducted in a university urology department. Eighty-two patients were invited to participate from January 2002 to March 2005. Thirty-two patients agreed to participate and were implanted an adjustable TVA mesh. The preoperative study included a medical history review, physical examination with full bladder, flowmetry, residue study, complete urodynamic study and the self-administered questionnaires I-QoL and ICIQ-SF. In the postoperative assessment, the PGI-I questionnaire was added, but a complete urodynamic study was not performed. RESULTS: Twenty-nine (90.6%) and 28 (87.5%) patients were continent in the stress test at 1 and 10 years, respectively. Twenty (62.5%) and 16 (50%) patients had no urine escape at 1 and 10 years, respectively. Twenty-eight (87.5%) and 25 (78%) patients were satisfied 1 and 10 years after the surgery, respectively. Twenty-eight (87.5%) and 21 (62.5%) patients had a good quality of life at 1 year and at 10 years, respectively. There were no significant complications at the end of the study period. CONCLUSIONS: Treatment of stress urinary incontinence with the TVA mesh presented a high degree of objective healing and satisfaction at 10 years, with no severe adverse effects. The study showed that satisfaction does not always mean total continence but rather it reflects the improvement of symptoms and consequent quality of life.

[TVA and TOA. New adjustable mesh for the treatment of female stress incontinence. Preliminaries results]. / TVA y TOA. Nuevas mallas ajustables de tensión en el tratamiento de la incontinencia urinaria de esfuerzo. Resultados preliminares.

OBJECTIVES: Evaluation of a new mesh for incontinence (TVA/TOA) which enables the degree of tension applied during surgery to be readjusted at the post-operative stage. PATIENTS AND METHOD: 62 patients treated with the TVA mesh and monitored over a 14-month period (SD 7.8, range 6-38). In 33 patients (53%) some other pelvic prolapse was corrected. Evaluation was carried out by clinical report, examination of bladder full of 250 saline solution, flowmetry and urinary residue. 40 patients filled in 4 quality of life questionnaires (QoL; ICIQ-SF; PGI-S; PGI-I). RESULTS: 42 patients were found to be objectively continent in the post-operative evaluation. Of these, it was necessary to reduce tension in 7 cases (11%) due to urinary obstruction (flow < 10 ml/sec and/or residue). The tension of the mesh was tightened in 20 patients (32%) due to continue with a certain degree of incontinence. All patients were discharged as continent and with no residue. In the last revision, 58 patients (93%) proved to be objectively continent and 4 (6.5%) showed a notable improvement in their incontinence. The Q(MAX) is 19.8 ml/sec (SD 9.8). The mictional urgency had disappeared or improved in 32 of the patients who had this prior to operation (76%) and had appeared in 3 of the patients who didn't (15%). The clinical report showed a high level of consensus with the ICIQ-SF survey (Kappa = 0.89) regarding stress incontinence, diminishing clearly (Kappa= 0.13) when urge incontinence was taken into account. 34 (85%) patients scored over 95 out of 110 in the QoL. 30 (75%) scored less than 6 in ICIQ-SF. 32 (80%) showed a perception of normality and 4 (10%) slight illness in the PGI-S. In the PGI-I 29 (72.5%) were much better and 11 (27.5%) quite a lot better. A relation exists between urgency and dismissed quality of life. CONCLUSION: With the TVA (trans-vaginal adjustable) mesh it is possible to adjust the tension originally applied during surgery at the post-operative stage, so that any defects or excesses can be corrected.

TVA y TOA. Nuevas mallas ajustables de tensión en el tratamiento de la incontinencia urinaria de esfuerzo. Resultados preliminares / TVA and TOA. New adjustable mesh for the treatment of female stress incontinence preliminaries resulted

Objetivos: Valoración de una nueva malla de incontinencia (TVA/TOA) que permite postoperatoriamente ajustar la tensión dada en quirófano. Pacientes y Métodos: 62 pacientes tratados con la malla TVA, seguimiento medio de 14 meses (DS 7,8, rango 6-38). En 33 pacientes (53%) se añadió corrección de algún prolapso. La valoración se ha realizado mediante historia clínica, exploración con vejiga llena con 250 cc de suero salino, flujometría y residuo. 40 pacientes han rellenado 4 cuestionarios de calidad de vida. (QoL; ICIQ-SF; PGI-S y PGI-I). Resultados: 42 pacientes eran continentes en la valoración post-operatoria. De estos, fue necesario disminuir la tensión en 7 (11%) por obstrucción urinaria (flujo< 10 ml/seg y/o residuo). En 20 pacientes (32%) se aumentó la tensión por continuar algún grado de incontinencia. Todos fueron dados de alta continentes y sin residuo. En la última revisión, 58 (93%) son totalmente continentes y 4 (6,5%) han mejorado notablemente su incontinencia. El QMAX es 19,8 ml/s (DS 9,8). La urgencia miccional ha desaparecido o mejorado en 32 (76%) de los pacientes que la presentaban preoperatoriamente y ha aparecido en 3 (15%) de los que no la presentaban. La historia clínica muestra un alto grado de concordancia con el cuestionario ICIQ-SF (Kappa= 0,89) en cuanto a incontinencia de esfuerzo se refiere, disminuyendo ostensiblemente (Kappa= 0,13) cuando se toma en consideración la incontinencia por urgencia. De los 40 pacientes que completaron los cuestionarios de calidad de vida, 34 (85%) tienen una puntuación superior a 95 sobre 110 en el QoL. 30 (75%) tiene una puntuación inferior a 6 en ICIQ-SF. 32 (80%) tienen una percepción de normalidad y 4 (10%) de enfermedad leve en el PGI-S. En el PGI-I 29 (72,5%) están mucho mejor y 11 (27,5%) bastante mejor. Existe relación directa entre urgencia miccional y pérdida de calidad de vida. Conclusión: La malla TVA (transvaginal ajustable) permite ajustar la tensión dada en quirófano, permitiendo corregir los defectos y los excesos

Objectives: Evaluation of a new mesh for incontinence (TVA/TOA) which enables the degree of tension applied during surgery to be readjusted at the post-operative stage. Patients and Method: 62 patients treated with the TVA mesh and monitored over a 14-month period (SD 7.8, range 6-38). In 33 patients (53%) some other pelvic prolapse was corrected. Evaluation was carried out by clinical report, examination of bladder full of 250 saline solution, flowmetry and urinary residue. 40 patients filled in 4 quality of life questionnaires (QoL; ICIQ-SF; PGI-S; PGI-I). Results: 42 patients were found to be objectively continent in the post-operative evaluation. Of these, it was necessary to reduce tension in 7 cases (11%) due to urinary obstruction (flow< 10 ml/sec and/or residue). The tension of the mesh was tightened in 20 patients (32%) due to continue with a certain degree of incontinence. All patients were discharged as continent and with no residue. In the last revision, 58 patients (93%) proved to be objectively continent and 4 (6.5%) showed a notable improvement in their incontinence. The QMAX is 19.8 ml/sec (SD 9.8). The mictional urgency had disappeared or improved in 32 of the patients who had this prior to operation (76%) and had appeared in 3 of the patients who didn’t (15%). The clinical report showed a high level of consensus with the ICIQ-SF survey (Kappa = 0.89) regarding stress incontinence, diminishing clearly (Kappa= 0.13) when urge incontinence was taken into account. 34 (85%) patients scored over 95 out of 110 in the QoL. 30 (75%) scored less than 6 in ICIQ-SF. 32 (80%) showed a perception of normality and 4 (10%) slight illness in the PGI-S. In the PGI-I 29 (72.5%) were much better and 11 (27.5%) quite a lot better. A relation exists between urgency and dismissed quality of life. Conclusion: With the TVA (trans-vaginal adjustable) mesh it is possible to adjust the tension originally applied during surgery at the post-operative stage, so that any defects or excesses can be corrected

[Techniques and current practice of urodynamics. Problems and traps]. / Técnica y actualidad de la urodinámica. Problemas y retos.

Development of urodynamics particularly during the past decade are highlighted, as well as a number of issues to be faced in the near future: research into the etiopathogenesis of different conditions, finding more sensitive and specific diagnostic procedures to overcome the current ones, establishing more comprehensive indications for urodynamics examinations and, as a result of all the above achieving greater improvement of certain surgical procedures. Both the technique and interpretation of the different urodynamic examinations, as well as the more recent innovations, implementation issues and controversies are detailed to a highly up-to-date level. Neuromodulation and ambulatory urodynamics deserve thoughtful consideration in this paper. Finally, attention is given to the controversies and future challenges such as urodynamic research providing accurate diagnosis of lower urinary tract obstruction in women, establishing the indication of urodynamic studies in women with urinary exertional incontinence, outlining the indications of neuromodulation and ambulatory urodynamics, applicability of artificial intelligence systems, improvement of artificial sphincter materials, tissue growth for bladder enlargement and actual prevention of myelodysplasia.

Técnica y actualidad de la urodinámica. Problemas y retos / Urodynamics technique and current situation. Issues and challenges

El presente artículo pone de manifiesto el avance experimentado por la urodinámica fundamentalmente en la última década, así como los problemas a los que tendrá que hacer frente en el futuro: investigación en la etiopatogenia de diferentes enfermedades, buscar procedimientos diagnósticos más sensibles y específicos que los actuales, establecer indicaciones más exhaustivas para las exploraciones urodinámicas y con ello, conseguir el perfeccionamiento de determinados procedimientos quirúrgicos. Se detalla la técnica e interpretación de las diferentes exploraciones urodinámicas a un nivel muy actual, así como las novedades existentes, las dificultades de aplicación y controversias. La neuromodulación y la urodinámica ambulatoria merecen detalle en este artículo. Finalmente se muestran las controversias y retos de futuro, como son la investigación urodinámica que proporcione de forma precisa el diagnóstico de la obstrucción del tracto urinario inferior en la mujer, establecer la indicación del estudio urodinámico en la mujer con incontinencia urinaria de esfuerzo, perfilar las indicaciones de la neuromodulación y de la urodinámica ambulatoria, aplicabilidad de sistemas de inteligencia artificial, mejorar los materiales del esfínter artificial, desarrollo de tejidos para realizar ampliaciones vesicales y la prevención real de la mielodisplasia (AU)

Development of urodynamics particularly during the past decade are highlighted, as well as a number of issues to be faced in the near future: research into the etiopathogenesis of different conditions, finding more sensitive and specific diagnostic procedures to overcome the current ones, establishing more comprehensive indications for urodynamics examinations and, as a result of all the above achieving greater improvement of certain surgical procedures. Both the technique and interpretation of the different urodynamic examinations, as well as the more recent innovations, implementation issues and controversies are detailed to a highly up-to-date level. Neuromodulation and ambulatory urodynamics deserve thoughtful consideration in this paper. Finally, attention is given to the controversies and future challenges such as urodynamic research providing accurate diagnosis of lower urinary tract obstruction in women, establishing the indication of urodynamic studies in women with urinary exertional incontinence, outlining the indications of neuromodulation and ambulatory urodynamics, applicability of artificial intelligence systems, improvement of artificial sphincter materials, tissue growth for bladder enlargement ad actual prevention of myelodysplasia (AU)

[Urodynamics of enterocystoplasty and continent diversions]. / Urodinámica de la enterocistoplastia y derivaciones continentes.

OBJECTIVE: To describe the filling and voiding urinary dynamics of enterocystoplasty and continent urinary diversion. METHODS: The different behaviour of the tubularized and detubularized intestinal segments and the different sphincteric lesions related with various surgical techniques are described. The possible causes of incontinence are discussed and the literature briefly reviewed. RESULTS/CONCLUSIONS: We underscore the importance of detubularizing the intestinal segment and preserving the sphincteric system as far as possible. Furthermore, voiding using abdominal pressure may cause post void residual urine, dilatation of the neobladder and renal changes. If warranted, self-catheterization should be performed.

[Prediction of continence in patients with neurogenic bladder who will be treated with bladder augmentation]. / Predicción de la continencia en pacientes con vejiga neurógena a quienes se va a realizar una ampliación vesical.

Twenty four patient with neurogenic bladder undergoing vesical enlargement were pre-operatively evaluated to determine the need to perform also an anti-incontinence technique. None of them had such a technique performed, so as to control whether our prediction was correct. Each patient had one or more video-urodynamic studies performed to evaluate adjustment and the likely vesical hyperreflexia, critical incontinence pressure, and the presence of leaks with cough and cervicourethral morphology at different filling times. Critical incontinence pressure and presence of contrast leaks with cough, the latter demanded with moderate intravesical pressures, have been the parameters which better predicted the likely incontinence, with reliability over 90%. With regard to myelodysplastic bladders, the study shows the relevance of the detrusor as a cause of incontinence and sustains the practice of implementing only the cervical cuff without the remaining components when the artificial sphincter is chosen as the anti-incontinence technique, when the likely cause, whether sphincter or detrusor, is unclear at the time of considering vesical enlargement.

[Renal and urinary tract leishmaniasis. A disease to keep in mind]. / Leishmaniasis renal y vías urinarias. Patología a tener en cuenta.

Report of a case of renal and urinary tract leishmaniasis in a 61-year old male patient. The ureteral lesion responded favourably to treatment, unlike the renal one which required conservative surgery. Review of the literature stressing the fact that no other case has been found of kidney and urinary tract involvement. It is concluded that in the future, at least in those areas with a high prevalence of leishmaniasis, this condition should be taken into account as differential diagnosis when facing a toxic picture with renal involvement of the calyceal ecstasies type.

[The acquired urethrorectal fistula: a rare pathology]. / Fístula uretro-rectal adquirida: patología poco frecuente.

OBJECTIVES: Conservative management of iatrogenic urethro-rectal fistula is discussed and the literature briefly reviewed. METHODS/RESULTS: The patient's only symptom was rectal voiding, which he considered was not enough to justify an operation. At one-year follow up, patient condition remains unchanged. CONCLUSION: Patients with urethro-rectal fistula and a competent bladder neck, whose only symptom is rectal voiding, can be managed conservatively if the patient refuses an operation.

[Treatment of urinary incontinence with the artificial sphincter AUS-800. Our experience]. / Tratamiento de la incontinencia urinaria con el esfínter artificial AUS-800. Nuestra experiencia.

The present study reviewed the first 25 incontinence prostheses implanted at the Urology Services of the Ramón y Cajal Hospital. The literature is briefly reviewed and the indications for the AUS-800 incontinence prosthesis are discussed.

[Retroperitoneal paraganglioma. Infrequent pathology]. / Paraganglioma retroperitoneal. Patología poco frecuente.

Presentation of 3 cases of retroperitoneal paraganglioma non pre-operatively diagnosed: one dependent of the Zuckerkandl's organ with ultrasound examination showing a panelled cystic mass, and two located in the renal parahilar area, all accidental findings during renal surgery. Lack of appropriate pre-operative background and diagnosis produced a hypertensive crisis in one patient during removal manoeuvres which was entirely controlled. After a 4-, 2- and 1-year follow-up, respectively, patients remain asymptomatic and disease-free. An analysis of the most relevant features in these retroperitoneal tumorations was carried out from a clinical, diagnostic, therapeutic and prognostic point of view.

[Primary amyloidosis in the bladder: diagnostic and therapeutic update]. / Amiloidosis primaria de localización vesical: actualización diagnóstica y terapéutica.

We describe an additional case of primary amyloidosis of the bladder whose form of presentation warranted a differential diagnosis from carcinoma of the bladder. The diagnosis was made on the histological findings and the immunohistochemical analyses revealed amyloid fibrils that reacted against the light chain lambda antiserum. The treatment of choice was TUR, which resolves the condition in most of the cases. Conservative surgery, however, does not prevent new deposits and undetected residual lesions may persist, which may warrant other complementary procedures in these patients. After the diagnosis has been made, it is important to discard systemic amyloidosis.

[New location of aggressive angiomyxoma: the bladder]. / Nueva localización del angiomixoma agresivo: la vejiga.

Presentation of one case of aggressive angiomyxoma with vesical location in a 31-year-old female patient who underwent partial surgery, and who 8 years later remains disease-free. Emphasis is made on the low frequency of these tumours, of which only 26 cases are described in the international literature. All these cases have been located in soft areas of the pelvis and the perineum, with the exception of the one presented here, the first one with a vesical location. Clinical behaviour is characterized by the absence of metastasis and a great tendency to local relapse, 70% of cases reported.

[Synchronous and bilateral inverted papilloma of the kidney pelvis. Conservative treatment]. / Papiloma invertido bilateral y sincrónico de pelvis renal. Tratamiento conservador.

Contribution of a new case of inverted papilloma (IP) of the upper urinary tract (UUT) with the idiosyncrasy of being bilateral and synchronic, a fact not found in the reviewed literature, treated with radical surgery on the left side and conservatively on the right one. Discussion on this pathology is addressed, emphasising its benign biological behaviour, which does not eliminate some cases of malignization. Treatment has to be conservative, and so we stress the relevance of defining a suspicion state to make pre- and peri- operative diagnosis in which endourological methods, that allow both direct visualization and the taking of a biopsy, play a preeminent role. Subsequent strict monitoring is essential due to the likelihood of relapse and malignant changes.

[Enterocystoplasty in the treatment of myelodysplastic bladder]. / La enterocistoplastia en el tratamiento de la vejiga mielodisplásica.

Over the last five years 18 myelodisplastic patients with neurogenic bladder have undergone in our Unit a surgical operation consisting in vesical enlargement with patch-like bowels. They all had incontinence and urinary infections and there was a high percentage of pyelonephritic events. A report on the results from 13 patients whose post-operative evolution is longer than one year is included. Eleven patients were completely and two partially continent; pyelonephritic events have ceased or became more spaced; renal function, assessed by UIV is within normal values or shows improvement in 22 renal units while only one patient, out of 11 pre-operative cases, continues having vesico-renal reflux.

[Diagnostic yield of the urodynamic study of the upper urinary tract in the orthotopic and transplanted kidney]. / Rentabilidad diagnóstica del estudio urodinámico del tracto urinario superior, en el riñón ortotópico y trasplantado.

Urodynamic pressure-flow studies (Whitaker test) of 28 kidneys (21 orthotopic and 7 transplanted) with equivocal obstruction of the upper urinary tract (UUT) yielded a sensitivity rate of 77.7% and a specificity rate of 75% in the orthotopic kidney, and sensitivity and specificity rates of 75% in the transplanted kidney. Trauma to the transplanted kidney (denervation, ischemia and surgery) does not modify the urodynamic of the pyelocaliceal system, thus conferring on the test the same diagnostic reliability as in the orthotopic kidney.

[Urinary de-diversion, technical modification for creating a low-pressure bladder]. / Desderivación urinaria, modificación técnica para la creación de una vejiga de baja presión.

Urinary unidiversion permits the possibility of enhancing the quality of life and probably the survivorship of previously diverted patients. A modification of this technique is described which utilizes Brickne's loop and a segment of the sigmoid to create a low pressure bladder, thus sparing more intestine. The good result achieved with this technique is underscored. In our view, urinary undiversion must meet the following two conditions: to enhance patient quality of life and not to deteriorate renal function .

[Instability of the detrusor. Treatment with oxybutynin chloride (Ditropan) in children]. / Inestabilidad del detrusor. Tratamiento con cloruro de oxibutinina (Ditropan) en niños.

We study the effect of oxybutynin chloride (Ditropan) in a random sample of 24 children with ages ranging from 5 to 14 years, diagnosed as having vesical instability from both the clinical and urodynamic standpoints. These effects were evaluated after a period of treatment that ranged from 10 to 36 months (x = 20). We obtained overall clinical improvement in 87.5%, and improvement of urodynamic alterations in 83.3% of the patients. We single out the beneficial effect of oxybutynin chloride with prolonged treatments, in instability of the detrusor, as well as its good tolerance.

[Ectopic opening of the ureter into the ejaculatory duct. Use of ultrasound-directed vesiculography in the diagnosis of this type of malformation]. / Desembocadura ectópica de uréter a conducto eyaculador. Utilidad de la vesiculografía directa ecodirigida en el diagnóstico de este tipo de malformaciones.

We report a right mesonephric duct malformation consisting of an ectopic ureter opening into the ejaculatory duct, ipsilateral renal agenesia, ipsilateral seminal vesicle cyst, and contralateral renal malrotation. The diagnostic methods considered useful in this condition are described, including direct ultrasound-guided vesiculography, a technique which, in our experience, is easy to perform and has proved to be very useful.