Long-term results of Burch colposuspension and anterior colpoperineorraphy in the treatment of stress urinary incontinence and cystocele.

OBJECTIVE: Female urinary incontinence and bladder prolapse are very common conditions whose treatment is not standardized. The aim of this study was to evaluate retrospectively the long-term results of Burch colposuspension and anterior colpoperineorrhaphy in the treatment of stress urinary incontinence (SUI) and cystocele, respectively. MATERIALS AND METHODS: We reviewed 36 female patients with a mean follow-up of 53 months. Mean patient age at time of surgery was 57.3 +/- 9.6 years (range 37-76). All patients were submitted to urodynamic investigation. Anterior colpoperineorrhaphy was performed in 18 cases (13 with cystocele, one with SUI and four with both). Burch colposuspension was performed in 14 cases (six with SUI and eight with both cystocele and SUI). The association of the two surgical procedures was used in four cases with both cystocele and SUI. RESULTS: Satisfactory results, such as disappearance of SUI with Burch colposuspension and cystocele with colpoperineorrhaphy, were obtained in the 88.8% and 85.8% of the cases, respectively. These results are even more excellent considering that 22.5% of the patients failed previous surgery. We observed no significant complications. CONCLUSIONS: The high percentage of long-term success confirms that anterior colpoperineorrhaphy and Burch colposuspension are two effective therapeutic choices for cystocele and SUI, respectively. The new mini-invasive techniques have to be compare with these traditional surgical treatments which efficacy is consolidated.

Iatrogenic ejaculation disorders and their prevention.

Ejaculation is mediated by sympathetic fibers originating from the D10-L2 medullar center. These nerves rise from the lumbar ganglia of the paravertebral sympathetic trunk and travel posteriorly to the vena cava and then to the interaortocaval space, on the right side, and laterally to the aorta, on the left side. They are the principal constituents of the superior hypogastric plexus. Many surgical operations can cause an ejaculation disorder, but the most important is retroperitoneal lymphadenectomy (RL) for testis cancer, because it involves young patients and it has been the subject of important researches in order to perform lymph node dissection without ejaculation loss (unilateral lymphadenectomy and nerve sparing lymphadenectomy). Our experience concerns 41 patients who underwent RL for testis cancer from 1983 to 1998. Survival rate was 95.2% (mean follow up 64 months). RL was performed bilaterally in 14 patients. Two of them died of metastases within 2 years after the operation. Ejaculation was maintained in only 4 of the 12 surviving patients (33%). All the 17 patients (100%) underwent right monolateral RL and 7 of the 10 (70%) underwent left monolateral RL preserved ejaculation. The anatomosurgical concepts of the RL sparing the ejaculation can be adopted in other retroperitoneal surgical operations that can produce ejaculation disorders, such as wide lymphadenectomy for renal cell carcinoma or tumors of the upper urinary tract, exeresis of pre- aortic tumors, exeresis or disjunction of horseshoe kidney and aorto-iliac revascularization. Surgical therapy of benign prostatic hyperplasia (BPH) (open surgery or transurethral prostatic resection) is associated with retrograde ejaculation in nearly 100% of cases. The mechanism of the dysfunction is clear, if following the procedure the bladder neck remains opened. Loss of ejaculation is reported in variable percentage after the newer endoscopic techniques for the treatment of BPH. Transurethral needle ablation (TUNA) seems to have the lower risk of retrograde ejaculation. Retrograde ejaculation can also be related to a traumatic injury of the posterior urethra, because of the trauma itself or the therapy. Finally, the ejaculation disorder can be produced by several drugs that block, as a main or secondary effect, the alpha-adrenoreceptors or act at the central level. This side effect has to be kept in mind when these drugs are used in young or sexually active patients.