Experience with a bone anchor sling for treating female stress urinary incontinence: outcome at 30 months.

OBJECTIVES: To evaluate the clinical and video-urodynamic outcome in women with by stress urinary incontinence (SUI) treated with a bone-anchored pubovaginal sling. PATIENTS AND METHODS: The study included 70 women with SUI (as evaluated by a clinical examination, a voiding questionnaire, a short pad-test and video-urodynamics) who had a bone-anchor sling procedure, with or without cystocele repair, from January 1999 to December 2001; they were re-evaluated after a long-term follow-up (mean 30 months). RESULTS: The long-term outcome showed a success rate of > 95%; the clinical and video-urodynamic findings showed good functional and anatomical results, and an improvement in voiding performance in most patients. There was a low incidence of complications during and after surgery (2.8%). CONCLUSIONS: This approach gives, in highly selected patients, a high success rate and low incidence of complications. The technique is easy to learn and the costs to the financing bodies and public healthcare are low, making it a candidate for an alternative procedure to the standard techniques for SUI.

Digital fluorographic video-urodynamics in the long-term morphofunctional evaluation of Alcini's Ileocecourethrostomy and ileal reservoir.

INTRODUCTION: The authors present the functional long-term follow-up by means of digital fluorographic video-urodynamics (DFVUDM) of two different surgical urinary diversions. MATERIALS AND METHODS: 64 of 101 patients submitted to radical cystectomy from 1983 to 1999 for infiltrating bladder cancer, were diverted by means of an Alcini's ileocecourethrostomy (ICUS+T), and the remaining 37 patients by means of an ileal reservoir (IR). All of those orthotopically diverted patients were submitted to an accurate follow-up which included DFVUDM 1, 3, 6, and 9 years after the surgical procedure (mean follow-up 51 +/- 42 months). RESULTS: All the evaluated patients showed a neobladder with good function during both the filling and the voiding phases. In 88.8% of the DFVUDM examinations, it was possible to find a residual peristaltic activity of the neobladder walls. Such a residual peristaltic activity caused urinary leakage during the examination in 11.1% of cases, while vesico-ureteral reflux was detected in 12.5%. The patients voided by relaxing the perineal floor and/or by contracting the abdominal muscles: the emptying of the reservoir was often excellent with average residual urine of 28.5 ml. None of the patients needed clean intermittent catheterization. EMG evaluation of the pelvic floor in some of patients showed a peculiar EMG pattern characterized by an insufficient voluntary control of the perineal musculature with a slight increase of EMG activity during bladder filling. Moreover, an insufficient relaxation of the pelvic floor muscles in the beginning of and during the micturition has been seen. This particular EMG pattern was present in 22.22% of all patients included in this study while it was particularly high (81.81%) in patients with leakage. CONCLUSION: DFVUDM evaluation represents a highly sophisticated tool which allows an accurate long-term morphofunctional evaluation of the urinary diverted patients. In this study, it is shown that the functional results of the two studied surgical procedures, namely Alcini's ICUS+T and IR, are quite similar, demonstrating that the taeniotomies on the cecal tract may have almost the same functional effects of detubularization. Although DFVUDM revealed imperfect functional performances in some patients, the quality of life of diverted patients in our series seems to be satisfactory.

Modulation of viscero-somatic H-reflex during bladder filling: a possible tool in the differential diagnosis of neurogenic voiding dysfunctions.

OBJECTIVE: Despite evidence that the activation of visceral afferents modulates spinal motoneurone activity in humans, the circuits responsible for this modulation remain unclear. The aim of the present study was to assess the effect of urinary bladder filling on the excitability of somatic spinal motoneurones in patients affected by overactive bladder secondary to neurogenic and non-neurogenic causes in both patients with bladder underactivity and normal subjects by means of a urodynamic evaluation. METHODS: In order to evaluate the influence of bladder filling on somatic reflexes, we studied the H-reflex evoked by electrical stimuli applied to the tibial nerve at the popliteal fossa and recorded from the soleus muscle. The H-reflex was tested in the following conditions: (1). empty bladder; (2). medium bladder filling; (3). maximum bladder filling; (4). five minutes after bladder emptying. The H-reflex amplitude at empty bladder was considered as the control value. RESULTS: In healthy subjects, we observed a progressive reduction in the H-reflex amplitude during bladder filling. In spinal cord-injured patients affected by a neurogenic overactive bladder, bladder filling failed to inhibit the H-reflex amplitude; a decrease in the H-reflex amplitude similar to that displayed by normal subjects was observed in patients with a non-neurogenic overactive bladder. By contrast, H-reflex behavior was unmodified in neurogenic underactive bladder patients and was similar to normal subjects in psychogenic underactive patients. CONCLUSIONS: As behavior of the H-reflex varies during bladder filling in neurogenic and non-neurogenic overactive bladder patients as well as in neurogenic and non-neurogenic underactive bladder patients, H-reflex modulation may be considered a useful tool in the differential diagnosis of voiding dysfunctions.