Surgical preparation: are patients "ready" for stress urinary incontinence surgery?

INTRODUCTION AND HYPOTHESIS: Patient preparedness for stress urinary incontinence (SUI) surgery is associated with improvements in post-operative satisfaction, symptoms and quality of life (QoL). This planned secondary analysis examined the association of patient preparedness with surgical outcomes, treatment satisfaction and quality of life. METHODS: The ValUE trial compared the effect of pre-operative urodynamic studies with a standardized office evaluation of outcomes of SUI surgery at 1 year. In addition to primary and secondary outcome measures, patient satisfaction with treatment was measured using a five-point Likert scale (very dissatisfied to very satisfied) that queried subjects to rate the treatment's effect on overall incontinence, urge incontinence, SUI, and frequency. Preparedness for surgery was assessed using an 11-question Patient Preparedness Questionnaire (PPQ). RESULTS: Based on PPQ question 11, 4 out of 5 (81 %) of women reported they "agreed" or "strongly agreed" that they were prepared for surgery. Selected demographic and clinical characteristics were similar in unprepared and prepared women. Among SUI severity baseline measures, total UDI score was significantly but weakly associated with preparedness (question 11 of the PPQ; Spearman's r = 0.13, p = 0.001). Although preparedness for surgery was not associated with successful outcomes, it was associated with satisfaction (r s = 0.11, p = 0.02) and larger PGI-S improvement (increase; p = 0.008). CONCLUSIONS: Approximately half (48 %) of women "strongly agreed" that they felt prepared for SUI. Women with higher pre-operative preparedness scores were more satisfied, although surgical outcomes did not differ.

5-year continence rates, satisfaction and adverse events of burch urethropexy and fascial sling surgery for urinary incontinence.

PURPOSE: We characterized continence, satisfaction and adverse events in women at least 5 years after Burch urethropexy or fascial sling with longitudinal followup of randomized clinical trial participants. MATERIALS AND METHODS: Of 655 women who participated in a randomized surgical trial comparing the efficacy of the Burch and sling treatments 482 (73.6%) enrolled in this long-term observational study. Urinary continence status was assessed yearly for a minimum of 5 years postoperatively. Continence was defined as no urinary leakage on a 3-day voiding diary, and no self-reported stress incontinence symptoms and no stress incontinence surgical re-treatment. RESULTS: Incontinent participants were more likely to enroll in the followup study than continent patients (85.5% vs 52.2%) regardless of surgical group (p<0.0001). Overall the continence rates were lower in the Burch urethropexy group than in the fascial sling group (p=0.002). The continence rates at 5 years were 24.1% (95% CI 18.5 to 29.7) vs 30.8% (95% CI 24.7 to 36.9), respectively. Satisfaction at 5 years was related to continence status and was higher in women undergoing sling surgery (83% vs 73%, p=0.04). Satisfaction decreased with time (p=0.001) and remained higher in the sling group (p=0.03). The 2 groups had similar adverse event rates (Burch 10% vs sling 9%) and similar numbers of participants with adverse events (Burch 23 vs sling 22). CONCLUSIONS: Continence rates in both groups decreased substantially during 5 years, yet most women reported satisfaction with their continence status. Satisfaction was higher in continent women and in those who underwent fascial sling surgery, despite the voiding dysfunction associated with this procedure.

Reference urodynamic values for stress incontinent women.

OBJECTIVE: To determine reference urodynamic values for preoperative urodynamic studies in women undergoing surgery for pure or predominant stress urinary incontinence (SUI). MATERIALS AND METHODS: Six hundred fifty-five women with pure or predominant SUI were enrolled in a multicenter surgical trial and were randomized to undergo a Burch or autologous fascia sling procedure as part of the Urinary Incontinence Treatment Network (UITN) Stress Incontinence Surgical Treatment Efficacy Trial (SISTEr). Preoperative free uroflowmetry, filling cystometry, and pressure flow studies were performed in all women using a standardized research protocol and standardized urodynamic interpretation guidelines. We define the normal range of urodynamic values in this population as the values that encompass 95% of the results. RESULTS: In 655 women undergoing filling cystometry in the standing position, baseline vesical and abdominal pressures were between 12 and 60 cm H(2)O. The upper limit of detrusor pressure increase during bladder filling to maximum cystometric capacity was 16 cm H(2)O. Ten percent of women who qualified for stress incontinence surgery with a positive cough stress test on physical exam did not demonstrate urodynamic stress incontinence (USI) and less than 10% of subjects in this study demonstrated detrusor overactivity. CONCLUSIONS: Results from a large cohort of women with SUI are now available for quantitative plausibility assessments or as reference values when interpreting urodynamic studies.

Long-term results of the FemSoft urethral insert for the management of female stress urinary incontinence.

A 5-year ongoing, controlled multicenter study enrolled 150 women. Outcome measures included pad weight tests (PWT), voiding diary (VD), quality of life (QOL) and satisfaction questionnaires. Outcome measures during the baseline period were compared to evaluations during follow-up. Concurrent evaluations with and without device use were also performed. Safety evaluations included urinalysis and culture, leak-point pressure (LPP) and cystoscopy. Adverse events (AE) were recorded throughout the study. One to 2 years of follow-up were collected on all study participants (mean 15 months). Statistically significant reductions in overall daily incontinence episodes (P<0.001) and PWT urine loss (P<0.001) were observed with the device at all follow-up intervals, and 93% of women had a negative PWT at 12 months. Women were satisfied with ease of use of the device, comfort and dryness, and significant improvements in QOL were observed (P<0.001). Subgroup analysis revealed that the insert was effective, despite the presence of urgency, low LPP, failed surgery and advanced age. AE included symptomatic urinary tract infection in 31.3%, mild trauma with insertion in 6.7%, hematuria in 3.3%, and migration in 1.3% of women. The results of PWT and VD demonstrated device efficacy. Women were satisfied and significant improvements in QOL were observed. AE were transient and required minimal or no treatment. The urethral insert should be considered as an option for the management of SUI.

A new injectable bulking agent for treatment of stress urinary incontinence: results of a multicenter, randomized, controlled, double-blind study of Durasphere.

OBJECTIVES: To assess the safety and effectiveness of Durasphere compared with bovine collagen in the treatment of stress urinary incontinence (SUI) due to intrinsic sphincter deficiency (ISD). METHODS: This multicenter, randomized, controlled, double-blind trial was composed of 355 women diagnosed with SUI due to ISD and used a standardized pad test and the Stamey continence grade as the primary endpoints. The participants' ages ranged from 26 to 84 years. All patients had an abdominal leak point pressure of less than 90 cm H(2)O (average 51). RESULTS: At 12 months after the first injection, the two materials were equivalent with respect to the improvement in continence grade and pad weight testing. Less Durasphere was injected to obtain comparable clinical results (Durasphere 4.83 mL versus bovine collagen 6.23 mL, P <0.001). When examined 1 year after the date of the last treatment, 49 (80.3%) of the 61 women treated with Durasphere showed improvement of 1 continence grade or more compared with 47 (69.1%) of 68 women treated with bovine collagen (P value for difference = 0.162). Although the adverse events reported for both groups were similar, the Durasphere group had an increased short-term risk of urgency and urinary retention. CONCLUSIONS: The use of Durasphere for the treatment of SUI due to ISD was equally effective as bovine collagen and used less material. The U.S. Food and Drug Administration granted market approval for Durasphere on September 13, 1999. The product design and initial clinical data suggest the potential for greater durability of the clinical benefit, with the possibility of a permanent solution for SUI due to ISD in some patients.

Geriatric urinary incontinence.

Urinary incontinence is abnormal at any age. The prevalence of urinary incontinence increases with age due to functional impairments and concurrent medical disease. A detailed history and physical is essential in evaluating these patients. Urinary incontinence is treatable in all age groups when a logical, multifactorial and persistent approach is undertaken.

Role of the four-corner bladder neck suspension to correct stress incontinence with a mild to moderate cystocele.

OBJECTIVES: Women undergoing four-corner bladder neck suspension were evaluated for subjective and objective results of the procedure. Patients were evaluated for continence, prolapse, and symptomatic status postoperatively. METHODS: Forty-seven women underwent four-corner bladder neck suspension for moderate cystocele with (44) or without (3) stress urinary incontinence. Mean and median follow-up were 37 months (range 15 to 80). To assess results of the four-corner bladder neck suspension, two sets of outcome measures were used (subjective questionnaire, including patient satisfaction, and objective physical examination, with standing voiding cystourethrogram) to compare pre- and postoperative data. RESULTS: At the time of follow-up, 25 patients (53%) reported no incontinence, 14 (30%) reported one incontinent episode per week, and 8 (17%) reported daily loss of urine. Twenty-seven (57%) had grade I or grade II cystoceles on follow-up examination and voiding cystourethrogram; however, only 12 (26%) experienced recurrent prolapse symptomatology. Overall patient acceptance of the procedure was high (70%). CONCLUSIONS: The four-corner bladder neck suspension is an effective option in the management of moderate cystocele.

High-energy visual laser ablation of the prostate in men with urinary retention: pressure-flow analysis.

OBJECTIVES: To assess the efficacy of high-energy visual laser ablation of the prostate (VLAP) in men with urinary retention, using subjective and objective data. METHODS: Seventeen men in urinary retention underwent high-energy VLAP. The mean patient age was 69 years, and the mean follow-up was 12 months. All men were urodynamically obstructed by pressure-flow analysis with a functioning detrusor muscle. Interviews assessed retrograde ejaculation and patient satisfaction. RESULTS: The mean total energy applied was 71,088 J (range 27,556 to 110,294). The mean peak noninvasive urine flow rates increased from 2.1 to 18.1 cc/s, and the mean postvoid residual volumes decreased from 550.0 to 39.0 cc. The mean detrusor pressure at peak flow decreased from 66.4 to 41.9 cm H2O, and the mean maximal detrusor pressure decreased from 72.2 to 49.2 cm H2O. Ten men (59%) voided to completion within 1 week post-VLAP. The mean postoperative International Prostate Symptom Score was 6. Nine men (53%) reported new retrograde ejaculation, and 14 men (82%) were satisfied with their outcome. CONCLUSIONS: High-energy VLAP is an effective procedure for relief of bladder-outlet obstruction in men with urinary retention.

Lack of correlation of the American Urological Association Symptom 7 Index with urodynamic bladder outlet obstruction.

The objective of this study is to assess whether subjective information from the American Urological Association (AUA) Symptom 7 Index correlates with or predicts objective urodynamic parameters of bladder outlet obstruction. Seventy-five men, mean age 67 years (range 42-85 years), were referred for evaluation of "prostatism." Evaluation consisted of the AUA Symptom 7 Index, noninvasive uroflow, post-void residual (PVR) urine measurement, and pressure-flow analysis. Men were categorized as "obstructed," "equivocal," or "unobstructed" according to pressure-flow nomogram of Abrams and Griffiths. The total AUA 7 score, and all individual components, were compared with all invasive urodynamic parameters, and to the pressure-flow categories of obstructed, equivocal, or unobstructed. The AUA index severity categories (mild 0-7, moderate 8-19, and severe > or = 20) were compared to the urodynamic pressure flow categories. Thirty-three men had severe symptoms, and 42 had moderate or mild symptoms. Forty men were urodynamically obstructed, and 35 men were equivocal or unobstructed. There was no correlation of any AUA index parameter (total symptom score, obstructive or irritative score component, or any individual question) with any noninvasive urodynamic parameter. The sensitivity and specificity of the AUA index for urodynamic obstruction was 42.5% and 54.3% respectively. Multivariable logistic regression analysis was used to determine whether clinical data easily obtained in the office setting (age, PVR, noninvasive maximum and average flow rates) could predict urodynamic obstruction when combined with any component of the AUA index. Only age was found to be a significant predictor of obstruction status (P = 0.026). Subjective information from the AUA Symptom 7 Index does not correlate with objective data assessing bladder outlet obstruction. Though the AUA index is a valid clinical tool, it should not be used to gauge the presence or severity of bladder outlet obstruction.

The effect of study methodology on reported success rates of the modified Pereyra bladder neck suspension.

PURPOSE: We compared surgical results in a cohort of women after modified Pereyra bladder neck suspension using questionnaire based outcomes analysis versus a retrospective chart review. MATERIALS AND METHODS: Of 151 patients who underwent modified Pereyra bladder neck suspension 102 had complete questionnaire and chart data for review. Mean patient age was 56 years and followup was 25 months. RESULTS: According to outcomes analysis 48 patients (47.1%) were cured and in 65 (64%) stress urinary incontinence improved compared to 74 (72%) cured and 89 (89%) improved by retrospective review. Of the 102 chart review patients 10 (9%) reported daily pad use compared to 55 of the 102 (53%) in the questionnaire study. CONCLUSIONS: This study controls for patient selection, definition of cure and length of followup, and demonstrates that study methodology profoundly affects reported outcomes for the modified Pereyra bladder neck suspension.

Intravesical thiotepa-induced eosinophilic cystitis.

Eosinophilic cystitis is a rare form of an allergic cystitis. Factors such as food allergens, parasites, and drugs have been implicated in the genesis of eosinophilic cystitis. Associated risk factors include bronchial asthma, atopic diseases, and environmental allergens. Intravesical mitomycin is a reported causative agent. We report the first case of eosinophilic cystitis that developed after intravesical instillation of thiotepa for treatment of superficial bladder cancer.

[Diverticulum of the female urethra]. / Diverticules de l'urètre féminin.

The diagnosis and successful treatment of female urethral diverticulum can be facilitated by a heightened clinical awareness coupled with appropriate evaluation and perioperative management. In particular, it is important to address all the preoperative factors to avoid complications de treatment such as recurrence of the diverticulum or urethro-vaginal fistula. The authors also report their clinical experience of evaluating 59 women with urethral diverticula over the last 11 years and describe the technique and complications of diverticulectomy in 49 women.

Success rate of modified Pereyra bladder neck suspension determined by outcomes analysis.

The reported success rates of the modified Pereyra bladder neck suspension vary from 51 to 90%. Retrospective chart review studies have reported cure rates of 77 to 90%. In contrast, a questionnaire based outcomes analysis, using a strict definition of cure, reported 51% of the patients to be cured of stress urinary incontinence after modified Pereyra bladder neck suspension. We conducted a questionnaire based outcomes analysis of the modified Pereyra bladder neck suspension at our institution. The objectives of the study were to determine the success rates of this procedure using strict criteria in an outcomes analysis format, assess the overall satisfaction of patients postoperatively and identify historical factors that may be predictive of outcome. Between September 1988 and December 1991, 151 patients underwent a modified Pereyra bladder neck suspension for urodynamically documented genuine stress urinary incontinence. Mean patient age was 56 years (range 19 to 82 years) and mean followup was 25 months (range 9 to 45). All patients had type 2 incontinence (anatomical) based on history (severity of symptoms), physical examination, and fluoroscopic assessment of the bladder neck and urethra. Preoperative pad use, and irritative and obstructive symptoms were retrospectively assessed, and a preoperative Stamey incontinence score was assigned. A standardized questionnaire was used to compare preoperative and postoperative voiding symptoms, perception of urinary control and satisfaction with the decision to undergo an operation. Followup telephone calls were made by a trained registered nurse not associated with the original procedure. Postoperative pad use also was quantified and a postoperative Stamey score was assigned. A total of 106 patients (70%) returned the questionnaires. Cure was strictly defined as no urine leakage under any circumstance. While 78% of the patients required no to minimal protection postoperatively, 50 (47%) reported cure of the stress urinary incontinence, 68 (64%) reported subjective improvement, 27 (26%) were the same and 11 (10%) were subjectively worse after modified Pereyra bladder neck suspension. Of the patients 77% were satisfied with the decision to undergo the operation. Patients subjectively worse were significantly older than those subjectively improved (66 versus 54 years, p = 0.05). Postoperative failures had significantly higher obstructive and irritative symptom scores. Questionnaire based outcomes analysis has consistently demonstrated success rates less than those reported in retrospective chart review studies. Outcomes analysis, based on patient assessment of satisfaction, may more accurately reflect the expected surgical outcome after a modified Pereyra bladder neck suspension. We emphasize the need for standardized questionnaires and outcomes analysis to evaluate patient satisfaction with surgery designed to improve quality of life.

Use of the neodymium:YAG laser to control refractory bleeding from the prostate.

Prostatic hemorrhage is a condition that often requires hospitalization and can be life-threatening. We present a simple, effective method using the neodymium:YAG laser with a right angle energy delivery system to control prostatic hemorrhage successfully in 3 difficult clinical situations.

Role of limited evaluation and aggressive medical management in multiple sclerosis: a review of 113 patients.

Multiple sclerosis has frequent urological manifestations. Medical management, based on clinical symptoms and urodynamic findings, incorporates clean intermittent catheterization, oral pharmacological agents (that is oral oxybutynin) or their combination (the desired end point of treatment being complete retention with clean intermittent catheterization). Our objectives were to evaluate the efficacy of medical management in multiple sclerosis patients, determine the incidence of hydronephrosis at presentation and during treatment, and evaluate the impact of electromyography on patient management. We reviewed retrospectively 113 patients with documented multiple sclerosis (mean age 45 years, range 20 to 75 years and mean followup 41 months, range 6 to 136 months). Presenting symptoms were irritative alone or combined with obstructive symptoms in 94 patients (83%). On cystometrography 79 patients (70%) had detrusor hyperreflexia and 17 (15%) had an areflexic bladder. Coaxial needle electromyography was performed on 54 patients and 15 (28%) had detrusor-sphincter dyssynergia. Patients with detrusor-sphincter dyssynergia had more advanced neurological disease. A total of 105 patients had radiological imaging of the upper tracts. Only 7 patients (6.6%) had hydronephrosis at presentation and all were stable or improved with medical management. No patient had hydronephrosis with aggressive medical management. No patient with detrusor-sphincter dyssynergia had hydronephrosis or elevated creatinine levels at presentation or during treatment. Medical management failed in 8 patients (7%) who required surgical intervention. Limited evaluation (voiding symptoms, post-void residual and cystometrography) of multiple sclerosis patients is sufficient to formulate an effective treatment program. Electromyography is not necessary in the routine evaluation of patients with documented multiple sclerosis. After baseline upper tract imaging, routine yearly evaluations are unnecessary (unless initially abnormal or indicated by a change in clinical status). Medical management of patients with multiple sclerosis is safe and effective. In this series, no patient had hydronephrosis on therapy, and only 7% of the patients failed aggressive medical management and required surgical intervention.

Outpatient visual laser-assisted prostatectomy under local anesthesia.

OBJECTIVE: Visual laser-assisted prostatectomy (VLAP) with a noncontact right-angle delivery system recently has been introduced as a new treatment option for symptomatic outlet obstruction secondary to benign prostatic hyperplasia. The right-angle laser technology has numerous potential advantages over traditional transurethral resection of the prostate. These advantages include the feasibility of performing the VLAP procedure under local anesthesia without bleeding. We summarize our experience with VLAP performed with local anesthesia administered with periprostatic block. METHODS: This technique was employed in 46 men with symptomatic BPH as an outpatient procedure. All men were evaluated prior to surgery with flow rates, residual volume determinations, and AUA-6 symptom score analyses. Follow-up occurred at three and six months and included repeat measures of flow rates, residual volumes, and symptom scores. RESULTS: Mean AUA symptom scores and uroflow parameters significantly improved with six months' follow-up. No significant complications were encountered. CONCLUSIONS: VLAP under local anesthesia as an outpatient procedure is a promising treatment alternative for men with symptomatic benign prostatic hyperplasia.

Transurethral incision of the prostate: an objective and subjective evaluation of long-term efficacy.

The emergence of less invasive therapies has demanded the reassessment of surgical procedures for the treatment of benign prostatic hyperplasia. This study was designed to evaluate the long-term efficacy of transurethral incision of the prostate using objective (urodynamic) and subjective (symptom score and assessment of satisfaction) parameters, and investigate sexual function. The results of transurethral incision of the prostate in 41 men (mean age 63.4 years) were reviewed, with a mean followup of 53 months (range 12 to 96). Preoperative symptom score (based on the Madsen-Iversen score) and urodynamic evaluation were compared to recent post-transurethral incision symptom score, urodynamic evaluation and interview to determine patient satisfaction. Total symptom score, as well as obstructive and irritative components, significantly decreased after transurethral incision of the prostate (p < 0.0001). Mean detrusor pressure at peak flow decreased from 85 to 44 cm. water (p < 0.0001) and mean maximal detrusor pressure decreased from 114 to 55 cm. water (p < 0.0001). Mean peak urine flow rates increased from 10.3 to 15.3 cc per second (p = 0.019). Of the men 32 (82%) reported long-term improvement after transurethral incision of the prostate, with an overall satisfaction rate of 67% (range 0 to 100). Regardless of objective urodynamic criteria (indicating obstruction or relief of obstruction), the number of men reporting subjective improvement and the degree of improvement were similar. Only 4 men (11%) reported new retrograde ejaculation. The proportion of men with improvement after transurethral incision of the prostate compares favorably to long-term data available on transurethral resection of the prostate. Assessing the degree of improvement (overall satisfaction) is unique and has not been previously reported. These results clearly demonstrate that in selected patients transurethral incision of the prostate is an effective procedure for long-term relief of outlet obstruction.

L N S C3: a proposed classification system for female urethral diverticula.

No descriptive criteria for the preoperative classification of female urethral diverticula have been proposed. Consequently, alternative therapies and different treatment series are not easily compared. Since 1982 the authors have evaluated 61 women with urethral diverticula and have identified those preoperative factors critical to an organized surgical approach to urethral diverticula. From this experience, a simple, comprehensive classification system for female urethral diverticula is proposed. The classification system is called L/N/S/C3. Each letter of the system represents a different characteristic of urethral diverticula. L = Location, the site of the diverticulum, i.e., distal, mid, or proximal urethra, with or without extension beneath the bladder neck. N = Number, whether single or multiple diverticula are present. S = Size, expressed in centimeters (cm). C3 = Configuration, Communication, and Continence Configuration (C1) describes whether we diverticulum is single, multiloculated, or saddle shaped. Communication (C2) indicates the site of communication with the urethral lumen, i.e., distal, mid, or proximal urethra. Continence (C3) is the presence of genuine stress urinary incontinence. Adhering to this format provides the surgeon a systematic means of approaching a urethral diverticulum and thus may minimize postoperative complications. Finally, the authors encourage other surgeons reporting series of urethral diverticula to adopt this system so that standard terminology may allow accurate comparison of surgical results.