C. Pajoncini

Intrinsic Sphincter Deficiency: Do the Maximum Urethral Closure Pressure and the Valsalva Leak-Point Pressure Identify Different Pathogenic Mechanisms?

Abstract: A prospective analysis of 166 women with genuine stress incontinence was performed comparing Valsalva leak-point pressure (VLPP) and maximum urethral closure pressure (MUCP) with age, previous urogynecologic surgery and/or hysterectomy, poor urethral mobility, weight, menopause and vaginal deliveries, to find correlations with intrinsic sphincter deficiency (ISD). Cut-off value for VLPP were 60 cmH2O and for MUCP 30 cmH2O. MUCP ≤30 cmH2O identifies a group of patients with more severe incontinence, a shorter urethral functional length (UFL) (P= 0.02), more previous urogynecologic operations and the menopause (P= 0.004 and P= 0.000), and older age (P= 0.000). VLPP ≤60 cmH2O identifies a group of patients with more severe incontinence, a shorter UFL (P = 0.005), more previous urogynecologic surgery (P = 0.006) and poorer urethral mobility (P= 0.004). As these two tests measure different components of urethral functions we can hypothesize that they detect different pathogenic processes contributing to ISD. When one or both tests is abnormal incontinence is more severe and the incidence of poor prognostic factors is increased.

Four-corner colposuspension: clinical and functional results

We report our experience with four-corner colposuspension and the long-term functional and objective results. Thirty-seven women aged 42–74 affected by cystocele, associated with stress incontinence in 27, underwent four-corner colposuspension, combined with posterior colpoperineoplasty in 5 and vaginal wall sling in 5. Preoperative work-up included clinical examination, a symptoms questionnaire, transrectal dynamic ultrasonography and a urodynamic test. The mean follow-up to date is 62 months (range 36–83). Check-ups included a clinical examination, responses to a questionnaire on symptoms, uroflowmetry, transrectal ultrasound, and a urodynamic test in 25. All patients underwent four-corner colposuspension, together with vaginal wall sling in 5 with severe incontinence and colpoperineoplasty in another 5 with symptomatic rectoceles. There were no major complications. The urethrocele was stably corrected in all. No relapses occurred in 19 patients with grades I–II cystocele preoperatively. Various forms of prolapse recurred in 12/18 patients with grade III cystocele. Incontinence was successfully resolved in 23/27 patients (85%). Instability persisted in 8/14 patients. Obstruction persisted in 6 patients with prolapse recurrence. The ideal candidate for four-corner suspension is a patient with moderate cystocele and no signs of uterine prolapse who may, or may not, be incontinent.

Uterus preservation in surgical correction of uro-genital prolapse

OBJECTIVE This study aimed to evaluate the efficacy of colposacropexy with uterine preservation as therapy for uterovaginal prolapse. Surgical techniques, efficacy and overall results are described. METHODS In this prospective, controlled study, 34 of the 72 consecutive patients with symptomatic uterovaginal prolapse were treated with colposacropexy with uterus conservation (hysterocolposacropexy, HSP) and the other 38 with hysterectomy followed by sacropexy (CSP). Anchorage was achieved with two rectangular meshes in CSP and with one posterior rectangular and one anterior Y-shaped mesh in HSP. Check-ups were scheduled at 3, 6 and 12 months and then yearly. Pre-operative patient characteristics, operative and post-operative events and follow-up results were recorded. Mean follow-up was 51 months (range 12-115). RESULTS No significant differences emerged in demographic and clinical characteristics between the HSP and CSP groups. Mean operating times, intra-operative blood loss and hospital stay were significantly less after HSP (p<0.001). At follow-up success rates were similar in the two groups in terms of uterine and upper vaginal support (100%). Recurrent low-grade cystoceles developed in 1/38 (2.6%) in the CSP group and in 5/34 (14.7%) in the HSP group (p=NS), recurrent low-grade rectocele developed in 6/38 (15.8%) and in 3/34 (8.8%) patients respectively (p=NS). No patient required surgery for recurrent vault or uterus prolapse. Urodynamic results showed that pressure/flow parameters improved significantly (p<0.001) in both groups. Thirty-one of the 34 patients (91%) in the HSP group and 33/38 (86.8%) in the CSP group were satisfied and would repeat surgery again. CONCLUSIONS Colposacropexy provides a secure anchorage, restoring an anatomical vaginal axis and a good vaginal length. HSP can be safely offered to women who request uterine preservation. Whether the uterus was preserved or not, patients had similar results in terms of prolapse resolution, urodynamic outcomes, improvements in voiding and sexual dysfunctions. HSP has shorter operating times and less blood loss.