Christopher C. Fitzpatrick

Clinical assessment of urethral sphincter function

Measurements of urethral pressures, such as maximum urethral pressure, are widely believed to have relevance in the management of urinary incontinence despite evidence to the contrary. In this study maximum urethral pressure and the abdominal pressure required to cause stress incontinence were measured in 125 women with stress incontinence. In women the abdominal pressure required to cause stress incontinence was unrelated to maximum urethral pressure. These findings indicate that maximum urethral pressure has little relationship to urethral resistance to abdominal pressure. In the 9 children with myelodysplasia we compared the detrusor pressure with the abdominal pressure required to induce urethral leakage. These values also were quite different, indicating that as far as the urethra is concerned abdominal pressure and detrusor pressure are not equivalent forces.

The surgical anatomy of needle bladder neck suspension

Objective To define the surgical anatomy of needle bladder neck suspension in order to explain this operations effect on urethral support and gain information useful in minimizing intraoperative complications. Methods Needle bladder neck suspension was carried out on two unembalmed, multiparous cadavers. After fixing the suspensory sutures in place, the pelvis of one cadaver was completely dissected. The second cadaver was serially sectioned at 1-cm intervals, and the sections were subjected to both anatomic and histologic examination. These findings were correlated with the findings noted during an autopsy dissection of a women who previously had undergone needle bladder neck suspension at our institution and with our surgical experience with this operation. Results The plane of dissection used to enter the space of Retzius lay between the vaginal mucous membrance and the visceral endopelvic fascia. The point of entry into the retropublic space lay between the levator ani muscles and its superior fascia, lateral to the arcus tendineus fasciae pelvis, the paraurethral vascular plexus, and bladder neck. It was cephalad to the perineal membrance (urogenital diaphragm). The paraurethral supporting tissues incorporated in the suspensory suture included the portion of the endopelvic fascia that lies between the vagina and urethra and, usually, the arcus tendineus fasciae pelvis. Attaching the suspensory sutures in needle bladder neck suspension seems to stabilize the bladder neck by providing a new point of lateral fixation for its supporting endopelvic fascia. Conclusion Needle bladder neck suspension stabilized the supportive fascia of the urethra, and vascular injury may be minimized by detailed knowledge of paraurethral anatomy.

Plastic Surgical Techniques in the Repair of Vesicovaginal Fistulas: A Review

A variety of plastic surgical techniques may be used in the repair of vesicovaginal fistulas. The indication for their use include: (a) diameter greater than 4 cm; (b) involvement of the bladder neck/proximal urethra; (c) radiation-induced fistulas; and (d) previous failed repair(s). In the developing world the vast majority of complex fistulas are caused by obstetric trauma; elsewhere they occur mainly following radiotherapy or radical surgery for gynecologic malignancy. The majority of complex fistulas requiring tissue donation may be effectively treated using a vaginal approach and a modified Martius graft. There is probably little or no advantage in encorporating bulbocavernosus muscle fibers in this graft. Although some concern exists regarding the long-term viability of these grafts in radiation-induced fistulas, in view of the relatively simple operative technique, together with the low associated morbidity, modified Martius grafts may be deemed suitable for first-time repairs. The gracilis muscle graft should be considered next in cases of exclusive transvaginal repair. The omental graft is undoubtedly the most versatile: it can be used in both abdominal and combined abdominovaginal procedures. The recently described posterosuperior sliding bladder flaps warrant further evaluation. For most fistulas involving the bladder neck/proximal urethra, there is no clear advantage in bladder flap reconstruction over vaginal flap reconstruction, the latter being augmented by an anti-stress incontinence procedure were appropriate. When continent urinary diversion is required, the Indiana pouch appears preferable to the Kock pouch; ureterosigmoidostomy is, however, technically and culturally more acceptable in these circumstances in the developing world.

Stress urinary incontinence and genital trauma after female pelvic trauma

Combined stress urinary incontinence (SUI) and genital prolapse after fracture of the female pelvis has not been well described to date; four such cases are reported. Three of the patients had undergone reconstructive urogynecologic surgery prior to referral. None of the patients had a history of urinary incontinence or genital prolapse prior to injury. In order to correct persistent urinary incontinence and prolapse the following operations were performed: pubovaginal sling and transvaginal cystocele repair, Raz needle suspension and rectus muscle graft to the pelvic floor followed by a unilateral Burch colposuspension. On follow-up at a mean interval of 14.2 months (range 12–17), 2 have mild SUI and all 4 are without significant genital prolapse.

Bladder dysfunction after repeat laparoscopic uterine nerve ablation (LUNA)

The authors report a case of voiding dysfunction with reduced sensation and areflexia 13 months after a repeat LUNA due to pelvic nerve injury. Anatomic distortion and increased vascularity were likely contributing factors. Repeat procedures may expose patients to a risk of such injury due to anatomic distortion.

Periurethral collagen for urinary incontinence after gender reassignment surgery

We report on 2 patients, one female and one male transsexual; in both, Type III stress urinary incontinence developed after gender reassignment surgery. Both patients were treated by periurethral injection of gluteraldehyde cross-linked collagen resulting in a marked symptomatic improvement in association with a significant rise in abdominal leak point pressures. We believe these are the first reported cases of collagen injection being used for urinary incontinence after gender reassignment surgery.

Vulvar vestibulitis and interstitial cystitis: A disorder of urogenital sinus‐derived epithelium?

Background: Vulvar vestibulitis and interstitial cystitis are enigmatic and controversial conditions. They are increasingly recognized as important causes of genitourinary pain in young women. This report proposes an etiologic association between the two conditions. Cases: We report three patients with both vulvar vestibulitis and interstitial cystitis. Although an association between these conditions has previously been proposed, these are the first case reports of the coexistence of these conditions in the same patient. Conclusion: Because both the vestibule of the vulva and the bladder are derived from the urogential sinus, we propose that the coexistence of vulvar vestibulitis and interstitial cystitis in some patients represents a generalized disorder of urogenital sinus-derived epithelium. (Obstet Gynecol 1993;81:860–2)

Experience of a combined gynecology/urology clinic in the University of Michigan Medical Center

Over a period of 30 months, 200 patients were seen in the combined gynecology/urology clinic of the University of Michigan Medical Center. Nintey-nine patients (49.5%) were referred by urologists and 86 (43%) by gynecologists. The mean number of visits by patients to the clinic was 1.7, with a range of 1–3; 78 patients (39%) visited the clinic on just one occasion; 116 patients (58%) had undergone previous gynecologic and/or urologic surgery. At least one diagnosis was confirmed in 183 patients (91.5%). A total of 151 operations were performed, 43 (28.5%) by gynecologists and urologists working together.

Vaginal delivery after pubovaginal sling surgery

For pregnant women who have had previous successful surgery for genuine stress urinary incontinence, an elective cesarean section is generally recommended. Many of these patients are multiparous and can be expected to have a relatively short and uncomplicated labor. We report a case of vaginal delivery after a pubovaginal sling and urethral diverticulectomy with preservation of continence at 1 year.

Intermittent Self-Catheterization of the Renal Pelvis: Report of 2 Cases

We review the long-term outcome of 2 patients in whom cutaneous ureterostomies were performed. Complications included necrosis and distal ureteral stenosis, peristaltic dysfunction, urosepsis, calculus formation and renal impairment. Fluoroscopic ureterometry confirmed high pressure collecting systems in both patients 14 to 17 years postoperatively. Subsequent management during the last 4 to 6 years with clean intermittent self-catheterization has resulted in a significant improvement in the urological status.