E. James Wright

PUBOVAGINAL SLING USING CADAVERIC ALLOGRAFT FASCIA FOR THE TREATMENT OF INTRINSIC SPHINCTER DEFICIENCY

PURPOSEnPubovaginal sling is the definitive management of female stress urinary incontinence due to intrinsic sphincter deficiency. Customarily, autologous fascia has been used, although synthetic material has its proponents. Harvesting autologous fascia at surgery is associated with postoperative discomfort, and synthetic material has a history of infection and erosion. To assess whether allograft fascia is free from these drawbacks, we retrospectively compared the outcome of women undergoing pubovaginal sling using either autologous or cadaveric allograft fascia.nnnMATERIALS AND METHODSnWe reviewed our experience during the last 28 months with patients treated with the pubovaginal sling for intrinsic sphincter deficiency. All patients underwent preoperative video urodynamics. The outcome was assessed using the SEAPI scoring system. Special attention was devoted to local sling tolerance. Operative time and length of hospital stay were compared between patients with allograft and autograft pubovaginal sling.nnnRESULTSnA total of 92 women (mean age 60 years) underwent allograft (59) or autograft (33) pubovaginal sling. Preoperative parameters, such as percent of patients who had had previous incontinence surgery, mean leak point pressure and SEAPI incontinence score, were similar in both populations. Mean followup was 11.5 months (range 1 to 28) for the overall population. The SEAPI scoring system showed that patients were markedly improved, with no significant difference between the allograft and autograft groups. Allograft and autograft pubovaginal slings were equally well tolerated, and no infection or erosion was encountered. Mean operative time and hospital stay were significantly shorter when using allograft compared to autograft fascia.nnnCONCLUSIONSnThe success rates of allograft and autograft pubovaginal sling were equally high, and no complications related to the cadaveric origin of the allograft fascia were observed. Allograft pubovaginal sling was well tolerated, and its use significantly shortened operative time and hospital stay.

Highlights From the Combined Society of Urodynamics and Female Urology and International Society of Pelvic Neuromodulation Annual Meeting

The second annual meeting of SUFU was held in conjunction with the annual meeting of the ISPiN on February 24 to 27, 2005 in Orlando, Florida. Presentations representing a broad range of research topics were combined with smaller breakout sessions, and state-of-theart lectures were offered in the areas of pelvic prolapse, translational applications of smooth muscle dysfunction in pelvic floor diseases and the role of urothelium in bladder pathology. Highlights of the lectures and reported abstracts are summarized. NEUROMODULATION Technique The technique of SNS has continued to evolve. Performance of a staged implant using a tined lead as an initial test, the use of intraoperative neurophysiological monitoring and a prolonged trial period of up to 1 month before completion of a second stage procedure were all factors that have been found to enhance therapy outcomes. Patients in whom an initial trial of SNS has failed using a staged implant technique may be salvaged by a repeat trial. There is emerging interest in PNS as an alternative to SNS. The techniques for accessing the pudendal nerve are varied and the use of neurophysiological monitoring is routinely advocated for PNS. There may be an advantage of this approach in patients with neurogenic voiding disorders or in those in whom prior SNS attempts have failed. A prospective, singleblinded, randomized, crossover trial comparing SNS to PNS was reported and there appeared to be a large proportion of neuromodulation naive patients who initially preferred PNS to SNS. The long-term results of PNS are not available for comparison at this point and its role as an alternative to SNS is under active evaluation. Patient Selection The role of SNS in neurogenic voiding disorders was explored. Patients with voiding dysfunction due to multiple sclerosis, cerebrovascular accident, SCI and other neuropathies were shown to respond favorably to a staged trial and chronic stimulation. Up to 70% success of a trial stimulation in patients with multiple sclerosis was reported, while only a third of patients with lumbar disc disease responded favorably. Patients with IC respond favorably to SNS and PNS. Despite the encouraging high success in patients with IC, as defined by progression to stage 2 implantation, there may be a decrease in clinical efficacy in the long term with only a 48% long-term success rate noted overall.

COMPARISON OF PERINEAL AND PENOSCROTAL APPROACHES FOR ARTIFICIAL URINARY SPHINCTER PLACEMENT

INTRODUCTION AND OBJECTIVES: It is unclear whether the efficacy of penoscrotal and perineal approaches for artificial urinary sphincter placement are equivalent. Proponents of the penoscrotal approach argue that the cuff site is identical to that of perineal placement. The purpose of this pilot study was to assess anatomic and manometric differences between these approaches in a cadaver model using direct urethral measurement and retrograde leak point pressure profilometry. METHODS: Artificial urinary sphincter implantation using both perineal and penoscrotal incisions was performed in 10 fresh male cadavers. The surgical goal was to place the cuffs as proximally as possible using each approach. Urethral circumference was assessed at each cuff site in the same cadaver. A separate 4.5 cm cuff of the AMS 800 Sphincter Urinary Control System was placed in each location. The 61-70cm H2O pressure reservoir was used for each cuff. Retrograde leak point pressure was assessed sequentially across each of these cuffs. RESULTS: The mean bulbar urethral circumference using the perineal surgical approach was 5.8 cm (range 4.5-7.5 cm). The mean urethral circumference isolated using the penoscrotal surgical approach was 4.1 cm (range 3.5-4.5 cm). The mean difference between the urethral circumferences was significant (p=0.0008). The mean retrograde leak point pressure of the perineal approach was 91.26 cm H20 (range 88.5-94.5 cm H2O) while the mean retrograde leak point pressure of the penoscrotal approach was 66.44 cm H2O (range 57-90 cm H2O). The mean difference between the retrograde leak point pressure of the urethral cuff placed using the penoscrotal and perineal approaches was 24.825 cm H2O (27.2%, p=0.000014). Anatomic comparison of the approaches demonstrated a more proximal urethral placement through a perineal incision. CONCLUSIONS: Although artificial urinary sphincter cuff implantation through a penoscrotal incision may be less technically demanding and conserve operative time, anatomic and manometric differences exist along the urethra which may limit efficacy. This pilot study demonstrates the need for further research evaluating urethral cuff placement techniques to provide optimal surgical outcomes

Surgery for urethra and sphincter — Which technique when?

With emerging solutions to the difficult problem of urethral and sphincteric injury, it is necessary to understand which surgical techniques are optimal and when they are best employed. We review recent advances in the areas of male and female urethroplasty as well as sphincter reconstruction. There is no panacea, and numerous diverse factors must be weighed to maximize success.