F. Zivkovic

Long-term effects of vaginal dissection on the innervation of the striated urethral sphincter.

Objective To study the long-term effects of vaginal dissection on the innervation of the striated urethral sphincter. Methods Perineal nerve terminal motor latency was measured before and 8 weeks and 1 year after anterior colporrhaphy, colpoperineoplasty, and vaginal hysterectomy in 33 women, 19 of whom also underwent endoscopic suspension of the bladder neck. Results In the entire series, the mean perineal nerve terminal motor latency was prolonged before surgery over that in normal continent women and further prolonged 8 weeks and 1 year postoperatively. In the subjects who underwent vaginal hysterectomy and anterior colporrhaphy, perineal motor latencies were not significantly prolonged at the 8-week postoperative follow-up and had almost returned to preoperative values 1 year later. However, in those who underwent additional endoscopic bladder neck suspension, perineal motor latencies were prolonged at both postoperative follow-up examinations. Perineal motor latencies were unchanged 1 year postoperatively in continent patients (N = 19) but were prolonged in incontinent patients (N = 14). Conclusion Vaginal dissection, especially during endoscopic bladder neck suspension, can worsen preexisting perineal neuropathy in patients with pelvic relaxation and stress incontinence.

Five-year results after anti-incontinence operations

OBJECTIVE This study was undertaken to evaluate continence rates 5 years after anterior colporrhaphy, anterior colporrhaphy with needle suspension of the bladder neck, and Burch colposuspension. STUDY DESIGN Among 544 women with stress incontinence who were operated on between 1989 and 1993, 327 women (60%) underwent clinical and urodynamic reevaluation 5 years after the operation. Choice of surgical procedure was made on the basis of clinical and urodynamic findings and of physician preference. Continence was defined as no loss of urine during cystometry or during coughing with the bladder filled to 300 mL. RESULTS The 327 patients underwent a total of 334 operations. The objective overall continence rates at 5 years were 61% (65/107) after anterior repair, 49% (59/121) after anterior repair with needle suspension, and 79% (84/106) after Burch colposuspension. Continence rates after anterior colporrhaphy were 82% (32/39) among patients with mild stress incontinence but 49% (33/68) among those with moderate or severe incontinence (P <.02). Continence rates among patients with moderate or severe incontinence were 49% (59/121) after anterior repair with needle suspension and 79% (84/106) after the Burch operation (P <.02). CONCLUSION Anterior colporrhaphy can cure mild stress incontinence but is inadequate to correct severe incontinence. Additional needle suspension may be of benefit for patients with moderate to severe incontinence. Abdominal colposuspension is superior to the vaginal operations for long-term cure of stress incontinence.

Body mass index and outcome of incontinence surgery

OBJECTIVE To analyze the influence of body mass on the outcome of surgery for urinary incontinence. METHODS Among 291 women operated on for stress incontinence, 187 (64%) were available for follow-up at 5 years. Eighty women had anterior colporrhaphy, 49 anterior colporrhaphy with needle suspension of the bladder neck, and 58 Burch colposuspension. Body mass index was calculated preoperatively and at follow-up. Women were classified as being of normal weight (body mass index [BMI] 20-25), overweight (BMI 26-30), or obese (BMI greater than 30). Reported continence rates were analyzed according to BMI for each operation and the BMIs of continent patients were compared with those of incontinent patients. RESULTS The continence rates at 5-year follow-up for anterior colporrhaphy, anterior colporrhaphy with needle suspension of bladder neck, and Burch colposuspension were 58, 51, and 86%, respectively (P < .001). The continence rates did not differ significantly among the three BMI groups for each procedure. A statistical power of 26% was found for the hypothesis that the outcome of the procedures does not depend on BMI. The preoperative and postoperative BMIs of continent and incontinent women for each procedure did not differ significantly. CONCLUSION We did not find preoperative obesity to be a risk factor for failure of incontinence surgery, but the power of our study was limited.

Pelvic floor exercise alone or with vaginal cones for the treatment of mild to moderate stress urinary incontinence in premenopausal women

The authors compared intensive pelvic floor exercise alone (A) with intensive pelvic floor exercise plus vaginal cones (B) in premenopausal women with mild to moderate stress urinary incontinence. Forty-six patients (mean 43±6 years) were randomized into two training groups and treated for 3 months. Pre- and post-therapy urethral pressure profiles at rest and under stress and subjective results were obtained from 29 patients. The subjective improvement rate of the compliant patients after 12 weeks was 85% in group A and 84% in group B. When the dropouts (9 in group A and 8 in group B) were included in the subjective results an overall improvement rate of 48% in group A and 52% in group B was obtained. In group A one pressure transmission ratio (PTR) improved significantly at 6 weeks and the position of maximum urethral closure pressure was shifted proximally at 12 weeks. In group B one PTR in the midurethra was improved significantly at 6 weeks. The other urodynamic parameters were unchanged. There were no differences between groups A and B in subjective results or urodynamic findings. These results suggest that intensive pelvic floor exercise with or without vaginal cones improves the symptoms of mild to moderate stress incontinence in about 85% of premenopausal women, but that it has little effect on urodynamic parameters. Vaginal cones provided no additional benefit but may be useful for women for whom closely supervised pelvic floor exercise is not available.

Beckenbodengymnastik allein oder mit Vaginalkonen bei prämenopausalen Frauen mit milder und mässiger Stressharninkontinenz

Das Ziel dieser Studie war es, Beckenbodengymnastik allein (Gruppe A) und Beckenbodengymnastik mit Vaginalkonen (Gruppe B) zu vergleichen. 46 pramenopausale Frauen mit milder oder massiger Stressinkon

TIMING OF URETHRAL PRESSURE PULSES BEFORE AND AFTER CONTINENCE SURGERY

In continent women, urethral pressure with stress events has been found to rise approximately 200 msec before pressure in the bladder begins to rise. We studied the time difference in incontinent women, women after successful and unsuccessful incontinence procedures, and continent women, to evaluate the timing of urethral pressure rises in correlation with continence status. We analyzed the urodynamic data of 20 incontinent patients before and after successful or unsuccessful (n = 10 each) Raz needle suspension. Ten continent women served as controls. The time difference between onset of the pressure increase in the urethra and in the bladder was noted before and after surgery. In all 10 continent women the pressure increase in the urethra started to rise approximately 160 msec before the pressure increase in the bladder. In 16 of 20 incontinent patients the pressure in the urethra and bladder rose simultaneously. Successful antiincontinence procedures restored the early onset of urethral pressure increases. Unsuccessful operations did not produce this effect. Successful antiincontinence operations permit timely compression of the urethra. This timely compression is associated with continence. Neurourol. Urodynam. 17:19–23, 1998.

Mechanism of postoperative urinary continence.

Abstract: Stress incontinence used to be attributed mostly to urethral hypermobility, and consequently most surgical techniques focused on the region of the bladder neck and proximal urethra. This article reviews our knowledge about the mechanism of postoperative urinary continence based on anatomic, imaging and urodynamic studies. Reduction of urethral mobility, as measured by cotton swab testing or imaging studies, is not the only reason why continence surgery succeeds. Imaging techniques are of limited value for elucidating the continence mechanism because radiologic landmarks and criteria are not reproducible. Urodynamically, the increased pressure transmission after successful continence surgery is attributed to the retropubic repositioning of the urethra, its compression against the anterior vaginal wall, and improved transmission of intra-abdominal pressure during stress. The role of the ‘functional’ urethral obstruction remains to be studied. In incontinent patients with hypermobility of the bladder neck and proximal urethra continence can be achieved by surgical correction. However, stress incontinence is possible in the absence of urethral hypermobility, and standard surgical techniques can fail to restore continence in these patients.

Contribution of the Posterior Compartment to the Urinary Continence Mechanism

Objective To describe the contribution of the posterior pelvic compartment to the urethral closure mechanism. Methods Urethral profilometry at rest and during stress was performed in 32 continent women before and after inserting a weighted (1 kg) posterior speculum to displace the posterior vaginal wall and levator ani muscles away from the bladder neck and the urethra. Results Insertion of the speculum decreased the pressure transmission ratios in the proximal quarter of urethra (from 81 to 76; P < .05) and the urethral closure pressure under stress in the proximal two urethral quarters (from 5 to −3 cm H2O in the first and from 12 to 0 cm H2O in the second urethral quarter; P < .05) in all 32 women. Before speculum insertion, 20 women had positive urethral closure pressure in the proximal urethra under stress, and 12 had negative urethral closure pressure in the proximal urethra under stress. In the 20 women with positive urethral closure pressures under stress in the proximal urethra without a speculum, the insertion of a posterior speculum decreased the pressure transmission ratios to the proximal urethral quarter (from 87 to 78; P < .05) and decreased the urethral closure pressures under stress in the proximal two urethral quarters (from 13 to −4 cm H2O in the first urethral quarter and from 24 to 2 cm H2O in the second urethral quarter; P < .01). In the 12 patients with negative urethral closure pressures under stress in the proximal urethra without a speculum, the profilometry values were unchanged by insertion of a speculum. Conclusion These observations indicate that the posterior vaginal compartment may contribute to the closure mechanism of the proximal urethra in continent women.

Guideline: Überwachung und Management bei Überschreitung des Geburtstermins1

Aufbauend auf der «evidence-based medicine» sollen Guidelines eine Hilfeleistung und Orientierung für Diagnostik und Therapie der individuellen Patientin erbringen. Die FMH legt Wert darauf, dass Guidelines insbesondere für die Ärzte in der Praxis, aber auch für den klinischen Bereich ihre Anwendung finden sollen. «Leitlinien» sind systematisch entwickelte Darstellungen und Empfehlungen mit dem Zweck, Arzt und Patientin bei der Entscheidung über zweckdienliche Massnahmen der Krankenversicherung (Prävention, Diagnostik, Therapie und Nachbehandlung) unter spezifischen klinischen Umständen zu unterstützen. Leitlinien stellen den Stand des Wissens über effektive und zweckdienliche Krankenversorgung zum Zeitpunkt der Veröffentlichung dar und wenden sich in erster Linie an den ärztlichen Bereich, erst sekundär an die Öffentlichkeit und die Versicherer. Wegen der Fortschritte der wissenschaftlichen Erkenntnisse müssen Leitlinien periodisch überarbeitet werden. Die Entscheidung darüber, ob einer bestimmten Empfehlung gefolgt werden soll, muss vom Arzt unter Berücksichtigung der bei der individuellen Patientin vorliegenden Gegebenheiten und der verfügbaren Ressourcen entschieden werden. Im Einzelfall müssen somit die aktuelle Situation der Patientin, ihr Umfeld, ihre sozio-ökonomische Situation, die Komorbidität und Nebendiagnosen, aber auch ihre ethische und religiöse Haltung mitberücksichtigt werden. Damit ist ein entscheidender ärztlicher Freiraum gegeben, welcher es überhaupt ermöglicht, Leitlinien in die Praxis umzusetzen. «Therapeutische Freiheit» bedeutet, dass der Arzt sowohl die Kompetenz hat wie auch die Verantwortung dafür trägt, dass die von ihm an der Patientin vorgenommene Diagnostik bzw. durchgeführte Therapie dem aktuellen Stand der Wissenschaft entspricht – therapeutische Freiheit somit gleichermassen als Freiheit wie auch als Verpflichtung, das Richtige zu tun.

Inadvertent ureteral catheterization with a microtip catheter at cystometry

Two patients in whom the right ureter was inadvertently catheterized at water cystometry are described. Accidental ureteral catheterization and filling was followed by colicky pain in the right flank and by an abrupt increase in the recorded pressure, up to 148 cmH2O. The pain disappeared and the intravesical pressure returned to baseline after the microtip catheter was withdrawn.