François Haab

Proposed cutoff values to define bladder outlet obstruction in women.

OBJECTIVES There is no accepted urodynamic definition of outlet obstruction in women. Currently, the diagnosis is made on the basis of history and radiographic and endoscopic findings. The goal of this study is to design a pressure-flow nomogram (PdetQmax/Qmax) and define cut-off values for obstruction. METHODS Two groups were studied prospectively in an open study: 124 control and 35 clinically obstructed patients. All had a complete history, physical examination, normal neurologic evaluation, cystoscopy, voiding cystography, and urodynamics-with-pressure-flow study. Pressure-flow plot and receiver operator characteristic curves (ROCs) were constructed to determine optimal cut-off values to predict obstruction for peak flow rate (Qmax) and detrusor pressure at maximal flow (PdetQmax). RESULTS The etiology of obstruction was previous anti-incontinence surgery (n = 13), large cystocele (n = 11), urethral stricture (n = 6), and other (n = 5). On the basis of ROC curves, using cut-off values of Qmax of 15 mL/s or less and 12 mL/s or less, sensitivity was 85.7% and 71.4%, and specificity 78.2% and 90.3%, respectively. Using cut-off values of PdetQmax of more than 25 and more than 30 cm H2O, sensitivity was 74.3% and 71.4%, and specificity 79.8% and 88.7%, respectively. Using a combined cut-off value of Qmax of 1 5 mL/s or less and PdetQmax of more than 20 cm H2O, sensitivity was 74.3% and specificity was 91.1%. CONCLUSIONS Based on this prospective, controlled study, preliminary cut-off values were obtained for refining the definition of outlet obstruction in women.

The role of urinary urgency and its measurement in the overactive bladder symptom syndrome: current concepts and future prospects

To review the concept of urinary urgency and its practical measurement in clinical trials, and advance the hypothesis that while urge is experienced by normal people, urgency is always pathological.

Female Stress Urinary Incontinence Due to Intrinsic Sphincteric Deficiency: Recognition and Management

PURPOSE The recent literature on intrinsic sphincteric deficiency is reviewed. MATERIALS AND METHODS We performed an extensive literature search related to the diagnosis, management and treatment of intrinsic sphincteric deficiency. RESULTS Stress urinary incontinence results from insufficient urethral resistance and/or support during increases in intra-abdominal pressure. Since treatment of stress urinary incontinence is closely related to the mechanism of urinary leakage, recognition of intrinsic sphincteric deficiency is of the utmost importance in its evaluation. Furthermore, to date there is no consensus on the treatment of intrinsic sphincteric deficiency and various procedures may be considered. CONCLUSIONS The pathophysiology of urinary incontinence in female patients is still controversial. Intrinsic sphincteric deficiency is best recognized by history and clinical examination in conjunction with documentation of severe stress urinary incontinence, a fixed urethra and a low Valsalva leak point pressure. The pubo-vaginal sling procedure still represents the most widely accepted treatment to correct intrinsic sphincteric deficiency.

Post-prostatectomy incontinence: urodynamic findings and treatment outcomes.

PURPOSE We examined urodynamic findings and treatment outcomes in a large population of men with post-prostatectomy incontinence. MATERIALS AND METHODS A total of 215 men was referred for evaluation and treatment of significant post-prostatectomy incontinence. Urodynamic evaluation consisted of provocation multichannel medium fill cystometry with vigorous attempts to demonstrate incontinence. Treatment was directed by the results of the urodynamic study. A pad scoring system was used to gauge the severity of incontinence before and after treatment. RESULTS Based on the results of urodynamic studies 40% of the men had genuine stress incontinence alone and approximately 60% had a major component of bladder dysfunction contributing to incontinence. Treatment results of 135 men demonstrated a significant decrease in pad score (p<0.001) for those treated with anticholinergics, those undergoing artificial sphincter insertion and those treated pharmacologically before sphincter placement. CONCLUSIONS In our large series most men with prostatectomy incontinence did not have genuine stress incontinence alone. Thus, urodynamic studies are critical, not only to define cause of incontinence but to direct effective therapy.

Treatment of Postprostatectomy Male Urinary Incontinence With the Transobturator Retroluminal Repositioning Sling Suspension: 3-Year Follow-up

BACKGROUND The AdVance male sling (American Medical Systems, Minnetonka, MN, USA) has been shown to be an efficacious device in short-term studies for postprostatectomy incontinence (PPI), but long-term studies are lacking. OBJECTIVE Examine the intermediate-term outcome with the AdVance sling for PPI management. DESIGN, SETTING, AND PARTICIPANTS A multicentre prospective evaluation was conducted on consecutive patients treated for PPI in three European tertiary reference centres. INTERVENTION Patients were implanted with the AdVance male sling with no associated surgery. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Measurements included daily pad usage, maximum flow rate (Qmax), postvoid residual urine (PVR), the International Consultation on Incontinence Questionnaire-Short Form, the Incontinence Quality of Life questionnaires, and complications of surgery. Paired Wilcoxon signed rank test univariable and multivariable analyses were used. RESULTS AND LIMITATIONS Follow-up was available for 156 patients for the majority of parameters. Pad usage was significantly decreased compared with baseline at 12 mo and 3 yr (p<0.0001). At 12 mo, 76.9% of patients could be classified as cured or improved; this percentage was maintained at 3 yr (76.8%). Cure rates (58.6% vs 42.3%) and improvement rates (23.2% vs 25.0%) were higher in patients with mild or moderate incontinence compared with severe incontinence. Univariable analysis showed that pretreatment pad usage and severity of incontinence were both significant predictors of success (p=0.0355 and p=0.0420, respectively). However, in multivariable analysis, only pad usage was an independent predictor of success. There were no perioperative or severe postoperative complications. Most complications were Dindo grade I. Seven patients required a second treatment for stress urinary incontinence. There was no worsening over time. Limitations of this study included no comparator group, quality of life questionnaires in only two centres, and no 24-h pad test. CONCLUSIONS The transobturator retroluminal repositioning sling suspension is effective and safe in the longer term for treating PPI.

Quality of Life and Continence Assessment of the Artificial Urinary Sphincter in Men With Minimum 3.5 Years of Followup

PURPOSE We determined the long-term efficacy and quality of life impact of the artificial urinary sphincter. MATERIALS AND METHODS We reviewed the medical records of 68 men who underwent artificial urinary sphincter placement for post-prostatectomy incontinence (64) or neurogenic disease (4) between March 1980 and March 1992 (mean followup 7.2 years). Quality of life was assessed in 52 patients who completed the incontinence impact questionnaire and the urogenital distress inventory. RESULTS At followup 54 men were socially continent (0 or 1 pad per day). Overall, pad score decreased significantly from 2.75 before to 0.97 after artificial urinary sphincter implantation (p < 0.001). The artificial urinary sphincter was permanently removed in 4 patients. Revisions for mechanical failure or urethral atrophy were required in 25% of the patients (mean 1.35 procedures per patient). The mechanical failure rate decreased significantly after 1987 due to device improvements (12.4 versus 44.4%, p < 0.01). Subjective improvement and overall satisfaction were rated as 4.1 and 3.9, respectively (scale 0 to 5). At followup the mean values of the incontinence impact questionnaire and urogenital distress inventory demonstrated the positive impact of the artificial urinary sphincter on quality of life. CONCLUSIONS This long-term study documents the positive impact of the artificial urinary sphincter on patient quality of life with few mechanical failures since 1987.

Mid-term evaluation of the transobturator male sling for post-prostatectomy incontinence: focus on prognostic factors.

Study Type – Therapy (outcomes research)

RESULTS OF THE TENSION-FREE VAGINAL TAPE PROCEDURE FOR THE TREATMENT OF TYPE II STRESS URINARY INCONTINENCE AT A MINIMUM FOLLOWUP OF 1 YEAR

PURPOSE We evaluated the safety and efficacy of the tension-free vaginal tape procedure for treating type II stress urinary incontinence in females. MATERIALS AND METHODS Between April 1998 and April 1999, 62 women 28 to 86 years old (mean age 62.8) were treated consecutively for stress urinary incontinence with the tension-free vaginal tape procedure. Preoperative evaluation included history, physical examination and multichannel video urodynamics. All patients had type II stress urinary incontinence, none had preoperative detrusor instability or significant pelvic prolapse and in 16 previous surgery for stress incontinence had failed. RESULTS All patients were followed at least 12 months after the procedure (median 16.2). A total of 42 and 20 women received spinal and local anesthesia, respectively. We noted 6 bladder perforations, including 5 in patients with a history of surgery for stress urinary incontinence. Blood loss was less than 200 cc in all cases. We observed no prolonged postoperative pain, infection or sling rejection. Post-void residual urine was less than 100 cc the day after surgery in 59 cases. Only 3 patients self-catheterized a maximum of 4 days. At followup 54 women (87.1%) were cured of stress urinary incontinence, 6 were improved (9.6%) and 2 had failure (3. 3%), while 4 (6.4%) had new onset detrusor instability without evidence of bladder outlet obstruction. CONCLUSIONS The tension-free vaginal tape procedure appears to be a minimally invasive, safe and effective treatment for type II stress urinary incontinence. A history of surgery for stress incontinence seems to be a risk factor for bladder perforation.

European Psychometric Validation of the CONTILIFE®: A Quality of Life Questionnaire for Urinary Incontinence

OBJECTIVE To validate 5 language versions (French, Dutch, German, English and Danish) of CONTILIFE, a urinary incontinence-specific measure of Quality of Life (QoL). METHODS CONTILIFE was administered to Belgian, Danish, English, French, German, and Dutch women with genuine stress incontinence. The internal consistency, the construct and clinical validity, and the responsiveness to change over time were assessed using standardised procedures. RESULTS 505 women filled in the CONTILIFE at baseline. Quality of completion was good. The mean number of missing data varied between 0.33 (1.17%) and 0.94 (3.36%) according to the country. Internal consistency was good for all dimensions except for the Effort Activities dimension. Construct validity was good for the Danish, French and pooled sample, and acceptable for English, German and Dutch samples. The distribution of QoL scores differed according to the number of urinary leaks (p<0.007). 477 women completed the questionnaire twice with a 28-day interval. Responsiveness to clinical improvement was good (/ES/> or =0.50) except for the Sexuality and Well-Being dimensions. CONCLUSION In this international European study, CONTILIFE matched the psychometric requirements to be used as a valid, reliable, and sensitive measure of the QoL of the patients. The Daily Activities, Effort Activities, Self-Image and Emotional Consequences dimensions are the most relevant and valid dimensions for purposes of comparison.

Improved quality of life in patients with overactive bladder symptoms treated with solifenacin.

To assess the effect of solifenacin succinate treatment on quality of life (QoL) measured in clinical trials in patients with overactive bladder (OAB).