Gamal M. Ghoniem

Evaluation and outcome measures in the treatment of female urinary stress incontinence: International Urogynecological Association (IUGA) guidelines for research and clinical practice.

Millions of women are afflicted with stress urinary incontinence (SUI) and pelvic organ prolapse (POP) around the globe, and the literature is abundant with different types of surgery to correct these problems. Only recently have outcome measures been applied to research in these areas. There are great variations in types of surgery performed, secondary to many factors such as surgeon’s training and socioeconomic factors. As the population of aging women increases worldwide, it is inevitable that these women’s disorders will become more prevalent. This will pose a major challenge to the health care systems.

Cross-Linked Polydimethylsiloxane Injection for Female Stress Urinary Incontinence: Results of a Multicenter, Randomized, Controlled, Single-Blind Study

PURPOSEnIn a pivotal trial we evaluated the effectiveness and safety of Macroplastique(R) as minimally invasive endoscopic treatment for female stress urinary incontinence primarily due to intrinsic sphincter deficiency.nnnMATERIALS AND METHODSnA total of 247 females with intrinsic sphincter deficiency were randomized 1:1 and treated with a transurethral injection of Macroplastique or Contigen. The latter group served as the control. Repeat treatment was allowed after the 3-month followup. Effectiveness was determined 12 months after the last treatment using Stamey grade, pad weight and Urinary Incontinence Quality of Life Scale scores. Safety assessment was recorded throughout the study.nnnRESULTSnAfter 12 patients were excluded from study 122 patients received Macroplastique injection and 125 received Contigen injection. Mean patient age was 61 years and the average history of incontinence was 11.2 years. Of the patients 24% had undergone prior incontinence surgery. At 12 months after treatment 61.5% of patients who received Macroplastique and 48% of controls had improved 1 Stamey grade. In the Macroplastique group the dry/cure rate was 36.9% compared to 24.8% in the control group (p <0.05). In the Macroplastique and control groups the 1-hour pad weight decrease was 25.4 and 22.8 ml from baseline (p = 0.64), and the mean improvement in Urinary Incontinence Quality of Life Scale score was 28.7 and 26.4 (p = 0.49), respectively.nnnCONCLUSIONSnMacroplastique injection was statistically more effective than Contigen for stress urinary incontinence primarily due to intrinsic sphincter deficiency with a 12.1% cure rate difference. Macroplastique can be administered on an outpatient basis. It should be considered a primary or secondary treatment option for stress urinary incontinence.

Pelvic Floor Dysfunction Management Practice Patterns: A Survey of Members of the International Urogynecological Association

Abstract The authors report results of a survey of the practice patterns of International Urogynecological Association (IUGA) members in the management of urinary incontinence and pelvic organ prolapse. A questionnaire regarding current urogynecological clinical practice was developed by the Research and Development Committee of IUGA and mailed to all members of IUGA. Age, specialty, and geographic location factors were used for response comparisons. One hundred and fifty-two surveys (30%) were returned, 35% from North America, 51% from Europe/Australia/New Zealand, and 14% from elsewhere. The average age of respondents was 47.2 years (SD = 9.5), 89% were gynecologists and 11% were urologists. Overall, the procedures of choice for stress incontinence (SUI) were tension-free vaginal tape (TVT; 48.8%) and Burch colposuspension (44%). There were significant geographic variations noted. For SUI with low-pressure urethra/intrinsic sphincteric deficiency, TVT was used by 44.6% and suburethral sling by 32.3%. Various materials are used for suburethral slings, including autologous fascia (46.5%), Marlex mesh (27.8%) and cadaveric fascia lata (11.6%). Bulking agent injection therapy is used for ISD by 75% of respondents. Traditional reconstructive procedures are performed by the majority of respondents, including sacrospinous fixation (78%), abdominal sacrocolpopexy (77%), paravaginal repair (65%) and vaginal enterocele repair (93%); 6.5% use defecography in evaluating rectoceles and 44% use the POP-Q. Seventy-two per cent use urodynamic evaluation routinely in prolapse cases with no manifest SUI. Most IUGA members perform commonly accepted procedures for surgical therapy of urinary incontinence and genital prolapse. IUGA members do not frequently use anorectal physiology and fluoroscopic investigations to evaluate rectoceles prior to repair.

Transperineal Repair of Complex Rectourethral Fistula Using Gracilis Muscle Flap Interposition—Can Urinary and Bowel Functions be Preserved?

PURPOSEnRectourethral fistula developing after prostate cancer treatment is usually complex and difficult to repair. We present our experience with 25 cases of complex rectourethral fistula using gracilis muscle interposition, addressing the efficacy of this technique as well as the postoperative urinary and fecal outcome.nnnMATERIALS AND METHODSnAfter receiving institutional review board approval we performed a retrospective chart review of patients with prostate cancer who had undergone gracilis muscle interposition for complex rectourethral fistula. A 1-page questionnaire was then mailed to all patients to assess urinary and bowel function.nnnRESULTSnAt mean followup of 28 months all patients had successful fistula closure with no recurrence. Of the 18 patients (72%) with urinary continence 5 were continent after artificial urinary sphincter implantation. Three patients (12%) were totally incontinent and lost to followup. Four patients (16%) had permanent urinary diversion due to a devastated urinary outlet, while a urethral stricture was found in 5 and bladder neck contracture was noted in 3. Regarding bowel control, 19 patients (76%) were continent, 2 (8%) had fecal incontinence and 4 (16%) required permanent colostomy due to a devastated fecal outlet. A total of 17 patients replied to the mailed questionnaire for a 68% response rate and all had significant improvement in all parameters. Factors predisposing to a suboptimal outcome were large fistula size, surgery followed by radiation and cryotherapy.nnnCONCLUSIONSnGracilis muscle transposition is an excellent procedure for treating complex rectourethral fistula. Several other local factors may affect the postoperative urinary and fecal outcome. The collaboration of colorectal and urological surgeons is necessary to achieve optimal results.

Durability of Urethral Bulking Agent Injection for Female Stress Urinary Incontinence: 2-Year Multicenter Study Results

PURPOSEnWe evaluated the durability of the urethral bulking agent Macroplastique for stress urinary incontinence in a 24-month study in women with a previously documented successful outcome 12 months after the last injection.nnnMATERIALS AND METHODSnIn a multicenter study females diagnosed with stress urinary incontinence primarily due to intrinsic sphincter deficiency successfully treated with Macroplastique, defined as 1 or greater Stamey grade improvement 12 months from baseline, were followed for 24 months to assess the sustained therapeutic response. Outcome measures were Stamey grade, Patient Global Impression of Improvement, Physician Assessment of Improvement, 1-hour pad weight, Incontinence Quality of Life scores and safety assessment.nnnRESULTSnAt 24 months 56 of 67 patients (84%) had sustained success since 12 months, of whom 45 of 67 (67%) were dry (Stamey grade 0). Of the dry patients at 12 months 33 of 38 (87%) maintained cure at 24 months. Also, 12 of 29 patients (41%) considered improved at 12 months were dry at 24 months. Overall Incontinence Quality of Life scores and all subscales showed statistically significant improvement from baseline (p <0.001). Mean pad weight was 24 gm at baseline, and 4 gm at 12 and 24 months. Patient and physician assessments rated 85% of patients dry or markedly improved 24 months after the last treatment.nnnCONCLUSIONSnSubstantial, durable results were sustained during 2 years with 84% of patients maintaining significant Stamey grade improvement from the 12-month assessment. Two-thirds of patients were dry at 24 months. The durability of Macroplastique shows its effectiveness as a viable long-term therapy for female stress urinary incontinence primarily due to intrinsic sphincter deficiency.

Obstructive suburethral mass after transurethral injection of dextranomer/hyaluronic acid copolymer

Dextranomer/hyaluronic acid copolymer (Zuidex®) is a new bulking agent. There is little data about the complications of using this substance as urethral bulking agent for the treatment of urinary stress incontinence. We are presenting a 59-year-old female patient who developed a suburethral mass and urinary retention after zuidex urethral injection. A stepwise approach for treatment was followed. Complete excision of the mass was the only curative procedure that succeeded.

The Arabic ICIQ-UI SF: An alternative language version of the English ICIQ-UI SF

AIMSnUrinary incontinence (UI) is a common and distressing condition. A variety of questionnaires are currently available to assess UI and its impact on patients lives. However, most have not been adapted for international use. Following a systematic review of the literature and existing questionnaires the International Consultation on Incontinence short form questionnaire (ICIQ-UI SF) was developed, and has since been translated into many languages for local use. This paper reports the development and validation of the first UI questionnaire in the Arabic language. The development of this questionnaire will facilitate the assessment of UI in both clinical practice and research in the Middle-East.nnnMETHODSnTranslation and validation of the Arabic version of the ICIQ-UI is described. Standard methods of translation by native Arabic and English speakers (including translation and back translation) are followed. The psychometric properties of the questionnaire, including its validity, reliability and sensitivity to change, are examined. The validation of the questionnaire involved patients attending urology outpatient clinics in two Middle-Eastern countries.nnnRESULTSnThe Arabic ICIQ-UI SF was found to be valid, reliable and responsive, indicating that the psychometric properties of the questionnaire have remained constant throughout the adaptation process. Furthermore, the findings of the psychometric testing confirm those found for the UK-English ICIQ-UI SF.nnnCONCLUSIONSnThe development of this questionnaire will allow the study of Arabic speaking groups with UI in many countries around the world. This may act as an example to initiate the translation and validation of other patient reported outcomes into the Arabic language, thereby enabling more multinational and cross-cultural research into diseases in given areas.

Urethral prolapse after durasphere injection

Urethral prolapse is an uncommon condition among adult patients. We report a case of adult female patient with urethral prolapse after Durasphere injection. The patient was successfully treated with excision of the prolapsed urethra and Durasphere mass, and fibrin glue injection to support the remaining part of urethra.

Grades of Intrinsic Sphincteric Deficiency (ISD) Associated with Female Stress Urinary Incontinence

Intrinsic urethral sphincter deficiency (ISD) is a clinical entity that should be suspected in women with stress urinary incontinence. If it is not diagnosed prior to surgery, it poses a significant risk factor for repair failure. We propose a classification of ISD based on videofluorourodynamic (VFUD) and abdominal leak-point pressures. One hundred female patients with stress urinary incontinence due to ISD were included in this study. History and physical examination were performed on all patients. Each patient underwent a standard VFUD study with abdominal leak-point pressure (ALPP) measurement. ISD is classified into subtypes according to VFUDS and ALPP. The findings were then correlated with the clinical presentation, etiology and proposed management. Three types of ISD/SUI were identified. ISD-A, subtle/urodynamic, was present in 32 patients (32%). It is most difficult to diagnose because radiologically the bladder neck is not open at rest, and it is only diagnosed by VFUD. The abdominal leak-point pressure was less than 12 cmH2O. ISD-B was present in 45 patients (45%). This is characterized by a beak-shaped open bladder neck at rest. The abdominal leak-point pressure was less than 90 cmH2O. ISD-C was present in 14 patients (14%). It is characterized by an open, fixed non-functioning urethra (pipe-stem) with high position of the bladder neck. The abdominal leak-point pressure was less than 70 cmH2O. All the three subtypes had proximal urethral closure pressure (PCUP) less than 10 cmH2O. Based on these data, the treatment options may vary from one subtype to another. For ISD-A, initial treatment was medical, with collagen injection being used for the failed cases. For ISD-B a modified pubovaginal sling was used, as it corrects the ISD and the urethral hypermobility at the same time. For ISD-C, urethrolysis and takedown of the previous suspension was required before using a sling. Collagen injections were used in selected cases. This classification identifies different subgroups of ISD, which is important in the diagnosis and management of this condition.

The outcome of transobturator cystocele repair using biocompatible porcine dermis graft: our experience with 32 cases

This study aims to evaluate the outcome of cystocele repair using Perigee® with biocompatible matrix (InteXen®). After IRB approval, a retrospective chart review of patients who underwent Perigee®/InteXen® repair was done. Success was defined as a postoperative anatomical stage 0 or I using POP-Q system. Thirty two patients were included with 14 (43.75%) who had failed previous repair. Preoperatively, eight patients (25%) had stage II cystocele, 21 (65.6%) had stage III, and three (9.4%) had stage IV. Twenty six patients (81.25%) were available for a median follow up of 8.72 (6–31)xa0months that showed success in 25 patients (96%) with 14 (54%) having stage 0 and 11 (42%) having stage I. Complications included bladder perforation (nu2009=u20091), incidental cystotomy (nu2009=u20091), mesh erosion (nu2009=u20091), and wound dehiscence (nu2009=u20091). This study suggests cystocele repair using Perigee® with InteXen® has a high short-term success with lower morbidity.