Harry A. M. Vervest

Micturition Symptoms and Urinary Incontinence after Non-Radical Hysterectomy

Abstract. The effects of 554 non‐radical vaginal and abdominal hysterectomies on micturition symptoms and urinary incontinence were studied. From the urological point of view, two groups of women may be distinguished prior to hysterectomy: one without urological symptoms and the second with urological complaints (present in no less than 57% of all women and differing significantly from the distribution of urological symptoms in the normal population). In the first group, frequency developed significantly more often than nocturia, dysuria, stress incontinence and nocturnal and diurnal urge incontinence. The type of hysterectomy was not related to this development, except that urgency more often followed vaginal hysterectomy. In the second group, highly significant improvement and disappearance of symptoms was observed. Age, parity, menopausal status, the presence of myomas, height, weight and body mass index had no influence.

A Randomized, Controlled Trial Comparing an Innovative Single Incision Sling With an Established Transobturator Sling to Treat Female Stress Urinary Incontinence

PURPOSE Mid urethral sling procedures have become the surgical treatment of choice for female stress urinary incontinence. Innovative modifications of mid urethral sling procedures were recently introduced with the claim of offering similar efficacy and decreased morbidity. We compared the efficacy and morbidity of an innovative single incision mid urethral tape and an established transobturator procedure. MATERIALS AND METHODS We performed a prospective, randomized, controlled trial in 6 teaching hospitals in Belgium and The Netherlands between 2007 and 2009. A total of 96 patients received a TVT Secur™ single incision sling and 98 received a TVT™ Obturator System. We collected data on patient characteristics, surgery related parameters, adverse events, clinical followup, Urogenital Distress Inventory and SF-36® scores, validated questionnaires on daily life activities and visual analog scores objectifying pain. Followup was 1 year. RESULTS One-year followup was available for 75 single incision sling and 85 obturator system cases. Stress urinary incontinence could be objectified in 16.4% of the patients with a single incision sling and in 2.4% with an obturator system (p <0.05). Stress urinary incontinence was subjectively reported by 24% of single incision sling and 8% of obturator system patients (p <0.05). One year after surgery the mean ± SD UDI incontinence domain score in the single incision sling and obturator system groups was 21 ± 24 and 13 ± 21, respectively (p <0.01). Patients with a single incision sling experienced significantly less pain during the first 2 weeks after surgery (p <0.05) and returned significantly earlier to normal daily activity. The OR of re-intervention for stress urinary incontinence 1 year after receiving a single incision sling vs an obturator system was 2.3 (95% CI 1.9-2.7). CONCLUSIONS The single incision sling procedure is associated with less postoperative pain and a lower objective cure rate than the obturator system procedure.

Risk factors for failure of retropubic and transobturator midurethral slings

OBJECTIVE The aim of our study was to identify and compare risk factors for failure of retropubic and transobturator procedures. STUDY DESIGN This was a retrospective cohort study. Women with predominant stress urinary incontinence who underwent a retropubic (n = 214) or transobturator tape procedure (n = 173) were included. Therapy was considered to have failed in women reporting any amount of urine leakage during stress after 2 and/or 12 months. RESULTS Risk factors for failure were mixed urinary incontinence (MUI; odds ratio [OR], 3.7; 95% confidence interval [CI], 1.5-9.1) and the observation of detrusor overactivity (DO) at urodynamics (OR, 8.6; 95% CI, 1.9-39.4) in the retropubic group. Reporting a history of previous incontinence surgery (OR, 3.9; 95% CI, 1.3-11.7) and a low mean urethral closure pressure (MUCP) at urodynamics (OR, 14.5; 95% CI, 1.5-139.0) were risk factors for failure in the transobturator group. CONCLUSION Women with previous incontinence surgery or a low MUCP might benefit more from a retropubic sling, whereas a transobturator procedure might be preferable in women with MUI or DO.

Radical Hysterectomy and the Function of the Lower Urinary Tract: Urodynamic quantification of changes in storage and evacuation function

The intermediate sequelae of radical hysterectomy on the storage and evacuation function of the lower urinary tract were studied by comparison of pre‐and postoperative urodynamic parameters. A modified surgical technique was employed in order to remove only the necessary part of the upper part of the vagina and paravaginal tissues. A non‐significant reduction in bladder capacity and compliance was found. Urethral function remained unaltered. The most prominent finding was a significant reduction in detrusor contractility and the development of abdominal straining in order to empty the bladder. The pathophysiologic mechanisms by which lower urinary tract is changed after radical hysterectomy are a decrease in the musculo‐elastic properties of the bladder wall caused by surgical injury, and partial damage to the neural innervation of the bladder.

Predictive value of urodynamics on outcome after midurethral sling surgery for female stress urinary incontinence

OBJECTIVE The aim of this study was to evaluate the value of urodynamic investigation in the preoperative workup of midurethral sling surgery and to identify risk factors for failure after 3 different midurethral sling procedures. STUDY DESIGN Retrospective cohort study. 437 women who underwent a tension-free vaginal tape, Monarc, or tension-free vaginal tape-obturator procedure without other simultaneously performed urogynecological surgery were included. Preoperative data were collected from the medical files. Patients who reported any amount of leakage were considered failures. The mean follow-up of the study population was 14 months. RESULTS After multivariate analysis, mixed urinary incontinence (P = .04), previous incontinence surgery (P = .022), and detrusor overactivity (P = .02) were significantly related to failure of midurethral sling procedures. There were no predictive urodynamic parameters for failure in patients with mixed urinary incontinence or previous incontinence surgery. CONCLUSION The standard use of urodynamic investigation in the preoperative workup of midurethral sling surgery needs to be revisited.

Preliminary results with the antiprogestational compound RU-486 (mifepristone) for interruption of early pregnancy

RU-486 (mifepristone) (Roussel-Uclaf, Paris, France) is an antiprogesterone that acts through a competitive binding at the site of the progesterone and cortisol receptor. It induced a complete expulsion in 29 (83%) of 35 patients with an unwanted pregnancy with up to 55 days of amenorrhea. A complete expulsion occurred in 17 (89%) of the 19 nulliparous women, and no serious side effects were seen. However, our results were less successful in ine patients with a more advanced pregnancy (between 8 and 10 weeks). In this group, only three complete expulsions were seen.

Non‐Radical Hysterectomy And The Function Of The Lower Urinary Tract: II: Urodynamic Quantification Of Changes In Evacuation Function

The intermediate sequelae of non‐radical abdominal and vaginal hysterectomies on the evacuation function of the lower urinary tract were studied by comparison of pre‐ and postoperative urodynamic parameters. No significant changes were observed in detrusor contractility or the contribution of abdominal straining after hysterectomy. Pressure‐flow studies revealed no development towards obstructive patterns. Uroflowmetry did not demonstrate any changes in flow rates or in flow patterns. Except in one woman, no major variations were seen in residual urine volumes. There were no differences between abdominal and vaginal hysterectomies. It is concluded that lower urinary tract evacuation function remains unaltered by total hysterectomy.

Non-Radical Hysterectomy and the Function of the Lower Urinary Tract: I: Urodynamic quantification of changes in storage function

The intermediate sequelae of non‐radical abdominal and vaginal hysterectomies on the storage function of the lower urinary tract were studied by comparison of pre‐ and postoperative urodynamic parameters. A statistically significant reduction in maximum cystometric capacity after abdominal extrafascial and vaginal hysterectomies was found, together with a decline in bladder compliance. Both findings are attributed to a decrease in the musculoelastic properties of the detrusor muscle caused by edema and surgical injury. This reduction in capacity and compliance, however, appeared to have no clinical importance. Sensory innervation remained unaltered. In general no evidence was found that hysterectomy contributed to the development of involuntary detrusor contractions and motor urge incontinence. Urethral competence, assessed by urethral pressure profilometry and urethral leakage pressure measurement, remained unaffected. No increase in stress incontinence was seen after hysterectomy. Vaginal hysterectomy appeared to influence storage function slightly more than abdominal hysterectomy did. Postoperative lower urinary tract dysfunction is for the most part determined by the preoperative urological status.

Outcome and complications of retropubic and transobturator midurethral slings translated into surgical therapeutic indices

OBJECTIVE We sought to determine and compare surgical therapeutic indices (STIs) of the retropubic tension-free vaginal tape (TVT) and 2 kinds of transobturator tape (TOT), Monarc (American Medical Systems, Minneapolis, MN), and tension-free vaginal tape obturator. STUDY DESIGN This was a retrospective cohort study. Patients with predominant stress urinary incontinence who underwent retropubic (TVT, n = 257) or TOT (n = 180) procedures were included. STIs for both groups were calculated by dividing cure by complication rate at, respectively, 2 and 12 months. RESULTS Two months after surgery the STI was significantly higher after TOT whereas 12 months after surgery results of STIs were equal. The explanation is more durable cure rates and declining long-term side effects after TVT procedures. CONCLUSION Both surgical approaches seem to have their own benefits. Based on the STI, the balance between cure rate and complications is on the short term in favor of TOT but on the long term similar for TOT and retropubic TVT.

Perspectives by patients and physicians on outcomes of mid-urethral sling surgery

Introduction and hypothesisThe aim of this study is to determine patient expectations regarding wanted and unwanted sequels of mid-urethral sling (MUS) procedures and to identify mismatches during the physician–patient information exchange prior to MUS procedures.MethodsA patient preference study (40 patients) and a questionnaire study with 20 experts as control group were conducted. Seventeen different sequels, defined by an expert team, were evaluated.ResultsBoth patients and expert physicians ranked cure and improvement of stress urinary incontinence as the most important goals of treatment. De novo urge urinary incontinence, requiring post-operative intermittent self-catheterisation and dyspareunia were considered to be the most important complications by patients. Time to resume work after the operation and dyspareunia were among the highest rated sequels in the patient group compared to re-operation and intra-operative complications in the expert group.ConclusionsNo differences were found in the five most important outcome parameters. In pre-operative counselling and future clinical trials, time to resume work and dyspareunia should be given more consideration by clinicians.