M. I. Frazer

Urine Flow Rates and Residual Urine Volumes in Urogynecology Patients

Abstract: Two hundred and fifty consecutive women referred because of symptoms of lower urinary tract dysfunction underwent a full clinical and urodynamic assessment. Their urine flow rates and residual urine volumes were analyzed. The urine flow rates of the urogynecology patients were found to be significantly less than those of an asymptomatic population. There were significant declines in urine flow rates in the presence of a previous hysterectomy and with increasing grades of prolapse, particularly uterine prolapse, cystocele and enterocele. Unlike the normal female population, there was also deterioration with increasing parity and age, the latter largely due to the increasing incidence of hysterectomy and prolapse with age. The 10th centile of the Liverpool Nomogram for the maximum urine flow rate was found to be the most useful discriminant for a final urodynamic diagnosis of voiding difficulties. Most urogynecology patients have no or small residual urine volumes, 74% <10 ml and 81% <30 ml (vs 95% <30 ml in asymptomatic women). In urogynecology patients residuals were larger where there had been a prior hysterectomy or with grade 2 or higher uterine prolapse, cystocele and enterocele. Mean residual was 14.8 ml (vs 4.8 ml in asymptomatic women). These data indicate a higher incidence of voiding difficulties (abnormally slow urine flow (under 10th centile) and/or abnormally high residual urine volume (over 30 ml) in urogynecology patients, particularly those with higher grades of prolapse and with prior hysterectomy.

Short‐term clinical and quality‐of‐life outcomes in women treated by the TVT‐Secur procedure

Background:  The TVT‐Secur (Ethicon, Somerville, NJ, USA) is a minimally invasive suburethral synthetic sling used in the treatment of female stress urinary incontinence. It claims to cause less postoperative pain and to enable performing in an office setting. However, this may be at the expense of a significant learning curve and a higher early failure rate.

The sacrospinous ligament: Conveniently effective or effectively convenient?

Summary The sacrospinous ligament has been used for over 50 years as a convenient structure for treating vaginal vault and more recently, uterine prolapse. The procedure has evolved over the years and its efficacy has been hotly debated with invariable comparisons made to abdominal sacral colpopexy. Mesh surgery has introduced a newer dimension to the debate. This review is an attempt to clarify the anatomy, reflect on various techniques and offer a critique on the current ‘status’ of the sacrospinous ligament.

Idiopathic sensory urgency and early interstitial cystitis

The sensory aspects of bladder function are not clearly defined, are poorly understood and imperfectly managed. Sensory urgency or bladder hypersensitivity often present with symptoms without an obvious cause (idiopathic sensory urgency). This article reviews the evidence that some of these symptomatic patients are actually suffering from early interstitial cystitis. The implications of such a possibility are discussed and the possible role of detrusor mast-cell infiltration in the genesis of bladder symptoms in women is examined.

Measurement of residual urine volumes in women: Urethral catheterization or transvaginal ultrasound?

The most practical and accurate method to measure residual urine volumes in women is yet to be determined. The practicality of transvaginal ultrasound in measuring the range of residuals typically encountered in a group of 100 symptomatic women attending for urodynamic investigations was tested and compared with urethral catheterization. Transvaginal ultrasound was found to be more comfortable, less invasive and quicker. In ideal circumstances for both techniques, mean time from voiding until residual assessment was 47 seconds for transvaginal ultrasound and 270 seconds for urethral catheterization. Transvaginal ultrasound was applicable to 99% of women, with accurate assessment of residuals possible in 96% (100% for urethral catheterization). Eighty-five percent of women were found to have a residual under the level of likely clinical significance (30 ml). Transvaginal ultrasound permits the avoidance of catheterization in these women. Transvaginal ultrasound allows for immediate retesting of the residual, a feature not possible if there is bladder drainage by urethral catheterization. Of the 22 women with residuals initially over 30 ml, 11 (50%) were able to lower this by an average of 69%, 7 (32%) of these to under 30 ml, with an immediate further attempt at voiding. In terms of practicality, transvaginal ultrasound is the method of choice for residual determination in the vast majority of women attending for urodynamic investigations. While it is not possible to directly compare the accuracy of the two techniques, a theoretical comparison is possible by summation of their respective sources of error. This comparison showed that the two techniques, in ideal circumstances, have similar accuracies over the range 0–175 ml. In non-ideal circumstances, urethral catheterization has more potential sources of error.

Comment: quicker trial of void after midurethral sling procedure many not lead to earlier discharge times

Dear Editor, We congratulate Myers et al. [1] on a well-designed study comparing two methods for trial of void after a midurethral sling procedure. The trial was aimed at assessing whether a retrograde fill in the operating theatre, as opposed to in recovery, would decrease the time spent in recovery before patients went home. We read the results with interest: initiating the trial of void in the operating theatre decreased the time taken to complete a successful trial but did not decrease the time until discharge. We recently had a similar randomised controlled trial accepted for publication in the Australian and New Zealand Journal of Obstetrics and Gynaecology [2] that compared the retrograde fill initiated in the operating theatre with our hospital’s standard auto-fill trial. In our Australian hospital setting, it is common for women to stay overnight after a midurethral sling procedure, often due to the length of time taken to pass the trial of void. We designed a study aimed at establishing whether a retrogradefill trial of void would result in more patients being discharged from recovery on the day of surgery. In keeping with the results of Myers et al. [1], we found that a retrograde-fill trial of void decreased the time it takes to pass the trial but did not result in more same-day discharges. In their discussion, Myers et al. suggested that there are likely to be several factors contributing to patients remaining in recovery despite passing their trial of void. Certainly in our study, we concluded that both nursing and patient expectations were significant contributing factors to this phenomenon. In our hospital setting, both patients and nurses generally expected patients to have an overnight admission, and we found that this expectation was difficult to override despite preoperation counselling.

Infusion‐fill method versus standard auto‐fill trial of void protocol following a TVT‐exact procedure: A randomised controlled trial

To establish whether the infusion method trial of void (TOV) after a mid‐urethral sling procedure, in contrast to the standard auto‐fill TOV, permits discharge home from recovery, as these procedures are eminently suited to same day discharge, and the delay in achieving a successful TOV often keeps the patient in hospital overnight.

Ornipressin in cold knife cone biopsy of the cervix

SummaryCold knife cone biopsy using ornipressin and a cervical encircling suture is described. Case notes from 81 patients using this technique were studied retrospectively. The 3-7 per cent incidence of haemorrhage requiring hospital re-admission compared very favourably with other surgical techniques used.

Abdominoperineal Urethral Suspension: A Report of 20 Cases

EDITORIAL COMMENT: We accepted this paper for publication because we consider Zacharins operation does not enjoy the popularity it deserves ‐ it is also ironical that this operation and the anatomy of the pubourethral ligament as described by Zacharin, and on which the technique is based, has been acknowledged in overseas journals (Obstet Gynecol Surv 1989; 44:833) but not our own. Zacharin uses abdominoperineal urethral suspension exclusively for patients with recurrent stress incontinence but he, unlike the authors of this paper, does not advocate its use as a primary procedure when there is uterovaginal prolapse. Most of the 335 patients Zacharin has operated on in the past 20 years for the relief of stress incontinence have had previous surgery, although there were a few without prolapse who had not (personal communication to the editor). Zacharin reported an 85% overall cure rate for his operation after long‐term follow‐up in a series of 194 women treated during the 15 years, 1965–1980 (Obstet Gynecol 1983; 62: 644–654). During the past 15 years Zacharin has been invited to perform his abdominoperineal urethral suspension procedure in university centres in the United States, Canada. Europe, the United Kingdom, Africa and Asia. The editorial board is unaware of any other Australian gynaecologist who is repeatedly asked to demonstrate a surgical procedure abroad ‐ it seems appropriate that the technique be reexamined by all gynaecologists who treat patients for stress incontinence when it recurs after primary surgery.