Mary T. McLennan

Treatment of intrinsic sphincter deficiency using autologous ear chondrocytes as a bulking agent.

Intrinsic sphincter deficiency (ISD) is frequently treated with collagen bulking at the bladder neck. The standard material used, Contigen, biodegrades over 3–19 months requiring repeated injections to maintain efficacy. The study objective was to evaluate use of autologous ear chondrocytes for treatment of ISD. Women with documented ISD had harvest of auricular cartilage. Chondrocytes were isolated from the cartilage and expanded in culture and formulated with calcium alginate to form an injectable gel. Thirty‐two patients received a single outpatient injection just distal to the bladder neck. Outcome measures included voiding diary, quality‐of‐life scores, incontinence severity grading, and pad weight testing. Incontinence grading indicated 16 patients dry, and 10 improved at 12 months for a total of 26 of 32 (81.3%) dry and improved after one treatment. Only four patients had a 12‐month pad weight test over 2.2 g. Quality‐of‐life scores improved significantly after treatment. There was a decrease in incontinence impact scores in all categories. The urogenital distress inventory declined for all categories except bladder emptying and lower abdominal pain. Endoscopic treatment of ISD with autologous chondrocytes is safe, effective, and durable with 50 % of patients dry 12 months after one injection. Twenty‐six of 32 patients dry or improved at 3 months after the injection maintained the effect at the 12‐month visit. Neurourol. Urodynam. 20:157–165, 2001.

Clinical and urodynamic predictors of delayed voiding after fascia lata suburethral sling

Objective To determine the time to resumption of normal voiding after a fascia lata sling and whether any clinical, operative, or urodynamic variables predict it. Methods Between January 1993 and September 1996, 62 women underwent fascia lata suburethral sling operations for intrinsic sphincter deficiency or recurrent stress incontinence. The demographic, operative, and urodynamic data of 61 of these patients were analyzed. Results The mean number of days to resumption of normal voiding was ten. Three patients (5%) developed permanent retention. Patients 65 years and older were more likely than younger patients to have prolonged catheterization (16 versus 7 days, P = .008). Women who had additional procedures voided at a mean of 15 days compared to nine days for those having slings only (P = .029). A preoperative urine flow rate less than 20 mL/sec was associated with late voiding. There was no significant relationship between preoperative voiding mechanism and voiding time. Conclusion Resumption of normal voiding occurred earlier than reported by others. Age over 65 years, additional surgical procedures, and low peak flow rates were risk factors for delayed voiding. Time to normal voiding was independent of the preoperative voiding mechanism.

SUPINE EMPTY STRESS TEST AS A PREDICTOR OF LOW VALSALVA LEAK POINT PRESSURE

Our objective was to determine whether a positive supine empty stress test is predictive of a low Valsalva leak point pressure (⩽60 cm of water). Evaluation was carried out on 179 patients with a history of genuine stress incontinence confirmed with urodynamic testing. All patients had a supine stress test performed after voiding. Residual urine determinations were all <100 cc. A vesical Valsalva leak point pressure determination (cough and strain) was performed during multichannel urodynamics with 150 cc in the bladder. Urethral profilometry was performed at maximum capacity. There was a statistically significant relationship between a low leak point pressure and a positive supine empty stress test (P < 0.000). The supine empty stress test had a sensitivity of 79% and a specificity of 62.5% for the detection of a low leak point pressure. The negative predictive value was high at 90%. For the age group 50 years and younger the negative predictive value was 95%. However, there was no significant relationship between a positive supine empty stress test and a low maximal urethral closure pressure. We conclude that the supine empty stress test is a useful screening test for a low leak point pressure but not a low urethral closure pressure. Its high negative predictive value is useful in excluding the presence of a low leak point pressure and may help the clinician to determine which patients with genuine stress incontinence need further assessment of the dynamic function of the urethral sphincter. Neurourol. Urodyn. 17:121–127, 1998.

Suburethral abscess : A complication of periurethral collagen injection therapy

Background Urinary tract infection after collagen injection is well documented. Other adverse reactions are rare. Cases Three women experienced suburethral abscess after repeat periurethral injections. All patients received local skin preparation and postprocedural antibiotics. Symptoms failed to resolve with antibiotics. The first two patients presented after 5 weeks and 10 days with irritative voiding symptoms and a tender suburethral swelling. The first patient was treated with excision. Spontaneous rupture into the urethra occurred with the second. The third woman presented with acute urinary retention at 102 days. A large suburethral mass was drained successfully in the office. Conclusion Suburethral abscess may be a delayed complication of periurethral collagen injections, not preventable by postprocedural antibiotics. Drainage is required.

Randomized trial of antibiotic prophylaxis for combined urodynamics and cystourethroscopy

OBJECTIVE To determine the efficacy of prophylactic nitrofurantoin in preventing bacteriuria after urodynamics and cystourethroscopy. METHODS We assumed that nitrofurantoin prophylaxis would decrease the rate of infection after urodynamics and cystourethroscopy from 19% to 5%. All women presenting for urodynamics and cystourethroscopy during a 27-month period were offered enrollment, and 142 were randomly assigned to receive two doses of long-acting nitrofurantoin 100 mg (n = 74), or two doses of placebo (n = 68). Nitrofurantoin and placebo capsules were identical, and subjects and physicians were masked to group assignment. Differences were assessed using Student t test for continuous data and chi2 analysis for dichotomous data. RESULTS There were no statistical differences in demographic characteristics or final diagnoses between groups. Seven women (5%) who had bacteriuria on initial urine culture were not included in the final analysis. The frequency of bacteriuria in the postinstrumentation urine cultures was 6% overall, 7% in the treatment group, and 5% in the controls, a nonsignificant difference ([relative risk] 1.49, [confidence interval] 0.37, 5.95). The power of the study was 33% to detect a significant difference. CONCLUSION Bacteriuria after combined urodynamics and cystourethroscopy was not improved by a 1-day course of nitrofurantoin.

Bladder perforation during tension-free vaginal tape procedures: analysis of learning curve and risk factors.

OBJECTIVE: To estimate whether rates of bladder perforation decrease with increasing surgical experience. METHODS: We performed a review of all patients undergoing a tension-free vaginal tape procedure performed by senior resident physicians under the guidance of a single surgeon. Physician experience was assessed by sequentially assigning case numbers to each procedure for each resident. For analysis of learning curve, cases were grouped in fives (ie, first five representing cases 1 to 5, second five cases 6 to 10). RESULTS: Twenty-three residents performed 278 procedures. The median number of cases performed was 13 (range 3 – 22); mean number was 12.1 (sd = ± 5.6). The rate of perforation was 34.2% (95/278, 95% confidence interval 28.8–39.9%). Age and weight were significantly associated with perforation. The cystotomy group was, on average 4.5 years younger (P = .007) and 7.86 kg (17.3 lb) lighter (P < .001). Rate of injury in the first five series was 40.9%, 30.7% in second series of five, and 25.9% in the third series of five and was statistically significant (linear-by-linear association &khgr;2 = 4.286, df = 1, P = .038). The relationship between the incidence of cystotomy and the cumulative number of cases performed was inversely correlated. As the number of cases a resident completed increased, there was a slight tendency for cystotomy to decrease (P.033). On cystoscopic examination, residents missed 35 of the 95 injuries (37%, 95% confidence interval 27.8–46.9%). CONCLUSION: A learning curve exists for tension-free vaginal tape procedures. Many injuries are missed on initial resident cystoscopic inspection, highlighting the need for comprehensive cystoscopic training during residency. LEVEL OF EVIDENCE: II-3

SURGICAL MANAGEMENT OF URINARY INCONTINENCE

Surgery for stress incontinence is selected according to specific problems in each patient. Patients with ISD can be identified and selected for sling surgery or collagen injection therapy. Other patients may be managed successfully by retropubic urethropexy, either open or laparoscopic. Diagnostic evaluation should be thoughtful and extensive, with good correlation of findings and presenting symptoms to apply therapy in a specific manner to each patient.

Leak-Point Pressure: Clinical Application of Values at Two Different Volumes

Abstract: A prospective analysis of 306 consecutive patients with genuine stress incontinence was performed to evaluate the clinical usefulness of additional leak-point pressure (LPP) determination at 200 ml. LPP values at both volumes were compared to maximal urethral closure pressure (MUCP) in an attempt to determine a critical cut-off value for the detection of a low MUCP (≤20 cmH2O). A positive LPP at 150 ml was found in 157 patients. The mean LPP for patients with a low MUCP was 58.5 cmH2O compared to 71.6 for those with a normal MUCP, which was statistically significant (p = 0.01). The correlation coefficient between LPP and MUCP was 0.317. A negative LPP was found in 30% (24/79) of the total having a low MUCP. The addition of values for LPP at 200 ml resulted in an increase in the number who leaked to 191, a 50% increase in the detection rate of low MUCP and a statistically significant relationship between LPP ≤60 cmH2O and low MUCP. Various critical cut-off values for LPP demonstrated good specificity but poor sensitivity for the detection of a low MUCP. It was concluded that there was a statistically significant relationship between LPP and MUCP. Performing LPP at 200 ml provides additional clinically useful diagnostic information.

Posterior tibial nerve stimulation in patients who have failed anticholinergic therapy: efficacy and time to response.

Objectives: We sought to determine the efficacy of posterior tibial nerve stimulation in patients who had failed anticholinergic medications. A secondary outcome was to determine the time to response for different parameters of overactive bladder. Study Design: The medical records of all patients treated with posterior tibial nerve stimulation from 2000 to 2009 seen in a university urogynecology practice were abstracted. Patients underwent weekly treatments. Patients were asked about the 4 index symptoms at each weekly visit. Descriptive statistics were performed on the data set using SPSS 15. Results: A total of 141 patients were analyzed. Of these patients, 67.4% were satisfied with treatment results. The median week to improvement was 5 weeks for nocturia, 7 weeks for frequency, 6 weeks for urgency, and 6 weeks for urge incontinence. Conclusions: Posterior tibial nerve stimulation is an effective treatment of overactive bladder in patients who have failed anticholinergic therapy. Most patients noted improvement by 6 weeks.

Fistula-in-Ano: An Uncommon Cause of Chronic Vulvar Symptoms

BACKGROUND: Rectal and anal fistulae are frequently missed diagnoses. Symptoms of fistula-in-ano may mimic other chronic vulvar conditions. CASES: Three patients presented with chronic symptoms including nonhealing ulcer, pruritus, dyspareunia, and discharge for 6–18 months. High clinical suspicion and rectal examination with concomitant perineal probing was useful in making a diagnosis. Once the diagnosis of fistula-in-ano was made, surgical correction was successful. CONCLUSION: When evaluating persistent vulvar problems, the clinicians differential diagnoses should include less common causes. The goals of treatment for fistula-in-ano should be to eliminate the nidus of infection and to preserve the anal sphincter during the repair.