Mervi Haarala

Tension-free vaginal tape and laparoscopic mesh colposuspension for stress Urinary incontinence

OBJECTIVE: To compare objective and subjective outcomes after the tension-free vaginal tape procedure (TVT) with laparoscopic mesh colposuspension as a primary treatment for female stress urinary incontinence. Objective outcome measures were stress test and 48-hour pad test. METHODS: In 6 departments of gynecology in Finland, including 4 university teaching hospitals and 2 central hospitals, 128 women with urodynamic stress incontinence were randomly allocated to 2 treatment groups. Seventy were treated with TVT and 51 by means of laparoscopic mesh colposuspension. There were 7 dropouts. Inclusion criteria were history of stress incontinence, positive stress test, and urodynamic conformation of stress incontinence. Exclusion criteria were age older than 70 years, previous incontinence surgery, more than 3 episodes of urinary tract infection within the last 2 years, coincident other gynecological surgery, body mass index more than 32 kg/m2, urethral closure pressure less than 20 cm H2O, and residual volume more than 100 mL in preoperative urodynamic evaluation. Assessment took place before treatment and at 12 months postoperatively with the cough stress test, Urge Score, 48-hour pad test, Kings College Health Questionnaire, Visual Analog Scale, and Urinary Incontinence Severity Score. RESULTS: When negative stress test was used as criteria for cure, 85.7% of women in the TVT group and 56.9% in the laparoscopic mesh colposuspension group were objectively cured. Subject satisfaction was significantly better after the TVT procedure than after laparoscopic mesh colposuspension. CONCLUSION: Treatment with TVT results in higher objective and subjective cure rates at 1 year than treatment by means of laparoscopic mesh colposuspension. LEVEL OF EVIDENCE: I

Comparison of a 10-mg controlled release oxybutynin tablet with a 5-mg oxybutynin tablet in urge incontinent patients.

Oxybutynin has long been used for the treatment of patients with detrusor overactivity and urinary urge incontinence. The short half‐life of oxybutynin administered as a conventional tablet formulation or syrup requires 2–3 times daily dosage to be effective. A new controlled release (CR) tablet for once‐daily administration has been developed. The efficacy and tolerability of this new controlled release tablet was compared to that of a 5‐mg conventional oxybutynin tablet administered twice daily. Seventeen female incontinent patients were studied in a double‐dummy crossover trial. Efficacy and tolerability were assessed by using a voiding diary, pad‐weighing test, visual‐analogue scale (VAS), and questionnaire. Adverse events were recorded spontaneously on a questionnaire by the patients themselves throughout the study. Serum concentrations of oxybutynin and its active metabolite N‐desethyloxybutynin were studied after both a single dose and multiple dosage.

Absence of Bacterial DNA in the Bladder of Patients With Interstitial Cystitis

PURPOSE Although bacterial infection has been long considered a possible cause of interstitial cystitis (IC), no definitive proof for or against this hypothesis has been presented so far. We have used 16S rDNA bacterial polymerase chain reaction to study bladder biopsies and sterile urine samples from patients suffering from IC. This method is sensitive and detects all known eubacteria. MATERIALS AND METHODS Bladder biopsies and sterile urine samples obtained by transabdominal puncture were studied from 11 patients with IC. As controls we studied 4 patients with other urological problems leading to partly similar symptoms and 5 healthy individuals. RESULTS All samples from the IC patients were negative. One positive sample was obtained from a woman with a history of urinary tract infections who suffered from nonIC ulcerative cystitis. Her sterile urine sample yielded Lactobacillus acidophilus. CONCLUSION These results indicate that an ongoing bacterial infection is not the cause of interstitial cystitis.

Lower urinary tract symptoms in patients with Sjögren's syndrome and systemic lupus erythematosus.

Abstract: Sjögren’s syndrome (SS) and systemic lupus erythematosus (SLE) are autoimmune diseases which have many similarities with interstitial cystitis (IC), a urinary bladder disease with unknown etiology. This survey on the occurrence, severity and nature of lower urinary tract symptoms among patients suffering from SS or SLE showed that these patients have significantly more urinary complaints, especially irritative bladder symptoms, than age- and sex-matched controls. We studied 36 patients with SS, 85 patients with SLE and 121 controls. In these groups, 25%, 29% and 66%, respectively, were free of urinary symptoms. The prevalences of mild symptoms were 61%, 62% and 27%, and severe symptoms 14%, 9% and 7% in the respective groups. SS and SLE patients with urinary complaints reported mostly urinary frequency (27% and 62%) and suprapubic pain (36% and 34%). The most common symptom in the control group was stress urinary incontinence. The frequency of lower urinary tract problems in patients with SS and SLE supports the concept that autoimmune disorders also have bladder affections.

Outcome of Burch retropubic urethropexy and the effect of concomitant abdominal hysterectomy: a prospective long-term follow-up study.

Abstract: A prospective follow-up study was performed to evaluate the effect of a concomitant abdominal hysterectomy with Burch colposuspension. Sixty-five women underwent Burch colposuspension (the Burch group) and 78 women colposuspension with concomitant abdominal hysterectomy (the hysterectomy group) during a 1-year period in Turku University Hospital. Subjective outcome was assessed with three questionnaires: at 6 weeks, 1 year, and a mean of 4.9 years after the operation. Complications related to the operation occurred in 19 patients (29.2%) in the Burch group and in 36 (46.2%) in the hysterectomy group (P= 0.038). No statistically significant difference in the frequency of any subgroup of complications was found. Instead, complications cumulated to fewer patients in the Burch group. During postoperative care in the hospital intermittent catheterization to treat transient urinary retention was needed more frequently in the Burch group than in the hysterectomy group (10.8% vs. 1.3%, P= 0.046). No significant difference was found in subjective short- and long-term outcome. In the long-term follow-up 79% were subjectively cured or improved, 77% in the Burch group and 81% in the hysterectomy group.

The role of Borrelia burgdorferi in interstitial cystitis.

Background/Aims: Borrelia burgdorferi spirochete has been found both in bladder biopsies and the urine of patients with Lyme disease (LD) as well as in experimental animals. The urological symptoms in borreliosis resemble those of interstitial cystitis (IC): frequency, urgency and nocturia. The aim of this studies is to find the role of B. burgdorferi in interstitial cystitis.Methods: We studied antibodies against B. burgdorferi from serum samples of 50 IC patients with two separate EIA tests. Patients with positive serology in both tests underwent cystoscopy and a bladder biopsy was taken. The presence of borrelia DNA was studied with borrelia–specific polymerase chain reaction (PCR), and with universal bacterial PCR.Results: IgM class antibodies to B. burgdorferi were not found, but IgG antibodies were found in four samples (8%). This was higher than in the control material (2%). One patient’s sample was strongly positive, whereas three samples were weakly positive. Bladder biopsies taken from the 4 patients were negative for borrelia DNA in both PCR tests. None of the seropositive patients had any symptoms consistent with LD.Conclusion: These results indicate that persistent infection of B. burgdorferi has no role in the etiology of IC. On the other hand a connection with a past borrelia infection and IC is not excluded.

Urinary Bacterial Flora of Women with Urethral Syndrome and Interstitial Cystitis

The aerobic and anaerobic bacterial flora in the first voided and in the midstream urine of healthy females (n = 5) and female patients with either urethral syndrome (US) (n = 5) or interstitial cystitis (IC) (n = 14) were studied. Bacteria were grown on media enabling isolation of fastidious and aerobic as well as obligatory anaerobic species. In healthy females only gram-positive rods were found whereas US patients also harbored streptococci. Patients with IC presented also with Enterobacteriae and anaerobic bacteria. Five IC patients with severe symptoms were treated with metronidazole; 2 out of 3 patients with anaerobic bacteria in the pretreatment specimens had no anaerobes after metronidazole therapy and in 1 patient streptococci disappeared after the therapy. One patient with severe symptoms and Bacteroides fragilis in the midstream urine became symptom-free after 2 weeks of metronidazole treatment. Although there is uncertainty whether the US and IC are not related to an infectious etiology, the bacterial flora in urethral and in midstream urine in these conditions differs considerably from that of healthy females.

Tension-free vaginal tape – a suitable procedure for patients with recurrent stress urinary incontinence

Objective. To evaluate the efficacy of the tension‐free vaginal tape operation (TVT) in patients with and without previous anti‐incontinence surgery. Design. Prospective follow‐up study. Setting. University hospital in Finland. Population. A total of 130 women who had a TVT procedure from August 1998 to December 2002. Main outcome measures. Subjective cure, complications and voiding symptoms. Methods. Sixty women with recurrent (group A) and 70 women with primary stress urinary incontinence (SUI) (group B) were compared. One follow‐up visit took place two months postoperatively and a questionnaire‐based evaluation was carried out three years after operation. Further information was collected a mean of eight years after the operation. Results. There was no difference in the transient postoperative retention rate (17 vs. 19%, p = 0.78) and number of complications (20 vs. 13%, p = 0.29) between group A and group B. At two months after operation, 85% of patients in group A and 94% in group B were cured of SUI and were satisfied with the operative result (p = 0.096). The satisfaction rates at three years were 86 and 91% in groups A and B, respectively, and cure rate of SUI was 93% in both groups. At follow‐up, 20% of the patients in group A and 5.7% in group B (p = 0.013) had de novo urge symptoms and the rate of voiding difficulties increased especially in group B women over time. Conclusions. TVT results in the same cure and complication rates when performed for primary SUI and recurrent SUI. The procedure is effective and associated with a low and acceptable level of complications. It is well suited to treat also recurrent SUI.

Posterior Transvaginal Mesh without Concurrent Surgery: How Does It have an Effect on the Untreated Vaginal Compartment?

Background/Aims: To report objective and subjective outcomes and adverse events after placement of Elevate® Posterior transvaginal mesh without concurrent surgery. Changes in non-affected anterior compartment were under special interest. Methods: A prospective study of Elevate® Posterior procedure in patients with symptomatic posterior compartment prolapse. Pelvic organ prolapse (POP) quantification (POP-Q) measurements and Pelvic Floor Dysfunction Inventory-20 (PFDI-20) and POP/urinary Incontinence Sexual Questionnaire (PISQ-12) questionnaires were used. Primary outcome was the incidence of de novo anterior prolapse. Secondary outcomes were complication rate and posterior compartment objective and subjective cure. Results: A total of 111 women underwent an Elevate® Posterior mesh procedure and 109 attended a control visit at 3 months. De novo anterior prolapse emerged in 3.2-15% of the women, depending on the definition. Posterior POP-Q stage ≤I was obtained in 92 (84%) women and leading edge at or above the hymen in 107 (98%) women. Bulge symptoms disappeared in 86% of the cases. One (0.9%) mesh exposure was detected. Reoperation rate was 2.8, and 3.7% patients experienced postoperative pain. PFDI-20 and PISQ-12 scores improved significantly. Conclusions: A trend of de novo prolapse formation in the non-affected vaginal compartment is observed. The Elevate® Posterior method is effective in terms of both objective and subjective outcomes. According to our results, the mesh exposure rate is low.

Hysterectomy for gynaecological cancer: A follow‐up study of subjective and objective outcome

Aims:  To evaluate morbidity and subjective outcome associated with hysterectomy either with or without pelvic or pelvic and para‐aortic lymphadenectomy for gynaecological cancer.