Philippe E. Zimmern

Evaluation of the urinary microbiota of women with uncomplicated stress urinary incontinence

BACKGROUND: Female urinary microbiota are associated with urgency urinary incontinence and response to medication. The urinary microbiota of women with stress urinary incontinence has not been described. OBJECTIVE: We sought to study the cross‐sectional relationships between urinary microbiota features and demographic and clinical characteristics of women undergoing stress urinary incontinence surgery. STUDY DESIGN: Preoperative urine specimens were collected from women without urinary tract infection and were available from 197 women (174 voided, 23 catheterized) enrolled in a multicenter prospective randomized trial, the Value of Urodynamic Evaluation study. Demographic and clinical variables were obtained including stress and urgency urinary incontinence symptoms, menopausal status, and hormone use. The bacterial composition of the urine was qualitatively assessed by sequencing the bacterial 16S ribosomal RNA gene. Phylogenetic relatedness and microbial alpha diversity were compared to demographics and symptoms using generalized estimating equation models. RESULTS: The majority of 197 urine samples (86%) had detectable bacterial DNA. Bacterial diversity was significantly associated with higher body mass index (P = .02); increased Medical, Epidemiologic, and Social Aspects of Aging urge index score (P = .04); and hormonal status (P < .001). No associations were detected with stress urinary incontinence symptoms. Increased diversity was also associated with a concomitant lower frequency of Lactobacillus in hormone‐negative women. CONCLUSION: Women undergoing stress urinary incontinence surgery have detectable urinary microbiota. This cross‐sectional analysis revealed that increased diversity of the microbiota was associated with urgency urinary incontinence symptoms, hormonal status, and body mass index. In contrast, the female urinary microbiota were not associated with stress urinary incontinence symptoms.

Complications of Vaginal Surgery

Vaginal surgery complications can at times be difficult to manage. Clearly the best management scheme entails steps to prevent complications. These steps require judicious preoperative planning with detailed knowledge of the patient’s case, operative anatomy, surgical indications, and expectations, as well as prudent use of preoperative diagnostic testing. This kind of preparation facilitates better recognition of intraoperative complications and consequent expeditious treatment.

Risk of Prolapse Recurrence after Native Tissue Anterior Vaginal Suspension Procedure with Intermediate to Long-Term Followup

PURPOSEnWe report our experience with recurrence of pelvic organ prolapse after native tissue repair for stage 2 anterior prolapse.nnnMATERIALS AND METHODSnWe reviewed a prospectively maintained, institutional review board approved database of women with symptomatic stage 2 anterior prolapse who underwent vaginal repair with anterior vaginal wall suspension between 1996 and 2014. Women with concurrent pelvic organ prolapse repair or hysterectomy or without 1 year followup were excluded from analysis. Failure was defined as stage 2 or greater prolapse recurrence on examination or reoperation for symptomatic pelvic organ prolapse. Outcome measures included validated questionnaires (Urogenital Distress Inventory-short form, quality of life), physical examination, standing voiding cystourethrogram at 6 months postoperatively, further surgery for pelvic organ prolapse in other compartments or for secondary stress urinary incontinence or fecal incontinence, and complications.nnnRESULTSnA total of 121 women met the study inclusion criteria with a mean followup of 5.8 ± 3.7 years. Prolapse recurrence rates were isolated anterior 7.4%, isolated apical 10.7%, isolated posterior 8.3% and multiple compartments 19%. Surgery for recurrent prolapse included anterior compartment 3.3% at 1.4xa0± 1.0 years, apical 9.9% at 2.8 ± 3.0 years, posterior compartment 5.8% at 2.0xa0± 1.0 years and multiple compartments 17.4% at 3.2 ± 3.3 years. There was a 1.6% rate of intraoperative complications and a 5.7% rate of 30-day complications (all Clavien I).nnnCONCLUSIONSnAnterior vaginal wall suspension for symptomatic stage 2 anterior prolapse offers a native tissue vaginal repair with minimal morbidity and a low anterior recurrence rate at intermediate to long-term followup. However, 33% ofxa0patients required secondary prolapse compartment procedures from 0.6 to 13xa0years later, highlighting the importance of long-term followup.

Management of recurrent stress urinary incontinence after burch and sling procedures

To examine treatment options selected for recurrent stress urinary incontinence (rSUI) in follow‐up after Burch, autologous fascial and synthetic midurethral sling (MUS) procedures.

Postoperative Imaging after Surgical Repair for Pelvic Floor Dysfunction

Pelvic floor dysfunction encompasses an extremely common set of conditions, with various surgical and nonsurgical treatment options. Surgical options include injection of urethral bulking agents, native tissue repair with or without bioabsorbable or synthetic graft material, placement of synthetic midurethral slings or use of vaginal mesh kits, and mesh sacrocolpopexy procedures. Numerous different synthetic products with varied imaging appearances exist, and some of these products may be difficult to identify at imaging. Patients often present with recurrent or new symptoms after surgery; and depending on the presenting complaint and the nature of the initial intervention, imaging with ultrasonography (US), magnetic resonance (MR) imaging, voiding cystourethrography, or computed tomography (CT) may be indicated. US and MR imaging can both be used to image urethral bulking agents; US is often used to follow potential changes in bulking agent volume with time. Compared with MR imaging, US depicts midurethral slings better in the urethrovaginal space, and MR imaging is better than US for depiction of the arms in the retropubic space and obturator foramen. Mesh along the vaginal wall may be depicted with both US and MR imaging; however, the distal arms of the mesh traversing the sacrospinous ligaments or within the ischiorectal fossae (ischioanal fossae) are better depicted with MR imaging. Scarring can mimic slings and mesh at both US and MR imaging. MR imaging is superior to US for depiction of sacrocolpopexy mesh and associated complications. Voiding cystourethrography and CT are used less commonly because they rarely allow direct depiction of implanted material. Online supplemental material is available for this article. (©)RSNA, 2016.

Management of Urinary Incontinence Following Suburethral Sling Removal

Purpose: We evaluated urinary incontinence outcomes following synthetic suburethral sling removal in women. Materials and Methods: We reviewed a prospectively maintained database of 360 consecutive women who underwent transvaginal suburethral sling removal from 2005 to 2015. We excluded patients with neurogenic bladder, nonsynthetic or multiple slings, prior mesh for prolapse, concomitant surgery during sling excision, urethral erosion or fistula, postoperative retention or less than 6‐month followup. Demographics, sling type, indications for removal, time to removal and patient reported outcomes were recorded. Outcomes were stratified by incontinence type, including stress predominant, urge predominant and mixed urinary incontinence. Subsequent management was evaluated, including observation, minimally invasive outpatient interventions (bulking agents, neuromodulation or onabotulinumtoxinA) or more invasive surgery (autologous fascial sling or bladder suspension). No patients elected to receive a subsequent synthetic sling. Success was defined by responses to UDI‐6 (Urogenital Distress Inventory) questions 2 and 3, self‐reported satisfaction with continence at the last visit and no further intervention. Results: Of the 99 patients who met inclusion criteria 27 denied any subjective leakage after suburethral sling removal alone while 72 experienced some degree of incontinence after removal. Stress predominant urinary incontinence occurred in 26 patients, which was persistent in 7 and de novo in 19, urge predominant incontinence was noted in 14, which was persistent in 6 and de novo in 8, and mixed urinary incontinence occurred in 32, which was persistent in 13 and de novo in 19. Mean followup was 23 months (range 6 to 114). The success rate following a single minimally invasive intervention after suburethral sling removal was 81%, 86% and 75% in patients with stress predominant, urge predominant and mixed urinary incontinence, respectively. Conclusions: Patients who undergo suburethral sling removal may show urinary control, or de novo or persistent incontinence with a higher predilection for stress predominant or mixed urinary incontinence. However, after a single minimally invasive intervention following suburethral sling removal the success rate reached 75% to 86%.

Detrusor contractility in women: Influence of ageing and clinical conditions

AIMSnWe assume that the voiding process in women is governed by the detrusor contractility and a urethral resistance. The value of these 2 parameters, respectively named k and U in the VBN (Valentini-Besson-Nelson) mathematical model of micturition is deduced from the VBN analysis of pressure-flow recordings (PFs). Our objectives were to search for a correlation between these 2 parameters and clinically relevant variables such as chief complaint, urodynamic diagnosis (UD), and age by decades.nnnMETHODSnPFs from 125 non-neurogenic women (mean age 58.0±17.2years [range 20-90years]) were retrospectively analyzed using the VBN model. VBN criteria for inclusion were maximum flow rate>2mL/s, voided volume>100mL, and non-interrupted flow. Evaluated parameters were k (without unit) and U (unit: cm H2O). Standard values were k=1.0 and U=0.nnnRESULTSnVBN parameter ranges were k [0.14-1.55] and U [0.0-73.0cm H2O]. There was a significant correlation between k and U for the whole population (P<0.0001) with k=(.259+0.015*U) (R(2)=0.723) and each chief complaint. For UD, significant difference comparing k and U in phasic detrusor overactivity with intrinsic sphincter deficiency and urodynamic stress incontinence was noted. In sub-groups defined according to decades of age, the values of k and U remained similar in sub-groups for those who are less than 50years old and decreased regularly with ageing.nnnCONCLUSIONnThe detrusor contractility can be easily evaluated in women; lower than in men, its range is less spread out but also adjusted to compensate a urethral resistance. Phasic detrusor overactivity and post-menopausal age significantly affect detrusor force value.nnnLEVEL OF EVIDENCEn3.

Economic analyses of stress urinary incontinence surgical procedures in women

To evaluate the quality of economic analysis (EA) of surgical procedures for stress urinary incontinence (SUI) in women.

Long-term functional outcomes following non-radiated urethrovaginal fistula repair

ObjectiveTo review long-term functional outcomes after urethrovaginal fistula (UVF) repair.Materials and methodsFollowing IRB approval, women who underwent transvaginal non-irradiated UVF repair with minimum 6-month follow-up were reviewed. Surgical outcomes were assessed by validated questionnaires: UDI-6, IIQ-7, FSFI and visual analogue scale for QoL. Two groups were compared: (1) synthetic sling-related versus (2) non-sling-related UVF. Descriptive statistics were applied with pxa0<xa00.05 for significance.ResultsFrom 1996 to 2013, 18 patients underwent UVF repair, with a mean age of 46xa0years (range 20–66), BMI 29 (range 21–42) and mean follow-up at 52xa0months (range 9–142). Overall repair success rate was 95xa0%. Prior failed UVF repair was recorded in 11 women (61xa0%). Statistical differences noted for Q4: 1.9 versus 0.8 (pxa0=xa00.03) and Q5: 1.3 versus 0 (pxa0=xa00.02) and VAS between the two groups, favoring the non-sling group; 1.5 (0.6) versus 5 (4) (pxa0=xa00.05). No differences in IIQ-7 were noted between the two groups (pxa0=xa00.09). Of the 18 patients, 5 remained sexually active and of those, 2 responded to FSFI (40xa0%) with low scores. Reoperation rate was 33xa0% (6 women) with 3 requiring periurethral-bulking agent for recurrent SUI, 2 transurethral laser for residual urethral sling mesh strands and 1 urethral dilation.ConclusionThis large contemporary series of non-radiated UVF indicates a satisfactory outcome in UVF closure repair at a mean 4- to 5-year long-term follow-up, with the synthetic sling-related group performing worse.

Urodynamics for incontinence after midurethral sling removal

We reviewed the role of urodynamics (UDS) in the management of women with incontinence following mid‐urethral sling removal (MUSR).