R. Duane Cespedes

OUR EXPERIENCE WITH PUBOVAGINAL SLINGS IN PATIENTS WITH STRESS URINARY INCONTINENCE

PURPOSE Pubovaginal slings successfully treat stress urinary incontinence in women with intrinsic sphincter deficiency. Because of its durability, it has been an attractive procedure in select patients with urethral hypermobility. We examine our experience with pubovaginal sling. MATERIALS AND METHODS A total of 150 patients were evaluated for pelvic prolapse and urinary incontinence. An abdominal leak point pressure was determined in all patients. Of patients with type II stress urinary incontinence, 36 patients (80%) underwent additional gynecological procedures at the time of the pubovaginal sling, compared to 29% with intrinsic sphincter deficiency and 33% with coexisting urethral hypermobility and intrinsic sphincter deficiency. RESULTS The overall cure rate was 93% with a mean followup of 22 months. At 1 week postoperatively spontaneous voiding was accomplished by 56% of the patients with urethral hypermobility and 57% with intrinsic sphincter deficiency. Only 2.8% of patients required surgical therapy for prolonged urinary retention. De novo urgency/urge incontinence occurred in 19% of women with a 3% incidence of persistent urge incontinence. CONCLUSIONS Pubovaginal slings are effective and durable. Voiding dysfunction is uncommon and is temporary in most patients.

Transvaginal urethrolysis for urethral obstruction after anti-incontinence surgery.

PURPOSE Urethral obstruction following a stress incontinence procedure occurs in 5 to 20% of patients. We examine the success of transvaginal urethrolysis in resolving voiding dysfunction. MATERIALS AND METHODS A retrospective chart review was performed on 39 patients who had undergone transvaginal urethrolysis for urethral obstruction following an anti-incontinence procedure. Preoperatively, a history was taken, and pelvic examination and either video urodynamics or cystoscopy were done. RESULTS All 39 patients complained of urge incontinence, 13% had urinary retention, 51% had incomplete bladder emptying and 36% voided to completion but had irritative voiding symptoms. Previous surgery included retropubic urethropexy in 41% of the cases, pubovaginal sling in 38% and bladder neck suspension in 21%. Mean length of followup after urethrolysis was 16 months. Of the 39 patients 33 (85%) had resolution of urge incontinence but 5 still required occasional intermittent catheterization. The remaining 6 patients had continued urge incontinence. An augmentation procedure was performed in 4 patients with improvement of symptoms. CONCLUSIONS Our data support transvaginal urethrolysis for the treatment of iatrogenic urethral obstruction. It is a rapid, effective and minimally invasive technique that should be considered if voiding dysfunction does not resolve spontaneously.

Occult stress urinary incontinence and the effect of vaginal vault prolapse on abdominal leak point pressures

OBJECTIVES To compare the difference in abdominal leak point pressures (ALPPs) between patients with large cystoceles and severe vaginal vault prolapse and to assess the frequency of occult stress urinary incontinence (SUI) in these groups. METHODS A total of 24 adult female patients with pelvic prolapse underwent prospective fluorourodynamic testing to determine the change in ALPP with and without reduction of the pelvic prolapse. Twelve patients had grade III-IV vaginal vault prolapse and 12 had large cystoceles without vault prolapse. ALPP testing was performed with the prolapse unreduced and then reduced using gauze packing and a vaginal speculum. RESULTS In patients with vault prolapse, the frequency of occult SUI was 50% (6 of 12) and the mean decrease in ALPP was 59 cm H(2)O after prolapse reduction. In the patients with cystocele, all patients had overt SUI, and the mean change in ALPP was 11 cm H(2)O after prolapse reduction. A component of intrinsic sphincter deficiency was identified in 9 (75%) of 12 women with vault prolapse after reduction, and 8 (66%) of 12 women with no vault prolapse had a component of intrinsic sphincter deficiency before reduction, with an additional 2 (17%) of 12 patients after reduction. CONCLUSIONS There is a high incidence of occult SUI in patients with vault prolapse and the ALPP after reduction is decreased to a much greater degree in patients with vaginal vault prolapse than in patients with cystocele alone. By reducing the pelvic prolapse during urodynamic testing, an accurate ALPP can be obtained, allowing the appropriate incontinence procedure to be performed.

ABDOMINAL SACRAL COLPOPEXY AND ABDOMINAL ENTEROCELE REPAIR IN THE MANAGEMENT OF VAGINAL VAULT PROLAPSE

Vaginal vault prolapse and enterocele represent challenging forms of female pelvic organ relaxation. These conditions are most commonly associated with other pelvic organ defects. Proper diagnosis and management is essential to achieve long-term successful outcomes. Physical examination should be carried out in the lithotomy and standing positions (if necessary) in order to detect a loss of vaginal vault support. With proper identification of the vaginal cuff, one should assess the degree of mobility of the vaginal cuff with a Valsalva maneuver. If there is significant descent of the vaginal cuff, vaginal vault prolapse is present, and correction should be considered. The abdominal sacral colpopexy is an excellent means to provide vaginal vault suspension. This procedure entails suspension of the vaginal cuff to the sacrum with fascia or synthetic mesh. This procedure should always be accompanied by an abdominal enterocele repair and cul-de-sac obliteration. In addition, many patients require surgical procedures to correct stress urinary incontinence, which is either symptomatic or latent (occurs postoperatively after prolapse correction). Complications include: mesh infection, mesh erosion, bowel obstruction, ileus, and bleeding from the presacral venous complex. If the procedure is carried out using meticulous technique, few complications occur and excellent long-term reduction of vaginal vault prolapse and enterocele are achieved. The purpose of this article is to review the preoperative evaluation of women with pelvic organ prolapse, and provide a detailed description of the surgical technique of an abdominal sacral colpopexy.

Acute urinary retention and urinary incontinence

AUR is a commonly seen genitourinary emergency. It has many etiologies, including obstructive, neurogenic, pharmacologic, and extraurinary causes. Treatment is immediate bladder decompression by transurethral catheterization and treatment of the provoking etiology. Urinary incontinence is less commonly seen as a presenting complaint in the ED. For the emergency physician, the key lies in recognizing its underlying cause. Neurologic and pharmacologic causes need to be considered in all patients. Urinary incontinence that is not caused by a neurologic emergency can be referred for further outpatient evaluation.

Anterior approach bilateral sacrospinous ligament fixation for vaginal vault prolapse.

The sacrospinous ligament fixation (SSLF) was first described as a unilateral fixation; however, bilateral fixation, when possible, allows a symmetrical vaginal reconstruction and provides additional vaginal vault support. We evaluated the outcome of treating total vault prolapse using a bilateral SSLF through an anterior vaginal approach. From July 1996 to July 1999, 28 patients (mean age 67) underwent bilateral SSLF procedures through an anterior vaginal approach. All patients had either grade 3 or 4 vault prolapse, and all patients had associated enteroceles, cystoceles, and rectoceles. All patients underwent fluorourodynamic evaluation including an abdominal leak point pressure (ALPP) with reduction of the vaginal prolapse. A pubovaginal sling was performed in 25 patients and all 28 patients underwent an anterior colporrhaphy, rectocele, and enterocele repair. A vaginal paravaginal repair was performed in 22 cases. At a mean follow-up of 17 months (range 5 to 35), 27 of 28 patients were cured, 1 patient had an asymptomatic unilateral grade 1 vault prolapse, 2 patients had developed small asymptomatic cystoceles and there had been no recurrence of rectoceles or enteroceles. Stress incontinence had been cured in all patients; however, 2 patients continued to have mild urge incontinence requiring <1 pad per day. Two patients complained of transient gluteal pain. We believe the anterior approach bilateral SSLF is a safe procedure with excellent medium term results in women with grade 3 to 4 vaginal prolapse.

QUESTIONNAIRE-BASED OUTCOMES OF URINARY INCONTINENCE AND SATISFACTION RATES AFTER RADICAL PROSTATECTOMY IN A NATIONAL STUDY POPULATION

OBJECTIVES To assess the incidence of incontinence and the associated quality of life in men younger than 65 years of age after radical prostatectomy. METHODS The TRICARE/CHAMPUS database was searched to identify 1000 patients who underwent radical prostatectomy within 2 years before study initiation. All patients were younger than 65 years of age at the time of surgery and had at least 18 months of postoperative follow-up. An eight-part questionnaire focusing on continence after surgery was mailed to the study population. Respondents reported on voiding dysfunction, degree of incontinence, satisfaction with continence, and lifestyle impact of incontinence. RESULTS A total of 674 eligible patients (78%) completed the survey. Any amount of pad use or changing of underwear to keep dry was reported by 31.7%, leakage once per day occurred in 16.8%, and leakage more than once per day in 9.2%. Severe urgency or urge incontinence occurred in 17.4% and was the primary cause of incontinence in one third of patients with incontinence. Only 8.9% of patients used two or more pads per day, and severe incontinence (more than four pads per day) occurred in 2.7%. Incontinence-corrective surgery was used by 4.9% of patients. Overall, 83.3% of patients reported satisfaction with their continence after surgery, and 12% considered postoperative incontinence to be a problem. CONCLUSIONS The results of this questionnaire-based outcomes evaluation of a large national sample of prostatectomy patients younger than 65 years of age demonstrate that incontinence rates in this younger population are similar to those in the Medicare population and may be more representative of the national experience than single-center reports.

Collagen injection or artificial sphincter for postprostatectomy incontinence: collagen.

T nature of this debate would suggest that collagen injection therapy and the artificial urinary sphincter (AUS) are competitive therapies and that only one procedure should be used at the exclusion of the other. In actuality, these therapies are complementary, each one being useful for selected groups of patients. When performing collagen injections, as with any procedure, proper patient selection and the establishment of optimal methods of treatment delivery are crucial for therapeutic success and patient satisfaction. At the time of Food and Drug Administration approval in December 1993, there was little information regarding this, and unfortunately, many patients subsequently “failed” collagen injection therapy because of this lack of data. Thereafter, many physicians were reluctant to treat patients with collagen, and some have since concluded that collagen injection therapy simply does not work for postprostatectomy incontinence (PPI). Recent data would suggest that collagen injection therapy does indeed work well in properly selected patients when the injections are performed according to the methods developed and perfected during the past few years. The data pertaining to proper patient selection are perhaps the most important gathered thus far. A study from 1996 noted that in postprostatectomy patients who used fewer than six pads per day, 72% were dry or significantly improved at 7 months after injection; only 29% of patients using more than six pads per day were dry.1 Additionally, patients who used fewer than three pads per day were dry or significantly improved in more than 80% of cases. Poor prognostic factors included postoperative radiation therapy, adjuvant cryotherapy, and vigorous bladder neck incisions. In the study, the patients rendered dry required a mean of 4.2 injections and 29 mL of collagen. Smith and colleagues2 reported a 38% overall cure rate in 54 patients with a mean follow-up of 29 months; however, in the group of patients who used three pads a day or less, they found a 50% cure rate. Patients rendered dry required a mean of four injections and 20.0 mL of collagen. Bevan-Thomas and colleagues3 recently reported their long-term data of 257 patients after prostatectomy, with a mean follow-up of 28 months. They found that 20% of patients were dry and an additional 39% were significantly improved, for an overall 59% dry or significantly improved rate. Patients who had milder degrees of incontinence and had not received adjuvant radiation or bladder neck incision fared better. A mean of 4.4 injections and 36 mL of collagen were used to obtain dryness in these patients. In a recent study4 focusing on the preoperative evaluation, the abdominal leak point pressure (ALPP) was found to be predictive of postoperative success when using collagen injection therapy. Sanchez-Ortiz and colleagues4 found that patients with a preoperative ALPP greater than 60 cm H2O were cured in 70% of cases, and those with an ALPP less than 60 cm H2O had a 19% cure rate. The data emanating from these studies confirm that the best results can be obtained by selecting patients with milder degrees of incontinence and a preoperative ALPP greater than 60 cm H2O. Important procedural techniques have also been learned from these studies. It is clear that the technique of injecting smaller quantities (2.5 to 7.5 mL) of collagen at longer intervals (greater than 4 weeks) and giving a minimum of four injections yields better cure rates. What this means is that published studies in which an average of two or three injections were given are of little clinical value. Transient but significant improvement after the first or second injection is not a cause for disappointment, as these patients will usually have a good result if additional injections are performed. The opinions contained herein are those of the authors and are not to be construed as reflecting the views of the Air Force or the Department of Defense. From the Department of Urology, Wilford Hall Medical Center, Lackland Air Force Base, Texas Reprint requests: R. Duane Cespedes, M.D., Female Urology and Urodynamics, Department of Urology (MMKU), Wilford Hall Medical Center, Lackland Air Force Base, TX 78236 Submitted: July 2, 1999, accepted (with revisions): August 31, 1999 EDITORIAL

Predicting Irreparable Renal Ischemic Injury Using a Real-Time Marker in the Porcine Model

PURPOSE We determined the maximal renal tolerance of warm ischemia using renal cortical interstitial metabolic changes to identify a potential real-time marker of irreparable renal function. MATERIALS AND METHODS Using a single kidney model 3 groups of 5 pigs each underwent 120, 150 and 180 minutes of warm ischemia, respectively. Microdialysis samples were collected before, during and after ischemia. Renal function assessments consisting of serum creatinine and GFR measurements were performed before ischemia and on post-ischemia days 1, 5, 9, 14 and 28. Kidneys exposed and not exposed to ischemia were collected for histological study. RESULTS Interstitial glucose and pyruvate concentrations decreased, while lactate concentrations increased to stable levels during ischemia. Glutamate spiked at 30 minutes of ischemia and subsequently tapered, while glycerol increased throughout warm ischemia time. At post-ischemia day 28 renal function returned to pre-ischemia baseline levels in the group with 120 minutes of ischemia but did not recover to baseline in the 150 and 180-minute ischemic groups. Functional data correlated with histological findings. The 120-minute maximal renal tolerance of warm ischemia correlated with a mean +/- SD glycerol concentration of 167 +/- 24 micromol/l. CONCLUSIONS Interstitial glycerol is a real-time, renal unit specific, minimally invasive marker of renal function deterioration. Exposure of porcine kidneys to ischemic insults resulting in renal cortical interstitial glycerol concentrations higher than 167 micromol/l is associated with irreparable functional damage in this model.

Significance of Hematuria in Patients Infected With Human Immunodeficiency Virus

PURPOSE We determined the importance of hematuria in patients infected with the human immunodeficiency virus (HIV). MATERIALS AND METHODS The records of 1,326 HIV infected patients with yearly evaluations were reviewed for hematuria and evaluation results. Mean followup was 2.1 years. RESULTS A total of 331 patients (25.0%) had 1 episode of hematuria and 67 were evaluated with 5 significant diagnoses made. Management was affected in only 3 of these patients. No occult genitourinary tumors were found. CONCLUSIONS In young, asymptomatic, HIV infected patients with microscopic hematuria a urological evaluation can be safely omitted in the presence of normal renal function and a benign urological history.