Ronen Gold

Combined genitourinary prolapse repair and prophylactic tension-free vaginal tape in women with severe prolapse and occult stress urinary incontinence : Preliminary results

OBJECTIVES Continent patients with a positive stress test demonstrated on repositioning of severe genitourinary prolapse are considered to be at high risk of developing postoperative symptomatic stress urinary incontinence (SUI). Our aim was to evaluate in a prospective study whether a prophylactic, tension-free vaginal tape (TVT) procedure, performed during prolapse repair, may prevent the development of postoperative SUI in these women. METHODS Thirty consecutive, clinically continent women (mean age 64.5 +/- 9.04 years) with severe genitourinary prolapse and occult SUI were prospectively enrolled. Occult SUI was defined as a positive stress test with repositioning of the prolapse during the preoperative urodynamic studies. All patients had urethral hypermobility; none had intrinsic sphincter deficiency. In addition to genitourinary prolapse repair, these patients underwent concomitant TVT to prevent postoperative SUI. Patients were followed up for at least 1 year. Repeated urodynamic studies were performed at 3 to 6 months postoperatively. The main outcome measures were postoperative SUI, persistent or de novo detrusor instability, and recurrence of prolapse. RESULTS The mean duration of follow-up was 14.25 +/- 3.08 months (range 12 to 24). None of the patients developed postoperative symptomatic SUI. However, three asymptomatic patients (10%) had a positive stress test during their postoperative urodynamic evaluation. Nine patients (30%) had detrusor instability before surgery, which persisted in six (66%) postoperatively. Postoperative de novo detrusor instability was diagnosed in four other patients (13.33%). None of the patients had recurrent urogenital prolapse, nor did they have clinical evidence of bladder outlet obstruction. CONCLUSIONS The preliminary results of TVT as a prophylactic procedure in clinically continent women with severe prolapse and occult SUI are encouraging. Long-term follow-up is required to confirm the durability of these results.

The Safety and Efficacy of the "Inside-Out" Trans-Obturator TVT in Elderly Versus Younger Stress-Incontinent Women: A Prospective Study of 353 Consecutive Patients

To analyze the safety and efficacy of the trans‐obturator tension‐free vaginal tape (TVT‐O) in elderly versus younger stress‐incontinent women.

Ten-Year Subjective Outcome Results of the Retropubic Tension-Free Vaginal Tape for Treatment of Stress Urinary Incontinence

STUDY OBJECTIVE To assess the 10-year subjective outcome of use of retropubic tension-free vaginal tape (TVT). DESIGN Structured telephone interview (Canadian Task Force classification II-3). SETTING Universitiy-affiliated tertiary medical center. PATIENTS Sixty consecutive women with urodynamically confirmed stress urinary incontinence (SUI) who underwent retropubic TVT surgery during 2000. At surgery, their mean (SD) age was 62.4 (9.3) years, and parity was 2.9 (1.3). INTERVENTIONS Retropubic TVT, with 10-year subjective outcome questionaire. MEASUREMENTS AND MAIN RESULTS Of the 60 patients, 52 (87%) were available for 10-year follow-up. Preoperatively, all patients reported substantial SUI, and 28 (54%) also had concomitant urge urinary incontinence (UUI). At 10 years postoperatively, 34 women (65%) considered their condition cured, 6 (12%) believed it was improved, and 12 (23%) thought surgery had failed. Eleven women (21%) reported SUI, 22 (42%) had UUI (de novo UUI in 9), and 8 (15%) had recurrent urinary tract infections. Two women (4%) underwent repeated TVT. Of the various perioperative variables, only postoperative impaired bladder emptying was a statistically independent risk factor for long-term failure (odds ratio, 6.4; 95% confidence interval, 1.3-30.1). CONCLUSIONS Ten-year subjective outcome of retropubic TVT are less favorable than previously reported. Early postoperative impaired bladder emptying is the most significant risk factor for long-term failure.

Long-term outcome of transobturator tension-free vaginal tape: efficacy and risk factors for surgical failure.

PURPOSE To assess the 5-year efficacy of the inside-out transobturator tension-free vaginal tape (TVT-O) for the treatment of stress urinary incontinence (SUI) and to explore possible predictors for long-term failure. METHODS Sixty-five consecutive patients who underwent TVT-O were prospectively enrolled. Patients who required concomitant anterior or apical pelvic organ prolapse repair or both and those with urodynamic occult SUI were excluded. Postoperatively, patients were scheduled for evaluation at 1, 3, 6, and 12 months and annually thereafter. Surgical failure was defined as positive stress test, daily episodes of SUI, and negative global satisfaction. Preoperative and interim clinical and urodynamic predictors for long-term failure were analyzed from a computerized database. RESULTS Sixty-one patients (mean age at surgery 56.6±10.2 years) completed 5 years of follow-up. Of these, 11 (18%) patients were classified as surgical failure, 5 (8%) as improved, and 45 (74%) as cured. Any SUI (100% vs. 10%, p=0.001), daily SUI (100% vs. 0%, p=0.001), overactive bladder (OAB) (100% vs. 48%, p=0.001), and the use of antimuscarinic drugs (64% vs. 26%, p=0.03) were found to be significantly more common among failure cases. Preoperative detrusor overactivity (odds ratio [OR] 7.6, 95% confidence interval [CI] 1.7-32.9), interim 1-year OAB (OR 20.5, 95% CI 1.9-215.4), and interim 1-year SUI (OR 26.4, 95% CI 1.5-475.2) were found to be significant independent risk factors for long-term surgical failure. CONCLUSIONS An 18% rate of surgical failure was observed 5 years after TVT-O. Larger studies with longer follow-up periods may facilitate the identification of risk factors for failure and, thus, enable better preoperative consultation.

Protracted postpartum urinary retention: The importance of early diagnosis and timely intervention

To evaluate the prevalence and obstetric risk factors of protracted postpartum urinary retention, beyond the third postpartum day.

Role of urethrocystoscopy in the evaluation of refractory idiopathic detrusor instability

OBJECTIVES To assess the role of diagnostic urethrocystoscopy in the evaluation of women with idiopathic detrusor instability (DI) refractory to conventional pharmacologic management. METHODS One hundred consecutive women (mean age 62.1 +/- 15.1 years) with idiopathic DI refractory to conventional pharmacologic management were prospectively enrolled. All patients underwent a meticulous evaluation, including a detailed history, urogynecologic questionnaire, micturition diary and pad test, urinalysis and culture, physical examination, and urodynamic studies. Refractory DI was defined as the lack of clinical improvement after at least 6 months of conventional drug therapy. These patients underwent additional evaluation with diagnostic urethrocystoscopy. RESULTS All patients had a normal urinalysis and negative cytologic findings. Diagnostic urethrocystoscopy revealed isolated bladder tuberculosis in one and transitional cell carcinoma in another. Seven other patients had bladder diverticula (only one of which was also diagnosed by sonographic examination) and 22 had mild-to-moderate bladder trabeculations. CONCLUSIONS The absence of other alarming signs (ie, recurrent urinary tract infection, hematuria, significant residual urinary volume, positive cytologic findings, or suspicious sonographic findings) cannot confirm the lack of significant lower urinary tract abnormalities among patients with refractory DI. Diagnostic urethrocystoscopy, a simple and safe office procedure, facilitates timely diagnosis and appropriate treatment for these patients.