Incontinence Urology (Part II) :

Tension-Free Vaginal Tape (TVT) in Morbidly Obese Patients with Severe Urodynamic Stress Incontinence as Last Option Treatment.
Skriapas K, Poulakis V, Dillenburg W, de Vries R, Witzsch U, Melekos M, Becht E
Eur Urol. 2005 Dec 19;.

OBJECTIVES: To determine the safety and efficacy of tension-free vaginal tape (TVT) in morbidly obese women with severe urodynamic stress incontinence (USI) as last option treatment. METHODS: Thirty-one patients with body mass index (BMI) >40kg/m(2), who had undergone the TVT procedure for urodynamically-confirmed USI were matched with 52 patients with BMI <30kg/m(2) who underwent the same procedure. BMI was calculated at the time of the surgery. Patients' characteristics and surgical data, complications and cure rates were analyzed for both groups. RESULTS: After a mean follow-up of 18.5 (range: 12-24) months the continence rates were 87% and 92% for morbidly obese women and control group, respectively (p=0.103). No serious intraoperative complications were noted in both groups. However, the early postoperative complications were significantly higher (p<0.05) in morbidly obese patients. In 4 patients from both group long term postoperative catheterization was necessary for 4 weeks. In one patient (2%) from the control group dilatation of urethra took place. No defect in healing or rejection of the tape occurred. CONCLUSIONS: TVT is a minimal invasive and safe procedure for morbidly obese patients suffering from severe USI with good outcome. Preoperative morbid obesity does not seem to be a risk factor for failure of this procedure.

Transobturator vaginal tape inside-out A minimally invasive treatment of stress urinary incontinence: Surgical procedure and anatomical conditions.
Reisenauer C, Kirschniak A, Drews U, Wallwiener D
Eur J Obstet Gynecol Reprod Biol. 2005 Dec 26;.

OBJECTIVE: The aim of this study was to review the surgical transobturator vaginal tape inside-out (Gynecare TVT-O, Ethicon Inc., Somerville, NJ) technique as described by de Leval and to present the relevant anatomical conditions of the lower pelvis on the basis of corpse dissections after TVT-O placement. STUDY DESIGN: In order to visualize the anatomical structures through which the tape runs, anatomical dissections of five corpses after TVT-O placement were performed. Furthermore, the dissections made possible to give a detailed description of the neighbouring neurovascular structures. RESULTS: The anatomical dissections show that the transobturator tape does not reach into the retropubic space at any time during the procedure, so that injuries of the bladder, of the epigastric vein and the external iliac vessels are not to be expected. The distance between the tape and the major neighbouring neurovascular structures shows slight individual differences, however without the danger of neurovascular injuries if the surgical procedure is performed as recommended. CONCLUSION: Precise knowledge about the anatomy of the area of operation provides the surgeon with the possibility to safely conduct the operation and it contributes to a reduction of perioperative complications.

The puzzle of overactive bladder: controversies, inconsistencies, and insights.
Dmochowski RR
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Dec 14;:1-9.

Overactive bladder (OAB) affects millions of individuals and may severely impair the quality of life of those affected. The contribution of human behavior to manifestations of this symptom complex remains poorly understood. Continued evolution of our understanding of the pathophysiology of OAB has identified contributory mechanisms, which in turn may open new therapeutic avenues. Recent improvements in drug delivery systems represent advances in the management of OAB. However, more complete symptom control with greater tolerability is desirable; this awaits the development of agents specific for newly emerging and as yet unidentified pathophysiologic pathways. Importantly, as understanding of outcomes assessment in OAB matures, refined assessments of disease severity, response to intervention, and patient preference should be possible.

Design of the Stress Incontinence Surgical Treatment Efficacy Trial (SISTEr).
Tennstedt S
Urology. 2005 Dec;66(6):1213-7.

OBJECTIVES: To describe the methods and rationale for the first randomized controlled trial conducted by the Urinary Incontinence Treatment Network. METHODS: The primary objective of this clinical trial is to compare two commonly performed surgical procedures for stress urinary incontinence-the Burch colposuspension and the autologous rectus fascial sling-for overall treatment success for urinary incontinence and stress-type symptoms of incontinence at 24 months after surgery. Secondary aims include a comparison of complications, quality of life, sexual function, patient satisfaction, costs, and the need for additional treatments or surgery; and an evaluation of the prognostic value of preoperative urodynamic studies. The Stress Incontinence Surgical Treatment Efficacy Trial is being conducted on 655 women with predominant stress urinary incontinence, as determined by history and physical examination, urinary stress test with witnessed leakage, and voiding diary. Administration of all questionnaires and performance of examinations, tests, and both surgical procedures are standardized within and across the clinical centers. Assessments occur preoperatively and at 6 weeks and 3, 6, 12, 18, and 24 months postoperatively. A sample of 655 women ensures 80% power to detect a 12% difference (60% versus 72%) at the 5% significance level. The intent-to-treat analysis will use Fisher's exact test and time-to-failure analyses. RESULTS: Enrollment was completed in June 2004 with 24 months of follow-up to end in June 2006. CONCLUSIONS: This is the first large, multicenter randomized clinical trial comparing these two standard-of-care procedures for stress incontinence.

Tension-free vaginal tape exposure presenting as a recurrent sterile paraurethral abscess.
Tate SB, Franco AV, Fynes MM
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Sep-Oct;16(5):420-3. Epub 2005 Apr 22.

We report a case of tension-free vaginal tape (TVT) exposure presenting as a recurrent sterile paraurethral abscess at 25 months and 40 months following successful continence surgery and describe the management of this problem.

Urinary incontinence after multiple gestation and delivery: impact on quality of life.
Goldberg RP, Kwon C, Gandhi S, Atkuru LV, Sand PK
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Sep-Oct;16(5):334-6. Epub 2005 Feb 8.

An anonymous 77-item urogenital symptom questionnaire was administered to 769 women with a history of previous multifetal gestation and delivery, including long forms of the Incontinence Impact Questionnaire (IIQ) and Urogenital Distress Inventory (UDI). IIQ and UDI scores were analyzed using univariate and multivariate regression to determine the impact of incontinence on quality of life (QOL). Mean age was 37 years (22-75), and nearly half [49.8% (365)] reported at least one type of incontinence. Higher mean UDI scores were reported by women with stress incontinence (SI) (12.3 vs 4.7, p=0.0001), urge incontinence (UI) (14.9 vs 5.7, p=0.0001), and mixed incontinence (15.1 vs 6.2, p=0.0001) compared to continent women. Similarly, higher mean IIQ scores were associated with SI (6.9 vs 1.9, p=0.0001), UI (9.4 vs 2.2, p=0.0001), and mixed incontinence (9.3 vs 2.7, p=0.0001). In conclusion, among "mothers of multiples," stress and urge urinary incontinence were associated with strongly adverse effects on QOL at a young age.

Impact of duloxetine on quality of life for women with symptoms of urinary incontinence.
Kinchen KS, Obenchain R, Swindle R
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Sep-Oct;16(5):337-44. Epub 2005 Jan 21.

The objective of this study was to evaluate the effectiveness of duloxetine in improving quality of life among women with stress and mixed urinary incontinence. The study included 451 women with self-reported stress incontinence episodes (>or=1/week) who were randomized to duloxetine (40 mg BID) or placebo in a double-blind, usual care design. Patients and physicians were allowed to titrate, augment, and/or discontinue treatment. Concomitant treatments were permitted. The primary outcome was the Incontinence Quality of Life Questionnaire (I-QOL) score, with assessments at 3, 6, and 9 months. Other measures included the Patient Global Impression of Improvement (PGI-I) and adverse events. The adjusted mean change in I-QOL total score was greater in the duloxetine group than in the placebo group and at a level comparable to that found in previous clinical trials, but the difference between placebo and duloxetine was not statistically significant in the intent-to-treat, last observation carried forward (LOCF) analysis. The difference approached statistical significance in favor of duloxetine at 3 months (p=0.07). PGI-I ratings did not demonstrate significant superiority for duloxetine in LOCF analysis; however, study completers taking duloxetine were significantly more likely to rate themselves as "better" (70.2%) than completers taking placebo (50.8%, p<0.05). Women utilized a variety of treatment methods including pelvic floor muscle training, estrogen, anticholinergic medication, weight reduction, and smoking cessation. In this study, while mean I-QOL change scores were numerically higher for the duloxetine group than mean change scores for the placebo group, this difference was not statistically significant. Among women who completed the study on study drug, a significantly greater proportion of duloxetine women versus placebo women rated their condition to be better.

Massive prolapse of the urethral mucosa following periurethral injection of calcium hydroxylapatite for stress urinary incontinence.
Palma PC, Riccetto CL, Martins MH, Herrmann V, de Fraga R, Billis A, Netto NR Jr
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Dec 9;:1-2.

The injection of bulking agents into the urethral submucosa is designed to create artificial urethral cushions that can improve urethral coaptation and hence restore continence. Ideally, a urethral bulking agent should be non-immunogenic and biocompatible, leading to minimal inflammatory and fibrotic response. The authors present a case report of a granulomatous reaction leading to urethral prolapse, 3 months after the transurethral injection of calcium hydroxylapatite. To our knowledge, this is the first granulomatous reaction described after calcium hydroxylapatite injection.

The direct cost of stress urinary incontinence among women in a Medicaid population.
Kinchen KS, Long S, Chang S, Girts TK, Pantos B
Am J Obstet Gynecol 2005 Dec;193(6):1936-44.

OBJECTIVE: To describe health care utilization and costs for women diagnosed with stress urinary incontinence in a Medicaid population. STUDY DESIGN: We utilized a pooled database of claims for women enrolled in Medicaid in 1 of 3 states. Health care utilization and costs were compared for 12 months before and 12 months after a woman's urinary incontinence diagnosis. Additional analyses utilized data from a fourth state. RESULTS: Of 13,672 women with diagnosed stress urinary incontinence, average urinary incontinence-related costs were approximately 800 dollars in the 12-month study period, less than 0.1% of total Medicaid spending. Thirteen percent of women underwent a surgery for stress urinary incontinence in the study period, with sling procedures performed most commonly. CONCLUSION: Although population prevalence estimates of any stress urinary incontinence symptoms often are high, diagnosis and health care utilization in the Medicaid population is low. Overall costs of stress urinary incontinence treatment in Medicaid currently are minimal. Further efforts to understand the appropriate detection, diagnosis, and treatment of women with stress urinary incontinence are needed.

Bleeding complications with the tension-free vaginal tape operation.
Kolle D, Tamussino K, Hanzal E, Tammaa A, Preyer O, Bader A, Enzelsberger H, Ralph G, Riss P
Am J Obstet Gynecol 2005 Dec;193(6):2045-9.

OBJECTIVE: This study was undertaken to analyze bleeding problems with tension-free vaginal tape (TVT) operations in a national registry. STUDY DESIGN: We studied patients for whom increased intraoperative bleeding or reoperation for bleeding/hematoma with TVT operation were reported to the registry. RESULTS: Bleeding problems were reported for 151 of 5578 (2.7%) TVT operations. Increased intraoperative bleeding was reported for 106 (1.9%) and reoperation (or conversion) in 45 (0.8%) patients (both in 5 patients). Increased intraoperative bleeding was managed conservatively in 103 patients (95%). Overall, 45 (0.8%) patients required reintervention for bleeding or hematoma. The reinterventions comprised 34 laparotomies, 4 transvaginal evacuations of hematomas, 3 revisions for bleeding from a suprapubic catheter site, and 2 revisions of the vaginal incision (details unclear in 1 patient). Bleeding was considered arterial in 12% (including 1 external iliac artery injury and 1 obturator artery injury) and venous or unknown in 88%. Of reoperated patients, 39% were reoperated within 24 hours, 20% within 2 to 10 days, and 41% within 11 to 56 days after TVT placement. Overall, 19 patients received blood transfusions (range, 1-10 units). There were no deaths from bleeding complications. CONCLUSION: Bleeding complications were reported with less than 3% of 5578 TVT operations. Most cases of increased intraoperative bleeding were managed conservatively; 0.8% of patients required conversion or reoperation.

Outcomes of vaginal reconstructive surgery with and without graft material.
Vakili B, Huynh T, Loesch H, Franco N, Chesson RR
Am J Obstet Gynecol 2005 Dec;193(6):2126-32.

OBJECTIVE: This study was undertaken to evaluate the outcomes of vaginal surgery for pelvic organ prolapse, comparing cases implementing graft augmentation to those without graft augmentation. STUDY DESIGN: This was a retrospective cohort study of 312 patients who underwent vaginal surgery for prolapse from February 1998 to January 2004. RESULTS: Of the 312 patients, 98 (31.4%) had graft augmentation. The median follow-up was 9 months (3-67 months). Graft use was not associated with reduction in recurrent prolapse, recurrent stage 3 prolapse, recurrent incontinence, or additional surgery for prolapse. After controlling for confounders, there was still no difference in surgical outcomes. Complications such as vaginal/graft infection (18.4% vs 4.7%; P < .001) and granulation tissue (38.8% vs 17.3%; P < .001) were more common after cases in which graft was used. CONCLUSION: In the early postoperative period, there was no benefit in using graft for prolapse repair. Graft use leads to a higher rate of postoperative complications.

Factors associated with incontinence frequency in a surgical cohort of stress incontinent women.
Richter HE, Burgio KL, Brubaker L, Moalli PA, Markland AD, Mallet V, Menefee SA, Johnson HW, Boreham MK, Dandreo KJ, Stoddard AM
Am J Obstet Gynecol 2005 Dec;193(6):2088-93.

OBJECTIVE: The aim of this study was to identify factors associated with urinary incontinence severity at baseline in women undergoing surgery for stress incontinence. STUDY DESIGN: Baseline data were obtained from 650 women (age 28 to 81 years) with stress incontinence participating in a randomized surgical trial. Severity of incontinence was defined by the mean number of incontinence episodes per day recorded in a 3-day bladder diary. The relationships between severity and several baseline variables were examined, including demographics, medical, obstetric, and gynecologic history, body mass index, smoking status, Q-tip displacement, and Pelvic Organ Prolapse Quantification stage (POP-Q). RESULTS: In a multivariable model, severity of incontinence was positively associated with body mass index (P = .0003) and current smoking (P = .01), and negatively associated with prolapse stage (P < .0001) and Q-tip displacement (P = .042). CONCLUSION: Incontinence severity in a surgical population was independently associated with 2 modifiable factors, obesity and tobacco use, as well as pelvic support.

Sacral neuromodulation for the treatment of refractory urinary urge incontinence after stress incontinence surgery.
Sherman ND, Jamison MG, Webster GD, Amundsen CL
Am J Obstet Gynecol 2005 Dec;193(6):2083-7.

OBJECTIVE: This study was undertaken to evaluate the response to sacral neuromodulation in women with refractory, nonobstructive urinary urge incontinence after stress incontinence surgery. STUDY DESIGN: We reviewed the medical records of women in whom sacral neuromodulation was performed for worsening or de novo urinary urge incontinence after a stress incontinence procedure. All patients had undergone preliminary test stimulation. Demographics, surgical and urogynecologic history, including bladder diary and pad weight test, and urodynamic parameters were evaluated. RESULTS: Of 34 women, 22 (65%) responded to the test stimulation and underwent permanent lead implant. There was no difference between responders and nonresponders with respect to type of stress incontinence surgery. Incontinence or urodynamic parameters were not different between responders and nonresponders. Factors that were predictive of a positive response were women aged less than 55 years (P = .01), the test stimulation performed within 4 years of the stress incontinence procedure (P = .01), and evidence of pelvic floor muscle activity (P = .03). CONCLUSION: Sacral neuromodulation is a viable option for the treatment of refractory urinary urge incontinence that occurs after stress urinary incontinence surgery. Older women with no pelvic floor activity who are remote from their incontinence surgery may have a suboptimal response.

Suburethral sling materials: best outcome with autologous tissue.
Simsiman AJ, Powell CR, Stratford RR, Menefee SA
Am J Obstet Gynecol 2005 Dec;193(6):2112-6.

OBJECTIVE: This study was undertaken to assess the outcome of suburethral slings by type of sling material. STUDY DESIGN: A retrospective review of women who underwent a suburethral sling between January 1997 and January 2003 with autograft, allograft or xenograft materials. Objective failure was defined as urinary leakage with cough stress testing at any time after 3 months, postoperatively. Objective cure was defined as no leakage with a standing cough stress test with at least 200 mL bladder volume at a minimum of 12 months postoperatively. Data were analyzed using Student t, Wilcoxon rank sum, and Kaplan-Meier survival tests. RESULTS: A total of 241 women were included in this study: 78 received autograft, 80 received allograft, and 83 received xenograft. Objective failure was 36% and 46% for allograft and xenograft, respectively compared with 13% for autograft (P < .001). CONCLUSION: Autograft has a significantly higher cure rate when used for suburethral slings.

Delivery mode is a major environmental determinant of stress urinary incontinence: results of the Evanston-Northwestern Twin Sisters Study.
Goldberg RP, Abramov Y, Botros S, Miller JJ, Gandhi S, Nickolov A, Sherman W, Sand PK
Am J Obstet Gynecol 2005 Dec;193(6):2149-53.

OBJECTIVE: We studied a large cohort of identical twin sisters, utilizing the unique properties of a twin research design to explore the relationship between obstetrical delivery mode and stress urinary incontinence. STUDY DESIGN: An anonymous 67-item survey was completed by 271 identical twin pairs (n = 542) at the world's largest annual gathering of twins. Logistic regression for repeated binary measures was used to evaluate risk factors and accounting for shared genetics within pairs. RESULTS: The twins had a mean age of 47.1 years (range 15 to 85 years), and stress urinary incontinence was reported by 51.8%. Stress urinary incontinence was associated with age (P = .001), parity (P = .001), obesity (P = .002), and birth mode, with vaginal delivery conferring a considerable increase in stress urinary incontinence risk relative to cesarean section (odds ratio 2.28, 95% confidence interval 1.14 to 4.55, P = .019). CONCLUSION: Vaginal delivery mode represents a potent determinant of stress urinary incontinence, carrying more than twice the risk of cesarean section. This study of identical twins provides new insight into the epidemiology of female incontinence.

Peri-Operative Complications and Pain After the Suburethral Sling Procedure for Urinary Stress Incontinence: A French Prospective Randomised Multicentre Study Comparing the Retropubic and Transobturator Routes.
David-Montefiore E, Frobert JL, Grisard-Anaf M, Lienhart J, Bonnet K, Poncelet C, Darai E
Eur Urol 2005 Nov 2;.

OBJECTIVE: To compare peri-operative complications, pain, and the immediate functional results of the sub-urethral sling procedure for urinary stress incontinence by the retropublic and transobturator routes, using a non-elastic polypropylene sub-urethral sling. PATIENTS AND METHODS: This prospective, multicentre study involved 88 women undergoing the sub-urethral sling procedure for stress urinary incontinence (SUI). The retropubic route (RPR) and the transobturator route (TOR) were used in respectively 42 and 46 cases. The characteristics of the women in the RPR and TOR groups were as follows: mean age (+/-standard deviation) 56.8+/-12 years and 53.4+/-10 years, respectively; mean BMI: 25 +/- 4 and 26 +/- 4; mean parity: 2.1+/-0.9 and 2+/-1 children; post-menopausal status: 66.7% and 58.7%; prior surgery for SUI: 7.1% and 6.5%; and prior hysterectomy: 21.4% and 26.1%. None of these characteristics differed significantly between the groups. Likewise, pre-operative urinary functional status (SUI stage, and pollakiuria, nocturia and urgency rates) was similar in the two groups. RESULTS: Mean hospital stay and overall morbidity rate were not significantly different between the RPR and TOR groups. Mean operating time was longer in the RPR group. Bladder injury was significantly more frequent in the RPR group and vaginal injury was significantly more frequent in the TOR group. Pain scores were significantly lower in the TOR group. The objective functional results at one month did not differ between the groups. Quality of life, evaluated with questionnaires and numerical rating scales, was similarly improved in the two groups. DISCUSSION: The suburethral sling procedure was less painful by the TOR route than by the RPR route. Bladder injury, haematomas and abscesses were only observed in the RPR group, while vaginal injury only occurred in the TOR group. The immediate functional results of the two approaches were similar.

Re: Chapple CR, Martinez-Garcia R, Selvaggi L, Toozs-Hobson P, Warnack W, Drogendijk T, Wright DM, Bolodeoku J. A Comparison of the Efficacy and Tolerability of Solifenacin Succinate and Extended Release Tolterodine at Treating Overactive Bladder Syndrome
Jonas U, Rackley RR
Eur Urol 2005 Nov 15;.

Diabetes and urinary incontinence in 50- to 90-year-old women: a cross-sectional population-based study.
Lewis CM, Schrader R, Many A, Mackay M, Rogers RG
Am J Obstet Gynecol 2005 Dec;193(6):2154-8.

OBJECTIVE: The purpose of this study was to examine the association between urinary incontinence and diabetes in a large community-based population of women. STUDY DESIGN: The Health and Retirement Study is a large multistage area probability sample of households in the United States. Data were collected from 10,678 women aged 50 to 90 years. Dependent variables were no, mild, and severe incontinence. Independent variables consisted of demographic and health data. Diabetes was dichotomized into insulin-requiring (IRDM) and non-insulin-requiring disease (NIRDM). Survey-based ordered logistic regression was used to simultaneously analyze associations between incontinence groups. RESULTS: Urinary incontinence was reported by 22% (2319/10,678) of women. IRDM was associated with urinary incontinence (odds ratio [OR] 1.63; 95% CI 1.28-2.09), but NIRDM was not (OR 1.20; 95% CI 1.00-1.45). CONCLUSION: IRDM is independently associated with urinary incontinence in women ages 50 to 90 years, independent of patient body mass index, comorbidities, or age.

Following midurethral versus bladder sling procedures.
Botros SM, Abramov Y, Goldberg RP, Beaumont JL, Gandhi S, Miller JJ, Sand PK
Am J Obstet Gynecol 2005 Dec;193(6):2144-8.

OBJECTIVE: The objective of the study was to compare detrusor overactivity and urge urinary incontinence rates after midurethral slings versus bladder neck slings. STUDY DESIGN: Three hundred forty subjects underwent midurethral slings or bladder neck slings. Comparisons were made using Student's t test and chi2 test. Multivariate analysis was performed to detect confounding factors. RESULTS: More patients in the midurethral sling group resolved detrusor overactivity than in the bladder neck sling group (38% versus 15%, P < .001). In addition, subjects in the midurethral sling group had significantly lower rates of de novo detrusor overactivity than subjects in the bladder neck sling group (29% versus 62%, P = .002). The only significant predictors of postoperative detrusor overactivity were preoperative detrusor overactivity (P < .001) and sling type (P < .001). After adjusting for preoperative detrusor overactivity, bladder neck slings significantly increased the risk for persistent detrusor overactivity (odds ratio 3.9). CONCLUSION: Midurethral slings have increased rates of resolution of detrusor overactivity and lower rates of de novo detrusor overactivity than transvaginal bladder neck sling procedures.

Suburethral sling using the transobturator approach: a quality-of-life analysis.
Lukban JC
Am J Obstet Gynecol 2005 Dec;193(6):2138-43.

OBJECTIVE: The objective of the study was to determine the degree of benefit of a transobturator midurethral polypropylene sling in patients with stress urinary incontinence through a quality-of-life instrument and outcome analysis. STUDY DESIGN: Forty-seven patients completed the validated Individual Incontinence Impact Questionnaire both before and after treatment. Subjects also completed the validated Patient Satisfaction Questionnaire postoperatively to complete outcome analysis. Statistical analyses included a paired Student t test for intrapair comparisons and 2-sample t tests to compare mean differences between groups. RESULTS: Individual Incontinence Impact Questionnaire scores for the entire sample declined from a preoperative mean of 43.0 +/- 27.0% to a postoperative mean of 11.8 +/- 16.4 (P < .0001). On review of Patient Satisfaction Questionnaire responses, 45 patients (95.7%) were completely satisfied or somewhat satisfied, and 42 subjects (89.4%) stated their leakage was much better or better. CONCLUSION: The transobturator midurethral sling provides a significant improvement in quality-of-life and high postoperative patient satisfaction.

Urinary incontinence in nulliparous women and their parous sisters.
Buchsbaum GM, Duecy EE, Kerr LA, Huang LS, Guzick DS
Obstet Gynecol 2005 Dec;106(6):1253-8.

OBJECTIVE: To investigate the role of vaginal delivery and familial factors in the development of urinary incontinence by comparing the prevalence of this condition in nulliparous women and their parous sisters. METHODS: A sample of 143 pairs of nulliparous/parous postmenopausal sisters completed a comprehensive questionnaire regarding symptoms of pelvic floor disorders. Of these, 101 pairs underwent clinical evaluation of urinary incontinence and genital prolapse. RESULTS: Among this sample of biological sisters, urinary incontinence was reported by 47.6% of nulliparous women and by 49.7% of parous women (P = .782). We found no difference in the severity or type of urinary incontinence between these 2 groups. There was a high concordance in continence status, however, within biological sisters. CONCLUSION: Vaginal birth does not seem to be associated with urinary incontinence in postmenopausal women. Considering the high concordance in continence status between sister pairs, and considering that the majority of parous women are continent, an underlying familial predisposition toward the development of urinary incontinence may be present. LEVEL OF EVIDENCE: II-2.

Women's narratives of long-term urinary incontinence.
Bradway C
Urol Nurs 2005 Oct;25(5):337-44.

PURPOSE: The purpose of this study was to use narrative analysis as a method for examining the lived experience and meaning of long-term, female urinary incontinence (UI). METHOD: Cognitive anthropology and critical medical anthropology provided the overall framework for this study. Theoretical saturation (Strauss, 1987) was achieved after 17 community-dwelling women with long-term (greater than 5 year's duration) UI were interviewed. Informants participated in two face-to-face, audiotaped, interviews and a semi-structured, topical outline for each interview was used. A field journal was used to supplement and validate other data. Informant's narratives were analyzed to emphasize the overall plot type of their stories. FINDINGS: In this study, three dominant plot types emerged from women's narratives: the UI Quest Narrative, UI Restitution and Redemption Narratives, and the UI Victim Narrative. These plot types provide a beginning understanding of the lived experience and meaning of long-term female UI. CONCLUSIONS: Study findings suggest (a) long-term female UI is primarily conceptualized as a condition integrated into a larger life story, (b) women with long-term UI relate stories that follow a narrative format, and (c) long-term, female UI is heterogeneous. Findings go beyond existing literature by suggesting that women's UI narratives serve an important function in understanding the lived experience and the meaning of UI.

Self-monitoring and pelvic floor muscle exercises to treat urinary incontinence.
Kincade JE, Dougherty MC, Busby-Whitehead J, Carlson JR, Nix WB, Kelsey DT, Smith FC, Hunter GS, Rix AD
Urol Nurs 2005 Oct;25(5):353-63.

Urinary incontinence (UI) is a common chronic condition among women. Treatment of UI can involve behavioral techniques, pharmacological strategies, or surgical intervention. Clinically, treatment strategies should start with the simplest and least invasive measures. To overcome the deficiencies in previous research and provide definitive information for clinical practice, a randomized clinical trial is currently underway. This clinical trial uses a pretest-posttest design to first determine the effectiveness of self-monitoring techniques before subjects are randomized into one of two treatment groups or an attentional control group with a 1-year followup. The study design, sampling plan, and interventions used in an ongoing clinical trial to assess the effectiveness of self-monitoring and efficacy of biofeedback to treat UI in women are described. Innovative techniques to assess adherence to the pelvic muscle exercise protocol are addressed.

Vaginal mesh extrusion associated with use of Mentor transobturator sling.
Siegel AL
Urology 2005 Nov;66(5):995-9.

OBJECTIVES: To describe my experience of vaginal mesh extrusion using the monofilament polypropylene transobturator sling, the Mentor ObTape. The Mentor ObTape was the first transobturator sling developed as an alternative to the retropubic commercially available suburethral slings for providing mid-urethral support as treatment of female stress urinary incontinence. METHODS: Thirty patients underwent transobturator suburethral sling placement for anatomic stress urinary incontinence using the ObTape from October 2003 to January 2005. A retrospective chart review was performed to retrieve data on the safety, efficacy, complications, and outcomes using this product. RESULTS: Six patients (20%) to date have presented with defective vaginal healing manifested by extrusion of the sling material. Five patients required surgical removal of the sling material, and one underwent a trial of conservative management. No urethral erosions were noted. CONCLUSIONS: In my experience, the Mentor ObTape sling, which uses a nonwoven, minimally elastic, micropore, monofilament polypropylene mesh, incurs an unacceptably high rate of defective vaginal wound healing and mesh extrusion.

Lower urinary tract symptoms after total and subtotal hysterectomy: results of a randomized controlled trial.
Gimbel H, Zobbe V, Andersen BJ, Sorensen HC, Toftager-Larsen K, Sidenius K, Moller N, Madsen EM, Vejtorp M, Clausen H, Rosgaard A, Villumsen J, Gluud C, Ottesen BS, Tabor A
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jul-Aug;16(4):257-62.

The aim of this Danish multicenter trial was to compare the proportion of women with lower urinary tract symptoms after total abdominal hysterectomy (TAH) and subtotal abdominal hysterectomy (SAH) for benign uterine disorders. A total of 319 women were randomized to TAH (n = 158) or SAH (n = 161). Women were followed up for 1 year by strict data collection procedures, including postal questionnaires. Results were analyzed by intention-to-treat analyses. Urinary incontinence was found less often among TAH women than among SAH women. This was due to a larger reduction of the number of women with stress and urinary incontinence in the TAH group. No other differences were found between the two operation methods. The number of women with urinary incontinence and frequency was reduced from study entry for follow-up, while double/triple voiding was increased. Incontinent women had significantly lower quality of life scores than continent women

Concomitant resection of congenital vaginal septum during the tension-free vaginal tape procedure.
Long CY, Juan YS, Liu CM, Wu CH, Tsai EM
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jul-Aug;16(4):311-2. Epub 2004 Nov 9.

This case report illustrates how the tension-free vaginal tape (TVT) procedure can be successfully combined with another gynecological intervention. A 38-year-old patient had been diagnosed with didelphys uterus during cesarean section. She came to us for treatment of confirmed genuine stress incontinence. In conjunction with the TVT procedure, we resected the congenital vaginal septum. The patient has remained continent for over 1 year.

Minimally invasive surgical techniques for stress incontinence surgery.
Morley R, Nethercliffe J
Best Pract Res Clin Obstet Gynaecol 2005 Dec;19(6):925-40. Epub 2005 Nov 7.

Minimally invasive techniques for surgical correction of stress incontinence date back to the late 1950s. Since that time there have been many developments to attempt to emulate the good results achieved by open surgery with less surgical morbidity. Needle suspensions have attempted to reposition the bladder neck in the same way as a colposuspension. However, although numerous variations have been described, they do not have the long-term outcomes of colposuspension. These variations, their complications and long-term outcome are discussed. Sling surgery, especially the tension-free vaginal tape (TVT), has probably had the largest impact on incontinence surgery in recent years, offering a procedure with low morbidity and, thus far in the medium term, outcomes comparable with those of more invasive procedures. This has led the TVT procedure to become the most common procedure performed worldwide for stress incontinence. With the benefit of lessons learnt from the use of synthetic material in the genitourinary tract, some worries remain with regard to the long-term complications of TVT. Other non-synthetic material should not be forgotten, and the advantages and disadvantages of various sling materials are compared. Injectables have an established place in the treatment of sphincter deficiency, though long-term results are poor compared to those of other procedures. Various materials used and the technique for their injection are discussed.

Anatomical and functional significance of urogenital hiatus in primary urodynamic stress incontinence.
Huang WC, Yang SH, Yang JM
Ultrasound Obstet Gynecol 2005 Dec 1;.

OBJECTIVES: To explore the correlations of anatomical and functional sonographic parameters of urogenital hiatus in primary urodynamic stress incontinence. METHODS: We reviewed retrospectively our urodynamic database from July 1996 to June 2003 and identified subjects with primary urodynamic stress incontinence who had had anatomical assessment of the lower urinary tract and the central part of the pelvic floor by ultrasound. The morphological changes that had occurred in the central pelvic floor were determined by the measurement of genitohiatal angle, genitohiatal distance and anorectal angle. RESULTS: A total of 396 women with a mean age of 48.8 +/- 10.7 (range, 26-82) years were included in the study. One hundred and eighteen subjects (29.8%) were postmenopausal. Stage I pelvic organ prolapse was found in 345 (87.1%) of the women, stage II in 19 (4.8%) and stage III in 32 (8.1%). The genitohiatal angle and genitohiatal distance were significantly and positively associated with resting and straining bladder neck angles. The genitohiatal angle was associated with bladder neck funneling and dependent cystocele during stress (r = 0.144, P = 0.016 and r = 0.140, P = 0.02, respectively), and it was negatively associated with functional profile length (r = -0.157, P = 0.012). The genitohiatal distance was negatively associated with functional profile length and maximum urethral closure pressure (r = -0.148, P = 0.018 and r = -0.227, P = 0.009, respectively). Increased genitohiatal distance was also related to a low Valsalva leak-point pressure (r = -0.199, P = 0.02). Multivariate analysis revealed that resting bladder neck angle was the independent factor for genitohiatal angle and genitohiatal distance. CONCLUSIONS: In primary urodynamic stress incontinence, an increased resting genitohiatal distance or genitohiatal angle on sonographic imaging implies anterior vaginal wall prolapse. In addition, an increased genitohiatal distance is associated with functional impairment of urethral closure. Copyright (c) 2005 ISUOG. Published by John Wiley & Sons, Ltd.

Management of ureteral injuries associated with vaginal surgery for pelvic organ prolapse.
Kim JH, Moore C, Jones JS, Rackley R, Daneshgari F, Goldman H, Vasavada S
Int Urogynecol J Pelvic Floor Dysfunct 2005 Nov 30;:1-5.

Due to the anatomic proximity of the urinary and genital tracts, iatrogenic ureteral injury during pelvic organ prolapse repairs is a serious complication that we have managed in increasing number at our institution. However, few centers have reported on their experience with ureteric injuries associated with gynecologic reconstructive surgery. These ureteral injuries may lead to much morbidity, in particular the formation of ureterovaginal fistula, and the potential loss of renal function especially when diagnosed postoperatively. It is necessary, therefore, for surgeons to have a thorough knowledge of ureteral anatomy and to take precautions to prevent such injuries. The purpose of this article is to review this pertinent anatomy and the key principles of management of ureteric complications of transvaginal surgery for pelvic organ prolapse. The present study illustrates the application of our treatment algorithm based on the time of presentation and the patient condition.

Prospective randomized comparison of transobturator suburethral sling (Monarc) vs suprapubic arc (Sparc) sling procedures for female urodynamic stress incontinence.
Wang AC, Lin YH, Tseng LH, Chih SY, Lee CJ
Int Urogynecol J Pelvic Floor Dysfunct 2005 Dec 3;:1-5.

The aims of this trial were to compare the attendant complications and postoperative voiding function of the Monarc and suprapubic arc (Sparc) suburethral sling procedures. This is the first article in English literature to compare different suburethral sling procedures using prosthesis of the same material and the same weave. Sixty women with urodynamic stress incontinence alone or combined with pelvic prolapse less than International Continence Society stage II were randomly allocated to either the Monarc or Sparc group. A comparison of the peri- and postoperative results comprising complications and symptoms of voiding function revealed no significant differences between the two groups in a follow-up ranged from 6 to 14 months (median, 9 months). However, the nonsignificant increase in tendency of inadvertent vaginal perforation and disability/pain of thigh (Monarc 12.9 vs Sparc 0.0%, p=0.112 and Monarc 12.9 vs Sparc 0.0%, p=0.112, respectively) has clinical significance. Based on the analyses of the comparison of Blaivas obstruction nomograms, postoperative voiding function was not significantly different between the two surgical groups. We concluded that Monarc and Sparc suburethral taping proved to be equally safe and posed no remarkable impact on voiding function in a short term postoperative follow up. However, intraoperative urethrocystoscopy is recommended for safety in both the Monarc and Sparc procedures.

Multicenter experience with the Monarc transobturator sling system to treat stress urinary incontinence.
Davila GW, Johnson JD, Serels S
Int Urogynecol J Pelvic Floor Dysfunct 2005 Nov 29;:1-6.

This study was conducted to report on the safety and efficacy of a transobturator sling approach for treatment of urodynamic stress incontinence (USI). Women with urodynamic stress incontinence were offered a novel polypropylene mesh sling procedure, implanted beneath the lateral pubic rami rather than retropubically. Retrospective data were collected at three U.S. sites. Two hundred women with a mean age of 59 years (range 27-93) underwent the sling procedure. Mean follow-up was 21.5 weeks (range 3-43). Perioperative safety parameters are reported for all subjects and efficacy parameters for those who were followed up for 26 weeks or more. Among the subjects, 95.3% reported being continent or substantially continent (occasional leakage of small amounts, with protection not needed). Mean operative time was 13.8 min (range 7-34). Preoperatively, 75% wore pads, with 5.3% continuing to do so at 26 weeks. Pre-op urgency was reported by 62.7%, with 41.5% receiving medication. Urgency was reported postoperatively by 20.5% of patients, but only 13.6% were medicated for urgency. Urinary retention was identified in 0.9% at 26 weeks. Transobturator slings are highly effective for treatment of SUI, and may offer increased safety relative to traditional and tension-free retropubic slings.

Spontaneous delivery following tension-free vaginal tape procedure.
Seeger D, Truong ST, Kimmig R
Int Urogynecol J Pelvic Floor Dysfunct 2005 Nov 28;:1-3.

There has been no report in the international literature concerning vaginal delivery following tension-free vaginal tape (TVT) procedure. Most gynecologists recommend cesarean section after TVT procedure. We present the case of a 37-year-old (gravida 2, para 2) woman who had spontaneous delivery at 40 weeks' gestation after TVT procedure performed 10 months prior because of stress urinary incontinence. Five months after spontaneous delivery, the patient was shown to be continent, with no urinary leakage occurring following stress maneuver. Urodynamic evaluation showed normal urethral pressure profile and sufficient maximum urethral closure pressure. Introital ultrasound demonstrated the correct position of the Prolene tape. In cases of pregnancy following TVT procedure, a general recommendation of delivery by cesarean section may be questioned, since the function and correct suburethral position of the Prolene tape can also remain intact following vaginal delivery.

A transvaginal ultrasound study comparing transobturator tape and tension-free vaginal tape after surgical treatment of female stress urinary incontinence.
de Tayrac R, Deffieux X, Resten A, Doumerc S, Jouffroy C, Fernandez H
Int Urogynecol J Pelvic Floor Dysfunct 2005 Nov 26;:1-6.

This study was carried out to compare ultrasonographic findings on patients after transobturator tape (TOT) and tension-free vaginal tape (TVT) procedures to evaluate displacement of tapes up to a 2-year follow-up and to test the correlation between bladder outlet obstruction and the tape position. Forty-nine patients had a transvaginal ultrasonographic evaluation after TOT (n=31) or TVT (n=18) procedures. Twenty-one patients from the TOT group and 12 from the TVT group had ultrasonographic evaluation both at 1 and 2 years follow-up. Tape position was evaluated with a complete sagittal view, and the width of the tape and the distance between the middle of the tape and the bladder neck were measured. Statistical analysis was performed using a t test. After clinical evaluation, stress test, and uroflowmetry with residual measurement, the tapes were compared on ultrasound with regard to clinical and urodynamic results: success in stress incontinence vs failure, bladder outlet obstruction vs no obstruction, and de novo urgencies vs no urgencies. No difference was found between TOT and TVT in the midurethral tape placement. The distance between the middle of the tape and the bladder neck at rest was similar at both 1 and 2 years after both TOT and TVT and was unchanged after coughing or Valsalva. The width of the tape was similar after TOT and TVT at both 1 and 2 years after the procedure. There was no difference in the distance between the middle of the tape and the bladder neck between cured patients, failure, bladder outlet obstruction, and de novo urgencies after both TOT and TVT. Transvaginal ultrasound examination showed no significant difference in the tape position between TOT and TVT. No correlation was found between ultrasonographic findings and postoperative voiding troubles for both techniques.

Solifenacin: as effective in mixed urinary incontinence as in urge urinary incontinence.
Kelleher C, Cardozo L, Kobashi K, Lucente V
Int Urogynecol J Pelvic Floor Dysfunct 2005 Nov 8;:1-7.

Patients with mixed urinary incontinence (MUI) are frequently treated with antimuscarinic therapy, despite little data being previously published for this patient group. We present a subgroup analysis of patients with overactive bladder syndrome, assessing the efficacy of once-daily solifenacin succinate in patients with MUI (n=1041) or urge urinary incontinence (UUI; n=1648) only. A greater proportion of patients receiving solifenacin achieved resolution of incontinence in both the MUI and UUI groups (MUI: 5 mg=43%, 10 mg=49%; UUI: 5 mg=55%, 10 mg=54%) compared with patients receiving placebo (MUI 33%, UUI 35%). Baseline to endpoint improvements in all other symptoms were statistically significant vs placebo for both solifenacin doses in both cohorts. The incidence of adverse events was comparable between the MUI and UUI cohorts. This analysis shows that once-daily solifenacin was as effective and well tolerated in patients with MUI as in patients with UUI.

Sulfated glycosaminoglycans of the periurethral tissue in women with and without stress urinary incontinence, according to genital prolapse stage.
Feldner PC Jr, Kati LM, Sartori MG, Baracat EC, Rodrigues de Lima G, Nader HB, Dietrich CP, Girao MJ
Eur J Obstet Gynecol Reprod Biol 2005 Nov 25;.

OBJECTIVE: The objective was to determine sulfated glycosaminoglycans (GAG) of the extracellular matrix (ECM) in women with and without stress urinary incontinence according to genital prolapse stage. STUDY DESIGN: Periurethral tissue was obtained from 30 women who underwent surgery for urinary incontinence, for pelvic organ prolapse, or for other benign gynecologic conditions. Biopsy specimens were assessed by biochemical methods to characterize and quantify sulfated glycosaminoglycans. Measurements were made of total glycosaminoglycans, chondroitin sulfate, dermatan sulfate, and of heparan sulfate. Data were compared using the t-test. RESULTS: In two groups, dermatan sulfate was the most predominant glycosaminoglycan. Women with stress urinary incontinence had significantly more total sulfated glycosaminoglycans (p<0.05) and dermatan sulfate (p<0.05) than women without stress urinary incontinence. We did not observe any differences in chondroitin sulfate and heparan sulfate. CONCLUSIONS: Women with stress urinary incontinence showed quantitative and qualitative differences in the biochemical characteristics of the extracellular matrix in periurethral tissue by analysis of sulfated glycosaminoglycans, according to genital prolapse stage.

MRI morphology of the levator ani muscle, endopelvic fascia, and urethra in women with stress urinary incontinence.
Tunn R, Goldammer K, Neymeyer J, Gauruder-Burmester A, Hamm B, Beyersdorff D
Eur J Obstet Gynecol Reprod Biol 2005 Nov 16;.

OBJECTIVE: To evaluate pathomorphologic changes of the levator ani muscle, endopelvic fascia, and urethra in women with stress urinary incontinence (SUI) by MRI. STUDY DESIGN: Fifty-four women with SUI were examined by MRI (1.5T): body phased-array coil, axial and coronal proton-density-weighted sequences. RESULTS: The urethral sphincter muscle showed a reduced thickness of its posterior portion (37%), an omega shape (13%) or higher signal intensity (50%); its abnormal configuration was associated with an increased signal intensity in 70% (p=0.001). The levator ani muscle comprised an unilateral loss of substance in 30%, a higher signal intensity in 28%, and alterated origin in 19%. Central defects of the endopelvic fascia were present in 39% (n=21), lateral defects in 46%. There was a significant association between loss of the symphyseal concavity of the anterior vaginal wall and lateral fascial defects (p=0.001) and levator ani changes (p=0.016). CONCLUSION: MRI yields findings supporting current theories on the pathogenesis of SUI.

Lower urinary tract symptoms in middle-aged women--prevalence and attitude towards mild urinary incontinence: a community-based population study.
Teleman P, Lidfeldt J, Nerbrand C, Samsioe G, Mattiasson A
Acta Obstet Gynecol Scand 2005 Nov;84(11):1108-12.

OBJECTIVE. To investigate the prevalence and perceived bother of lower urinary tract symptoms (LUTS) in middle-aged women with and without self-reported urinary incontinence. PATIENTS AND METHODS. In the Women's Health In the Lund Area study (WHILA 1995--2000), 32% of the participating 6,917 women, 50--59 years, reported urinary incontinence defined as involuntary urinary leakage causing a social and/or hygienic problem. Out of these, 1,500 women with (INCONT) and 1,500 without incontinence (CONT) received the Bristol Female lower urinary tract symptoms (LUTS) questionnaire in January 2001. RESULTS. A total of 2,682 (89%) women were included. Most common LUTS in the INCONT and CONT groups, respectively, were any urinary leakage (93.8% vs. 53.3%, P<0.001), urgency (86.2% vs. 62.5%, P<0.001), stress incontinence (85.1% vs. 41%, P<0.001), and frequency (86.9% vs. 35.6%, P<0.001). The two groups differed significantly in the degree of reported bother by infrequently occurring stress and urge incontinence. Urinary leakage more than once a week was reported as bothersome by 97.5%. The prevalence of self-reported urinary incontinence increased from 32% to estimated 66% if the demand for social and/or hygienic bother was omitted from the definition. Conclusion. The prevalence of self-reported urinary incontinence increased from 32% to estimated 66%, if the demand for social and/or hygienic bother was omitted from the definition. LUTS other than incontinence are common in middle-aged women, with a significantly higher prevalence in women with self-reported incontinence than in continent women. The attitude towards stress- and urge incontinence varied widely when the symptoms occurred infrequently. Urinary leakage more than once a week was considered bothersome by 97.5%.

Efficacy and complications in the surgical treatment of stress urinary incontinence by insertion of a silicone-coated polyester tape (Lift((R))).
Girard JM, Deruelle P, Collinet P, Lucot JP, Therby D, Cosson M
Eur J Obstet Gynecol Reprod Biol 2005 Oct 24;.

OBJECTIVES: To evaluate the efficacy and safety of a surgical treatment for stress urinary incontinence by implantation of a silicone-coated polyester tape (Lift((R))). MATERIALS AND METHODS: This retrospective study included 72 female patients having had a suburethral silicone-coated polyester tape inserted as treatment for stress urinary incontinence, combined or not with pelvic surgery. We recorded the patient's characteristics, the surgical procedure, the short and long-term results and complications. RESULTS: Seventy-two patients were operated, 60 of whom were fully evaluated. The average follow-up was 17 months. On 48 patients (80%) the treatment was successful, 3 (5%) were improved, and 9 (15%) were regarded as a failure. Dysuria occurred in six (10%) patients, five were de novo, and one was persistent. Ten patients (16.6%) presented de novo urge incontinence. The main complication was a higher rate of severe infections, accompanied by defective healing (4, i.e. 6.7%). CONCLUSION: The procedure using a silicone-coated polyester tape seems to be efficient, but insufficiently secure. This higher rejection rate leads us to prefer other synthetic materials proved to be better tolerated.

Comparison between monofilament and multifilament polypropylene tapes in urinary incontinence.
Bafghi A, Valerio L, Benizri EI, Trastour C, Benizri EJ, Bongain A
Eur J Obstet Gynecol Reprod Biol 2005 Oct 1;122(2):232-236.

OBJECTIVE: We compare the efficacy and late complications between a polypropylene monofilament tape (TVT) and a polypropylene multifilament tape (IVS) in the surgical implant of sub-urethral, tension free tape for the treatment of stress urinary incontinence (SUI). METHODS: It is a non-randomised, monocentric retrospective study. Two questionnaires were sent to the patients. The first questionnaire determined the efficacy of the tape and the tolerance of the urinary process. The second questionnaire evaluated discomfort and consequences linked to urinary incontinence and associated urinary troubles. RESULTS: The study included 313 female patients and 256 (82%) responded to the questionnaire (137 TVT, 119 IVS). Patient satisfaction was 88.3% for the TVT tape and 73.5% for the IVS tape (p<0.005). The improvement of the quality of life was also higher for the polypropylene monofilament tapes. "De novo" urge incontinence was more common in the TVT group. However, the rates of dysuria and infection of tapes were more common in the IVS group. CONCLUSION: The type of tape appears to influence efficacy and the emergence of late complications. Our results point at the greater efficacy of the polypropylene monofilament tape.

Long-term urinary continence rates after simple sling incision for relief of urinary retention following fascia lata pubovaginal slings.
Thiel DD, Pettit PD, McClellan WT, Petrou SP
J Urol 2005 Nov;174(5):1878-81.

PURPOSE: We examined long-term urinary continence rates in patients after midline simple sling incision for urinary retention following suburethral fascia lata slings. MATERIALS AND METHODS: A retrospective review was completed of 13 women undergoing a simple sling incision for catheter dependent obstruction after suburethral sling surgery more than 4 years previously. Urinary continence was evaluated by use of the Groutz-Blaivas anti-incontinence surgery response score. The scores were statistically compared as binary categories at mean 111-day and 60.8-month followup. RESULTS: A total of 13 women underwent a simple sling incision for catheter dependent urinary retention after sling surgery, and 11 patients (mean age 73.4 years) were available for long-term followup (60.8 months). The simple sling incision procedure was completed an average of 65 days (range 36 to 235) after original sling placement. Mean post-void residual urine volume at least 1 month after sling surgery was 289 ml (range 75 to 500). At a mean followup of 60.8 months, no patient required catheterization. Of 11 patients 5 wore no pads. There was no statistical difference in leakage episodes per day (p = 1.0), pads per day (p = 0.3), or patient perceived condition (p = 0.3) during long-term followup. The mean Groutz-Blaivas score did not change statistically during the 5-year followup period (p = 0.6). CONCLUSIONS: Midline simple sling incision provides relief of catheter dependent obstruction following fascia lata sling surgery while preserving urinary continence in the majority of patients during a 5-year followup period.

Factors that distinguish continent from incontinent older adults with detrusor overactivity.
Rosenberg LJ, Griffiths DJ, Resnick NM
J Urol 2005 Nov;174(5):1868-72.

PURPOSE: In older adults detrusor overactivity (DO) is almost as common in continent individuals as in those with urge incontinence (UUI). Thus, UUI likely reflects the contribution of additional factors. We postulated that of functionally independent individuals in whom transient causes were excluded those in whom DO was accompanied by UUI would be more likely to have smaller functional bladder capacity, less warning and less ability to avert urine loss in the face of DO. MATERIALS AND METHODS: While blinded to continence status, we reviewed the records of all 52 cognitively intact and nonobstructed volunteers older than 65 years who had DO associated with urgency during urodynamic testing and had been asked to try to prevent leakage for 2 minutes. Of these individuals 31 were continent at home. RESULTS: In patients with UI mean functional bladder capacity +/- SD was smaller (313 +/- 153 vs 390 +/- 178 ml, p = 0.06) and warning was briefer (87 +/- 81 vs 120 +/- 116 ml), although the association with warning was less impressive (p = 0.14). The ability to forestall leakage for at least 2 minutes correlated strongly with being continent at home (p < 0.002). For continence detrusor suppression at the onset of DO was more important than sphincter contraction. CONCLUSIONS: Urge incontinence in older adults involves more than simply the presence of DO. Physical function, cognitive function and medications are already known to be important for continence. Our data suggest that functional bladder capacity and the ability to suppress involuntary contraction (and possibly warning) are also potentially important covariates. These factors may represent additional potential targets for behavioral and pharmacological therapy.

Brain control of normal and overactive bladder.
Griffiths D, Derbyshire S, Stenger A, Resnick N
J Urol 2005 Nov;174(5):1862-7.

PURPOSE: Bladder control problems are common but their cause is often unclear. Many investigators have sought causes in the lower urinary tract, but fewer in the supraspinal control system. We have used functional magnetic resonance imaging (fMRI) to determine brain responses to bladder filling in subjects with normal and with poor bladder control (detrusor overactivity). MATERIALS AND METHODS: Cerebral responses to bladder infusion were recorded in 1 male and 11 females without overt neurological abnormality, aged 26 to 83 years. Six had good bladder control and 6 had poor control on prior urodynamics. fMRI was performed while repeatedly infusing and withdrawing liquid into and out of the bladder, and monitoring intravesical pressure. Measurements were made at small and large bladder volumes. RESULTS: fMRI detected activation of many brain regions involved in bladder control, including periaqueductal gray, thalamus, insula, dorsal anterior cingulate, and ventromedial cerebellum. Orbitofrontal cortex, pontine micturition center and preoptic hypothalamus were visible in subgroup analyses. Activations outweighed deactivations and responses became stronger at large bladder volumes. Among subjects with good control, this strengthening of response was prominent in the orbitofrontal cortex. Among those with poor control cortical responses were exaggerated at larger bladder volumes, except in the orbitofrontal cortex, which remained weakly activated. This difference was not due to concurrent detrusor activity. CONCLUSIONS: Poor bladder control is specifically associated with inadequate activation of orbitofrontal cortex. Clinically, frontal cortical lesions cause bladder control problems. This study suggests a similar neurophysiological basis for poor bladder control in the absence of overt neurological lesion.

Bladder Perforation During Tension-Free Vaginal Tape Procedures: Analysis of Learning Curve and Risk Factors.
McLennan MT, Melick CF
Obstet Gynecol 2005 Nov;106(5):1000-1004.

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 chi(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.

The Effect of Ultralow-Dose Transdermal Estradiol on Urinary Incontinence in Postmenopausal Women.
Waetjen LE, Brown JS, Vittinghoff E, Ensrud KE, Pinkerton J, Wallace R, Macer JL, Grady D
Obstet Gynecol 2005 Nov;106(5):946-952.

OBJECTIVE: To estimate the effect of 2 years of treatment with ultralow-dose transdermal estradiol (E2) on incontinence in postmenopausal women. METHODS: Ultra Low Dose Transdermal estRogen Assessment (ULTRA) was a multicenter, randomized, double-blinded, placebo-controlled trial of unopposed ultralow-dose (0.014 mg/d) transdermal E2 for prevention of osteoporosis in 417 postmenopausal women aged 60 to 80 years. Frequency of incontinence episodes was assessed at baseline and after 4 months and 2 years of treatment using a self-reported questionnaire. We used an intention-to-treat analysis to compare change in incontinence frequency, improved (decreased 2 or more episodes per week), unchanged (increased or decreased no more than 1 episode per week), or worsened (increased 2 or more episodes per week) between the E2 and placebo groups among women with and without at least weekly incontinence at baseline. RESULTS: At baseline, the prevalence of at least weekly incontinence was similar between E2 and placebo groups (43%). After 2 years, there was no difference between groups in the proportions of women with incontinence at baseline whose incontinence improved, worsened, or was unchanged. The odds ratio for worsening incontinence in the E2 compared with placebo group was 1.35 (95% confidence interval 0.75-2.42. In women without incontinence at baseline, the odds of developing at least weekly incontinence after 2 years in the E2 compared with placebo group was not significant (odds ratio 1.2, 95% confidence interval 0.7-2.2). CONCLUSION: Two years of treatment with unopposed ultralow-dose transdermal E2 did not substantially change the frequency of incontinence symptoms or alter the risk of developing at least weekly incontinence. LEVEL OF EVIDENCE: I.

Postmenopausal hormone therapy: does it cause incontinence?
Steinauer JE, Waetjen LE, Vittinghoff E, Subak LL, Hulley SB, Grady D, Lin F, Brown JS
Obstet Gynecol 2005 Nov;106(5):940-5.

OBJECTIVE: To estimate the effect of hormone therapy on risk of stress and urge urinary incontinence. METHODS: The Heart Estrogen/progestin Replacement Study was a randomized, placebo-controlled, double-blinded trial to evaluate daily oral conjugated estrogen (0.625 mg) plus medroxyprogesterone acetate (2.5 mg) therapy for the prevention of heart disease events in women with established heart disease. The 1,208 participants in Heart Estrogen/progestin Replacement Study who reported no loss of urine in the previous 7 days at baseline are included in this analysis. RESULTS: During 4.2 years of treatment, 64% of women randomly assigned to hormone therapy compared with 49% of those assigned to placebo reported weekly incontinence (P < .001). The higher risk of incontinence in the hormone group was evident at 4 months, persisted throughout the treatment period, and was independent of the age of the women. The odds ratios for weekly incontinence among women on hormone therapy compared with placebo were 1.5 for urge incontinence (95% confidence interval [CI] 1.2-1.8; P < .001) and 1.7 for stress incontinence (95% CI 1.5-2.1; P < .001). Four years of treatment with hormone therapy caused an excess risk of 12% for weekly urge incontinence and 16% for weekly stress incontinence; the corresponding numbers needed to harm were 8.6 (95% CI 5.8-16.6) and 6.2 (95% CI 4.6-9.4). CONCLUSION: Estrogen plus progestin therapy increases risk of urge and stress incontinence within 4 months of beginning treatment. LEVEL OF EVIDENCE: I.

Retropubic Hematoma After Transobturator Sling Procedure.
Rajan S, Kohli N
Obstet Gynecol 2005 Nov;106(5):1199-1202.

BACKGROUND: The transobturator tape procedure is one of the newer minimally invasive sling procedures used for the surgical treatment of genuine stress urinary incontinence. CASES: Two cases of retropubic hematomas following transobturator tape procedure are reported. One patient was managed conservatively and did not require reoperation, and the other patient required computed tomography-guided drainage of the hematoma. In both cases the patients' hematomas resolved, and they remained continent 3-6 months after surgery. CONCLUSION: The transobturator tape procedure is a minimally invasive alternative to the tension-free vaginal tape operation for stress urinary incontinence, but it may be associated with vascular complications.

Treatment of stress incontinence with the SPARC sling: intraoperative and early complications of 445 patients.
Hodroff MA, Sutherland SE, Kesha JB, Siegel SW
Urology 2005 Oct;66(4):760-2.

OBJECTIVES: To review our series of 445 patients to obtain safety and early outcome information regarding use of the SPARC mid-urethral sling. The SPARC mid-urethral sling is commonly used to treat stress urinary incontinence. The SPARC technique involves passage of the trocars from an initial suprapubic approach. METHODS: We retrospectively reviewed the charts of all SPARC slings performed from the first procedure in August 2001 through December 2003. The Urogenital Distress Inventory and Incontinence Impact Questionnaire short-form surveys were mailed to the patients. All SPARC procedures were performed on an outpatient basis unless the patient was undergoing a concurrent procedure. RESULTS: The average patient age was 60 years. Concurrent prolapse repair and/or hysterectomy were performed in 97 patients (22%). The mean time from surgery to questionnaire response was 15 months. Ninety-one percent would undergo the procedure again, and 84% would recommend the SPARC to a friend. One patient was admitted postoperatively for a rectus hematoma. Another presented after 3 days with abdominal pain resulting from a small bowel perforation. Sling release was performed in 19 patients (4.3%) because of large postvoid residual urine volume or obstructive voiding symptoms. CONCLUSIONS: The SPARC mid-urethral sling is an effective outpatient surgical procedure to treat stress urinary incontinence.

Sacral neuromodulation for intractable urge incontinence: are there factors associated with cure?
Amundsen CL, Romero AA, Jamison MG, Webster GD
Urology 2005 Oct;66(4):746-50.

OBJECTIVES: To determine the variables that affect the cure rate in patients with urge incontinence treated with sacral neuromodulation. METHODS: This prospective analysis of patients with refractory urinary urge incontinence who underwent placement of a neuromodulator lead and generator was undertaken between October 2000 and December 2003. Quantitative assessment of the severity of their urinary leakage was assessed by preoperative and postoperative 3-day bladder diaries documenting leakage episodes, number of pads used per day, and a 24-hour pad weight assessment. Cure was defined as no daily leakage episodes after permanent implantation. Subjective outcome was assessed using the Incontinence Impact Questionnaire. Two-sample independent t tests, two-way chi-square tests, and tests of two proportions were performed when appropriate, with P < 0.05 considered significant. RESULTS: The mean postimplantation follow-up was 29 months, and the average age was 60 years (range 29 to 83). The cure rate was associated with age, with individuals younger than 55 years having a statistically significant greater cure rate (65% versus 37% for older individuals; P < 0.05). Having three or more chronic conditions was associated with a lower cure rate in both younger and older individuals. Patients with a neurologic condition also had a lower cure rate, but no specific neurologic condition was associated. CONCLUSIONS: Age older than 55 years and more than three chronic conditions were independent factors associated with a lower cure rate in patients implanted with a sacral neuromodulator for refractory urge incontinence. A neurologic condition may be associated with a decrease in the cure rate.

Complications of transvaginal silicone-coated polyester synthetic mesh sling.
Govier FE, Kobashi KC, Kuznetsov DD, Comiter C, Jones P, Dakil SE, James R Jr
Urology 2005 Oct;66(4):741-5.

OBJECTIVES: To report a premarket multicenter trial to test the feasibility of a transvaginal silicone-coated polyester synthetic mesh sling in women with anatomic incontinence. METHODS: Fifty-one patients in four centers underwent transvaginal placement of a silicone-coated polyester synthetic mesh sling (American Medical Systems) during an 8-month period. Of the 51 patients, 31 were part of a prospective institutional review board-approved feasibility trial in three centers funded by American Medical Systems (group 1) and 20 underwent implantation by a single surgeon and their data were retrospectively reviewed (group 2). The studies were done concomitantly, and all slings were fixed transvaginally with bone anchors. All patients in group 1 were followed up at 4 weeks, 6 months, and 1 year (as applicable) with repeat questionnaires, physical examinations, and pad tests. RESULTS: In group 1, 20 patients completed 6 months of follow-up. Ten patients (32%) required a second surgical procedure at an average of 183 days (range 68 to 343) postoperatively. Eight patients (26%) had vaginal extrusion of the mesh, one (3%) required sling lysis, and one (3%) required sling removal because of infection. In group 2, 8 patients (40%) underwent sling removal for vaginal extrusion at a mean of 160 days (range 83 to 214). CONCLUSIONS: Transvaginally placed silicone-coated mesh slings used for the treatment of urinary incontinence demonstrated an unacceptably high vaginal extrusion rate in this study. Once identified, this study was immediately terminated, and this product was not marketed for this application in the United States.

Urinary stress incontinence treatment with Remeex in a patient with epispadias: a case report.
Soligo M, Proietti F, Cortese M, Villa M, Maruccia S, Milani R
Int Urogynecol J Pelvic Floor Dysfunct 2005 Oct 26;:1-2.

Epispadias is a rare condition in women. A postmenopausal 53-year-old woman with a known problem of epispadias came to our outpatient clinic complaining of persistent severe urinary stress incontinence without overactive bladder symptoms. She had previously undergone an inefficacious tension-free vaginal tape (TVT) procedure in another institution. We implanted a Remeex (Mechanic External Regulation) device without applying any tension to the sling. Two tape regulations were performed the day after surgery and 2 months later to gain continence. At 13 months of follow up, this woman was asymptomatic and satisfied. As documented by this case here, the Remeex procedure is particularly suitable in selected high-risk patients where TVT and TVT live slings are less effective.

The efficacy of the tension-free vaginal tape in the treatment of five subtypes of stress urinary incontinence.
Segal JL, Vassallo BJ, Kleeman SD, Hungler M, Karram MM
Int Urogynecol J Pelvic Floor Dysfunct 2005 Oct 18;.

Purpose: To determine the efficacy of tension-free vaginal tape (TVT) for the treatment of five sub-types of stress urinary incontinence (SUI).Materials and methods: A retrospective review was performed from November 1998 to November 2001 on all patients with SUI who underwent a TVT procedure either alone or with other reconstructive pelvic procedures. The patients were subdivided into five categories. Intrinsic sphincter deficiency (ISD) was defined by a maximum urethral closure pressure <20 cm H(2)O or a mean Valsalva leak point pressure <60 cm H(2)O above baseline. Urethral hypermobility (UH) was defined by a straining Q-tip angle greater than 30 degrees from the horizontal. Cure was defined as the subjective resolution of SUI without the development of voiding dysfunction or de novo urge incontinence. Improvement was defined as the subjective improvement of SUI without complete resolution or the subjective resolution of SUI occurring with the development of prolonged voiding dysfunction lasting greater than 6 weeks or de novo urge incontinence. Failure was defined as the subjective lack of improvement of SUI, the need for an additional procedure to correct SUI or the need for revision or takedown of the TVT for persistent voiding dysfunction or mesh erosion.Results: The cure, improvement and failure rates for each of the following groups are respectively as follows: group 1 (+UH, -ISD) (n=121): 101 (83.5%), 13 (10.7%), 7 (5.8%); group 2 (-UH, +ISD) (n=22): 17 (77.3%), 3 (13.6%), 2 (9.1%); group 3 (+UH, +ISD) (n=32): 26 (81.3%), 4 (12.5%), 2 (6.2%); group 4 (-UH, -ISD) (n=25): 21 (84.0%), 3 (12.0%), 1 (4.0%); group 5 (occult SUI) (n=67): 57 (85.1%), 10 (14.9%), 0 (0%).Conclusion: This study shows that the TVT is effective in treating all five sub-types of SUI.

Learning outcomes of a group behavioral modification program to prevent urinary incontinence.
Sampselle CM, Messer KL, Seng JS, Raghunathan TE, Hines SH, Diokno AC
Int Urogynecol J Pelvic Floor Dysfunct 2005 Nov-Dec;16(6):441-6. Epub 2005 Mar 15.

This study describes acquisition of knowledge and motor skill in bladder training (BT) and pelvic floor muscle training (PFMT) and adherence following a behavioral modification program (BMP). Essentially continent (0-5 episodes in past year) community-dwelling older women (n=359) were randomized to treatment (n=164), a 2-h group education session supplemented by one brief individualized session of approximately 10 min, or control (n=195), no instruction, and followed for 12 months. Knowledge, motor skill, and adherence to the BMP were documented. Changes in pelvic muscle function and voiding interval were used to validate self-reported adherence. Following group instruction, mean BT and PFMT knowledge was 90 and 86%, respectively; 68% demonstrated correct PFMT technique without additional instruction, 29% required brief instruction, and 3% were unable to learn PFMT technique. Adherence ranged from 63 to 82% for PFMT and 58 to 67% for BT. Group instruction supplemented with brief individual instruction as needed is an effective teaching method for BT and PFMT.

Factors influencing the long-term success of periurethral collagen therapy in the office.
Koduri S, Goldberg RP, Kwon C, Dobrez DG, Sand PK
Int Urogynecol J Pelvic Floor Dysfunct 2005 Oct 14;:1-6.

INTRODUCTION: Glutaraldehyde crosslinked bovine collagen has been used for periurethral bulking for the treatment of urodynamic stress incontinence since 1989 with variable success. A retrospective study was undertaken to evaluate the factors involved in the long-term success of glutaraldehyde crosslinked bovine collagen used for periurethral bulking in the office. METHODS: Patients were followed objectively with stress testing after receiving periurethral collagen injection in the office under local anesthesia. Repeat injections were done as necessary during their follow-up appointments. The "success" group was defined as those women who demonstrated negative stress tests for over 1 year following their first injection. RESULTS: Nineteen of 184 women (10.3%) demonstrated negative stress tests for over 1 year following only one initial injection of glutaraldehyde crosslinked collagen. Their success lasted a mean of 829 days up to the time of follow-up. CONCLUSION: Prior anti-incontinence surgery was the one factor analyzed that showed a trend toward this long lasting success. No other factors were predictive of negative stress tests for over 1 year. Prior anti-incontinence surgery seems to represent a factor involved in the long-term success of periurethral bulking in the office with glutaraldehyde crosslinked bovine collagen for the treatment of urodynamic stress incontinence.

Evaluation of early pelvic floor physiotherapy on the duration and degree of urinary incontinence after radical retropubic prostatectomy in a non-teaching hospital.
Cornel EB, Wit RD, Witjes JA
World J Urol 2005 Oct 7;:1-3.

The objective of this study was to study the effect of early pelvic floor re-education on the degree and duration of incontinence and to evaluate the results of radical retropubic prostatectomy (RRP) performed in a non-teaching hospital. This is a non-randomised study. From March 2000 to November 2003, 57 consecutive men, who underwent RRP for localized prostate cancer, participated in a pelvic floor re-educating program. Continence was defined as a loss of no more than 2-g urine on the 24-h pad test and no use of pads. The 24-h pad test was performed once in every 4 weeks until the patient indicated that he was continent. Diurnal and nocturnal continence was achieved after 1, 2, 3, 6 and 12 months post catheter removal in 40, 49, 70, 86 and 88% of all men, respectively. Comparison of our results with current literature suggest that the time period towards continence after a RRP can be shortened relevantly if pelvic floor re-education is started directly after catheter removal.

New hammock hypothesis-based method for the treatment of stress urinary incontinence: the first 29 urethral supports with a small fascial patch.
Yamada T, Hayashi T, Kamata S, Ohno R, Horiuchi S
Int J Urol 2005 Sep;12(9):806-9.

Abstract Aim : We have developed a new method requiring no manipulations of the retropubic passages, and carried out a retrospective study to assess the effectiveness, safety and early results of this new procedure in the treatment of female stress urinary incontinence. Methods : From January 2001 to September 2003, 29 patients underwent our new surgery for the treatment of SUI. A 3 x 2 cm vertical rectangle was harvested from the rectus fascia. A convex horizontal incision was made over the mid urethra and bladder neck. The retropubic space was entered to the urethropelvic ligament spreading toward the junctions between urethropelvic ligament and tendinous arc. One suture was made at the point lateral to the bladder neck. Another suture was made behind the pubic bone. These two sutures were sutured again and tied with the short side end of the harvested fascia. The same procedure was performed on the other side. Results : Of 29 patients, 26 (89.7%) were cured of stress urinary incontinence and 3 were improved. None of the patients had difficulty in voiding after the operation. Maximum flow rates were almost the same before and after surgery. None of the patients had any adverse events. Conclusion : This procedure, which requires no manipulations of the retropubic passages, is safe and effective for the treatment of stress urinary incontinence.

Solvent-dehydrated cadaveric dermis: a new allograft for pubovaginal sling surgery.
Onur R, Singla A
Int J Urol 2005 Sep;12(9):801-5.

Abstract Aim : The aim of this study was to evaluate the efficacy of solvent-dehydrated cadaveric dermis in pubovaginal sling surgery for the first time in the literature. Methods : Twenty-five women with stress urinary incontinence underwent pubovaginal sling surgery using 2 x 12 cm allograft dermis. Preoperatively, all patients were evaluated by a detailed urogynecologic evaluation, voiding diary, pelvic examination and urodynamic investigation. Outcome was assessed by the Urogenital Distress Inventory short form and standardized follow-up questionnaires. Results : Twenty (80%) patients were cured of stress incontinence symptoms. Seventeen wore no pad and three reported occasional stress urinary incontinence and used no or one pad at a mean follow up of 12 months. Five (20%) patients in our series experienced the same amount of leakage as before the surgery. Seventy-six percent of the patients indicated that urinary incontinence was no longer negatively affecting their daily life and were satisfied with the procedure. Conclusions : Questionnaire-based assessment of outcome suggests that solvent-dehydrated cadaveric dermis is effective in the treatment of stress urinary incontinence. However, larger and comparative prospective studies with long-term results and randomized comparison of tissue preparation techniques are warranted.

Translevator posterior intravaginal slingplasty: anatomical landmarks and safety margins.
Smajda S, Vanormelingen L, Vandewalle G, Ombelet W, Jonge E, Hinoul P
Int Urogynecol J Pelvic Floor Dysfunct 2005 Sep-Oct;16(5):364-8. Epub 2005 Jan 27.

The posterior intravaginal sling is a new tension-free needle suspension technique. It is used for the treatment of middle compartment (vaginal vault or uterine) prolapse. The Prolene sling suspends the vagina at the upper border of level II support as described by DeLancey (Am J Obstet Gynecol 166:1717, 1992). Human cadaveric dissections were undertaken to explore the pertinent anatomy that is involved when using this blind needle technique. Pre-dissected cadaveric material was used to obtain didactic illustrations of the anatomy of the procedure. Description of the surgical technique using anatomical landmarks and relative distances of the needle to these landmarks will improve the surgeon's visual understanding of the procedure. The measurements obtained demonstrate that the needle stays at a minimal distance of 4 cm away from the major (pudendal) vessels that could potentially cause life-threatening haemorrhage.

Anatomical study of the obturator foramen and dorsal nerve of the clitoris and their relationship to minimally invasive slings.
Achtari C, McKenzie BJ, Hiscock R, Rosamilia A, Schierlitz L, Briggs CA, Dwyer PL
Int Urogynecol J Pelvic Floor Dysfunct 2005 Oct 7;:1-5.

OBJECTIVES: The objective of the study is to clarify potential risks to the dorsal nerve of the clitoris (DNC) and obturator canal using different minimally invasive slings. STUDY DESIGN: Ten embalmed hemipelves were dissected to demonstrate the course of the DNC and the obturator canal. On each cadaver, tension-free vaginal tape (TVT), transobturator in-out (TVT-O) and transobturator out-in (Monarc) procedures were performed. Distances between the DNC and the obturator canal to the different devices were measured. RESULTS: The DNC passes beneath the pubic bone at a distance of 14.3+/-4.7 mm of the midline. The distances of the different devices to the DNC were similar. The distance to the obturator canal was significantly different, with TVT being the furthest (40.1+/-3.7 mm) and TVT-O the closest (19.3+/-3.1 mm; p<0.0001). CONCLUSION: Given the course of the DNC along the medial aspect of the ischiopubic ramus, the out-in technique may be safer. The in-out technique is the closest to the obturator canal.

Tension-free vaginal tape for the treatment of urodynamic stress incontinence with intrinsic sphincteric deficiency.
Ghezzi F, Serati M, Cromi A, Uccella S, Salvatore S, Triacca P, Bolis P
Int Urogynecol J Pelvic Floor Dysfunct 2005 Oct 7;:1-5.

The purpose of this study was to evaluate the outcome of tension-free vaginal tape (TVT) procedure in women with urodynamic stress incontinence diagnosed as having intrinsic sphincteric deficiency (ISD). The combination of a maximal urethral closure pressure <20 cm H(2)O and a Valsalva leak point pressure <60 cm H(2)O was considered as diagnostic of ISD. Subjects with detrusor overactivity on preoperative urodynamics were excluded. A total of 35 patients with both low closure pressure and leak point pressure were enrolled. Bladder perforation occurred in three (8.6%) cases. Postoperative urinary voiding difficulties occurred in nine (25.7%) women. Two patients underwent surgical detension of the tape, with complete resolution of urinary retention and no relapse of incontinence. Women with postoperative voiding dysfunction had a significantly lower detrusorial pressure at the peak flow on preoperative urodynamics compared to those who voided efficiently after TVT. The mean (range) follow-up time was 12.5 months (3-36). The objective cure rate for stress incontinence was 91.4%. Two of the three (66%) patients in whom the TVT procedure failed had a fixed urethra. De novo urge incontinence was found in five (14.3%) patients.

Vaginal erosion, sinus formation, and ischiorectal abscess following transobturator tape: ObTape implantation.
Babalola EO, Famuyide AO, McGuire LJ, Gebhart JB, Klingele CJ
Int Urogynecol J Pelvic Floor Dysfunct 2005 Sep 27;:1-4.

A 50-year-old woman was referred for evaluation with an 8-month history of intermittent malodorous vaginal discharge initially noted 2 months after placement of a transobturator tape for stress urinary incontinence. Evaluation revealed erosion of the tape through the vaginal wall with a sinus tract associated with an ischiorectal abscess. Surgical removal of the tape with excision of the sinus tract, drain placement, and antibiotic therapy was needed for complete resolution of the symptoms. Infectious complications need to be considered when counseling women prior to synthetic sling placement. A high index of suspicion, meticulous sub- and periurethral inspection, along with aggressive surgical management are required to treat an infected draining abscess following synthetic transobturator sling placement.

Overactive bladder.
Freeman RM, Adekanmi OA
Best Pract Res Clin Obstet Gynaecol 2005 Sep 19;.

The overactive bladder is a common condition, which has significant effects on quality of life. The aetiology in most cases is unknown, and treatment outcomes have until recently been unsatisfactory. Management includes excluding pathology and implementing behavioural changes such as caffeine reduction, bladder and pelvic floor training, as well as antimuscarinic drug therapy. Compliance is often problematic, and this can be improved with some of the newer antimuscarinics with fewer side-effects, and a good therapist/patient relationship. In the majority of cases this 'treatment package' is successful, but in those where it is not, intravesical therapies have been introduced, e.g. neuromodulation, alternative drug therapies (e.g. vanilloids, botox) and surgery. With a better understanding of the aetiology and identification of risk factors better outcomes from treatment are likely.

Midurethral Tissue Fixation System sling - a 'micromethod' for cure of stress incontinence - preliminary report.
Petros PE, Richardson PA
Aust N Z J Obstet Gynaecol 2005 Oct;45(5):372-5.

Aims: To assess the effectiveness of the Tissue Fixation System (TFS) in patients with stress incontinence. The TFS uses two small plastic anchors to fix an (adjustable) midurethral polypropylene mesh sling into the soft tissues below the pubic bone. Patients and methods: Thirty-six patients with stress incontinence, mean age 55 (35-87), mean weight 76 kg (33-117 kg), mean 0.8 previous operations for stress incontinence, underwent a TFS midurethral sling operation. The patients were preoperatively assessed with a structured questionnaire, 24-h urinary diary, cough stress test, transperineal ultrasound, and urodynamics. Using the TFS delivery system, a midurethral mesh tape was attached to the fibromuscular tissues behind the perineal membrane. The suburethral vaginal fascia was also tightened. Post-operatively. the patients were reviewed at 6 weeks, and at 3-monthly intervals with ultrasound, and cough stress tests. Results: Primary symptomatic cure rate at mean 9 months (3-15 months) was 83.4% (n = 36). Pad test loss decreased from a mean 12.7 g to a mean of 0.2 g; mean operating time was 5 min, and mean hospital stay was 24 h (12-48 h). There were no cases of obstructed micturition, and minimal analgesia only was required postoperatively. Conclusion: The TFS is a promising new method. The results at this stage are similar to those achieved previously with the 'tension-free' tape operations, but with greater safety and shorter operating time. Testing by other surgeons will be required to evaluate this method further.

Transobturator tape for stress incontinence: The North Queensland experience.
Naidu A, Lim YN, Barry C, Goodwin S, Corstiaans A, Rane A
Aust N Z J Obstet Gynaecol 2005 Oct;45(5):446-9.

A prospective observational study of 96 patients undergoing insertion of the MONARC transobturator tape (American Medical Systems, Minnetonka, USA) for treatment of urodynamic stress incontinence was conducted to investigate its' the safety and efficacy. Although there were no major intraoperative complications, sling protrusion was observed in 11/91 patients (12.1%) at early follow up visits. At these visits, 80 women (87.9%) were either completely or substantially continent and 74 women (81.3%) were satisfied with the operation. Objectively, 74 women (81.3%) were cured on urodynamic assessment and only one woman (1.1%) was found to have voiding dysfunction. As a conclusion, it would appear that this new technique is effective for the treatment of stress incontinence; but further studies are needed to investigate its long-term results and complications.

Validation of a Two-Item Quantitative Questionnaire for the Triage of Women With Urinary Incontinence.
Bent AE, Gousse AE, Hendrix SL, Klutke CG, Monga AK, Yuen CK, Meadows ES, Yalcin I, Muram D
Obstet Gynecol 2005 Oct;106(4):767-773.

OBJECTIVE: To evaluate the reproducibility, construct validity, and preferences for the 2-item Stress/Urge Incontinence Questionnaire. METHODS: The questionnaire asks a patient to recall the number of stress urinary incontinence and urge urinary incontinence episodes she experienced during the preceding week. The 4-week prospective study included 3 office visits and enrolled women with stress, urge, or mixed urinary incontinence symptoms. The test-retest reproducibility was assessed after 3 days, and the construct validity of the questionnaire was evaluated against a diary and other measures of incontinence severity and effect. The bother associated with completing (patients) or analyzing (physicians) the diary was assessed. Both groups also reported their time requirements and preferences for the questionnaire or diary. RESULTS: Reproducibility for the classification of symptoms was moderately strong (kappa = .536). Test-retest agreement was good (64-80%) for all but balanced mixed incontinence (38%). Intraclass correlations revealed good reproducibility for the number of stress (.694), urge (.703), and total (.726) incontinence episodes. Significant (P < .01) correlations with other measures of incontinence established construct validity. Patients and physicians reported it took less time to complete the questionnaire than the diary, but the majority said the completion or analysis of the diary was of little or no bother and preferred the diary. CONCLUSION: The Stress/Urge Incontinence Questionnaire is a valid tool that can be used in clinical practice to differentiate between symptoms of stress and urge urinary incontinence to make an initial diagnosis, especially in primary care where incontinence is not a focus of the practice. LEVEL OF EVIDENCE: III.

Objective analysis of mechanical resistance of tension-free devices.
Boukerrou M, Lambaudie E, Collinet P, Rubod C, Boulanger L, Dubois P, Fasel J, Cosson M
Eur J Obstet Gynecol Reprod Biol 2005 Sep 14;.

INTRODUCTION: The "tension-free" procedures are widely used by surgeons for the treatment of urinary incontinence and prolapse. The clinical results are largely in favour of these procedures. The aim of our study is to determine objectively the mechanical tissue resistance when using these techniques, before healing begins. MATERIAL AND METHODS: We measured the mechanical resistance using four different routes: the retro-pubic space, the transobturator, the translevator ani muscle and the trans-sacrospinous ligament. We compared five different meshes, TVT((R)), IVS((R)), Lift((R)), Prolene((R)) and Prolene Soft((R)). In order to study the effect of increasing dimensions, we tested Prolene((R)) tapes measuring 1, 1.5 and 2cm in width. We performed traction tests on meshes implanted in cadavers. Measurements were made with a dynamometer and the results expressed in Newtons. RESULTS: This study shows that TVT((R)) offers a better resistance to traction via the retro-pubic space route. There was no significant difference among the four routes when the same type of mesh measuring 1cm was used. However, an increase in the dimensions of Prolene((R)) tapes improves their resistance in the tissues, thereby facilitating fixation before healing begins. Also, these increasing dimensions (in width) show that there is better resistance with the trans-sacrospinous ligament compared with the transmuscular one. DISCUSSION: The increasing size of prosthetic meshes does not show the superiority of certain routes with commercial meshes of 1cm in width. The higher resistance obtained with wider tapes is probably due to an increased surface area between the tissues and meshes. This increase in resistance does not seem to be important for the treatment of urinary incontinence. However, it should be of interest for the treatment of prolapse where traction and surface are more important. CONCLUSION: Two different recommendations can be deduced from our study. On one hand, the arms of prosthetic meshes for pelvic floor repair should measure more than 1cm in width in order to improve their maintenance in the tissues in the immediate post-operative period. On the other hand to improve fixation, the posterior arms of the transperineal mesh should be passed through the sacrospinous ligament rather than via the transmuscular route. The resistance of tissues is also influenced by the armature of the prosthetic mesh. They must therefore be developed commercially specifically for "tension-free" fixation. Our results need to be confirmed by further studies including more cadavers and younger patients.

Tension-free vaginal tape (TVT) for treatment of stress urinary incontinence in women with low-pressure urethra.
Meschia M, Pifarotti P, Buonaguidi A, Gattei U, Spennacchio M
Eur J Obstet Gynecol Reprod Biol 2005 Sep 1;122(1):118-21.

OBJECTIVE: To assess the results of TVT in patients with urinary stress incontinence, urethral hypermobility, and low-pressure urethra. STUDY DESIGN: We retrospectively analysed 265 consecutive women who underwent a TVT procedure for urodynamic stress urinary incontinence over a 31-month period. Women were divided into two groups depending on their preoperative maximum urethral closure pressure (MUCP). Group 1 (61 women with MUCP </=20cm H(2)O) were compared with 204 women (group 2) with a MUCP >20cm H(2)O. Subjective and objective outcome data were assessed from routine postoperative visits. Office and hospital records were reviewed to check patients' characteristics, intraoperative findings, and surgical outcomes. RESULTS: Women with low-pressure urethra were older than those with MUCP >20cm H(2)O; they were more likely to have had a hysterectomy or anti-incontinence surgery. The mean duration of follow-up was 31 (+/-11) months. Cure rates among patients with low- or normal-pressure urethra were similar (77% and 86%, P=0.70). Nevertheless, the former were more likely to complain of voiding dysfunction. Conclusion: TVT is a highly effective treatment even in women with intrinsic sphincter deficiency.

Duloxetine for the treatment of stress urinary incontinence in women: An integrated analysis of safety.
Hurley DJ, Turner CL, Yalcin I, Viktrup L, Baygani SK
Eur J Obstet Gynecol Reprod Biol 2005 Sep 24;.

OBJECTIVE: The objective was to characterize the safety of duloxetine for treatment of stress urinary incontinence (SUI) in women, using an integrated database generated from four published placebo-controlled clinical trials. METHODS: The database included 1913 women randomized to duloxetine (N=958) or placebo (N=955), examining adverse events (AEs), serious adverse events (SAEs), vital signs, electrocardiograms, and laboratory analytes. AEs occurring initially or worsening during the double-blind treatment period were considered treatment-emergent (TEAE). Differences between duloxetine-treated and placebo-treated groups were compared statistically. RESULTS: Common TEAEs included: nausea (23.2%), dry mouth (13.4%), fatigue (12.7%), insomnia (12.6%), constipation (11.0%), headache (9.7%), dizziness (9.5%), somnolence (6.8%), and diarrhea (5.1%). Most TEAEs that emerged early were mild to moderate, rarely worsened, and resolved quickly. Overall AE discontinuation rates were 20.5% for duloxetine and 3.9% for placebo (P<.001). Most discontinuations (83%) occurred within the first month of treatment. SAEs were uncommon and did not differ between treatments. Statistically significant, but clinically unimportant mean increases in heart rate (2.4bpm) and systolic and diastolic blood pressure (</=2mmHg) occurred. No arrhythmogenic potential was observed and any rare, transient, asymptomatic increases in hepatocellular enzymes normalized. CONCLUSIONS: Duloxetine was safe and tolerable, although transient AEs were not uncommon.

Trans-Obturator Vaginal Tape (TOT((R))) for Female Stress Incontinence: One Year Follow-Up in 120 Patients.
Roumeguere T, Quackels T, Bollens R, de Groote A, Zlotta A, Bossche MV, Schulman C
Eur Urol 2005 Sep 20;.

OBJECTIVES: The aim of this study was to evaluate the effectiveness of a new minimally invasive surgical procedure, the Trans-obturator Vaginal Tape (TOT((R))) in the treatment of female urodynamic stress incontinence (USI) and to analyse functional results and quality of life after one year of follow up. MATERIAL AND METHOD: 120 consecutive women with stress urinary incontinence underwent the procedure since February 2002 under general or loco-regional anesthesia. Minimum follow up was one year (range 12-30 months). Mean age was 58 years (range 31-86). 70% of the patients had pure USI. 5 patients were previously operated for USI. In 10 cases, concomitant repair of pelvic floor defects was mandatory. Collection of the data included operative time, pre- and post-operative complications. Patients were post-operatively assessed at one week, one month and one year. A validated urinary incontinence-specific measure of Quality of Life (QoL) questionnaire (Contilife((R))) was sent and completed 12 months after surgery. RESULTS: The mean operative time was 12min (range 6-30) with a catheterisation time of 0,9 day (range 0-2). No severe bleeding was observed. There were 13 minor lateral tears of the vagina without any sequelae. Three perforations of the urethra and one of the bladder occurred during the learning phase. In two cases a re-intervention was necessary for tape removal when the injury was not recognised during the procedure. Two transient urinary retention needed a supra pubic catheter and tape release. Eleven women presented transient voiding outflow obstruction. After one month, 93% patients were cured with no pad and a negative cough test with a full bladder. Uroflowmetry did not show any significant changes between pre- and post-operative time in all the population. De novo urgency occurred only in 2.5% and persistent dysuria (Q(max) <10ml/s and/or post-void residual volume >120cc) in 4%. 80% of patients were completely dry after one year and 12% were greatly improved. According to the pre-operative maximal urethral closure pressure, continence rate was 86% above 30cm H(2)O and 76% below 30cm H(2)O respectively. Global satisfaction of women at 1 year was 78% with good scores based on daily and effort activities, self-image, emotional and sexual activities. CONCLUSIONS: TOT((R)) is a safe and effective new minimal invasive procedure for USI with a low rate of complications. To confirm the success of TOT((R)), longer follow up in large population is mandatory to assess the reliability of this attractive technique.

Severe mesh complications following intravaginal slingplasty.
Baessler K, Hewson AD, Tunn R, Schuessler B, Maher CF
Obstet Gynecol 2005 Oct;106(4):713-6.

OBJECTIVE: Synthetic meshes are increasingly used in the management of stress urinary incontinence and pelvic organ prolapse. This report describes severe complications following anterior and/or posterior intravaginal slingplasties employing a multifilament polypropylene mesh. METHODS: We describe the symptoms, findings, subsequent management, and outcome of 19 consecutive women who have been referred with complications following anterior (n = 11) and/or posterior intravaginal slingplasty (n = 13) employing the multifilament polypropylene tape. RESULTS: The main indications for removal of the 11 anterior intravaginal slings were intractable mesh infection in 6 women, retropubic abscess with cutaneous sinus in one, and vesico-vaginal fistula in one, intravesical mesh and pain syndrome in one, and voiding difficulties and pain syndrome in two. The main indications for removal of the 13 posterior intravaginal slings were intractable mesh infection in three and pain syndrome and dyspareunia in 10 women. Removal of the slings was performed after a median time of 24 months post-slingplasty. At follow-up between 6 weeks and 6 months, in all women genital pain, chronic vaginal discharge and bleeding, voiding, and defecation difficulties had been markedly alleviated (5) or they had ceased (14). Twelve of 17 sexually active women (71%) resumed sexual intercourse without difficulties. Ten women required subsequent surgery for stress incontinence and pelvic organ prolapse. CONCLUSION: Surgeons should be aware of the potential complications of synthetic meshes. Until data on the safety and efficacy of the intravaginal slingplasties are available, these procedures cannot be recommended. LEVEL OF EVIDENCE: III.


Removal of a missed polypropylene tape by a combined transurethral and transabdominal endoscopic approach.
Cornel EB, Vervest HA
Int Urogynecol J Pelvic Floor Dysfunct 2005 May-Jun;16(3):247-9. Epub 2004 Oct 21.

Surgical intervention for bladder perforation caused by application of a transvaginally placed polypropylene tape is rare. Open as well as endoscopic procedures for removal from the bladder have been described earlier. In this case report we describe the removal of an intravesical polypropylene tape by a combined transurethral and transabdominal endoscopic approach 3 months after the initial surgical procedure.

[Intraurethral injections of Zuidex: evaluation of the morbidity of the technique in the treatment of female urinary incontinence]
Ferchaud J, Girard F, Ciofu C, Peyrat L, Haab F
Prog Urol 2005 Jun;15(3):494-7.

OBJECTIVE: To evaluate the feasibility and morbidity of intraurethral injections of dextranomer/hyaluronic acid (Zuidex), performed under local anaesthesia as an outpatient procedure in the treatment of female urinary incontinence. MATERIAL AND METHODS: Twenty one patients with a mean age of 67 years (range: 29-93 years) presenting urinary incontinence related to sphincter incompetence were treated by intraurethral injection of Zuidex. Injections were performed with the Implacer system provided with the product under local anaesthesia. RESULTS: For nine of these patients (43%), a second injection after 6 weeks was performed due to an insufficient result on incontinence. A total of 30 injections were therefore performed. No significant problem was observed during the injections. Three injections (10%) were difficult because of a short urethra. In 7 cases (23%), the patient reported pain during the injection. In 3 cases (10%), macroscopic haematuria was observed after treatment and another 4 cases (13%) developed lower urinary tract infection. Six patients (20%) developed transient acute urinary retention with resumption of micturition after 24 to 48 hours. CONCLUSION: Intraurethral injection of Zuidex has the advantage of being minimally invasive and can be performed under local anaesthesia, as an outpatient procedure, with good safety and a low complication rate. Resumption of spontaneous voiding must be monitored in view of the risk of urinary retention. The long-term results have not yet been evaluated.

[Artificial urinary sphincters in women: indications, techniques, results]
Roupret M, Chartier-Kastler E, Richard F
Prog Urol 2005 Jun;15(3):489-93.

Artificial urinary sphincter (AUS) is one of the last resort surgical treatments proposed to patients with stress urinary incontinence (SUI) due to severe sphincter incompetence. Despite convincing functional results, AUS implantation in women is a preferred treatment option only for certain teams. An abdominal approach for implantation of the prosthesis is often preferred to the transvaginal approach. The most recent data show that more than 84% of patients are continent at 5 years. The 5-year sphincter revision rate is about 20%. In 2005, AUS is still a valid treatment option in SUI and has a real place in the urologist's therapeutic armamentarium even in the age of synthetic suburethral tape.

A nationwide analysis of transvaginal tape release for urinary retention after tension-free vaginal tape procedure.
Laurikainen E, Kiilholma P
Int Urogynecol J Pelvic Floor Dysfunct 2005 Aug 24;.

The role of transvaginal release procedure (TRP) for the treatment of urinary retention after TVT operation in Finland by the end of the year 2002 was evaluated. Questionnaires regarding the TVTs and the TRPs were sent to 56 hospitals. A retrospective review of the records of 48 women undergoing the TRP was available for analysis. TVT was performed on 9040 patients under local (94%), spinal (4%) or general (2%) anesthesia. TRP was made under local (48%), light (48%) or spinal (4%) anesthesia. The number of TRPs was 50/9040 (0.6%) in the whole country. Forty-nine percent of the patients were completely cured of their retention and remained continent after TRP by subjective report and by stress test. The retention following a TVT did not resolve in four patients (12%) who underwent TRP. This nationwide analysis proved that half of the patients remained continent after TRP, which is in our opinion an important information for all proceduralists.

Does the MONARC transobturator suburethral sling cause post-operative voiding dysfunction? A prospective study.
Barry C, Naidu A, Lim Y, Corsitaans A, Muller R, Rane A
Int Urogynecol J Pelvic Floor Dysfunct 2005 Aug 11;.

The aim of this study was to compare pre-operative and post-operative voiding parameters following insertion of the MONARC transobturator tape (TOT), for treating women with urodynamic stress incontinence. This prospective observational study was conducted at a tertiary referral urogynaecology unit, in North Queensland, involving 83 women who were prospectively assessed pre-operatively and at 6-8 weeks following the procedure. Information collected included patient demographics, concomitant surgery, pre-operative and post-operative symptomatology (using validated questionnaires), and pre-operative and post-operative urodynamic parameters. Parameters used to assess voiding function included symptoms of voiding difficulty (incomplete emptying and irritative symptoms) as well as objective parameters including maximum flow rate (Q(max)), adjusted maximum flow rate (Q(maxadj)) using the Liverpool nomogram (LN), maximal urethral pressure, and post-void residual (PVR). Pre-operative average Q(max) was 23.7 ml/s compared to 21.1 ml/s post-operatively (p=0.064). When the Q(max) was adjusted for voided volume using the LN, Q(maxadj) was seen to decrease significantly from 26 ml/s to 18 ml/s (p<0.05). Women with PVR>50 ml did not differ significantly pre-operatively and post-operatively, 5/83(6%) vs 7/83 (8.4%) (p=0.75). The number of women with a flow rate <10th centile on LN was 22 (26.5%) pre-operatively vs 29 (34.9%) post-operatively (p=0.21). One (1.2%) post-operatively had voiding dysfunction diagnosed by an abnormal voiding pattern (p=0.728), which was not statistically significant. Objective voiding dysfunction as determined by adjusted flow rates <10th centile LN and >50 ml PVR was seen in four women (4.8%). Adjusted free flow rates are significantly reduced following insertion of the MONARC TOT, as are some symptoms related to voiding dysfunction. Despite this, satisfaction rates remain high with observed voiding dysfunction or objective measures of voiding dysfunction showing no statistical change in the short term. Long-term follow-up is planned at 1 year.

Twelve-month results of nonsurgical radiofrequency energy micro-remodeling for stress incontinence.
Sotomayor M, Bernal GF
Int Urogynecol J Pelvic Floor Dysfunct 2005 May-Jun;16(3):192-6; discussion 196. Epub 2004 Sep 17.

This pilot clinical trial was performed to evaluate the safety and impact on quality of life and incontinence episode frequency of nonsurgical radiofrequency energy (RF) tissue micro-remodeling in women with stress urinary incontinence (SUI). The palpation-guided treatment produces focal denaturation of submucosal collagen, resulting in reduced luminal wall compliance without luminal narrowing. Forty-one women suffering from SUI associated with urethral hypermobility were enrolled into four treatment groups which differed in total number and lower urinary tract location of micro-remodeling sites. No serious and only limited minor adverse events were associated with the treatment. Incidence of quality of life score improvement at 12 months ranged from 75 to 78%, and statistically significant incontinence episode frequency reduction was demonstrated by three of four treatment groups. RF micro-remodeling demonstrated 12-month safety, quality of life improvement, and incontinence episode frequency reduction. No one treatment group demonstrated clear superiority in efficacy outcomes.

Risk factors influencing the complication rates of tension-free vaginal tape-type procedures.
Cetinel B, Demirkesen O
Curr Opin Obstet Gynecol 2005 Oct;17(5):530-4.

PURPOSE OF REVIEW: Tension-free vaginal tape (TVT)-type procedures are gradually becoming the new gold-standard treatment for female stress urinary incontinence. Studies trying to determine the influence of possible risk factors on complications of TVT surgery are needed in order to achieve more favorable results in the future. This review attempts to summarize the current studies which address the possible risk factors influencing the complication rates of TVT-type procedures. RECENT FINDINGS: Articles published in 2004 and 2005 were included and focused, while the older articles were used for historical purposes and achieving the integrity. Risk factors stated in the literature for immediate, infectious, vaginal and urethral erosion complications are found to be mostly on anectodal and speculative bases. The role of concomitant surgery as a risk factor for complications is conflicting, while preoperative low urine flow and low detrusor contractility for urinary retention, and previous anti-incontinence surgery and old age for de-novo urgency seem to appear as possible risk factors. SUMMARY: Most of the risk factors stated were anecdotal and speculative. No consensus exists on concomitant surgery's being a risk factor for postoperative urinary retention and bladder perforation, while prior anti-incontinence surgery and old age were found to be possible risk factors for postoperative overactive bladder symptoms. Multicentric data collection with well designed parameters under the surveillance of a well known organization is needed in order to identify the risk factors influencing the complications of TVT-type procedures.

Intravesical injection of botulinum toxin for the treatment of overactive bladder.
Ho MH, Lin LL, Haessler AL, Bhatia NN
Curr Opin Obstet Gynecol 2005 Oct;17(5):512-8.

PURPOSE OF REVIEW: In recent years, botulinum toxin has been investigated for the treatment of various types of lower urinary tract dysfunctions. This review discusses recently published data related to the therapeutic applications of botulinum toxin in overactive bladder as well as the effects of repeated doses, cross-reactivity between different serotypes, and side effects of the toxin injection into the detrusor muscle. RECENT FINDINGS: Botulinum toxin A has been employed initially in the treatment of neurogenic detrusor overactivity in spinal cord injured patients. Since then, several reports, including a large multicenter study, have confirmed the therapeutic effects of this neurotoxin. The application of botulinum toxin A was extended to the treatment of idiopathic detrusor overactivity and similar results were obtained. Repeated injections of botulinum toxin A had the same sustained benefit. Recently, botulinum toxin B was investigated for the treatments of both neurogenic and idiopathic detrusor overactivity as well as for the management of botulinum toxin A resistant cases. SUMMARY: Although intradetrusal injection of botulinum toxin is not yet an approved treatment for overactive bladder, available data suggest that botulinum toxin can be a therapeutic option in patients with neurogenic and nonneurogenic detrusor overactivity who are refractory to anticholinergic medications. There is a need, however, for further investigation to determine the optimal conditions for these applications. A randomized, double-blinded, placebo-controlled trial to evaluate the therapeutic effects of botulinum toxin is under way.

Overactive bladder: epidemiology and social impact.
Tubaro A, Palleschi G
Curr Opin Obstet Gynecol 2005 Oct;17(5):507-511.

PURPOSE OF REVIEW: Overactive bladder epidemiology is a rapidly evolving field. The new terminology of lower urinary tract function, introduced in 2002, modified the definitions of all four components of overactive bladder. In the same year, the lack of specific information on overactive bladder prevalence was identified and consequently new studies were launched and recently published. RECENT FINDINGS: Following the new terminology, overactive bladder now includes both a purely sensory disorder and a condition related to an altered bladder behaviour. Studies conducted in selected countries and populations suggested comparable prevalence data worldwide, although the syndrome is considered to be underreported. 'U