Urinary Incontinence

The effects of antimuscarinics on health-related quality of life in overactive bladder: a systematic review and meta-analysis.
Khullar V, Chapple C, Gabriel Z, Dooley JA
Urology. 2006 Aug;68(2 Suppl):38-48.

The objective of this study was to review the effects of antimuscarinic treatments on health-related quality of life (HRQL) in patients with overactive bladder (OAB). MEDLINE, EMBASE, the Cochrane Controlled Trials Register, and the Cumulative Index to Nursing and Allied Health Literature databases were searched from 1966 through August 2004 for randomized controlled trials of antimuscarinic agents. HRQL data from included trials were extracted, and meta-analysis was performed where possible. Of 56 trials included, 25 (45%) reported HRQL and/or patient-reported outcomes. The most commonly used instruments were the Incontinence Impact Questionnaire (3 trials), the King's Health Questionnaire (KHQ; 5 trials), the Medical Outcomes Study Short Form-36 (2 trials), the Gaudenz Appraisal Questionnaire (3 trials), and the Urogenital Distress Inventory (2 trials). Results from the meta-analyses of placebo-controlled trials showed statistically significant differences in favor of antimuscarinic therapy. Differences in HRQL as assessed using the KHQ were also clinically meaningful. The meta-analysis results of active-controlled trials did not show significant differences among antimuscarinic agents. This review provides evidence that antimuscarinics provide an HRQL benefit to patients with OAB. HRQL outcomes using validated instruments are recommended for inclusion in active-controlled trials, and agreement on the most appropriate HRQL instrument is now required.

Long-term results of tension-free vaginal tape (TVT) for the treatment of female urinary stress incontinence.
Chene G, Amblard J, Tardieu AS, Escalona JR, Viallon A, Fatton B, Jacquetin B
Eur J Obstet Gynecol Reprod Biol. 2006 Aug 4;.

OBJECTIVES: Prospective evaluation of outcome and complications over a 5-year period post-treatment of urinary stress incontinence by TVT, and comparison of our results with the reference studies. MATERIALS AND METHODS: About 94 patients were treated for urinary stress incontinence only by one TVT procedure (single surgical procedure), between April 1997 and December 1998; 68% of patients presented pure urinary stress incontinence and 32% mixed incontinence. We found also a 25.5% rate of sphincter deficiency (UCP<20cmH(2)O) in this cohort. Patients were evaluated after 5 years: 52 complete evaluations (clinical, flow measurement with measurement of post-mictional residue, 24h PAD-test, quality of life questionnaire), 30 complete telephone interviews, 12 lost to follow-up (2 patients deceased). RESULTS: About 87% of the patients had a 5-year follow-up. The success rate was 79.2% overall (84.5% for the pure urinary stress incontinence and 67% for the mixed incontinence cases), and 72.2% for the cases of associated sphincter deficiency. We had only a 13% rate of patients lost to follow-up. More than half of the urinary urgency cases were treated successfully, however with a less satisfactory outcome in cases of bladder instability. The urodynamic exploration appeared to reveal that TVT caused dysuria: 52% of patients had a maximum flowrate below 15ml/s, but the quality of life was improved, with a 95% rate of satisfaction without functional problems. We observed no late complications such as vaginal erosion or rejection of the prolene; the de novo syndrome was rare, with 8.5% of urinary frequency, 6% of urinary urgency and only 5.7% of invalidating dysuria. We saw no cases of pelvic floor disease after TVT treatment. DISCUSSION: Our casuistry results are comparable with the reference studies by Scandinavian authors, Rezapour and Ulmsten, confirming the long-term success of the TVT procedure. Concerning the apparently elevated rates of post-TVT dysuria found by urodynamic exploration, a distinction has to be drawn between post-TVT urinary problems (frequent but oligosymptomatic), and true, severe dysuria (rare). However, "dysuria" in the broad sense did not affect the patients' quality of life, and is a reminder of the absolute necessity of meticulous compliance with the correct surgical techniques. CONCLUSION: Treatment of urinary incontinence by TVT is a reliable, mini-invasive, reproducible technique, almost suitable for outpatients, with no serious complications; it is inexpensive and very successful, including in complicated cases such as sphincter deficiency. All the recent data confirms, with this 5-year follow-up, that the TVT procedure is comparable to the previously gold standard, the Burch colposuspension.

[New male sling "Argus" for the treatment of stress urinary incontinence]
Moreno Sierra J, Victor Romano S, Galante Romo I, Barrera Ortega J, Salinas Casado J, Silmi Moyano A
Arch Esp Urol. 2006 Jul-Aug;59(6):607-13.

OBJECTIVES: Male stress urinary incontinence is usually a consequence or sequel of a prostatic surgical procedure (radical prostatectomy, surgery for BPH or bladder neck sclerosis: adenomectomy, conventional and/or bipolar transurethral resection, laser...). This kind of surgery may have undesirable effects on the quality of life and patients' expectations, although we should bear in mind that the primary objective in patients with prostate adenocarcinoma is to cure cancer and for patients with obstructive lower urinary tract symptoms to improve their voiding quality Over the last decade, surgical procedures to compress the bulbar urethra with slings have been employed successfully in the treatment of male stress urinary incontinence, being considered highly effective in the treatment of post-prostatectomy incontinence in the long-term by groups with large experience. To describe the elements of the Argus system, its indications, and the surgical technique for its implant and adjustment, modified from Schaeffer and carried out by Victor Romano. METHODS: Argus system: The sling has three components: radiopaque cushioned system with silicone foam, 42 mm x 26 mm x 9 mm, which is waterproof to body fluids; two silicone columns formed by multiple conical elements, which allow system readjustment; and two radiopaque silicone washers (15 mm diameter and 2.9 mm width) which enable proper fixation and readjustment (Figure 1). Once the system is open, it is recommended to place the sling within antibiotic solution until implantation. CONCLUSIONS: 1. It is a safe, easy to implant, reproducible system, with few complications and a good cost-benefit relation. 2. Results are comparable to the gold standard, but it has the following advantages: immediate voiding control recovery and no need for patient training. 3. This article does not intend to show our short experience with only five cases, but we want to mention that all of them are continent with a good quality of life. 4. Our objective will be to publish our results when we can show a minimal follow-up.

Urinary incontinence and age at the first and last delivery: the Norwegian HUNT/EPINCONT study.
Rortveit G, Hunskaar S
Am J Obstet Gynecol. 2006 Aug;195(2):433-8. Epub 2006 Apr 21.
OBJECTIVE: This study was undertaken to investigate the association between maternal age at the first and last delivery, and urinary incontinence later in life. STUDY DESIGN: In the Norwegian EPINCONT study (a substudy of HUNT 2), cross-sectional data on incontinence from 11,397 women aged 20 to 64 years was linked with prospectively obtained data on exposures from the Medical Birth Registry of Norway. Bivariate and multivariate methods were applied. RESULTS: Women 25 years or younger at their first delivery had a lower risk of incontinence than their older counterparts (23% vs 28%, P < .01). No significant effect of maternal age at the first delivery was found in women with actual age 50 to 64 years. Adjusting for confounders did not change any results. Age at the last delivery was less associated with incontinence. CONCLUSION: Being older than 25 years at the first delivery was associated with incontinence. The effect attenuated with actual age.

Pharmacologic Treatment in Postprostatectomy Stress Urinary Incontinence.
Filocamo MT, Li Marzi V, Del Popolo G, Cecconi F, Villari D, Marzocco M, Nicita G
Eur Urol. 2006 Aug 15;.

OBJECTIVES: The aim of this study was to assess efficacy and safety of association of duloxetine and rehabilitation compared with rehabilitation alone in men with SUI after radical retropubic prostatectomy (RRP), and to compare continence rate even after planned duloxetine suspension. METHODS: After catheter removal, 112 patients were randomized to receive rehabilitation and duloxetine (group A) or rehabilitation alone (group B), for 16 wk. Inclusion criteria: postprostatectomy SUI with daily incontinent episodes frequency (IEF) of four or greater. After 16 wk both groups suspended duloxetine/placebo and continued rehabilitation. All patients completed incontinence quality of life (I-QoL) questionnaire and bladder diary. Wilcoxon test was used to analyse changes in IEF and in I-QoL score; Fisher exact test was used to compare in continent patients between the groups. RESULTS: Adverse events for duloxetine was 15.2%. 102 men completed the study. There was a significant decrease in pad use in group A. After 16 wk, 39 patients versus 27 were dry (p=0.007). At 20 wk, 4 wk after planned interruption of duloxetine, we observed a U-turn, 23 patients were completely dry in group A versus 38 in group B (p=0.008). Whereas, after 24 wk, 31 in group A versus 41 in group B were dry (p=0.08). The decrease in IEF and improvements in I-QoL scores were significantly greater in group A for the first 16 wk. CONCLUSIONS: The data suggest that combination therapy might provide another treatment option for SUI in men that might increase the percentage of early postsurgery continence.

Botulinum Toxin Injections for Neurogenic and Idiopathic Detrusor Overactivity: A Critical Analysis of Results.
Patel AK, Patterson JM, Chapple CR
Eur Urol. 2006 Aug 4;.

OBJECTIVE: In recent years there has been an increasing use of the botulinum neurotoxins for the management of conditions characterised by detrusor overactivity. Early studies showed promising results in an area where few options previously existed between pharmacotherapy and surgery. This has led to an urgent need to assess the wide range of techniques and therapies available, as well as the efficacy and tolerability of the treatment. We performed a critical analysis of the numerous clinical studies for this novel treatment option in the management of neurogenic and idiopathic detrusor overactivity, with a view to directing further research and assisting urologists in the management of these conditions. METHODS: A systematic review of the literature, as well as a search for abstracts presented to relevant peer-reviewed meetings, was performed. All articles from 1988 onwards were included, prior to which no articles describing urologic use of botulinum neurotoxins had been published, although the majority of the articles have been published since 2000. RESULTS AND CONCLUSIONS: Although many of the studies were small, overwhelming evidence supports the efficacy, safety, and tolerability of the botulinum toxins, specifically serotype A, for the management of these conditions. Before this is accepted as a widespread treatment modality, good-quality evidence from large-scale randomised controlled trials is needed. These studies should identify not only the most appropriate patients to treat but also the best dose, administration technique, and frequency for treatment.

Acute Urodynamic Effects of Posterior Tibial Nerve Stimulation on Neurogenic Detrusor Overactivity in Patients with MS.
Fjorback MV, van Rey FS, van der Pal F, Rijkhoff NJ, Petersen T, Heesakkers JP
Eur Urol. 2006 Aug 7;.
OBJECTIVES: The aim of this study was to investigate whether acute electrical stimulation of the posterior tibial nerve could suppress detrusor contractions in multiple sclerosis (MS) patients with neurogenic detrusor overactivity. METHODS: Two successive slow-fill cystometries (16ml/min) were carried out in eight MS patients with neurogenic detrusor overactivity. The first filling served as control without stimulation. In the second filling, electrical stimulation using needle electrodes was applied automatically to the posterior tibial nerve when the detrusor pressure exceeded 10cm H(2)O. An additional filling in which the needle electrodes were replaced by surface electrodes was carried out in three patients. RESULTS: The control filling showed detrusor overactivity in eight patients, but electrical stimulation of the posterior tibial nerve failed to suppress detrusor contractions in all tested patients. CONCLUSIONS: Although neuromodulative effects may be obtained with therapeutic electrical stimulation of the posterior tibial nerve, no acute effects were demonstrated. For this reason, electrical stimulation of pudendal afferents remains the only option if acute suppression of a detrusor contraction is required.

Incidence and remission of urinary incontinence after hysterectomy-a 3-year follow-up study.
Neumann GA, Lauszus FF, Ljungstrom B, Rasmussen KL
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Aug 1;.

The aim of the study is to investigate the changes in continence status in a population of women hysterectomized in 1998-2000. Four hundred fifteen hysterectomized women who participated in a questionnaire study on continence status in September 2001 were retested with the same questionnaire on actual continence status in January 2005. As controls we used 97 women who had a laparoscopic cholecystectomy in 1999-2000 and were tested and retested similarly. Urinary incontinence was defined as involuntary urinary leakage at least once a week. Stress incontinence was defined as leakage when coughing, laughing, or lifting heavy weights. Urge incontinence was defined as an uncontrollable desire to void with leakage before reaching the toilet. Stress incontinence was reported by 30% of the hysterectomized women in 2005 vs 28% in 2001. The similar prevalences of urge incontinence were 15 and 13%, respectively. Women who had a subtotal hysterectomy significantly more often had stress incontinence compared to controls in 2005 and 2001. No other significant differences were found. However, the similar prevalences of incontinence reflected that 16% of the hysterectomized women changed from continent in 2001 to stress incontinent in 2005, while 32% changed from stress incontinent to continent. For urge incontinence the similar changes were 8 and 35%, respectively. A large proportion of women change from continent to incontinent or from incontinent to continent during the 3 years of investigation, which should be born in mind when prevalence studies on urinary incontinence are evaluated. Previous hysterectomy does not seem to be of great importance for the development of de novo incontinence or remission.

Retropubic and transobturator tape procedures: reply to letter by A.C. Wang.
But I
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Aug 5;.

Result of the tension-free vaginal tape in patients with concomitant prolapse surgery: a 2-year follow-up study. An analysis from the Netherlands TVT database.
Schraffordt Koops SE, Bisseling TM, van Brummen HJ, Heintz AP, Vervest HA
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Aug 15;.

This study assessed the long-term outcome of tension-free vaginal tape (TVT) in women with concomitant pelvic surgery. A prospective cohort study of 746 patients in 41 hospitals was undertaken. The Incontinence Impact Questionnaire (IIQ-7) and Urogenital Distress Inventory (UDI-6) were used to measure the results of the TVT. Fifty-nine patients with concomitant prolapse surgery were compared with 687 women with TVT only. The decrease in IIQ/UDI mean scores were statistically significant in both groups after the TVT. The success rates of "no leakage at all" is comparable for both groups. This study, with 54 gynecologists and urologists participating, showed the long-term (2 years) success rates of TVT with concomitant prolapse surgery. It shows that the procedure in conjunction with prolapse surgery can be safely performed with good results.

Analysis of risk factors associated with surgical failure of inside-out transobturator vaginal tape for treating urodynamic stress incontinence.
Chen HY, Yeh LS, Chang WC, Ho M
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Aug 15;.

The goals of this study were to assess the efficacy of inside-out transobturator vaginal tape (TVT-O) as a treatment of urodynamic stress incontinence (USI) and to explore the possible factors determining surgical success and failure. Each woman had a 20-min pad test and urodynamic study including uroflowmetry, cystometry, and stress urethral pressure profile before and after treatment. Forty-six of the 54 women (85%) were cured of the disease, and two (4%) showed clinical improvement; TVT-O had failed to treat USI in six patients (11%) during the 9-month follow-up period. We assessed the relationship between clinical features, urodynamic parameters, and treatment outcome. Of these, only age and previous anti-incontinence surgery were significant risk factors for surgical failure. The success rate during the 9-month follow-up period decreased significantly in women >==60 years and in women with previous anti-incontinence surgery. Women with USI can be treated by the TVT-O procedure.

Solifenacin significantly improves all symptoms of overactive bladder syndrome.
Chapple CR, Cardozo L, Steers WD, Govier FE
Int J Clin Pract. 2006 Aug;60(8):959-66.

Overactive bladder syndrome (OAB) is a chronic condition characterised by urgency, with or without associated urge incontinence. Solifenacin succinate is a once daily, bladder selective antimuscarinic available in two doses (5 and 10 mg). The recommended dose is 5 mg once daily and can be increased to 10 mg once daily if 5 mg is well tolerated. This article presents pooled efficacy and safety data from four large, placebo-controlled, multinational phase III trials of solifenacin succinate with a total enrolment of over 2800 patients. Data from these trials show that solifenacin 5 and 10 mg once daily is significantly more effective than placebo at reducing urgency, incontinence, micturition frequency and nocturia and at increasing volume voided per micturition. Adverse events were mainly mild-to-moderate in all treatment groups. The results of these phase III trials support the use of solifenacin in the treatment of OAB.

Epidemiology, prescribing patterns and resource use associated with overactive bladder in UK primary care.
Odeyemi IA, Dakin HA, O'Donnell RA, Warner J, Jacobs A, Dasgupta P
Int J Clin Pract. 2006 Aug;60(8):949-58.

This study aimed to estimate the incidence and prevalence of overactive bladder (OAB) symptoms in the UK and analyse the use of anticholinergic/antispasmodic medications and other healthcare resources within UK general practice. Patients with a record of urinary frequency, urgency, nocturia, urge incontinence or irritable/unstable bladder between 1987 and 2004 were identified from the General Practice Research Database. Demographic characteristics, referrals, consultations, investigations and prescriptions for medications licensed for use in OAB were identified. Regression analyses were used to identify the factors determining switches between medications, referrals and use of healthcare resources. The overall prevalence of OAB-related symptoms was 3.87 per 1000 persons, with an incidence of 2.79 per 1000 person-years. Among 68,910 patients with OAB symptoms, 19,444 (28.2%) received anticholinergic medication, of whom 14,454 (74.3%) received one drug and 4055 (20.9%) received two medications sequentially. Overall, 59.1% of patients were referred to relevant secondary care specialities, 2.8% underwent urinary tests/investigations in primary care and 0.2% were seen by a continence nurse. Resource use was higher among patients who tried several different medications. In conclusion, this study suggests that OAB may be under-diagnosed in the UK and that current guidelines recommending use of anticholinergic medication, continence nurse consultations and urinary tests/investigations are inadequately followed.

Re: Midurethral Tissue Fixation System sling.
Sivaslioglu AA
Aust N Z J Obstet Gynaecol. 2006 Oct;46(5):464-5.

Tension-free transobturator tape procedure for stress urinary incontinence.
Ho MH, Lin LL, Haessler AL, Bhatia NN
Curr Opin Obstet Gynecol. 2006 Oct;18(5):567-74.

PURPOSE OF REVIEW: Recent data on the tension-free transobturator tape procedure for the treatment of female stress urinary incontinence are reviewed. RECENT FINDINGS: Although long-term data are not available, the effectiveness and safety of the tension-free transobturator tape procedure as reported during the past 5 years are very promising and this procedure is becoming a popular surgical treatment for female stress urinary incontinence. The continence rates obtained have been similar to those obtained using the retropubic tension-free vaginal tape on short-term follow-up. Clinical data as well as studies on cadaveric dissections suggest that complication rates can be decreased significantly with the transobturator approach. In the original tension-free transobturator tape procedure, the tape is inserted through the obturator foramen from the outside-to-inside direction (skin incision to vaginal incision). The inside-to-outside approach with passage of the tape from the vaginal incision to the obturator foramen has also been described. SUMMARY: The tension-free transobturator tape procedure provides a useful alternative to the retropubic tension-free vaginal tape approach while maintaining the principles of tension-free midurethral support. By avoiding the intrapelvic and retropubic passage, complications can be decreased. The effectiveness of this approach is similar to that of tension-free vaginal tape on short-term follow-up.

Re: Magnetic stimulation for mixed urinary incontinence.
I. But, M. Faganelj and A. Sostaric. J Urol, 173: 1644-1646, 2005. Shafik A
J Urol. 2006 Sep;176(3):1257; author reply 1257-8.

Re: Is the bladder a reliable witness for predicting detrusor overactivity?
H. Hashim and P. Abrams. J Urol, 175: 191-195, 2006.
Schaefer W
J Urol. 2006 Sep;176(3):1255-7; author reply 1256-7.

Calcification of glutaraldehyde cross-linked collagen in bladder neck injections in children with incontinence: a long-term complication.
Knudson MJ, Cooper CS, Block CA, Hawtrey CE, Austin JC
J Urol. 2006 Sep;176(3):1143-6; discussion 1146.

PURPOSE: We report the incidence of calcifications developing at the bladder neck/urethra in pediatric patients treated with glutaraldehyde cross-linked collagen for urinary incontinence. MATERIALS AND METHODS: We reviewed charts of patients treated with glutaraldehyde cross-linked collagen injections for urinary incontinence between 1994 and 1999. Etiology of incontinence, pertinent medical history, operative details and postoperative imaging were examined. RESULTS: Of 31 patients 4 (13%) had development of submucosal calcifications in the bladder neck/urethra. All 4 patients had received multiple injections of glutaraldehyde cross-linked collagen for incontinence secondary to neurogenic bladder. The calcifications were confirmed surgically. Pathology reports available for 2 of 4 patients showed chronic inflammation without dysplasia or malignant changes. Mean followup was significantly different between calcified and noncalcified cases (10.3 vs 7.2 years, p = 0.009), as was total volume of collagen injected (21 vs 12 cc, p = 0.012). Mean time to diagnosis of calcifications was 8.8 years (range 7 to 11) after first injection. A total of 24 patients without calcification underwent bladder imaging at a mean of 6.8 years (+/-2.2) after glutaraldehyde cross-linked collagen injection, which was not significantly different than the time to diagnosis (p = 0.089). The number of injections was not significantly different between the 2 groups (p = 0.426). CONCLUSIONS: Of our patients 13% had development of calcifications at the site of prior glutaraldehyde cross-linked collagen injections for incontinence. These calcifications were surrounded by chronic inflammation. Patients who have undergone glutaraldehyde cross-linked collagen injections may benefit from long-term followup with bladder imaging to detect and follow calcifications at prior injection sites.

Long-term effects of dextranomer endoscopic injections for the treatment of urinary incontinence: an update of a prospective study of 61 patients.
Lottmann HB, Margaryan M, Lortat-Jacob S, Bernuy M, Lackgren G
J Urol. 2006 Oct;176(4 Suppl):1762-6.

PURPOSE: To treat sphincteric deficiency in children endoscopic bladder neck injections may avoid or salvage more complex procedures. A prospective study to assess the efficacy of bladder neck injections of dextranomer based implants (Deflux(R)) was done in a 7-year period in 61 patients. MATERIALS AND METHODS: From September 1997 to September 2004 we enrolled in the study 41 males and 20 females 5 to 18 years old with severe sphincteric incompetence, including exstrophy-epispadias in 26, neuropathic bladder in 27, bilateral ectopic ureters in 5, and miscellaneous in 3. Preoperative evaluation consisted of medical history, urine culture, urinary tract ultrasound and videourodynamics. This evaluation was repeated 6 months and 1 year after treatment, and yearly thereafter. Of the patients 17 underwent 2 and 4 underwent 3 treatment sessions to achieve a definitive result. At each evaluation the case was considered cured-a dryness interval of 4 hours between voids or CIC, significantly improved-minimal incontinence requiring no more than 1 pad daily and no further treatment required, and treatment failure-no significant, long lasting improvement. Videourodynamics were mainly useful to study the evolution of bladder capacity, activity and compliance. Followup after the last injection was 6 to 84 months (mean 28). RESULTS: Mean injected volume per session was 3.9 cc (range 1.6 to 12). Postoperative complications were temporary dysuria in 2 patients nonfebrile urinary tract infection in 10, orchid-epididymitis in 1 and urinary retention with pyelonephritis in 1. The incidence of dryness or improvement during followup was 79% (48 of 61 patients) at 1 month, 56% (31 of 55) at 6 months, 52% (24 of 46) at 1 year, 51% (18 of 35) at 2 years, 52% (16 of 31) at 3 years, 48% (12 of 25) at 4 years, 43% (9 of 21) at 5 years, 36% (4 of 11) at 6 years and 40% (2 of 5) at 7 years. The success rate according to pathological condition was similar in cases of neuropathic bladder and the exstrophy-epispadias complex (48% and 53%, respectively). The success rate in re-treated cases was 38%. After treatment a contracted bladder developed in 6 patients. Also, of the 35 patients with at least 2 years of followup an increase in capacity of at least 50% was observed in 12 of 18 with an initially small bladder. No side effects related to the substance were observed. CONCLUSIONS: Endoscopic treatment for pediatric severe sphincteric deficiency with dextranomer implant, a nontoxic, nonimmunogenic, nonmigratory synthetic substance, was effective up to 2 years in half of the patients. Subsequently at up to 7 years of followup a slow decrease in efficacy was observed and treatment remained beneficial in 40% of the patients.

14 years of experience with the artificial urinary sphincter in children and adolescents without spina bifida.
Ruiz E, Puigdevall J, Moldes J, Lobos P, Boer M, Ithurralde J, Escalante J, de Badiola F
J Urol. 2006 Oct;176(4 Suppl):1821-5.

PURPOSE: The efficacy of the artificial urinary sphincter to treat sphincteric incontinence in pediatric patients with spina bifida has been clearly reported. The possibility of maintaining spontaneous voiding has usually been the main reason for prosthetic device surgery. We reviewed our experience with the artificial urinary sphincter in patients without spina bifida who had had previous surgery of the bladder neck or proximal urethra. MATERIALS AND METHODS: From 1990 to 2004, 112 children and adolescents underwent implantation of an AMS 800trade mark artificial urinary sphincter. Of the patients 19 males and 4 females (20.5%) between ages 4 and 17 years (mean 8.1) had no spina bifida. Instead there were bladder exstrophy in 12 patients, anorectal malformation with a rectourethral or vesical fistula in 7 and epispadias in 4. A bladder neck cuff between 5.5 and 7.5 cm, and a 61-70 balloon were used in all patients. RESULTS: Only 1 patient was lost to followup. In 22 patients (95.6%) mean followup was 80 months (range 4 to 155). Three sphincters in patients with exstrophy were removed because of erosion and/or infection 5, 49 and 60 months after initial surgery, respectively. A total of 19 sphincters remained in place (86.3% survival rate) with 5 revisions (26.3%) because of the pump (2), the cuff (2) or balloon fluid leakage. In this group 13 patients (68.4%) voided spontaneously and 6 (31.6%) performed clean intermittent catheterization, although 3 also voided spontaneously. Overall continence was good in 87% of patients because 2 were still incontinent at night. CONCLUSIONS: The artificial urinary sphincter is a good long-term solution to urinary incontinence secondary to sphincter incompetence despite multiple previous surgeries of the bladder neck or proximal urethra. Patients with bladder exstrophy and many previous bladder procedures are more exposed to complications such as erosion compared with patients with epispadias or anorectal malformation. The high percent of patients maintaining spontaneous voiding and the good rate of continence are the most important benefits of this type of surgical option for sphincter incompetence.

Patient related risk factors for recurrent stress urinary incontinence surgery in women treated at a tertiary care center.
Daneshgari F, Moore C, Frinjari H, Babineau D
J Urol. 2006 Oct;176(4):1493-9.

PURPOSE: We examined patient related risk factors for recurrent stress urinary incontinence in women treated at a tertiary referral center. MATERIALS AND METHODS: A case-control study was done in 18 to 75-year-old women with signs and symptoms of genuine or mixed stress urinary incontinence and no prior surgical treatment who underwent an open anti-incontinence procedure between 1990 and 2002 at our institution. Cases were defined as patients who underwent more than 1 anti-incontinence surgery and controls were defined as patients who underwent only 1 anti-incontinence procedure with followup during that period. Cases and controls were matched for surgery type, surgeon and date of surgery within 1 year. A total of 47 variables were examined, including patient age, parity, incontinence type, urodynamic findings, medical history (peripheral vascular, pulmonary and cardiac disease), past and concomitant pelvic surgery, social history (alcohol and tobacco use) and body mass index. Univariate conditional logistic regression was done first to determine which variables were potential protective or risk factors. Multivariate conditional logistic regression analysis was then used to determine which factors were statistically significant. RESULTS: The records of 2,550 women with stress or mixed urinary incontinence who underwent an open surgical procedure between 1990 and 2002 were reviewed. A total of 53 cases and 146 controls were identified. Each case was matched with 1 to 4 controls. Data on cases and controls were collected using a standardized form. At a significance level of 0.05 the possible risk factors for recurrent stress urinary incontinence based on univariate analysis were diabetes mellitus (OR 3.579, p = 0.026), pelvic organ prolapse (OR 5.635, p = 0.03) and concomitant rectocele repair (OR 5.353, p = 0.04). Smoking was marginally protective (OR 0.497, p = 0.068). After multivariate conditional logistic regression analysis diabetes mellitus (adjusted OR 3.413, p = 0.045), pelvic organ prolapse (adjusted OR 8.195, p = 0.021) and concomitant rectocele repair (adjusted OR 17.079, p = 0.012) remained significant risk factors, while smoking remained a protective factor (adjusted OR 0.264, p = 0.012). Body mass index, age, race, parity and estrogen status were not identified as risk factors for recurrent stress urinary incontinence requiring a second anti-incontinence procedure. CONCLUSIONS: In a cohort of women with stress or mixed urinary incontinence treated at our institution between 1990 and 2002 women with diabetes mellitus, pelvic organ prolapse or concomitant rectocele repair were at increased risk for repeat anti-incontinence surgery, while women who smoked were at slightly decreased risk.

Noninvasive therapies for treating post-prostatectomy urinary incontinence.
Joseph AC
Urol Nurs. 2006 Aug;26(4):271-5, 269; quiz 276.

Incorporation of a noninvasive program for both body and mind can lead to successful outcomes in men suffering from post-prostatectomy urinary incontinence. Key factors in the initial assessment and a detailed description of effective, unique treatment interventions for men with post-prostatectomy urinary incontinence are described.

Tolterodine extended release improves overactive bladder symptoms in men with overactive bladder and nocturia.
Kaplan SA, Roehrborn CG, Dmochowski R, Rovner ES, Wang JT, Guan Z
Urology. 2006 Aug;68(2):328-32.

OBJECTIVES: To evaluate the efficacy and safety of nighttime dosing with tolterodine extended release (TER) in men with overactive bladder (OAB) and nocturia. METHODS: This was a post hoc analysis of data from two 12-week, double-blind, placebo-controlled trials of nighttime (<4 hours before bedtime) TER (4 mg daily) dosing. Men with a mean micturition frequency of eight or more times in 24 hours, including a mean of 2.5 or more nocturia episodes/night, were included. For each micturition, patients used 7-day diaries to record urinary urgency on a 5-point urgency rating scale (1, none; 2, mild; 3, moderate; 4, severe; 5, urgency urinary incontinence). Micturitions were analyzed post hoc by urgency rating categories: total (1 to 5), non-OAB (1 to 2), OAB (3 to 5), and severe OAB (4 to 5). Adverse events were recorded throughout the study. RESULTS: A total of 745 men (mean age 64 years) were randomized to placebo (n = 374) or TER (n = 371). Of the 745 men, 73% reported no incontinence episodes in a 7-day diary at baseline. At week 12, the weekly values for nighttime severe OAB micturitions and 24-hour and daytime total, OAB, and severe OAB micturitions were significantly reduced in the TER group versus the placebo group. The TER-treated men also reported a significant reduction in the mean urgency rating versus placebo. Adverse events associated with TER were low and comparable to those in the placebo group, with the exception of dry mouth (11% versus 4%). Withdrawals because of adverse events were infrequent (3% TER, 4% placebo). Five men were withdrawn for symptoms suggestive of urinary retention (3 TER, 2 placebo). CONCLUSIONS: Nighttime TER dosing reduced urgency-related micturitions and was well tolerated in men with OAB and nocturia.

Symptom assessment tool for overactive bladder syndrome--overactive bladder symptom score.
Homma Y, Yoshida M, Seki N, Yokoyama O, Kakizaki H, Gotoh M, Yamanishi T, Yamaguchi O, Takeda M, Nishizawa O
Urology. 2006 Aug;68(2):318-23.

OBJECTIVES: Overactive bladder (OAB) is a common symptom syndrome with urgency, urinary frequency, and urgency incontinence. To collectively express OAB symptoms, we developed the overactive bladder symptom score (OABSS). METHODS: Four symptoms--daytime frequency, nighttime frequency, urgency, and urgency incontinence--were scored. The weighing score was based on a secondary analysis of an epidemiologic database. Psychometric properties were examined in five patient groups: OAB (n = 83), asymptomatic controls (n = 34), stress incontinence (n = 29), benign prostatic hyperplasia (n = 28), and other diseases with urinary symptoms (n = 26). RESULTS: The maximal score was defined as 2, 3, 5, and 5 for daytime frequency, nighttime frequency, urgency, and urgency incontinence, respectively. The sum score (OABSS 0 to 15) was significantly greater in the patients with OAB (8.36) than in the other patient groups (1.82 to 5.14). The distribution of the OABSS showed a clear separation between those with OAB and asymptomatic controls. The OABSS correlated positively with the individual scores (Spearman's r = 0.10 to 0.78) and quality-of-life scores assessed by the King's Health Questionnaire (Spearman's r = 0.20 to 0.49). The weighted kappa coefficients were 0.804 to 1.0 for each symptom score and 0.861 for OABSS. The posttreatment reduction in the OABSS was consistent with the global impression of patients of the therapeutic efficacy. CONCLUSIONS: The OABSS, the sum score of four symptoms (daytime frequency, nighttime frequency, urgency, and urgency incontinence), has been developed and validated. OABSS may be a useful tool for research and clinical practice.

Patient-reported outcomes in overactive bladder: the influence of perception of condition and expectation for treatment benefit.
Marschall-Kehrel D, Roberts RG, Brubaker L
Urology. 2006 Aug;68(2 Suppl):29-37.

Patient perceptions of overactive bladder (OAB) symptoms, expectations for treatment benefit, and overall treatment satisfaction share complex relations. Multiple studies have demonstrated associations between factors, such as age, sex, and ethnicity, and patient perceptions of OAB symptoms, especially urgency urinary incontinence. Perceptions of OAB are also shaped by symptom severity and impact on health-related quality of life, as well as by perceptions of family members, caregivers, and clinicians. The literature further suggests discrepancies in the reporting among patients, physicians, and family members/caregivers of the impact that urinary symptoms have on patients' emotional well-being, productivity, and daily life. Understanding the factors that affect patients' perceptions is important because these perceptions affect treatment expectations, which may predict treatment outcomes. Studies designed to evaluate the relations between expectations for OAB treatment and patient satisfaction have not been performed to date, but studies in other patient populations suggest that expectations of positive outcomes are associated with greater treatment satisfaction. We emphasize that patient satisfaction with treatment is directly related to fulfillment of positive expectations, and that patient expectations should be realistic and agreed on by patient and physician. We also discuss strategies that may be used by physicians managing patients with OAB to develop stronger patient-physician partnerships, including the effective communication required to make treatment decisions and set realistic expectations.

Assessment of treatment outcomes in patients with overactive bladder: importance of objective and subjective measures.
Abrams P, Artibani W, Gajewski JB, Hussain I
Urology. 2006 Aug;68(2 Suppl):17-28.

Overactive bladder (OAB) is a highly prevalent symptom syndrome that negatively affects health-related quality of life (HRQL). In clinical practice, the diagnosis and treatment of OAB are largely driven by a patient's reporting of symptoms, often in combination with objective assessment. Thus, OAB provides the opportunity to examine the relations between objective (eg, urodynamic studies, bladder diary variables) and subjective (eg, symptom bother, HRQL) outcomes. We compared objective and subjective results from 27 trials recently evaluated in a systematic review and meta-analysis of antimuscarinic agents used to treat OAB. Many studies demonstrated concurrent improvements in both types of outcomes. However, several reports showed that although pharmacotherapy may reduce micturition frequency or increase bladder capacity, treated patients may not perceive a significant benefit to HRQL. We conclude that objective assessments can help determine the underlying causes of OAB symptoms and assess the effects of treatment, but that these results are not always predictive of subjective outcomes, which are influenced by a patient's priorities and lifestyle, and thus highly individualized. A patient's perception of treatment success should be regarded as an important measure of efficacy because a patient considers the trade-offs between symptom improvement, adverse events, and effects on daily life when assessing overall treatment benefit. We recommend that subjective measures become standard considerations in the initial evaluation and treatment of patients with OAB.

Development and validation of patient-reported outcomes measures for overactive bladder: a review of concepts.
Coyne KS, Tubaro A, Brubaker L, Bavendam T
Urology. 2006 Aug;68(2 Suppl):9-16.

Patient-reported outcome (PRO) measures are a valuable means for determining how a disease and its treatment affect patients, including effects on health-related quality of life (HRQL). To ensure that the results obtained with PROs are clinically useful, data must be gathered using valid and reliable instruments. Developing such instruments requires a multistep, structured process that incorporates cognitive psychology, psychometric theory, and patient and clinician input. The process begins by determining the intent and purpose of the PRO and culminates in studies that demonstrate the measure's validity, reliability, and responsiveness. Several valid and reliable PROs are available for assessing the effects of treatment on symptom severity, symptom bother, and HRQL in patients with overactive bladder.

Patient-reported outcomes in overactive bladder: importance for determining clinical effectiveness of treatment.
Brubaker L, Chapple C, Coyne KS, Kopp Z
Urology. 2006 Aug;68(2 Suppl):3-8.

Overactive bladder (OAB) is a condition defined by its symptoms--urinary urgency with or without urgency urinary incontinence and often with frequency and nocturia. As such, determining the efficacy of OAB treatments using objective measures, such as urodynamic testing, can be difficult. A better means of gauging treatment efficacy for symptom-based conditions is through the use of patient-reported outcomes (PROs). With PROs, clinicians can gain insight into how a treatment affects a patient's symptoms and whether improvement in symptoms has a positive effect from the patient's perspective. PROs are increasingly being included as end points in clinical trials, including those of antimuscarinic drugs for OAB. Consequently, clinicians should become familiar with the most commonly used instruments. We provide an overview of instruments used to assess symptoms, health-related quality of life, and treatment satisfaction in patients with OAB and discuss how PROs can be incorporated into clinical trial protocols.

Periurethral cellular injection: comparison of muscle-derived progenitor cells and fibroblasts with regard to efficacy and tissue contractility in an animal model of stress urinary incontinence.
Kwon D, Kim Y, Pruchnic R, Jankowski R, Usiene I, de Miguel F, Huard J, Chancellor MB
Urology. 2006 Aug;68(2):449-54.

OBJECTIVES: To compare muscle-derived cells (MDCs) and fibroblasts with regard to their potential for restoration of urethral function on injection in a previously established animal model of stress urinary incontinence. METHODS: The animals were divided into four (dosage) or five (cell concentration) experimental groups: normal, nontreated controls (normal group) or bilateral sciatic nerve transection with either periurethral injection of saline (saline group), MDCs (MDC group), fibroblasts (fibroblast group), or MDC/fibroblast mixture (mixed group). At 4 weeks after injection, the leak point pressure (LPP) was measured and contractility testing and histologic analysis were performed. RESULTS: The histologic examination demonstrated muscular atrophy in the saline group and new striated muscle fibers at the sites of MDC injection in the MDC group, but not in the fibroblast group. Denervation of the urethra resulted in a significant decrease of maximal fast-twitch muscle contraction amplitude to only 9% of normal. MDC injection into the denervated urethra significantly improved the fast-twitch muscle contraction amplitude to 73% of normal. The LPP of the normal, saline, MDC, fibroblast, and mixed groups at 4 weeks after treatment was 43.3 +/- 2.5, 25.8 +/- 1.4, 38.2 +/- 4.2, 38.3 +/- 1.2, and 34.5 +/- 3.3 cm H2O, respectively. In the cell dosage experiment, the LPP increased with increases in the injected cell number. Evidence of obstruction was observed in the high-dose (1 x 10(7) cells) fibroblast group. CONCLUSIONS: Although both MDCs and fibroblast injection increased the LPP in a stress urinary incontinence rat model, only MDCs significantly improved urethral muscle strip contractility. Moreover, urinary retention developed with high-dose fibroblast injection, but not with MDC injection.

Effects of potassium channel modulators on human detrusor smooth muscle myogenic phasic contractile activity: potential therapeutic targets for overactive bladder.
Darblade B, Behr-Roussel D, Oger S, Hieble JP, Lebret T, Gorny D, Benoit G, Alexandre L, Giuliano F
Urology. 2006 Aug;68(2):442-8.

OBJECTIVES: Increased urinary bladder detrusor smooth muscle phasic contractility has been suggested to be associated with idiopathic bladder overactivity (OAB). We examined the role of voltage-dependent L-type calcium channels, adenosine triphosphate-sensitive potassium (K(ATP)) channels, and calcium-activated potassium (BK(Ca) and SK(Ca)) channels in the regulation of human detrusor phasic contractile activity. METHODS: Isolated human bladder strip phasic contractions were measured and quantified as the mean area under the force-time curve, amplitude, and frequency of phasic contractions in 22 bladder samples. RESULTS: Human detrusor strips displayed myogenic phasic contractions in the presence of atropine (10(-6) M), phentolamine (10(-6) M), propranolol (10(-6) M), suramin (10(-5) M), and tetrodotoxin (10(-6) M). The L-type calcium channel inhibitor nifedipine (300 nM) abolished the contractile activity. Blockade of K(ATP) channels by glibenclamide (1 and 10 microM) did not alter myogenic contractions. In contrast, the K(ATP) channel opener pinacidil (10 microM) markedly inhibited phasic contractility. Iberiotoxin (100 nM) and apamin (100 nM), potent and selective inhibitors of BK(Ca) and SK(Ca) channels, respectively, significantly increased the area under the force-time curve and the amplitude of contractions. CONCLUSIONS: Phasic contractions of human detrusor are dependent on calcium entry through L-type calcium channels. BK(Ca) and SK(Ca) channels play a key role in the modulation of human detrusor smooth muscle phasic contractility. Furthermore, these observations support the concept that increasing conductance through K(ATP), BK(Ca), and SK(Ca) channels may represent attractive pharmacologic targets for decreasing phasic contractions of detrusor smooth muscle in OAB.

July

Transvaginal suture placement for bleeding control with the tension-free vaginal tape procedure.
Neuman M
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Feb;17(2):176-7. Epub 2005 Feb 24.

Tension-free vaginal tape (TVT) is a well-established surgical procedure for the treatment of female urinary stress incontinence. The operation, described by Ulmsten in 1995, is based on a midurethral Prolene tape support. TVT is accepted as an easy-to-learn and safe minimally invasive surgical technique. Intraoperative bleeding was described as complicating former surgical methods for correction of female urinary stress incontinence as well as TVT. The aim of this paper was to describe a simple transvaginal hemostatic suture placement to control accidental intraoperative hemorrhage. Of 566 patients undergoing TVT and followed for up to 68 months, 9 (1.6%) had intraoperative bleeding of 200-800 ml, all of which were diagnosed and corrected among the first 466 procedures. The last 100 patients had a transvaginal hemostatic suture placed whenever more than minimal bleeding occurred and hemostasis was achieved immediately with all. The benefit of this minimal, fast, and simple surgical step is assessed and discussed.

In vivo comparison of suburethral sling materials.
Slack M, Sandhu JS, Staskin DR, Grant RC
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Feb;17(2):106-10. Epub 2005 Jul 2.

In vivo tissue responses were compared for three commercially available polypropylene suburethral slings that differ markedly in fabric structure and in size of resulting interstices and pores. All three elicited the same basic inflammatory response; however, individual fabric structures produced distinct differences in tissue formation within each mesh. The presence of numerous, closely spaced, small diameter filaments prevented formation of extensive fibrous connective tissue within two slings (ObTape and IVS Tunneller mesh). The much larger diameter monofilament and open knit structure of the Monarc sling permitted the most extensive fibrous tissue integration. These differences may be of interest to physicians considering clinical use.

Bladder wall abscess following midurethral sling procedure.
Madjar S, Frischer Z, Nieder AM, Waltzer WC
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Feb;17(2):180-1. Epub 2005 Jun 18.

Midurethal sling procedures are gaining popularity as the treatment of choice for stress urinary incontinence. Complications that were described include bladder perforation, urinary retention, pelvic hematoma and suprapubic wound infection. Sling erosion and pelvic abscess are rare complications of midurethral slings. We report the first case of an abscess formed within the wall of the urinary bladder, 7 months following a midurethral sling procedure.

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. 2006 Feb;17(2):120-4. Epub 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 H2O or a mean Valsalva leak point pressure < 60 cm H2O 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.

TVT versus SPARC: comparison of outcomes for two midurethral tape procedures.
Gandhi S, Abramov Y, Kwon C, Beaumont JL, Botros S, Sand PK, Goldberg RP
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Feb;17(2):125-30. Epub 2005 Aug 4.

To compare the subjective and objective cure rates in women who underwent either the SPARC or the TVT midurethral sling for the treatment of stress urinary incontinence. This retrospective study included all 122 consecutive women undergoing a TVT or SPARC midurethral sling procedure for objective stress urinary incontinence between January 2000 and March 2003 at the Evanston Continence Center. Primary outcomes were subjective and objective stress incontinence cure rates. Subjects underwent multichannel urodynamics preoperatively and 14 weeks postoperatively, and stress testing at last follow-up. The two groups were compared using univariate and multivariate analyses. Seventy-three subjects underwent a TVT and 49 subjects had a SPARC procedure. There were no statistical differences in demographic factors between the two groups. Subjects undergoing SPARC were more likely to void by Valsalva effort. One hundred and seven women returned for objective postoperative evaluation after surgery. The TVT procedure was associated with higher subjective (86 vs. 60%, P = 0.001) and objective (95 vs. 70%, P < 0.001) stress incontinence cure rates. There was no difference between the TVT and SPARC groups in the resolution of subjective and objective urge urinary incontinence. TVT was associated with a higher stress urinary incontinence cure rate than SPARC in this retrospective study. As new midurethral sling products are introduced, prospective randomized controlled trials should be conducted to evaluate their relative efficacy and safety.

[Surgical management of chronic refractory pain after TVT treatment for stress urinary incontinence]
Misrai V, Chartier-Kastler E, Cour F, Mozer P, Almeras C, Richard F
Prog Urol. 2006 Jun;16(3):368-71.

OBJECTIVE: To evaluate the results of surgical treatment of iatrogenic pelviperineal pain following TVT treatment for stress urinary incontinence (SUI). MATERIAL AND METHODS: Eight patients developed chronic pain after TVT that was refractory to symptomatic medical treatment. Pain was characterized by clinical interview and clinical examination and an aetiological assessment demonstrated the role of TVT in pathogenesis of the pain. TVT was removed by open surgery or by laparoscopy. Pain and continence were evaluated postoperatively. RESULTS: TVT was completely (n = 3) or partially (n = 5) removed. With a mean follow-up of 31 months, no patient has experienced pain recurrence. Five patients have remained continent and 3 patients were treated for recurrent urinary incontinence. CONCLUSION: Although medical treatment may be disappointing, surgical resection provides good results on refractory pain, but preservation of continence is inconstant.

Role of bladder neck mobility and urethral closure pressure in predicting outcome of tension-free vaginal tape (TVT) procedure.
Viereck V, Nebel M, Bader W, Harms L, Lange R, Hilgers R, Emons G
Ultrasound Obstet Gynecol. 2006 Jul 21;28(2):214-220.

OBJECTIVE: To investigate how urethral mobility and urethral closure pressure affect the outcome of tension-free vaginal tape (TVT) insertion for stress incontinence. METHODS: A total of 191 consecutive women with genuine stress urinary incontinence with or without intrinsic sphincter deficiency were evaluated prospectively with multichannel urodynamics, 24-h voiding diaries, clinical stress tests and introital ultrasound measurements preoperatively and 6 months after surgery. Additional introital ultrasound examinations were performed immediately after the operation, at 12 months and annually thereafter. 177/191 patients had completed a 36-month follow-up at the time of writing. Urethral mobility was described as linear dorsocaudal movement (LDM), with hypermobility being defined as LDM > 15 mm on sonography. Intrinsic sphincter deficiency was defined by a maximum urethral closure pressure (MUCP) of <20 cmH(2)O. RESULTS: The overall cure rate at the 36-month follow-up was 89.5% (Kaplan-Meier estimator), with secondary cure (within 6 months of surgery) in 10.5% of these patients. The operation failed in 4.2% of the women and recurrence was seen in 6.3% of the cases. Bladder neck mobility was significantly reduced at the 6-month follow-up (P < 0.001). Compared with primary cure, therapeutic failure and secondary cure were associated with a significantly lower postoperative bladder neck mobility (P < 0.05). Postoperative hypermobility reduced the risk of therapeutic failure. In addition, women with therapeutic failure or secondary cure had a significantly lower MUCP than did those with primary cure (P < 0.01). CONCLUSION: The effectiveness of the TVT sling appears to depend on adequate postoperative urethral mobility and urethral closure pressure.

Tension-free vaginal tape surgery for stress urinary incontinence: a prospective multicentered study in Japan.
Ohkawa A, Kondo A, Takei M, Gotoh M, Ozawa H, Kato K, Ohashi T, Nakata M
Int J Urol. 2006 Jun;13(6):738-42.

AIM: To report the prospective multicentered study of the tension-free vaginal tape (TVT) procedure for stress urinary incontinence. METHODS: One hundred and fifty-one women with stress urinary incontinence were operated on by the TVT procedure and were followed up at 3, 12, and 24 months after surgery. Patients' age and body mass index (BMI) averaged 57 years and 23.9, respectively. Forty-nine women were classified as type I, 46 women type II and 56 women type III (McGuire's classification). Local anesthesia was used in the operations on 137 women (91%) and epidural or general anesthesia was used in 14 (9%). Surgical outcomes were analyzed with Kaplan-Meier survival curves. RESULTS: The subjective and objective cumulative cure rates 24 months later were 92% and 77%, respectively (P > 0.05). The TVT operation for women with type III (62%) resulted in a significantly lower cure rate compared to those with type I or with type II (83%) (P < 0.001). Post-operatively a urethral catheter was indwelt one day in 77 women (51%), two days in 14 (9%) and 3-7 days in 60 (40%). Surgical complications were encountered in 43 women (28%). The most frequent was bladder perforation in 24 women followed by postoperative difficulty in urination and de novo urgency. CONCLUSIONS: The TVT surgery was promising for the treatment of stress incontinence because of minimal surgical invasiveness and satisfactory surgical results. Women with type III incontinence resulted in fewer satisfactory outcomes than those with type I or II incontinence.

Comparison of the efficacy, safety, and tolerability of propiverine and oxybutynin for the treatment of overactive bladder syndrome.
Abrams P, Cardozo L, Chapple C, Serdarevic D, Hargreaves K, Khullar V
Int J Urol. 2006 Jun;13(6):692-8.

AIM: To compare the effects of propiverine and oxybutynin on ambulatory urodynamic monitoring (AUM) parameters, safety, and tolerability in patients with overactive bladder. METHODS: This was a randomized, double-blind, placebo-controlled, multicentre, crossover study. Patients (n = 77) received two of the following treatments during two 2-week periods: propiverine 20 mg once daily, propiverine 15 mg three times daily, oxybutynin 5 mg three times daily, and placebo. AUM parameters, salivary flow, visual near point, and heart rate were assessed. RESULTS: A consistent order in the efficacy between active treatment groups was observed for the reduction in mean involuntary detrusor contractions (IDCs; oxybutynin 15 mg </= propiverine 45 mg </= propiverine 20 mg). Differences between the oxybutynin and propiverine 20 mg groups were statistically significant for several AUM endpoints. Statistically significant differences between the oxybutynin and both propiverine groups were also noted in salivary flow rate and heart rate (oxybutynin 15 mg < both propiverine regimens) and in heart rate variability (both propiverine regimens < oxybutynin 15 mg). All active treatments lengthened visual near point. The incidence of dry mouth was significantly more pronounced in the oxybutynin group than in either propiverine group. Treatment with propiverine 45 mg resulted in the highest rates of constipation, lengthening of the visual near point, and effects on heart rate. CONCLUSIONS: Oxybutynin 15 mg was more effective than propiverine 20 mg in reducing symptomatic and asymptomatic IDCs in ambulatory patients. The primary differences between the two drugs were the incidence and type of adverse events, which varied with the antimuscarinic receptor specificity of each agent.

Risk of stress urinary incontinence twelve years after the first pregnancy and delivery.
Viktrup L, Rortveit G, Lose G
Obstet Gynecol. 2006 Aug;108(2):248-54.

OBJECTIVE: To estimate the impact of onset of stress urinary incontinence in first pregnancy or postpartum period, for the risk of symptoms 12 years after the first delivery. METHODS: In a longitudinal cohort study, 241 women answered validated questions about stress urinary incontinence after first delivery and 12 years later. RESULTS: Twelve years after first delivery the prevalence of stress urinary incontinence was 42% (102 of 241). The 12-year incidence was 30% (44 of 146). The prevalence of stress urinary incontinence 12 years after first pregnancy and delivery was significantly higher (P<.01) in women with onset during first pregnancy (56%, 37 of 66) and in women with onset shortly after delivery (78%, 14 of 18) compared with those without initial symptoms (30%, 44 of 146). In 70 women who had onset of symptoms during first pregnancy or shortly after the delivery but remission 3 months postpartum, a total of 40 (57%) had stress urinary incontinence 12 years later. In 11 women with onset of symptoms during the first pregnancy or shortly after delivery but no remission 3 months postpartum, a total of 10 (91%) had stress urinary incontinence 12 years later. Cesarean during first delivery was significantly associated with a lower risk of incontinence. Other obstetric factors were not significantly associated with the risk of incontinence 12 years later. Patients who were overweight before their first pregnancy were at increased risk. CONCLUSION: Onset of stress urinary incontinence during first pregnancy or puerperal period carries an increased risk of long-lasting symptoms. LEVEL OF EVIDENCE: II-2.

Short- and long-term results of the tension-free vaginal tape procedure in the treatment of female urinary incontinence.
Ankardal M, Heiwall B, Lausten-Thomsen N, Carnelid J, Milsom I
Acta Obstet Gynecol Scand. 2006;85(8):986-92.

Background. The aim was to describe the short- and long-term results of treatment for urinary incontinence (UI) in women using the tension-free vaginal tape (TVT) procedure at a single unit and to identify factors predictive of successful outcome. Material and methods. Consecutive female patients (n=707) treated for UI with the TVT procedure at Karlstad Hospital from November 1996 to June 2004 were included. After a standardized preoperative evaluation, the women were classified as having either stress urinary incontinence (SUI) or mixed urinary incontinence (MUI). The results of surgery were evaluated after 1, 2, and 5 years, by means of a postal questionnaire. An objective evaluation was performed after 5 years in a subsample of the first patients included (n=59). Factors influencing the cure rate were analyzed using multiple regression analysis. Results. The subjective cure rate was 83% after 1 year and 73% after 5 years. The objective cure rate was 83% in the subgroup after 5 years. Surgical time was 30+/-9 min (mean+/-SD). The rate of bladder perforations was 1.7%. In patients with MUI the cure rate was lower than in patients with SUI (after 5 years 54.9% versus 81.0%). Type of incontinence was the only independent variable found to influence surgical outcome. Conclusions. The TVT procedure, performed in over 700 women at a single gynecological unit, was found to be a safe and efficient surgical procedure. Type of incontinence was the only independent variable found to predict for outcome of surgery.

Is HCl duloxetine effective in the management of urinary stress incontinence after radical prostatectomy?
Zahariou A, Papaioannou P, Kalogirou G
Urol Int. 2006;77(1):9-12.

INTRODUCTION: Up to 70% of patients who undergo radical prostatectomy complain about urine leakage, but persistent stress incontinence 1 year after surgery affects <5% of them. HCl duloxetine is a dual serotonin and norepinephrine reuptake inhibitor that relieves the symptoms of stress urinary incontinence. The purpose of this study was to evaluate the efficacy of HCl duloxetine in the management of urinary incontinence after radical prostatectomy and its impact in urodynamic parameters such as maximal urethral closure pressure (MUCP), abdominal leak point pressure (ALPP) and retrograde leak point pressure (RLPP). MATERIAL AND METHODS: The study included 18 men with stress urinary incontinence 12 months after radical prostatectomy. All underwent a pad test to quantify the degree of urine loss and a urodynamic evaluation before and after a three month treatment with HCl duloxetine. The intrinsic sphincter was evaluated by ALPP and RLPP and the striated sphincter by MUCP. RESULTS: At the pretreatment evaluation the mean ALPP was 52.1 cm H(2)O, the mean MUCP was 52.5 cm H(2)O and the mean RLPP was 43.1 cm H(2)O. After 3 months of HCl duloxetine treatment the mean ALPP was 59.1 cm H(2)O, the mean MUCP was 67.3 cm H(2)O and the mean RLPP was 45.1 cm H(2)O. There was a statistically significant correlation among RLPP, MUCP and ALPP before treatment. After HCl duloxetine treatment there was significant correlation between RLPP and ALPP. CONCLUSION: The use of HCl duloxetine results in mild increase of MUCP and in significant reduction of urine loss. Its action on the extrinsic sphincter does not provide a complete treatment option for postprostatectomy incontinence.

June

[Ultrasound for the diagnosis of female urinary incontinence]
Jimenez Cidre MA, Lopez-Fando Lavalle L, Quicios Dorado C, de Castro Guerin C, Fraile Poblador A, Mayayo Dehesa T
Arch Esp Urol. 2006 May;59(4):431-9.
OBJECTIVES: The value of ultrasonography for the study of female urinary incontinence has been redefined over the last years. METHODS: We review the literature about the value of ultrasound in the workup of females with urinary incontinence, mainly transperineal ultrasound for the female stress urinary incontinence (SUI). RESULTS: Many papers have been published over the last few years. Upper urinary tract ultrasound has not a place in the workup of genuine female SUI. Transperineal ultrasound allows to evaluate the mobility of the bladder neck and urethra, the thickness of the bladder wall, the funnel shape of the bladder neck, the presence of SUI or pelvic organ prolapse (POP), to visualize mesh implants, to help with biofeedback, and to evaluate changes after surgical treatment. CONCLUSIONS: Ultrasounds in general, and transperineal or translabial ultrasound in particular, are in the process of becoming the standard diagnostic method in urogynecology. Their wide availability, the standardization of parameters, the possibility of evaluating not only the bladder but also the levator ani muscle or pelvic organ prolapses (POP) contribute to this fact. It allows to obtain data in a non invasive way before and after therapy.

Frequency of de novo urgency in 463 women who had undergone the tension-free vaginal tape (TVT) procedure for genuine stress urinary incontinence-A long-term follow-up.
Holmgren C, Nilsson S, Lanner L, Hellberg D
Eur J Obstet Gynecol Reprod Biol. 2006 Jun 30;.

BACKGROUND: To determine risk factors for the appearance of de novo urgency symptoms, and subsequent accompanying problems, after the tension-free vaginal tape (TVT) procedure in women with stress urinary incontinence. METHOD: A structured preoperative analysis of the incontinence symptoms was made. A mailed questionnaire was distributed to 970 women that underwent the TVT procedure between 1995 and 2001. Average follow-up was 5.2 years (range 2-8 years). The questionnaire included specific questions on current urinary symptoms and incontinence. The disease-specific quality of life instruments IIQ-7 and UDI-6 were used to compare women with, and those without de novo urgency. RESULTS: Seven hundred and sixty women (78.3%) responded and 463 of those were identified as genuine stress incontinence preoperatively. De novo urgency occurred in 67 (14.5%) of the women. The frequency was similar irrespective of duration since the TVT procedure. The women that reported de novo urgency symptoms were compared with those without symptoms. Risk factors for occurrence of de novo urgency symptoms were older age (64.7 years versus 60.9 years; p=0.01), parity (2.6 versus 2.3; p=0.05), history of cesarean section (9.5% versus 2.5%; odds ratio 5.4), and history of recurrent urinary infections (29.7% versus 18.8%; odds ratio 1.6, but non-significant. De novo urgency had a severe impact on quality of life, as compared to the remaining study population. CONCLUSION: Old age, parity and history of cesarean section were risk factors for de novo urgency after TVT surgery. Postoperative de novo urgency symptoms are as bothersome for the patient as the preoperative stress urinary incontinence.

Overactive bladder made ridiculously simple?
Rosenberg MT
Int J Clin Pract. 2006 Jun;60(6):631-3.

Laparoscopic Burch colposuspension and the tension-free vaginal tape procedure.
Paraiso MF
Curr Opin Obstet Gynecol. 2006 Aug;18(4):385-90.

PURPOSE OF REVIEW: Minimally invasive procedures for urinary incontinence and pelvic organ prolapse have gained increasing popularity in the past decade. The advantages of minimal access through laparoscopic and vaginal routes include smaller incisions, shortened hospital stay, decreased analgesia, rapid recovery and rapid return to work. The laparoscopic Burch colposuspension and the tension-free vaginal tape procedure were at the forefront of minimal access antiincontinence procedures. The most recent and significant publications regarding laparoscopic Burch colposuspension and tension-free vaginal tape procedure are highlighted in this article. RECENT FINDINGS: The laparoscopic Burch is time-consuming and requires a steep learning curve in laparoscopic suturing, thwarting its adoption and staying power. The advantages and success of the retropubic midurethral sling procedures such as tension-free vaginal tape have largely replaced all other antiincontinence procedures and have ignited the development and adoption of transobturator midurethral sling procedures and vaginal 'kit' procedures for pelvic organ prolapse. SUMMARY: Clinical trials show that laparoscopic Burch cure rates are equal or inferior to tension-free vaginal tape cure rates. Publications regarding laparoscopic Burch colposuspension have tapered significantly in the past year, which may represent the ebb of its utilization. Tension-free vaginal tape and other midurethral sling procedures may become the new 'gold standard' antiincontinence therapy.

Tolterodine extended release improves patient-reported outcomes in overactive bladder: results from the IMPACT trial.
Roberts R, Bavendam T, Glasser DB, Carlsson M, Eyland N, Elinoff V
Int J Clin Pract. 2006 Jun;60(6):752-8.

We evaluated the effect of tolterodine extended release (ER) on patient- and clinician-reported outcomes in a primary care setting. Patients had overactive bladder (OAB) symptoms for >or=3 months and were at least moderately bothered by their most bothersome symptom, as indicated on the patient-completed OAB Bother Rating Scale. Patients completed the Overactive Bladder Questionnaire (OAB-q), American Urological Association Symptom Index (AUA-SI), and Patient Perception of Bladder Condition at each visit; investigators completed the Clinical Global Impression-Improvement at week 12. By week 12, there were statistically significant and clinically meaningful decreases on the OAB-q and AUA-SI total and subscale scores (p < 0.0001). Seventy-nine per cent of patients experienced some improvement in their overall bladder condition. Physicians reported that 68% of patients were 'much improved' or 'very much improved'. For symptom-defined conditions, patient-reported outcomes are a valuable means for determining responses to treatment.

Symptom-specific efficacy of tolterodine extended release in patients with overactive bladder: the IMPACT trial.
Elinoff V, Bavendam T, Glasser DB, Carlsson M, Eyland N, Roberts R
Int J Clin Pract. 2006 Jun;60(6):745-51.

We evaluated the efficacy of tolterodine extended release (ER) for patients' most bothersome overactive bladder (OAB) symptom in a primary care setting. Patients with OAB symptoms for >or=3 months received tolterodine ER (4 mg q.d.) for 12 weeks. Among incontinent patients (n = 772), the most bothersome OAB symptoms were daytime frequency (28%), urgency urinary incontinence (UUI; 27%), nocturnal frequency (26%) and urgency (19%); among continent patients (n = 91), they were daytime frequency (47%), nocturnal frequency (42%) and urgency (10%). Sixty-nine per cent of patients had one or more comorbid conditions. By week 12, there were significant reductions in patients' most bothersome symptom: -80% for UUI, -78% for urgency episodes, -40% for nocturnal frequency and -30% for daytime frequency (p < 0.0001). The most common adverse events were dry mouth (10%) and constipation (4%). In primary care practice, bothersome OAB symptoms can be effectively and safely treated with tolterodine ER, even in patients with comorbid conditions.

High Rate of Vaginal Erosions Associated With the Mentor ObTapetrade mark.
Yamada BS, Govier FE, Stefanovic KB, Kobashi KC
J Urol. 2006 Aug;176(2):651-4.

PURPOSE: The transobturator tape method is a newer surgical technique for the treatment of stress urinary incontinence. Limited data exist related to complications with this approach or the types of mesh products used. We report our experience with vaginal erosions associated with the Mentor ObTapetrade mark and American Medical Systems Monarctrade mark transobturator slings. MATERIALS AND METHODS: Beginning in December 2003 selected female patients with anatomic urinary incontinence were prospectively followed after placement of the Mentor ObTapetrade mark. Beginning in January 2004 we also began using the American Medical Systems Monarctrade mark in similar patients. Patients were admitted overnight after surgery, discharged on oral antibiotics, and seen in the clinic at 6 weeks postoperatively. RESULTS: A total of 67 patients have undergone placement of the Mentor ObTapetrade mark and 9 of those patients (13.4%) have had vaginal extrusions of the sling. Eight patients reported a history of persistent vaginal discharge. One patient presented initially to an outside facility with a left thigh abscess tracking to the left inguinal incision site. Each patient was taken back to the operating room for mesh removal. A total of 56 patients have undergone placement of the AMS Monarctrade mark and none have had any vaginal erosions. CONCLUSIONS: Our high rate of vaginal extrusion using the ObTapetrade mark has led us to discontinue the use of this product in our institution. Continued followup of all of these patients will be of critical importance.

Comparison of the q-tip test and voiding cystourethrogram to assess urethral hypermobility among women enrolled in a randomized clinical trial of surgery for stress urinary incontinence.
Walsh LP, Zimmern PE, Pope N, Shariat SF
J Urol. 2006 Aug;176(2):646-50.

PURPOSE: We compared 2 measures of urethral hypermobility, the Q-tip test and voiding cystourethrogram, preoperatively in women recruited in 1 center participating in a multicenter randomized clinical trial comparing Burch colposuspension with autologous rectus fascia sling. MATERIALS AND METHODS: Following institutional review board approval, women with stress urinary incontinence and pelvic organ prolapse stage 2 or less underwent a standardized standing voiding cystourethrogram and a Q-tip test at a 45 degree angle reclining position preoperatively. Urethral angle at rest and straining were measured with a radiological ruler (voiding cystourethrogram) or goniometer (Q-tip) by 2 different investigators blinded to each other findings. RESULTS: In 43 patients the mean urethral angle at rest and UAS were 20 degrees +/- 12 and 51 degrees +/- 20, by voiding cystourethrogram compared to 16 degrees +/- 9 and 58 degrees +/- 10 by Q-tip test, respectively. The mean angle difference (urethral angle with straining minus urethral angle at rest) was greater for the Q-tip test (42 degrees +/- 9) than that for the voiding cystourethrogram test (32 degrees +/- 17; p <0.05). Fewer patients (14% by Q-tip, 28% by voiding cystourethrogram) had urethral hypermobility using the definition of urethral angle at rest greater than 30, while almost all patients (91% by voiding cystourethrogram, 100% by Q-tip) had urethral hypermobility using the definition of urethral angle with straining greater than 30. However, using the definition of urethral angle with straining minus urethral angle at rest greater than 30, only 58% of patients had urethral hypermobility by voiding cystourethrogram compared to 98% by Q-tip. CONCLUSIONS: The voiding cystourethrogram and the Q-tip test measure urethral hypermobility differently. This may affect which patients are classified as having urethral hypermobility, and the choice of anti-incontinence surgery.

Therapeutic effect of multiple resiniferatoxin intravesical instillations in patients with refractory detrusor overactivity: a randomized, double-blind, placebo controlled study.
Kuo HC, Liu HT, Yang WC
J Urol. 2006 Aug;176(2):641-5.

PURPOSE: Previous study has shown that multiple intravesical instillations of resiniferatoxin (Sigma(R)) at 10 nM has therapeutic effects in patients with detrusor overactivity. To our knowledge the placebo effect of multiple instillations of low dose resiniferatoxin for neurogenic and nonneurogenic detrusor overactivity has not been investigated. In this randomized, double-blind, placebo controlled study we evaluated the therapeutic effects of this resiniferatoxin treatment. MATERIALS AND METHODS: A total of 54 patients with detrusor overactivity refractory to anticholinergics were enrolled and randomly treated with 4 weekly intravesical instillations of 10 nM resiniferatoxin (26) or vehicle, consisting of 10% ethanol in normal saline, as the control group (28). The clinical effects of treatment on incontinence grade, incontinence episodes, general satisfaction, lower urinary tract symptoms and urodynamic parameters were assessed. RESULTS: Three months after completing the 4 intravesical treatments the resiniferatoxin treatment group had a significantly higher percent of patients with excellent and improved results compared to the control group (19.2% vs 7.1% and 42.3% vs 14.2%, respectively, each p <0.001). Treatment remained effective at 6 months in 13 patients (50%) in the resiniferatoxin group but in only 3 (11%) in the control group (p <0.001). Bladder capacity was significantly increased and symptom scores significantly improved 3 months after treatment in the resiniferatoxin group but not in the control group. CONCLUSIONS: Multiple intravesical instillations of 10 nM resiniferatoxin were effective for improving the incontinence grade in 62% of patients at 3 months, of whom 50% maintained a therapeutic effect 6 months after treatment. The therapeutic effect of resiniferatoxin was significantly superior to that of placebo.

Urgency is the Core Symptom of Female Overactive Bladder Syndrome, as Demonstrated by a Statistical Analysis.
Hung MJ, Ho ES, Shen PS, Sun MJ, Lin AT, Chen GD
J Urol. 2006 Aug;176(2):636-40.

PURPOSE: We determined overactive bladder symptoms in combination with other lower urinary tract symptoms and illustrated their relationships using a statistical analysis. Furthermore, we also describe the potential contributory factors and adaptation strategies in patients that are associated with overactive bladder subtypes. MATERIALS AND METHODS: A total of 1,930 women with a mean age +/- SD of 46 +/- 15 years (range 15 to 91) with troubling lower urinary tract symptoms were successfully interviewed with a validated questionnaire at the urology and urogynecology clinics at 14 medical centers in Taiwan. The questionnaire was constructed to evaluate 6 lower urinary tract symptoms and 7 adaptation strategies. A log linear statistical model and multiple logistic regression analysis were used to assess the associations among lower urinary tract symptoms and the potential overactive bladder contributory factors, respectively. RESULTS: No single or isolated symptom presented in patients with overactive bladder. Most patients reported a combination with other lower urinary tract symptoms. These female patients can be categorized into 3 groups, including 1 is associated with dry symptoms (urgency, frequency and nocturia), 1 associated with wet symptoms (urgency, urge incontinence and mixed stress incontinence) and a small group that may have overactive bladder symptoms combined with voiding difficulty symptoms. in contrast to patients with dry overactive bladder (urgency associated with frequency and/or nocturia without urge incontinence), after multiple logistic regression analysis patients with wet overactive bladder (urgency with urge incontinence) had a greater average age and higher body mass index, and made more adaptation efforts (p <0.05). CONCLUSIONS: We used statistical analysis to determine and suggest that urgency is the core symptom of female overactive bladder syndrome and there are 3 distinctive overactive bladder subtypes, which differ in their symptom combinations. Different symptom combinations and patient characteristics affect female adaptation to overactive bladder syndrome.

Bladder reservoir function in children with monosymptomatic nocturnal enuresis and healthy controls.
Hagstroem S, Kamperis K, Rittig S, Djurhuus JC
J Urol. 2006 Aug;176(2):759-63.

PURPOSE: We investigated bladder reservoir function in children with monosymptomatic nocturnal enuresis and in healthy controls. MATERIALS AND METHODS: A total of 18 children with monosymptomatic nocturnal enuresis and 119 controls who were 7 to 13 years old were recruited. Children completed frequency volume charts and measurements of nocturnal urine production. Mean diuresis in the period preceding each voiding was calculated. Those with enuresis were grouped according to bladder capacity and hospitalized for 4 nights, including a baseline night and 3 with an oral water load. Enuresis volumes and post-void residual volume were estimated, allowing the calculation of bladder volume at the time of enuresis. RESULTS: Nine children with monosymptomatic nocturnal enuresis were characterized as having normal bladder capacity and 9 had decreased bladder capacity. We found large intra-individual variability in daytime voided volume in all 3 groups of participants. Children with enuresis and small bladder capacity generally voided with volumes close to maximal voided volume. A total of 93 enuresis episodes were recorded. Large intra-individual variability was seen in bladder volume at enuresis and it was lower than maximal voided volume in more than 50% of episodes. Variability in bladder volume at enuresis was greatest in the patient group with decreased bladder capacity. We found a significant correlation between diuresis and bladder capacity in all groups during the day and night. CONCLUSIONS: There is a great intra-individual diurnal variability in voided volume in children with enuresis and in healthy children. Enuresis seems to occur at bladder volumes that are smaller and larger than the maximal voided volume obtained from voiding charts.

Desmopressin toxicity due to prolonged half-life in 18 patients with nocturnal enuresis.
Dehoorne JL, Raes AM, van Laecke E, Hoebeke P, Vande Walle JG
J Urol. 2006 Aug;176(2):754-8.

PURPOSE: Desmopressin has been used extensively for primary nocturnal enuresis and it is associated with a low incidence of adverse effects. The only reported serious side effect is seizure or altered levels of consciousness resulting from water intoxication, which has been reported for the nasal spray. We describe 18 children with clinical symptoms of water intoxication due to the prolonged bioactivity of desmopressin nasal spray. MATERIALS AND METHODS: We evaluated 18 patients with clinical suspicion of prolonged desmopressin bioactivity during treatment with intranasal desmopressin for primary nocturnal enuresis. The control group consisted of 50 children with primary nocturnal enuresis and proven nocturnal polyuria who were treated with the same desmopressin regimen. RESULTS: All patients had prolonged maximal urinary concentration capacity and delayed restoration of daytime diluting capacity (p <0.01). Of the patients 15 had the characteristic clinical symptoms of water intoxication with vomiting, headache, decreased consciousness and hyponatremia. We suspect that these symptoms are secondary to prolonged desmopressin bioactivity. CONCLUSIONS: Prolonged desmopressin bioactivity may increase the risk of water intoxication.

Desmopressin resistant nocturnal polyuria secondary to increased nocturnal osmotic excretion.
Dehoorne JL, Raes AM, van Laecke E, Hoebeke P, Vande Walle JG
J Urol. 2006 Aug;176(2):749-53.

PURPOSE: We investigated the role of increased solute excretion in children with desmopressin resistant nocturnal enuresis and nocturnal polyuria. MATERIALS AND METHODS: A total of 42 children with monosymptomatic nocturnal enuresis and significant nocturnal polyuria with high nocturnal urinary osmolality (more than 850 mmol/l) were not responding to desmopressin. A 24-hour urinary concentration profile was obtained with measurement of urine volume, osmolality, osmotic excretion and creatinine. The control group consisted of 100 children without enuresis. RESULTS: Based on osmotic excretion patients were classified into 3 groups. Group 1 had 24-hour increased osmotic excretion, most likely secondary to a high renal osmotic load. This was probably diet related since 11 of these 12 patients were obese. Group 2 had increased osmotic excretion in the evening and night, probably due to a high renal osmotic load caused by the diet characteristics of the evening meal. Group 3 had deficient osmotic excretion during the day, secondary to extremely low fluid intake to compensate for small bladder capacity. CONCLUSIONS: Nocturnal polyuria with high urinary osmolality in our patients with desmopressin resistant monosymptomatic nocturnal enuresis is related to abnormal increased osmotic excretion. This may be explained by their fluid and diet habits, eg daytime fluid restriction, and high protein and salt intake.

The impact of attention deficit hyperactivity disorders on brainstem dysfunction in nocturnal enuresis.
Baeyens D, Roeyers H, Hoebeke P, Antrop I, Mauel R, Walle JV
J Urol. 2006 Aug;176(2):744-8.

PURPOSE: In a specialized university setting the prevalence of attention deficit hyperactivity disorder in general and particularly the inattentive subtype attention deficit hyperactivity disorder of the predominantly inattentive subtype is highly increased. We replicated previous research findings that enuresis is associated with a brainstem deficit and investigated the impact of attention deficit hyperactivity disorder on this brainstem deficit in enuresis. MATERIALS AND METHODS: Electromyography recorded startle eye blink modification with and without attentional modulation was used to measure brainstem functioning in 158 children between 6 and 12 years old. Performance in 3 enuresis groups, including children with enuresis, enuresis plus attention deficit hyperactivity disorder of the predominantly inattentive subtype and enuresis plus attention deficit hyperactivity disorder combined, respectively, was compared with that in normally developing controls and in children with attention deficit hyperactivity disorder subtypes without enuresis. RESULTS: In an automatic attentional task the enuresis groups showed decreased brainstem inhibition compared to that in the control and attention deficit hyperactivity disorder groups (p <0.006). In a controlled attentional task children with and without enuresis who had attention deficit hyperactivity disorder of the predominantly inattentive subtype were unable to show attentional modulation in all age groups (p <0.02). CONCLUSIONS: Startle eye blink modification research reveals a brainstem inhibition deficit in children with enuresis, which could explain why they are unable to remain dry at night. When additional attention is allocated to specific trials in the task, children with attention deficit hyperactivity disorder of the predominantly inattentive subtype fail to optimize sensory gating. With respect to enuresis, this could result in an identification problem of bladder signals, leading to an inadequate or absent arousal effect in attention deficit hyperactivity disorder of the predominantly inattentive subtype.

May

Intravaginal electrical stimulation: a randomized, double-blind study on the treatment of mixed urinary incontinence.
Amaro JL, Gameiro MO, Kawano PR, Padovani CR
Acta Obstet Gynecol Scand. 2006;85(5):619-22.

BACKGROUND: The aim of this study was to compare effective and sham intravaginal electrical stimulation (IES) in treating mixed urinary incontinence. METHODS: Between January 2001 and February 2002, 40 women were randomly distributed, in a double-blind study, into two groups: group G1 (n=20), effective IES, and group G2 (n = 20), sham IES, with follow up at one month. Different parameters was studied: 1. clinical questionnaire; 2. body mass index; 3. 60-min pad test; 4. urodynamic study. The protocol of IES consisted of three 20-min sessions per week over a seven-week period. The Dualpex Uro 996 used a frequency of 4 Hz. RESULTS: There was no statistically significant difference in the demographic data of both groups. The number of micturitions per 24 h after treatment was reduced significantly in both groups. Urge incontinence was reduced to 15% in G1 and 31.5% in G2; there was no significant difference between the groups. In the analog wetness and discomfort sensation evaluations were reduced significantly in both groups. The pretreatment urodynamic study showed no statistical difference in urodynamic parameters between the groups. Ten percent of the women presented involuntary detrusor contractions. In the 60-min pad test, there was a significant reduction in both groups. In regards to satisfaction level, after treatment, 80% of G1 patients and 65% of G2 patients were satisfied. There was no statistically significant difference between the groups. CONCLUSION: Significant improvement was provided by effective and sham electrostimulation, questioning the effectiveness of electrostimulation as a monotherapy.

Abscess of the thigh and psoas muscle after transobturator suburethral sling procedure.
Agostini A, De Lapparent T, Bretelle F, Roger V, Cravello L, Blanc B
Acta Obstet Gynecol Scand. 2006;85(5):628-9.

Hysterectomy and incontinence: a study from the Swedish national register for gynecological surgery.
Engh MA, Otterlind L, Stjerndahl JH, Lofgren M
Acta Obstet Gynecol Scand. 2006;85(5):614-8.

BACKGROUND: Hysterectomy is one factor that has been suggested to be a risk factor for developing stress incontinence. In Sweden, with a population of 8.86 million, a national register was set up in 1997 in order to have data for assessing the quality of gynecological surgery for benign disorders. METHODS: Data in the Swedish national register for gynecological surgery during the period 1997-2002 were investigated. Surgical methods compared during this time period were: total hysterectomy (abdominal/laparoscopic, n=198/116), subtotal hysterectomy (abdominal/laparoscopic, n=163/86), and total hysterectomy (vaginal/laparoscopic assisted vaginal, n=265/7). Patients who underwent endometrial destruction (endometrial ablation, endometrial balloon treatment, n=187) were used as a control group. Only patients with no preoperative complaints were included. Outcome measures were answers to subjective questions asked pre- and postoperatively regarding urinary problems and incontinence. RESULTS: De novo symptoms of stress incontinence, urgency and urgency incontinence, and/or mixed incontinence were noted in all groups. No differences were found among the groups. CONCLUSION: Factors other than hysterectomy should be discussed causing stress incontinence in women.

Three-dimensional power Doppler measurement of perfusion of the periurethral tissue in incontinent women -- a preliminary report.
Liang CC, Chang SD, Chang YL, Wei TY, Wu HM, Chao AS
Acta Obstet Gynecol Scand. 2006;85(5):608-13.

BACKGROUND: This study was designed to test the hypothesis that decreased periurethral vascularization and blood flow might lead to urinary incontinence. Three-dimensional color histogram may better quantify the vasculature than traditional two-dimensional Doppler ultrasound imaging. METHODS: Between June 2002 and July 2003, 57 patients were invited to undergo three-dimensional power color Doppler study of the periurethral vessels before surgery. In group 1, 29 women with stress urinary incontinence underwent tension-free vaginal tape procedures and in group 2, 28 continent women underwent other procedures for treatment of benign gynecologic disease and without urological problems. We used 3 indices of color histogram to quantify the vascularization and blood flow within a tissue block from the bladder neck to the urethral meatus and the periurethral area within 5 mm of the urothelium borders. The values of 3 indices of histogram, vascularization index, flow index and vascularization-flow index, were analyzed. RESULTS: Judging from the values of vascularization index, flow index and vascularization-flow index generated in our study, significantly decreased periurethral vasculature was found in women with stress urinary incontinence and women in the postmenopausal status as compared with women in the continent group and those in the premenopausal status, respectively (p<0.05). CONCLUSIONS: Three-dimensional histogram measurement revealed less periurethral vessels and flow in women suffering from stress urinary incontinence, a finding that might play a role in the pathogenesis of stress urinary incontinence.

Quality of life in relation to TVT procedure for the treatment of stress urinary incontinence.
Bakas P, Liapis A, Giner M, Creatsas G
Acta Obstet Gynecol Scand. 2006;85(6):748-52.

Background. The aim of the study was to assess the impact of tension-free vaginal tape (TVT) procedure as anti-incontinence surgery on patients' urinary symptoms and quality of life. Methods. Ninety-eight patients participated in the study. All patients were operated for urodynamic stress incontinence with the TVT procedure. Patients with prolapse more than first degree according to International Continence Society classification, previous anti-incontinence surgery, detrusor overactivity, or intrinsic sphincter deficiency were excluded from the study. Patients' quality of life assessment was performed with the use of the short form of Incontinence Impact Questionnaire and short form of Urinary Distress Inventory (UDI-6). Results. Mean follow-up time was 12.4 +/-4.2 months (range: 6-18 months). The cure rate for TVT procedure was 87.6%. There was a statistically significant improvement of quality of life postoperatively. In addition, the domains of UDI-6 concerning irritative symptoms and stress urinary incontinence symptoms showed statistically significant improvement postoperatively, while the domain concerning obstructive symptoms did not show statistically significant difference. Conclusions. Tension-free vaginal tape procedure as anti-incontinence surgery significantly improves the quality of life in female patients with urodynamic stress incontinence.

SPARC Sling System for Treatment of Female Stress Urinary Incontinence in the Elderly.
Dalpiaz O, Primus G, Schips L
Eur Urol. 2006 Apr 27;.

OBJECTIVE: To investigate the safety and efficacy of the suprapubic arch (SPARC) sling procedure for the management of stress urinary incontinence (SUI) in elderly women. METHOD: Forty-three women, aged 65-91 yr, underwent the SPARC procedure for urodynamic SUI. Before surgery, a complete medical history was obtained and a urogynecology examination and urodynamic test were performed. The objective cure rate was evaluated by clinical and urodynamic examination at 3, 6, and 12 mo and the subjective cure rate was assessed using a visual analogue score and a global patient impression questionnaire. RESULTS: No severe intraoperative or postoperative complications occurred. No patient referred de novo urge incontinence. Significant differences were found between the preoperative and postoperative number of daytime voidings (p<0.001), the pad weights and numbers of pads used (p<0.001), and the visual analogue score (p=0.021). No significant differences in preoperative and postoperative urodynamic parameters were reported. At the mean follow-up of 36+/-14 mo (range, 12-54 mo), objective and subjective cure rates were 91% and 95%, respectively. CONCLUSIONS: The SPARC procedure is effective and offers a satisfactory cure rate without significant morbidity in elderly women with SUI.

A New Artificial Urinary Sphincter with Conditional Occlusion for Stress Urinary Incontinence: Preliminary Clinical Results.
Knight SL, Susser J, Greenwell T, Mundy AR, Craggs MD
Eur Urol. 2006 May 2;.

OBJECTIVES: To perform a preliminary clinical investigation to determine the safety and efficacy of a novel artificial urinary sphincter (AUS) with conditional occlusion for the treatment of stress urinary incontinence. METHODS: Male patients with urodynamically proven stress urinary incontinence after a prostatectomy were implanted with the novel AUS. They were followed up over a period of 12 months and the device tested for efficacy by using objective measurements of urinary leakage and continence. We derived a new measure for continence called the Continence Index. RESULTS: We have demonstrated that the patients receiving the new AUS showed a reduction of greater than 10-fold in mean daily leakage volume from 770.6ml to 55.1ml. There was an overall improvement in the Continence Index from 54% to 97%. CONCLUSIONS: The new AUS with conditional occlusion provides good continence rates and enables adjustment of regulating pressure in situ.

Five-Year Outcomes of the Tension-Free Vaginal Tape Procedure for Treatment of Female Stress Urinary Incontinence.
Doo CK, Hong B, Chung BJ, Kim JY, Jung HC, Lee KS, Choo MS
Eur Urol. 2006 May 2;.

OBJECTIVES: We evaluated the long-term efficacy and safety of a tension-free vaginal tape (TVT) procedure for the treatment of female stress urinary incontinence (SUI) in a Korean population. METHODS: We included 134 patients (mean age, 52.3+/-9.3 yr) who underwent the TVT procedure for SUI in three institutions and followed for 5 yr (mean, 67.0 mo; range, 60-76 mo) postoperatively. We analysed voiding diaries and complete multichannel urodynamic studies preoperatively as well as cough stress tests, uroflowmetry, and questionnaires postoperatively. RESULTS: The overall 5-yr success rates (cure/improved) were 94.9% (76.9% and 18.0%, respectively), with an 86.6% patient satisfaction rate. Although the success rates between 1 and 5 yr were similar (97.7% vs. 94.9%), the cure rate decreased from 90.1% to 76.9% (p<0.001) at 5 yr. The 5-yr cure rate for mixed urinary incontinence (MUI) was 72.0%, which was not significantly different from pure SUI (78.0%, p>0.05). Maximal flow rate dropped from 25.9+/-10.3ml/s to 20.4+/-8.6ml/s at 1 mo postoperatively and recovered to 24.8+/-8.5ml/s at 5 yr. Complications included bladder perforation in 5 patients (3.7%), tape cutting or release in 11 (8.2%), and persistent suprapubic pain in 3 (2.2%). Urgency and urge incontinence improved in 46.7% and 48.0% of patients, respectively. CONCLUSIONS: TVT was an effective and safe procedure for SUI and MUI with high success rates in the long-term follow-up. It also improved concomitant overactive bladder symptoms and initially reduced postoperative urine flow, which recovered over time.

[Trans-obturator-tape (TOT) for the surgical repair of stress urinary incontinence: our experience]
Schanz Pardo J, Ricci Arriola P, Sola Dalenz V, Tacla Fernandez X
Arch Esp Urol. 2006 Apr;59(3):225-32.

OBJECTIVES: To evaluate the safety and efficacy of the TOT surgical technique in the treatment of female stress urinary incontinence (SUI). METHODS: Prospective study of 49 patients undergoing TOT at the Gynecology Unit of the Obstetrics and Gynecology Department in Barros Luco-Trudeau Hospital between November 2003 and January 2005. The mesh used was polypropylene, macropore, monofilament (Prolene). Median age was 52 years. The observational phase was completed in November 2005. RESULTS: Median operative time was 15 minutes. Thirty-two cases (65%) underwent a second gynecologic surgery. One patient had an intraoperative bladder lesion. In the immediate postoperative period there was one case of lower urinary tract infection and another acute pyelonephritis. At the end of the observation phase 47 (96%) patients were cured, 1 (2%) improved, and 1 (2%) had a failure. The failure appeared after a trauma three months after surgery. CONCLUSIONS: The TOT is an effective technique for the correction of SUI. It is easier than TVT. Although rare, it is not free of complications.

Management of urinary incontinence in Medicare managed care beneficiaries: results from the 2004 Medicare Health Outcomes Survey.
Mardon RE, Halim S, Pawlson LG, Haffer SC
Arch Intern Med. 2006 May 22;166(10):1128-33.

BACKGROUND: Despite the high prevalence of urinary incontinence (UI) among older persons and the existence of effective treatments, UI remains underreported by patients and underdiagnosed by clinicians. We measured the occurrence of UI problems in Medicare managed care beneficiaries, frequency of physician-patient communication regarding UI, and frequency of UI treatment. METHODS: We used cross-sectional data from the 2004 Medicare Health Outcomes Survey, which measured self-reported UI (accidental leakage of urine) and UI problems in the past 6 months, 36-Item Short-Form Health Survey health measures, discussions of UI with a health care provider, and receipt of UI treatment. RESULTS: The overall incidence of UI within the past 6 months was 37.3%, consistent with previous estimates. Problems with UI were strongly associated with poorer self-reported health. Mean 36-Item Short-Form Health Survey physical and mental health scores were lower by more than 5 points (on a 100-point scale, P<.001) for respondents with major UI problems when controlling for age, sex, race, Hispanic ethnicity, and major comorbidities. These differences were among the largest of any condition measured. Only 55.5% of those with self-reported UI problems reported discussing these problems during their recent visit to a physician or other health care provider. The rate of patient-reported UI treatment was 56.5% and was lower (P<.001) for older individuals (eg, 46.3% for those aged 90-94 years) or those with poor self-reported health status (50.5%). CONCLUSIONS: Among older persons, UI is common, underdiagnosed, and associated with substantial functional impairment. There appears to be considerable opportunity to mitigate the effects of UI on health and quality of life among community-dwelling older persons.

Tension-Free Vaginal Tape versus Tension-Free Vaginal Tape Obturator in Women with Stress Urinary Incontinence.
Liapis A, Bakas P, Giner M, Creatsas G
Gynecol Obstet Invest. 2006 May 16;62(3):160-164.

Background: To assess the efficacy and complications of tension-free vaginal tape (TVT) versus tension-free vaginal tape obturator in women with urodynamic stress incontinence. Methods: Prospective, randomized study. Initially, 91 patients were included in the study and 89 of them were available at 12 months follow-up. Forty-six patients were subjected to classic TVT procedure and 43 to transobturator vaginal tape from inside to outside (TVT-O) operation. There was no significant difference between the groups for age, BMI, menopausal status and prolapse. No patients had cystocele greater than stage I. Subjective and objective cure and improvement rate, mean operative time, hospital stay and complications incidence were assessed. Results: Mean operative time was significant shorter in the TVT-O group (17.4 +/- 6.9 min) compared to the TVT group (26.7 +/- 8.6 min). There was no significant difference in the duration of hospital stay between two groups. The objective cure rate for TVT group was 89%, the improvement rate was 6.5%, the failure rate was 4.3% and the subjective cure rate 73.9%. The objective cure rate for TVT-O group was 90%, the improvement rate was 7.6%, the failure rate was 2.5% and the subjective cure rate 76.7%. The hemoglobin loss ranged between 1.0 +/- 0.5 g/dl for TVT group and 0.9 +/- 0.4 g/dl for TVT-O group. Conclusion: The TVT-O technique presents success rates comparable to the classic TVT method in the short term. Copyright (c) 2006 S. Karger AG, Basel.

Effectiveness and tolerability of extended-release oxybutynin vs extended-release tolterodine in women with or without prior anticholinergic treatment for overactive bladder.
Anderson RU, Macdiarmid S, Kell S, Barada JH, Serels S, Goldberg RP
Int Urogynecol J Pelvic Floor Dysfunct. 2006 May 3;.

The efficacy and the tolerability of extended-release oxybutynin chloride, 10 mg daily, and extended-release tolterodine tartrate, 4 mg daily, in women with or without prior anticholinergic treatment for overactive bladder (OAB) were compared in a post-hoc analysis of data from the Overactive Bladder: Performance of Extended Release Agents (OPERA) trial. The patient population and study methods have been described previously (Diokno et al., for the OPERA Study Group, Mayo Clin Proc 78:687-695, 2003). Among the group with anticholinergic experience, extended-release oxybutynin was significantly more effective than extended-release tolterodine in reducing micturition frequency at last observation (p=0.052). Complete freedom from urge incontinence was reported by significantly more patients taking oxybutynin than tolterodine at last observation (23.6 vs 15.1%, p=0.038). In addition, among patients completing a full 12 weeks of oxybutynin treatment, significantly greater reductions were observed compared with those taking tolterodine on the primary efficacy variable, number of urge incontinence episodes (p=0.049), and the combined total of urge and non-urge episodes (p=0.012), although the differences between treatment groups were not significant at last observation. In the anticholinergic-naive group, efficacy and tolerability outcomes were similar across treatments, except that oxybutynin was associated with a significantly lower frequency of micturition at last observation (p=0.035). No efficacy differences favoring tolterodine were observed, and tolerability of the treatments was comparable. Dry mouth (mostly mild to moderate in severity) was reported significantly more often among participants taking extended-release oxybutynin than extended-release tolterodine (32.2 vs 19.2%, p=0.004), but only among those with previous anticholinergic experience. Discontinuation rates were comparably low across groups. The results demonstrate the appropriateness of initiating treatment for OAB with extended-release oxybutynin, particularly in women presenting with incontinence.

Incisional hernia after a tension-free vaginal tape procedure.
Duggan P, Williams R
Int Urogynecol J Pelvic Floor Dysfunct. 2006 May 12;.

A case is presented of an incisional hernia of the inguinal canal presenting 9 months after a tension-free vaginal tape (TVT) procedure and anterior vaginal repair. The TVT and repair procedure was complicated by prolonged postoperative urinary retention requiring midline incision of the tape for resumption of normal voiding. The patient had a hysterectomy several years earlier via a Pfannenstiel incision. No other risk factors for hernia were identified. There are no previous reports of TVT-related incisional hernia. We conclude that incisional hernia is a rare complication of the TVT procedure and that the characteristics of the TVT tape may contribute to late occurrence of herniation.

Severe soft tissue infection of the thigh after vaginal erosion of transobturator tape for stress urinary incontinence.
Karsenty G, Boman J, Elzayat E, Lemieux MC, Corcos J
Int Urogynecol J Pelvic Floor Dysfunct. 2006 May 24;.

Since the beginning of use of synthetic midurethral slings, several complications, usually benign, have been reported. Recently, three consecutive cases of severe thigh infection secondary to transobturator insertion of a synthetic tape alarmed us. This is a case report about these three cases and a review of literature about complications of transobturator tapes.

Quality of life in women with multiple sclerosis and overactive bladder syndrome.
Quarto G, Autorino R, Gallo A, De Sio M, D'Armiento M, Perdona S, Damiano R
Int Urogynecol J Pelvic Floor Dysfunct. 2006 May 13;.

The aim of this study was to evaluate the impact of symptoms of overactive bladder syndrome (OAB) on the quality of life (QoL) in female patients with or without multiple sclerosis (MS) and their correlation with findings from urodynamics (UDS). We enrolled 107 female patients with clinically definite MS and urinary symptoms of OAB. One-hundred female patients with similar OAB symptoms were used as a control group. Data on OAB symptoms, onset and progression, and results of any previous investigation were obtained, and any urinary complications were documented. A complete UDS investigation was performed. Health status assessment was obtained using the Kings Health Questionnaire. Results showed that urinary symptoms had a greater impact on the QoL in patients with MS. Nevertheless, the perception of the severity of these symptoms was minor in the MS group compared to the control group. No significant correlations were found between the dysfunctions as detected by UDS and the OAB symptoms in both groups. Recurrent urinary tract infections represented the main complication in the study population. In conclusion, OAB symptoms have a major impact on the QoL in patients with MS, even if their perception of QoL impairment remains limited. Optimal management in these subjects should include a complete UDS assessment.

[Cellular therapy of the urethral sphincter insufficiency]
Yiou R
Prog Urol. 2005 Dec;15(6 Suppl 1):1293.

Delayed urethral erosion after tension-free vaginal tape.
Powers K, Lazarou G, Greston WM
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Aug;17(4):422-5. Epub 2006 Apr 26.

Urethral erosions have been reported with various sling materials placed by means of various techniques. The patient often presents in the immediate postoperative period, although late presentations have been described. The diagnosis is made on cystoscopy, and mesh excision with urethral reconstruction is advocated. We present the cases of two patients with urethral erosion after mid-urethral polypropylene sling who presented 3 months after surgery with urethral pain, mid-urethral blockage and symptoms of bladder dysfunction. Urethroscopy revealed the mesh bridging the lumen of the urethra. Trans-vaginal mesh excision and layered urethral reconstruction was curative in both patients.

Vaginal revision of intravesical tension-free vaginal tape 44 h after initial placement: a case report.
Labin LC, Morse AN, Young SB
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Apr 21;.

Unintentional cystotomy is a known complication of the tension-free vaginal tape procedure and is commonly diagnosed intraoperatively. Delayed diagnosis does occur and various reparative techniques have been described, some requiring laparotomy with intentional cystotomy and repair. We report a case where a 46-year-old woman underwent vaginal reconstructive surgery including placement of a tension-free vaginal tape, which was complicated by unilateral cystotomy. A delayed diagnosis of intravesical tape placement was made requiring reoperation. The patient underwent a minimally invasive transvaginal procedure for removal and immediate replacement of the malpositioned arm of the tape. We conclude that a transvaginal approach may be an acceptable technique for revision and replacement of the tension-free vaginal tape where cystotomy is identified within 44 h after the initial procedure. With this technique, a more invasive surgery including laparotomy with cystotomy might successfully be avoided.

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