Search

Objective To review the incidence of defunctionalized bladder–related complications in patients who have had a supravesical urinary diversion for intractable urinary incontinence without concomitant cystectomy. Materials and Methods We retrospectively analyzed the records of patients requiring urinary diversion for intractable urinary incontinence from 1996 to 2011 at our institution. Patients were excluded from the cohort if they had evidence of bladder outlet obstruction or a cystectomy at time of diversion, or had been diverted for active malignancy. Sixty patients underwent a supravesical urinary diversion without concomitant cystectomy for intractable urinary incontinence. The etiology of the urinary incontinence was overtly neurogenic in 28 patients and non-neurogenic in 32 patients. Patients had an average follow-up of 45 months (range, 9-96). The indications for surgery, previous surgical interventions, complications of surgery, and long-term outcomes, including the incidence of pyocystis and the need for secondary cystectomy in the postoperative period were reviewed. Results Four of 60 patients (7%) experienced complications relating to the defunctionalized bladder; this included pelvic pain and pyocystis. Only 1 patient required admission to hospital for treatment of pyocystis, the remaining 3 patients were successfully managed as outpatients with oral antibiotics or analgesics. No patient required a secondary surgical procedure for the defunctionalized bladder. Conclusion Pyocystis and the need for a secondary cystectomy were rare complications in this cohort; we therefore believe that a concomitant cystectomy is unnecessary in patients undergoing supravesical urinary diversion for intractable urinary incontinence.

OBJECTIVE: To evaluate our experience with tension-free transvaginal tape (TVT) placement for the management of stress urinary incontinence (SUI) in women who had previously undergone a failed midurethral synthetic sling (MUS) procedure. MATERIALS AND METHODS: Ten women underwent retropubic TVT insertion for continued or recurrent SUI following a prior MUS procedure. No attempt was made to remove the previously placed sling at the time of surgery. A retrospective chart review was performed to obtain perioperative and follow-up patient information. Post-operatively, each patient completed a mailed incontinence questionnaire to assess self-reported urinary continence outcomes. RESULTS: All 10 women were available for follow-up at a mean period of 16 months (range 6 to 33). Four of the 10 patients achieved complete continence, and another three patients reported significantly improved continence and quality of life. Three women stated that their continence did not improve. CONCLUSIONS: TVT placement may be a viable option for the management of women with persistent or recurrent SUI following an initial MUS procedure.

Diabetes mellitus is a systemic disease estimated to affect 7% of the US population. Patients with diabetes cannot properly regulate glucose in the body secondary to insulin deficiency or insulin resistance. The resultant hyperglycemic environment leads to a variety of complications, including diabetic cystopathy, which refers to the effects of diabetes on the bladder. The clinical presentation of diabetic cystopathy varies dramatically. Patients may be asymptomatic, or have a wide variety of voiding complaints. On urodynamic testing, cystopathy is characterized by a hyposensate, acontractile detrusor muscle. In some patients, urgency and involuntary detrusor activity predominate. Diagnosis is made with history and physical examination as well as urodynamic evaluation. Treatment is guided by urodynamic findings. This review focuses on diagnosis and treatment of diabetic cystopathy, emphasizing pathophysiology and recent developments in our understanding of the effects of diabetes on the bladder.

Because hydronephrosis and reflux are reversible, we believe cortical loss represents true renal deterioration in children with spinal dysraphism. Our goal was to better define risk factors for cortical loss.After institutional review board approval, we reviewed the medical records of 272 children with spinal dysraphism. The following factors were evaluated: age, sex, renal and bladder imaging, urodynamic parameters, medications, catheterization program, continence, infections, and surgical history. Renal cortical loss was defined by scarring or a differential function greater than 15% using a nuclear scan. Univariate and multivariate logistic regression models were fitted to test the associations of specific variables with cortical loss.Renal cortical loss was found in 41% of children with high-grade reflux vs. 2% of children without reflux. Univariate analysis showed only high-grade reflux and female sex to be independent risk factors. Controlling for age and sex, reflux and initiation of catheterization after 1 year of age are significant risk factors. High bladder pressure and hydronephrosis in the absence of reflux were not associated with cortical loss. Multivariate analysis showed that girls with reflux have a 55-fold increased risk of cortical loss.By limiting the definition of renal deterioration to cortical loss, we identified relevant risk factors: reflux, female sex, and delayed initiation of clean intermittent catheterization. We have also discounted other suspected risk factors: hydronephrosis and elevated bladder pressure. Rather than continuing our focus on hydronephrosis and urodynamics, we believe more research and management debate should be afforded to females with reflux.

Objectives To assess the long-term success of suprapubic bladder neck closure in patients with irreparably damaged bladder outlets. Methods A cohort of 35 patients with intractable urinary incontinence secondary to severe posterior urethral/bladder neck damage underwent suprapubic bladder neck closure. Patients were assessed with regard to the success of procedure, as well as early and late complications. Results With a mean follow-up of 79 months (range 12 to 164), suprapubic bladder neck closure was successful in 29 (83%) of 35 patients. One revision of the bladder neck improved the success rate to 94% (33 of 35). Early and late complications, excluding bladder neck fistula, were reported in 3 (9%) and 5 (14%) of 35 patients, respectively. Conclusions High success and acceptable complication rates can be achieved with suprapubic bladder neck closure for the treatment of severe urinary incontinence secondary to a devastated bladder outlet.

Objective To prospectively evaluate and quantify the efficacy of cadaveric fascia lata (CFL) as an allograft material in pubovaginal sling placement to treat stress urinary incontinence (SUI). Patients and methods Thirty-one women with SUI (25 type II and six type III; mean age 63 years, range 40–75) had a CFL pubovaginal sling placed transvaginally. The operative time, blood loss, surgical complications and mean hospital stay were all documented. Before and at 4 months and 1 year after surgery each patient completed a 3-day voiding diary and validated voiding questionnaires (functional inquiry into voiding habits, Urogenital Distress Inventory and Incontinence Impact Questionnaire, including visual analogue scales). Results The mean (range) operative time was 71 (50–120) min, blood loss 78.7 (20–250) mL and hospital stay 1.2 (1–2) days; there were no surgical complications. Over the mean follow-up of 13.5 months, complete resolution of SUI was reported by 29 (93%) patients. Overactive bladder symptoms were present in 23 (74%) patients before surgery, 21 (68%) at 4 months and two (6%) at 1 year; 80% of patients with low (

Objective To compare the long-term outcome of artificial urinary sphincter (AUS) implantation in patients after prostatectomy, with and with no history of previous irradiation. Patients and methods The study included 98 men (mean age 68 years) with urinary incontinence after prostatectomy for prostate cancer (85 radical, 13 transurethral resection) who had an AUS implanted. Twenty-two of the patients had received adjuvant external beam irradiation before AUS implantation. Over a mean (range) follow-up of 46 (5–118) months, the complication and surgical revision rates were recorded and compared between irradiated and unirradiated patients. The two groups were also compared for the resolution of incontinence and satisfaction, assessed using a questionnaire. Results Overall, surgical revision was equally common in irradiated (36%) and unirradiated (24%) patients. After activating the AUS, urethral atrophy, infection and erosion requiring surgical revision were more common in irradiated patients (41% vs 11%; P 80% of patients stating that they would undergo surgery again and/or recommend it to others, despite previous irradiation and/or the need for surgical revision. Conclusions Despite higher complication and surgical revision rates in patients who have an AUS implanted and have a history of previous irradiation, the long-term continence and patient satisfaction appear not to be adversely affected.

Patients with intractably diminished bladder storage function are encountered frequently by neurourologists, occasionally requiring reconstructive surgery for appropriate resolution. Although sacral neuromodulation is a recognized effective therapeutic modality, present techniques are technically demanding, invasive, and expensive. This study investigated the effect of non-invasive third sacral nerve (S3) stimulation on bladder activity during filling cystometry. One hundred forty-six patients underwent standard urodynamic filling cystometry that was then immmediately repeated. Patients in the study group (n = 74) received antidromic transcutaneous sacral neurostimulation during the second fill and the control group (n = 72) underwent a second fill without neurostimulation. A statistically significant increase in bladder storage capacity without a corresponding rise in detrusor pressure was observed in the neurostimulated patients. This improvement in functional capacity is an encouraging finding that further supports the use of this non-invasive treatment modality in clinical practice. Neurourol. Urodynam. 20:73–84, 2001. © 2001 Wiley-Liss, Inc.

Purpose: We determine the long-term efficacy and safety of the UroLume stent as minimally invasive treatment for external detrusor-sphincter dyssynergia in spinal cord injured men.Materials and Methods: A total of 160 spinal cord injured men with a mean age plus or minus standard deviation of 36.3 +/− 12.1 years (range 16 to 74) were prospectively treated with an endoprosthesis at 15 centers as part of the North American UroLume trial for external detrusor-sphincter dyssynergia. Urodynamic parameters, including voiding pressure, residual urine volume and bladder capacity, were compared before treatment and at 1, 2, 3, 4 and 5 years after treatment.Results: Mean voiding pressure was 75.1 +/− 28.2 cm. water before treatment in the 160 patients, and 37.4 +/− 23.9 at year 1 in 97, 39.5 +/− 22.2 at year 2 in 84, 42.6 +/− 27.3 at year 3 in 61, 46.3 +/− 33.2 at year 4 in 57 and 44.2 +/− 28.9 cm. at year 5 in 41 after stent insertion (p

Purpose: We retrospectively reviewed 39 patients with a tethered spinal cord to evaluate whether surgical release positively influenced urological symptoms or urodynamic findings.Materials and Methods: The patients were divided into 2 groups: group 1-11 with occult spinal dysraphism and group 2-28 with secondary spinal cord tethering after previous closure of a myelomeningocele or resection of a lipomyelomeningocele. Diagnosis was confirmed in all cases by magnetic resonance imaging or spinal ultrasound. A comprehensive urodynamic evaluation was done immediately preoperatively and 2 to 21 months (mean 7) postoperatively.Results: In group 1 the most common preoperative urodynamic finding was hyperreflexia, which improved or resolved after untethering in 62.5% of the patients. Four adults also reported improved bladder sensation or decreased urgency. In group 2 the most common urodynamic finding was impaired compliance, followed closely by detrusor hyperreflexia. Urodynamic patterns of detrusor hype...

We investigated patient satisfaction with the artificial urinary sphincter and established criteria for a successful outcome by inquiring about patient perceived satisfaction, continence achieved and comparison with the surgeon office records.During 9 years 65 patients with post-prostatectomy incontinence underwent placement of the AMS800 artificial urinary sphincter. Review of charts and a telephone questionnaire were conducted to determine patient perceived satisfaction.A total of 50 patients participated in the survey. Median followup was 23.4 months. Preoperative incontinence was severe. Of the patients 90% reported continuous leakage, and 70% wore an average of 6 diapers and 24% wore an average of 7.4 pads daily. The long-term complete continence rate was 20%. Of the patients with wetness 55% had leakage of a few drops daily and 22% had leakage of less than a teaspoon. Of all patients 50% had leakage daily, 24% had leakage 1 or more times a week and wore an average of 1.5 pads per day, and 6% reported changing clothes due to wetness. A total of 90% of the patients reported satisfaction with the artificial urinary sphincter and 96% stated that they would recommend or had recommended the artificial urinary sphincter to a friend. In retrospect, 92% of the patients would have the artificial urinary sphincter placed again, 90% of those undergoing revision reported no change in satisfaction and 14% reported improved sexual activity.Patient satisfaction with the artificial urinary sphincter for post-prostatectomy incontinence is uniformly high. Although postoperative continence was not 100%, relative improvement in continence was the most significant factor affecting patient perceived outcome. Using these parameters criteria for a successful outcome can be established, and patient concerns regarding the artificial urinary sphincter can be dispelled.

OBJECTIVES To evaluate the success of a continent catheterizable stoma in females with cervical spinal cord injury which resulted in neurogenic bladder dysfunction, the management of which may require clean intermittent catheterization despite altered hand function. PATIENTS AND METHODS Six female tetraplegic patients with a lesion at C7 or above (age range 12-22 years) had a continent catheterizable abdominal stoma formed as part of their bladder management. As an objective measure of effectiveness, the time to complete catheterization was assessed before and after surgery. A quality-of-life survey at a mean (range) of 44 (6-90) months was also evaluated. RESULTS All six patients can catheterize while in their wheelchair. The mean (range) time required for catheterization decreased from 27 (10-40) to 7.8 (1-15) min after surgery. All six reported a significant improvement in continence, body image, independence, convenience, time saving and satisfaction. CONCLUSION Constructing a continent catheterizable stoma is a valuable option in selected tetraplegic patients.

Purpose: Urological complications in adults with spinal cord injuries (SCIs) are well documented. We sought to determine the effect of SCI on the developing bladder and kidneys in the child. Materials and Methods: We retrospectively reviewed cases of SCI with 1-year minimum followup. We identified 42 children with an average age at injury of 5.3 years (range 1 day to 14 years). Mean followup was 5.5 years (range 1 to 15.5). Videourodynamics, sonograms, infection, medications and continence were reviewed. Safe bladder capacity was defined as the pressure specific volume at 40 cm water or less. Patients were divided into 3 groups based on level of injury—cervical (10), thoracic (26) and lumbar (6). Results: Bladder management included clean intermittent catheterization in 40 of 42 patients and antispasmodics in 37. No patient had reflux, hydronephrosis or renal scarring. In the cervical group safe bladder capacity was less than the expected capacity in 80% of patients but all patients undergoing multiple urodynamics had increasing capacity with time. In the thoracic group 58% of patients had a safe bladder capacity less than expected and 76% of those undergoing multiple urodynamics had increasing capacity. In the lumbar group 50% of patients had a safe bladder capacity less than expected and 67% of those undergoing multiple urodynamics had increasing capacity. Conclusions: To our knowledge this is the largest and longest urological study of young children with SCI. Early clean intermittent catheterization and use of anticholinergics appear to prevent upper tract deterioration, improve continence and decrease infections. Serial urodynamics confirm increasing safe capacity with growth in most children. Close followup is necessary as bladder characteristics may change with time.

Purpose: The Malone antegrade continence enema has revolutionized the management of intractable fecal incontinence and constipation. When the appendix is absent, surgical options are limited. Small series with short-term followup have demonstrated the feasibility but not the reliability of the continent colonic tube. We present our experience with a lateral based colonic tube. We also compared lateral based colonic tubes to medial based tubes. Materials and Methods: The medical records of patients treated with a continent colonic tube for intractable fecal incontinence were reviewed. We identified 8 patients who underwent the procedure between July 2000 and February 2003. The literature was reviewed to compare lateral vs medial based tubes. Results: Average followup was 28 months (range 10 to 41). Stomal stenosis developed in 4 patients (50%) within 3 to 6 months of surgery. Passive dilation at the clinic corrected the problem in 3 patients and 1 required operative stomal revision. All 8 patients reported almost complete relief of rectal incontinence and constipation. A literature review demonstrated a significantly higher rate of stomal stenosis in lateral vs medial based colonic tubes (40% vs 12%). Conclusions: The continent colonic tube is a safe and effective alternative in patients with refractory fecal incontinence and constipation who do not have an available appendix. These results appear durable during the described period. We believe that this technique is an alternative to the cecostomy button and it should be offered to suitable patients. The lateral based colonic tube appears to have a higher rate of stomal stenosis than medial based colonic tubes, which may be attributed to the local blood supply of the colon.

Objectives Recurrent incontinence after implantation of an artificial urinary sphincter (AUS) may be due to urethral atrophy. Treatment options consist of decreasing the cuff size, increasing the balloon pressure, implanting a double-cuff system, or proximal cuff repositioning. The first three options may increase the risk of erosion. Increasing the balloon pressure does not effectively increase cuff pressure. This article demonstrates that proximal cuff repositioning is a safe, simple, and effective technique in the management of recurrent incontinence as a result of a loss of cuff compression due to urethral atrophy. Methods Six patients underwent proximal repositioning of the AUS (AS-800) cuff for recurrent post-prostatectomy incontinence. Urethral atrophy was determined by a thorough systematic evaluation. A detailed description of the surgical technique is provided. Results Five of 6 patients (83%) had significant improvement in incontinence with an average follow-up of greater than 1 year. In 1 patient with no improvement, preoperative urodynamics revealed poor detrusor compliance in addition to sphincter weakness due to loss of cuff compression. Conclusions Proximal cuff repositioning on the bulbar urethra is an effective, safe, and simple technique in the management of recurrent incontinence due to urethral atrophy and may minimize the risk of erosion.

The urologic management of the spina bifida child has evolved considerably over the past 10 years. Clinicians now more fully understand the nature of the bladder dysfunction and are therefore able to modify this behavior by either conservative or surgical measures. The spina bifida child and parents can now be confident that the bladder can be appropriately rehabilitated with significant improvement in quality of life.

Purpose: We reviewed the outcome of cuff downsizing with an artificial urinary sphincter for treating recurrent incontinence due to urethral atrophy.Materials and Methods: We analyzed the records of 17 patients in a 7-year period in whom clinical, radiological and urodynamic evidence of urethral atrophy was treated with cuff downsizing. Cuff downsizing was accomplished by removing the existing cuff and replacing it with a 4 cm. cuff within the established false capsule. Incontinence and satisfaction parameters before and after the procedure were assessed by a validated questionnaire.Results: Mean patient age was 70 years (range 62 to 79). Average time to urethral atrophy was 31 months (range 5 to 96) after primary sphincter implantation. Mean followup after downsizing was 22 months (range 1 to 64). Cuff downsizing caused a mean decrease of 3.9 to 0.5 pads daily. The number of severe leakage episodes decreased from a mean of 5.4 to 2.1 The mean SEAPI (stress leakage, emptying, anatomy, protection, ...

Objective . To determine the efficacy of the vaginal wall sling in the management of recurrent stress urinary incontinence (SUI) in an elderly female population. Method . Eighteen elderly female patients (average age 68.4 years) with recurrent stress urinary incontinence were studied with a thorough evaluation including videourodynamics. Thirteen patients were diagnosed with type III SUI and 5 patients had type II SUI. A description of the technique, first described by Raz, is provided. Results . Follow-up ranged from six to forty-two months (average 18 months.) All patients are completely dry and express satisfaction with their outcome. Seventeen of 18 patients (94%) are voiding spontaneously. One patient at twelve months' postoperation requires clean intermittent catheterization. Conclusion . Many elderly female patients with recurrent stress urinary incontinence have intrinsic urethral sphincteric incompetence as well as recurrent hypermobility that often classifies them as type II SUI. The vaginal wall sling addresses both problems and is a safe, simple, and effective procedure in the management of recurrent incontinence in elderly female patients.

This is a case report of a fatal spontaneous perforation of an augmentation enterocystoplasty in a twenty-nine-year-old T12 paraplegic, thirteen months post augmentation and placement of artificial urinary sphincter. A review of the literature involving 41 episodes in 31 patients is provided with a discussion concerning presentation, etiology, and management.

A total of 43 infants with spina bifida was evaluated with a standard simplified urodynamic technique to determine whether bladder behavior altered with development and the optimal timing for urodynamic testing. Using urodynamic evaluation plus renal ultrasound and voiding cystourethrography the patients were divided into 2 groups: 1) those with a favorable prognosis and 2) those with an unfavorable prognosis. Only 55% of the initial urodynamic studies were predictive of future clinical course. The patients who worsened generally did so in the first 6 months of life. Of the patients initially believed to have an unfavorable prognosis 86% improved or stabilized with therapy. Urodynamic testing appears to be an important adjunct at 6-month intervals in infancy and early childhood as bladder behavior continues to evolve.

Various aspects of the histological appearance of the bladder wall in interstitial cystitis have been emphasized over the 75 years since Hunner described the condition. The major focus of interest in this disease during the last decade has been the study of the relative significance of detrusor mastocytosis. Although this was for some years considered pivotal in establishing a diagnosis of interstitial cystitis, most recent studies have not shown mastocytosis to be a consistent feature of the disease. The histological picture of this condition is now considered to be that of a chronic inflammatory infiltrate of the lamina propria, possibly with fibrosis of the detrusor or lamina propria. The authors attempted to determine if there is a correlation between the severity of inflammation and fibrosis, and detrusor mastocytosis, on initial biopsy and the response of symptoms to conservative treatment. Of 39 patients, 10 required major surgical intervention. Although not reaching statistical significance, most cases with mild disease responded to conservative management. However, over 50% of cases showing severe histological disease also responded well to this type of treatment. Histological assessment of the interstitial cystitis bladder is more useful in ruling out other diseases than in allowing the demonstration of specifical diagnostic features of this condition. A severely abnormal microscopic picture does not necessarily indicate a poor prognosis.

Duplex ultrasound with pulsed Doppler and color flow sonography were used to image the penis and conduct blood flow velocity studies in 5 patients. Cavernous body cross sectional area, cavernous artery diameters and peak systolic velocities were measured in the flaccid shaft, after transient exposure to negative pressure in a vacuum constriction device, and with a vacuum constriction device band applied to the tumescent shaft. We found that exposure to vacuum transiently increased central cavernous arterial blood flow velocities compared to baseline values in all patients. After a trial of a vacuum constriction device and application of the constricting band cavernous body cross sectional areas doubled. Despite increased cavernous arterial diameters in 4 of 5 patients and increased blood flow in all patients after vacuum-induced tumescence alone, we could not visualize arterial inflow in the penile shaft once the constricting band was in place. Color Doppler ultrasound can detect cavernous artery systolic flow as low as 2 to 9 cm. per second. Our data suggest that the erectile state maintained distal to the vacuum constriction device band is low flow and relatively ischemic.

Aims Incontinent ileovesicostomy was popularized in the mid-1990s as a surgical option for patients with neurogenic voiding dysfunction who lack the dexterity to perform clean catheterization. There are several case series in the literature, but few studies look at the long-term outcomes and complications associated with this procedure. Methods We review the outcomes of 12 patients who underwent incontinent ileovesicostomy for management of neurogenic voiding dysfunction since its introduction at our institution in 1998. We discuss, specifically, the preoperative and postoperative problems encountered as well as complications pertaining to ileovesicostomy itself. Results At an average of years follow-up, all 12 patients who underwent incontinent ileovesicostomy have experienced some form of urinary tract problem either associated with the ileovesicostomy or with their underlying neurogenic voiding dysfunction. After ileovesicostomy, seven of 12 patients (58%) have been able to reduce antibiotic usage and/or hospital admission related to chronic upper tract infection. Two patients (17%) have subsequently been converted to ileal conduit. Conclusions Incontinent ileovesicostomy is a useful option for patients with lower urinary tract dysfunction who are unable to perform clean intermittent catheterization. It should be reserved for those patients who have exhausted less invasive therapy and in whom quality of life benefits cannot be achieved without diversion. Experience shows that there are no absolute indications for this procedure. The clinician and the patient must be aware of the importance of continued surveillance after this procedure for problems related to neurogenic voiding dysfunction and/or the ileovesicostomy itself. Neurourol. Urodyn. 28:483–486, 2009. © 2009 Wiley-Liss, Inc.

SUMMARY The treatment of voiding complaints and incontinence in painful bladder syndrome requires careful attention to detail. As the exact nature of these conditions is unknown, no single modality is effective, and multiple treatments may be required. A sympathetic and supportive physician is necessary in all these cases.

Female urethral stricture disease is a rare entity. The most common etiologies are traumatic injury, iatrogenic injury, and inflammatory disease resulting in periurethral fibrosis. Hallmark symptoms are frequency and urgency, and may also be dysuria, hesitancy, slow stream, incontinence, and recurrent urinary tract infections. Female bladder outlet obstruction is a difficult entity to define, and the subset representing stricture disease may also be elusive. The diagnosis of female urethral stricture disease is usually based on symptoms, meatal appearance, and difficult instrumentation of the patient. Other testing, such as urodynamics, voiding urography, or cystoscopy, may be helpful. Treatment options are conservative management with dilatation, endoscopic treatment, or open repair with various tissue flaps or grafts. Considerable controversy surrounds the efficacy of urethral dilatation in women with voiding dysfunction.

Stenosis of stomas sited at the umbilicus presents a surgical challenge. A paucity of literature exists on the surgical management of this problem, despite its relatively frequent occurrence. A simple technique is described, using scar incision and advancement of an umbilical skin flap, to accomplish stomal revision.

Aims To assess the early results of mid-urethral slings placed via the transobturator approach (TVT-O) for stress urinary incontinence (SUI) in women with high (>60 cm H2O) and low (≤60 cm H2O) valsalva leak point pressure (VLPP). Materials and Methods Forty-three women with urodynamically proven SUI underwent TVT-O. Patients were divided into either high (>60 cm H2O) or low (≤60 cm H2O) VLPP categories based on preoperative urodynamic studies. Patient outcomes were assessed based on degree of postoperative SUI as either dry (no pads, no SUI), or wet (any leakage). Follow-up visits were at 1, 6, 12, and 24 weeks. Results Overall, 65% (28/43) women were cured following TVT-O for SUI. When stratified based on preoperative VLPP, 77% (24/31) of patients with VLPP greater than 60 were cured while only 25% (3/12) of patients with VLPP less than or equal to 60 were cured. No intraoperative complications were noted. The odds of continued SUI following TVT-O were 12 times greater for women with VLPP ≤60 compared to those with VLPP >60. Conclusions With limited follow up, TVT-O appears to be a safe and effective surgical treatment for female SUI producing excellent results in patients with VLPP >60 cm/H20. Patients with low VLPP may consider conventional, retropubic mid-urethral slings or other procedures as treatment for SUI. Neurourol. Urodynam. 25:685–688, 2006. © 2006 Wiley-Liss, Inc.

OBJECTIVES To evaluate the outcomes of primary artificial urinary sphincter (AUS) placement for the treatment of postprostatectomy stress urinary incontinence in patients aged 75 years or older at surgery. METHODS From September 1987 through June 2005, 33 men aged 75 years or older underwent AUS insertion for postprostatectomy stress urinary incontinence. Through retrospective chart review and personal/family interview, the patients' outcomes with regard to continence, complications, and the need to deactivate the AUS for medical or social reasons were determined. RESULTS Four patients were lost to follow-up and were excluded from the analysis. The mean patient age was 77.6 years (range 75 to 83). The average follow-up was 5.0 years (range 1 to 11). After AUS insertion, the mean pad use improved from 6.7 (range 3 to 10) to 0.8 (range 0 to 2) per day. Overall, 16 (55%) of 29 men reported no complications. AUS revision was necessary in 4 men (14%), and sphincter removal in 4 (14%). Six men (21%) required deactivation of the implant because of poor overall health an average of 47 months after placement. The "success" rate improved to 72% (21 of 29 men) when cuff deactivation without revision or removal was not considered a complication. CONCLUSIONS In our study, elderly men did well after AUS placement for postprostatectomy stress urinary incontinence. The procedure should not be withheld solely on the basis of the age of the patient.

Urological complications are well documented in patients with traumatic spinal cord injury. We examined the long-term urological outcomes in a large population of children affected by transverse myelitis.We retrospectively reviewed the medical history, imaging studies and urodynamic findings in 22 children with transverse myelitis. Age at disease onset ranged from 3 months to 18 years (average 8.8 years).At a mean followup of 7.1 years 19 patients (86%) had persistent bladder dysfunction and 17 (77%) had persistent bowel dysfunction. Initial evaluation at least 1 month after disease onset revealed detrusor overactivity in 59% of patients, detrusor external sphincter dyssynergia in 41%, low compliance in 47% and detrusor leak point pressure greater than 40 cm water in 12%. Functional motor recovery and absence of lower extremity spasticity did not reflect normal urodynamic findings. Of the 19 patients with imaging available for review 5 (26%) had upper tract changes. One patient had development of chronic renal insufficiency. Low compliance (p = 0.02) and upper tract changes (p = 0.1) were more frequent in patients who started clean intermittent catheterization more than 2 years after disease onset.Persistent bowel and bladder dysfunction is common in transverse myelitis. Urodynamic abnormalities may be present despite normal neurological examination and absence of urinary symptoms. All pediatric patients with transverse myelitis require baseline renal ultrasound and urodynamic evaluation to guide treatment. Early institution of clean intermittent catheterization appears to preserve bladder compliance and decrease upper tract disease, and should be instituted at disease onset.

The male lower urinary tract is well adapted to the rigors of everyday life in providing an effective lowpressure storage organ and a sophisticated, relatively trouble-free sphincter mechanism. The majority of male incontinence cases encountered presently are related to prostate pathology, many being due to sphincteric weakness following radical surgery. This review article will discuss the anatomy and neurophysiology of the lower urinary tract in the male and the causes, evaluation, and management of incontinence.

Prospective longitudinal studies where LUTS are evaluated before and after hysterectomy with a questionnaire should help to eliminate bias. In 209 patients undergoing abdominal hysterectomy and supravaginal amputation, 10% had preoperative nocturia and dysuria, which was unchanged when assessed a year after surgery, suggesting little effect of surgery. In a separate study, 57% of women complained of LUTS before the procedure, which was significantly reduced by the intervention of hysterectomy [5,6], whereas an increase from 58% to 75% of patients with troublesome LUTS after hysterectomy was reported in another study [7]. Analysis of symptom questionnaires can be criticised because they are subjective; they depend on the reliability and validity of the questionnaire. There are many potential reasons to explain the discrepancy between different studies. Hysterectomy is a common operation and LUTS increase with age. The prevalence of both these conditions is high and may explain their apparent association. Common findings in patients after undergoing hysterectomy are haematoma, oedema and minor trauma to the bladder or urethra, possibly explaining the short duration of symptoms. Patients may often associate the onset of LUTS with the hysterectomy, as they remember a specific event such as an operation.

Purpose: Tension-free vaginal tape (TVT) has been introduced and demonstrated to be an effective treatment for stress urinary incontinence. Improved general health in the elderly population has led to a greater number of patients seeking surgical treatment for incontinence. We evaluated the impact of TVT on quality of life in elderly patients, defined as age 70 and older.Materials and Methods: We prospectively evaluated 67 patients with genuine stress incontinence differentiated by age into 2 groups, namely 21 who were 70 years and older, and a control group of 46 younger than 70 years, with a validated questionnaire. We assessed quality of life changes following TVT for incontinence treatment.Results: At the most recent followup quality of life scores improved significantly in the 2 groups (p

We reviewed the outcome of cuff downsizing with an artificial urinary sphincter for treating recurrent incontinence due to urethral atrophy.We analyzed the records of 17 patients in a 7-year period in whom clinical, radiological and urodynamic evidence of urethral atrophy was treated with cuff downsizing. Cuff downsizing was accomplished by removing the existing cuff and replacing it with a 4 cm. cuff within the established false capsule. Incontinence and satisfaction parameters before and after the procedure were assessed by a validated questionnaire.Mean patient age was 70 years (range 62 to 79). Average time to urethral atrophy was 31 months (range 5 to 96) after primary sphincter implantation. Mean followup after downsizing was 22 months (range 1 to 64). Cuff downsizing caused a mean decrease of 3.9 to 0.5 pads daily. The number of severe leakage episodes decreased from a mean of 5.4 to 2.1 The mean SEAPI (stress leakage, emptying, anatomy, protection, inhibition) score decreased from 8.2 to 2.4. Patient satisfaction increased from 15% to 80% after cuff downsizing. In 1 patient an infected cuff required complete removal of the device.Patient satisfaction and continence parameters improved after cuff downsizing. We believe that this technique is a simple and effective method of restoring continence after urethral atrophy.

In developed nations, vesicovaginal fistulas are most commonly encountered as a complication after gynecologic surgery. Most fistulas are corrected using a transvaginal approach; however, complicated cases often require intraabdominal repair. A novel abdominal approach is described, using a small anterior cystotomy and omental pedicle interposition.

The clinical outcome of the vaginal wall sling was retrospectively evaluated to determine patient perception, satisfaction and factors contributing to postoperative success.An outcome based study was conducted of 51 patients undergoing construction of a vaginal wall sling for genuine stress incontinence or intrinsic sphincteric deficiency. Preoperative symptoms, demographic parameters and video urodynamic studies were correlated with postoperative patient perception of symptoms to determine patient satisfaction and factors contributing to overall success.Of 42 patients (82%) available for followup 31 (74%) reported improvement in continence, 26 (62%) are currently satisfied with the urinary status, 72% in retrospect would repeat the procedure and 69% would recommended the vaginal wall sling to others. Despite long-term resolution of stress incontinence in 92% of those with genuine stress incontinence and 75% with intrinsic sphincter deficiency, postoperative urge incontinence was the single most important factor affecting patient satisfaction (p = 0.001). Patients without postoperative urge incontinence enjoyed the greatest levels of satisfaction, in excess of 90% (p = 0.001). Although preoperative leak point pressure correlated with resolution of stress incontinence, no preoperative demographic factors, symptoms or urodynamic parameters could reliably predict postoperative patients satisfaction.The vaginal wall sling represents an excellent option for the treatment of genuine stress incontinence and an acceptable option of intrinsic sphincteric deficiency. Patient perception and satisfaction remain closely associated with presence or resolution of postoperative urge incontinence. However, prediction of postoperative urge incontinence remains a challenge and should be considered when counseling patients preoperatively.

We performed multichannel urodynamics before and after augmentation cystoplasty in 26 patients (11 females, 15 males) to determine which bowel segment is best to achieve a large volume and low pressure reservoir. All 26 patients had a neurogenic cause for their bladder dysfunction. Ileum was used in 14 patients and sigmoid was used in 12 patients. Detubularization was performed in all patients. Capacity improved significantly in both the ileum and the sigmoid group after surgery. When detubularized ileum was used, the maximum amplitude of uninhibited reservoir contractions was significantly improved or eliminated postoperatively. When sigmoid was used, uninhibited reservoir contractions did not significantly improve postoperatively and were, in fact, more common than preoperatively. Despite the detubularization, pressure waves were identified in 15 of the 26 patients postoperatively. There was significant improvement in end filling pressures at capacity (compliance) with both ileum and sigmoid postoperatively. However, end filling pressures were significantly higher in the sigmoid group. In conclusion, good capacity was achieved with both ileum and sigmoid postoperatively. However, ileum provided lower reservoir pressures and better compliance. We feel that urodynamically detubularized ileum is better suited than sigmoid for augmentation cystoplasty in patients with neurogenic bladder dysfunction.