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Objectives To provide a detailed step-by-step operative technique, and to report on long-term functional and metabolic outcomes in secondary continence mechanisms in the form of secondary intussuscepted ileal nipple valves in revisional surgery of ileocecal pouches. Methods From May 1997 to May 2015, 18 female and 10 male patients suffering from dysfunctional primary continence mechanisms of their ileocecal pouch underwent revisonal surgery to create a secondary ileal nipple valve at our tertiary referral center. The average follow-up period was 65.4 months. Results After surgery, 24 patients were continent by day and night, and four patients showed minor incontinence with the use of a safety pad. The average frequency of clean intermittent catheterization decreased both during the day and at night. The diameter of the catheters used for clean intermittent catheterization increased significantly. No patient showed stomal stenosis, change of stool habits or metabolic situation in the follow-up period. Furthermore, the creation of the secondary ileal nipple valves did not affect the capacity of the reservoir. In the long-term follow up, two patients required the construction of a third continence mechanism, making for an overall success rate of 92% in the study group. Conclusion To our knowledge, this is the first study of long-term results after the creation of secondary ileal nipple valves. We provide evidence that the creation of a secondary ileal nipple valve is a safe and reliable procedure for continence restoration in ileocecal pouches with excellent functional and metabolic long-term outcomes.

Surgical management of female urethral stricture remains challenging. Its high vascularity, lack of definite intraluminal anatomical landmarks, along with an ill-defined continence mechanism make urologists reluctant to attempt urethroplasty.

Continent cutaneous urinary diversion (CCUD) requires the use of intestinal segment to construct a urinary reservoir as well as a catheterizable continence mechanism. It constitutes an ideal solution for patients who are not candidates for orthotopic neobladder and do not want to have incontinent diversions. In this chapter, we explain the selection and preparation process for patients undergoing radical cystectomy with CCUD. We also describe the most commonly used surgical techniques for CCUD and focus mostly on Indiana pouch creation, which is the most common CCUD performed at our institution.

Recent advances in transperineal and endovaginal ultrasound have enabled better understanding of static and dynamic sling function. There is compelling evidence in favor of the primacy of location in the continence mechanism of slings. However, sling location is only one component underlying dynamic sling function: best outcomes following sling surgery are found to be associated with concordance of urethral movement with the sling and midurethral location at maximal Valsalva followed by deformability of the sling on dynamic assessment. The three parameters often work together to compensate for the failure of an individual parameter to ensure successful outcome. Voiding dysfunction or de novo urgency is more common if the tape is placed too tightly. Patients who undergo transobturator sling surgery and cystocele repair through the same incision are more likely to have the sling located more proximally when compared with patients who undergo sling surgery alone. Lastly determination of the location of a failed sling is an essential step in deciding the future course of treatment.

ProACT is an extra urethral bulking system made of a silicone balloon connected with a dual lumen tubing (12–14 cm) to a titanium scrotal port that allows the postoperative adjustment (Fig. 6.1). It was introduced in the European market in 2000 as the first non-circumferential compressive device. The continence mechanism is guaranteed by a bilateral compression of the urethra, augmenting maximum urethral closure pressure (MUCP). In a study by Reuvers et al. this mechanism was demonstrated in a cohort of 23 successfully implanted patients in which a significant increase in MUCP from 58 cmH2O to 79 cmH2O was observed [1].

Introduction Restoration of supporting structures around the urethral rhabdosphincter is key to preservation of continence mechanism post-RARP. This video aims to: (1) present the step-by-step SPARTAN technique, a novel easy-to-perform, simplified total anatomical reconstructed UV anastomotic technique incorporating the application of fibrin sealant for added water-tightness; (2) report the short- to intermediate-term outcomes on early day-4 catheter removal and continence recovery. Patients and methods This video presents a single-surgeon 20-patient RARP series performed with a standardized SPARTAN UV anastomotic technique. Post-operative outcomes measured were the success rate of early Day-4 catheter removal, and patient-reported continence outcome on day-1, -15, -30, -60 and -90 post-catheter removal. The stepby-step SPARTAN technique is outlined sequentially as follows: (1) modified Rocco's Stitch for posterior musculofascial plate reconstruction; (2) the same modified Rocco's Stitch is used to incorporate the 6 O'clock UV anastomosis; (3) completion of anastomosis by Velthoven technique; (4) application of peri‑anastomotic fibrin sealant; and (5) anterior reconstruction. Results The patient cohort consists of 85% (17/20 patients) low- or intermediate-risk cases by D'Amico classification, and 85% had nerve-sparing RARP. About two-third (75%) of these patients had recovered continence by day-30 post-catheter removal as defined by the usage of one or no safety-liner per-day. Two patients had immediate continence recovery. Ten patients had cystogram at day-4 with none showed any sign of urinary leakage and all but one had successful trial removal of catheter. Conclusion SPARTAN is an easy-to-perform, simplified total anatomical reconstructed UV anastomotic technique incorporating the application of fibrin sealant around the anastomosis for added water-tightness. SPARTAN is a consistently reproducible, tension-free, water-tight UV anastomotic trechnique in RARP that allows for early catheter removal and continence recovery.

A damaged sphincteric unit or support system, unstable urethral deformability or damaged sensory innervation are all potential causes of a dysfunctional urethral sphincter. With the current improvement in pharmacological targets and urodynamic understanding, studies have begun quantifying individual structures and their importance in closure pressure and consequently urethral continence. However, when it comes to the function of the longitudinal urethral smooth muscle layer, there is currently no consensus. The intent of this structured review is to critically examine literature regarding the female urethral anatomy and closure mechanism. We hypothesized that the longitudinal smooth muscle is a prerequisite for sufficient urethral closure and not merely involved during micturition. Overall opinions on a dysfunctional closure mechanism are controversial. Nonetheless, basic mechanics may be applied to understand simple urodynamics. With the assumption of longitudinal muscles forming a plug when contracted, this could have a substantial effect on the continence mechanism.

The pelvic floor has been poorly studied from a biomechanical perspective probably because of its complex structure comprised of many muscle layers and multiple muscle insertions with concave format in a three-dimensional architecture. An objective assessment of the pelvic floor muscles' (PFM) physical and mechanical capabilities is highly recommended to document changes in PFM function throughout rehabilitation protocols. Besides the magnitude of PFM force-generating capacity, other force/pressure-related parameters are important for the continence mechanism and sexual function, which are also correlated to different urogynecological dysfunctions. The existing devices for PFM assessment can be classified as manometers, dynamometers, electromyographers, or imaging techniques. So far, there is no perfect instrument or gold standard; however, each method has its advantages and disadvantages, and some of them will be discussed in this chapter. Recently, a new objective and reliable mechanical tool has been developed, being capable of measuring the magnitude and spatiotemporal distribution of pressures along the vaginal canal, taking into account the PFM structure, the directions of PFM contractions, and its ventro-cephalic resultant force. In this chapter, this device will be described and some of its clinical applications will be shown.

The continent cystostomy technique was first described by Mitrofanoff in 1980 and originally applied to children with neurological disorders [1]. It consists in fashioning a catheterizable channel with a flap-valve continence mechanism, in order to be both continent to promote storage and accessible to allow emptying. This method allows an alternative procedure for patients with urethral disease (congenital or acquired after surgery: exstrophy-epispadias complex) or for those with neurological disabilities who are unable or unwilling to access the urethral meatus. Indications for the procedure are varied: it may be used as isolated procedure for clean intermittent catheterization (CIC) or associated with bladder augmentation and another bladder surgery.

Introduction: A major secondary goal of robotic radical prostatectomy (RARP) is continence. We report a new technique of RARP with a combined anterior–posterior approach involving anatomic...

Author(s): Wasenda, Erika J; Kirby, Anna C; Lukacz, Emily S; Nager, Charles W | Abstract: AIMS:Traditional technology to characterize urethral pressure changes during dynamic conditions is limited by slow response times or artifact-inducing withdrawal maneuvers. The 8F high-resolution manometry (HRM) catheter (ManoScan™ ESO, Covidien) has advantages of fast response times and the ability to measure urethral pressures along the urethral length without withdrawal. Our objective was to determine static and dynamic maximum urethral closure pressures (MUCPs) and resting functional urethral length (FUL) in women using HRM before and after transurethral bulking and compare results to other women who underwent midurethral sling (MUS). METHODS:We recorded rest, cough, and strain MUCPs and FUL in 24 women before and after transurethral bulking with polydimethylsiloxane (Macroplastique®) using the HRM catheter and compared these changes to HRM values from 26 women who had the same measures before and after MUS. RESULTS:At rest, MUCPs increased minimally after both urethral bulking and MUS (3 vs 0.4 cm H2 O respectively, P = 0.4). Under dynamic conditions there were statistically insignificant small increases in MUCP and these increases were markedly less than after MUS (cough: 1.5 vs 63.8 cm H2 O, P l 0.001 and strain: 11.5 vs 57.7 cm H2 O, P l 0.001). FUL increased by 0.5 cm after transurethral bulking (P = 0.003), and decreased by 0.25 cm after MUS placement (P = 0.012). CONCLUSIONS:The mechanism of continence after urethral bulking differs from MUS. While MUS increases dynamic MUCP, bulking may rely on increasing the length of the continence zone.

INTRODUCTION AND HYPOTHESIS: The premise of midurethral sling (MUS) surgery is to apply a tension-free vaginal tape in the midurethra that does not constrict the urethra at rest but stabilizes the urethra and prevents downward descent and opening of the urethra during stress maneuvers, but current technology has limitations in measuring urethral pressures during dynamic conditions. Our objective was to describe the change in maximum urethral closure pressures (MUCPs) after MUS surgery using an 8-French high resolution manometry system (HRM) that can measure urethral pressures during cough and strain maneuvers (ManoScan® ESO, Given Imaging) without migration or withdrawal limitations. METHODS: We measured rest, cough, and strain MUCPs in 26 women before and after retropubic or transobturator MUS for stress urinary incontinence using the HRM system. RESULTS: The objective success rate after MUS was 92.3% based on postoperative cough stress testing. Mean resting MUCPs measured by HRM did not change after surgery (59.3 preop vs 59.7 cm H(2)0 postop) (p = 1.0). Mean cough MUCPs measured by HRM increased from 36.9 to 100.7 cm H(2)0 (p < 0.001), and strain MUCPs increased from 35.0 to 92.7 cm H(2)0 (p < 0.001). CONCLUSIONS: Advanced HRM technology to measure MUCPs under cough and strain conditions without withdrawal techniques provides new insights into the continence mechanism after tension-free MUS: MUCPs do not change at rest but do increase significantly during cough and strain maneuvers.

Objectives To report a novel and straightforward technique of a secondary continent outlet for continent cutaneous urinary diversion (CCUD) reservoirs without the need for further bowel resection, reducing operation time and hospitalization. Patients And Methods From 2015 to 2017, 6 patients with unreconstructable, incontinent outlets (out of a total pool of n=595 CCUD patients) have undergone the technique described here at our department. It relies on the Mitrofanoff principle, using a stapled full-thickness pouch wall plication, which creates a flap-valve continence mechanism. Results All patients enjoyed full continence with ease of CIC in the postoperative period and on follow-up to a mean of 12,4 months (7-18 months). No major complications were encountered in all patients and the average capacity of the reservoirs was not compromised by the procedure (540 ml preoperatively vs. 500 ml in further follow-up). Conclusion In revisional surgery for secondary CCUD incontinence - especially if the patient has already lost a significant amount of bowel or has previously undergone radiation therapy – the technique described here represents a safe and effective alternative to restore continence. This article is protected by copyright. All rights reserved.

Objective To evaluate in a rabbit experimental model a mechanism of continence of catheterizable urinary conduits (CUC), focusing on the behavior of intersected rectal muscle fibers in relation to the channel by histological and histochemical analysis, and secondarily to register conduit continence rates from clinical and urodynamic data. Materials and methods 12 rabbits were submitted to construction of a CUC from two abdominal skin flaps and divided into two groups: 8 with a urinary neo-sphincter created according to Yachia and 4 controls. We registered clinical outcome, urodynamic studies and microscopic analysis of CUC on the surface of the conduit, which was in direct contact with the mechanism of continence. We took muscle samples from the mechanisms of continence and performed histochemical evaluation by enzymatic reactions. Results Histological evaluation of the CUC showed no difference between groups. Histology and immunohistochemistry of the muscle fibers showed that areas of necrosis, cell atrophy and motor neuron injury from the first eight weeks recovered by the end of 16th week. Conduit complications occurred in 4 animals (33%). The average detrusor leakage point pressure through the conduit was 90 cm H 2 O versus 39 cm H 2 O through the urethra. Conclusion The mechanism of continence did not promote ischemic stress on the conduit, was able to promote high pressure resistance and showed good recovery of intersected muscle fibers, after an initial slight atrophy, suggesting good durability of the neo-sphincter.

We compared two hypotheses as to why obesity is associated with stress urinary incontinence (SUI): (1) obesity increases demand on the continence system (e.g. higher cough pressure) and (2) obesity compromises urethral function and urethrovaginal support. A secondary analysis was performed using data from a case–control study of SUI in women. Measurements of urethrovaginal support (POP-Q point Aa, urethral axis), urethral function (maximal urethral closure pressure, MUCP), and measures of continence system demand (intravesical pressures at rest and during maximal cough) were analyzed. Cases and controls were divided into three body mass index (BMI) groups: normal (18.5–24.9 kg/m2); overweight (25.0–29.9 kg/m2); and obese (≥30 kg/m2). Logistic regression models where created to investigate variables related to SUI for each BMI group. Structural equation modeling was used to test the direct and indirect relationships among BMI, SUI, maximal cough pressure, MUCP, and POP-Q point Aa. The study included 108 continent controls and 103 women with SUI. MUCP was the factor most strongly associated with SUI in all BMI groups. Maximal cough pressure was significantly associated with SUI in obese women (OR 3.191, 95% CI 1.326, 7.683; p

Continent cutaneous urinary diversion (CCUD) utilizes an intestinal segment to create a low-pressure urinary reservoir and a catheterizable continence mechanism. It provides a urinary tract reconstruction option for patients who are not candidates for continent orthotopic urinary diversion and in patients with whom an ileal conduit is not desirable. The ideal candidate for a CCUD is the same patient who would be considered for orthotopic neobladder but may not have a usable urethra. In this chapter, we describe the surgical technique used for the most commonly used CCUDs.

PURPOSE OF REVIEW: Over 90% of all prostate cancer patients are diagnosed at a stage when the disease is organ-confined and potentially curable. Currently, more than 60% of all prostate cancer surgeries in the USA are performed using the robotic approach. We review the current literature evaluating the technical advances to optimize continence recovery following robotic prostatectomy. RECENT FINDINGS: Recent studies suggest that the several technical nuances during robotic prostatectomy can result in earlier continence recovery in patients without compromising the oncologic outcome. The key is in delicate handling of tissues, reducing trauma, preserving support structures, and restoring postoperative anatomy as close as possible to preoperative anatomy. There should also be standardization in assessment of continence recovery. SUMMARY: Much progress has been achieved in elucidating the anatomic, physiologic, and neural basis of the male continence mechanism, resulting in novel adaptations of the conventional approach to radical prostatectomy with the aim of preserving continence and accelerating its return. Various principles for augmenting continence return have been proposed which have been evaluated in series of open, laparoscopic, and robotic-assisted radical prostatectomy. Going forward, we foresee a paradigm shift from individual techniques toward a unified approach of interwoven principles aimed at preserving and augmenting the functional and innervative anatomy of the continence mechanism.

Objectives The tension-free vaginal tape (TVT) insertion technique generally does not take into account individual urethral length. In this study we investigated whether preoperative sonographic measurement of individual urethral length allows for reliable TVT positioning under the midurethra, which is a critical segment for the continence mechanism. Methods Urethral length was measured by preoperative introital ultrasonography in 102 consecutive female patients with stress urinary incontinence. TVT procedures were performed as recommended by the manufacturer. The suburethral incisions were initiated at one-third of the sonographically measured urethral length. TVT position and tape–urethra distance were followed up 6 months postoperatively. Results At 6-month examination of the 102 study participants, 93.1% were cured and 6.9% showed improved continence. TVTs were found in the target range of 50–70% of the urethral length in 88.2% of the cohort. Women with the TVT in the 50–70% urethral length range and a 3–5-mm tape–longitudinal smooth muscle distance had a greater likelihood of being cured without complications (P < 0.001). Conclusions Preoperative sonographic measurement of urethral length, combined with the one-third rule, may aid in reliable midurethral TVT positioning. Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.

Aims To report the conclusions of the Think Tank on mechanisms of incontinence and surgical cure in female and male SUI: surgical research initiatives during the ICI-RS meeting in 2010. Methods The sub-group considered five areas for future research in stress urinary incontinence (SUI); (i) epidemiology and public health efforts in SUI, (ii) the basic sciences examining the physiology and pathophysiology of the continence mechanism, (iii) diagnostic techniques and clinical assessment of SUI, (iv) the future of treatment and surgical cure, and (v) the separate issue of male SUI. Results Roadblocks to progress were identified for each of the five directions. Conclusions Future research directions are suggested for each of these areas. Neurourol. Urodynam. 30:704–707, 2011. © 2011 Wiley-Liss, Inc.

Use of mid-urethral slings to treat stress urinary incontinence is based on the integral theory that the mid-urethra has an important role in the continence mechanism. Transobturator vaginal tape (TOT) involves passage of the sling transvaginally through the obturator foramen so as to avoid the pelvic organs and vasculature. In this report, we describe the operative steps of the transobturator approach.

Objective: evaluating the recurrence of anterior wall and pelvic apical prolapse by comparing techniques for correcting pelvic failure via integral management using synthetic mesh compared to traditional ones . Methods : two cohort groups were evaluated at the Clinica Universitaria Bolivariana in Medellin, Colombia; the first group was treated with surgical vaginal synthetic mesh and traditional techniques were used with the second one. Two evaluations were carried out at six-month intervals following the surgery. Follow-up involved classifying the degree of recurrence and early or late complications. The gynaecologist carrying out the follow-up did not know the patients and did not have any information about the cohorts. Informed consent had been previously signed by each patient. Results : the most commonly recurring prolapse happened in the anterior compartment but occurred less frequently when vaginal synthetic mesh was used. No prolapses recurred in the posterior compartment in this cohort and a less frequent apical failure rate was also detected in this group. The techniques used in integral management protected against surgical failure. Six-month follow-up relative risk was 0.26 (0.10-0.69 95%CI; p = 0.001). One-year follow-up confirmed that this technique did protect against anterior compartment failure (RR = 0.32; 0.12-0.81 95%CI; p = 0.004). Discussion: the surgical techniques used in integral management did protect against surgical failure. The greatest challenge for a pelvic surgeon lies in controlling the anterior compartment because of the different kinds of pelvic failure. Para-vaginal and posterior defects are not usually fixed during abdominal or traditional surgery, although they do become the target during integral management. The synthetic mesh used on the exposed cohort was placed in anatomical sites, aimed at producing tissue neo-formation and thereby rescuing the functional continence mechanism. A systematic review of Cochrane data (2007) supported this paper’s results, reinforcing integral anterior compartment management and confirming that synthetic material use leads to a lower rate of recurrence.

Shorter urethral sphincter length on preoperative endorectal magnetic resonance imaging has been associated with an increased risk of postoperative urinary incontinence as well as longer time to achieve continence. We determined that our techniques of anatomical reconstruction for restoring the continence mechanism could markedly improve continence outcomes, especially in patients with a shorter urethral sphincter.Our cohort consisted of 274 patients who underwent robotic radical prostatectomy, as performed by a single surgeon, and for whom preoperative magnetic resonance imaging and postoperative evaluations were available. All sphincter lengths were measured on T2-weighted images as the distance from the prostatic apex to the penile bulb, cross-referencing all 3 planes. Continence was defined as zero pads or a liner used for security reasons only.The 2 surgical modifications considerably hastened the return of continence at 6 months. The continence rate in the shorter sphincter group (less than 14 mm) was 47% for the control technique, 81% for anterior reconstruction and 90% for total reconstruction. The continence rate in the longer sphincter group (more than 14 mm) was 80% for the control technique and 83% for anterior reconstruction, while it approached 99% for total reconstruction. With the control technique the average time to achieve continence was significantly different between the shorter and longer sphincter groups (25 vs 12 weeks, p = 0.037). The significance disappeared for anterior reconstruction (7.4 vs 6.2 weeks, p = 0.27) and total reconstruction (3.6 vs 2.7 weeks, p = 0.13).The results of this study are encouraging for patients with a short urethral sphincter who are considering radical prostatectomy.

This paper reports on the currently available information regarding urethral dysfunction as presented during the scientific session of the 2006 Society for Urodynamics and Female Urology meeting in Atlanta, GA. Anatomic studies of the urethral sphincter complex contribute to our understanding of the continence mechanism, particularly as it relates to sex differences and the effect of androgens. It is important to understand biomechanical concepts of load and stress as they relate to the demonstration of incontinence on urodynamic studies. Urethral imaging complements our ability to accurately diagnose clinical problems. The pharmacologic components of urethral pressure are also discussed. Continued advances in our understanding of urethral dysfunction will guide improved diagnosis and treatment of these disorders.

The surgical management of stress incontinence in women should encompass a combined approach by the family practitioner and the specialist. This review, in two parts, discusses the place of the family practitioner in this process. The continence mechanism, pre-operative counselling, appropriate surgical procedures, post-operative complications and aftercare are all discussed, to enable the family practitioner to provide adequate support to the patient.

Neurophysiologic function of the continence mechanism in the male has been largely focused on voiding difficulties and directed to explore the obstruction instead of incontinence. Over the past 20 years, much has been elucidated about the pathophysiology of male SUI. As improved diagnostic modalities have provided new insight into the function and dysfunction of the urethral continence mechanism, theories have evolved from being purely anatomic to being both functional and anatomic.

This article examines the anatomy of the female continence mechanism and the traditional and newer theories relevant to the etiology and surgical correction of genuine stress incontinence. The authors review the classical theories of incontinence and unify them with more recent ones, stressing that central to all explanations is the concept that urinary loss secondary to an underactive outlet results from a relative lack of continence mechanism resistance with respect to intravesical pressure. They also propose an explanation for the success of newer techniques that involve mid-urethral suspensions. Surgical stabilization of the continence mechanism, at the bladder neck or mid-urethra, compensates for the existing loss of urethral support or function by creating a new zone that provides compression, absorbs transmitted pressure, and preserves sphincteric configuration.

To reevaluate the submucosally embedded in situ appendix as continence mechanism in a large single institutional series of ileocecal urinary reservoirs.Between November 1990 and June 1999 an ileocecal reservoir with appendico-umbilical stoma was created in 118 patients (84 men, 34 women) aged 3.9-82.7 (mean 56.8) years as a primary urinary diversion or after failure of previous reconstruction. The most common indication for urinary diversion was bladder replacement after anterior exenteration for pelvic malignancies (n = 98), followed by functional or morphological bladder loss due to various benign conditions. The patients were followed prospectively according to a standard protocol.There were no perioperative deaths. In 3 patients necrosis of the appendix resulted in total incontinence with subsequent replacement by an intussuscepted ileal nipple. Impaired catheterization due to stomal stenosis was observed in 19 patients with recurrence in 6 and a total of 25 minor revisions. With a mean follow-up of 60 months all patients are continent day and night.Over 10 years, the submucosally embedded in situ appendix has survived as a continence mechanism in the original technique reliably providing continence in ileocecal reservoirs.

Maintaining the quality of life after surgery in the radical prostatectomy patient is of paramount importance. One of the major dilemmas in surgical management of radical retropubic prostatectomy (RRP) is preservation of the neurovascular bundle and, hence, erectile function and the continence mechanism. This manuscript addresses anatomical considerations for the surgeon and discusses the following issues with regard to medical and surgical therapies: (1) incidence of erectile dysfunction solely due to complications during RRP; (2) nerve damage during RRP; (3) vascular damage during RRP; (4) current medical and surgical therapies for restoring or maintaining potency; and (5) new advances on the horizon for management of the prostatectomy patient. International Journal of Impotence Research (2000) 12, Suppl 4, S47-S52.