Impact of intrinsic sphincter deficiency on mid-urethral sling outcomes.

INTRODUCTION AND HYPOTHESIS: Our primary objective was to study outcomes of patients with intrinsic sphincter deficiency (ISD) following mid-urethral slings (MUS) at 1-year. Our secondary objective was to delineate factors affecting success in these patients. METHODS: Six hundred eighty-eight patients who had MUS between January 2004 and April 2017 were reviewed retrospectively; 48 women were preoperatively diagnosed with ISD. All completed urodynamic studies and validated quality-of-life (QOL) questionnaires at baseline and 1 year. Primary outcomes were objective and subjective cure of stress incontinence, defined as no involuntary urine leakage during filling cystometry and 1-h pad test < 2 g and negative response to Urogenital Distress Inventory-6 Question 3. Ultrasound was performed to determine tape position, urethral mobility and kinking at 1 year. RESULTS: Women with ISD had significantly lower objective and subjective cure rates of 52.1% and 47.9%, respectively, compared to an overall of 88.2% and 85.9%. QOL scores significantly improved in those with successful surgeries. The sling type did not make a difference. Multivariate logistic regression identified reduced urethral mobility [OR 2.11 (1.24-3.75)], lower maximum urethral closure pressure (MUCP) [OR 1.61 (1.05-3.41)] and tape position [OR 3.12 (1.41-8.71)] to be associated with higher odds of failed slings for women with ISD. CONCLUSIONS: Although there are good overall success in women undergoing MUS, those with ISD have significantly lower cure rates at 1 year. Factors related to failure include reduced urethral mobility, low MUCP and relative tape position further away from the bladder neck. Optimal management of patients with ISD and reduced urethral mobility remains challenging.

The Visualized Urethral Mobility Profile in Stress Urinary Incontinence Described by Four-Dimensional Transperineal Ultrasound.

OBJECTIVES: To describe the urethral mobility during urine leaking in stress urinary incontinence (SUI) by transperineal ultrasound (TPUS) with urethral mobility profile (UMP) analysis. METHODS: This was a prospective study of 380 women who had a cough stress test (CST) with TPUS. UMP software automatically placed six equidistant points from the bladder neck (Point 1) to the external urethral meatus (Point 6) and determined their x and y coordinates relative to the symphysis pubis. Urethral mobility vector of Points 1-6 (Vectors 1-6) and the distance between the six points and the symphysis (Dist. 1-6) were calculated and compared between the two groups. The visualized UMP was created by reproducing the positions of the six points at rest and on Valsalva. RESULTS: Valid data of 188 women with SUI and 174 continent women were analyzed. The mean age of all 362 women was 49.3 years. Mean body mass index in the SUI group was significantly increased (23.8 vs 22.2 kg/m2 , P < .001). During CST, Vectors 1-6 and Dist. 2-6 were significantly increased (all P < .005) in the SUI group. The UMP showed the mid-urethral rotated down around the symphysis pubis. The upper urethral profile in the two groups was similar. But the gap between the mid-urethra and the symphysis was wider in the SUI group. CONCLUSIONS: The visualized UMP illustrated the mid-urethral hypermobility in SUI by showing a wider gap due to the unstable connection between the mid-urethra and the symphysis pubis.

[Bonney maneuver and its derivatives: History, technique, significance and prognostic value]. / Manœuvre de Bonney et ses dérivés : histoire, technique, signification et valeur pronostique.

INTRODUCTION: Historically a positive Bonney maneuver indicates the need for surgical management of stress urinary incontinence. This maneuver is regularly used in French daily practice without formal proof of its predictive value. MATERIAL: A Medline search was performed with the terms "Bonney test" and "urinary incontinence" to include 10 relevant articles in this review. RESULTS: Eight articles study the mechanism of the maneuver or its derivatives, evoking a direct pressure on the urethra. Two studies are interested in the real predictivity of the maneuvers on the success of surgical treatment by urethral strip, reporting a positive predictive value of the Bonney maneuver between 96.2 and 100%. CONCLUSION: Further studies are needed to objectify the utility of this maneuver.

Epidemiological Features of the Bladder Neck Rest Position and Mobility.

The data concerning epidemiological determinants of the bladder neck (BN) mobility are scarce. The aim of the study was to determine epidemiological features and identify factors influencing BN position at rest and BN mobility in patients without pelvic organ prolapse (POP). Seven hundred and ninety-six patients that attended two outpatient clinics were enrolled in the study. Position and mobility of the BN were measured with the use of pelvic floor ultrasound. Demographic and functional factors that were hypothesized to influence BN mobility were assessed. Vaginal deliveries (VDs) and age ≥65 were associated with lower BN position at rest. Higher BN mobility was observed in women with stress urinary incontinence (SUI). In obese women, higher BN position and lower BN mobility was observed compared to non-obese women, and it was correlated with longer urethras in this group of patients. VDs and their number were associated with increased BN mobility, independently of body mass index (BMI). To conclude, obesity, VDs, and age are factors associated with changes in bladder neck position at rest and its mobility. Higher BMI correlates with restricted BN mobility, and, therefore, the incidence of SUI in obese patients is probably not connected to BN hypermobility.

Real-time assessment of the behaviour of the bladder neck and proximal urethra during urine leaking in the cough stress test (CST) in supine and standing positions using transperineal ultrasound.

INTRODUCTION AND HYPOTHESIS: The objective was to describe the behaviour of the bladder neck and proximal urethra during urine leaking in the cough stress test (CST) in supine and standing positions using transperineal ultrasound (TPUS). METHOD: We carried out prospective data collection and a retrospective data analysis of 102 women with stress urinary incontinence (SUI) who had a positive CST with TPUS in the supine and/or standing position. On TPUS, the behaviour of the bladder neck and proximal urethra was described by the urethral length, urethral funnelling, bladder neck descent (BND), retrovesical angle (RVA) and urethral rotation angle (URA). Differences between the ultrasound findings in the two positions were evaluated. RESULTS: In the 102 women, the mean age was 48 years and mean BMI was 23.8 kg/m2. On TPUS, urine leakage was detected in the supine or standing position in 102 women and in both positions in 81. Between the two positions, significant differences were found in the URA and RVA. In the standing position, the median RVA of 166° was significantly larger than that of 133° in the supine position (p < 0.001), and the median URA of 35° was significantly smaller than that of 64° in the supine position (p < 0.001). CONCLUSIONS: TPUS in both positions can be used to detect the real-time behaviour of the bladder neck and urethra in the CST. In the standing position, less rotation and more straightening of the bladder neck and proximal urethra occurred during urine leakage.

[Age-related changes of the female urethra.]

The minimum and maximum indicators of the length, width, area or volume of organs and structures in the lower urinary tract can normally vary up to 2-3 times. With age, at healthy women the absolute and relative length of the urethra, the urethrovesical angle, and the inclination of the urethra do not change. Both smooth and striated muscle tissues, which are part of various departments of the female urethra, undergo atrophy during the aging process. Smooth muscle tissue is less variable with age, but striated muscle symplasts are sometimes completely absent in urethral biopsies from elderly patients. With age, the vascularization and density of the innervation decrease in the urethral structures, but the content of connective tissue in the external urethral sphincter increases. Urinary tract mobility at young women is more pronounced than at older women. The apparent insufficiency of modern investigations about age-related changes in the lower urinary tract indicates the relevance and need to continue studying of the organ and tissue transformation in the urinary system during aging, this may be important for determining the etiology and pathogenesis of some pathological conditions, such as stress urinary incontinence, as well as for differential diagnosis between age norm and pathology.

Medium-term outcomes for primary native tissue reconstructive surgeries with and without transobturator vaginal meshes in stress continent women with stage 3 or higher pelvic organ prolapse.

AIMS: To compare the surgical outcomes of conventional surgeries with or without concomitant transobturator vaginal mesh (TVM) for ≥Stage 3 pelvic organ prolapse (POP). METHODS: We retrospectively investigated 166 women who received conventional surgery including vaginal total hysterectomy, modified McCall culdoplasty, and AP-repair (conventional group) and 98 women with concomitant TVM (mesh group). Follow-up at 3, 12, and 24 months comprised symptom interview, pelvic examination, and ultrasound assessments. The primary outcome was anatomical success defined as ≤Stage 1 POP. Secondary outcomes were subjective symptoms, ultrasound manifestations, and complications. RESULTS: Both groups showed improvements in functional and anatomical outcomes after operations. Compared with the conventional group, the mesh group had higher rates of de novo stress urinary incontinence (SUI) at 3-month (3.6% vs 19.4%; P < .001), 12-month (3.7% vs 26.4%; P < .001), and 24-month (2.4% vs 21.4%; P = .001) follow-up, a higher POP-C point (-7.3 ± 0.7 cm vs -7.6 ± 0.6 cm; P < .001) at 3-month follow-up, a smaller straining bladder neck angle indicating a more cranioventral straining bladder neck position (117 ± 25° vs 102 ± 20°; P < .001) at 3-month follow-up, and a less bladder neck mobility at 3-month (19 ± 24° vs 8 ± 14°; P = .002) and 12-month (26 ± 18° vs 12 ± 15°; P = .003) follow-up. CONCLUSIONS: Concomitant TVM is associated with a higher rate of de novo SUI, more cranioventral straining bladder neck position, and less bladder neck mobility.

Utility of 2D-ultrasound in pelvic floor muscle contraction and bladder neck mobility assessment in women with urinary incontinence.

INTRODUCTION AND HYPOTHESIS: Assessment of pelvic floor muscle (PFM) contraction and bladder neck (BN) mobility in women with stress urinary incontinence (SUI) is essentially clinical. Ultrasound is increasingly used as a method for evaluating BN mobility and PFM contraction, but has not been standardized. The aim of this study was to review ultrasound technics and parameters that might be relevant for PFM contraction and BN mobility assessment in women with urinary incontinence (UI). METHODS: We reviewed articles indexed in the MEDLINE database between 1988 and 2018 and selected articles which had a cohort of women with UI who had undergone functional 2D-ultrasound evaluation of PFM or BN mobility. RESULTS: Transperineal ultrasound provides a panoramic view of the pelvic organs without modifying the anatomical relationship between the urethra and surrounding structural landmarks. One of the measurements used to assess urethral mobility is bladder neck descent (BND), which has been shown to be extremely reliable. Measuring the anteroposterior diameter (APD) of the urogenital levator hiatus can also reliably quantify PFM contraction in women. The more recently developed technique of elastography could be an additional useful non-invasive method for measuring periurethral striated muscle stiffness. CONCLUSIONS: Several ultrasound parameters such as BND, anorectal angle displacement and periurethral stiffness as measured by elastography are relevant for investigating UI in women undertaking pelvic floor muscle training. Our hypothesis is that these ultrasound parameters can be correlated with urinary symptoms and clinical contraction assessment. They need to be validated for clinical use.

Perineal ultrasound for the measurement of urethral mobility: a study of inter- and intra-observer reliability.

INTRODUCTION AND HYPOTHESIS: Ultrasound measurement of urethral mobility is an attractive approach to directly visualize bladder neck descent (BND) during stress. BND assessed by transperineal ultrasound appears to be associated with stress urinary incontinence (SUI) severity. This study evaluated the inter- and intra-observer reliability of ultrasound BND measurement and its correlation with clinical examination. METHODS: We included 50 women from the multicenter randomized 3PN study ("Prenatal Perineal Prevention"). BND was measured by two operators either during pregnancy (at 20 weeks of gestation) or 2 months after delivery. Two measurements were taken by each operator. Intra-class coefficient correlations were used for analysis. Urethral mobility was clinically assessed by measuring the point Aa of the POP-Q classification during maximum strain (Valsalva maneuver) with an empty bladder. RESULTS: Ultrasound analysis showed high intra-observer reliability in the overall population: intraclass correlation coefficients (ICC) = 0.75 (0.59-0.85) and 0.73 (0.55-0.84) for each operator. Intra-observer agreements were considered moderate to high in the post- and antepartum groups. Inter-observer agreements were moderate in the antepartum period [ICC = 0.58 (0.26-0.78) for the first measurement and 0.68 (0.42-0.84) for the second] but low in the postpartum period [ICC = 0.15 (0.10-0.41) and 0.21 (0.10-0.58)]. Correlations between ultrasound and clinical measurements were considered low to moderate (Spearman coefficient, rho = 0.34 and 0.50 for post- and antepartum periods, respectively). CONCLUSIONS: Inter-observer reliability of ultrasound urethral mobility measurements by the transperineal route is moderate antepartum and low postpartum. The correlation with point Aa is low to moderate.

How accurate are we in urethral mobility assessment? Comparison of subjective and objective assessment.

OBJECTIVE: The knowledge of the mobility of urethra plays important role in patients with stress urinary incontinence and its assessment is a part of standard urogynecological examination. It has been assumed that increased mobility is associated with higher likelihood of successful treatment. There is arbitrary defined cut-off for hypermobile urethra - descend of more than 15 mm or 30-degree resp. 50-degree rotation or more during Valsalva manoeuvre. Clinically we routinely categorize mobility of the urethra as high mobile or hypermobile urethras, low mobile urethra and the situation in-between as mobile urethras. But how accurate are we with such a subjective assessment? We have provided retrospective analysis of mobility of the urethra assessed during the clinical examination by transperineal ultrasound (US) with subjective scoring of the mobility (low, norm, hyper) and compared this assessment with detailed measurement of descent and rotation of the urethra. DESIGN: Retrospective cohort study. SETTING: Ob/Gyn department First Faculty of Medicine, Charles University and General University Hospital, Prague. METHODS: This is a retrospective analysis of urethral mobility of women diagnosed with urodynamic stress incontinence (USI) and treated with tension free vaginal slings during the period 01/2009 - 10/2016. For each patient, there was available description of mobility at the time of preoperative assessment (low-, norm- or hyper-mobile) and we compared this assessment with measured parameters of bladder neck mobility analysed later from stored 4D US volumes. We have measured dorsocaudal movement of the bladder neck (BN) (H-distance). This is the distance of the BN from the horizontal line at the level of lower margin of the symphysis and we compared the position at rest and at Valsalva. Secondly, we measured rotation of the urethra using the gama angle - angle between the line connecting BN to lower margin of symphysis and axis of symphysis at rest and during the Valsalva manoeuvre. Mobility of the BN is the difference between the rest and Valsalva position. We compared the objective parameters of mobility with subjective assessment. We have provided correlation of both objective parameters. RESULTS: 427 patients were treated during the analysed period, 393 had available stored 4D US volume for analysis. Mean age 56.5 years (min 29, max 87, SD 7.9), mean BMI 27.4 (min 18.3, max 39.6, SD 7.9), mean parity 2.14. Mean descent of the bladder neck was 11.8 mm (min -1, max 37; SD 6.9) Mean rotation of the bladder neck was 38.8 degree (min -5, max 118, SD 20.0). When we subjectively assessed the mobility as low the mean mobility was 23.9 ° resp. 7.3 mm, for normal 34.8 ° resp. 10.4 mm and 48.6 ° resp. 15 mm for hypermobile uretras. We have found good correlation of both parameters - H-distance, gama angle - r = 0.693. CONCLUSION: Subjective assessment of mobility of the urethra seems to be reasonably accurate for distinguishing between low and hypermobile uretra.

Is Bariatric Surgery a Prophylaxis for Pelvic Floor Disorders?

INTRODUCTION: Obesity is one of the well-documented risk factors of pelvic floor disorders (PFDs). The PFDs include urinary and fecal incontinence (UI, FI) and pelvic organ prolapse (POP). Surgery-induced weight loss improves different kinds of incontinence as well as POP symptoms. However, there is a lack of evidence how bariatric surgery influences pelvic floor anatomy and function in women without previous PFDs and whether it may be concerned as PFD prophylaxis tool. MATERIALS AND METHODS: The present analysis is a prospective, non-randomized case-control study from January 2014 to September 2017. Participants underwent pelvic floor ultrasound examination with bladder neck position estimation at rest, during levator ani tension, and at Valsalva maneuver before surgery and 12-18 months after. Pelvic organ prolapse quantification (POPQ) > 2 stage and PFD complaints were the exclusion criteria. RESULTS: Fifty-nine patients underwent bariatric surgery (57 sleeve gastrectomy and 2 gastric bypass). Mean BMI decreased from 43.8 ± 5.9 to 29 ± 4.6 kg/m2 after surgery (p < 0.001). Statistically significant higher position of the bladder neck at rest, during tension, and at Valsalva maneuver (p < 0.05) was shown after surgery. We did not demonstrate differences in bladder neck mobility and bladder neck elevation at tension after weight loss. CONCLUSIONS: Bariatric surgery is associated with a betterment of bladder neck position at rest, tension, and Valsalva maneuver in women without PFDs. We postulate that bariatric surgery may be a tool for PFD prevention. It does not improve levator ani function and does not limit bladder neck mobility, which implicates that it has no influence on preexisting pelvic dysfunction.

The analysis of repeatability and reproducibility of bladder neck mobility measurements obtained during pelvic floor sonography performed introitally with 2D transvaginal probe.

OBJECTIVES: The aim of the study was the evaluation of repeatability and reproducibility of chosen urethral neck mobility measurements obtained during introital pelvic floor sonography performed with a 2D transvaginal probe. MATERIAL AND METHODS: In order to assess the repeatability and reproducibility, independent measurements on the ultra-sound image were taken by two specialists on 92 female patients at rest and at strain (Valsalva maneuver). 2D ultrasound examination was performed introitally with a transvaginal probe (PFS-TV). The location of the urethral internal orifice was defined with coordinates of two points. Point CI marks the urethral anterior edge visualized on ultrasound as closer to the pubic symphysis. Point CII marks the posterior edge visualized more peripherally from pubic symphysis. RESULTS: Repeatability and reproducibility measurements of point CI location and mobility were good and very good (0.6710-0.9961), while of point CII - were medium, good and very good (0.5738-0.9944). Point CI was clearly visible in all cases. It was not possible to accurately mark point CII in 4.3-17.4% of cases. CONCLUSIONS: The possibility to visualize point CI in every single case with very good and good repeatability and reproduc-ibility of measurements of this point's location and mobility allows the usage of CI point as a universal reference point for evaluation of bladder neck mobility and position during PFS-TV in the clinical practice and for research purposes.

Is prenatal urethral descent a risk factor for urinary incontinence during pregnancy and the postpartum period?

INTRODUCTION AND HYPOTHESIS: Obstetric trauma during childbirth is considered a major risk factor for postpartum urinary incontinence (UI), particularly stress urinary incontinence. Our aim was to investigate the relation between postpartum UI, mode of delivery, and urethral descent, and to define a group of women who are particularly at risk of postnatal UI. METHODS: A total of 186 women were included their first pregnancy. Validated questionnaires about urinary symptoms during pregnancy, 2 and 12 months after delivery, were administered. Urethral descent was assessed clinically and by ultrasound at inclusion. Multivariate logistic regression analysis was used to determine the risk factors for UI during pregnancy, at 2 months and 1 year after first delivery. RESULTS: The prevalence of UI was 38.6, 46.5, 35.6, and 34.4 % at inclusion, late pregnancy, 2 months postpartum, and 1 year postpartum respectively. No significant association was found between UI at late pregnancy and urethral descent assessed clinically or by ultrasound. The only risk factor for UI at 2 months postpartum was UI at inclusion (OR 6.27 [95 % CI 2.70-14.6]). The risk factors for UI at 1 year postpartum were UI at inclusion (6.14 [2.22-16.9]), body mass index (BMI), and urethral descent at inclusion, assessed clinically (7.21 [2.20-23.7]) or by ultrasound. The mode of delivery was not associated with urethral descent. CONCLUSIONS: Prenatal urethral descent and UI during pregnancy are risk factors for UI at 1 year postpartum. These results indicate that postnatal UI is more strongly influenced by susceptibility factors existing before first delivery than by the mode of delivery.

What is normal bladder neck anatomy?

INTRODUCTION AND HYPOTHESIS: Functional anatomy of the bladder neck and proximal urethra has been studied extensively because of the belief that it is important for urinary continence. The aim of this study was to explore the limits of normality for pelvic floor ultrasound parameters of bladder neck and urethral mobility associated with stress urinary incontinence (SUI) and urodynamic stress incontinence (USI). METHODS: A retrospective study was conducted on 589 women seen for urodynamic testing in a tertiary urogynaecology clinic. All women were assessed following a protocol including interview, clinical examination, flowmetry, urodynamic testing and 4D pelvic floor ultrasound. Volume data sets were analysed offline to assess for bladder neck descent (BND), urethral rotation and the retrovesical angle (RVA) on maximal Valsalva. RESULTS: After excluding women with previous incontinence or prolapse surgery, 429 datasets were available. SI was significantly associated with the RVA (p = 0.033) and BND (p = 0.036); USI was associated with urethral rotation (p = 0.021) and BND (p < 0.001). On multivariate logistic regression analysis, controlling for confounders including age, BMI, parity, previous hysterectomy and maximal urethral pressure, the association between SUI and BND remained significant (OR [per 10 mm] = 1.23; 95 % CI: 1.01 to 1.51; p = 0.043), as did the association between USI and BND (OR [per 10 mm] = 1.58; 95 % CI: 1.3 to 1.91; p < 0.001). ROC statistics for BND suggested a cut-off of 25 mm in describing the limit of normality. CONCLUSIONS: Measures of functional bladder neck anatomy are weakly associated with SUI and USI (with association between BND and USI being the strongest). It is suggested that a BND of 25 mm or higher be defined as abnormal ("hypermobile") on the basis of its association with USI.

Do different vaginal tapes need different suburethral incisions? The one-half rule.

AIM: Despite a wide array of vaginal tapes to treat stress urinary incontinence (SUI), evidence suggesting that both patient characteristics and tape positioning influence outcomes, and differing tape insertion pathways (retropubic vs. transobturator), it remains unclear if the same incision location is effective for all tapes. The aim of the study was to compare outcomes using two different surgical incision locations when inserting a transobturator vaginal tape (TOT) to treat SUI. METHODS: We compared patient characteristics, tape positioning, and surgical outcomes in 123 women undergoing a TOT procedure who were randomly assigned to have the surgical incision begin at 1/3 of the sonographically-measured urethral length (similar to the traditional retropubic approach) or 1/2 of the urethral length. RESULTS: It was feasible to place the tape according to intention in 99.2% of the study cohort. The overall cure rate was higher when the incision site began at 1/2 the urethral length (83.6%) than 1/3 (62.9%) (P = 0.01). In the subgroup analyses, only patients with normal urethral mobility had significantly different cure rates (85.7% vs. 55.2%, P = 0.02). No significant differences in cure rates were observed between the other mobility categories of the study groups-hypermobility was consistently associated with high cure rates and hypomobility with low cure rates. CONCLUSIONS: When surgically treating SUI with a TOT, incision at the mid-urethra using the 1/2 rule is recommended as it leads to better outcomes for most patients, particularly those with normal urethral mobility.