Usefulness of an algebraic fitting of nomograms allowing evaluation detrusor contractility in women.

AIMS: Nomograms based on Valentini-Besson-Nelson (VBN) model implying only 3 measurements (filling bladder volume, maximum flow-rate [Qmax] and detrusor pressure at Qmax) were recently developed to evaluate detrusor contractility (k) and urethral obstruction (U) in women. As their algebraic fitting leads to fast evaluations (Excel® software), our aims were applications to populations of non-neurologic women without and with bladder outlet obstruction (BOO). METHODS: The software was applied to measurements obtained during pressure flow studies. Hidden hypothesis of nomograms were no significant contribution of abdominal pressure between onset of flow and Qmax and standard nervous excitations until Qmax. Studied populations were 202 women without symptom suggestive of obstruction and 125 women with proven anatomical urethral obstruction who underwent urodynamic study. RESULTS: For non-obstructed women, a good agreement was found between the values of k and U obtained using nomograms or a complete VBN analysis of the recorded curves. Whatever the obstructive status, there was a good correlation between the value of k and U. Evolution with ageing was similar with higher values of k and U in the BOO group. Curves k(age) and U(age) gave coefficients allowing an age adjustment. The high k value in the detrusor overactive (DO) group was consistent with a similar effect to that of BOO on the detrusor. CONCLUSION: Evaluation of detrusor contractility (k) and urethral obstruction (U) can be obtained from the point of Qmax during pressure-flow study. Evolution with ageing is similar with (higher values) or without BOO. DO also induces an increased detrusor contractility. LEVEL OF EVIDENCE: 4.

Detrusor contractility in women: Influence of ageing and clinical conditions.

AIMS: We assume that the voiding process in women is governed by the detrusor contractility and a "urethral resistance". The value of these 2 parameters, respectively named k and U in the VBN (Valentini-Besson-Nelson) mathematical model of micturition is deduced from the VBN analysis of pressure-flow recordings (PFs). Our objectives were to search for a correlation between these 2 parameters and clinically relevant variables such as chief complaint, urodynamic diagnosis (UD), and age by decades. METHODS: PFs from 125 non-neurogenic women (mean age 58.0±17.2years [range 20-90years]) were retrospectively analyzed using the VBN model. VBN criteria for inclusion were maximum flow rate>2mL/s, voided volume>100mL, and non-interrupted flow. Evaluated parameters were k (without unit) and U (unit: cm H2O). Standard values were k=1.0 and U=0. RESULTS: VBN parameter ranges were k [0.14-1.55] and U [0.0-73.0cm H2O]. There was a significant correlation between k and U for the whole population (P<0.0001) with k=(.259+0.015*U) (R(2)=0.723) and each chief complaint. For UD, significant difference comparing k and U in phasic detrusor overactivity with intrinsic sphincter deficiency and urodynamic stress incontinence was noted. In sub-groups defined according to decades of age, the values of k and U remained similar in sub-groups for those who are less than 50years old and decreased regularly with ageing. CONCLUSION: The detrusor contractility can be easily evaluated in women; lower than in men, its range is less spread out but also adjusted to compensate a "urethral resistance". Phasic detrusor overactivity and post-menopausal age significantly affect detrusor force value. LEVEL OF EVIDENCE: 3.

[Quantification of bladder-outlet obstruction in males: standard method vc VBN method]. / Quantification de l'obstruction chez l'homme: comparaison des méthodes usuelles avec la méthode VBN.

GOAL: To compare the merits of two methods, standard (Abrams-Griffiths number, Schafer's classification, etc.) and VBN, to study bladder-outlet obstruction in men with benign prostatic hyperplasia (BPH). MATERIAL AND METHODS: The parameters deduced from both methods and from repeated pressure-flow studies were computed for a population of patients with BPH. Correlation coefficients between standard and VBN parameters were systematically evaluated. Test-retest reliability and inter-rater reliability of the VBN parameters were investigated. RESULTS: The VBN obstruction parameter was linearly corelated to the A-G number (R = 0.992) and thus is related to the provisional ICS obstruction nomogram. A simple modification to the standard index projected isometric pressure (PIP) yields an mPIP parameter strongly correlated with the VBN detrusor contraction-strength parameter (R = 0.962). VBN analysis reveals minor phenomena such as premature fading of the detrusor contraction to be responsible for much of the void-to-void variability of pressure-flow studies. Consequently, the primary VBN obstruction and contraction-strength parameters exhibit better test-retest and inter-rater reliability than the standard parameters and are less sensitive to changes in testing circumstances (bladder volume, urethral catheter size and psychological factors). CONCLUSION: With the standard approach to test bladder obstruction, two values: A-G and mPIP, derived from pressure-flow studies, best qualify the patient's voiding status. These parameters are simple to calculate but are sensitive to testing variations and minor phenomena. The VBN approach is more complicated, but its parameters for obstruction and detrusor contraction strength are less dependent on testing variations.

Pudendal enterocele with bladder involvement.

A 72-year-old diabetic women presented with a large left labial mass following multiple prior vaginal surgeries to correct vaginal vault prolapse, including two failed right-sided sacrospinalis fixation procedures and a near total colpocleisis. After failure of conservative management, a translabial repair of this pudendal hernia containing bladder was performed. Return of the labial mass 9 months later prompted a more extensive abdominal approach. To close the defect in the urogenital diaphragm and prevent its recurrence, an absorbable mesh was used. Then, to prevent enterocele recurrence, vaginal vault suspension to the sacral promontory and closure of the Douglas pouch were performed. A review of the literature is presented, with an analysis of risk factors and corrective surgical techniques.

Female outlet obstruction after repeated collagen injections.

An elderly woman who presented with severe irritative lower urinary tract symptoms after three consecutive collagen injections was diagnosed as being obstructed. The diagnosis was based on urodynamic, cystoscopic, and radiographic findings that disclosed numerous collagen deposits obstructing the bladder outlet and the proximal urethra. A transurethral resection of the collagen was performed with improvement in symptoms and flow pattern. Although irritative lower urinary tract symptoms after collagen injection could be related to local inflammatory changes, persistence and eventually worsening of these symptoms should alert to the presence of iatrogenic bladder outlet obstruction.

Contrast media reactions during voiding cystourethrography or retrograde pyelography.

Contrast media can be absorbed across the urothelium in amounts sufficient to cause severe anaphylactoid reactions. We report 2 cases of anaphylactoid reactions during voiding cystourethrography (VCUG) or retrograde pyelography (RGP). A retrospective review of 783 consecutive VCUGs or RGPs performed at our institution over the last five years revealed no other systemic contrast media reactions. Although our findings and a review of the literature discloses that the incidence appears to be extremely low, urologists and radiologists need to be aware that an anaphylactoid or vagal contrast medium reaction may develop during VCUGs or RGPs. In addition, these physicians need to be prepared to treat a reaction should one occur.

Proposed cutoff values to define bladder outlet obstruction in women.

OBJECTIVES: There is no accepted urodynamic definition of outlet obstruction in women. Currently, the diagnosis is made on the basis of history and radiographic and endoscopic findings. The goal of this study is to design a pressure-flow nomogram (PdetQmax/Qmax) and define cut-off values for obstruction. METHODS: Two groups were studied prospectively in an open study: 124 control and 35 clinically obstructed patients. All had a complete history, physical examination, normal neurologic evaluation, cystoscopy, voiding cystography, and urodynamics-with-pressure-flow study. Pressure-flow plot and receiver operator characteristic curves (ROCs) were constructed to determine optimal cut-off values to predict obstruction for peak flow rate (Qmax) and detrusor pressure at maximal flow (PdetQmax). RESULTS: The etiology of obstruction was previous anti-incontinence surgery (n = 13), large cystocele (n = 11), urethral stricture (n = 6), and other (n = 5). On the basis of ROC curves, using cut-off values of Qmax of 15 mL/s or less and 12 mL/s or less, sensitivity was 85.7% and 71.4%, and specificity 78.2% and 90.3%, respectively. Using cut-off values of PdetQmax of more than 25 and more than 30 cm H2O, sensitivity was 74.3% and 71.4%, and specificity 79.8% and 88.7%, respectively. Using a combined cut-off value of Qmax of 1 5 mL/s or less and PdetQmax of more than 20 cm H2O, sensitivity was 74.3% and specificity was 91.1%. CONCLUSIONS: Based on this prospective, controlled study, preliminary cut-off values were obtained for refining the definition of outlet obstruction in women.

Role of the four-corner bladder neck suspension to correct stress incontinence with a mild to moderate cystocele.

OBJECTIVES: Women undergoing four-corner bladder neck suspension were evaluated for subjective and objective results of the procedure. Patients were evaluated for continence, prolapse, and symptomatic status postoperatively. METHODS: Forty-seven women underwent four-corner bladder neck suspension for moderate cystocele with (44) or without (3) stress urinary incontinence. Mean and median follow-up were 37 months (range 15 to 80). To assess results of the four-corner bladder neck suspension, two sets of outcome measures were used (subjective questionnaire, including patient satisfaction, and objective physical examination, with standing voiding cystourethrogram) to compare pre- and postoperative data. RESULTS: At the time of follow-up, 25 patients (53%) reported no incontinence, 14 (30%) reported one incontinent episode per week, and 8 (17%) reported daily loss of urine. Twenty-seven (57%) had grade I or grade II cystoceles on follow-up examination and voiding cystourethrogram; however, only 12 (26%) experienced recurrent prolapse symptomatology. Overall patient acceptance of the procedure was high (70%). CONCLUSIONS: The four-corner bladder neck suspension is an effective option in the management of moderate cystocele.

Intravesical oxybutynin chloride: experience with 42 patients.

To evaluate the efficacy of intravesical oxybutynin chloride, 42 patients who were incontinent secondary to uninhibited detrusor contractions and had failed oral anticholinergic therapy were begun on intravesical oxybutynin chloride. Indications for intravesical therapy were detrusor hyperreflexia (N = 20), detrusor instability (N = 19), and bowel/bladder overactivity after augmentation cystoplasty (N = 3). A 5-mg tablet dissolved in 30 cc of sterile water was instilled into the bladder two to three times daily via clean self intermittent catheterization. With a mean follow-up of 18.4 months, no patient reported side effects as a result of the intravesical therapy. Nine patients (21%) dropped out of the study due to inability to tolerate the catheterization or difficulty retaining the solution in the bladder. Eighteen of the 33 patients (55%) who followed the protocol experienced elimination or significant improvement of their incontinence. The results of the current study confirm the safety and usefulness of intravesical oxybutynin in treating uninhibited detrusor contractions in a difficult patient population.

Dimethyl sulfoxide does not trigger urine histamine release in interstitial cystitis.

OBJECTIVES: Dimethyl sulfoxide (DMSO), an agent that provides symptomatic relief in patients with interstitial cystitis (IC) works via an unknown mechanism. We investigated whether DMSO acts as a chemical stimulant of mast cell degranulation. METHODS: A radioimmunoassay (RIA) specific for histamine was used to test this hypothesis. Twelve women with strictly diagnosed IC were treated with intravesical instillations of DMSO. Treatments were repeated at varying intervals, and each patient received three to six treatments. Urine histamine levels were measured before and after each intravesical instillation of DMSO. Dilutional effects of DMSO were corrected for by conversion of urine histamine concentration to urine histamine:creatinine ratio. RESULTS: The RIA was unaffected by the addition of DMSO to urine. No consistent change in the urine histamine:creatinine ratio following DMSO instillation was found. Trend analysis revealed no trend in the histamine:creatinine ratio with time. CONCLUSIONS: The relief of symptoms reported in 50% to 77% of patients treated with intravesical DMSO is not related to detectable mast cell release of histamine. Other mechanisms of action must be investigated to explain the beneficial effect of this agent.

Chemoattractant agents and nerve growth factor stimulate human spermatozoal reactive oxygen species generation.

OBJECTIVE: To investigate the ability of N-formyl-methionyl-leucyl-phenylalanine (f-MLP), complement 5a (C5a), and nerve growth factor (NGF) to stimulate human spermatozoal reactive oxygen species generation in fertile and infertile patients. DESIGN: Prospective, controlled study measuring human spermatozoal reactive oxygen species generation after addition of f-MLP, C5a, or NGF. SETTING: A large health maintenance organization. PATIENTS, PARTICIPANTS: The fertile group consisted of 14 men with established fertility and normal bulk semen parameters. The infertile group was comprised of 8 men who were infertile after > 18 months of unprotected sexual intercourse. INTERVENTIONS: The sperm samples were subjected to four test conditions: f-MLP stimulation, C5a stimulation, NGF stimulation, and no stimulation (control). MAIN OUTCOME MEASURE: Reactive oxygen generation was measured over a 15-minute period using the method of chemiluminescence. RESULTS: In both the fertile and infertile groups, reactive oxygen species generation was significantly enhanced by f-MLP, C5a, and NGF compared with controls. No significant difference in f-MLP- and C5a-stimulated reactive oxygen production was demonstrated between the infertile and fertile groups; however, there was a significant difference in reactive oxygen generation between infertile and fertile subjects when stimulated with NGF. CONCLUSIONS: The current study represents the first report of f-MLP-, C5a-, and NGF-stimulated reactive oxygen species generation by human spermatozoa. Nerve growth factor enhanced reactive oxygen species production to a greater extent in infertile subjects compared with fertile subjects. This points to a possible NGF-mediated biochemical defect in the sperm of infertile patients.

The pathophysiology of stress incontinence.

The factors contributing to stress incontinence of urine are reviewed and categorized with respect to their effects on coaptation and compression of the urethra. Intrinsic urethral dysfunction and poor anatomic support are discussed from both a functional and a pathophysiologic approach.

Transvaginal needle bladder neck suspension.

Like the transabdominal bladder neck suspension, the aim of the transvaginal needle suspension of the bladder neck is to suspend the bladder neck and urethra in a fixed retropubic position. Because the transvaginal technique does not require the splitting of the abdominal wall fascia, postoperative discomfort and convalescence may be lessened. Different techniques of transvaginal needle bladder neck suspension, including suspension of the bladder neck with a fascial sling, are discussed in detail.

Genitourinary fistulae. Vaginal approach for repair of vesicovaginal fistulae.

Controversy still remains concerning the timing of repair, the type of approach, and the technical guidelines most likely to prevent recurrence of both radiated and nonradiated vesicovaginal fistulae. The authors advocate the transvaginal approach because it avoids a cystotomy and involves minimal blood loss and consequently is followed by less postoperative discomfort and a shorter hospital stay. Included in this discussion are the techniques and results of the transvaginal approach for simple vesicovaginal fistulae as well as for complex cases and radiation fistulae.

Smooth-muscle physiology.

In the last several years, significant advances have been made in the understanding of bladder smooth muscle physiology. This article provides a summary for the clinician of current knowledge about the detrusor smooth muscle cell structure, function, and the relationship of structure to function in terms of bladder storage and physical properties such as compliance. The integration of this basic science knowledge into clinical practice is illustrated in discussion of two common disorders: detrusor instability, and outflow obstruction.

Complications of bladder neck suspension procedures.

Typical genuine stress urinary incontinence is the result of an anatomic defect, with most procedures designed to restore the support of the proximal urethra and bladder neck. Complications associated with these procedures have been presented to help facilitate an understanding of their etiology and prevention. Careful attention to patient selection, history and physical examination, and surgical detail can prevent most of these complications.

[Transatlantic view on tension-free vaginal tape]. / Le T.V.T vu d'une autre rive.

T.V.T. is still presented as a minimally invasive operation, but this is not the case in all hands according to the various series reported at the recent EAU congress in Brussels. The indications are also still poorly defined and the long-term effects of a synthetic, suburethral tension tape remain uncertain.

[Fixation of the vaginal vault by high midline levator myorrhaphy]. / Fixation du fond vaginal par myorraphie haute médiane des releveurs.

The treatment of prolapse of the vaginal vault is complex and requires abdominal or vaginal procedures associated with significant morbidity. For the last 10 years, the authors have been using a simple transvaginal vault fixation technique, which satisfies the requirements of functional surgery: restoration of anatomy, reduced morbidity, easeto learn. This article is intended to precisely describe the surgical technique and to present the results based on a series of 51 patients operated bwiththis technique.

[Interstitial cystitis: reevaluation of patients who do no respond to standard treatments]. / Cystites interstitielles: réévaluation des patients ne répondant pas aux thérapeutiques standards.

OBJECTIVE: Insterstitital cystitis (IC) is an uncommon disease without an existing positive diagnostic test. Our experience has been that it tends to be overly considered, with many patients treated for long periods with several different regimens and no improvement. This impression prompted a review of our recent experience in the exclusionary diagnosis of IC. MATERIAL AND METHODS: A retrospective review of patients referred to our specialty clinic between December 1995 and October 1998 revealed 23 patients (21 women, 2 men) who had been diagnosed with IC, and had received at least one treatment for this disease (intravesical DMSO or Heparin, Elmiron, 1-Arginine, or therapeutic hydrodistension) with little or no benefit. Our own evaluation of these patients included urinalysis, non-invasive uroflow, post void residual determination and office cystoscopy (all patients), filling cystometrogram and pressure-flow-EMG studies (21 patients), voiding cystourethrogram (17 patients), urethral MRI (9 patients), and other studies as indicated. The results of our reevaluation are reported. RESULTS: Of the 23 patients referred with a diagnosis of IC, only 4 were considered to meet the diagnostic criteria as established by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) after a thorough evaluation. One other patient did not meet the criteria but responded to medications for IC. Urethral pathology was a common finding (distal periurethral fibrosis causing obstruction in 5 patients, intraurethral wall diverticulum in 2, and chronic urethritis in 2), particularly among women with abnormal pressure flow studies during urodynamics. CONCLUSIONS: In our experience, many patients who carried the diagnosis of interstitial cystitis were found to have other causes contributing to their urinary symptoms after careful reassessment. Urodynamic studies were found to be of paramount importance in excluding the diagnosis in many cases. On the basis of our findings, we recommend that if local urethral tenderness is noted on physical examination or an abnormal pressure-flow relationship is seen during urodynamics, further investigation is warranted.

[Study of urethral anatomy and pelvic floor using MRI with surface and endorectal coil]. / Etude de l'anatomie urétrale et du plancher pelvien par IRM avec antenne de surface et antenne endorectale.

PURPOSE: Although high resolution MRI can play a critical role in the evaluation of diseases affecting the female urethra, normative values have not been established. In this retrospective study, the normal values for female urethral dimensions and its supportive structures were measured and compared using a body coil (BC) and endorectal coil (ERC), and correlated with age and menopause. MATERIAL AND METHODS: BC and/or ERC images of the pelvis in 20 patients (ages 27-82) with confined cervical cancer (stage IB or less) were reviewed. None of the patients had a history of urinary symptoms, pelvic prolapse, pelvic radiation, or prior bladder or urethral surgery. Images evaluated included axial and/or sagittal T2 weighted SE images of the lower pelvis before and/or after endorectal coil placement. Several measurements including urethral and bladder dimensions were obtained independently by two radiologists and compared statistically. Calculated urethral volume was correlated with the patients' age and menopausal status. The impact of calculated bladder volume on urethral dimensions was evaluated. Additional measurements of contiguous supporting structures were also correlated with age. RESULTS: Inter-rater reliability showed a strong intra-class correlation (95% CI) for urethral dimensions. A statistically significant difference between raters was only noted for the right pubovesical ligament measurement. Inter-technique reliability was also strong (95% CI) except for the distal transverse urethral dimension. Bladder volume did not effect measurement of urethral dimensions (p > .39). Lastly, calculated urethral volume utilizing the ERC technique showed an inverse correlation with age (p < 0.05) and with the BC a correlation with menopausal status (p < 0.05). CONCLUSIONS: Measurement of urethral dimensions by either ERC or BC MRI is reliably reproducible by independent radiologists. There is no need for standardization of bladder volumes during urethral MRI. Normative values for all measured angles and dimensions are presented. There is evidence of correlation of urethral volume with age and menopause, though a larger study is warranted.