Retropubic tape surgery for stress urinary incontinence: can women be cured without voiding dysfunction?

PURPOSE: Retropubic tension free vaginal tape (RP-TVT) has become the gold standard for surgical management of female stress urinary incontinence but is associated with voiding dysfunction (VD). We developed for more than 10 years a reproductible and totally tension free tape procedure. Our goal is to determine efficiency of this technique compared to the incidence of VD. METHODS: We retrospectively reviewed patients who underwent RP-TVT in our center between 2011 and 2019. Subjective cure, VD (determined as maximum urinary flow rate (Qmax) < 15 mL/s or post void residual (PVR) volume > 150 mL, or tape's section or resection requirement for underactive bladder (UB) with significant PVR) was assessed at 1 year. The main objective was the evaluation of subjective cure and VD at 1 year. RESULTS: On the 319 patients reviewed, 93% of the patients were dry and 10.9% presented VD at one year. UB (OR = 5.01 [1.55-16.44], p = 0.008), preoperative Qmax < 15 mL/s (OR = 0.89 [0.84-0.95], p = 0.001) and previous incontinence surgery (OR = 4.20 [1.54-11.46], p = 0.005) were associated with VD. Acute urinary retention concerned 4.7% of the population and all were resolved after 6 weeks postoperatively. We reported 0.3% of de novo urgency and patients without VD showed a significant decrease of their voiding time at 1 year. CONCLUSION: The placement of RP-TVT without intraoperative tightening seems to be a safe technique ensuring a high cure rate and low occurrences of bladder outlet obstruction.

[Intravesical instillations for inflammatory and sensory chronic bladder diseases: Literature review and guide to clinical practice]. / Instillations endovésicales pour les cystopathies chroniques inflammatoires et douloureuses : revue de la littérature et guide de la pratique clinique.

INTRODUCTION: Inflammatory and sensory chronic bladder diseases have a significant impact on quality of life. These pathologies share alteration of the layer between urine and urothelium, making the use of topical agents appropriate. OBJECTIVES: Review the efficacy and tolerance of intravesical treatments for these pathologies. Give practical guidelines for the use of agents currently available in France. METHOD: A narrative review was performed in March 2021 using PubMed/MEDLINE, Google Scholar and the international guidelines. Pharmaceutical companies and pharmacies were interviewed. RESULTS: Although numerous molecules were tested over the last 5 decades, only dimethylsulfoxyde and glycosaminoglycans are available in France today. Results are promising: response rates are up to 95% and 84% respectively in bladder pain syndrome. In urinary tract infections, glycosaminoglycans could decrease annual number of cystitis by 2.56 (95% confidence interval (CI) -3.86, -1.26; P<0.001) and increase the time to first cystitis recurrence by 130 days (95% CI: 5.84 - 254.26; P=0.04). In radiation cystitis, results could be comparable to hyperbaric oxygen regarding pain and frequency of voiding (-1.31±1.3 visual analogic scale et -1.5±1.4 voiding per day, respectively, at 12 months, P<0.01). However, literature has a low level of evidence. CONCLUSION: Chronic bladder diseases have limited treatment options. Intravesical agents are a good alternative, although their cost is significant and their outcome uncertain.

2021 opinion from the CUROPF on THE efficacy and safety of mid-urethral slings used in women WITH urinary stress incontinence.

OBJECTIVE: To determine the usefulness of mid-urethral slings (MUS) in the surgical management of women presenting with urinary stress incontinence (USI) METHOD: A consensus committee of multidisciplinary experts (CUROPF) was convened and focused on PICO questions concerning the efficacy and safety of MUS surgery compared to other procedures and concerning which approach (retropubic (RP) vs transobturator (TO)) should be proposed as a first-line MUS surgery for specific subpopulations (obese; intrinsic sphincteric deficiency (ISD); elderly) RESULTS: As compared to other procedures (urethral bulking agents, traditional slings and open colposuspension), the MUS procedure should be proposed as the first-line surgical therapy (strong agreement). MUS surgery can be associated with complications and proper pre-operative informed consent is mandatory (strong agreement). Mini-slings (SIS/SIMS) should only be proposed in clinical trials (strong agreement). Both RP and TO approaches may be proposed for the insertion of MUS (strong agreement). However, if the woman is willing to accept a moderate increase in per-operative risk, the RP approach should be preferred (strong agreement) since it is associated with higher very long-term cure rates and as it is possible to completely remove the sling surgically if a severe complication occurs. The RP approach should be used for the insertion of MUS in a woman presenting with ISD (strong agreement). Either the RP or TO approach should be used for the insertion of MUS in an obese woman presenting with USI (strong agreement). In very obese women (BMI ≥35-40kg/m2), weight loss should be preferred prior to MUS surgery and bariatric surgery should be discussed (strong agreement) CONCLUSION: The current Opinion provides an appropriate strategy for both the selection of patients and the best therapeutic approach in women presenting with USI.

[Complications of mid-urethral sling - A review from the Committee for Female Urology and Pelviperineology for the French Association of Urology]. / Complications des bandelettes sous urétrales : une revue de la littérature par le Comité d'urologie et pelvipérinéologie de la femme de l'Association française d'urologie.

INTRODUCTION: Placement of a mid-urethral sling is the gold standard in the surgical management of stress urinary incontinence in women in France. The cure rate of this material is no longer to be demonstrated, but the per- and post-operative complications are currently the subject of a growing controversy not only in Europe but also across the Channel and across the Atlantic, having led to the modification of operative indications. In France, recommendations are also evolving with a stricter framework for indications for surgery by multidisciplinary consultation meeting and an obligation for postoperative follow-up in the short and long term. OBJECTIVES: In this context, CUROPF realized a review of the literature bringing together the available scientific evidence concerning the occurrence of per- and post-operative complications relating to the installation of mid urethral sling. The bibliographic search was carried out using the Medline database and 123 articles were selected. RESULTS: Analysis of the data highlights various complications, depending on the implanted material, the patient and the indication for surgery. The retro-pubic mid urethral sling provides more bladder erosion during surgery (up to 14%), more suprapubic pain (up to 4%) and more acute urinary retention (up to 19,7%) and postoperative dysuria (up to 26%). The trans obturator mid-urethral sling is responsible for more vaginal erosion during the operation (up to 10,9%), more lower limb pain of neurological origin (up to 26,7%). The risk of developing over active bladder is similar in both procedures (up to 33%). But these risks of complications must be balanced by the strong impact of urinary incontinence surgery on the overall quality of life of these women. CONCLUSION: Thus, surgical failure and long term complications exist but should not limit the surgical management of stress urinary incontinence with mid urethral tape. Women should be treated with individualized decision-making process and long-term follow -up is necessary.

[Vaginal LASER therapy for genito-urinary disorders: A systematic review and statement from the Committee for Female Urology and Pelviperineology of the French Association of Urology]. / Utilisation du LASER vaginal pour le traitement des pathologies génito-urinaires : revue systématique de la littérature et position du CUROPF.

INTRODUCTION: Vaginal LASER therapy is increasingly used in the field of urogynecology, but several points remain unclear. Our goal was to produce a systematic review of available evidence and provide a critical appraisal of available data. METHODS: A systematic review until march 2020 was conducted using PubMed/MEDLINE, Cochrane and Embase databases. All studies about vaginal LASER use in the field of urogynecology were included. RESULTS: Forty studies have been included (8 for genitourinary syndrome of menopause, 19 for stress urinary incontinence, 3 for overactive bladder, 7 for urogenital prolapse, 3 for other indications). Data were heterogeneous, and level of evidence was weak or very weak. Few studies were comparative, and only 3 were randomized). Mild improvement of symptoms and quality of life and limited satisfaction were seen for genitourinary syndrome, stress urinary incontinence, overactive bladder and prolapse. Few adverse events were reported. However, major methodological biases were noted regarding efficacy and safety evaluation. No long-term results were available. CONCLUSIONS: While Vaginal LASER therapy seem to provide encouraging results, the level of evidence supporting its use was weak, especially regarding long-term outcomes. Studies of better quality are warranted before any recommendation can be made. Current use should be limited to clinical research.

Risk factors and management of persistent postpartum urinary retention.

INTRODUCTION AND HYPOTHESIS: Our objective was to identify the risk factors for persistent postpartum urinary retention (PUR). MATERIAL AND METHODS: This multicenter retrospective case-control study included 91 women with PUR exceeding 400ml during the first urinary catheterization performed after delivery, from 2010 through 2015. Two groups were defined: one included 25 women with PUR that persisted longer than 3 days, and the other, comprising 66 women with PUR that lasted three days or less. We compared the two groups to define the risk factors. We also studied the outcome of the women with persistent PUR. RESULTS: The time until diagnosis/management and the urinary volume at the first catheterization after delivery were both significantly greater in the group with persistent PUR (11h vs 7.8h and 1020ml vs 715ml, P<0.05). Multivariate logistic regression indicated that cesarean delivery, perineal tear or episiotomy, and fluid administration in the delivery room were also associated with the persistence of PUR (P<0.05). CONCLUSION: Time in the management of urinary retention can cause bladder overdistension that can substantially delay its resolution. More attentive monitoring of voiding, could reduce the duration of this complication and thereby improve patient comfort and minimize long-term complications. BRIEF SUMMARY: This multicenter retrospective study show that the time in the management of urinary retention is a major factor of persistent urinary retention.

[Laparoscopic sacrocolpopexy for pelvic organ prolapse: guidelines for clinical practice]. / Traitement du prolapsus génital par promontofixation laparoscopique : recommandations pour la pratique clinique.

INTRODUCTION: Open sacrocolpopexy have demonstrated its efficiency in surgical treatment of pelvic organ prolapse with an important backward on a large number of patients. Laparoscopic sacrocolpopexy reproduced the same surgical technique with reduced morbidity and may benefits from the recent development of robotic. Numerous technical variants have been developped around the original procedure but results seems not ever equivalent. Our objectives are to establish practical recommendations issues from the data of the litterature on the various technical aspects of this technique. METHODS: This work leans on an exhaustive lecture of the literature concerning meta analyses, randomized tries, registers, controlled studies and the largest non controlled studies published on the subject. Recommendations were developed by a multidisciplinary workgroup then reread and amended by an also multidisciplinary group of proofreaders (urologists, gynecologists, gastroenterologists and surgeons). The methodology follows at best the recommendations of the HAS with a scientific argument for every question (accompanied with the level of proof, NP) and the recommendations, the officers (In, B, C and agreement of experts) and validated at the end of the phase of review. RESULTS: Surgical treatment of uro-genital prolapse by abdominal route classically associated hystero and anterior vaginopexy on the sacral ligament with a synthethic mesh. There are no argument to systematically associated a posterior vaginopexy to prevent secondary rectocele (level C). The consensual indication of laparoscopic rectopexy is represented by symptomatic rectal prolapse, the anatomical and functional results of which are the best estimated (level C). The surgical treatment of rectocele, elytrocele and enterocele with a posterior vaginopexy is not well estimated (level 3). Thus, it is not possible to conclude on the results of a posterior vaginal fixation with a mesh in these indications (AP). In the absence of colpocèle, the interest brought by the posterior vaginal mesh is not established (level 3). There is no comparative studies which allows to conclude on the type and mode of fixation of the prostheses of sacrocolpopexy. We would only report the most common practices without other conclusion. The anterior mesh is usually fixed upper on the anterior part of uterus cervix and lower on the anterior vaginal wall. These fixations are most of the time made by suture and on the promontory with non absorbable suture. The great majority of the authors recommend to make a peritonisation of prostheses to limit the risk of post-operative occlusion. It is now recommended to use only 2 kind of not absorbable prostheses: type I (macroporous polypropylene) or type III (polyester) and not to use any more prostheses type II (PTFE, Silicone) (level C) because of a high rate of mesh erosion: PTFE (9 %) or Silicone (19%) (level 3). Biological prostheses are no more recommended, because of short and medium-term lower anatomical results (level B). Anatomical and functional results are not stastistically differents between laparotomy and coelioscopy (NP1) but the comparison of tong-term results between both ways is not yet established. Coelioscopy allows significant reduction of blood losses, hospital stay and return to normal activity (level 1). Furthemore, there is a higher level of post-operative complications in laparotomy (level 1). When sacrocolpopexy is indicated, coelioscopy is thus recommended (level B). During coelioscopic sacrocolpopexy, anatomical and functional result have not shown any significance difference when using or no a robotics assistance but real randomised studies does not exist (level 2). In comparison to coelioscopy, robotic seems not to improve post-operative consequences and not to decrease the rate of complications of sacrocolpopexy (level 3). Robotic assistance cannot be yet recommended when a coelioscopic sacrocolpopexy is indicated (rank B). CONCUSION: Sacrocolpopexy using not absorbable meshes allows to cure pelvic organ prolapses with very good results with few complications in terms of prothetic exposure and infection and thus is now considered as the referent prothetic surgical technique in this indication. Thus, it seems very important to establish clear recommendations on the numerous operating technical variants which developed around the original technique. © 2016 Published by Elsevier Masson SAS.

[Are there selection criteria between abdominal approach and vaginal route for genital prolapse surgical management?]. / Existe-t-il des critères de choix entre les voies abdominale et vaginale dans la cure du prolapsus génital ?

INTRODUCTION: The never ending debate over the surgical approach of genital prolapse repair (abdominal versus vaginal route) is as passionate as ever. The available literature may support a multidisciplinary analysis of our expert daily practice. OBJECTIVE: Our purpose was to define selection criteria for surgical approach between abdominal and vaginal route in the management of genital prolapse by reviewing the literature. MATERIAL AND METHODS: Systematically review of the literature concerning comparative anatomical and functionnal results of surgery of pelvic organ prolaps by vaginal or abdominal route. RESULTS: We were confronted to the lack of data in the literature, with few prospective randomized comparative studies. Many limitations were identified such as small populations in the studies, no description of sub-population, multiplicity of surgical procedures. Moreover, vaginal route was compared to sacral colpopexy by open abdominal approach, whereas laparoscopic sacrocolpopexy is now recommended. Only one prospective randomized comparative trial assessed laparoscopic sacrocolpopexy and vaginal approach, in which was used a mesh withdrawn from the market. CONCLUSION: The lack of available randomized trials makes it impossible to define HAS compliant guidelines on this topic. However, selection criteria for each surgical approach and technique were drawn from experts' advices. © 2016 Published by Elsevier Masson SAS.

[Intrinsic sphincter deficiency and female urinary incontinence]. / Insuffisance sphinctérienne et incontinence urinaire de la femme.

OBJECTIVE: Stress urinary female incontinence (SUI) is primary due to intrinsic sphincter deficiency (ISD) and urethral hypermobility. Despite a lack of standardised international definition, ISD needs to be clearly diagnosed in order to be correctly treated. This work is an update about the female ISD produced from a review of a published article. MATERIAL AND METHODS: This review of article published on this subject in the Medline (Pubmed database), selected according to their scientific relevants, of consensus conferences and published guidelines, has been performed by the committee for women pelvic floor surgery of the French Urological Association. RESULTS: Although there is no international consensus definition, we can consider that the ISD is a composite concept combining urodynamic data (MUCP < 20 or 30 cmH20) and one or more clinical information (no urethral mobility, negative urethral support test, failure of a first surgery, leakage during abdominal straining, high stress incontinence scores). Imaging can provide additional evidence for intrinsic sphincter deficiency diagnosis, but the correlation between imaging and function remains low. By standardizing methodology and interpretations to better diagnose women with ISD, it may be possible to improve preoperative planning and outcomes for these patients. A retropubic midurethral sling can be performed as a first surgery. In case of a lack of urethral mobility, the artificial urinary sphincter (AUS) remains the gold standard. Adjustable continence therapy (ACT(®)) can be proposed as an alternative option. The efficacy and safety of muscle-derived cell therapy in ISD needs more studies. Injection of bulking agents may be an option according to the severity and the expectations of the patient. Bladder overactivity needs to be treated as first-line in case of mixed urinary incontinence. In elderly women, a careful evaluation of the bladder contractility and comorbidity must be performed. A geriatric evaluation can be necessary. CONCLUSION: Clinical and paraclinical assessment allow to confirm the diagnosis of female ISD, to estimate its severity, and to identify associated mechanisms of incontinence (urethral hypermobility, bladder overactivity) to choose the most adapted treatment.

[Guidelines for the treatment of non-neurological urinary incontinence in women using periurethral balloons]. / Recommandations pour le traitement de l'incontinence urinaire féminine non neurologique par ballons péri-urétraux.

A new minimally invasive technique using an adjustable implantable material has recently been developed: adjustable periurethral balloons. Initially designed by Uromedica, Inc., Plymouth, MN, USA, they are currently marketed in France by Medtronic (Minneapolis, MN, USA), called ACT (Adjustable Continence Therapy). Given the data reported in the literature today, ACT devices in women should only be a last-resort technique. They can only be implanted in patients presenting urinary incontinence due to sphincter deficiency with no urethral hypermobility (negative support maneuvers), in cases of failure of other therapies, or when placing an AUS is contraindicated or refused by the patient (French National Health Authority).

[Synthesis of the guidelines for the treatment of non-neurological urinary incontinence in women]. / Synthèse des recommandations pour le traitement de l'incontinence urinaire féminine non neurologique.

The last two decades have brought about new medical and surgical treatments revolutionizing care for non-neurological urinary incontinence in women. Many studies, often randomized prospective studies with sufficient follow-up, have validated the therapeutic choices and shown them not to be part of a fad or marketing pressures. The French Association of Urology (L'Association Française d'Urologie), through its Committee on Women's Urology and Pelviperineology (Comité d'Urologie et de Pelvipérinéologie de la Femme), proposes its recommendations. These were established by an expert group of specialists (urologists, gynecologists, and physical therapists), based on a review of the literature but taking into account the daily practices in academic and private practice settings. Between evidence-based medicine and reality in the field, these recommendations attempt to propose realistic and applicable strategies.

[Neurourological consequences of gynaecological surgery (endometriosis, simple hysterectomy, radical colpohysterectomy), colorectal surgery and pelvic radiotherapy]. / Les conséquences neuro-urologiques de la chirurgie gynécologique (endométriose, hystérectomie simple, colpo-hystérectomie elargie), de la chirurgie colo-rectale et de la radiothérapie pelvienne.

Apart from damage to bladder innervation, a number of local diseases and treatments such as radiotherapy can induce lower urinary tract functional disorders. Some of these disorders can be treated according to the principles used in the management of neurogenic bladder The purpose of this review is to report the functional consequences of pelvic endometriosis, radiotherapy, colorectal surgery and urinary incontinence surgery with particular emphasis on situations in which a neurogenic mechanism is suspected.

[Unusual metastasis of renal carcinoma]. / Metastases inhabituelles du cancer du rein.

Renal carcinoma, the third most common urological cancer, induces presence of metastases in 75% of cases. The most affected sites for metastasis are the lungs, the lymphatic system, bones, the liver, adrenal glands and the brain with sometimes a cancer free period of several years prior to evolutionary recurrence of the disease. The aim of this literature review is to report on secondary uncommon renal localizations by underlining their clinical significance, as well as main characteristics, in order to provide guidelines for effective patient diagnosis and therapeutic management.

Management of coralliform lithiasis on renal allograft with bricker-type ureterointestinal anastomosis.

PURPOSE: The authors report the management of a coralliform lithiasis that occurred in a renal allograft in association with a Bricker ureterointestinal anastomosis for urinary diversion. MATERIALS AND METHODS: A 58-year-old patient with a significant previous urological history, ie, surgery for childhood incomplete bladder extrophy, trans-ileal Bricker type ureterostomy, and in the end a renal allograft, presented with hematuria and septicemia. Complete radiological examination revealed an obstructive upper tract coralliform lithiasis in the transplanted kidney. A percutaneous nephrolithotomy also was performed for surgical treatment. RESULTS: On postoperative day 2, a urinary fistula was observed at the nephrostomy orifice. The Bricker ureterointestinal anastomosis was located at the same level as the nephrostomy orifice, which maintained upper urinary high pressures as well as the fistula. CONCLUSIONS: Possible preexistent lithiasis in a donor kidney should not be overlooked. In the management of kidney stones larger than 3 cm, percutaneous nephrolithotomy remains the "gold standard" procedure even in cases of external urinary diversion. We proposed an original management of the previously described postoperative complication using a hyperpression drainage tube device in association with a JJ stent.

[Role of helical tomodensitometry in the early diagnosis of renal infarction]. / Intérêt de la tomodensitométrie hélicoïdale dans le diagnostic précoce de l'infarctus rénal.

INTRODUCTION: Renal infarction is a rare and often difficult diagnosis. The objective of this study was to demonstrate that contrast-enhanced spiral CT in patients presenting features of renal colic, can establish the diagnosis by confirming the presence of infarction of the renal parenchyma. MATERIAL AND METHODS: Over a 10-month period, the authors proposed the following decision flow-chart for all patients admitted with clinical features of renal colic: plain abdominal x-ray and first-line renal ultrasound, which, in the absence of a diagnosis (stones or dilatation of cavities), were completed by unenhanced spiral CT scan. When these examinations were normal, contrast-enhanced spiral CT scan was then performed. RESULTS: 300 patients were included in this study, and CT was performed in 40 cases. This management allowed the diagnosis of infarction of the renal parenchyma in three patients, who are described here. When unenhanced CT sections do not reveal any abnormality, contrast-enhanced sections are essential to visualize the infarcted zone, seen as a triangular low density lesion with clearly defined margins and a vascular topography. CONCLUSION: Contrast-enhanced spiral CT should now be considered to be the reference examination for the assessment of non-documented renal colic. This recent imaging modality should allow the diagnosis of a greater number of infarctions of the renal parenchyma, which formerly remained undiagnosed.