5-year continence rates, satisfaction and adverse events of burch urethropexy and fascial sling surgery for urinary incontinence.

PURPOSE: We characterized continence, satisfaction and adverse events in women at least 5 years after Burch urethropexy or fascial sling with longitudinal followup of randomized clinical trial participants. MATERIALS AND METHODS: Of 655 women who participated in a randomized surgical trial comparing the efficacy of the Burch and sling treatments 482 (73.6%) enrolled in this long-term observational study. Urinary continence status was assessed yearly for a minimum of 5 years postoperatively. Continence was defined as no urinary leakage on a 3-day voiding diary, and no self-reported stress incontinence symptoms and no stress incontinence surgical re-treatment. RESULTS: Incontinent participants were more likely to enroll in the followup study than continent patients (85.5% vs 52.2%) regardless of surgical group (p<0.0001). Overall the continence rates were lower in the Burch urethropexy group than in the fascial sling group (p=0.002). The continence rates at 5 years were 24.1% (95% CI 18.5 to 29.7) vs 30.8% (95% CI 24.7 to 36.9), respectively. Satisfaction at 5 years was related to continence status and was higher in women undergoing sling surgery (83% vs 73%, p=0.04). Satisfaction decreased with time (p=0.001) and remained higher in the sling group (p=0.03). The 2 groups had similar adverse event rates (Burch 10% vs sling 9%) and similar numbers of participants with adverse events (Burch 23 vs sling 22). CONCLUSIONS: Continence rates in both groups decreased substantially during 5 years, yet most women reported satisfaction with their continence status. Satisfaction was higher in continent women and in those who underwent fascial sling surgery, despite the voiding dysfunction associated with this procedure.

Lost to follow-up in high level evidence-based studies related to the surgical management of lower urinary tract symptoms secondary to benign prostatic enlargement: does it matter?

AIMS: A contemporary review of the literature on benign prostatic hyperplasia (BPH) for lost to follow-up (LTF) rate was performed to evaluate the significance of LTF in the surgical management of lower urinary tract symptoms (LUTS) secondary to benign prostatic enlargement (BPE). METHODS: Randomized clinical trials (RCT level I) on the surgical treatment of LUTS secondary to BPE, with at least 12-month follow-up, from 1/1995 to 10/2010 were searched on PUBMED. Data reviewed included types of study, number of participating centers or hospitals, sample size calculation, surgical techniques, power calculation, estimated dropout rate, duration of follow-up, rate and reasons for LTF. RESULTS: Forty-eight RCT articles were identified. Eleven articles gave details on sample size calculation, and 13 explained their LTF rate after reaching LTF patients by mail or telephone. Percentages of LTF patients were 12% (492/4202) at 12 months in 39 articles, 21% (398/1891) at 24 months in 16 articles, 33% (485/1479) at 36 months in 11 articles, 41% (283/694) at 48 months in 6 articles, and 56% (409/729) at ≥60 months in 6 articles. Fifteen articles reported no missing data, mostly because of small sample size or short follow-up. Only 7 articles defined LTF patients as treatment failure and reported outcomes accordingly. CONCLUSIONS: The increase in LTF rate over time compromises the strength of the conclusions from the leftover patient population. Only 15% of RCTs adhered to the CONSORT statement by considering their LTF patients as treatment failures.

Quality of life after surgery for stress incontinence.

This study investigated changes in condition-specific quality of life (QOL) after surgery for stress urinary incontinence. Data from 655 women in a clinical trial comparing the Burch and fascial sling were examined. Improvement in QOL, measured with the Incontinence Impact Questionnaire (mean decrease 133.1; SD 109.8), was observed 6 months after surgery and persisted at 24 months. Women for whom surgery was successful (regardless of surgery type) had greater improvement in QOL (mean decrease 160.0; SD 103.9) than did women for whom surgery was not successful (mean decrease 113.6; SD 110.9; p < 0.0001), although not statistically significant after adjusting for covariates. Multivariable analysis showed that QOL improvement was related to decreased urinary incontinence (UI) symptom bother, greater improvement in UI severity, younger age, Hispanic ethnicity, and receiving Burch surgery. Among sexually active women, worsening sexual function had a negative impact on QOL. Improved QOL was explained most by UI symptom improvement.

Reference urodynamic values for stress incontinent women.

OBJECTIVE: To determine reference urodynamic values for preoperative urodynamic studies in women undergoing surgery for pure or predominant stress urinary incontinence (SUI). MATERIALS AND METHODS: Six hundred fifty-five women with pure or predominant SUI were enrolled in a multicenter surgical trial and were randomized to undergo a Burch or autologous fascia sling procedure as part of the Urinary Incontinence Treatment Network (UITN) Stress Incontinence Surgical Treatment Efficacy Trial (SISTEr). Preoperative free uroflowmetry, filling cystometry, and pressure flow studies were performed in all women using a standardized research protocol and standardized urodynamic interpretation guidelines. We define the normal range of urodynamic values in this population as the values that encompass 95% of the results. RESULTS: In 655 women undergoing filling cystometry in the standing position, baseline vesical and abdominal pressures were between 12 and 60 cm H(2)O. The upper limit of detrusor pressure increase during bladder filling to maximum cystometric capacity was 16 cm H(2)O. Ten percent of women who qualified for stress incontinence surgery with a positive cough stress test on physical exam did not demonstrate urodynamic stress incontinence (USI) and less than 10% of subjects in this study demonstrated detrusor overactivity. CONCLUSIONS: Results from a large cohort of women with SUI are now available for quantitative plausibility assessments or as reference values when interpreting urodynamic studies.

Interrater reliability of filling cystometrogram interpretation in a multicenter study.

PURPOSE: As part of a continuous quality control effort to measure the interrater reliability of urodynamic studies performed at multiple centers, we compared agreement levels for urodynamic studies between central and local physician reviewers. We report interrater reliability findings for the filling cystometrogram. MATERIALS AND METHODS: Following a satisfactory interrater reliability study among 4 central physician reviewers in 33 tracings 36 urodynamic study tracings from 9 Urinary Incontinence Treatment Network continence treatment centers and 13 Urinary Incontinence Treatment Network certified urodynamic study testers were randomly selected for review. These tracings were originally interpreted by 11 local physician reviewers using standardized Urinary Incontinence Treatment Network interpretation guidelines. Each of the 4 central physician reviewers reviewed 9 randomly assigned tracings and none reviewed tracings from his or her center. Local and central physician reviewers were instructed to categorize values as invalid if specified technical quality assurance standards were not met or the signal pattern suggested implausible values because of technical deficiencies. An intraclass correlation coefficient was calculated for continuous (numerical) variables and a kappa statistic was calculated for qualitative values with acceptable agreement defined a priori as an intraclass correlation coefficient of greater than 0.6. RESULTS: Filling cystometrogram baseline pressure, Valsalva leak point pressure, and volume and pressure measurements at maximum cystometric capacity had excellent intraclass correlation coefficients of 0.74 to 0.99. There were no significant differences between local and central physician reviewer means, indicating excellent agreement. CONCLUSIONS: With proper quality control measures in place and a set of standardized interpretive guidelines excellent interrater reliability between local and central physician reviewer can be achieved for numerical cystometrogram variables.

[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.

Standing cystourethrogram: an outcome measure after anti-incontinence procedures and cystocele repair in women.

OBJECTIVES: To evaluate the standing voiding cystourethrogram (VCUG) with lateral views as an outcome measure to objectively document the correction of the urethral angle and cystocele in women who underwent various types of pelvic surgery. METHODS: A control group of 76 continent patients was selected who had VCUGs performed for indications other than incontinence. Patients with preoperative and postoperative VCUGs after anterior vaginal wall suspension for urethral hypermobility and grade 1 or 2 cystocele (UH group) or repair of grade 3 cystocele (C group) were selected and compared with age-matched controls from the control group. RESULTS: Among the control group, the mean +/- SD urethral angle at rest was 12.5 degrees +/- 13.1 degrees and the urethral angle at straining was 24.7 degrees +/- 15.6 degrees (P <0.001). The urethral angle at rest increased significantly from women in their 20s to their 80s. In the UH group (n = 52), the preoperative mean urethral angle at rest and at straining was 25.7 degrees +/- 13.6 degrees and 42.6 degrees +/- 15.9 degrees, respectively, a difference of approximately 20 degrees. The postoperative urethral angles at rest and at straining did not statistically differ from those of the age-matched controls. In the C group (n = 36), the postoperative urethral angle at rest did not statistically differ from that of the age-matched controls. The lateral height of the cystocele demonstrated significant improvement in the UH and C groups. CONCLUSIONS: The standing VCUG is a reproducible outcome measure to preoperatively and postoperatively document the urethral angle. Using age-matched controls, a more objective definition of urethral hypermobility was obtained. Changes in cystocele height were observed postoperatively with a return to comparable age-matched control values.

[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.

Up-regulation of a gene homologous to the human tumor necrosis factor receptor associated factor 6 gene in the obstructed rabbit bladder determined by differential display polymerase chain reaction.

PURPOSE: We identified differentially expressed genes in the rabbit bladder after partial outlet obstruction. MATERIALS AND METHODS: Differential display polymerase chain reaction (PCR) was performed on smooth muscle tissue from normal, 2 and 6-week obstructed rabbit bladders. Semiquantitative reverse transcriptase PCR, Western and RNA blot analysis were done to confirm messenger RNA and protein up-regulation. RESULTS: A signal transducing protein human tumor necrosis factor receptor associated factor 6 (TRAF6)-like protein was identified on differential display PCR. TRAF6-like protein was up-regulated in rabbit bladders after 2 weeks of partial outlet obstruction. Reverse transcriptase PCR demonstrated TRAF6-like protein in bladder muscle tissue and semiquantitative analysis confirmed up-regulation in 2-week obstructed tissue. These findings were confirmed by RNA and Western blot analysis. CONCLUSIONS: TRAF6-like protein is up-regulated during the early phase of bladder outlet obstruction in rabbits. To our knowledge involvement of this gene in bladder outlet obstruction has not been described previously. TRAF6 may have a role in the regulation of molecular changes during the early bladder response to outlet obstruction, such as the up-regulation of growth factors and proto-oncogenes. Further understanding of this signaling pathway and its role in bladder outlet obstruction may open new avenues for treating detrusor dysfunction.

Contractile protein expression in bladder smooth muscle is a marker of phenotypic modulation after outlet obstruction in the rabbit model.

PURPOSE: We determined changes in contractile protein expression before and after the relief of partial bladder outlet obstruction in the rabbit model and assessed their potential role as predictors of recovery. MATERIALS AND METHODS: We examined the ratio of the smooth muscle myosin heavy chain isoforms SM2-to-SM1, caldesmon isoform expression and bladder function in obstructed and unobstructed adult rabbit bladders. Cystometry, sodium dodecyl sulfate-polyacrylamide gel electrophoresis and Western blot analysis were done to determine changes in bladder function and contractile protein expression. RESULTS: Overall we observed significant correlation of bladder weight with the SM2-to-SM1 ratio (p <0.05). Regardless of the duration of obstruction (up to 10 weeks) the ratio appeared to stabilize around a value comparable to that in fetal rabbit smooth muscle cells, suggesting a reversal of SM2 and SM1 expression to a level similar to that at the fetal stage. The pattern of h and l-caldesmon isoform expression showed an increase in l-caldesmon expression in obstructed bladders. Except for decreased leak point pressure in the obstructed group we noted no statistically significant urodynamic changes in bladder capacity or compliance. CONCLUSIONS: There is significant correlation of bladder weight, which is the best known marker of obstruction, with the SM2-to-SM1 ratio. The myosin heavy chain isoform expression ratio appears to be an indicator of phenotypic modulation in bladder smooth muscle before and after the relief of bladder outlet obstruction. Thus, it may be useful as a marker of bladder dysfunction and predictor of functional recovery. Regression to a fetal pattern of protein expression may suggest irreversible damage to smooth muscle cells, possibly limiting recovery.

Vaginal vault fixation and prevention of enterocele recurrence by high midline levator myorraphy: physical examination and questionnaire-based follow-up.

OBJECTIVES: To assess outcome following a vaginal repair (high midline levator myorraphy, HMLM) for vaginal vault prolapse. METHODS: Women were identified who had undergone HMLM between December 1995 and September 1998. A structured telephone interview consisting of 5 questions was conducted in all those who could be reached. The most recent results of physical examination, based on office records, were also collected. RESULTS: Thirty-five of 47 women completed the interview (average age 71 years, mean time since surgery, 27.9 months). Five patients had developed recurrent prolapse requiring repair (anterior enterocele in 3, vault prolapse in 1, symptomatic cystocele in 1). Recurrent cystoceles were noted on examination in 7 women (5 grade 1, 2 grade 2). Overall, 17 women were extremely satisfied with the result (>90% satisfied); 6 were dissatisfied (<50%). Five women were noted to have transiently reduced unilateral ureteral drainage intraoperatively, and all cases were resolved after the removal or replacement of one of the levator myorraphy sutures. One patient required re-exploration for ureteral obstruction, which resolved after replacement of a suture and stenting. CONCLUSIONS: Levator myorraphy is safe, effective, and easily taught. The rate of recurrent prolapse associated with this technique is similar to other techniques for vaginal vault fixation, but it avoids the disadvantages of an abdominal approach and is more technically straightforward to perform than sacrospinalis fixation.

Medical treatment modalities for lower urinary tract symptoms: what are the relevant differences in randomised controlled trials?

OBJECTIVES: Relevant differences in efficacy and tolerability will be reviewed among medical treatment modalities for lower urinary tract symptoms (LUTS) suggestive of benign prostatic obstruction (BPO). Available data on the long-term effectiveness of these treatments will be also discussed. METHODS: Information reviewed here comes mainly from published scientific articles and abstracts describing direct comparative trials among alpha1-adrenoceptor antagonists, finasteride, and/or phytotherapy. RESULTS: Direct comparative trials demonstrated alpha1-adrenoceptor antagonists to be more effective than finasteride in improving symptoms and increasing urinary flow. Moreover, finasteride did not perform better than placebo in those studies that included a placebo arm. While finasteride treatment appears more beneficial in patients with an enlarged prostate volume (>50 ml), the efficacy of alpha1-adrenoceptor antagonists is not related to prostate size. To study the efficacy of plant extracts, adequately performed placebo-controlled and direct comparative trials are needed. Medical treatment modalities generally have a low incidence of adverse events. Regarding long-term effectiveness of medical treatment, the few available data show that finasteride can reduce the risk of acute urinary retention (AUR) and surgery. Short-term, direct comparative studies suggest that, like finasteride, alpha1-adrenoceptor antagonists have a comparable positive effect on disease progression. CONCLUSION: More comparative information is needed on the long-term efficacy, tolerability, and effectiveness of medical treatments for LUTS. Information on disease progression (i.e., long-term complications related to BPO) and treatment outcomes (i.e., switch to other therapy or surgery) is necessary because such information directly effects a treatment's cost-effectiveness.

Cadaveric fascia lata sling: analysis of five recent adverse outcomes.

OBJECTIVES: To report a series of adverse outcomes of urethral sling procedures that used allograft fascia lata and to review the literature regarding the use of this material in genitourinary reconstruction. METHODS: Five neurologically normal patients presented to our center between August 1999 and October 1999 with complaints of recurrent incontinence or voiding dysfunction after undergoing urethral sling procedures at outside institutions that used fascia lata allografts. All patients underwent a thorough evaluation, including history and physical examination, voiding cystourethrography, and urodynamic studies. Sections of fascia were removed for histology in 2 patients at the time of operation. RESULTS: Three patients were diagnosed with de novo bladder outlet obstruction, 1 with recurrent urethral hypermobility, and 1 with intrinsic sphincteric deficiency. Histology of cadaveric fascia demonstrated collagen with almost complete absence of cellularity. There was no evidence of capillary or fibroblast ingrowth. All patients underwent reoperation and have had clinical improvement with short-term follow-up. CONCLUSIONS: Although distressing, the present series of adverse outcomes may simply reflect an overall increase in the number of sling procedures being performed nationally. Although decreased operative time and morbidity have been attributed to the use of fascia lata in urethral sling procedures, it is essential to ensure that long-term safety and efficacy will not be jeopardized before accepting it as a new standard of care.

[Modelled analysis of the effect of cystocele reduction with vaginal pack on miction in women with grade IV cystocele]. / Analyse modélisée de l'effet de la réduction d'une cystocèle par un pack vaginal sur la miction des femmes ayant une cystocèle de grade IV.

OBJECTIVES: To evaluate the effect of reduction of a cystocele by vaginal pack on the voiding of women with grade IV cystocele. METHODS: Two successive pressure-flow analyses were performed in a series of 21 patients: the first after insertion of a vaginal pack to reduce the cystocele, and the second after removal of the pack. The VBN method was applied to analyse uroflowmetries, allowing evaluation of two parameters for each uroflowmetry: one reflecting the urethra and the other reflecting the detrusor. RESULTS: Only 14 patients were able to perform the 2 uroflowmetries in a single stream with a volume greater than 100 ml. The vaginal pack improved the urethral parameter in 10 patients, but had no effect in the other 4 patients; it did not alter detrusor function. The urethral parameter was improved in patients whose obstruction was relieved according to the urodynamic criterion. CONCLUSIONS: Modelized analysis of pressure-flow analyses with and without a vaginal pack supports the conclusions of urodynamic tests concerning the preoperative status of patients with high grade cystocele by identifying those patients in whom the cystocele affects bladder emptying.

Sexual function after vaginal surgery for stress incontinence: results of a mailed questionnaire.

OBJECTIVES: To address the issue of sexual dysfunction after vaginal surgery for incontinence based on responses to a mailed questionnaire. METHODS: A sexual function questionnaire was mailed to 93 women who underwent anterior vaginal wall suspension for stress urinary incontinence alone (group 1) or in conjunction with a concomitant posterior repair (group 2) at least 1 year previously. RESULTS: A total of 56 (60%) women responded. Following surgery, 10 (37%) women in group 1 reported themselves as sexually active and 12 (41%) in group 2, which was similar to preoperative values. Only 1 woman in group 1 and 3 women in group 2 attributed their sexual inactivity to their own lack of desire or inability to have intercourse. Overall, 20% of women noted pain during intercourse, a finding slightly lower than the preoperative incidence (29%). No difference in the incidence of dyspareunia was noted between groups. Still, several women (18%) reported intercourse to be worse following surgery. Women who were either premenopausal or on hormone replacement therapy were more likely to be sexually active following surgery (46%) than those not on hormone replacement (17%). CONCLUSIONS: Overall, the percentage of women who were sexually active did not appear to be affected by a vaginal suspension procedure for incontinence. Symptomatic vaginal narrowing was rare, even among women undergoing simultaneous posterior repair. Still, nearly 20% of women considered intercourse to be worse postoperatively, although not all women reported dyspareunia. The possible causes for postoperative sexual dysfunction require further investigation.

Transvaginal repair of postcystectomy peritoneovaginal fistulae.

To our knowledge, peritoneovaginal fistula is a complication of cystectomy that has not been reported before. We describe 2 patients in whom a transvaginal approach using a Martius flap was utilized to repair persistent vaginal leakage after cystectomy. At a mean follow-up of 20 months, both patients are free from vaginal leakage and have no evidence of recurrent fistula. This approach offers a safe and effective way to repair a peritoneovaginal fistula in a cystectomy patient.

[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.

Pressure flow analysis may aid in identifying women with outflow obstruction.

PURPOSE: We refined recently developed pressure flow cutoff values for female bladder outlet obstruction and applied these values in a consecutive group of women undergoing urodynamic testing for various lower urinary tract symptoms. MATERIALS AND METHODS: A total of 87 women with clinical obstruction determined by history and presenting complaint were enrolled in our prospective evaluation of pressure flow studies. We identified 3 groups of participants according to the suspected cause of obstruction, including prolapse in 33, previous incontinence surgery in 25, and no likely source of obstruction identified from history and physical examination only in 29. An additional 124 patients presenting for evaluation of stress urinary incontinence served as controls. Optimal cutoff values for determining obstruction were developed using receiver operating characteristic curves. To determine the prevalence of bladder outlet obstruction these values were prospectively applied to 106 women undergoing urodynamics for various voiding complaints. RESULTS: In controls the average maximum flow rate was 23 cc per second and average detrusor pressure was 21.9 cm. water, whereas the corresponding values in those with clinical obstruction were 10.7 cc per second and 40.8 cm. water (p <0.001). No differences were noted in the various obstruction groups. Receiver operating characteristics analysis revealed that cutoff values of 11 cc per second or less and 21 cm. water or more optimized the selection of patients with bladder outlet obstruction. Using these values we noted a bladder outlet obstruction prevalence of 20% in a consecutive cohort of women undergoing urodynamic studies at our center. CONCLUSIONS: We propose cutoff pressure flow values for identifying women with bladder outlet obstruction although they should be used only in conjunction with the overall clinical situation. Neither pressure flow data only nor clinical symptoms alone may be sufficient for diagnosing obstruction in women.

Altered response to partial bladder outlet obstruction in mice lacking inducible nitric oxide synthase.

INTRODUCTION: Following prolonged partial bladder outlet obstruction (BOO) in the mouse, cholinergic mediated detrusor contractility decreases. Previous work has demonstrated an increase in the inducible form of nitric oxide synthase (iNOS) at the mRNA and protein levels soon after obstruction. Since nitric oxide (NO), the product of the action of iNOS on molecular oxygen and l-arginine, produces vasodilation and decreases platelet aggregation, we believe it is an integral part of the initial detrusor response to obstruction. These experiments evaluated the detrusor response in mice incapable of producing iNOS. MATERIALS AND METHODS: Wild type and knockout mice were partially obstructed for 1, 3, and 5 weeks. Physiologic evaluation consisted of cystometric analyses, and muscle strip studies in response to cholinergic and electrical stimulation. Strips were also relaxed with L-arginine, sodium nitroprusside, and 8-bromoguanosine 3' - 5' cyclic GMP, after precontraction. RESULTS: After 5 weeks of obstruction, both wild type (WT) and knockout (KO) mouse bladders increased significantly in weight. WT bladders obstructed for 5 weeks had the greatest capacity (increase of 42%, p = 0.022), and a decreased contractile response to carbachol (decrease of 32% at 10-5 M, p = 0.018). No differences were noted at 1 and 3 weeks of obstruction. In contrast, KO mice had a significantly larger bladder capacity at 1 week of obstruction compared with WT, and had significantly lower responses to electrical stimulation than WT at the same time (p = 0.03). Additionally, after 5 weeks of obstruction, bladder capacity and contractility returned to baseline levels in KO mice, at a time when WT mice had significantly larger capacity and decreased contractility. CONCLUSIONS: Bladder function following partial BOO in mice incapable of producing iNOS differed significantly from the normal response. Our data suggest that generation of iNOS soon after obstruction is necessary to prevent detrusor dysfunction at that time. Moreover, the enhanced function seen in KO bladders after longer periods of obstruction (5 weeks) in comparison to WT bladders suggests that reactive nitrogen species-induced protein nitrosylation may be involved in the loss of contractile function observed after more prolonged periods of obstruction.

Identifying patients who require urodynamic testing before surgery for stress incontinence based on questionnaire information and surgical history.

OBJECTIVES: To determine whether knowledge about previous surgical history for incontinence and responses to a validated lower urinary tract symptom questionnaire for women could identify those who should undergo urodynamic testing before surgery for stress urinary incontinence (SUI). METHODS: A retrospective analysis of all women who completed the Urogenital Distress Inventory-6 questionnaire (UDI-6) and then underwent complete urodynamic studies was conducted. The critical urodynamic diagnoses to determine before anti-incontinence surgery were defined as coexisting SUI and detrusor instability (DI), Valsalva leak point pressure less than 60 cm H(2)O, and DI alone in women suspected clinically of having SUI. Models were established for deciding who should undergo urodynamic studies on the basis of questionnaire responses and information about previous surgical history. Cost savings and the ability of the various models to identify patients with critical urodynamic diagnoses were calculated. RESULTS: A total of 174 women completed the UDI-6 and underwent urodynamics studies. Sixty-two had SUI (36%), 54 had DI (31%), 18 had both SUI and DI (10%), and 19 women suspected of having SUI were found instead to have DI (11%). Among women with SUI, 39 had a Valsalva leak point pressure less than 60 cm H(2)O (63%). No group of question responses or combination of question responses and presence of previous incontinence surgery was able to identify all three critical urodynamic diagnoses with statistical significance. Still, the combination of a response of "2" or "3" to question 3 on the UDI-6 and a positive history of previous surgery would have identified 91% of the critical diagnoses, and a substantial cost savings would have been realized. CONCLUSIONS: Using the UDI-6 and information obtained from the patient's history to determine who should undergo urodynamic testing before surgery for SUI can result in substantial cost savings without sacrificing patient care.