RESUMO
OBJECTIVE: To present the contemporary evidence on transvaginal urogenital fistulae (UGF) repair with Martius fat pad (MFP), compared to direct graftless fistula repair. METHODS: We reviewed all available studies reporting lower UGF repair via the transvaginal approach in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL). The primary outcome of interest was the fistula closure rates. When available, patients' baseline characteristics, indications for surgery, and early and late postoperative complications with focus on MFP-related complications are reported. RESULTS AND DISCUSSION: In obstetric fistulae, tissue interposition has been almost completely abandoned, with contemporary large series reporting closure rates of >90% with graftless repair, even for complex fistulae. Similarly, most simple, non-irradiated iatrogenic fistulae can be closed safely without or with tissue interposition with success rates ranging between 86% and 100%. However, MFP is valuable in fistulae with difficulty achieving tension-free and layered closure, with significant tissue loss, urethral involvement and with poorly vascularised tissues after radiotherapy, with reported success rates between 80% and 97% in those challenging situations. CONCLUSION: A UGF repair should be individualised after considering the specific characteristics and complexity of the procedure. MFP interposition is probably unnecessary for the majority of low (obstetric) fistulae within otherwise healthy tissues. However, MFP may still have a place to maximise outcomes in low-income settings, in select cases with higher (iatrogenic) fistulae, and in most cases with radiotherapy.
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Tecido Adiposo , Humanos , Feminino , Tecido Adiposo/transplante , Fístula Vesicovaginal/cirurgia , Fístula Vesicovaginal/etiologia , Resultado do Tratamento , Fístula Vaginal/cirurgia , Fístula Vaginal/etiologiaRESUMO
PURPOSE: The benefits and harms of the available types of surgical management for lichen sclerosus-related (LS) strictures remain unclear and, thus, clear and robust clinical practice recommendations cannot be given. MATERIALS AND METHODS: To assess the role of single-stage OMGU in the management of LS strictures and explore how its benefits and harms compare with the alternative management options. Medline, Embase and Cochrane controlled trial databases (CENTRAL, CDSR) were systematically searched. Randomized (RCTs) and nonrandomized studies (NRCSs) comparing single-stage OMGU with other surgical management options for LS strictures and single-arm studies on single-stage OMGU were included. Risk of bias (RoB) was assessed. RESULTS: Of the 1912 abstracts identified, 15 studies (1 NRCS and 14 single-arm studies) were included, recruiting in total 649 patients. All studies were at high RoB. In the only NRCS available, stricture-free rate (SFR) for single-stage and staged OMGU was 88% vs 60%, respectively (p = 0.05), at a mean follow-up of 66.5 months. SFR range for single-stage OMGU in single-arm studies was 65-100% (mean/median follow-up, 12-59 months). Single-stage OMGU had low complication rates and beneficial impact on LUTS and QoL. CONCLUSIONS: The present SR highlights the methodological limitations of the available literature. In the absence of adverse local tissue conditions, and taking into consideration benefit-harm balance and surgeon's skills and expertise, single-stage OMGU can be justified in patients with LS strictures.
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Líquen Escleroso e Atrófico , Estreitamento Uretral , Constrição Patológica/cirurgia , Humanos , Líquen Escleroso e Atrófico/complicações , Líquen Escleroso e Atrófico/cirurgia , Masculino , Mucosa Bucal/transplante , Qualidade de Vida , Estudos Retrospectivos , Resultado do Tratamento , Uretra/cirurgia , Estreitamento Uretral/etiologia , Procedimentos Cirúrgicos Urológicos Masculinos/efeitos adversosRESUMO
AIM: The aim of this study is to examine the functional outcomes of ona-botulinum toxin A (BTX-A) injection into the external urethral sphincter (EUS) for female patients with nonneurogenic nonrelaxing sphincter as the underlying cause of voiding dysfunction (VD). METHOD: A retrospective analysis was performed for all the patients with the urodynamic findings of higher than expected maximum urethral closure pressure (MUCP) who received their first injection during the study period. All patients were evaluated with preoperative videourodynamic study and urethral pressure profilometry and received 100 U of EUS BTX-A. Patients aged less than 18 years and those with neurogenic bladder were excluded. All patients were followed up with the free flow, postvoid residuals (PVR), and patient global impression of improvement (PGI-I) scale at 6 weeks and then at 3 monthly intervals. RESULT: We identified 35 female patients with a mean age of 37.5 ± 15 years (range 18-72 years) with a mean follow-up of 20 months. More than 50% of patients had a history of prior surgical intervention and 28 (80%) patients were catheter dependent, a suprapubic catheterization, or clean intermittent self-catheterization. Mean MUCP was 97.1 ± 22 cm of water. After treatment with BTX-A, 21 (60%) patients were able to void per urethral (p = 0.02). The mean maximum flow rate (Qmax) improved from 8.8 to 11 mls/s and the mean PVR decreased from 200 to 149 mls (p < 0.05). On multivariate analysis, we identified high preoperative PVR, high preoperative actual MUCP, and previous surgical intervention (urethral dilatation, sacral neuromodulation, and pelvic surgery) as predictors of successful voiding restoration. The mean duration of response was 4.7 months, 46% of patients requested repeat injection, and 29% were established on maintenance injections. On the 5-point PGI-I score, 13 (37%), 12 (34%), and 10 (29%) patients reported good, some, and no improvement, respectively. Quality of life was also improved in 60% of patients. Two patients had transient stress urinary incontinence (for <6 weeks) and there were no significant long-lasting adverse events. CONCLUSION: EUS BTX-A is a valid treatment option for VD considering therapeutic options are limited. The patient must be made aware of the need for repeat treatments.
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Toxinas Botulínicas Tipo A , Humanos , Feminino , Lactente , Pré-Escolar , Criança , Toxinas Botulínicas Tipo A/efeitos adversos , Uretra , Estudos Retrospectivos , Qualidade de Vida , Resultado do Tratamento , Urodinâmica/fisiologiaRESUMO
AIMS: Percutaneous tibial nerve stimulation (PTNS) is a simple neuromodulation technique to treat an overactive bladder. It is unclear whether the response to PTNS would suggest a similar response to sacral nerve stimulation (SNS), and whether PTNS could be utilized as an alternative test phase for an SNS implant. This study assessed whether PTNS response was a reliable indicator for subsequent SNS trials. METHODS: We performed a retrospective review of the hospital databases to collect all patients who had PTNS and who subsequently had an SNS trial in two tertiary hospitals from 2014 to 2020. Response to both interventions was assessed. A 50% reduction in overactive symptoms (frequency-volume charts) was considered a positive response. McNemar's tests using exact binomial probability calculations were used. The statistical significance level was set to 0.05. RESULTS: Twenty-three patients who had PTNS subsequently went on to a trial of SNS. All patients except one had previously poor response to PTNS treatment. Eight of them also failed the SNS trial. However, 15 patients (including the PTNS responder) had a successful SNS trial and proceeded with the second-stage battery implantation. The difference in response rates between the PTNS and SNS trial was statistically significant (p < 0.001). CONCLUSIONS: Poor response to PTNS does not seem to predict the likelihood of patients responding to SNS. A negative PTNS trial should not preclude a trial of a sacral nerve implant. The predictive factors for good and poor responses will be the subject of a larger study.
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Incontinência Fecal , Estimulação Elétrica Nervosa Transcutânea , Bexiga Urinária Hiperativa , Incontinência Fecal/terapia , Humanos , Nervos Espinhais , Nervo Tibial/fisiologia , Estimulação Elétrica Nervosa Transcutânea/métodos , Resultado do Tratamento , Bexiga Urinária Hiperativa/terapiaRESUMO
INTRODUCTION AND HYPOTHESIS: We aim to determine the presentation of and immediate and longer-term outcomes of vaginal surgical excision of urethral extrusion of mid-urethral tape (MUT). METHODS: We performed a retrospective analysis of all patients with urethral extrusion of MUT having vaginal surgical excision between 2007 and 2018. The MUT was removed either partially (via vaginal approach) or completely (via combined vaginal and laparoscopic approach). Functional outcomes and any re-interventions are described. RESULTS: Thirty-four patients of median age 53 (range 34-82) years were identified. Preoperative symptomatic recurrent/persistent urinary incontinence was present in 29/34(85%) with 24/34(71%) women having recurrent/persistent stress urinary incontinence (SUI) or stress predominant mixed urinary incontinence (s-MUI) on urodynamics. Vaginal surgical excision was performed alone in 33/34(97%) women and in combination with laparoscopic removal of abdominopelvic MUT in 1/34(3%) woman. In the longer term vaginal/urethral pain resolved or improved in all 15/15(100%) patients presenting with this complaint whilst patient reported poor flow resolved in 8/9 (89%) women. Twenty-eight of 34 women (82%) had persistent/recurrent SUI or s-MUI following MUT excision. Twenty-four of 34 women (71%) had further SUI surgery with cure or improvement of SUI in 20/24 (83%) patients. CONCLUSIONS: The outcome of vaginal surgical excision of the MUT was cure or improvement of pain in 100% and resolution of poor flow in 89% women. Recurrent/persistent SUI or s-MUI was present in 82% following removal as compared to 71% women prior to removal. Of the 71% of women electing to have further surgery for recurrent/persistent SUI/s-MUI, 83% were dry or improved afterwards.
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Slings Suburetrais , Incontinência Urinária por Estresse , Incontinência Urinária , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Dor Pélvica/etiologia , Estudos Retrospectivos , Slings Suburetrais/efeitos adversos , Resultado do Tratamento , Incontinência Urinária/etiologia , Incontinência Urinária por Estresse/etiologia , Incontinência Urinária por Estresse/cirurgia , Incontinência Urinária de Urgência/etiologiaRESUMO
PURPOSE: To establish the correlation between flow rate curve shape and video-urodynamic findings in women with lower urinary tract symptoms (LUTS). METHODS: A retrospective review of consecutive women with LUTS who performed a free flow study immediately before undergoing video-urodynamic investigations over a 28-month period. Flow rate curve shape and video-urodynamic parameters were analysed. Free flow curves were defined into five categories: bell-shaped, prolonged, fluctuating, intermittent or plateau. Women who voided less than 150 ml on the free flow study were excluded from the analysis. RESULTS: A total of 250 women with LUTS, with a mean age 48 years (range 18-83), were included. Bell-shaped tracings excluded obstruction in 89%. Prolonged flow rate curves diagnosed obstruction in 62% and detrusor underactivity in 8%. Fluctuating and intermittent flow rate curves were associated with urodynamic obstruction in 37 and 39%, respectively, and detrusor underactivity in 25 and 29%, respectively. A plateau flow rate curve was indicative of urodynamic obstruction in all three cases observed. CONCLUSION: Flow rate curve patterns can be suggestive of urodynamic diagnoses. Women without a prolonged void and bell-shaped traces had normal voiding urodynamics in 76% of cases, and the majority could be managed without invasive investigations. Patients with fluctuating and intermittent flow rate curves demonstrate a spectrum of urodynamic diagnoses with a third of cases having obstruction and a third of cases having detrusor underactivity. Plateau flow rate curve patterns are associated with urethral obstruction.
Assuntos
Sintomas do Trato Urinário Inferior/fisiopatologia , Obstrução do Colo da Bexiga Urinária/diagnóstico , Obstrução do Colo da Bexiga Urinária/fisiopatologia , Bexiga Inativa/diagnóstico , Bexiga Inativa/fisiopatologia , Urodinâmica , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Correlação de Dados , Humanos , Sintomas do Trato Urinário Inferior/complicações , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Obstrução do Colo da Bexiga Urinária/complicações , Bexiga Inativa/complicações , Gravação em Vídeo , Adulto JovemRESUMO
PURPOSE: To investigate pre-operative urodynamic parameters in male sling patients to ascertain whether this might better predict surgical outcomes and facilitate patient selection. METHODS: We performed a retrospective, case notes and video-urodynamics, review of men who underwent AdVanceXP male sling in three London hospitals between 2012 and 2019. Urodynamics were performed in all centres, while retrograde leak point pressure (RLPP) was performed in one centre. RESULTS: Successful outcome was seen in 99/130 (76%) of men who required one pad or less per day. The dry rate was 51%. Pad usage was linked to worse surgical outcomes, mean 2.6 (range 1-6.5) for success vs 3.6 (range 1-10) although the ranges were wide (p = 0.002). 24 h pad weight also reached statistical significance (p = 0.05), with a mean of 181 g for success group versus 475 g for the non-successful group. The incidence of DO in the non-successful group was significantly higher than in successful group (55% versus 29%, p = 0.0009). Bladder capacity less than 250 ml was also associated with worse outcomes (p = 0.003). Reduced compliance was not correlated with outcomes (31% for success groups vs 45% for non-successful group, p = 0.15). Preoperative RLPP was performed in 60/130 patients but did not independently reach statistical significance (p = 0.25). CONCLUSION: Urodynamic parameters related to bladder function-detrusor overactivity and reduced maximum cystometric capacity predict male sling outcomes and may help in patient selection for male sling (or sphincter) surgery; whereas urodynamic parameters of sphincter incompetency (RLPP) were not predictive. Further larger scale studies are required to confirm these findings.
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Complicações Pós-Operatórias/cirurgia , Prostatectomia , Neoplasias da Próstata/cirurgia , Slings Suburetrais , Bexiga Urinária/fisiologia , Incontinência Urinária/cirurgia , Urodinâmica , Idoso , Idoso de 80 Anos ou mais , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Valor Preditivo dos Testes , Período Pré-Operatório , Prostatectomia/efeitos adversos , Estudos Retrospectivos , Resultado do Tratamento , Incontinência Urinária/etiologiaRESUMO
AIMS: To determine the bleeding risk in patients taking anticoagulants (AC) and antiplatelets (AP) before onabotulinumtoxinA (BoNT-A) injections and improve peri-operative decision making and counseling. METHODS: We performed a retrospective review of patients having intravesical BoNT-A in three teaching hospitals from January 2016 to July 2018. Demographic data, indication for intravesical BoNT-A injection, and side-effects of significant bleeding requiring intervention were recorded. RESULTS: Five hundred and thirty-two patients had intravesical BoNT-A injections during this time. Sixty-three patients of mean age 69 years (range 19-89) had a total of 114 separate rounds of BoNT-A injections whilst on treatment dose AC/AP therapy. Of the 63, there were 33 males, with 46 having idiopatic detrusor overactivity and 17 with neurogenic detrusor overactivity. Each patient had between 1 and 7 repeat injections during the studied period. AC/AP use across the 114 episodes included; aspirin 44, clopidogrel 37, warfarin 19, and NOAC (novel/non-vitamin K oral anticoagulant) 14. Patients on warfarin who had point of care testing all had international normalized ratio less than 3. BoNT-A dose varied from 100U to 300U-modal dosage was 200U.1/114(0.88%) injection episodes resulted in postinjection hematuria requiring overnight admission. This resolved spontaneously, with an overnight catheter. This patient was on rivaroxaban and had 300U of BoNT-A injected through 20 sites, on a background of previous prostate radiotherapy and self-catheterization. CONCLUSIONS: Continuation of AP/AC therapy during intravesical BoNT-A injection treatment appears to be safe-with a 0.88% rate of spontaneously resolving hematuria.
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Toxinas Botulínicas Tipo A , Bexiga Urinária Hiperativa , Administração Intravesical , Adulto , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/efeitos adversos , Toxinas Botulínicas Tipo A/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Bexiga Urinária Hiperativa/tratamento farmacológico , Adulto JovemRESUMO
PURPOSE: To evaluate postoperative pain and complications following AdVance™/AdVance™ XP male sling implantation. MATERIALS AND METHODS: A multi-center retrospective medical notes review of patients implanted for bothersome post-prostatectomy incontinence was conducted. All patients were telephoned to provide further information on pain or further complications related to their surgery. Statistical evaluation utilized logistical regression analysis. Additionally, a literature review was conducted reviewing pain outcomes following AdVance™/AdVance™ XP implantation. RESULTS: One-hundred and twenty-seven men were reviewed over an 8-year period. The mean age was 70 years, with mean follow up 52 months. Of those with mild stress urinary incontinence, 45 (79%) had a successful outcome compared to 42 (72%) in the moderate group. Twenty-nine (23%) men reported postoperative pain, with a mean maximal pain score of 6 (range: 0-10). The majority of pain resolved within 4 weeks (19/29 men). A further seven patients resolved by 3 months. Only three men (2.3%) had chronic pain greater than 3 months, which all resolved by 1 year. Men less than 65 years were more likely to suffer pain (p = 0.009). Acute urinary retention occurred in 23 (18%) men and correlated significantly with postoperative pain (p = 0.04). Overactive bladder symptoms, severity of incontinence or radiotherapy were not correlated with postoperative pain. In our cohort, there were no extrusions, divisions, or explantations. CONCLUSION: Approximately a quarter of men experience pain in the early postoperative period. However, the severity and rates of chronic pain (>3 months) are low (2.3%) but all settle within a year.
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Dor Crônica , Slings Suburetrais , Idoso , Dor Crônica/epidemiologia , Dor Crônica/etiologia , Humanos , Masculino , Prevalência , Prostatectomia/efeitos adversos , Estudos Retrospectivos , Telas Cirúrgicas , Resultado do Tratamento , Incontinência Urinária por Estresse/epidemiologia , Incontinência Urinária por Estresse/etiologia , Incontinência Urinária por Estresse/cirurgiaRESUMO
BACKGROUND: Synthetic midurethral sling (MUS) procedures, purported for the last two decades as the gold standard surgical treatment for stress urinary incontinence, have been in creasingly scrutinized in recent years with regard to the rate and severity of complications. METHODS: During the International Consultation on Incontinence Research Society meeting held in Bristol, UK, in 2019, a multidisciplinary panel held a think tank and discussed the contemporary evidence pertaining to the classification, investigation, and treatment of MUS complications. RESULTS: The current classification system of mesh-related complications was discussed, and shortcomings were identified. The lack of a standardized clinical pathway was noted, and the value of clinical investigations and surgical treatments was difficult to fully evaluate. The paucity of high-level evidence was a common factor in all discussions, and the difficulties with setting up relevant randomized-controlled trials were highlighted. CONCLUSIONS: The outcome of the think-tank discussions is summarized with a set of recommendations designed to stimulate future research.
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Complicações Pós-Operatórias/terapia , Slings Suburetrais/efeitos adversos , Incontinência Urinária por Estresse/cirurgia , Algoritmos , Feminino , HumanosRESUMO
AIMS: This article reviews the clinical outcomes and basic science related to negative effects of radiotherapy (RT) on the lower urinary tract (LUT) when used to treat pelvic malignancies. METHODS: The topic was discussed at the 2019 meeting of the International Consultation on Incontinence-Research Society during a "think tank" session and is summarized in the present article. RESULTS: RT is associated with adverse effects on the LUT, which may occur during treatment or which can develop over decades posttreatment. Here, we summarize the incidence and extent of clinical symptoms associated with several modes of delivery of RT. RT impact on normal tissues including urethra, bladder, and ureters is discussed, and the underlying biology is examined. We discuss innovative in vivo methodologies to mimic RT in the laboratory and their potential use in the elucidation of mechanisms underlying radiation-associated pathophysiology. Finally, emerging questions that need to be addressed through further research are proposed. CONCLUSIONS: We conclude that RT-induced negative effects on the LUT represent a significant clinical problem. Although this has been reduced with improved methods of delivery to spare normal tissue, we need to (a) discover better approaches to protect normal tissue and (b) develop effective treatments to reverse radiation damage.
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Sintomas do Trato Urinário Inferior/etiologia , Neoplasias Pélvicas/radioterapia , Lesões por Radiação/terapia , Uretra/fisiopatologia , Bexiga Urinária/fisiopatologia , Feminino , Humanos , Sintomas do Trato Urinário Inferior/terapia , MasculinoRESUMO
AIM: Bladder outflow in women (bladder outlet obstruction [BOO]) has no well-accepted defining diagnostic criteria. Various nomograms exist based on flow rates, pressure-flow data, and fluoroscopy. We have prospectively evaluated the Solomon-Greenwell bladder outflow obstruction nomogram (SG BOO nomogram) as a measurement of BOO resolution following targeted surgical intervention. METHODS: The routine posttreatment urodynamics of 21 unselected women with an original urodynamic diagnosis of BOO on fluoroscopy and the SG BOO nomogram (BOO boundary defined as Qmax > 2.2 Pdet.Qmax + 5) were reviewed. All women had symptomatic BOO secondary to anterior pelvic organ prolapse (aPOP), urethrovaginal fistula (UVF), previous stress urinary incontinence (SUI) surgery, urethral stricture (US), or urethral diverticulum (U Div). Following treatment, all presenting symptoms resolved and simple urodynamics were performed as part of routine follow-up. RESULTS: The urodynamic findings preoperatively and postoperatively showed statistically significant changes posttreatment in mean flow rate which increased from 9.38 to 14.71 mL/s, mean Pdet.Qmax which decreased from 38 to 18.38 cmH2 O, and mean SG BOO nomogram probability (PBOO) which reduced from PBOO = 0.68 to 0.08. Mean SG BOO nomogram PBOO was significantly reduced posttreatment in all individual categories except UVF where a nonsignificant reduction from PBOO = 0.55 to 0.05 occurred. CONCLUSIONS: All urodynamic parameters significantly improve in women who become asymptomatic following surgical treatment of BOO. This improvement is best demonstrated by the change in probability of BOO according to the Solomon-Greenwell nomogram. These findings underline the validity of the Solomon-Greenwell female BOO nomogram for diagnosing and monitoring BOO in women.
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Estreitamento Uretral/complicações , Obstrução do Colo da Bexiga Urinária/diagnóstico , Incontinência Urinária por Estresse/complicações , Urodinâmica/fisiologia , Adulto , Idoso , Feminino , Humanos , Pessoa de Meia-Idade , Nomogramas , Estudos Retrospectivos , Estreitamento Uretral/fisiopatologia , Obstrução do Colo da Bexiga Urinária/etiologia , Obstrução do Colo da Bexiga Urinária/fisiopatologia , Incontinência Urinária por Estresse/fisiopatologiaRESUMO
AIMS: To investigate the role of onabotulinumtoxinA (BTX-A) injections in patients with failed augmentation cystoplasty for neuropathic or idiopathic detrusor overactivity (NDO or IDO). METHODS: A retrospective review of all cystoplasty patients who underwent onabotulinumtoxinA injection at a tertiary center between 2008 and 2019 was performed. Details including indications and time from cystoplasty, video-urodynamic parameters, onabotulinumtoxinA dose, and clinical outcomes were analyzed. Telephone interview was performed for patients that requested repeat onabotulinumtoxinA injections. The interview included a modified PGIC7 and UDI6 questionnaires. A positive clinical response was considered improvement of overactive symptoms sufficient to merit repeat onabotulinumtoxinA injection and a modified PGIC7 of four or above. RESULTS: Thirty patients were identified (11 men and 19 women). The indications for augmentation were IDO (n = 18) or NDO (n = 12). Mean age at the time of cystoplasty was 42 years (range, 10-61). Interval between cystoplasty and initial onabotulinumtoxinA was 98 months (range, 3-271). Video-urodynamics before onabotulinumtoxinA revealed low compliance in 13 patients, DO in 22 patients, and combined low compliance/DO in 10. The median maximum cystometric bladder capacity was 338 mL (range, 77-570 mL). Thirteen patients responded to onabotulinumtoxinA injections. Higher peak DO pressure was associated with a significantly higher chance that the patient would experience benefit from the injections P = .026). The patients that responded to onabotulinumtoxin A underwent a total of 115 procedures (mean, 8.8 injections) over a mean 88 months (range, 20-157 months). CONCLUSIONS: Forty-three percent of patients responded well to intra-detrusor onabotulinumtoxinA injections. This avoided the need for more invasive surgery and had a positive impact on their quality of life.
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Toxinas Botulínicas Tipo A/uso terapêutico , Qualidade de Vida , Bexiga Urinária Hiperativa/tratamento farmacológico , Adolescente , Adulto , Toxinas Botulínicas Tipo A/administração & dosagem , Criança , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cooperação do Paciente , Estudos Retrospectivos , Resultado do Tratamento , Bexiga Urinária Hiperativa/fisiopatologia , Urodinâmica/fisiologia , Adulto JovemRESUMO
AIMS: Lower urinary tract (LUT) function can be investigated by urodynamic studies (UDS) to establish underlying functional abnormalities in the LUT. A multicentre registry could present an opportunity to improve the scientific evidence base for UDS. During the International Consultation on Incontinence Research Society (ICI-RS) meeting in Bristol, United Kingdom 2019, an expert panel discussed the potential of a multicentre urodynamic registry to improve the quality of urodynamic output. METHODS: the potential importance of a multicentre urodynamic registry, parameter inclusion, quality control, and pitfalls during a registry roll-out were reviewed and discussed. RESULTS AND CONCLUSIONS: The clinical utility, evaluation, and effectiveness of UDS remain poorly defined due to a lack of high quality evidence and large study populations. Therefore, the ICI-RS proposes formation of a urodynamic panel for future roll-out of a registry. The inclusion of basic parameters was discussed and the essential parameters were defined as well as the potential pitfalls of a registry roll-out. The discussion and recommendations in this paper form the base for future urodynamic registry development.
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Sintomas do Trato Urinário Inferior/diagnóstico , Bexiga Urinária/fisiopatologia , Urodinâmica/fisiologia , Técnicas de Diagnóstico Urológico , Humanos , Sintomas do Trato Urinário Inferior/fisiopatologia , Estudos Multicêntricos como Assunto , Reino UnidoRESUMO
AIMS: To investigate typical pad weight gain (PWG) in asymptomatic women who have never reported any episodes of urinary incontinence. METHODS: An observational study was performed by measuring the increase in weight of small sanitary pads worn by 35 healthy, female volunteers of a median age 36 (range, 23-56) years. Each pad was worn for a minimum of 5 h which is the typical maximum duration of an ambulatory urodynamics study. RESULTS: The median duration of pad wear was 6 h (interquartile range [IQR], 5-8). The median PWG was 0.111 g (IQR, 0.047-0.255). The maximum recorded PWG was 0.621 g and the minimum was 0.012 g. PWG was not significantly affected by age, parity, years since last delivery, body mass index, or menopausal status. CONCLUSIONS: PWG over a median duration of 6 h (IQR, 5-8) is typically <0.7 g in women who are asymptomatic of urinary incontinence. Therefore, PWGs in excess of 0.7 g over a 5-h ambulatory urodynamics study in symptomatic women are likely to be diagnostic of urinary incontinence.
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Incontinência Urinária/diagnóstico , Urodinâmica/fisiologia , Adulto , Feminino , Humanos , Tampões Absorventes para a Incontinência Urinária , Pessoa de Meia-Idade , Incontinência Urinária/fisiopatologia , Adulto JovemRESUMO
INTRODUCTION AND HYPOTHESIS: Vesicovaginal fistulae (VVF) repair success rates for simple surgical fistulae are high, but constitute a significantly greater challenge when occurring in a radiotherapy field. We aim to evaluate the causes, assessment, closure rates and functional outcomes of VVF surgery in patients with previous radiotherapy. METHODS: Data on all VVF repairs were collected prospectively. A retrospective review of outcomes in those with VVF performed between 2009 and 2018 was carried out. Details including time from radiotherapy, pre-operative assessments, approach to surgery and functional outcome were analysed. RESULTS: Twenty women with VVFs were identified. The mean age was 59 (range 25-88) years. Primary malignancy was cervical in 16 women, with the remaining 4 women having ovarian, urethral, endometrial and rectal cancer respectively. All women had external beam radiotherapy with 6 (30%) undergoing boosted brachytherapy. Mean interval between radiotherapy and fistula repair was 19 (range 0-40) years. Fistulae arose spontaneously in 14 patients, whereas 6 occurred following a further surgical intervention.Closure was attempted vaginally in 7 women and abdominally in 1, whereas 12 had a primary diversion owing to significant bladder contracture and ureteric involvement. The closure rate in those attempted was 62.5%, 40% in those with spontaneous fistulae compared with 100% for post-surgical fistulae, but only 20% for the total cohort. CONCLUSIONS: Closure of VVF is a significant challenge, with an initial success rate of 20% and an overall success rate of only 25%. Seventy percent required primary or secondary urinary diversion. Vaginal surgery was utilised in the majority to try to avoid a hostile pelvis, but the surgical approach should be tailored to individual circumstances.
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Derivação Urinária , Fístula Vesicovaginal , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Pessoa de Meia-Idade , Pelve , Estudos Retrospectivos , Resultado do Tratamento , Fístula Vesicovaginal/etiologia , Fístula Vesicovaginal/cirurgiaRESUMO
INTRODUCTION AND HYPOTHESIS: The objective was to assess the comparative provider costs of vaginal and open abdominal repair of vesicovaginal fistula (VVF) and to determine the most cost-effective means of managing VVF. METHODS: A prospectively acquired database of all women undergoing VVF repair by a single surgeon between 2007 and 2015 was retrospectively reviewed to determine operating time, perioperative complications, inpatient stay and 30-day readmissions. The success and cost of the VVF repair were identified. Statistical analysis was by unpaired t test, Chi-squared test and Mann-Whitney U test. RESULTS: Forty-seven consecutive women of mean age 51 years (range 21-88) undergoing a first attempt at VVF repair at our institution were included; 32(68%) had vaginal repair with Martius fat pad interposition and 15 (32%) had open abdominal repair with omental interposition. There were no perioperative complications or 30-day readmissions in either group. Mean operative time was longer for open abdominal (223.4 min) than vaginal repair (196.9 min). Median inpatient stay was longer for an open abdominal (8 days) than for a vaginal approach (4 days). Successful anatomical closure was achieved in 91% of vaginal and 86% of open abdominal repairs at first attempt, and in 100% after second repair, where required. Mean/median costs for an abdominal repair were significantly higher, at £4,608.69/£4,169.20 than for vaginal repair at £3,381.50/£3,009.24 (P<0.05). CONCLUSIONS: Vesicovaginal fistulae were successfully repaired in 89% of cases at first attempt. The success rate did not differ between approaches. Vaginal repair is significantly more cost-effective than abdominal repair owing to the shorter operative time and length of stay.
Assuntos
Fístula Vesicovaginal , Adulto , Idoso , Idoso de 80 Anos ou mais , Análise Custo-Benefício , Feminino , Procedimentos Cirúrgicos em Ginecologia , Humanos , Pessoa de Meia-Idade , Estudos Retrospectivos , Fístula Vesicovaginal/cirurgia , Adulto JovemRESUMO
PURPOSE OF REVIEW: The aim of the present report was to review the recent evidences regarding the use of artificial urinary sphincter (AUS) in adult females. RECENT FINDINGS: While the excellent functional outcomes of AUS in female patients with stress urinary incontinence (SUI) due to intrinsic sphincter deficiency (ISD) have been reported for decades, its use has remained confidential in most countries likely due to its challenging implantation and inherent morbidity. Over the past few years, laparoscopic and, more recently, robotic techniques of AUS implantation in female patients have been described with promising perioperative outcomes. As a result, the use of AUS has increased in several countries. The indications are mostly recurrent or persistent SUI after previous anti-incontinence procedures and neurogenic SUI. Owing to its unique potential to restore continence while maintaining low outlet resistance during the voiding phase, AUS may be of special interest in female patients with detrusor underactivity. High level of evidence data from trials which are underway, along with developments in robotic surgery and technological refinements of the device, may well, almost 50 years after its introduction, give to the AUS its momentum as a major contributor in the female SUI armamentarium. While the use of AUS in female patients has been restricted to some countries and a few high-volume centers, it has started spreading again over the past few years, thanks to the rise of minimally invasive approaches which facilitate its implantation, and this is yielding promising outcomes.
Assuntos
Implantação de Prótese , Incontinência Urinária por Estresse/cirurgia , Esfíncter Urinário Artificial , Adulto , Feminino , Humanos , Laparoscopia , Implantação de Prótese/métodos , Procedimentos Cirúrgicos Robóticos , Resultado do Tratamento , Esfíncter Urinário Artificial/efeitos adversosRESUMO
PURPOSE: We report long-term data on a large cohort of adults who underwent formation of a continent catheterizable channel for various indications. We examined outcomes according to the tissue used for channel formation. MATERIALS AND METHODS: We retrospectively reviewed the case notes of 176 consecutive adult patients in whom a continent catheterizable channel was created using the Mitrofanoff principle for a broad range of indications a median of 142 months (range 54 to 386) previously. We evaluated outcomes in terms of continued use and continence for each type of material used for channel formation. RESULTS: At the time of this review 165 of the 173 patients (95.4%) included in this study were alive. We included 114 women (65.9%) and 59 men (34.1%) who underwent surgery at a median age of 42 years (range 18 to 73) with a mean followup of 78.6 months (median 60, range 2 to 365). The rate of revision for all causes was higher in the ileal group than in the group with an appendiceal channel (channel stenosis rate 22.7% vs 17.2%, p = 0.39, and channel incontinence rate 36.0% vs 19.5%, p = 0.03). Although 38.7% of patients underwent major surgical revision of the channel at some point, 75.9% of channels continued to be used, of which 90.2% were continent. CONCLUSIONS: This study provides a pragmatic overview of the outcome of these challenging cases. Mitrofanoff channel formation represents a durable technique. Appendix and ileum are each a viable choice for tissue use. Tissue selection depends on availability and individual patient factors.
Assuntos
Apêndice/transplante , Íleo/transplante , Cateterismo Urinário/métodos , Coletores de Urina , Adolescente , Adulto , Fatores Etários , Idoso , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Resultado do Tratamento , Cateterismo Urinário/efeitos adversos , Transtornos Urinários/etiologia , Transtornos Urinários/cirurgia , Adulto JovemRESUMO
OBJECTIVES: To analyse the results of the stress urinary incontinence (SUI) audit conducted by the British Association of Urological Surgeons (BAUS), and to present UK urologists' contemporary management of SUI. PATIENTS AND METHODS: The BAUS audit tool is an online resource, to which all UK urologists performing procedures for SUI are invited to submit data. The data entries for procedures performed during 2014-2016 were collated and analysed. RESULTS: Over the 3-year period analysed, 2917 procedures were reported by 109 surgeons, with a median of 20 procedures reported per surgeon. A total of 2 366 procedures (81.1%) were recorded as a primary surgery, with 548 procedures (18.8%) performed for recurrent SUI. Within the time period analysed, changes were noted in the frequency of all procedures performed, with a trend towards a reduction in the use of synthetic mid-urethral tapes, and a commensurate increase in the use of urethral bulking agents and autologous fascial slings. A total of 107 (3.9% of patients) peri-operative complications were recorded, with no association identified with patient age, BMI or surgeon volume. Follow-up data were available on 1832 patients (62.8%) at a median of 100 days postoperatively. Reduced pad use was reported in 1311 of patients (84.5%) with follow-up data available and 86.3% reported a pad use of one or less per day. In all, 375 patients (85%) reported being satisfied or very satisfied with the outcome of their procedure at follow-up, although data entry for this domain was poor. De novo overactive bladder (OAB) symptoms were reported by 15.2% of patients (263/1727), and this was the most commonly reported postoperative complication. For those reporting pre-existing OAB prior to their SUI surgery, 28.7% (307/1069) of patients reported they got better after their procedure, whilst 61.9% (662/1069) of patients reported no change and 9.4% of patients (100/1 069) got worse. CONCLUSIONS: This review identified that, despite urological surgeons undertaking a relatively low volume of procedures per year, SUI surgery by UK urologists is associated with excellent short-term surgeon- and patient-reported outcomes and low numbers of low grade complications. Complications do not appear to be associated with surgeon volume, nor do they appear higher in those undergoing mesh surgery. Shortfalls in data collection have been identified, and a longer follow-up period is required to comment adequately on long-term complications, such as chronic pain and tape extrusion/erosion rates.