Urinary retention after tension-free vaginal tape procedure: incidence and treatment.

OBJECTIVES: To review our experience with persistent urinary retention after the tension-free vaginal tape (TVT) procedure and report our treatment results. Ulmsten recently introduced the TVT procedure for female stress urinary incontinence. Although the morbidity is minimal, no surgical procedure is without risks, and experience will better define the morbidity of the TVT procedure. METHODS: Since November 1998, we have collectively performed 600 TVT procedures. Of these, 17 patients (2.8%) developed urinary retention or symptoms consistent with obstruction (including hesitancy, straining to void, or feeling of incomplete emptying) lasting more than 1 week from the date of the procedure. We reviewed the operative record, noting the operative time, estimated blood loss, presence of bladder penetration, and any reported complications. All 17 patients subsequently underwent transvaginal release on an outpatient basis. RESULTS: Seventeen patients (mean age 56 years, range 38 to 81) underwent sling release a mean of 64 days (range 6 to 228) after the TVT procedure. All patients voided to completion within 24 hours of release and reported no further subjective complaints of outlet obstruction. None of the subjects reported de novo urge incontinence or urgency. In each patient, the estimated blood loss was minimal; the operative time averaged 15 minutes. One urethral injury occurred and was managed intraoperatively without sequelae. Sixteen patients who underwent sling release have remained dry; the remaining patient, in whom a urethral injury was repaired, redeveloped stress incontinence and underwent an uncomplicated successful transvaginal sling procedure. CONCLUSIONS: Outlet obstruction is a risk of the TVT procedure and occurred with an incidence of 2.8% in our experience. The TVT mesh can be released by a simple vaginal incision under local anesthesia with rapid return to normal voiding. Although the number of patients studied was small, stress incontinence did not recur after uncomplicated release in our series.

The tension-free vaginal tape procedure: innovative surgery for incontinence.

This article reviews the most recent studies of the tension-free vaginal tape procedure. It describes studies investigating the procedure's mechanism in correcting stress incontinence and its efficacy and morbidity. Additionally, the article identifies areas for future research.

Low valsalva leak-point pressure and success of retropubic urethropexy.

The aim of this study was to determine whether an isolated low Valsalva leak-point pressure (VLPP) is predictive of intrinsic sphincter deficiency (ISD) and can be an independent risk factor for retropubic urethropexy failure in patients with a normal maximal urethral closure pressure (MUCP). Twenty-four women with urodynamically proven genuine stress incontinence with low VLPP (<60 cmH2O) and normal MUCP (>20 cmH2O) were evaluated subjectively and objectively by complex urodynamic testing before and after undergoing a modified Burch urethropexy. Success rates were then compared to historical success rates for subjects with ISD treated with retropubic urethropexy using an exact one-sample test for binomial proportions. Patients were followed postoperatively for a mean of 11.1 months, with a range of 5-16 months. Twenty-two of the 24 (91.7%) were continent on postoperative cystometry. This differs significantly from the published success rates of 50% (P < 0.001), if a low VLPP alone were predictive of ISD. Retropubic urethropexy was successful in the majority of our patients with genuine stress incontinence with a low VLPP and normal MUCP.

United States experience with tension-free vaginal tape procedure for urinary stress incontinence: assessment of safety and tolerability.

PURPOSE: The tension-free vaginal tape (TVT) procedure is an operation for treatment of stress urinary incontinence. A polypropylene mesh tape is placed to support the midurethra through a small vaginal incision. In this study, we present our preliminary results evaluating the safety, tolerability, and perioperative morbidity of this procedure. MATERIALS AND METHODS: One hundred patients with stress urinary incontinence underwent the TVT procedure as part of an observational study. Patients were evaluated prospectively with history and pelvic examination, urodynamic studies, perioperative protocol, outcome and satisfaction questionnaire, and postoperative visits at 3 weeks and 2 months. RESULTS: The procedure was performed with the patient under local anesthesia, using intravenous sedation in 97 patients and regional anesthesia in 3. Mean surgical time was 35.5 minutes. Bladder penetration occurred in 24 patients. Forty-two required overnight urethral catheterization. Mean hospital stay was 0.18 days. By 24 hours after the procedure, 95% were able to void. At 3-week follow-up, 88% of patients were completely continent and 9% significantly improved. CONCLUSIONS: The TVT procedure for stress urinary incontinence is a safe, minimally invasive operation with minimal perioperative morbidity. Considering these preliminary findings and long-term European data of 1 to 3 years' experience with continence rate averaging 85%, the TVT procedure may prove to be the operation of choice to treat stress urinary incontinence for many women.

A review of the tension-free vaginal tape procedure: outcomes, complications, and theories.

In the last century, the pathophysiology of stress urinary incontinence (SUI) has been investigated and several surgical techniques have been utilized for cure. The most recent evolution in the study of SUI is the minimally invasive tension-free vaginal tape (TVT) procedure, which can be done under local anesthesia and intravenous sedation and is individualized for each patient. The procedure recreates the "hammock" of the anterior vaginal wall and endopelvic fascia with a mesh tape of polypropylene. The cure rates of the initial studies are equal to or better than other anti-incontinence procedures, and the permanent supportive mesh is very well tolerated. The TVT creates a backboard on which the urethra compresses itself when it rotates posteriorly during cough or stress. The procedure accomplishes subjective and objective cure without elevating the bladder neck or altering urethral mobility.

The tension-free vaginal tape procedure for the treatment of stress incontinence in the female patient.

The newest development in the treatment of female stress incontinence is the tension-free vaginal tape (TVT) procedure. This procedure was first described by Ulmsten et al. in 1996 and involves recreating suburethral support with a polypropylene mesh, without repositioning the bladder or urethra. In their initial study, Ulmsten et al. reported an 84% cure rate at 2-year follow-up. The purpose of this report is to discuss the evolution and technical aspects of the TVT procedure and to outline the pre- and postoperative care recommended. A brief summary of our initial experience in our first 100 patients is included.

Current status of urethral occlusive devices in management of urinary incontinence.

Treatment of outlet incontinence with urethral occlusive devices encompasses simple and complex modalities. The implantable artificial urinary sphincter has been used for 25 years, and a growing fund of clinical information is available to define its indications. Other simple occlusive devices are available that provide an effective, nonsurgical and reversible treatment. The present review summarizes recent clinical investigations into the safety and efficacy of urethral occlusive devices.

Transvaginal bladder neck suspension with Cooper's ligament fixation. Long-term urodynamic results.

OBJECTIVE: To evaluate the long-term urodynamic efficacy of transvaginal bladder neck suspension with Cooper's ligament fixation. STUDY DESIGN: Nineteen women underwent transvaginal bladder neck suspension with Cooper's ligament fixation. Patients underwent complete clinical and urodynamic testing before and four to five years after surgery. Cure was defined as absence of urine leakage with stress maneuvers at cystometric capacity and lack of symptoms of urine loss. RESULTS: A successful outcome was documented in 12/14 patients. One patient developed de novo detrusor instability, and two had stress incontinence. Five were lost to long-term follow-up. CONCLUSION: Transvaginal bladder neck suspension with Cooper's ligament fixation is an effective surgical option in the treatment of genuine stress incontinence.

Urodynamic outcome after surgery for severe prolapse and potential stress incontinence.

OBJECTIVE: Women with severe prolapse may be paradoxically continent because of kinking of the urethra. It is currently a common practice to perform urethropexy in women who demonstrate stress incontinence on preoperative reduction of the prolapse with a pessary. We compared the urodynamic outcomes after reconstructive operations that included suspending urethropexy with outcomes after those that did not. STUDY DESIGN: A review was performed of the charts of the Gynecologic Urology Clinic at Los Angeles County-University of Southern California Women's and Children's Hospital from 1991-1997 of patients with grade III uterovaginal prolapse or procidentia in whom the pessary test was used to determine whether urethropexy was included in the reconstructive operation. Urodynamic outcomes were compared statistically with the Fisher exact test, and P < or =.05 denoted statistical significance. RESULTS: Fifty-five patients underwent urethropexy in addition to repair of the prolapse, and 70 underwent reconstruction alone. Twenty-three patients in the first group and 20 in the second were available for a mean urodynamic follow-up of 3.5 years. In the urethropexy group 7 (30%) patients had de novo detrusor instability and 1 (4%) had stress incontinence. In the reconstruction-only group 1 (5%) patient had detrusor instability and none had stress incontinence. CONCLUSIONS: Preoperative barrier testing is useful in identifying patients who do not require an antiincontinence procedure. Prophylactic Burch retropubic urethropexy increases the incidence of bladder instability.

The tension-free vaginal tape procedure: correction of stress incontinence with minimal alteration in proximal urethral mobility.

OBJECTIVES: To prospectively assess the degree of urethral hypermobility in the preoperative and postoperative periods after the tension-free vaginal tape (TVT) procedure and correlate our findings with surgical outcome. METHODS: Twenty patients with stress incontinence underwent the TVT procedure. A Q-tip test was performed before the procedure and at the 3-week postoperative follow-up visit. Cure was defined as the absence of the subjective complaint of urine leakage and the absence of stress incontinence on stress testing at cystometric capacity. RESULTS: Seventeen patients (85%) were cured by the TVT procedure, 2 patients (10%) were improved, and 1 patient (5%) was unchanged. The mean preoperative and postoperative Q-tip values were 42.75 degrees and 31.75 degrees, respectively. Twelve patients had a Q-tip test result of 30 degrees or greater after surgery and 11 (92%) of these 12 patients were cured by the procedure. CONCLUSIONS: On the basis of these results, we propose that the cure of stress incontinence does not require the correction of proximal urethral hypermobility.

Urodynamics changes in voiding after anti-incontinence surgery: an insight into the mechanism of cure.

OBJECTIVES: To measure the effect on voiding pressure and flow rate of three different operations for stress urinary incontinence. METHODS: In a previous study of cure rates, 289 women with genuine stress incontinence and genital prolapse were prospectively allocated in a randomized manner to one of three procedures: the Burch retropubic urethropexy, anterior repair, or the modified Pereyra procedure. In the current derivative study, we retrospectively evaluated the urodynamic indicators of voiding dysfunction in the original subjects preoperatively and at the 1-year postoperative follow-up visit. RESULTS: One hundred thirty-two charts were available for review. One year after surgery, pressure and flow during voiding were altered to more obstructive levels with the suspension procedures (Burch and modified Pereyra). The proportion of patients with obstructive and equivocal voiding patterns after the suspension procedures was significantly greater than after anterior repair. CONCLUSIONS: This post hoc comparison of randomized data shows a difference in postoperative voiding indexes between suspension procedures and anterior colporrhaphy. Successful bladder neck suspension depends on altering the pressure and flow during voiding to more obstructive levels. Suspension procedures alter the voiding pressure and flow toward obstruction to a greater extent than anterior repair.

Bladder neck suspension for stress urinary incontinence: how does it work?

The objective of this study was to compare urethral resistance as determined in pressure-flow studies before and after Burch retropubic urethropexy. Urethral resistance was retrospectively determined from pressure-flow studies in 178 patients before and 1 year after Burch retropubic urethropexy. Results of cotton swab tests, pressure transmission to the proximal urethra, and urethral functional length were also recorded. Results were analyzed statistically using the two-tailed paired t-test. Voiding studies in 176 patients were analyzed before and after Burch retropubic urethropexy. Mean urethral resistance increased significantly over preoperative values after successful surgery, from 0.051 to 0.099. The mean urethral resistance in patients in whom surgery failed to cure stress incontinence was unchanged from the preoperative value of 0.041. There was no direct correlation between stabilizing the bladder base, as evaluated by the cotton swab test, and cure of stress incontinence. When successful in curing genuine stress urinary incontinence, the Burch retropubic urethropexy increases urethral resistance. Creating bladder neck support without affecting urethral resistance does not, by itself, restore continence. Neurourol. Urodynam. 18:623-627, 1999.

Long-term results after antegrade collagen injection for stress urinary incontinence following radical retropubic prostatectomy.

OBJECTIVE: To evaluate the long-term success of antegrade collagen injection in men with stress urinary incontinence after radical prostatectomy. METHODS: Between October 1994 and January 1996, 20 patients underwent antegrade collagen injection for stress urinary incontinence caused by radical prostatectomy. Evaluation by pad test, urodynamics, and subjective scores was performed before and after injection. RESULTS: At a mean follow-up of 28 months, 10% of the patients were cured and 35% were improved. All patients received a single treatment (mean total volume of collagen injected 14.5 mL). In 11 patients without long-term improvement, 2 had undergone irradiation previously and 7 had failed retrograde collagen injections. Two patients with vesical neck contracture were successfully treated. Preoperative incontinence severity and stress leak point pressure did not correlate with failure. CONCLUSIONS: A 45% cured or improved rate at long-term follow-up is possible in men with stress incontinence after radical prostatectomy using a single antegrade collagen injection. Although antegrade delivery of collagen for stress incontinence minimized short-term, technique-related failures, for a substantial number of patients therapy had failed at long-term follow-up.

Comparison of anchors used in anti-incontinence surgery.

OBJECTIVES: To compare the resistance to caudally directed force at different fixation points used in female anti-incontinence surgery. METHODS: Sutures were placed in Cooper's ligament, rectus fascia, and in bone anchors on the pubic symphysis in 6 fresh, unembalmed cadavers and transposed vaginally with a ligature carrier. Force was applied in a caudal direction to each suture. Displacement of the suture with increasing force and the force required to overcome the cranial fixation point were measured with a highly precise force gauge. Two measurements were made for each anchor point and the measurements were averaged. RESULTS: With caudally directed force, sutures fixed to Cooper's ligament were displaced to an equal extent as sutures attached to a bone anchor. Sutures anchored to the rectus fascia were displaced the most with increasing force. The maximal force supported by Cooper's ligament fixation and bone anchors was similar. The event limiting each test was suture breakage, except when one suture anchored in the rectus fascia tore out. CONCLUSIONS: In a cadaver model, bone anchors placed in the pubic symphysis offer no structural advantage over Cooper's ligament fixation.

Bladder injury during the Burch retropubic urethropexy: is routine cystoscopy necessary?

The aim of this study was to investigate the incidence of operative injury to the lower urinary tract after retropubic urethropexy. We prospectively evaluated the incidence of lower urinary tract injury in 97 consecutive patients after pelvic surgery, which included primary Burch retropubic urethropexy. None of the subjects sustained intraoperative injury of the bladder or ureters as evidenced by an intact bladder mucosa and prompt efflux of dye from both ureteral orifices. In our experience, the incidence of lower urinary tract injury with retropubic urethropexy is low. We do not support the routine use of intraoperative cystoscopy with Burch retropubic urethropexy.

Intraoperative transvesical cystoscopy for urogynecologic procedures.

Intraoperative cystoscopy is a useful adjunct to surgical procedures that may compromise the integrity of the lower urinary tract. Ureteral injury and the placement of intravesical sutures are risks, especially at teaching facilities, during operations such as retropubic urethropexy, paravaginal repair, or even simple hysterectomy. The conventional use of transurethral cystoscopy during open surgical cases may require repositioning of the patient if not previously placed in Allen stirrups. Alternative practices of bladder examination include placement of a standard cystoscope via an intentional cystotomy through the dome of the bladder. The authors have implemented the direct insertion of a 2 mm microlaparoscope through the bladder dome to verify an intact lower urinary system and found this method to be both efficacious and safe. Visualization is not compromised by the slightly smaller visual field compared to the standard 0 degrees or 30 degrees cystoscope. The perspective of the bladder neck region may be more easily oriented from the superior viewing angle. The authors prefer transvesical cystoscopy with the microlaparoscope for its ease of use, compared to their experience of performing a small cystotomy or routine transurethral cystoscopy.

Transvaginal bladder neck suspension to Cooper's ligament: a modified Pereyra procedure.

We describe a modified Pereyra procedure with fixation of the bladder neck to Cooper's ligament. The anterolateral attachments of the paraurethral tissue to the inferior pubic ramus are exposed through a vaginal incision. Sutures are placed in the detached endopelvic fascia together with vaginal wall without epithelium and passed suprapubically through small ipsilateral skin and fascial incisions made slightly lateral to and at the level of the pubic symphysis, allowing visualization of Cooper's ligament. The sutures are passed through Cooper's ligament and tied to suspend the bladder neck. All ten women in whom we have done this operation have been subjectively cured of stress incontinence. Five have had long-term urodynamic follow-up. Four of these were dry by objective criteria, after a mean follow-up time of 18 months (range 15-23). The other patient was subjectively dry but had urodynamic evidence of recurrent stress incontinence.

Hormonal influence on the urinary tract.

This article describes the hormonal changes in the female and the effect of these changes on the urinary tract. Current concepts in hormone replacement therapy as it relates to incontinent, estrogen-deficient women are discussed, along with the relationship between collagen and estrogen. Finally, the authors assess the published research on the effect of estrogen on incontinence.

Interferon as an adjuvant treatment for genital condyloma acuminatum.

OBJECTIVE: To evaluate the effect of alpha-interferon as an adjuvant to laser or fluorouracil treatment in patients with recurrent genital human papillomavirus (HPV) infection. METHODS: Sixty-two females and 21 males were treated for recurrent HPV infection, with either fluorouracil (Efudex 5%) cream or laser ablation of the lesions. Half of the patients were then randomly treated with adjuvant alpha-interferon, to the lesions for patients treated with fluorouracil, or beneath areas previously treated by laser, once a week, for 8 weeks. The other half of the patients did not receive interferon adjuvant. Evaluation of both groups was done using colposcopy and acetic acid, to assess recurrence rates up to 1 year after treatment. RESULTS: Of the 83 patients followed for 1 year, colposcopy revealed recurrent anogenital lesions in 3 of 45 receiving interferon, compared with 9 of 38 patients treated without adjuvant interferon. CONCLUSION: Interferon is effective as adjuvant treatment in controlling the recurrence of genital HPV.

Laparoscopic treatment of ureteral obstruction secondary to ovarian remnant syndrome.

A case is presented in which an ovarian remnant following total abdominal hysterectomy and bilateral salpingo-oophorectomy resulted in unilateral ureteral obstruction. The obstructing tissue was excised laparoscopically with simultaneous ureteroscopic monitoring.