Ureteric injury after laparoscopic hysterectomy: a report of 3 cases and brief literature review.

OBJECTIVES: The application of minimally invasive laparoscopic techniques in gynecologic surgery gained popularity due to quicker recovery, shorter hospital stays as well as lower risk of complications. Ureteric injuries at laparoscopic hysterectomies are incidental and occur in less than 1% of cases. They can be identified intra-operatively but most of them are undetected. In most cases, the symptoms of an injury are non-specifically manifested after several days or even months following surgery. MATERIAL AND METHODS: We described different clinical symptoms suggesting ureteric injury based on 3 laparoscopic hysterectomies. Methods of diagnosis and repair techniques were also presented. CONCLUSIONS: All complications following laparoscopic hysterectomy should be analyzed meticulously and ureteral injury must be considered as one of the possible causes of abnormal patient recovery.

Uterovesical fistula caused by cervical pessary placed for the prevention of preterm delivery - case report.

Uterovesical fistulas are the rarest of all urogenital fistulas, mostly occurring as a complication of cesarean section. We present a case of a 32-year-old woman, who noticed continuous vaginal urine leakage starting immediately after a vaginal delivery. The shortening of the uterine cervix was reported at 26th week of gestation, and a cervical pessary was placed. Shortly after delivery, the patient noticed the loss of urinary continence control, and she was diagnosed with urinary incontinence and hematuria. The office diagnostic hysteroscopy revealed uterovesical fistula. The correction procedure by transabdominal approach was performed by the team of gynecological and urological surgeons. One year of follow-up, the patient reports no symptoms related to lower urinary tract dysfunction. Based on the literature search, we believe that his is the first study of a uterovesical fistula followed by the use of a cervical pessary for the prevention of preterm delivery. Our case is a clear reminder that symptoms of urinary incontinence after vaginal delivery should be carefully managed.

Reliability of the Polish version of the Overactive Bladder Symptom Score (OABSS) questionnaire : Correlation of the OABSS with urodynamic study and the UDI-6 and IIQ-7 questionnaires.

INTRODUCTION AND HYPOTHESIS: Overactive bladder (OAB) and mixed urinary incontinence (MUI) are significant problems worldwide. Their broad definition makes them difficult to diagnose; therefore, specialists need a tool to confirm diagnosis. The Overactive Bladder Symptom Score (OABSS) is used in the objective diagnosis of OAB. We aimed to develop and evaluate the effectiveness of OABSS for patients in Poland suffering from OAB and MUI and to correlate it with UDI-6 and IIQ-7. METHODS: A total of 824 women suffering from urinary incontinence (UI) aged between 18 and 75 years were included. SUI (n = 290); OAB (n = 285) and MUI (n = 249) were confirmed by medical history and urodynamic study. Of the subjects, 821 women completed the Polish version of OABSS on two separate visits: weeks 0 and 2. In addition, they undertook UDI-6 and IIQ-7 during Week 2. The Cronbach's alpha (α) was used to estimate the internal consistency. Scores were compared using the intraclass correlation coefficient (ICC). RESULTS: We observed statistically significant differences (p < 0.0005) between mean scores of OABSS among patients from the study groups OAB-SUI and MUI-SUI. We did not observe statistically significant differences between patients from the MUI and OAB groups (p > 0.11). Analysis also did not show statistically significant differences between visits. The internal consistency was very good: α = 0.89 (SUI); = 0.9 (OAB); = 0.82 (MUI). In all groups, test-retest reliability was excellent; ICC was >0.99. CONCLUSIONS: The Polish version of the OABSS is a reliable tool for females suffering from UI. However, OABSS does not distinguish patients with MUI from patients with OAB.

Should We Always Use Antibiotics after Urodynamic Studies in High-Risk Patients?

AIM: The aim of this observational study was to evaluate the effectiveness of a phytotherapic drug (Canephron N) in preventing urinary tract infection (UTI) in high-risk women undergoing urodynamic studies (UDS). METHODS: The study protocol was approved by the local institutional ethical committee. Adult women with at least one risk factor for acquiring UTI (defined as: age over 70, elevated postvoid residual urine>100 ml, recurrent UTI, pelvic organ prolapse (POP) ≥II in POP-Q scale, and neurogenic bladder) had received after UDS either a single oral dose of fosfomycin trometamol (FT) (3 grams) or a phytodrug containing centaury herb, lovage root, and rosemary leaves (5 ml taken orally three times daily for one week). All patients included in the study had no pyuria according to urine dipstick (nitrite and/or blood and/or leukocyte esterase) and negative urine culture (CFU < 103/ml) before UDS. Urine samples were also tested 7 days after UDS. RESULTS: Seventy-two high-risk participants completed the study. Seven days after urodynamic studies UTI symptoms, pyuria (nitrite and/or blood and/or leukocyte esterase) and bacteriuria with E. coli occurred in two patients (one (2.8%) in the FT and one (2.7%) in the phytodrug group, respectively). No statistical differences in UTI incidence were found between both treatment groups. We did not observe any additional adverse events in both groups. The major disadvantage of prophylaxis with the phytodrug as compared to FT was the necessity of continuing therapy for 7 days. CONCLUSION: Prophylaxis of UTI with a phytodrug (Canephron N) may be considered a good alternative to antibiotic prophylaxis use after UDS in high-risk female patients.

Novel biomarkers of overactive bladder syndrome.

The social aspect of overactive bladder syndrome (OAB) and the lack of objective diagnostic methods for this syndrome have spurred research into its potential biomarkers which can constitute useful diagnostic tools, while also allowing the evaluation of the intensity of clinical symptoms and the efficacy of implemented pharmacotherapy in OAB patients. Due to the complex etiopathogenesis of this syndrome, the researchers are seeking biomarkers connected with inflammation or nerve growth. The aim of this review was to analyse the latest literature data regarding potential biomarkers in OAB. The most promising opportunities are connected with the diagnostic use of the nerve growth factor (NGF), the brain derived neurotrophic factor (BDNF), C-reactive protein (CRP), prostaglandins and cytokines. Despite the most promising results to date having been obtained with regards to neurotrophic factors, it seems that, at the moment, none of these meets the criteria for becoming an isolated OAB marker. It is also suggested that the combined use of several biomarkers will facilitate obtaining the appropriate level of specificity and selectivity to allow their use in clinical practice.

Development and validation of the Polish version of the Urogenital Distress Inventory short form and the Incontinence Impact Questionnaire short form.

OBJECTIVE: The Incontinence Impact Questionnaire (IIQ) measures the impact of urinary incontinence on activities, roles, and emotional states of women, whereas the Urogenital Distress Inventory (UDI) measures how troubling the symptoms are. The aim of this study was to develop and assess the effectiveness of a Polish version of the IIQ and UDI. STUDY DESIGN: The translation into Polish followed standardized procedures. 206 women aged between 31 and 83 years were included into the study. All patients were recruited from women attending the Outpatient Clinic of the 2nd Gynecology Department of the Medical University in Lublin. SUI was observed in 116 cases; OAB in 16 patients and 24 had MUI (confirmed by medical history, bladder diary and urodynamic investigation). 50 healthy women served as control. All patients completed the Polish version of the ICIQ - 'the gold standard' in UI diagnosis - as well as the newly translated Polish versions of the UDI-6 and IIQ-7 questionnaires at baseline. Moreover, 116 women repeated the UDI-6 and IIQ-7 self-assessment again 7days later. RESULTS: The internal consistency was tested by calculating Cronbach's alpha, using baseline scores. The high reliability of the scale indicates a value greater than 0.7. The reliability was calculated by way of the Intraclass Correlation (ICC) and was considered acceptable when ICC was≥0.7. In fact, ICC in all investigated groups was >0.95. The Cronbach's alpha values were as follows: for SUI patients - 0.74; for OAB - 0.78; and for MUI - 0.28 (the UDI-6 total score for the whole study group was 0.72). Cronbach's alpha total score for IIQ-7-0.89 (SUI group - 0.89; OAB group - 0.93; and MUI group - 0.77). Finally, the Cronbach's alpha total score for the ICIQ Questionnaire was 0.73 (SUI group - 0.71; OAB group - 0.65 and MUI group - 0.81). CONCLUSIONS: The Polish versions of the UDI-6 and IIQ-7 Questionnaires are reliable, valid, and responsive instruments for assessing the severity of symptoms and quality of life in females suffering from urinary incontinence.

The polymorphisms of the MMP-1 and the MMP-3 genes and the risk of pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: To investigate the associations between single nucleotide polymorphism (SNP) type 1G/2G at position -1607/-1608 of the matrix metalloproteinase (MMP)-1 gene and SNP type 5A/6A at position -1612/-1617 of the MMP-3 gene and the development of pelvic organ prolapse (POP) in women. METHODS: 133 patients with symptomatic POP were included in the study group. The control group consisted of 132 women with a normal pelvic floor. 1G/2G MMP-1 and 5A/6A MMP-3 SNPs were determined by polymerase chain reaction (PCR) and restriction fragments length polymorphism analysis. RESULTS: When estimated individually none of the investigated SNPs were associated with POP. The combined MMP-1/MMP-3 SNP analysis showed that the following polymorphic pairs were overrepresented in women with POP: 1G/2G -5A/6A, 2G/2G -5A/6A, 2G/2G -5A/5A, 1G/1G -6A/6A, p=0.005. CONCLUSIONS: The combined effect of -1607/-1608 MMP-1 and -1612/-1617 MMP-3 SNPs may contribute to the development of POP in some women.

Transvaginal Prolift(®) mesh surgery due to advanced pelvic organ prolapse does not impair female sexual function: a prospective study.

OBJECTIVES: To evaluate sexual function among women with advanced pelvic organ prolapse (POP) before and after Prolift(®) vaginal reconstructive mesh surgery. STUDY DESIGN: Assessments were performed preoperatively and 12-18 months after the surgery, including physical examination using the Pelvic Organ Prolapse Quantification (POP-Q) scale as well as the Female Sexual Function Index (FSFI) questionnaire. RESULTS: Fifty-nine sexually active patients who underwent vaginal reconstructive surgery due to advanced POP between June 2008 and January 2010 were included in the study. Analysis of the FSFI questionnaire showed no statistically significant differences after surgery, despite proper anatomical results. When comparing the group of women who underwent additional surgical restoration of the perineal body with patients without this procedure we also did not observe any differences in FSFI scores. CONCLUSIONS: Surgical treatment of advanced POP with the Prolift(®) system does not negatively influence sexual function, but patients should not expect a significant improvement after this type of operation. Additionally performed surgical restoration of perineal body does not reduce sexual function, either.

Tape fixation: an important surgical step to improve success rate of anti-incontinence surgery.

PURPOSE: Mid urethral slings are effective surgical treatment for stress urinary incontinence. However, 5% to 20% of patients still experience surgical failure with clinically significant recurrent or persistent stress urinary incontinence. Since a subset of these failures may be caused by improper tape position, we elucidated whether additional paraurethral fixation of a tape to prevent displacement during tensioning could improve the transobturator sling outcome. MATERIALS AND METHODS: The study was done in 463 patients with stress urinary incontinence who were randomly allocated to treatment with a standard transobturator intravaginal monofilament sling procedure (232) or to an intravaginal transobturator monofilament sling with additional 2-point tape fixation (231). Another 2 absorbable sutures parallel to the urethra were added to fix the tape and prevent displacement during tape tensioning. Outcome was assessed by a cough test and a 1-hour pad test at 12 months. RESULTS: Clinical efficacy of the procedure with fixation was significantly higher with 195 women (95.12%) cured or improved compared to the 199 (88.73%) cured or improved with the standard sling (chi-square 5.71, p = 0.0169). There was no increase in intraoperative or postoperative complications. Also, among patients with intrinsic sphincter deficiency we noted a significantly better outcome in the fixation group than in the control group, that is 39 of 41 patients (95.1%) cured or improved vs 31 of 42 (73.8%) (chi-square 10.65, p = 0.0011). CONCLUSIONS: Tape fixation significantly increases the clinical efficacy of the transobturator sling, especially in patients with intrinsic sphincter deficiency.

[Sacral nerve stimulation in the treatment of the lower urinary tract function disorders]. / Stymulacja nerwów krzyzow ych w leczeniu zaburzen czynnosciowych dolnych dróg moczowych.

Functional disorders of the female lower urinary tract like urge incontinence, idiopathic urinary retention and symptoms of urgency-frequency occasionally do not respond properly to classical behavioral and pharmacological therapy Therefore, additional alternative therapies are needed to alleviate these bothersome symptoms. Sacral neuromodulation (SNS) utilize mild electrical pulses which activate or suppress neural reflexes responsible for voiding by stimulating the sacral nerves that innervate the bladder, external urethral sphincter and pelvic floor muscles. The exact mechanism of SNS action is not yet fully understood but it is assumed that it influences the neuroaxis at different levels of the central nervous system and restores the balance between inhibitory and activatory control over the voiding reflex. There is numerous evidence on the success of SNS not only in the treatment of refractory urge incontinence in adult and children but also in idiopathic urinary retention and symptoms of urgency-frequency

[MMP-1 and MMP-3 gene encoding polymorphism and the risk of the development of pelvic organ prolapse and stress urinary incontinence]. / Polimorfizm genów kodujacych MMP-1 oraz MMP-3 a ryzyko wystapienia wysilkowego nietrzymania moczu i zaburzen statyki dna miednicy mniejszej.

OBJECTIVES: The estimation of the association between the polymorphism at position -1607/1608 of the gene promoter encoding matrix metalloproteinase type 1 (MMP- 1) and the polymorphism at position -1612/1617 of the gene promoter encoding stromelysin type 1 (MMP-3) and the risk of the occurrence of pelvic organ prolapse (POP) and stress urinary incontinence (SUI). MATERIAL AND METHODS: 347 women were included into the analysis. POP study: the study group consisted of patients with clinically significant POP (POP-Q scale: 2, 3, 4). Women with normal pelvic floor statics (POP-Q scale: 0, 1) and not reporting symptoms of urinary incontinence were included into the control group. SUI study: the study group--patients with symptoms of stress urinary incontinence, the control group--continent women with normal pelvic floor statics (POP-Q scale: 0, 1). Samples of DNA were isolated from whole blood. The type of polymorphism was detected by RFLP method. RESULTS: Both, in the POP and the SUI study we have observed no statistically significant differences in the occurrences of MMP-1 and MMP-3 promoter polymorphisms between the study and the control groups. Also, the presence of the alleles G/GG (MMP-1) or 5A/6A (MMP-3) did not modify the risk of the POP and SUI development. CONCLUSIONS: Polymorphism type G/GG of gene promoter encoding MMP-1 and polymorphism type 5A/6A of the gene promoter encoding MMP-3 are not associated with the risk of the development of POP and SUI.

[The quality of life of patients with overactive bladder after local injections of botulinum toxin A--a preliminary report]. / Jakosc zycia pacjentek z pecherzem nadreaktywnym po zastosowaniu toksyny botulinowej--doniesienie wstepne.

OBJECTIVES: The purpose of this work was to evaluate the quality of life of patients suffering from urge urinary incontinence resistant to anticholinergic therapy treated with intradetrusical injections of 200 U botulinum toxin A. MATERIALS AND METHODS: The study group consisted of 10 female patients who were diagnosed with urge urinary incontinence. Standard King's questionnaire was used for the assessment of the change in the quality of life after treatment. Questionnaires were filled in by all patients before the treatment and during control visits, 3 months after the injection of botulinum toxin A. RESULTS: Statistically significant improvement in the quality of life for the majority of the domains of King's questionnaire (except the evaluation of urinary incontinence impact on the general health condition and social relations) was observed in 7 out of 10 patients subjected to botulinum toxin therapy (p < 0.05). CONCLUSIONS: Based on the results of this study we can conclude that treatment of patients with urge urinary incontinence not responding to classical anticholinergic treatment with botulinum toxin causes a significant improvement in the quality of their life.

Body mass index does not influence the outcome of anti-incontinence surgery among women whereas menopausal status and ageing do: a randomised trial.

INTRODUCTION AND HYPOTHESIS: A few series comparing the clinical efficacy of midurethral slings in obese and postmenopausal patients are available. The aim of the study was to assess clinical efficacy of suburethral tape operations for the surgical treatment of female stress urinary incontinence (SUI) stratified by obesity, menopause and ageing. METHODS: Five hundred thirty-seven patients underwent either retropubic or transobturator sling procedure. Patients were randomly allocated into two study groups in a ratio of 1:1. After 18 months, 398 women were available for a follow-up efficacy evaluation. RESULTS: The clinical effectiveness of surgical SUI treatment did not depend on patients' body mass index (BMI) and type of midurethral sling, but menopausal status and ageing significantly influenced the outcome of the surgery. CONCLUSIONS: We found that BMI does not influence the clinical effectiveness of SUI treatment, whereas both menopause and ageing had a detrimental influence on the final outcome of the surgery.

Botulinum toxin--a new therapeutic agent in girls with non-neurogenic overactive bladder--a case report and review of the literature.

The aim of this article is to present the safety and efficacy of intradetrusor botulinum toxin injections in the treatment of non-neurogenic overactive bladder in pediatric patients. The electronic database MEDLINE (1966-2009) was searched including the following entries: non-neurogenic overactive bladder and botulinum overactive bladder. Data on the investigation topic are scarce. Most of the papers concern neurogenic overactive bladder in adults, with only a few dealing with children with neurological disturbances. Therefore, the following paper presents a case of botulin toxin treatment in girl with overactive bladder. The patient did not tolerate the standard anticholinergic therapy and did not present neurollogical disturbances. Successful outcome allows us to state that intradetrusor botulinum toxin type A injection is a promising new treatment method in the refractory cases of non-neurogenic pediatric overactive bladder.

The clinical effectiveness of retropubic (IVS-02) and transobturator (IVS-04) midurethral slings: randomized trial.

BACKGROUND: Few series comparing the clinical efficacy of retropubic slings versus transobturator slings for the treatment of female stress urinary incontinence (SUI) are available. OBJECTIVE: To compare clinical efficacy of retropubic tape operations and transobturator suburethral tape operations for the surgical treatment of female SUI. DESIGN, SETTING, AND PARTICIPANTS: From January 2003 to December 2005, 611 patients underwent clinical and urodynamic evaluation before surgical treatment for SUI. Patients with advanced urogenital prolapse (pelvic organ prolapse-quantification scale [POP-Q] scale grade >1) were excluded, and 537 patients were included in this study. After 18 mo, 398 women were available for follow-up efficacy evaluation at a tertiary academic center. INTERVENTION: All patients underwent either a retropubic sling procedure or a transobturator sling procedure. Patients were randomly allocated into two study groups at a ratio of 1:1. MEASUREMENTS: After 18 mo all enrolled patients were clinically checked for clinical efficacy of both procedures. RESULTS AND LIMITATIONS: Demographic and urodynamic parameters of patients were similar in both groups. No bladder injury occurred in the transobturator sling group (IVS-04), whereas 13 intraoperational bladder perforations (6.5%) occurred in the retropubic sling group (IVS-02) (p<0.001). The tape erosion rate was <2.5% in both groups (p=0.7). After 18 mo, 398 patients (201 in the IVS-02 group and 197 in the IVS-04 group) were evaluated in terms of clinical efficacy of the procedures. We found out that there was no statistically significant difference in clinical efficacy between these two procedures (chi(2)=1.88, p=0.39). In the IVS-02 group, 75.1% of patients (n=151) remained dry (cured), 16.9% of patients (n=34) reported significant improvement, and 8.0% of patients (n=16) were considered as failures. In the IVS-04 group, 74.1% of patients (n=146) remained dry, 14.2% of patients (n=28) reported significant improvement, and 11.7% (n=23) were considered as failures. CONCLUSIONS: Based on an 18-mo follow-up, the efficacies of both techniques are comparable; however, the retropubic route appears to be more efficient in the intrinsic sphincter deficiency (ISD) group.

[Rho kinase--a new target for pharmacological treatment of an overactive bladder]. / Kinaza Rho--nowy cel dla leczenia farmakologicznego pecherza nadreaktywnego.

Rho kinase plays a key role in the regulation of smooth muscles contraction, including those of the urinary bladder detrusor. Rho kinase pathway modulates the level of phosphorylation of the myosin light chain, mainly through the inhibition of myosin phosphatase. Recent experimental data indicate that its role might be exacerbated in local and systemic pathological conditions which affect the bladder. It seems that Rho kinase inhibitors, such as Y27632, may turn out to be an effective group of drugs in pharmacotheraphy of an overactive bladder (OAB), which will influence the storage phase of the micturition cycle, without interfering with the physiological voiding.

Changing trends in the surgical treatment of female stress urinary incontinence--twenty two years observation.

OBJECTIVES: The aim of this study was to analyze the changing trends in surgical treatment of female urinary incontinence (UI). MATERIAL AND METHODS: Medical records of all women admitted to II Department of Gynecology from 1985 to 2006 were analyzed in order to find out how the female SUI treatment changed over these years. RESULTS: During analyzed time 36819 patients were hospitalized in our Department and 77.6% (28568) of them were operated because of various indications. The number of SUI surgeries among all hospitalized women steadily rose from 1.93% in 1985 to 10.96% in 2006 reaching maximum in 2005 (13.73%). Clinical effectiveness of SUI surgeries markedly improved from 35% for anterior colporrhaphy to almost 90 % for suburethral slings. CONCLUSIONS: Introduction into clinical practice modern suburethral slings improved clinical efficacy of SUI treatment. The percentage of women admitted and treated surgically because of SUI steadily increased over the last years.

Relationship between estrogen receptor-alpha polymorphism and serum levels of vascular cell adhesion molecule-1, intercellular adhesion molecule-1, C-reactive protein and homocysteine in postmenopausal women.

BACKGROUND AND AIM: Genetic variation in the estrogen receptor-gene (ERalpha) may influence the risk of cardiovascular diseases in postmenopausal women. This effect, at least in part, may be dependent on the decrease in expression of injury and inflammatory markers in the vascular wall. The aim of the present study was to evaluate the relationship between ERalpha PvuII and XbaI polymorphisms and serum levels of soluble vascular cell adhesion molecule-1 (sVCAM-1), soluble intercellular adhesion molecule-1 (sICAM-1), C-reactive protein (CRP) and homocysteine in postmenopausal women. SUBJECTS AND METHODS: Subjects of the study were 64 postmenopausal women. PvuII and XbaI ERalpha gene polymorphisms were analyzed by polymerase chain reaction-restriction fragment length polymorphism. RESULTS: Mean sVCAM-1 level was significantly higher in pp homozygotes in comparison with PP homozygotes and Pp heterozygotes, as well as higher in xx homozygotes in comparison with XX homozygotes and Xx heterozygotes. Levels of sVCAM-1 were also significantly higher in women with px haplotype compared with PX and Px haplotypes. There were no relationships between investigated genotypes or haplotypes and levels of sICAM-1, CRP and homocysteine. CONCLUSION: The results of our study suggest that genetic variation in ER gene may influence blood levels of VCAM-1 in women after the menopause.

[The prospective comparison of the clinical effectiveness and the complication rate of retropubic (IVS-02) and transobturator (IVS-04) midurethral slings in the treatment of female stress urinary incontinence]. / Prospektywne badanie porównujace efektywnosc kliniczna i czestosc wystepowania powiklan sród- i poopera- cyjnych slingu zalonowego (IVS-02) i slingu przezzaslonowego (IVS-04) zastosowanych w leczeniu wysilkowego nietrzymania moczu u kobiet.

UNLABELLED: The prospective comparison of the clinical effectiveness and the complication rate of retropubic (IVS-02) and transobturator (IVS-04) midurethral slings in the treatment of female stress urinary incontinence. OBJECTIVES: The purpose of this study was the prospective comparison of clinical efficacy and safety of retropubic (IVS-02) and transobturator suburethral tape techniques (IVS-04) in the treatment of female stress urinary incontinence. MATERIAL AND METHODS: From January 2003 to June 2004, 145 patients with uro-dynamically proven stress urinary incontinence underwent surgical treatment (IVS-02 or IVS-04). During pretreatment work-up, all patients had under-gone full clinical and urodynamic evaluation. Patients with mixed, urge incontinence and the advanced urogenital prolapse (POPQ scale > 2) were excluded from the study. RESULTS: Patients clinical characteristics and urodynamic parameters were comparable between the analyzed groups. At one year follow-up, 122 patients (61 in each group) were evaluated in terms of clinical efficacy of the procedure. The total cure (78.7% in IVS-02 vs 70.5% in IVS-04), the improvement (14.7% vs 21.3%) and the failure rates (6.6% vs 8.2%) were similar in both analyzed groups, chi2 = 0.58; (p = 0.75). CONCLUSIONS: The transobturator route for the treatment of stress urinary incontinence appears to be as effective as the retropubic one at one year follow-up. Moreover, the shorter operation time and no need to perform cystoscopy during the surgery make the transoburator route a very attractive alternative to retropubic approach.