Mechanism of postoperative urinary continence.

Stress incontinence used to be attributed mostly to urethral hypermobility, and consequently most surgical techniques focused on the region of the bladder neck and proximal urethra. This article reviews our knowledge about the mechanism of postoperative urinary continence based on anatomic, imaging and urodynamic studies. Reduction of urethral mobility, as measured by cotton swab testing or imaging studies, is not the only reason why continence surgery succeeds. Imaging techniques are of limited value for elucidating the continence mechanism because radiologic landmarks and criteria are not reproducible. Urodynamically, the increased pressure transmission after successful continence surgery is attributed to the retropubic repositioning of the urethra, its compression against the anterior vaginal wall, and improved transmission of intra-abdominal pressure during stress. The role of the 'functional' urethral obstruction remains to be studied. In incontinent patients with hypermobility of the bladder neck and proximal urethra continence can be achieved by surgical correction. However, stress incontinence is possible in the absence of urethral hypermobility, and standard surgical techniques can fail to restore continence in these patients.

Differential regulation of endothelin secretion and endothelin receptor mRNA levels in JAR, JEG-3, and BeWo choriocarcinoma cell lines and in human trophoblasts, their nonmalignant counterpart.

Endothelin (ET) secretion and expression of both ET-A and ET-B receptor subtypes have been found in a number of primary cancers. The present study tested (1) whether choriocarcinoma cells and their nonmalignant counterpart, the trophoblast, secrete ET-1 and express ET-A and ET-B receptors; (2) whether ET-1 secretion and receptor mRNA levels are regulated by the same factors in nonvascular tissues as in vascular tissues; and (3) whether such regulation is similar in malignant and nonmalignant cells. All cells secreted ET-1 in similar amounts (approximately 0.8 fmol/10(6) cells per 24 h) and secretion was unaffected by culture and treatment. Whereas ET-B accounted for almost all (>98%) ET receptor transcripts in the choriocarcinoma cells, the trophoblasts expressed about 20% ET-A receptor mRNA. During control cultures, ET-B mRNA levels rose in choriocarcinoma, with the greatest relative increase (6-fold; P < 0.05 vs 0 h) in BeWo, whereas in trophoblasts, ET-A mRNA transiently changed after 24 and 48 h. Treatment with dexamethasone and glucose did not alter the mRNA levels in all cells. Insulin induced changes (P < 0.05) in ET-B mRNA levels in BeWo (+90 and +60% after 24 and 48 h, respectively) and JEG-3 (-70%), but not in JAR and trophoblast cells. We conclude that malignant transformation affects the responsiveness of the endothelin receptor system to external stimuli and that the regulation of the endothelin system differs in vascular and nonvascular tissues.

Parametrial spread in patients with endometrial carcinoma undergoing radical hysterectomy.

The objective of this paper is to study parametrial involvement in patients with endometrial carcinoma undergoing radical hysterectomy. We reviewed indications for surgery, pathology findings, and outcome of a series of 24 patients with endometrial carcinoma who underwent radical hysterectomy. The uterus, cervix and parametrial tissue were processed as step-serial sections. Histologically, 16 patients (67%) had carcinoma involving the cervix. Two of these patients (8%) had frank histologic parametrial involvement and four (17%) had disease extending to the transitional zone of the cervix. Parametrial involvement was continuous and seen only in patients with involvement of the cervical stroma. Six patients (25%) had pelvic node metastases. With a median follow-up of 53 months (range 2-140), four patients (17%) developed recurrences (all within 24 months). Twelve patients (50%), including one of the two with parametrial invasion, were free of disease for 5 years or longer. We conclude that direct parametrial extension can occur in locally advanced endometrial cancer. Radical hysterectomy with lymphadenectomy can be an adequate operation for such patients.

Five-year results after anti-incontinence operations.

OBJECTIVE: This study was undertaken to evaluate continence rates 5 years after anterior colporrhaphy, anterior colporrhaphy with needle suspension of the bladder neck, and Burch colposuspension. STUDY DESIGN: Among 544 women with stress incontinence who were operated on between 1989 and 1993, 327 women (60%) underwent clinical and urodynamic reevaluation 5 years after the operation. Choice of surgical procedure was made on the basis of clinical and urodynamic findings and of physician preference. Continence was defined as no loss of urine during cystometry or during coughing with the bladder filled to 300 mL. RESULTS: The 327 patients underwent a total of 334 operations. The objective overall continence rates at 5 years were 61% (65/107) after anterior repair, 49% (59/121) after anterior repair with needle suspension, and 79% (84/106) after Burch colposuspension. Continence rates after anterior colporrhaphy were 82% (32/39) among patients with mild stress incontinence but 49% (33/68) among those with moderate or severe incontinence (P <.02). Continence rates among patients with moderate or severe incontinence were 49% (59/121) after anterior repair with needle suspension and 79% (84/106) after the Burch operation (P <.02). CONCLUSION: Anterior colporrhaphy can cure mild stress incontinence but is inadequate to correct severe incontinence. Additional needle suspension may be of benefit for patients with moderate to severe incontinence. Abdominal colposuspension is superior to the vaginal operations for long-term cure of stress incontinence.

Body mass index and outcome of incontinence surgery.

OBJECTIVE: To analyze the influence of body mass on the outcome of surgery for urinary incontinence. METHODS: Among 291 women operated on for stress incontinence, 187 (64%) were available for follow-up at 5 years. Eighty women had anterior colporrhaphy, 49 anterior colporrhaphy with needle suspension of the bladder neck, and 58 Burch colposuspension. Body mass index was calculated preoperatively and at follow-up. Women were classified as being of normal weight (body mass index [BMI] 20-25), overweight (BMI 26-30), or obese (BMI greater than 30). Reported continence rates were analyzed according to BMI for each operation and the BMIs of continent patients were compared with those of incontinent patients. RESULTS: The continence rates at 5-year follow-up for anterior colporrhaphy, anterior colporrhaphy with needle suspension of bladder neck, and Burch colposuspension were 58, 51, and 86%, respectively (P < .001). The continence rates did not differ significantly among the three BMI groups for each procedure. A statistical power of 26% was found for the hypothesis that the outcome of the procedures does not depend on BMI. The preoperative and postoperative BMIs of continent and incontinent women for each procedure did not differ significantly. CONCLUSION: We did not find preoperative obesity to be a risk factor for failure of incontinence surgery, but the power of our study was limited.

Inadvertent ureteral catheterizaion with a microtip catheter at cystometry.

Two patients in whom the right ureter was inadvertently catheterized at water cystometry are described. Accidental ureteral catheterization and filling was followed by colicky pain in the right flank and by an abrupt increase in the recorded pressure, up to 148 cm H2O. The pain disappeared and the intravesical pressure returned to baseline after the microtip catheter was withdrawn.

[Needle suspension methods in the treatment of urinary stress incontinence]. / Nadelsuspensionsmethoden für die Behandlung der Stressinkontinenz.

In 1959 A.J. Pereyra published a simple transvaginal surgical method to elevate and fixate the bladder neck and proximal urethra with a specially designed needle in women with stress urinary incontinence. This method was repeatedly modified during the last 35 years. Mild to moderate stress incontinence with or without pelvic floor relaxation is regarded as an indication for needle bladder neck suspension. Contraindications include severe stress incontinence, low-pressure urethra, urge incontinence and recurrent stress incontinence. Postoperative continence rates range from 40% to 91% depending on inclusion criteria, preoperative diagnostics, criteria for success or failure, and duration of follow-up. There are no controlled clinical studies comparing different needle suspension techniques.

Contribution of the posterior compartment to the urinary continence mechanism.

OBJECTIVE: To describe the contribution of the posterior pelvic compartment to the urethral closure mechanism. METHODS: Urethral profilometry at rest and during stress was performed in 32 continent women before and after inserting a weighted (1 kg) posterior speculum to displace the posterior vaginal wall and levator ani muscles away from the bladder neck and the urethra. RESULTS: Insertion of the speculum decreased the pressure transmission ratios in the proximal quarter of urethra (from 81 to 76; P < .05) and the urethral closure pressure under stress in the proximal two urethral quarters (from 5 to -3 cm H2O in the first and from 12 to 0 cm H2O in the second urethral quarter; P < .05) in all 32 women. Before speculum insertion, 20 women had positive urethral closure pressure in the proximal urethra under stress, and 12 had negative urethral closure pressure in the proximal urethra under stress. In the 20 women with positive urethral closure pressures under stress in the proximal urethra without a speculum, the insertion of a posterior speculum decreased the pressure transmission ratios to the proximal urethral quarter (from 87 to 78; P < .05) and decreased the urethral closure pressures under stress in the proximal two urethral quarters (from 13 to -4 cm H2O in the first urethral quarter and from 24 to 2 cm H2O in the second urethral quarter; P < .01). In the 12 patients with negative urethral closure pressures under stress in the proximal urethra without a speculum, the profilometry values were unchanged by insertion of a speculum. CONCLUSION: These observations indicate that the posterior vaginal compartment may contribute to the closure mechanism of the proximal urethra in continent women.

Timing of urethral pressure pulses before and after continence surgery.

In continent women, urethral pressure with stress events has been found to rise approximately 200 msec before pressure in the bladder begins to rise. We studied the time difference in incontinent women, women after successful and unsuccessful incontinence procedures, and continent women, to evaluate the timing of urethral pressure rises in correlation with continence status. We analyzed the urodynamic data of 20 incontinent patients before and after successful or unsuccessful (n = 10 each) Raz needle suspension. Ten continent women served as controls. The time difference between onset of the pressure increase in the urethra and in the bladder was noted before and after surgery. In all 10 continent women the pressure increase in the urethra started to rise approximately 160 msec before the pressure increase in the bladder. In 16 of 20 incontinent patients the pressure in the urethra and bladder rose simultaneously. Successful antiincontinence procedures restored the early onset of urethral pressure increases. Unsuccessful operations did not produce this effect. Successful antiincontinence operations permit timely compression of the urethra. This timely compression is associated with continence.

Effects of vaginal surgery on the lower urinary tract.

Vaginal surgery performed for pelvic floor relaxation, genuine stress incontinence or both can have intended and unintended effects on the lower urinary tract. Intended effects are restoration of anatomy and urinary continence; unintended effects include operative injury, recurrent prolapse, persistent or unmasked stress incontinence, and voiding difficulties. Objective long-term follow-up and new investigational techniques have led to a critical reexamination of standard and time-honoured vaginal operations, particularly anterior colporrhaphy. This review addresses the effects of different vaginal operations on the lower urinary tract and conduction studies of the perineal nerve.

Long-term effects of vaginal dissection on the innervation of the striated urethral sphincter.

OBJECTIVE: To study the long-term effects of vaginal dissection on the innervation of the striated urethral sphincter. METHODS: Perineal nerve terminal motor latency was measured before and 8 weeks and 1 year after anterior colporrhaphy, colpoperineoplasty, and vaginal hysterectomy in 33 women, 19 of whom also underwent endoscopic suspension of the bladder neck. RESULTS: In the entire series, the mean perineal nerve terminal motor latency was prolonged before surgery over that in normal continent women and further prolonged 8 weeks and 1 year postoperatively. In the subjects who underwent vaginal hysterectomy and anterior colporrhaphy, perineal motor latencies were not significantly prolonged at the 8-week postoperative follow-up and had almost returned to preoperative values 1 year later. However, in those who underwent additional endoscopic bladder neck suspension, perineal motor latencies were prolonged at both postoperative follow-up examinations. Perineal motor latencies were unchanged 1 year postoperatively in continent patients (N = 19) but were prolonged in incontinent patients (N = 14). CONCLUSION: Vaginal dissection, especially during endoscopic bladder neck suspension, can worsen preexisting perineal neuropathy in patients with pelvic relaxation and stress incontinence.

[Effect of needle suspension on continence mechanisms]. / Einfluss der Nadelsuspension auf den Kontinenzmechanismus.

OBJECTIVE: To compare the separation in time of urethral and bladder pressure pulses and urodynamic parameters after successful and unsuccessful anterior colporrhaphy and needle suspension of the bladder neck in patients with stress urinary incontinence. STUDY DESIGN: Retrospective evaluation of urethral pressure profiles at rest and under stress in 10 successfully and 10 unsuccessfully operated patients. RESULTS: In the successfully treated group, the onset of the urethral pressure increase preceded that of the bladder pressure by an average of 300 ms. Pressure transmission ratios in the 3 proximal quartiles of the urethra were significantly improved after successful surgery. Women who remained incontinent showed neither an advanced onset of the urethral pressure pulse during stress nor improved pressure transmission ratios. CONCLUSION: Successful anterior repair and needle suspension of the bladder neck support the bladder neck and thus improve the pressure transmission to the urethra. Improved pressure transmission is associated with the finding that pressure increases in the urethra precede those in the bladder in continent women.

[5 years results of incontinence operations]. / Fünf-Jahres-Ergebnisse nach Inkontinenzoperation.

OBJECTIVE: To evaluate results 5 years after anterior colporrhaphy with or without needle suspension of the bladder neck and after Burch colposuspension. METHODS: 186/291 women (64%) operated on between 1989 and 1990 underwent clinical and urodynamic reevaluation. RESULTS: Objective continence rates after anterior colporrhaphy were 80% (20/25), 46% (22/47) and 12.5% (1/8) in patients with first-, second- and third-degree stress incontinence according to Ingelman-Sundberg. Continence rates in patients with second- and third-degree stress incontinence were 59% (29/49) after additional needle suspension and 86% (50/58) after the Burch procedure. CONCLUSIONS: Anterior colporrhaphy can cure mild stress incontinence but is not indicated for severe incontinence. The Burch procedure provides the best continence rates in patients with severe stress incontinence.

[Neuro-urodynamic sequelae of vaginal continence surgery]. / Die neurourodynamischen Folgen der vaginalen Kontinenzchirurgie.

This study aimed to investigate the influence of anterior repair on pudendal nerve terminal motor latency. Neurourodynamic investigation (urethral profilometry, measurement of pudendal nerve terminal motor latency according to the method of Snooks and Swash) was performed before and 8 weeks after anterior repair (n = 14) and before and after additional endoscopic bladder neck suspension (n = 23). Stress incontinence and pudendal neuropathy were found preoperatively in all patients. In 17/37 (48%) of patients who were incontinent postoperatively the pudendal nerve latency was significantly prolonged.

[Pelvic floor exercises without or with vaginal cones in premenopausal women with mild to moderate stress incontinence]. / Beckenbodengymnastik allein oder mit Vaginalkonen bei prämenopausalen Frauen mit milder und mässiger Stressharninkontinenz.

This study aimed to compare pelvic floor exercise only (group A) with pelvic floor exercise plus vaginal cones (group B) for the treatment of stress urinary incontinence. 46 premenopausal women were randomized into two groups. The subjective improvement or cure rates were 85.5% in group A and 84.5% in group B. Urethral pressure profiles showed a significant improvement in the transmission factor in the midurethra in each group and for the maximum urethral closure pressure in group A.