Combined laparoscopic surgery for the treatment of pelvic organ prolapse and recurrent urinary incontinence. / Técnica quirúrgica para la corrección simultánea del prolapso de órganos pélvicos y la incontinencia urinaria recidivada mediante laparoscopia.

INTRODUCTION: Laparoscopic sacral colpopexy (LSC) is the gold standard treatment for apical pelvic organ prolapse (POP). Artificial urinary sphincter (AUS) has a high success rate in treating recurrent stress urinary incontinence (SUI). OBJECTIVE: To describe the first simultaneous LSC and AUS implantation through a vesicovaginal approach to the bladder neck. MATERIAL AND METHODS: Operation is performed through a transperitoneal approach. The rectovaginal space is created and the posterior mesh is fixed. The vesicovaginal and both laterovesical spaces are dissected. The vesicovaginal space is connected to both lateral spaces. This is main step of the procedure because it let us place the cuff around the bladder neck in a non-blind fashion. The anterior mesh is fixed to the vagina. The anterior side of the bladder neck is dissected and the cuff implanted. Both meshes are fixed to the promontory. Pressure-regulating balloon is inserted, the pump is placed in the labia majora and the components are connected. Peritoneum is closed. RESULTS: Surgical time was 180 minutes, bladder catheter was removed at 5th postoperative day, hospital stay was 5 days. The AUS was activated 6 weeks after surgery. No perioperative complications occurred. After 12 months the patient is pad-free and prolapse was objectively and subjectively cured. CONCLUSIONS: Vesicovaginal dissection is a shared step in this technique of LSC and AUS implantation. This approach could minimize the risk of bladder neck injury. We propose this technique in selected cases of prolapse and recurrent SUI.

Clinical and urodynamic impact of detrusor overactivity in women with overactive bladder. / Repercusión clínica y urodinámica de la presencia de hiperactividad del detrusor en mujeres con vejiga hiperactiva.

OBJECTIVE: To evaluate the clinical and urodynamic differences (associated with the presence or absence of detrusor overactivity [DO]) in women with overactive bladder (OAB) referred to Functional Urology and Urodynamic Units in Spain. MATERIAL AND METHODS: Observational, cross-sectional, multicenter and prospective study conducted in Spain in women with clinical diagnosis of OAB, who had been referred to urodynamic study (UDS) of which centralized reading was performed. Patients completed the 3-day voiding diary (DM3d) with the PPIUS scale (Patient Perception of Intensity of Urgency Scale), the B-SAQ (Bladder Self-Assessment Questionnaire) and the OABq-SF (Overactive Bladder Questionnaire Short Form). The questionnaires and UDS variables of women with OAV, with or without DO, were compared using the Mann-Whitney test (continuous variables) and the chi-square test (χ2) (categorical variables). RESULTS: A total of 247 women with OAB were evaluated, and 103 of them had DO. According to the presence or absence of DO, significant differences were observed in the number of episodes of urge urinary incontinence (UUI), urinary frequency, nocturia, mean micturition volume and number of pads (P<.05 for all comparisons). A higher percentage of patients with OAB and DO presented reduced bladder capacity, urgency, urge urinary incontinence (UUI) and lower volume for first voiding desire, strong desire to void and maximum cystomanometric capacity in UDS compared with patients without DO (P<.05 for all comparisons). The only significant differences between both groups were regarding the B-SAQ symptoms scale (P=.011). CONCLUSIONS: The presence of DO in women with OAB is related to a more severe alteration of the bladder filling phase.

A new approach to laparoscopic implantation of the artificial urinary sphincter: Vesicovaginal approach to the bladder neck. / Nueva aproximación al implante laparoscópico del esfínter urinario artificial: abordaje vesicovaginal al cuello vesical.

INTRODUCTION: The artificial urinary sphincter (AUS) is not used extensively in the treatment of female urinary stress incontinence (USI) due to the poor reproducibility of the techniques used. We describe a new approach to laparascopic implantation, of which dissection of the vesicovaginal space is an essential step. This enables an approach under direct vision to the posterior surface of the bladder neck. MATERIAL AND METHODS: We present two cases where this approach was used. A transperitoneal approach was made in the Trendelenburg position. The main steps were: creating the vesicovaginal space until identifying the bladder neck, creating two laterovesical spaces, communicating these with the vesicovaginal space, and dissecting the anterior surface of the bladder neck, attempting to preserve the pubovesical ligament. The cuff and reservoir were inserted through the 12mm infraumbilical trocar. The connections were externalised through a left suprapubic incision and a subcutaneous tunnel created up to the labia majora where the activation pump was placed. The procedure was completed with closure of the peritoneum. It is essential to use a vaginal valve to facilitate dissection. RESULTS: Surgery time: 140 and 135minutes, with no intraoperative complications. After removing the urinary catheter, one patient had elevated postvoid residual urine volume, which was managed conservatively. Hospital stay: 72h. At 3 and 9 months the patients were fully continent. CONCLUSIONS: We present the preliminary results of laparoscopic implantation of an AUS through a vesicovaginal approach to the posterior surface of the bladder neck, which might reduce potential complications that have been observed after the routine techniques.

OnabotulinumtoxinA in overactive bladder: Evidence-based consensus recommendations.

OBJECTIVE: To offer a set of useful recommendations for urologists who are starting to provide treatment of overactive bladders with onabotulinumtoxinA. METHODS: A literature search to December 2013 was conducted, as well as a subsequent critical reading of the selected publications. The coordinators prepared a document that was submitted for review by the members of the Spanish Group for the use of Botulinum Toxin in Urology. RESULTS: The expert group considered that onabotulinumtoxinA may be used for overactive bladder syndrome with urinary urge incontinence secondary to neurogenic or idiopathic detrusor overactivity for patients for whom conservative treatment and first-line medical treatment has failed, is not tolerated or is contraindicated. Treatment in most cases was performed with local intravesical anesthesia, although it can also be performed under epidural or general anesthesia. Patients must be informed of the possibility of requiring self-catheterization or temporary catheterization. Clinicians should ensure that the patients are capable of performing this catheterization before the treatment is conducted. Patients must also be informed of the need for antibiotic prophylaxis to reduce the risk of urinary tract infections. At least 2 follow-up visits are recommended: the first at days 7-14 after the injection and the second at 2-3 months. Reinjection is indicated when the effect of the treatment decreases. CONCLUSION: These guidelines can help clinicians in their daily decisions and limit the potential risks associated with the incorrect use of the drug.

How should we address the diagnosis of overactive bladder in women?

OBJECTIVE: Determine the degree of completion, agreement and diagnostic performance of various instruments for assessing the presence and intensity of urgency and other symptoms of idiopathic overactive bladder (OAB) and determine which is the best diagnostic combination. MATERIAL AND METHODS: Observational, noninterventional, cross-sectional multicentre study on 247 women aged 18 years or older, with a clinical diagnosis of OAB, evaluated in 55 functional urology and urodynamic units. The women completed the Patient Perception of Intensity of Urgency Scale questionnaire, an independent bladder control self-assessment questionnaire (B-SAQ), the Overactive Bladder Questionnaire Short-Form and a 3-day voiding diary (VD3d), and they underwent a urodynamic study (UDS). The degree of completion and agreement among the instruments was assessed using the Kappa index (95% CI) and Cramér's V. The diagnostic performance of each tool and their combination was studied using absolute frequencies of positive cases for each OAB symptom. RESULTS: The patients mean age was 57.66 years (SD, 13.43). There was a high degree of completion (>85%). The agreement among the instruments was poor or moderate, and there was no agreement with the UDS. The best combination of tools for the diagnosis of OAB in women was the B-SAQ and VD3d. CONCLUSIONS: The degree of completion of all instruments was high, the agreement between them was poor-moderate and not significant for the UDS. The instruments that had the best diagnostic performance for assessing urgency and other OAB symptoms, providing data on their severity and discomfort, were the B-SAQ and the VD3d.

[Urinary incontinence: anticholinergic treatment]. / Tratamiento farmacológico con anticolinérgicos.

The bladder and urethra are a functional unit controlled and coordinated by the central and peripheral nervous systems. Voluntary or involuntary contraction of the Detrusor muscle depends mainly on muscarinic receptor stimulation by Acetylcholine, which is released from parasympathetic terminals. This receptors are the antimuscarinic (anticholinergic) drug target. Anticholinergic drugs are the first line of treatment for overactive bladder. They have been widely investigated and have shown superior efficacy to placebo in numerous studies. Their effects on bladder function result in an increase of the capacity at which involuntary detrusor contractions are produced, a decrease in its amplitude and an increase in bladder capacity. The purpose of this Literature Review is to provide an up-to-date overview of the current situation of this form of treatment (Oxybutinin, Long Acting Tolterodine, Trospium Chloride) and the main developments in this area. Some of these drugs are already commercially available in Spain (Long Acting Tolterodine), some may appear soon (Extended Release Oxybutinin, Transdermal Oxybutinin), and others are available for specific cases (Intravesical Oxybutinin). Other drugs, which are theoretically more uroselective (Darifenacin or Solifenacin), are not yet freely available on the open market, while yet others are already in use in other countries (Propioverine). Finally I would like to mention the increasing use of Botulinum Toxin detrusor injection for bladder hyperactivity that fails to respond to conservative treatments.

[Posterior sacral root neuromodulation in the treatment of chronic urinary dysfunction]. / Neuromodulación de raíces sacras posteriores en el tratamiento de la disfunción miccional crónica.

OBJECTIVES: To describe the effectiveness of sacral root neuromodulation in ameliorating symptoms of refractory voiding disfunction in our center. MATERIAL AND METHODS: During the period from december 1998 throught december 2001, 31 Percutaneous Nerve Evaluation (PNE) was performed to 20 patients with refractory voiding dysfunction; a sacral nerve stimulation device was implanted in 10 patients (8 female, 2 male). The median age was 49 years. Refractory voiding dysfunction included: mixed disorders (30%), idiopathic nonobstructive chronic urinary retention (20%), urgency/frequency (20%), faecal and urinary incontinence with absence of sphincter defect (20%) and frequency (10%). RESULTS: The 2 patients with frequency/urgency decreased their symptoms more than 50%, bladders were emptied without post-void residual urine in 2 patients with urinary retention, faecal and urinary incontinence in 2 patients and mixed disorders in other 3, reduced their symptoms more than 90% without residual urine. The frequency improved more than 50% in 1 patient. CONCLUSIONS: Sacral Root Neuromodulation is a successful treatment in some cases of idiopathic chronic micturition dysfunction which don't respond to pharmacotheraphy or bladder retraining. The effects of neuromodulation are long-lasting and associated morbidity is low.

Neuromodulación de raíces sacras posteriores en el tratamiento de la disfunción miccional crónica / Sacral root neuromodulation as a treatment of chronic micturition dysfunction

OBJETIVOS: Describir la experiencia de nuestro centro en el tratamiento con neuromodulación de raíces sacras posteriores de pacientes con disfunción miccional crónica tras el fracaso de tratamiento conservador. MATERIAL Y MÉTODOS: Desde diciembre de 1998 a diciembre de 2001, hemos realizado a 20 pacientes 31 test de estimulación de nervios periféricos (ENP), y 10 implantes definitivos (8 fueron mujeres y 2 varones). Edad media: 49 años. El cuadro clínico más frecuente fueron los trastornos mixtos (30 per cent), seguidos por retencionistas crónicos (20 per cent), urgencia/frecuencia miccional (20 per cent), incontinencia urinaria y fecal con integridad esfinteriana (20 per cent) y cuadro de frecuencia miccional elevada (10 per cent). RESULTADOS: Los 2 pacientes con frecuencia e incontinencia por urgencia mejoraron la sintomatología más del 50 per cent. Los 2 pacientes con retención urinaria crónica completa recuperación micción espontánea sin residuo post-miccional, 3 pacientes con trastornos mixtos redujeron sus síntomas más del 90 per cent sin residuo post-miccional significativo. Los pacientes con incontinencia fecal y urinaria mejoraron su sintomatología más de un 90 per cent. El paciente con cuadro de frecuencia miccional elevada también redujo los síntomas más del 50 per cent. La única complicación post-quirúrgica fue seroma de herida quirúrgica en 3 casos. CONCLUSIONES: La neuromodulación de raíces sacras es útil en los casos de disfunción miccional crónica idiopática que no responden a tratamiento farmacológico y/o de reeducación. La neuromodulación de raíces sacras produce, en pacientes seleccionados, una mejoría prolongada y la técnica presenta escasa morbilidad (AU)