A novel technique for thulium laser enucleation of the prostate: anterior releasing with ThuLEP (ARTh technique).

Thulium laser enucleation of the prostate (ThuLEP) is a highly effective approach to the treatment of benign prostatic hyperplasia. We present here a description of the "ARTh Technique" and the benefits it offers in terms of improved visualization, short operation times, and easy recognition of the dissection plane, describing specifically the anterior release (AR) technique using ThuLEP(Th). Included in this retrospective study were 32 consecutive patients operated on between January 2022-November 2022. Parameters were measured before and after the procedure: the International Prostate Symptom Score(IPSS), maximum flow rate(Qmax), post-void residual urine(PVR) prostate-specific antigen(PSA), prostate volume, operation-time, morcellation-time, catheterization-time and presence of transient urinary incontinence, and compared. The median age of patients undergoing enucleation of the prostate using the ARTh technique was 64 years (range: 44-83). The median prostate volume of the patients was 83.5 ml(50-128 ml), preoperative-IPSS was 24.8(15-33), postoperative-IPSS was 7(5-11), preoperative-Qmax was 8.1 ml/Sects. (5-11.5 ml/sec), postoperative-Qmax was 26.9 ml/Sect. (20.8-34 ml/sec), preoperative-PVR was 145 ml(75-258 ml), postoperative-PVR was 36.2 ml(0-66 ml), total operation time was 51.4 min(28-82 min), enucleation time was 36.9 min(19-51 min) and morcellation time was 15.3 min(8-27 min). The ARTh technique is a safe procedure that allows the surgeon to easily recognize and adhere to the defined dissection plane, thus decreasing operation times, significantly reducing the rate of postoperative transient urinary incontinence (TUI).

A randomized trial of retropubic versus single-incision sling amongst patients undergoing vaginal prolapse repair.

BACKGROUND: Choice of midurethral sling type may impact efficacy and complications in women undergoing transvaginal native tissue repair of pelvic organ prolapse (POP). OBJECTIVE: The primary aim was to determine if single-incision (SI) sling is noninferior to retropubic (RP) sling for management of stress urinary incontinence (SUI) amongst patients undergoing reconstructive or obliterative native tissue vaginal repair. The secondary aims were to compare adverse events and surgeon ease of use with sling assignment. STUDY DESIGN: A multicenter, noninferiority, randomized trial of women with ≥ Stage II POP and objectively confirmed SUI undergoing reconstructive or obliterative vaginal repair was performed. Women were randomized to concomitant SI (Altis sling, Coloplast Minneapolis, MN) with suprapubic sham incisions or RP sling. The primary, dichotomous outcome was abnormal lower urinary tract function within 12 months post-surgery, defined as: bothersome SUI symptoms (>1 PFDI question #17); retreatment for SUI; or treatment for urinary retention. Secondary outcomes were adverse events, patient global impression of improvement of bladder function (PGI-I) and surgeon ease of use (1 worst, 10 best). All subjects completed validated questionnaires and underwent a POP-Q, cough stress test and post void residual (PVR) pre-operatively, at 6 weeks and 12 months post operatively. Assuming a subjective cure rate for RP of 82%, 80% power and one-sided 5% significance level, we estimated that 127 patients in each arm were needed to declare noninferiority of the SI sling if the upper bound of the 95% confidence interval for the between group difference per protocol in abnormal bladder function was less than 12%. Assuming a 10% loss to follow-up, the total enrollment goal was 280. RESULTS: Between 12/2018 and 1/2023, 280 subjects were enrolled across 7 sites and 255 were randomized: 126 to SI and 129 to RP sling. There were no pre-operative or operative characteristic differences between groups. Overall, 81% had reconstructive and 19% had obliterative native tissue repairs. The primary outcome, abnormal lower urinary tract function at 12 months, occurred in 29 (25%) of SI vs. 24 (20%) of RP sling group (Risk difference 0.04472, 95% CI (-0.03-0.1133), p = 0.001 for noninferiority). Bothersome SUI occurred in 20% vs. 17% (p=0.27) and was re-treated in 4% vs. 2% (p=0.44) of SI vs. RP groups, respectively. Adverse events were reported in 24 (16%) of SI vs. 14 (9%) of RP group (95% CI, 0.95-3.29; p=0.7) and included de novo or worsening urgency incontinence symptoms, urinary tract infection, mesh exposure, need for prolonged catheter drainage, and de novo pain, without differences between groups. PGI-I (very satisfied & satisfied) was 71% vs. 67% (p=0.43) and median surgeon ease of sling use was 8 [7-10] vs. 9 [8-10], p=0.03 in SI vs. RP, respectively. CONCLUSION: For women undergoing vaginal repair, SI was noninferior to RP sling for SUI symptoms and complications, including treatment for urinary retention, did not differ.

Autologous rectus abdominis fascia sling surgery following unsuccessful synthetic midurethral sling.

Introduction: We performed autologous rectus abdominis fascia sling surgery using Advantage™ following an unsuccessful synthetic midurethral sling. Case presentation: At the age of 76 years, the patient experienced stress urinary incontinence recurrence. A 1-h pad test resulted in 259 g of leakage. A pressure flow study verified urine leakage while coughing and straining without detrusor overactivity. Abdominal leak point pressure was 10 cmH2O. Autologous rectus abdominis fascia sling surgery was performed using Advantage™. One month postoperatively, a 1-h pad test resulted in 0 g of leakage. Conclusion: We believe that this method will allow the fascia sling procedure to be performed reliably even if one is unfamiliar with conventional autologous rectus abdominis fascia sling surgery.

Change in microbiota profile after vaginal estriol cream in postmenopausal women with stress incontinence.

Introduction: Vaginal estrogen is a treatment for genitourinary symptoms of menopause (GSM), which comprises vaginal atrophy and urinary dysfunction, including incontinence. Previous studies show that estrogen therapy promotes lactobacilli abundance and is associated with reduced GSM symptoms, including reduction of stress incontinence. However, detailed longitudinal studies that characterize how the microbiome changes in response to estrogen are scarce. We aimed to compare the vaginal microbiota of postmenopausal women, before and 12 weeks after vaginal estrogen cream. Methods: A total of 44 paired samples from 22 postmenopausal women with vaginal atrophy and stress incontinence were collected pre-vaginal estrogens and were compared to 12 weeks post-vaginal estrogen. Microbiota was characterized by 16S rRNA amplicon sequencing and biodiversity was investigated by comparing the alpha- and beta-diversity and potential markers were identified using differential abundance analysis. Results: Vaginal estrogen treatment was associated with a reduction in vaginal pH and corresponded with a significant reduction in alpha diversity of the microbiota. Healthy vaginal community state type was associated with lower mean pH 4.89 (SD = 0.6), in contrast to dysbiotic state which had a higher mean pH 6.4 (SD = 0.74). Women with lactobacilli dominant community pre-treatment, showed stable microbiota and minimal change in their pH. Women with lactobacilli deficient microbiome pre-treatment improved markedly (p = 0.004) with decrease in pH -1.31 and change to heathier community state types. Conclusion: In postmenopausal women with stress incontinence, vaginal estrogen promotes Lactobacillus and Bifidobacterium growth and lowers vaginal pH. Maximum response is seen in those with a dysbiotic vaginal microbiota pre-treatment.

A Full Bladder Is Not Needed for the Male Stress Incontinence Grading Scale.

INTRODUCTION: Our objectives were to evaluate the Male Stress Incontinence Grading Scale to stratify male patients with stress urinary incontinence for either artificial urinary sphincter or sling using a standing cough test and determine if an emptier bladder at the time of assessment carries increased risk of treatment failure. METHODS: Retrospective chart review of male patients undergoing sling and artificial urinary sphincter placement. The standing cough test score and bladder scan results were documented at initial evaluation. RESULTS: Forty patients underwent sling and 43 underwent naïve artificial sphincter placement. Median follow-up was 7.11 months. Thirty-six/forty slings had complete incontinence resolution or reduction to a safety pad vs 40/43 after sphincter (90% vs 93%, P = .62). Four sling patients (10%) had persistence or recurrence of incontinence. Cough test scores were similar between sling failure (67% grade 0, 33% grade 1) and success groups (83% grade 0, 3% grade 1, 14% grade 2). Bladder scan mean was 18.5 cc in the sling failure (SD 21.1) and 38.0 cc in the success groups (38.3), with 32% of success patients having bladder scans of 0 cc, and 63% of < 50 cc. Mean for sphincter patients was 45 cc (56.9). Ten patients with scan = 0 and 7 patients with scans < 30 cc demonstrated grade 4 incontinence. CONCLUSIONS: Cough test is a noninvasive, reliable tool to assess stress urinary incontinence severity. Our data suggest it is reliable even when bladders are nearly empty and can effectively stratify patients for sling vs artificial urinary sphincter with a high rate of success.

More With Less: Single-Incision Sling Insertion Techniques.

STUDY OBJECTIVE: To demonstrate reproducible procedures for efficient single-incision sling insertion and troubleshooting. DESIGN: Narrated video footage with stepwise demonstration of single-incision sling insertion technique with anchor system. SETTING: The mesh midurethral sling is a highly effective and safe procedure that is considered the gold standard for surgical treatment of stress urinary incontinence. Retropubic and transobturator approaches for midurethral slings have similar subjective cure rates with differing surgical risk profiles [1,2]. The retropubic route has a higher risk of injury to the bladder, nerves, and vascular structures, whereas the obturator approach carries a risk of groin or thigh pain [3-5]. Use of a single-incision sling decreases these risks and allows flexibility to perform the procedure without sedation or general anesthesia. Recent literature demonstrates similar subjective and objective success and safety of single-incision slings compared with both retropubic and transobturator approaches, although long-term data are forthcoming [5]. INTERVENTIONS: We demonstrate a stepwise approach for the insertion of a single-incision sling using a helical trocar. Easily reproducible procedures for setup and sling anchor management allow for efficient placement without assistance. In addition, we outline hand positioning, trocar management, and anchor deployment with troubleshooting techniques for potential placement difficulties. Finally, we review methods for sling tensioning to prevent complications such as voiding dysfunction and mesh or suture exposures. CONCLUSION: Given that single-incision slings are more likely to be performed under local anesthesia and are less invasive with decreased recovery time, it has the potential to become the preferred approach in the future. This video demonstrates clear and detailed steps to facilitate successful placement of the single-incision mesh midurethral sling.

Neurological sphincter deficiency: is there a place for artificial urinary sphincter?

PURPOSE: Neurogenic stress urinary incontinence (N-SUI) is a condition with serious impact on the quality of life. There are several treatment modalities of which the artificial urinary sphincter (AUS) stands out as the most suitable technique for addressing sphincter insufficiency. In this article, the purpose is to describe practical considerations, outcomes, and complications of the artificial urinary sphincter in neurological sphincter deficiency in both males and females. METHODS: A narrative review of the current literature. RESULTS: The outcomes of AUS are reasonably good in patients with NLUTD, the surgical technique is discussed as well as the limitations and special considerations in this complex and heterogeneous patient population. CONCLUSION: The available evidence suggests that its efficacy and functional durability may be lower in patients with neurogenic lower urinary tract dysfunction (NLUTD) compared to those without neurological deficits. However, studies have shown that AUS can still provide effective and safe continence outcomes in both male and female patients, with long-term device survival rates ranging from several years to over a decade.

Continence Is Not Affected after Sling Revision with Transvaginal Tape Elongation for Post-Sling Voiding Dysfunction.

Voiding dysfunction (VD) after sling operation is not uncommon. Sling revisions by incision/excision are usually effective; however, they may result in recurrent stress urinary incontinence (SUI). We aimed to evaluate continence status after an innovative sling revision procedure that preserves the integrity of the sling. Patients who underwent either a single-incision (AJUST) or a trans-obturator (TVT-O) mid-urethral sling were studied. Transvaginal tape elongation (i.e., sling midline incision and mesh interposition) was performed on patients with post-sling VD. Factors that may affect recurrent SUI were investigated by statistical analyses. Of 119 patients, 90 (75.6%) (45 AJUST and 45 TVT-O) were available for long-term (median 9; 8-10 years) follow-up. A significantly higher rate (17.2% vs. 3.3%, p = 0.014) of VD was noted after AJUST (N = 10) than after TVT-O (N = 2). After sling revision, four (33%) of the 12 cases reported recurrent SUI, which was not significantly different (p = 1.000) from the rate (37%, 29/78) of patients who did not undergo sling revision. Further statistical analyses revealed no significant predisposing factors affecting the recurrence of SUI. Surgical continence did not seem to be affected by having had sling revision with transvaginal tape elongation for post-sling VD.

Obesity is not an independent risk factor for peri- and post-operative complications following mid-urethral sling (MUS) surgeries for the treatment of stress urinary incontinence (SUI).

OBJECTIVE: To inquire whether obesity is a risk factor of peri- and post-operative complications following Mid-urethral sling (MUS) surgeries for SUI repair using the Clavien-Dindo classification system (CDcs). METHODS: This retrospective cohort included 304 women who undergone a MUS in a 1000 beds tertiary University medical center between the years 2012-2018. Univariate analysis was conducted to compare clinical and operative traits by BMI group and to examine associations of obesity and complications rates and severity according to the CDcs. Multivariate analysis was conducted to assess the risk for post-operative complications and adjust to potential confounders. RESULTS: The study group included 106 (34.9%) women with BMI 30 or higher and the comparison group included 198 (65.1%) women with BMI lower than 30. In the study group we found a significantly higher prevalence of hypertension (P = 0.019), previous abdominal surgeries (P = 0.012) including cesarean section (P = 0.025), previous pelvic floor surgeries (P = 0.005) and pelvic organ prolapse (P = 0.02). In the control group we found a significantly higher rates of concomitant hysterectomy which performed during the MUS (P = 0.005). Obesity was not associated with increased rates of peri and post-operative complications (P = 0.973). CONCLUSIONS: In our study, obesity was not associated with peri- and post-operative complications following MUS.

How older men live with stress urinary incontinence: Patient experience and navigation to treatment.

OBJECTIVES: To explore the context in which older men navigate treatment for stress urinary incontinence (SUI) following prostate surgery by characterizing lived experience of men with symptomatic SUI. SUBJECTS/PATIENTS AND METHODS: Mixed method study using surveys and semistructured interviews to examine a cohort of men who underwent evaluation for treatment of postprostatectomy SUI. RESULTS: Thirty-six men were interviewed after consultation for SUI and 31 had complete quantitative clinical data. Twenty-six underwent surgery and 10 chose no surgical intervention. In qualitative interviews, respondents experienced substantial decline in quality of life due to incontinence citing concerns associated with use of pads and worrying about incontinence. Most patients reported "workarounds"-efforts to mitigate or manage incontinence including Kegels, physical therapy, and garments. Participants also reported lifestyle changes including less strenuous physical activity, less sexual activity, and/or fewer social gatherings. Patients then described a "breaking point" where incontinence workarounds were no longer sufficient. After seeking evaluation, men described challenges in exploring treatment for SUI, including access to care and provider knowledge of treatment options. CONCLUSION: In a novel study of patients living with SUI a predictable lived experience was observed that culminated in a desire for change or "breaking point." In all men, this led to treatment-seeking behaviors and for many it led to SUI intervention. Despite effective treatments, patients continue to meet barriers gaining access to SUI evaluation and treatment.

Impact of childbirth on pelvic floor dysfunction in women who have undergone previous pelvic floor reconstructive surgery: systematic review and meta-analysis.

INTRODUCTION AND HYPOTHESIS: The aim of the study was to perform a systematic review and meta-analysis of the impact of pregnancy and childbirth (vaginal delivery [VD]) or cesarean section (CS) on the recurrence of pelvic floor disorders in women who had previously undergone pelvic floor reconstructive surgery for pelvic organ prolapse (POP) or stress urinary incontinence (SUI), to facilitate future evidence-based counseling. METHODS: PubMed, Cochrane, Embase, BJOG, Scopus, etc. were screened, from 1990 to date. Inclusion criteria included cohort studies, case-control studies, case series, and case reports that reported on the primary outcome measure of the review. Exclusion criteria included studies on surgical procedures whose outcomes are unlikely to be impacted by pregnancy and childbirth or are obsolete. Meta-analysis was performed using Review Manager 5.3. RESULTS: Seven papers on midurethral slings (MUS; 181 women in both VD and CS groups respectively) and three papers on different hysteropexy techniques (47 and 29 women in the VD and CS groups respectively), were included in the meta-analysis. No difference was seen between the two groups regarding the recurrence of SUI in women who had previously undergone MUS surgery (OR: 1.18 [0.66, 2.09]; Z = 0.56; p = 0.58) or the recurrence of POP following hysteropexy using various apical suspension procedures (OR: 1.81 [0.04, 80.65]; Z = 0.31; p = 0.76). There are insufficient data to support meta-analyses for individual MUS sub-types or hysteropexy procedures. CONCLUSION: Current literature does not demonstrate a protective effect of CS in preventing recurrent SUI in women who had undergone MUS surgery for SUI. When hysteropexy is considered irrespective of the apical suspension procedure employed, the incidence of recurrent POP appears similar after CS and VD.

Post-prostatectomy incontinence: a guideline of guidelines.

AIM: To provide a comprehensive review of guidelines from various professional organisations on the work-up and management of post-prostatectomy Incontinence (PPI). MATERIALS AND METHODS: The following guidelines were included in this review: European Association of Urology (EAU 2023), American Urological Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (AUA/SUFU 2019), International Consultation on Incontinence (ICI, 2018), the Canadian Urological Association (CUA, 2012) and the Urological Society of India (USI, 2018). RESULTS: In general, the guidelines concur regarding the significance of conducting a comprehensive history and physical examination for patients with post-prostatectomy incontinence (PPI). However, there are variations among the guidelines concerning the recommended additional investigations. In cases of troublesome PPI, male slings are typically recommended for mild to moderate urinary incontinence (UI), while artificial urinary sphincters are preferred for moderate to severe UI, although the precise definition of this severity remains unclear. The guidelines provided by AUA/SUFU and the ICI have offered suggestions for managing complications or persistent/recurrent UI post-surgery, though some differences can be observed within these recommendations as well. CONCLUSION: This is a first of its kind review encompassing Guidelines on PPI spanning over a decade. Although guidelines share overarching principles, nuanced variations persist, posing challenges for clinicians. This compilation consolidates and highlights both the similarities and differences among guidelines, providing a comprehensive overview of PPI diagnosis and management for practitioners. It is our expectation that as more evidence emerges in this and other areas of PPI management, the guidelines will converge and address crucial patient-centric aspects.

The effect of biofeedback pelvic floor training with ACTICORE1 on urinary incontinence: a multicenter randomized clinical pilot trial.

Background: Pelvic floor training with biofeedback has been shown to significantly reduce symptoms of urinary incontinence. The present study aimed to evaluate the effectiveness of pelvic floor training with the ACTICORE1 biofeedback device, which uses a noninsertable pelvic floor sensor with a digital interface. Materials and methods: A multicenter randomized controlled clinical pilot study in Germany was conducted between October 2021 and January 2022. The intervention group was instructed to use ACTICORE1 for 6 min daily to train the pelvic floor for 12 weeks. The control group was instructed not to do any pelvic floor training. Over 18-year-old men and women with urinary incontinence and an International Consultation on Incontinence Questionnaire score (ICIQ) of ≥5 were included in the study. The primary endpoint was the ICIQ score 12 weeks after enrollment. The secondary endpoints were the ICIQ score and quality of life using the EG-5D-3L questionnaire 4, 8, and 12 weeks after patients' enrollment. Results: A total of 40 individuals with urinary incontinence were recruited for the present study (35 females, 5 males; 40% lost to follow-up). In terms of biometric data, both groups did not differ. At 4, 8, and 12 weeks, the ICIQ scores of those in the ACTICORE1 group decreased from 12.9 to 7.5. The ICIQ score in the control group decreased from 11.0 to 10.5. The intraindividual improvement of patients in the ACTICORE group was statistically significant. Conclusion: Biofeedback training with ACTICORE1 significantly reduces symptoms of urinary incontinence after 12 weeks.

Predictors of urinary outcomes following robotic-assisted laparoscopic prostatectomy.

Introduction: Incontinence and urgency are common after prostatectomy. The University of Virginia prostatectomy functional outcomes program (PFOP) was developed to comprehensively assess and optimise continence outcomes following robotic-assisted laparoscopic prostatectomy (RALP). Patients are prospectively evaluated by a Female Pelvic Medicine and Reconstructive Surgery specialist. This study assessed for predictors of 3- and 6-month stress urinary incontinence (SUI) and urgency symptom outcomes following RALP. Methods: We performed a post hoc review of patients from our PFOP receiving a minimum of 6-month follow-up. Urinary symptoms are prospectively assessed using the validated International Consultation on Incontinence Questionnaire-Male Lower Urinary Tract Symptoms (ICIQ-MLUTS) questionnaire and daily pad use (pads per day [PPD]). Primary study outcomes included ICIQ-MLUTS SUI and urgency domain scores and PPD. Multivariable linear regression was performed to identify variables associated with outcomes at 3 and 6 months postoperatively. Variables included patient, oncologic and surgical factors. Each variable was run in a separate model with pelvic floor muscle therapy and surgeon to reduce confounding and prevent overfitting. Results: Forty men were included. In assessment of ICIQ-MLUTS SUI domain score, at 3 months, body mass index (BMI) was associated with worse scores, and at 6 months, BMI, hypertension and estimated blood loss (EBL) were associated with worse scores, whereas bilateral nerve-sparing technique was associated with better scores. For ICIQ-MLUTS Urgency domain score, at 3 months, preoperative use of benign prostatic hyperplasia (BPH) medication was associated with better scores. No covariates predicted 6-month ICIQ-MLUTS Urgency domain scores. For PPD use, at both 3 and 6 months, BMI was a positive predictor, while preoperative use of BPH medication was a negative predictor. Conclusion: Increased BMI, EBL and hypertension are associated with worsened SUI outcomes following RALP, whereas bilateral nerve-sparing technique and preoperative BPH medication are associated with improved SUI outcomes. These data may inform patient counselling and help identify patients who may benefit from closer surveillance and earlier anti-incontinence intervention.

Is Surgical Treatment for Obesity Able to Cure Urinary Incontinence in Women?-A Prospective Single-Center Study.

There is enough evidence to support weight loss in order to improve urinary incontinence. Nevertheless, weight loss and maintaining a lower weight are not easy to achieve in the general population. Our study aims to evaluate whether bariatric surgery has a positive effect on the symptoms of urinary incontinence in female patients. We performed a prospective study on obese female patients before and after bariatric surgery, over a period of 9 years. Patients with a BMI ≥ 33 kg/m2 were included if they described involuntary loss of urine and no previous surgery for urinary incontinence was performed. The patients underwent laparoscopic surgery, either gastric sleeve, bypass or banding, performed by four surgeons in our hospital. The type of incontinence was not assessed at the initial visit carried out by the surgeon. All patients who declared being incontinent were referred to the urologist where they received the ICIQ-UI-SF questionnaire before their bariatric surgery and during follow -up visits. The sum of points obtained at questions 3, 4 and 5 was used to evaluate the severity of incontinence, as well as the impact on the quality of life. Our evaluation collected data on age, time since onset of symptoms, pad usage, number and type of deliveries, concomitant conditions and medications. The type of incontinence was assessed by the urologist before bariatric surgery as urge, stress or mixed incontinence. At follow-up visits, the patients were also asked to fill out a 10-point VAS questionnaire evaluating their perception on the evolution of incontinence symptoms. Data were analyzed using t-test statistical analysis. Our objective defined changes in incontinence as cure, improved, no change and worse. We included 54 women from whom initial data and at least 18 months of follow-up were available. We observed that about 50% of all women undergoing bariatric surgery have some degree of urinary incontinence. The ICIQ score improved from 13.31 ± 5.18 before surgery to 8.30 ± 4.49 points after surgery (p < 0.0001). Before surgery, 38 patients (70%) described severe incontinence compared to only 20 patients (37%) after surgery. A total of 16 women (31%) reported complete cure of urinary incontinence after bariatric surgery. Data from the VAS questionnaire show improvement in 46 cases (85%). Pad usage improved from 7.04 ± 2.79 to 3.42 ± 2.77 (p < 0.001) per day. The number of patients using more than one pad per day decreased from 35 (65%) to 9 (17%). The type of incontinence did not seem to be relevant, but our sample size was too small to lead to statistically significant results. There was no impact on the outcome of incontinence of number/type of delivery, age or BMI. Our data show that bariatric surgery is able to cure urinary incontinence in one of three obese women. A significant improvement was obtained in more than two-thirds of the patients, regardless of the type of incontinence. For an obese female with urinary incontinence, treatment for obesity should prevail and incontinence should be treated only if symptoms remain.

Contemporary male slings for stress urinary incontinence: advances in device technology and refinements in surgical techniques.

Synthetic male sling (MS) is considered an effective surgical treatment to restore male stress urinary incontinence. The modern MS can be categorised into adjustable or non-adjustable types, while the surgical techniques can be divided into retropubic or transobturator approaches. This narrative review paper evaluates the contemporary MS devices in the current commercial market regarding clinical outcomes and refinements in surgical techniques. Scientific advances in device design and technology, coupled with further surgical refinements will enhance the clinical outcomes and improve the safety profile of MS surgery. The newer generation of modern MS not only provides direct compression of the bulbar urethra but also allows for proximal urethral relocation by realigning the mobile sphincter complex to provide further urethral sphincter complex coaptation. Strict patient selection, use of MS with proven clinical records, adherence to safe surgical principles and judicious postoperative care are critical to ensure a high continence rate, good patient satisfaction and low postoperative complications.

Relationship between Q-Tip Test and Urethral Hypermobility on Perineal Ultrasound.

BACKGROUND: The aim of this study was to assess the correlation between the overall rest-stress distance measured by transperineal ultrasound (TPUS) and Q-tip test angle in women with urodynamic stress incontinence (USI), and determine a cut-off value of rest-stress distance for predicting urethral hypermobility (UH). METHODS: Women with USI scheduled for mid-urethral sling surgery were retrospectively recruited. UH was defined as a Q-tip angle more than or equal to 30 degrees. Ultrasonic measurement of the overall rest-stress distance was defined as the linear distance of bladder-neck position change from resting status to maximal strain. RESULTS: Among the 132 enrolled women, the Pearson correlation coefficient between the overall rest-stress distance in TPUS and Q-tip test angle was 0.9104 (95% CI, 0.8758-0.9357, p < 0.001). In receiver-operating-characteristic-curve analysis, a rest-stress distance of more than 13.3 mm was an optimal cut-off value to predict UH (sensitivity = 76.47%, specificity = 93.3%; area = 0.937, 95% confidence interval: 0.881-0.972). CONCLUSIONS: The overall rest-stress distance in TPUS correlated well with the Q-tip test angle, indicating that it can be an alternative method for the assessment of USI. A rest-stress distance of more than 13.3 mm was an optimal cut-off value to predict UH in women with USI.

A New Proximal Adjustable Sling ATOMS SSP® Implantation Technique with Focus on the Urethral Bulb: Lessons Learned from Revision Surgery.

BACKGROUND: Adjustable sling ATOMS-SSP results in ventral compression of the urethra with favorable results in the treatment of men with mild to moderate stress incontinence. However, with transobturator tunneling and mesh fixation, the surgeon has a range of options, which leads to different results and sometimes unfavorable positioning of the silicone cushion. Using retrograde urethrography (RUG), we identified ATOMS patients with considerable misplacement. We then modified the implantation technique when we performed the revision, and now present here our first experiences with this new surgical technique. METHODS: Patients after ATOMS-SSP implantation at our clinic were systematically subjected to a RUG if incontinence persisted after adjustments. In case of unfavorable positioning, a revision was performed with the aim of achieving an idealized urethroproximal position of the silicone pad. During follow-up, a repeat RUG was performed, and both subjective and objective outcome parameters were recorded. RESULTS: Four men met the above criteria and underwent revision with reimplantation using our new technique. All patients postoperatively experienced significantly improved continence. RUGs demonstrated an ideal ATOMS position immediately below the proximal bulbar urethra. CONCLUSIONS: Our proximal implantation technique, presented here for the first time, allows optimal positioning of the ATOMS SSP, which is reflected in the objective parameters and RUG. Its use in primary implantation should also be considered and an expansion to the indication of severe stress incontinence seems possible, but this should only be done in studies.

Urethral fistula repair, including urethral elongation and an anti-incontinence procedure - a case report.

Vesicovaginal fistula remains a significant cause of female urinary incontinence and impaired quality of life worldwide. Urethral-vaginal fistulas are less common, and difficult to manage, posing difficulties in terms of diagnostic evaluation, the surgical approach to closure, and how the associated complication of stress urinary incontinence is addressed. In this case report the management of a 34-year-old woman who presented with a urethral fistula following initial surgery for a urethral abscess is presented, including fistula closure; lengthening of the urethra; and addressing the loss of sphincter function. This case highlights the fact that a successful outcome in these patients depends on proper surgical technique, and the experience and skill of the management team.