In Continent Female

Evaluation of the Incontinent Female David Stanford, M.D.

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I.

Introduction A.

With a detailed history, physical examination, and neurologic exam of the lower extremities and perineum (lumbosacral nerve roots), augmented by a few simple clinical tests, an accurate diagnosis can usually be established in 90% of patients

C. For the vast majority of women presenting with complaints of B urinary incontinence who have not had prior failed anti-incontinence operations nor the history of neurologic injury, this simple type of evaluation is all that is needed II.

History A.

The details of the general medical, gynecological, and urological history may be obtained with standard questionnaires

B.

History cannot be used alone as a basis for therapy

C. The history provides an error rate of at least 50% in arriving at a correct diagnosis. The history serves as a guide for emphasis during the subsequent evaluation process D. Concomitant drug therapy for medical disease 1.

Frequently produces side effects referable to the lower urinary tract

2.

Alterations of drugs or dosages (ie, diuretics, "-blockers) may diminish the need for further in-depth evaluation and decrease the patient's symptoms to tolerable levels

3.

The menopausal status of the patient is important. If the patient has any historical or clinical evidence of low estrogen, intravaginal estrogens are prescribed, usually on an every-night basis, until a desired effect is achieved or 6 weeks have passed

4.

Gradual tapering of the frequency of usage is generally possible until a once or twice weekly maintenance schedule is reached, or the patient is given oral maintenance estrogen replacement

III.

Physical Examination A.

Uroneurogynecologically-oriented physical examination 1.

Detection of fistula or neurological disease immediately directs further evaluation and treatment

2.

The clinical evaluation does not allow for accurate assessment of the presence of an anatomical defect

B.

Further studies are indicated to confirm the presence of urethral hypermobility prior to undertaking a surgical procedure to treat stress incontinence. The "Q-tip"test is very helpful

C. The fluid bridge test may be used to detect funneling D. A stress test is used to demonstrate urinary leakage with increased intra-abdominal pressure E.

In some patients, radiologic studies may be necessary to

Urinary incontinence is a condition where there is an involuntary loss of urine, which is a social and hygienic problem, which is objectively demonstrable. We want to be sure that we document that someone has stress incontinence with what we call positive stress test and you have seen them leak urine which increases intra-abdominal pressure. If you are going to consider operating on them or even treating them for stress incontinence in general, you want to document this in your chart. Failure to do so in two cases that I have already seen has lead to the rapid conclusion and favor of the plaintiff in lawsuits. Most women who have urinary incontinence will have genuine stress incontinence as all or part of the problem. In fact about 75% of all incontinent woman have this as part or their entire problem. There is an involuntary loss of urine associated with increases in intra-abdominal pressure from any source whether it be playing golf, tennis, coughing, intercourse. The bladder pressure exceeds the urethral pressure in the absence of a bladder contraction. It is usually caused by an underlying problem with urethral hypermobility but not always. The second most common condition that we see is called detrusor overactivity. This is involuntary bladder contractions that result in urinary leakage. This can occur in the idiopathic condition where someone is neurologically normal, or they have detrusor instability where the involuntary bladder contraction seems to occur on a functional basis. When it is caused by an underlying neurologic lesion, we call that detrusor hyperreflexia. This is where the bladder contractions that are occurring are linked not just causally but also temporarily to an underlying neurologic condition. There are some other conditions that we seen in adults and pediatric populations that can cause leakage. They are just not nearly as common as the three conditions that we have mentioned. Genuine stress incontinence and detrusor overactivity in general, probably account for 92-96% of all urinary incontinence that we are going to see in women. There are subvariants that we will focus on about intrinsic urethral function in the like, but the other conditions like overflow incontinence, uninhibited urethral relaxation, these are rare. These are conditions, which probably affect 1 in 200 incontinent patients or less. Overflow incontinence, we always think about and diabetics who have neuropathy, it really outside of the post-surgical iatrogenic condition of overflow incontinence, this really is probably only seen in about 1 in 750 incontinent people. Sensory urgent continence is a little bit different. TI is probably more prevalent, but it is so difficult to characterize. It is a condition where the urge to urinate, increased afferent sensation overwhelms the patient, and they sort of subconsciously but yet voluntarily urinate. They just let the urine go so bad bladder infections, interstitial cystitis, and urethral syndrome, all these things can result in a strong urge. We treat the underlying inflammatory condition, for example an 85-year-old woman with atrophic urethritis treated with some estrogen cream for two months, she will come back and tell you the urgency and frequency is gone and I do not leak urine anymore. We then retrospectively make the diagnosis of sensory urgent incontinence. Psychogenic incontinence is important not be fooled by this. That is why we need to document objectively that there is urinary leakage and understand what is going on. Congenital causes like diverticula; distal diverticula will act as a reservoir and collect urine. When the patient stands up and walks away from the toilet, they will dribble urine as the urine falls out. Most people have dribbling because of involuntary bladder contractions and not a diverticulum. Proximal diverticula, infected pockets of pus, the bladder increases afferent sensation and act through the pathway of sensory urgent incontinence to cause urinary leakage.

demonstrate anatomic defects

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F.

No surgical procedure should be undertaken without objectively documenting the presence of a significant anatomic defect and urine leakage during testing

IV.

Postvoid Residual Urine A.

Measurement of postvoid residual urine (PVRU), either directly, with the use of a catheter, or indirectly, by ultrasound (US) or other radiographic techniques, is an essential part of any evaluation of urinary incontinence

B.

Therapies for stress and urge incontinence will increase urethral resistance or decrease bladder contractility, which can result in a worsening of preexisting urinary retention 1.

If this occurs, the patient who originally had a problem with detrusor instability or genuine stress incontinence (GSI) might then develop a problem with urinary retention associated with urinary tract infection (UTI) or overflow incontinence as an alternative to their original problem

2.

Trading one problem for another is not the desired outcome

C. The measurement of PVRU is important to evaluate whether an occasional patient is suffering from overflow incontinence, where the patient's bladder almost always remains fully distended, with the patient voiding very small amounts and rapidly refilling to her maximal bladder capacity 1.

The patient will often complain of symptoms of stress incontinence because of intermittent leakage of urine with any minor activity due to overdistention of the bladder

2.

overflow incontinence, possibly due to peripheral neurologic injury and afferent dysfunction D. The residual urine should be <30--50 mL On a functional basis, residual urine <100 mL. may even be acceptable as long as the cause of this mild voiding dysfunction is well understood 2.

50 mL is a boundary for determining who has urinary retention

3.

Patients who consistently have residual urine >50 mL undergo more extensive evaluation with voiding pressure studies or a voiding cystourethrogram

4.

If a patient is asked to void in a commode in your office when she is seeing you for the first tune, she may have an artificially elevated residual urine due to her discomfort with the new voiding environment

5.

We always start with a good history. We are going take a history. I send out a six-page questionnaire to people with a voiding diary, and we ask them to write down when they urinate, when they leak urine, whether there is an urge associated and what they are taking in, so we understand. Especially if you want to use behavioral therapy or nonsurgical therapy later on, we need to know what their behavior is currently. It also helps to correlate with the symptoms that they are telling us and lend some varicosity to the conditions of urgency and frequency of micturition. Sometimes you will see a patient that will come in say, I urinate all the time now, and I used to urinate just every eight hours. Now I am urinating every three to four hours. That doesn’t seem to be much of a problem. We may want to understand for the individual, but if that is backed up by their voiding diary that is helpful. People tend not to urinate also as often on their voiding diaries as they say they do historically. It helps us understand about the pattern. It also lets us pick up things like reverse diuresis and nocturnal diuresis conditions, where someone may have problem with ADH, and we can treat this quite simply. The other things we want to know about is what medications they are using. You want to be careful. A big pearl to take away from this is to understand that alpha blockers, Hytrin, Minipress, these agents for blood pressure will cause urinary incontinence by decreasing urethral resistance. You can treat people quite successfully just by switching them off these medications.

By obtaining a PVRU, one can assess that this is not GSI causing the symptoms of stress incontinence, but instead

1.

Those are sort of the conditions that can represent the patient’s symptoms. The patient comes into your office, and she wants to know from you, what can I do about this? To a patient this is sort of an unidimensional problem. I leak urine and, you are a doctor, and you should be able to tell me why. Give me a pill, and I should be able to leave here, and a week from now not have this problem. It certainly isn’t that easy unfortunately, and what we have to do is sort of play detective and begin to understand exactly what the patient does suffer from and doesn’t suffer from. We have to determine what is going on. I see this is kind of complicated because more than 60% of our patient’s have more than one reason for leaking urine and about 15% of our patient’s actually have three or more conditions that contribute to the urine loss and problems. It can get quite tricky in terms of trying to make the diagnosis.

This test should be repeated on multiple occasions before deciding that the patient has an abnormal residual urine and

A history is great and very important to outline the underlying condition. It acts sort of as the outline for what we are going to fill in and explain. Because no evaluation that you do, whether you do it simply with no equipment or have a hundred thousand dollar lab that you are going to do it with and spend hours and hours, it does not matter if it fails to explain the patients symptoms. On the other hand, the mistake we make as gynecologists, family practitioners and urologists is assuming that a history will tell us the underlying condition. Here we find that history is no more accurate than a good educated coin toss. When we look at patients symptoms and try to see if they are pathognomonic for underlying conditions, like stress incontinence proving that someone has genuine incontinence, urgent incontinence being indicative detrusor instability. You can see that the specificity here, especially is quite poor, and in this study of 288 consecutive women with urinary incontinence undergoing multichannel urodynamic testing, the sensitivity was 100% but that really isn’t true in the literature as a whole. In most groups who have shown sensitivities there that range in 80 to low 90% range. Some people say that if you have the women who just complains of genuine stress incontinence, she is under the age of 60, she doesn’t have any other complaints of frequency urgency or urgent incontinence or nocturia, that you don’t need to evaluate that patient, that she will always have genuine stress incontinence. We start with a physical exam. Obviously we want to augment the history and understand the anatomic problems. You want to do a good

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a problem with urinary retention. The patient who has urinary retention due to significant voiding dysfunction will consistently have elevated residual urine E.

The PVRU in our laboratory is usually obtained immediately following a spontaneous uroflowmetry study done at the initiation of the examination 1.

This is usually directly removed with a catheter

2.

This specimen should be obtained when the patient is in the supine position, as supine urinary residuals may not fully reflect the total residual bladder volume

3.

Tilting the patient in reverse Trendelenburg or having the patient stand with the catheter inserted may aid in fully emptying the bladder

4.

This PVRU is then sent for urine culture to rule out preexisting infection which would cause sensory urge incontinence or detrusor overactivity. It is essential to rule out UTI before proceeding with a complex urodynamic evaluation

5.

On rare occasions, the chronically-infected patient will respond to antibiotic therapy with total resolution of urinary incontinence, making further work-ups unnecessary

V.

Stress Test A.

Urinary incontinence is defined as a condition where there is involuntary loss of urine that is objectively demonstrable and represents a social or hygienic problem 1.

Demonstrating the patient's urinary leakage during an increase in intra-abdominal pressure is essential in the diagnosis of GSI every patient complaining of urinary incontinence should undergo a stress test the standing position has been shown to be far more sensitive, it is the preferred position

2.

A patient who leaks urine when supine with a relatively empty bladder has a more severe problem with stress incontinence than the patient who only leaks in the standing position at maximum cystometric capacity with repetitive coughing and Valsalva

B.

The stress test is performed immediately following simple cystometry with the patient's bladder fully distended at maximum cystometric capacity 1.

Once the filling catheter is removed, the patient may be asked to Valsalva and cough repetitively or perform some other exercises to try to induce urinary leakage under direct visualization.

2.

Patients are initially tested with repetitive coughs, three times, in the supine position followed by intermittent Valsalva maneuvers three times in the supine position. Then they are

pelvic exam, neurologic exam and check good lumbosacral nerve roots because these are the nerves that help control bladder and urethral function. Of course we want to focus on the pelvic exam but sometimes it can be quite overwhelming. You see somebody who has complete procidentia and a vaginal wall inversion, and it is hard to begin to think about this and what really helps I think is to compartmentalize it. I think for mere mortals and clinical gynecologists especially just looking this and thinking about anterior and posterior compartment defects and atypical prolapse and just these basic concepts and far come structures out of the vagina or how far they protrude down into the vagina say using the Beden-Walker 0, 1°, 2° and 3° prolapsed scale really will help you break things down. To prove that, it is obvious to all of us that this uterus is now protruding beyond the vagina, and there is 3rd or 4th degree depending on whose scale you use. She has an anterior compartment defect and a systole, but does she have a paravaginal defect? She obviously has a paravaginal defect because paravaginal defect implies that the anterolateral vaginal sulcus is detached from the arcus tendentious fascial pelvis, which is still inside the patient’s body. That is sort of apart of the defect that we might want to repair when we repair this prolapse. In addition, she obviously has a cystocele, and we want to get an idea if that is very small. We want a direct vaginal exam and understand that. She at least has a traction enterocele because her culde-sac obviously is out of the patient’s body here. We also want to understand whether this was the propelling property and usual with uterine prolapse it is a traction enterocele. You want to do a good neurologic exam. You want to make sure that the lumbosacral nerve roots are intact. Check for motor strength in the lower extremities, reflexes and you can check for sensation from L2 –S2 by checking the dermatomes above the knee. Then you augment this with bulbocavernosus and clitoral reflexes to look at the sacral nerve roots. When you stroke the labia, you should see contraction of the levator ani muscles and an anal wink. Likewise when you tap the clitoris, you should see the same thing. Clitoris is S1 and S2 afferently. The labia are S2 and S3 and obviously anal wink is S4 and S5. This helps you cover the ground. We prefer to do this with a Q-tip, so that we don’t bring up any questions in the patient’s mind as to what is actually happening. There are a number of clinical tests that we can do to augment are basic physical exams. Simple thing that you can do in the office. Be sure she has urethral hypermobility because around 12% of the population that has genuine stress incontinence will have it with a well-supported urethra. We call that subgroup type III incontinence. Those people won’t have urethral hypermobility, and they won’t benefit from your MMK. The cure rate is only about 30 to 40%, and I can cure them in the office with periurethral injections, fat, collagen, Teflon or other new things that are coming down the road, much more cheaply and much more simply under a local anesthesia. We can do numerous tests to look at urethral hypermobility. I prefer the Q-tip test because it is simple, cheap, and it does not expose people to radiation. There are standards in the literature that establish that if the straining Q-tip angle goes more than 30° positive from the horizontal then somebody has urethral hypermobility. The surgical success will follow expected outcomes. If the urethral hypermobility is less than a straining angle positive 30°, and it is the straining angle that is important. It is the straining angle that matters. You can do this with a Q-tip in. You can just put a Sims speculum or the back half of a Graves’s speculum and look at the anterior vaginal wall and see that it moves and say qualitatively this woman has urethral hypermobility. That is fine. Next thing we can do is a stress test. This is crucial to making the diagnosis of genuine stress incontinence, that we objectively demonstrate the sign of stress incontinence. If someone is coughing and

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moved to the standing position, where the same maneuvers are repeated. 3.

If they are unable to recreate urinary leakage, the patients are then asked to cough in series five times or Valsalva five times to try to induce leakage. If this fails, the patient then is asked to jump up and down in place three times or to run on the spot to see if this induces urinary leakage.

4.

When this fails, the patient may be asked to do deep knee bends or lift heavy objects off the floor to try to induce leakage.

5.

Record not only the volume at which the testing was done and the position of the patient, but also if activities other than Valsalva or Coughing are used to elicit urinary leakage. This may help accurately assess the degree of the patient's problem.

C. The stress test is deemed a positive test when urinary leakage occurs with increased intra-abdominal pressure 1.

In some patients, urinary leakage may be seen to occur not only at the moment of increased intra-abdominal pressure but may continue long after the patient has relaxed

2.

While such testing is positive because urinary incontinence occurred, this needs to be qualified because the patient may be demonstrating stress- induced involuntary detrusor contractions

3.

Up to 5-10% of women with detrusor instability may have stress-induced detrusor contractions

4.

If a patient has a stress test such as this and fails to show evidence of involuntary detrusor contractions on simple cystometry, she should be evaluated with multichannel urethrocystometry

D. Advantages 1.

Stress testing is simple and easy to perform. The patient with a full bladder is asked to increase intra-abdominal pressure, while the examiner tries to visualize urinary egress from the urethral meatus

2.

It is a reliable test, but the examiner must be cautious about

false-positive results in patients who have a.

Pooled vaginal fluid

b.

Increased vaginal discharge

c.

Fistulas who may have urinary leakage that is extraurethral during stress testing

VI.

straining and we see them leak urine. The best way to do this, standing up with a full bladder. It is the most sensitive position. Have the patient do whatever she needs to do at home to cause leakage. If that is hitting a tennis ball, have her reduplicate her swing. Have her close her eyes and pretend she is hitting a backhand as hard as she can or an overhead. Have her lift suitcases or bend down. Do whatever it takes in your office to redocument the leakage of urine coincident with increased intra-abdominal pressure. If she coughs and then starts to leak urine continuously about three seconds after she coughed, you want to think about stress provoked involuntary bladder contractions. One thing we can do is not just do a stress test, but we discovered a few years back something called the supine empty stress test. Here we discovered that people who have low urethral closure pressure, intrinsic sphincteric dysfunction, will leak urine even with a small amount of urine in their bladder with first or second cough laying down. There is a difference and you know it. There is a patient you see who leaks urine when she plays tennis and not at any other time. In your office you have to have her cough and strain repetitively with a full bladder before she leaks one drop. There is another patient your seeing who just emptied her bladder, and she is lying down and you have her cough and the urine squirts out and hits you in the chest. What do you know about those two women? You know that the intrinsic muscular function of one is much stronger than the intrinsic muscular function of the other or the patient may have what we call low-pressure urethra. When we correlate this with our work on closure pressures of 20 or less, we found that there is a positive predicted value for all patients, even high-risk patients of 90%. In the lowest population “out there in the normal world” the positive predicted value should be about 95%. If you see someone leak urine lying down with not much in their bladder, you have to assume that they have a lowpressure urethra and instead of thinking to do an MMK or a Burch, that patient needs a sling. Burch procedure is only going to work about 45% of the time to objectively cure that patient. She needs not only support of her urethra but squeeze or compressure. We want to think about that and maybe refer that patient for multichannel urodynamic testing to understand not just to close her pressure but avoiding mechanism and other concurrent problems, which will impact the patient that we might want to do a sling on. We do cystoscopy also on people of irritated voiding symptoms, but it is not apart of the routine work-up of urinary incontinence. It is important if people have blood in their urine obviously. It is also important if people have nocturia, dysuria, and suprapubic pain to evaluate them for various inflammatory conditions as well as neoplasia. We want to look at the voiding function of patients that we are evaluating for urinary incontinence to make sure that they don’t have overflow incontinence from total retention, and also to appreciate that most things that we do to treat urinary incontinence are going to increase urethral resistance or decrease detrusor contractility. Both of the factors tend to promote retention of urine. When we are treating people for incontinence we are really trying to alter this balance. We are trying to make them retain a little bit more but not too much that we cause a pathologic condition where they are retaining urine completely. Treating involuntary bladder contractions, we like to decrease detrusor contractility. We have to hit it just right. We want to understand just a little bit about peoples intrinsic voiding function, so we can do something called spontaneous uroflowmetry and see how fast they urinate and what pattern. In boys who have prostatic hypertrophy, it is very important that we measure the numbers, the speed.

"Q-Tip" Test A.

Assess as urethral hypermobility 1.

Measurement of the "Q-tip" angle when resting and during straining allows for a quantitative analysis of the mobility of

Because obstruction in woman isn’t due to physical changes. It is due to functional changes, spasm, irritation and inflammation. We look at the pattern, and it is just like anything else, a bell-shaped curve, and that is what defines normal because men and women are different.

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the proximal urethra and bladder neck 2.

The primary underlying pathology of GSI is relative hypermobility of the proximal urethra, resulting in decreased pressure transmission to the urethra when compared to the bladder

3.

While almost all patients with GSI have urethral hypermobility, many patients with urethral hypermobility are not found to have urinary incontinence

4.

Therefore, this test cannot be used as a predictor of who has GSI, but instead is of greater significance when it is found to not demonstrate urethral hypermobility in a patient believed to have GSI. This patient often is found to have a deficient "intrinsic sphincteric mechanism" and type III incontinence

5.

Different investigators have suggested different cut-off points to define urethral hypermobility, ranging from a straining angle of 20-350 a.

These angles are good estimates of adequacy of periurethral support

B.

Procedure 1.

The "Q-tip" test is performed by placing a sterile cotton tip applicator, lubricated with 2% lidocaine hydrochloride (Xylocaine jelly), in to the urethra until resistance abates, signaling that the cotton tip has reached the bladder neck

2.

The cotton tip applicator is snugged back against the bladder neck, and the resting angle is measured relative to the horizontal

3.

The patient is asked to Valsalva and cough repetitively, and the maximal straining angle is then recorded

4.

A normal resting angle is usually <0E,and a normal straining angle is < 30-35 E.

5.

If the straining "Q-tip" angle is in excess of 30, the "Q-tip" test is said to be positive, demonstrating

urethral

hypermobility. C. Advantages 1.

This test can be done quickly with minimal discomfort to the patient, and it offers a simple way to assess urethral mobility without the need for x-ray or US

2.

It offers a simple, quantitative, and relative measure of urethral mobility, which can be compared to postoperative testing to assess the adequacy of urethral support

VII. Simple Single-Channel Cystometry A.

Cystometry is the measurement of bladder pressure during filling. If is essential to the evaluation of all incontinent females.

B.

It may be performed by numerous methods of varying complexity 1.

Multichannel studies using electrical microtransducer

Men are women are different and no where are it more true probably when one comes to voiding function. We boys can only urinate with normal flow rates one way by relaxing our urethra and contracting our bladders. That is because the male urethra is really very long compared the female urethra which usually is about 4 or 5 cm in length. These leads to changes in voiding function. Women are amazing. They can urinate not just by urethra relaxation and bladder contraction but 5 different ways normally. They can urinate by urethra relaxation with or without a bladder contraction and with or without Valsalva. We like to see a bell-shaped pattern but here is sort of a roller coaster pattern or an intermittent interrupted flow. This can be one of two things. It was that the patient was Valsalva voiding that the woman had stress incontinence and had learned that she could in and out of the ladies room quickly by just pushing because her urethra is a push over. She takes a deep breath in and push, grab a breath-push, grab a breathpush, etc., rest here for a while and here somebody calling and she pushes again to get the last little bit out. On the other hand, this could represent the neurologic condition detrusor sphincter dyssynergy, where there is intermittent urethral contractions that is autominous and not coordinated with the bladder contraction where the urethra intermittently spasms and eventually totally extinguishes the bladder contraction and can lead to retention. We see a pattern like this we need to evaluate someone with multi-channel urodynamics to understand which it is. The last simple test that we should all do in the office to evaluate incontinent people is the cystometry or the study of storage pressures in the bladder during bladder filling. I think it is important that we do this in everyone because if detrusor overactivity is the second most common condition, we would at least like to rule it in or out. Here we are measuring urethral single-channel bladder pressure as we fill the patients bladder retrogrades. This happens to be a filling Foley and a 3-French catheter that we can measure pressure with. One means 100 mL, two means 200 mL. At 225 the patient says I first fell like I can urinate. Filling with water that is normal. Somewhere between 75 and 250 mL, people should routinely feel the first sensation to void. She feels full enough to urinate and go out of her way to find a toilet. At 550 she starts to have an involuntary inhibited detrusor contraction before she reached her maximum systematic capacity. This point where she couldn’t stand anymore fluid going into her bladder. Before that happened she has this bladder contraction and urine was leaking around the catheter onto the floor. This is an objective sign of detrusor overactivity. This woman was neurologically normal, so we said she had detrusor instability idiopathic condition. You can do this for $29.95 or if you are value oriented like me, you can do it almost for free. Filling 50 mL at a time, stopping to measures the pressure and if the pressure increases by more than 15 cm of water pressure you say the patient had an involuntary bladder contraction. If it doesn’t increase by more than 15 cm, you keep going until you reach your maximum cystometric capacity where she can’t stand anymore and if her bladder pressure doesn’t increase by 10-15 cm or more you say that she has a stable or normal bladder. Using those criteria comparative to multichannel urodynamic studies we found one CMG is 84% sensitive as a screening test for detrusor instability and two CMGs on two different days, which you probably wouldn’t do, are 92% sensitive. In an older population just took a Foley catheter and did eyeball cystometry. He took a Foley catheter, put it in the patient’s bladder lying down, a Toomey syringe on top of it, and he was about 25 cm above the patient’s pubic symphysis, and he just poured water in. If the miscus was falling the whole time he poured water in then there was no bladder pressure increase. When the meniscus starts to rise, why, because the bladder is contracting and the fluid would overflow the Toomey syringe and that was indicative of detrusor instability. He had an 85% sensitivity compared to multichannel urodynamics in a high-risk population. You can use a very simple test to tell what is

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catheters measuring urethral, abdominal, and bladder pressures with or without electromyelogram (EMG) can be used with computer-based physiologic recorders to perform complex urethrocystometry studies. 2.

Patients may undergo simple, single-channel "eyeball' cystometry by slowly filling their bladder through a Foley catheter and irrigation syringe at the bedside.

3.

Multichannel electronic eystometry equipment may cost anywhere from $10,000-55,000, whereas simple single-

going on. Go into the operating room and into the anesthesia cart in the bottom drawer there is a CDP manometer. Rip open the box and pull out the manometer. The second drawer is the IV extension tubing. Take a couple of links of IV extension tubing and attach that to the Foley catheter. The IV tubing is going to go on the other side of the manometer, which you are going to connect to the saline bags. The fourth drawer is the bags of saline or sterile water. You can take either, and they will work well. In the OR their Foley catheters and Christmas tree adapters, grab a few. You can hook up this cystometer Foley to Christmas tree adapter to IV extension tubing and back to the manometer out to the tubing and the bag and then you need an IV pull. On your way out of the OR just takes one they don’t need it. Bring it back to your office and hook it up like this and you are ready to go.

channel cystometry can be performed for under $10. Both the expensive multichannel systems and the simple singlechannel studies attempt to diagnose bladder pressure changes during the storage phase of micturition. C. The bladder should be able to fill to maximum cystometric capacity (the point where the patient is no longer able to tolerate any further bladder infusion because of severe discomfort) without any significant increase in bladder pressure, or urinary leakage. D. Simple cystometry may be divided into 1.

Those which measure bladder pressure

2.

Those, such as "eyeball" cystometry, which merely make a qualitative assessment as to whether there are involuntary bladder contractions or not.

E.

Simple single--channel quantitative cystometry has been shown in numerous studies to have a diagnostic sensitivity ranging from 53-93 % when compared with multichannel urodynamic studies. This sensitivity is largely dependent on the position of the patient and the provocative maneuvers used during the study

F.

"Eyeball" cystometrics 1.

The simplest form of cystometric evaluation available

2.

Involves minimal equipment

3.

Procedure a.

A simple catheter is transurethally placed into the patient's bladder; this is usually connected to an irrigation syringe

b.

The syringe is then held upright above the patient's pubic symphysis, and sterile water is poured into the syringe in an intermittent fashion

c.

This is done until the patient reaches maximum cystometric capacity

d.

Should the patient have an involuntary unihibited detrusor contraction during filling, the meniscus within the syringe will back up and often overflow the open syringe as a qualitative demonstration of detrusor overactivity

We really should be trying to look at cystometry and figure out whom has detrusor instability. When these simple tests don’t give us an answer or somebody has had prior surgery or think for some reason they are high-risk of surgical failure or treatment failure, you want to know more. They may not void completely or they void in a roller coaster pattern, in those people you are going want to think about getting multichannel urodynamic testing to further see that is going on. What is that compromise? Urethral cystometry is probably the most crucial part where we measure multiple pressures in the body to look at what is going on during the storage phase of micturition, as our body is trying to store urine in a low-pressure reservoir that we call the bladder. Once you have your subject you can use microtransducer or water catheters. These are little state microtransducer catheters. One goes in the urethra to measure urethral and bladder pressure, 6 cm distally, and the other one in the vagina or rectum. What we do is measure numerous pressures at the same time. Instead of just measuring bladder pressure like we did in the other study, we are going to measure EMG or electrical activity of pelvic floor, rectal pressure, abdominal pressure, urethral pressure, and then the computer gives is these two subtractive pressures. True detrusor pressure is the bladder pressure minus the abdominal pressure. If you bear down or cough, you are going to see an increase in the bladder pressure, but if it occurs here in the rectal or abdominal pressure lead, it is going to be subtracted out, and there will be no increase. This tells you what is going on inside the bladder irrespective of what is going on inside the abdomen. Urethral closure pressure is urethra pressure minus bladder pressure. If this is above 0 everywhere in the urethra then you stay dry. If it is below 0 everywhere in the urethra then it means the bladder pressure has exceeded urethral pressure, and you are going to leak urine or your patient is going to leak urine. This sort of testing not only improves our specificity to know that this isn’t a bladder contraction and this is but also our sensitivity in that it lets us see the whole picture of what is going on in the patients pelvis so we might be tipped off to go a little bit further or sometimes see a very low pressure bladder contraction that we might miss in a single-channel study. Urethral pressure flowmetry, the measuring of the intrinsic function of the urethra is very important in understanding the patient’s eventual outcomes with therapies. We can measure what is called urethral closure pressure profile, pull the transducer out through the urethra and measure the pressure each step along the way. It generates a curve that looks like it starts when the catheter moves into the bladder and ends where the catheter comes out of the urethral meatus. Because of limitations of time, I don’t want to make you experts on how to do this or even the concepts behind, but I thought it might just help to show some differences. This is an incontinent female. Here we have blown up the bottom line or the urethral closure pressure in this study. We are going from supine with an empty bladder to supine with a full bladder and then sitting on the full bladder to sitting with full bladder and repetitive coughing. The normal patient augments. She increases

7

4.

Following such an evaluation, the catheter may be removed and stress testing may be done

G. Simple incremental single-channel cystometry 1.

Retrograde cystometry may also be accomplished with a simple mariometric cystometer which allows for the measurement of bladder pressure. This can be accomplished in a continuous fashion with two transurethral bladder catheters or in an incremental fashion through a single simple transurethral catheter

2.

Procedure a.

Incremental

standing

retrograde

single-channel

cystometry may be accomplished by transurethrally placing a simple Foley catheter in the patient's bladder and distending the balloon to 5 ml. b.

A "Christmas tree"-type adaptor is placed in the Foley catheter (1) Two lengths of IV extension tubing are connected to this and to a simple manometer, taken from either a cell volume profile or lumbar puncture tray

her pelvic floor skeletal muscle activity around the urethra, and the pressure curve gets better as we stress her. The incontinent patient on the other hand usually starts out in general with lower pressure to begin with and as we stressed her, she deteriorates. She can’t augment. She can’t compensate for the increased stress of bladder filling and in a more upright position and repetitive coughing more pressure gets added to the bladder, negative pressure transmission, which causes urinary incontinence. We resupport a proximal urethral in a high retropubic position. Restore positive pressure transmission even though the resting pressure may stay low, these cough spikes will be positive, and the patient won’t leak urine. We also can do these tests in people who have prolapse to see what is behind the prolapse. Here is a resting profile without support. There is a high urethral pressure profile with a big kink in the middle. We take away the kink and the mechanical obstruction of the urethral folding on itself, and we see a very low pressure. In this case it is maintained. The patient doesn’t have stress incontinence, and when she coughs and strains, there is actually a pressure increase. She didn’t need to have an anti-incontinence surgery at the time of her pelvic floor reconstructive surgery, but most people do. 60-70% of the people that I see who have prolapse in the anterior or posterior compartment that comes to the introitus or beyond, 60% for posterior compartment and 70% for anterior compartment have potential genuine stress incontinence. Even though they don’t leak urine at home, if you resupport the prolapse and take away the mechanical obstruction or kink in their urethra just like unlinking a garden hose, they will leak urine. You would like to know about that before surgery rather than after surgery.

(2) This is taped to an IV pole so that it is zeroed at the level of the patient's symphysis c.

The other end of the cystometric manometer is attached to simple IV tubing, which goes back to a bag of sterile water

d.

The patient's bladder is filled in an incremental fashion with 50 mL H20 at a time, stopping every minute or so to measure the baseline resting pressure as well as to measure the pressure after stabilization following provocative maneuvers such as: (1) Coughing (2) Valsalva (3) Heel bouncing

The last component of multichannel urodynamic testing is instrumented uroflowmetry with EMG or electromyography. Here this lets us look behind things. This is a patient I showed you her roller coaster voiding pattern. This is the same exact patient and what we see is that she voids by Valsalva and bladder contraction and urethral relaxation initially. She is doing all of three things at the same time to empty her bladder completely but in this intermittent interrupted pattern. That is important for us to understand. In the case of detrusor sphincter dyssynergia, the other pathologic picture, just graphically shown here, we fill the patients bladder and we ask her to void when the bladder contracts and the bladder pressure increases, the urethra and EMG activity should go silent. If it increases, it is called detrusor sphincter dyssynergia. That is what is going on with this patient with MS. Here she has a bladder contraction and she is trying to void, her urethral pressure goes up and down and the EMG activity increases. This is detrusor sphincter dyssynergia. There is an underlying neurologic problem that leads to a lack of coordination between bladder and urethra.

(4) Exposing the patient to running water e.

The baseline pressure is taken, and the patient is filled until she notes the first sensation to void and then until maximum cystometric capacity. A rise in bladder pressure > 15 cm H20 from the baseline pressure is interpreted as a positive test

f.

This is especially significant if, when the Foley catheter is removed, the patient is seen to have involuntary leakage of urine coincident with this increased bladder pressure .

3.

Continuous monitoring of bladder pressure with a manometric or electronic cystometer allows for continuous recording of bladder pressure and the rapid detection of small phasic

We have made a diagnosis, and we have a patient who has genuine stress incontinence with or without detrusor instability. We have offered her all of the nonsurgical options. Let’s talk about different types of anti-incontinent surgery. When I think about incontinent surgeries, I divide them up into 5 classes. Vaginal operations like the Kelly-Kennedy plication that we are not going to talk about in any detail today, retropubic urethral plexis; Birches, MMKs, perivaginal repairs, needle suspension, where we somehow put sutures in the vagina and suspend them someway abdominally usually upwards or anteriorly with a needle, and sling procedures. In 1949, MarshallMarchetti-Krantz reported on the MMK, and this was sort of the rebirth of retropubic urethral praxes. I am going to talk about Tonnages modification described in 1976, but birch first reported his work in 1961, and this is the most commonly performed anti-incontinence operation and its various modifications right now in the world. Some deserve to be called modified berches and probably some that should have there own unique names. In the medical literature, there is

8

changes, which may only last 15-30 seconds and not be detected with the incremental methodology. 4.

Incremental single-channel cystometry has been shown to be 85-93 % sensitive in diagnosing detrusor instability when compared to multichannel studies. Its sensitivity is augmented by performance of the study on more than one occasion.

H. Electronic retrograde single-channel cystometry 1.

Continuous measurement of bladder pressure with a singlechannel recorder is more accurate than incremental methods or qualitative assessment with bedside cystometry

2.

Procedure a.

Usually a small filling catheter is used to fill the bladder in a retrograde fashion with water, saline, or CO2 gas.

b.

Another smaller catheter (4) is usually connected to an electronic water or gas manometer to measure the bladder pressure continuously

3.

The addition of an electronic cystometer significantly increases the cost of such studies, but often an intrauterine pressure catheter and manometer may be utilized to perform these studies, thus making the obtainment of additional equipment unnecessary for many hospital centers

4.

These studies may be performed in the supine, sitting, and standing positions, but are most sensitive in the standing position

5.

Similar to the other cystometric studies, this study is performed by placing both catheters in the bladder and filling through the filling catheter with either liquid or gas while the electronic cystometer is zeroed at the level of the pubic symphysis

6.

Bladder pressure a.

Measured continuously throughout filling

b.

A small chart strip recorder graphs a continuous cystometric curve during bladder filling

c.

Any bladder pressure increase that results in either significant symptoms of urgency or urinary leakage are significant.

7.

are not made due to Valsalva Increased intra-abdominal pressure will be recorded in the bladder as an increase in bladder pressure 9.

What we fixed here anteriorly, this doesn’t move when someone coughs and strains. This is why berch procedures and MMKs last so well, especially if you take away the question of permanent versus absorbable suture. If you are using premature suture, you stabilize people and you have them recuperate appropriately and restrict them for three or four months from strenuous activities and stool softeners, they will heal well and these people are going to do great. Probably forever, the majority of these people. Certainly for five or ten years, these people are going to do very well. It is 1.5-2 cm lateral to the urethra and then down 1-1.5 cm from there. A figure of 8 stitches that are then put up in Cooper’s ligament or iliopectineal ligament here. What this does is stabilizes the posterior wall, the urethra, by stabilizing the anterior wall of the urethra. We put a backstop here, so that when pressure is transmitted into this picture A from anterior to posterior, it is going to cause the urethra to compress on itself against the anterior vaginal wall. If there is urethral hypermobility, and there is no support, the pressure is going to largely be transmitted through and no reflected back. You don’t see nearly the same pressure increase. That is the short version of the physics of how Copel suspensions work. Perivaginal repair trys to do the same thing, but it says lets be anatomic about this. Let’s put the anterolateral vaginal sulcus back to where it is broken away from the arcus tendentious fascia with multiple sutures and just in front of the ischial spine all the way back beyond bladder neck. That is great, but people like me who really do this where it should be done, at the anterolateral vaginal sulcus. If you just put this back in the anterior vaginal wall still sagging in the middle, someone is still going to have urethral hypermobility. What I think a lot of people do who are successful with perivaginal repairs, is they probably put there stitches here where I put my Birch stitches and then sew that out to the arcus tendentious fascia to the pelvis tensing the anterior vaginal wall. That is fine. Suspending it going up to the arcus tendentious, long-term it should be stronger than suspending it directly at a right angle to the arcus tendentious fascia of the pelvis. Long-term, how well do the perivaginal repairs compared to Birches. Personally if I want to repair a perivaginal defect I do this surgery. If I want to repair incontinence, I do a berch procedure if I am operating abdominally and I have chose to do that. If I need to both, I do both.

Care must be taken with all single-channel cystometry studies that false-positive diagnoses of detrusor overactivity

8.

support for objective cure rates of 80-95% with similar subjective cure rates slightly higher. There is excellent longevity. This slide is a little bit old because there is actually ten-year data that came out last year that showed 86-89% objective cure rates from Italy and Argentina. Detrusor instability, the surgery creating involuntary bladder contractions, and this happens with all the surgeries that we do in varying degrees and you need to understand that, occurs about 7-10% of the time. The concept is that we want to resupport the proximal urethra, to stabilize the proximal urethra and restore positive pressure transmission to the urethra compared to bladder. How do we do it? We suture the anterior vaginal wall and developing endopelvic connective tissue posteriorly to some anterior point of support, which is immobile. The anterior vaginal wall moves when the patient coughs and strain, pressure is exerted downward in the space of Retzius, if this is stabilized the pressure will increase within this lumen.

Without the measurement of coincidental abdominal pressure either through a vaginal or rectal catheter, confusion can exist as to whether a pressure increase represents an

There are numerous needle suspensions in the literature. These operations and there cure rates in the literature short-term tend to be 79-90%, subjective cure rates above that. Their longevity is poor. A 10-year follow-up in the AUA series showed subjective cure rates below 30%. Their recommendation was that traditional needle suspensions should probably not be done and they should look for other operations. De Nova detrusor instability reported to occur 10-21% of the time, and there is significant amount of voiding dysfunction, which ranges with urgency frequency syndromes and retention anywhere from 15-30% of people. When we are operating on this woman and doing

9

involuntary bladder contraction 10. Such confusion may sometimes be avoided by asking the patient to deeply inspire during such pressure elevations. This should at least momentarily eradicate any increase in intra-abdominal pressure 12. Electronic retrograde single-channel cystometry performed with any of these methods may be used to screen for detrusor instability with a diagnostic accuracy in excess of 75% a.

When suspicious or equivocal studies arise or the results of the studies do not confirm the patient's symptomatology,

more

complicated

multichannel

studies are indicated b.

These studies should be performed with the patient in the standing position when possible because of increased sensitivity

c.

Provocative maneuvers may be used to augment the sensitivity of these studies (1) Coughing (2) Valsalva (3) Heel bouncing (4) Running water

d.

CO2, when placed in the bladder, may form acid and directly irritate the bladder wall, resulting in falsepositive studies.

e.

Cold infusions are more likely to elicit bladder contractions than body temperature infusions

VIII. Uroflowmetry A.

A study of voiding velocity with the measurement of the numerous parameters utilized to screen for voiding dysfunction 1.

During spontaneous urofiowmetry, without instrumentation, one is able to measure the maximum voiding velocity, the mean velocity or flow rate, as well as flow time and the time to the point of maximum flow

2.

Because voiding flow rates are dependent on bladder volume at the time of voiding (much in the same way as the stroke volume of the heart is dependent on the endiastolic volume or filling volume of the heart), results obtained vary widely depending on bladder volume

3.

Normal values a.

It is difficult to assess and define normal values without the use of a continuous nomogram varying by bladder volume.

b.

Nonetheless, when uroflowmetry is used as a screening test for voiding abnormalities, maximum flow rates <15-

a vaginal reconstruction which I believe that is a very good thing to do. Nonetheless, if you are going to operate on this woman vaginally, wouldn’t it be nice to have a needle suspension that you could do that adds 15-20 minutes to the operation rather than needing it go above and making a separate incision and do a Birch procedure or an MMK or something like that. It is just logical, but it has to be as good. That is what we are going to talk about a little bit on a theoretical basis. Needle suspensions aren’t as good because they resupport the proximal urethra but trying to do the same thing berch procedures do but the way they do it, suture endopelvic connective tissue and anterior vaginal wall here, but anteriorly to erectus fascia, which is mobile. If you put a thick loop of suture in between these, the suture you would like to just lift this up anteriorly. The suture doesn’t know to do that. It is not that smart. It acts circumferentially. What it does is it pulls these two layers closer together. Instead of lifting the pointer up like this, it justs put the layers together and you tie them under tension. If this comes up halfway, this has to go down halfway. Tension with a permanent suture in between these two layers like a wafer, what happens when the patient gets into the delivery room? Coughing and straining and the pressure are being exerted in the space Roexius. It is going to try to separate these two layers. The fixed suture loop is going to pull through the tissue like a cheese wire cutting through cheese at some point. It is not surprising that we would see the longevity of these operations is poor. In addition, if we have to compress these two layers together, we obviously increase urethral resistance, we will have more voiding dysfunction, and it is not surprising that we are going to have more detrusor overactivity. If we are just doing the operation alone, we can make incisions on either side of the bladder neck in the anterolateral vaginal sulcus, probably just two 2.0 cm wide, dissect underneath the pubic ramous and perforate through either with our fingers or the scissors, put the finger in and tear the tissue off the pubic ramous where it inserts in the undersurface of the pubic ramous to open tunnels perivesically on either side. The medial edge of the tissue that we separate off is a condensation of the endopelvic connective tissue, which is just fibril fatty, and neurovascular bundle tissue. We call it the posterior pubic urethral ligament. We envelop it in a helical suture like this with a Ross, and we also incorporate the vaginal tissue here that we reflected off and then we bring it back up into the abdominal field with a blunt ligature carrier perforating just through the rectus fascia. Because we dissected up to the undersurface of the rectus muscles from below, it improves the safety of these operations by doing the dissection directly rather than just blindly with our needles like a Ghedies or a Stamy procedure is done. Then you tie down. The question is always how tight do you tie. I tie my needle suspension with a Q-tip in the urethra, so it just goes to 0°, and the posterior urethral wall just starts to lift up or flatten out. That seems to work fairly well, but the problem is we have trouble with sutures pulling through. What we have been working on over the last three years is not anchoring anteriorly to rectus fascia but to some fixed immobile point trying to make our needle suspensions more like Birch and MMKs. We can use a titanium anchor anteriorly to fix the suture into the pubic symphysis and then this picture looks like the diagram for the Birch procedure or an MMK as opposed to when we try to put rectus fascia to anterior vaginal wall, and we have the problem that we talked about before illustrated by the Stamy procedure where the tissue planes want to separate and pull apart. If we fix it anteriorly all we do here is sort of stabilize and that is the name percutaneous bladder neck stabilization, which is essentially what birches and MMKs are. They are transcutaneous bladder neck suspensions. Here we make a small incision just on the near side of the top of the pubic symphysis over the pubic tubercle about 1.0 cm put a pinpoint bone locator, we take a drill guide here, and it anchors into the bone. On a flat surface we can drill in the titanium screw and anchor. We then take the suture and put it on a suture passer and bring it down the back of the pubic bone to bladder neck and look here as we just perforate through as marked by

10

20 ml/second represent some degree of obstruction as long as the voided volume is >150 mL c.

Most people should be able to void moderate volumes within 20-30 seconds, usually achieving peak flow rates within the first 10 seconds of voiding

4.

Uroflowmetry is a screening test which looks at the end result of a complex coordination between the bladder, urethra, and the voluntary muscles of the pelvic floor to cause micturition. Evidence of an obstructive or retentive pattern requires further evaluation with voiding pressure studies or voiding cystourethrograms.

B.

The clinical significance of uroflowmetry is quite different in men than in women 1.

In males, obstructive urofiow patterns (low flow rates) usually represent some degree of physical obstruction, usually due to prostatic hypertrophy

2.

In women, physical obstruction is quite rare, and most obstructive uroflowmetry studies in women are from functional obstruction either due to neurologic or nonneurologic (inflammatory) causes

3.

Males normally void by urethral relaxation and detrusor contraction, whereas women can achieve normal urofiow patterns by five different mechanisms a.

Thus, the interpretation of uroflowmetry in females is significantly limited to that of a screening tool

b.

In males, on the other hand, the information obtained about flow rates can often be used as a direct measure of the degree of prostatic hypertrophy and its response to treatment

C. Uroflowmetry can be accomplished by two different methods 1.

One involves the uses of electronic uroflowmeters, which take advantage of measuring urine velocity either by translating the centripetal force of a water wheel into velocity, or by the use of an instantaneous fluid weight scale to measure the increasing weight of urine voided over time

2.

A simpler method utilizes a stop watch, but allows neither for calculations of maximum flow rate nor time to peak flow. It gives the an estimate of the mean flow rate by measuring the volume of urine voided over a given period of time

D. Perhaps the most important part of uroflowmetry is the assessment of voiding completeness. Catheterization or some other investigation of the urinary residual will determine who has the most significant voiding dysfunction E.

Assessment with electronic uroflowmetry 1.

Generates a strip chart recording of voiding velocity as well

the Foley catheter through the anterior vaginal wall. It perforates at 1.5-2.0 cm lateral to the bladder. We then drop off the suture, move the needle over a centimeter and a half, come back through at point two and pick up the suture. Then move down top three and complete a Vstitch by moving over to four. What this is a figure of eight suture on one side that encompasses where I put two sutures of a tonogo Birch of about two square centimeters of tissue on either side of the bladder neck staying about 1.5 cm lateral to the proximal urethra. We do this on both sides. We bring the needle back out and tie down over the suture space, which puts a ¾ cm gap in each suture, so we stabilize rather than compress. It automatically forces you to gap this operation by 1.5 cm of relaxation. It leaves us with 2 square cm area of tissue being pulled up and stabilized by the bone anchor or stabilizing the anterior vaginal wall on either side of the urethra. The sling procedure is the last operation that we have that we routinely do, and this is where we seek to not only support the urethra but by using some sort of strap underneath the urethra or a combination of tissue and suture in some cases, we try to compress the urethra as well as resupport it. We compress the proximal urethra and resupport it by suturing either rectus fascia, which is mobile. When we cough or strain, rectus fascia moves anteriorly out like this even if you are in great shape and that will pull a moment of force up on the arms of the sling and tend to compress it. We can anchor it to Cooper’s ligament, which is immobile, and form a rigid backstop that the urethra can be pushed down on and likewise compress upon itself. Either way we get urethral compression against a broad backstop. Cure rates in the literature are excellent. We see objective cure rates of 80-95%. What is really neat about slings and those of you that are familiar with these and do them, is there longevity is nearly 100%. Once a sling works, it will stay working potentially forever, especially when we use heterologous materials like Mersilene, Marlex, Gore-Tex, Medx, etc. These materials are stronger than our body tissues, and they will stay in place and not move forever. The problem is that while they work great, there is a big problem with De novo detrusor instability in 1030%. They only resolve concurrent detrusor instability about 20-25% of the time, so they are not good operations when it comes to urge incontinence and detrusor instability. In addition, there are a lot of problems with retention. If you make slings just a little bit too tight, they are very unforgiving. A primary indication for slings is people who have low-pressure urethras because we know that those people will fail the prior operations that we described somewhere between 45-60% of the time. When you are trying to operate for 10 or 15% failure rate and your failure rate is really going to be 50 or 60%, it is time to find another operation. We operate for low-pressure urethras or type III incontinence if they fail periurethral injections. If you fail the MMK you should always do a sling. I am tempted to that sometimes but really most of the people in this group actually fall into the low pressure group. High risk patient like people of COPD, connective tissue diseases or morbidly obese, then these are other reasons that we see for doing slings. Fascial lata slings of 88 patients with an 89% cure rate. Half of them resolved their concurrent detrusor instability, which is quite high, to only 7% who have de novo detrusor instability, which is quite low. 1% had permanent retention. Temporary retention beyond six weeks occurred in ¼ of his patients. UTI and almost all those people had 1% wound infections and sarcomas even using their own body tissues. When we use heterologous materials we have to worry about infection rates that may be even higher. This is a fascia lata sling here harvesting above the knee. The other alternative is to do a rectus fascia sling or an Altridge sling where we harvest a strip or two strips from the rectus fascia anteriorly and then we tape these and bring them into the vagina and anchor it underneath the urethra at the bladder neck. Either set the tension abdominally like I like to with rectus fascia slings because it is easier to set the tension. You want to not

11

as a printout of a.

The volume voided

b.

Maximum and mean flow rates

c. Time to peak flow d. EMG activity when measured 2.

When the maximum flow rate is in excess of 20 mL/second, and the patient has no significant retention, uroflowmetry is said to be normal in men

3.

In women, when maximum flow rates are >15-20 mL/second and the flow rate is bell-shaped the urofiowmetry study is assessed as normal a.

Uroflowmetry in women can be used qualitatively discern who might be Valsalva voiding. Usually Valsalva voiders have an intermittent or roller coaster type pattern to the uroflow curve

b.

Identification of women who are largely dependent on the use of Valsalva to void, prior to any surgical intervention, is helpful in trying to recognize which group of patients might be at greater risk of voiding difficulty following a surgery that increases urethral resistance and prevents urinary leakage during Valsalva

F.

Uroflowmetry serves as a rapid screening method to assess the

voiding adequacy of patients 1.

Care must be taken, especially in women, not to overinterpret the results.

2.

When abnormalities are found, the testing should be repeated a.

Depending on bladder volume, flow rates may vary widely.

b.

Initial uroflowmetry studies are often falsely abnormal because of the patient's unfamiliarity with such testing and devices.

c.

The patient who consistently shows evidence of obstruction on uroflowmetry should be evaluated more thoroughly with multichannel voiding pressure studies with EMG.

think about support or compression. All you want to do is sort of stabilize the urethra back at around 0 to +10° with a horizontal. You sort of want to put in close to where it was, and it will work fine for curing stress incontinence. The problem so much isn’t curing stress incontinence, as it is not creating retention in detrusor instability. With heterologous materials, Morgan’s reported a five-year success rate some years ago of 77% just suturing Marlex to Cooper’s ligament with very little morbidity at 1% official of formation rate and a 3% infection rate. Nichols used Marlex, but he did an active sling. He put it to rectus fascia with a 95% success rate in curing or improving patients. Those were not all cures. Some of the people were improved. We had a 92% cure rate using Gore-Tex to anterior rectus fascia, which was excellent. Objective cure rate, people didn’t leak a drop of urine four months after surgery on testing to maximum systematic capacity. The problem was we only cured 20% of people who had concurrent detrusor instability, and we created concurrent detrusor instability 30% of the time. 1/3 of our people while we cured their stress incontinence, we gave them a new problem, which was urge incontinence. That is not very impressive. To get around some of those problems of retention and voiding dysfunction. We sue vaginal wall slings in people of low-pressure urethras, weak bladder contractions and urge incontinence. We feel that this is the weakest sling that we can use. While Sholmer cures 91% of people, I was just hoping that I could cure 71% of people. In fact, we reported our one-year cure rate objectively, and it is exactly that. We don’t do as well with our Gore-Tex slings or rectus fascia slings. You know what, in doing this for five years and we probably do about 40 of these a year, we have only had one woman need to self cath for any period of time. Prior to that, if you look at other literature on others and ours the retention rate with slings can be anywhere from 3-18%. It is a very good operation for nonincreasing urethra resistance very much. We see a resolution rate of detrusor instability in about 35-40% of people instead of 20% with our more aggressive slings. People of both problems we use this operation. If you have a vertical incision, you stop here and just trace out a trapezoid above. You can make a blockade dissection where this is the advancement flap. We really don’t do that. We just trace out a trapezoid underneath the proximal bladder neck and urethra, dissect away the tissue on either side and make tunnels just like we did with the Pererra procedure. Put four sutures in the four corners and bring them up to rectus fascia and sew them down above. The only problem is that while we have a 71% cure rate of one year, we found that anatomically only 61% of these people had negative Q-tip tests. 39% of them had already developed urethral hypermobility at one year. They said this isn’t very good. This is going to be like modified Pererra. It looks pretty good in the beginning, and it fades with time. The same concepts involved with the sling you can bone anchor this put a simple mattress suture in the vaginal epithelium and do what is called an in situ sling of vaginal sling that is bone anchored. What we found now at one year, we’ve seen that we have with our fascial patch slings where we harvest a piece of fascia instead of the vaginal epithelium which is a little more aggressive, we have a 97% anatomic correction rate at one year. 97% of people have negative Q-tip tests instead of 61%. We can use this concept and sort of leverage the concept of bone anchoring and do it toward in situ slings or harvest the fascial patch sling or a piece of Mersilene or Gore-Tex and suspend it as you see here to the bone anchor. Likewise hope to have really improved longevity, and this is the way we are going. Laparoscopic retropubic urethropexy. There are numerous techniques that have been described in the literature, but the point remains that two and a half years ago Burton, an Australian physician, did a prospective randomized trial after doing over 200 open Birches and over 100 scope Birches with traditional laparoscopic suturing. He

12

showed that the cure rates were equal at six weeks. One patient out of 30 in each group failed. At one year it was still one patient out of thirty that failed and had recurrent stress incontinence where as in the scope Birch group already you saw nine people or 27% failed. At two years the rate went even higher. The real concern is the strength of the bites that we take with traditional laparoscopic suturing using small needles and needle holders that as you know as well as I do don’t always hold quite as well as we would like delivering them at incident angles that might not be quite what we do through an open dissection. We have done a number of things to deal with this. I have tried six different laparoscopic operations. It is just the pericurtineal balloon, and we use gasless laparoscopy. What we do is place sutures in at the bladder neck through Cooper’s ligament. When I am done I get the same Birch procedure. It is not 30 minutes with staples and Mesh with one suture. It takes a lot longer. We do Birches through a 4.0 cm incision instead of the old 15-cm incision I used to use. It takes us a little bit longer. It takes us about 45-60 minutes instead of 30-45 minutes. Cosmetically they are a 4.0 cm incisions because it is equal to the three punctures we used to make for laparoscopy. We can cosmetically do the same thing. If you think about he needle suspensions and bone anchor suspensions we were talking about, they are less invasive, more consistent, and give us good long-term results also. I am not sure that going at it with laparoscopic, so called birches or staples and Mesh, may be the best way to treat our patients long-term.

13