Continence and complications rates after male slings as primary surgery for post-prostatectomy incontinence: A systematic review

Objectives: to analyze continence and complications rates after male slings as first line surgical treatment, in order to improve patient counseling for the management of SUI postprostatectomy. Method: A MedLine search using specified search terms was done on January 23, 2012. This research rendered 160 records. Results: No controlled trial was available for analysis. The majority of papers dealing with out- come and complications came from a few centres. At a median follow-up of 15 months the pooled cure rates for all kinds of slings was 77.4; in the AdVance group the pooled cure rates was 72.5%; in the InVance group it was 74.2% while in the Remeex group it was 84.3%. Conclusions: Only a few number observational studies addressed review selection criteria. The pooled overall cure rates is high but there are no data concerning reliable pre- and postopera- tive prognostic factors affecting treatment failure and complications rates, thus it is not possi- ble to have suitable criteria for a better patient selection. The statistically pooled results obtained should be interpreted with caution because of several limitations due to several study selection limitations: observational study design, few number of analysed studies, heterogene- ity, lack of outcome definition and standardisation, between-study variability, high risk of bias

Bulking agents: anesthesia techniques.

Bulking therapy for the minimally invasive treatment of stress urinary incontinence(SUI) may be offered to women with urodynamic SUI, wishing to avoid the complicationsassociated with more invasive surgery, on the basis of low operative morbidity and low longtermsuccess rates. These bulking agents may be injected by a retrograde or antegradetechnique in the periurethral tissue around the bladder neck and proximal urethra. This therapyis strongly dependent on the anesthetic technique of choice; moreover its applicationas an outpatient procedure implies the potential for a cost-effective treatment for selectedpatients with SUI. In the present paper all factors affecting the choice of different types ofanesthetic techniques are discussed.

SACRAL NEUROMODULATION IN THE MANAGEMENT OF LOWER URINARY TRACT DYSFUNCTIONS: A NEUROPHYSIOLOGICAL EVALUATION

Hypothesis / aims of study Currently, sacral neuromodulation (SNM) stands as the single licensed second-line treatment for the management of intractable overactive bladder syndrome (OAB). SNM can be considered a promising, potential solution to bladder dysfunctions which have a serious impact on patients\u2019 health status and quality of life, in carefully selected patients. However several questions are still unanswered, regarding the following topic: patient selection, prognostic factors, mechanism of action, complications and revision rates, effects on central and peripheral nervous system. Neurophysiology studies could be employed to provide more evidence on SNM mechanism of action and peripheral effect. The aim of this study was to evaluate clinical and neurophysiologic characteristics of patients with lower urinary tract dysfunctions (LUTD) undergone SNM implant trying to better understand neurophysiologic modification pre- and post-implant, defining responders\u2019 pre-implant neurophysiological characteristics. Study design, materials and methods Data (demographics, medical history,urologic investigations, and diagnosis) from all patients attending our institution from February 2006 to September 2009 for a SNM implant were collected. All patients underwent a pre-implant neurophysiologic evaluation as follows: Pudendal Nerve Somatosensory Evoked Potentials (PN-SSEPs); bilateral external anal sphincter electromyography (EAS-EMG); evaluation of the bilateral pudendal-anal reflex (PAR); Electromyographic and neurographic studies of lower limbs. A post-implant neurophysiological evaluation was performed in all implant removal candidates. For comparison Student's t test was used. Results A total of 22 consecutive patients (mean age 63.1 years) attending our institution (19 women and 3 men), with refractory overactive bladder (OAB) (54.5%), non-obstructive urinary retention (UR) (27.3%), mixed urinary incontinence (9.1%); chronic pelvic pain (CPP) (9.1%) underwent a permanent SNM implant. At a mean follow-up of 3.5 months (range 2-24 months), half of the patients have their implants removed (tables I-II). Table III shows pre- and post-implant PN-SSEPs findings in patients with durable beneficial from SNM. In patients undergone implant removal, values of PN-SSEPs, EAS-EMG and PAR were normal apart one case with an increase in bilateral pudendal nerve latency. Figure I shows pre-implant EAS-EMG findings in patients having beneficial from SNM. Pre-implant EAS-EMG findings were normal in 90.9% of patient undergone implant removal. Table IV summarizes pre- and post-implant R1 and R2 latencies of PAR in patients with effective SNM implant. Interpretation of results The greater effectiveness of SNM has been observed in patients with neurological damage neurophysiologically documented. To date there are no definitive data about the exact mechanism of action of SNM although it is conceivable a modulation on the somato-sensory afferents as well as a secondary effect on both somatic (pudendal nerve) and autonomic efferent motor pathways. Concluding message Our results suggest that the neurophysiologic exploration of the pelvic floor is an important step for the identification of suitable candidates for treatment with SNM. Further well-designed trials are needed in order to better define the role of neurophysiology in SNM, not just in identifying appropriate candidates for intervention, but also to guide the surgeon in more accurate positioning of the electrodes, using intraoperative monitoring, and to change the parameters of stimulation in patients unresponsive to treatment. Table I. Characteristics of patients undergon

ROBOT-ASSISTED LAPAROSCOPIC HYSTEROSACROPEXY FOR PELVIC ORGAN PROLAPSE

Introduction Pelvic organ prolapse (POP) surgery can be performed either transperineally or transabdominally. The individual woman\u2019s surgical history and goals, as well as her individual risk for surgical complications, prolapse recurrence and de novo symptoms impact the selection of surgical route. Transabdominal repairs are the most common surgical procedures for POP and are associated to recurrence rates up to 10%, whereas transperineal approaches are reported to be a source of higher recurrence rates. Transabdominal procedures can be performed either by laparotomy or by laparoscopy. Recently several series have reported that laparoscopic approach to treat POP (with or without robotic assistance) is feasible and safe with good short and intermediate-term results, comparable to open approaches. This paper describes the technical aspects of robot-assisted laparoscopic hysterosacropexy (RALHSP) using the da Vinci surgical system. Design Since 2006, 10 consecutive patients with POP (mean age 54.5 years), who wished to preserve the uterus, underwent RALHSP as single reconstructive procedure. Two surgeons performed all procedures with the same technique. All complications were collected at a 90-day follow-up using the standardised Clavien classification system. The following outcomes were evaluated: operative time, blood loss, complications, in hospital stay, catheterization time, cure rate. The surgical steps were: bilateral dissection of the perimetrium; identification and extraperitonealization of the uterine cervix; incision of the peritoneum at presacral level and distal to the cervix; placement of a 20 x 2.5 cm polypropylene mesh, willing to embrace the cervix, secured to the anterior longitudinal sacral legament with 0 Tycron stitches; mesh extraperitonealization. Results Al procedures were performed successfully using the Robot-assisted approach. No additional reconstructive procedures were thought to be necessary at the end of surgery. The mean operative time was 103 minutes; the mean blood loss was 18 mL. Neither intra- nor major post-operative complications occurred. According to the Clavien classification system, 4 patients (40%) had grade 1 early complications (two nausea episodes, two electrolyte disturbance); and one patient (10%) had grade 2 complication (diarrhoea). At a mean follow-up of 9.3 months all patients declared themselves satisfied with the anatomical and functional results achieved. Conclusion RALHSP represents an effective option for the management of POP in selected women who wish to preserve the uterus. Moreover da Vinci robotic system allows performing similar procedures to those performed by standard laparoscopy or laparotomy without increasing the morbidity rate when compared to standard laparoscopy, and allows the same functional results

SACRAL NEUROMODULATION FOR THE TREATMENT OF REFRACTORY LOWER URINARY TRACT DYSFUNCTION: RESULTS FROM A MULTICENTER STUDY

Hypothesis / aims of study Sacral neuromodulation (SNM) has been used as a safe, effective treatment option for patients with lower urinary tract dysfunction (LUTD). Several clinical studies demonstrated its positive effects on refractory urge incontinence, non-obstructive urinary retention, urgency frequency syndrome, as well as on other non urological disorders, such as faecal incontinence and chronic constipation. The aim of this research project was to evaluate the efficacy and safety of sacral neuromodulation on the management of LUTD refractory to the standardised first line treatment options. Study design, materials and methods We retrospectively collected and evaluated data from patients undergoing SNM between September 2001 and November 2010 in 4 Urological Centres of Northeast Italy. The patients were affected by Overactive Bladder Syndrome (OAB) and non-obstructive Urinary Retention (UR). All the patients were evaluated with voiding diaries, before and after implantation. Patients included in the present evaluation were followed in a network of 4 Italian urological centres which participate to the Italian Clinical Service project - a national urological database and medical care project aiming at describing and improving the use of implantable urological devices in the Italian clinical practice. To evaluate the patient reported outcome (PRO) of the impact of SNM on refractory OAB, we retrospective revised files from all implanted patients who completed pre and post-operatively the King\u2019s Health Questionnaire (KHQ). KHQ is a specific assessment instrument of the heath related quality of life (HRQoL) for patients with OAB, and incontinence symptoms. It consists of 21 items distributed in nine dimensions: general health (GH), incontinence impact (II), role limitations (RLs), personal limitations (PLs), social limitations (SLs), personal relationship (PR), emotions (Em), sleep/energy (Slp/En), and severity measures (SMs). The score of each dimension ranges from 0 (lower OAB symptoms impact; better HRQoL) to 100 (higher OAB symptoms impact; worse HRQoL). Continuous normally distributed variables were reported as the mean value \ub1 standard deviation (SD). Continuous non-normally distributed variables were presented as the median values and an interquartile range (IQR). The t-test, the Mann-Whitney and Wilcoxon tests were used to compare continuous variables, as appropriate. A two-sided p < 0.05 was considered statistically significant. Results Overall, 135 patients underwent implantation of SNM during the period under review. Eighty-three out of 135 (61.5%) patients complained of OAB, and 52 (38.5%) of UR. In patients treated for OAB, we documented a statistically significant reduction in the mean number of: incontinence episodes/die, pads/die, daily micturitions, nocturnal micturitions and global micturitions (see table I). In patients treated for UR, we observed a statistically significant reduction in the mean post voiding residual volume and in the number of self catheterization (see table II). Concerning the impact of SNM on HRQOL from patients complaining of refractory OAB, only nineteen patients (17 female and 2 male), from a single centre, filled-in the KHQ pre- and/or postoperatively The median patients\u2019 age was 70 years (range 65-74) with a median follow-up of 42 months (range 17.5-48). Median and range of quality of life KHQ of general health and personal relationship pre- and post-operatively were reported in table III. Table I. SNM clinical outcomes in patients with refractory OAB Variable N Baseline FU P-value Incontinence episode/die, mean\ub1SD 48 4.1\ub12.7 1.5\ub12.1 <0.001\ub0 Pads/die, mean\ub1SD 44 3.4\ub12.4 1.3\ub11.4 <0.001\ub0 Voided volume, mean\ub1SD 45 143.6\ub169.9 206.7\ub188.5 <0.001* Daily micturition, mean\ub1SD 48 10.4\ub14.2 7.4\ub12.5 <0.001\ub0 Nightly micturition, mean\ub1SD 48 2.6\ub11.8 0.8\ub10.9 <0.001\ub0 Global micturition, mean\ub1SD 48 13.0\ub15.3 8.1\ub12.7 <0.001\ub0 *T-Test; \ub0 Wilcoxon test Table II. SNM clinical outcomes in patients with non-obstructive urinary retention Variabile N Baseline FU P-value Post void reisdual urine, mean\ub1SD 30 321.4\ub1153.5 87.2\ub196.9 <0.001\ub0 Catheterism/die, mean\ub1SD 30 3.8\ub11.4 1.3\ub11.3 <0.001\ub0 Daily micturition, mean\ub1SD 29 4.7\ub13.8 5.4\ub12.0 0.159\ub0 Nightly micturition, mean\ub1SD 29 0.7\ub11.3 0.7\ub11.1 0.886\ub0 Global micturition, ,mean\ub1SD 29 5.4\ub14.6 6.1\ub12.5 0.328\ub0 *T-Test; \ub0 Wilcoxon test Table III. Median and range of HRQoL assessed pre- and postoperatively by King\u2019s Health Questionnaire* of general health and personal relationship of patients underwent SNM for refractory OAB. Dimension pre-SNM median (rance) post-SNM median (range) p-Value Wilcoxon matched pairs test GH 50 (37.5-50) 50 (25-62.5) 1 II 100 (100-100) 100 (50-100) 0.063 RLs 83.3 (50-100) 50 (33.3-100) 0.102 PLs 83.3 (66.7-100) 33.3 (16.7-83.3) 0.026 SLs 77.8 (50-94.4) 0 (0-50) 0.017 PR 0 (0-25) 0 (0-33.3) 0.785 Em 77.8 (22.2-88.9) 33.3 (11.1-44.4) 0.14 Slp/En 50 (33.3-75) 50 (16.7-66.7) 0.109 SMs 58.3 (33.3-79.2) 66.7 (25-75) 0.671 *The score ranges from 0 (lower OAB symptoms, better HRQoL) to 100 (higher OAB symptoms, worse HRQoL). In comparison of the preoperative setting, patients after the implant showed a better scores in many KHQ dimensions. In particular for personal limitations (p=0.026), and social limitations (p=0.017). The length of follow-up did not significantly impact on HRQoL scores. Interpretation of results SNM offers objective benefits for people with refractory OAB and for those with urinary retention without structural obstruction. Concerning the PRO, because OAB symptoms in general may have a serious impact on a person\u2019s daily activities and social life, the effect of treatment on disease-specific HRQoL also reflects its efficacy. In our series we observe a significant improvement of HRQoL for the following KHQ items: personal limitations and social limitations. We observe a better, although not significant, HRQoL also for the following items: Incontinence Impact, Role Limitations, and Emotions. We did not found any correlation between the follow-up length and HRQoL. We should take great caution in interpreting these results because all the measures of the impact of SNM on the HRQOL comes from a small number of patients\u2019 perspective. Concluding message This multicenter research project confirmed the midterm safety and effectiveness of sacral neuromodulation in the treatment of refractory overactive bladder syndrome and non-obstructive urinary retention, showing high cure rates and low complication rates

ROLE OF SYMPTOMS DURATION AS PROGNOSTICATOR FOR SACRAL NEUROMODULATION IN REFRACTORY OVERACTIVE BLADDER

Hypothesis / aims of study Sacral neuromodulation (SNM) offers a well-tolerated treatment option for patients with overactive bladder syndrome (OAB) refractory to conservative treatment. The advantageous effect of SNM depends on the accurate identification of suitable candidates during pre-implant percutaneous nerve evaluation. In the Literature there are conflicting data regarding the role of age, duration of complaints and neurogenic bladder dysfunction in predicting the effect of SNM, and up to-date no specific urological pre-treatment factors have been associated with response to SNM. The aim of this multicentric study was to investigate data from 103 patients with refractoy OAB who underwent SNM implant in order to evaluate the role of symptoms duration as possible pre-treatment prognosticator. Study design, materials and methods From September 2001 to November 2010 a total of 103 patients attending four different urological centres with refractory OAB underwent a temporary SNM implant. Patient data (demographics, medical history,urologic investigations, and diagnosis) were collected. Temporary implant results were evaluated from a voiding diary and patient history. More than 50% improvement of voiding parameters was considered a successful SNM and those patients were selected for implantation. We test the duration of complaints as prognosticator for predicting SNM result. We performed the Pearson correlation analysis. For comparison between groups either Student's t test or Mann-Whitney test were used, as appropriate. Results Eighty patients (77%) underwent a definitive implant. At a mean follow-up of 25.2 \uf0b1 22.9 months we observed a significant decrease (p<0.001) in the mean number of incontinence episodes/die (1.3\ub1 1.9 versus 4.6\ub12.4), number of pads/die (1.2 \ub1 1.4 versus 3.7 \ub1 2.2), daily urinary frequency (8.7 \ub1 2.8 micturitions/die versus 12.7 \ub1 4.8). Stratifying patients according to the lower urinary tract dysfunction aetiology (idiopathic, neurogenic, iatrogenic), we did not find any significant correlation between symptoms duration (neither as continuous nor categorical variables) and the improvement rates of incontinence episodes (figures 1-2), and micturition frequency (figures 3-4), although we observed better results mainly in neurogenic patients with < 4- year history of urinary symptoms (figure 5). Interpretation of results Patients with urgency and urge urinary incontinence due to neurogenic lower urinary tract dysfunction for a relatively long period of time may have a lower chance of a positive test compared with patients with neurogenic dysfunction for a relatively short period. Concluding message Duration of complaints was not found to be significant predictive factor for the success of SNM. Disclosure

Urinary incontinence related to perineal muscle strength in the first trimester of pregnancy: cross-sectional study

Objective To analyze pelvic floor muscle strength (PFMS), urinary continence and quality of life related to urinary incontinence (UI) of women in the first trimester of pregnancy. Method Cross-sectional study with a sample of 500 women who started prenatal care in a complementary healthcare facility in Guarulhos, state of São Paulo, from 2012 and 2013. Pelvic floor muscle strength was evaluated through perineometry. The pregnant women who presented UI answered the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF). Results It was found that maternal age (OR=1.06; CI95% 1.02-1.11) and prior UI (OR=15.12; 95%CI 8.19-27.92) are the variables that, in tandem, best explain the occurrence of UI at the beginning of pregnancy. The mean score on the ICIQ-SF was 8.2 (SD=3.9), considered a moderate impact on quality of life. Conclusion Older pregnant women with prior UI are more likely to have UI in the first trimester of pregnancy.
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Women’s pelvic floor muscle strength and urinary and anal incontinence after childbirth: a cross-sectional study

Abstract OBJECTIVE To analyse pelvic floor muscle strength (PFMS) and urinary and anal incontinence (UI and AI) in the postpartum period. METHOD Cross-sectional study carried out with women in their first seven months after child birth. Data were collected through interviews, perineometry (Peritron™), and the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF). RESULTS 128 women participated in the study. The PFMS mean was 33.1 (SD=16.0) cmH2O and the prevalence of UI and AI was 7.8% and 5.5%, respectively. In the multiple analyses, the variables associated with PFMS were type of birth and cohabitation with a partner. Newborn’s weight, previous pregnancy, UI during pregnancy, and sexual activity showed an association with UI after child birth. Only AI prior to pregnancy was associated with AI after childbirth. CONCLUSION Vaginal birth predisposes to the reduction of PFMS, and caesarean section had a protective effect to its reduction. The occurrence of UI during pregnancy is a predictor of UI after childbirth, and women with previous pregnancies and newborns with higher weights are more likely to have UI after childbirth.AI prior to pregnancy is the only risk factor for its occurrence after childbirth. Associations between PFMS and cohabitation with a partner, and between UI and sexual activity do not make possible to conclude that these variables are directly associated

Sistema nervoso e pavimento pelvico

Per garantire la continenza urinaria e fecale e la corretta statica pelvica sono necessari sia il continuo controllo del sistema nervoso sia la perfetta integrit\ue0 del retto, dell\u2019utero e dei suoi annessi, delle relative fasce, del pavimento pelvico e delle strutture anatomiche che formano l\u2019unit\ue0 anatomo-funzionale del tratto urinario inferiore (vescica, collo vescicale, uretra e componenti sfinteriche). La coordinazione tra la vescica, l\u2019uretra e la muscolatura del pavimento pelvico \ue8 mediata da multiple vie riflesse con centro nel cervello e nel midollo spinale. Alcuni riflessi sono preposti all\u2019accumulo di urina, mentre altri facilitano la minzione. E\u2019 possibile inoltre che i singoli riflessi possano essere collegati tra loro in maniera seriale, a creare complessi meccanismi di feedback. Il controllo della muscolatura striata nelle lesioni neurologiche del basso tratto urinario costituisce un\u2019attiva area di ricerca e sta producendo risultati relativi ai problemi della vescica sovraccarica da causa neurogena e non neurogena, se questi sono causati da lesioni del sistema nervoso centrale o dei nervi periferici (1). L\u2019organizzazione fisiologica dei nuclei di Onuf e dei motoneuroni del muscolo elevatore dell\u2019ano ed il controllo riflesso dell\u2019attivit\ue0 di tipo tonico che \ue8 essenziale per la generazione di una forza costante nelle fibre muscolari a lenta contrazione \ue8 una parte importante del normale funzionamento di questo sistema. Nell\u2019uomo la corteccia motoria \ue8 di cruciale importanza nel controllo motorio volontario anche per quanto riguarda la muscolatura del pavimento pelvico, sebbene siano implicate altre aree del cervello nelle attivit\ue0 della muscolatura del pavimento pelvico, collegate al comportamento emotivo

Diagnostica strumentale in Urologia

Il valore clinico di tutti i presidi che definiscono la cosiddetta \u201cdiagnostica strumentale\u201d nel management delle disfunzioni urinarie non \ue8 sempre univoco, mancando spesso di una sufficiente standardizzazione e di chiare evidenze scientifiche. Nella valutazione di ciascuno di tali test diagnostici occorre porre sul piatto della bilancia da un lato la sensibilit\ue0, la specificit\ue0, la riproducibilit\ue0 e l\u2019accuratezza diagnostica, dall\u2019altro l\u2019efficaci, la morbilit\ue0, il disagio per il paziente, la disponibilit\ue0 e l\u2019invasivit\ue0. La diagnostica strumentale delle disfunzioni urinarie si avvale principalmente di neurofisiologici e di diagnostica per immagini