Transurethral bladder eversion concurrent with uterovaginal prolapse.

BACKGROUND: Transurethral bladder eversion is rare. A case of transurethral bladder eversion with concurrent uterovaginal prolapse is presented. CASE: The patient was postmenopausal, had a long history of uterovaginal prolapse, and developed bladder eversion. Examination under anesthesia revealed full-thickness transurethral bladder eversion and complete uterine procidentia. Temporary reduction of the prolapse was done initially because of her unstable medical condition. After medical stabilization, definitive surgical reconstruction was completed by a vaginal approach. CONCLUSION: Full-thickness, transurethral bladder eversion can be surgically treated by a vaginal approach

Effect of tension-free vaginal tape procedure on urodynamic continence indices.

OBJECTIVE: To assess the difference in measured urethral function before and after tension-free vaginal tape procedure (TVT). METHODS: Women who underwent TVT for genuine stress incontinence with or without intrinsic sphincter deficiency completed this study. Multichannel urodynamic testing was performed preoperatively and 6 weeks postoperatively. Maximum urethral closure pressure and pressure transmission ratio were recorded. Valsalva leak point pressures were determined at 150 mL and at full bladder capacity. Resting and straining urethral angles were measured using the cotton swab technique. Subjects completed both the Incontinence Impact Questionnaire and Urodynamic Distress Inventory preoperatively and postoperatively. RESULTS: Thirty-five consecutive women were studied. Twenty-three (65.7%) had a preoperative diagnosis of intrinsic sphincter deficiency as defined by maximum urethral closure pressure less than 20 cm H(2)O and/or Valsalva leak point pressure less than 60 cm H(2)O. Subjective and objective success rates were 91% and 83%, respectively. Subjects showed an 86.8% (95% CI 71.9%, 100.0%) improvement in their Incontinence Impact Questionnaire score and a 72.9% (95% CI 62.6%, 83.1%) improvement in their Urodynamic Distress Inventory score. The mean change in maximum urethral closure pressure was -1.3 cm H(2)O (95% CI -5.9, 3.3), whereas the pressure transmission ratio increased 15.7% (95% CI 5.0%, 26.3%). The mean decrease in straining urethral angle was 16.3 degrees (95% CI -23.9 degrees, -8.7 degrees ). Cured subjects demonstrating hypermobility preoperatively continued to do so postoperatively. CONCLUSION: There was a significant increase in pressure transmission ratio, but not maximum urethral closure pressure, after TVT. These changes are similar to those reported after retropubic urethropexy and traditional sling procedures. The effectiveness of the TVT sling does not appear to depend on a clinically significant change in the straining urethral angle

Detrusor biopsy as a potential clinical tool.

Previous published work suggests that electron microscopic findings in bladder biopsies correlate with urodynamic diagnoses of bladder dysfunction in geriatric patients. Our goal was to determine the reproducibility of this previous work and to evaluate the use of detrusor biopsy as a clinical tool in the diagnosis and management in a urogynecology referral population. All patients underwent an initial evaluation, including history, physical examination and urodynamics. Urodynamic evaluation included uroflowmetry, provocative cystometry, instrumented voiding study, urethral profilometry, pressure-flow studies, and evaluation of postvoid residual urine. A cystoscopic-guided detrusor muscle biopsy was obtained from all patients. Each patient was assigned one of four urodynamic diagnoses: detrusor overactivity, obstructed voiding, both overactivity and obstruction, or neither. Each was given a subgroup of normal or ineffective contractility. All detrusor biopsies were evaluated by electron microscopy. Each biopsy was assigned one of four pathologic diagnoses: dysjunction, hypertrophy, both dysjunction and hypertrophy, or neither. Each was given a subgroup of the presence or absence of degeneration. All diagnoses were assigned in a double-blind fashion. All urodynamic and pathologic diagnoses were then compared to determine the percentage agreement. Twenty-six women participated, mean age 52.7 years, range 29-77. Overall agreement among diagnoses was 30% (95% CI 11%-50%). Comparison of each category revealed the following percentage agreements: detrusor overactivity/dysjunction, 52% (95% CI 32%-73%); obstructed voiding/hypertrophy, 78% (95% CI 61%-95%); ineffective contractility/degeneration, 65% (95% CI 45%-85%). The use of detrusor biopsy as a clinical tool was not supported in this population, as demonstrated by the low percentage agreement between urodynamic and pathologic diagnoses. The etiology of bladder dysfunction should be investigated by looking beyond organ-specific structural changes