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Journal:	BJU International
Authors:	Bae J.H., Moon D.G. and Lee J.G.	Issue:	2001; 88: 771-75

Title:

The effects of a selective noradrenaline reuptake inhibitor on the urethra: an in vitro and in vivo study

Abstract:
This elegant study assesses the effects of venlafaxine, a selective noradrenaline reuptake inhibitor, on urethral perfusion pressure (UPP) in rabbits and rats. The in vitro study took muscle strips from rabbit bladder and urethra and assessed contractile response to electrical stimulation with and without venlafaxine pre-perfusion. In the in vivo study 80 rats were studied to see the effect of intra-arterial and intra-urethral administration of venlafaxine, phenylephrine, phentolamine and fluoxetine on intravesical pressure and UPP, as measured by dual lumen urethral catheters. The authors found that pre-perfusion, with venlafaxine, significantly decreased the contractility of the rabbit detrusor muscle strips, and significantly increased the contractility of the urethral muscle strips. The in vivo experiments showed that venlafaxine, by both intra-arterial and intra-urethral routes, significantly increased rat UPP and had no effect on intravesical pressure. The authors concluded that venlafaxine effectively increased UPP both in vitro and in vivo, and that these results imply that it may be useful for treating stress urinary incontinence by this method. This study is well constructed and shows significant results. It suggests there may be a role for venlafaxine in the treatment of urinary incontinence, both in stress urinary incontinence by increasing UPP and in detrusor overactivity by decreasing detrusor contractility. However, it must be remembered that human physiology, especially lower urinary tract physiology, is different from rabbit and rat physiology. Further, although known to be safe in humans (venlafaxine is a commonly prescribed antidepressant; Trade name Efexor in UK), there are significant side-effects associated with this type of medication and these can be very unpleasant. Moreover, there may be some withdrawal effects when this type of medication is discontinued. It should also be remembered that there is no simple relationship between UPP and continence. Low UPP does not equate directly with incontinence nor does high UPP with continence. Raising UPP in continent rats does not equate to curing incontinence. However, these experiments do provide enough hope to suggest an RCT involving incontinent women, and/or women with detrusor overactivity, is called for.

Reviewer: Steve Garnett

Journal:	Neurourol Urodyn
Authors:	Arvonen, T; Fianu-Jonasson, A; Tyni-Lenne, R	Issue:	2001: 20: 591-599

Title:

Effectiveness of two conservative modes of physical therapy in women with stress urinary incontinence

Abstract:
This paper reports a randomized clinical trial comparing two techniques to improve pelvic floor function in women with stress urinary incontinence, and their efficacy in improving continence. The study compared “standard” pelvic floor muscle exercises with a new treatment mode called vaginal balls. Assessment included objective measures such as pad testing and digital pelvic floor muscle strength testing (Brink scale), and subjective measures such as self-reported perceptions. Thirty-seven women aged 25-65 years were randomized to either a pelvic floor muscle training programme or to a training programme using weighted vaginal balls; each for 4 months. The vaginal balls have been previously shown to be effective in increasing pelvic floor muscle strength, and the round shape is felt to be more comfortable than vaginal cones. The vaginal balls (Vagitrim, Ipex Medical AB, Stockholm, Sweden) are used in a graded fashion from 50g up to 100g and have a diameter of 32mm. They are colour-coded and have a nylon thread attached for retrieval. For each arm of the trial, 3 outpatient visits only were allowed. Both training modes were found to be effective in reducing urinary leakage, and in increasing pelvic floor muscle strength. However, the reduction in urinary leakage after 4 months with the vaginal balls was significantly better than in the group performing pelvic floor muscle exercises alone. This study is limited by small numbers and the lack of blinding. The physiotherapists were assessing and instructing the patients. Furthermore, the patients in the vaginal ball arm did spend more time actually squeezing their pelvic floor muscles. However, the results are encouraging and merit further investigation. Previous work has shown vaginal cones to be inferior to pelvic floor exercises in increasing pelvic floor muscle strength and reducing urinary leakage. Thus it may be that such devices are of more benefit and interest to the physiotherapists teaching the exercises than to patients performing them.

Reviewer: Steve Garnett

Journal:	Neurourol Urodyn
Authors:	Knutson Tomas, Edlund Christer, Fall Magnus, Dahlstrand Christer	Issue:	2001; 20: 237-247

Title:

BPH with Coexisting Overactive Bladder Dysfunction - An everyday Urological Dilemma

Abstract:
It is known that the incidence of lower urinary tract symptoms (LUTS) increases with age, common causes being bladder outlet obstruction (BOO) and the overactive bladder (OB). This study embarks on the challenging task of systematically quantifying and describing the coexisting phenomena of BOO and OB. After excluding neurological disorders, prostate cancer and other serious chronic illnesses, 162 consecutive patients with a mean age of 69 years were recruited. A standardised schedule including cystometry, pressure flow studies (pQS), TRUS, uroflowmetry including voided volume (VV) and Qmax, post-void residual volume (PVR) and the bladder cooling test was employed. Obstruction was classified according to the Schafer nomogram and mean linPURR factor (DAMPF) scale. The cohort was divided into 3 subgroups based on their obstruction: minor (DAMPF<43), moderate (DAMPF 43-65), and severe (DAMPF >65). Of the 162 men 89 (54.9%) had stable bladders with ‘pure’ BPO. 73 (45%) men had coexisting BOO and OB. In this group, the mean IPS score was 19.2, mean Qmax 10.8, mean prostate size was 41.6 cc, and there was a mean obstruction grade of 68.7 DAMPF. There were no significant differences between the two groups with respect to Qmax, PVR, IPS score or TRUS volume (slightly larger in the BOO+OB group) and these were therefore not predictive factors of BOO+OB. However, the patients with BOO+OB had a significantly higher obstruction grade (mean DAMPF 68.7 vs 56.6), and were also older (mean age 70.6 vs 68.1 years) and had higher PSA levels (mean 4.8 vs 3.4 µmol/mL) than men with BOO without OB. The VV was smaller in the BOO+OB group. The results showed the rate of OB increased significantly with increasing obstruction (16, 43.1, and 59.9% respectively). The distribution of OB subtypes in the BOO+OB group was phasic detrusor instability in 36% and uninhibited OB in 64%; 30% of the latter group had positive bladder cooling tests. Overall, 65% of the BOO+OB patients (29% of the total cohort) had a more severe urodynamic abnormality, which indicated a risk of postoperative urge incontinence following TURP or open surgery. This excellent paper systematically identifies positive and negative predictive factors for BOO+OB but an instrument for easy preoperative clinical identification of the 29% of patients who may encounter postoperative urge incontinence remains undetermined. The authors have lucidly discussed the various hypotheses that have been proposed to explain the aetiology of obstructive detrusor instability, and the reader is directed to the original article for this.

Reviewer: Jay Khastgir

Journal:	Journal of Urology
Authors:	Davila G, Daugherty C, Sanders S	Issue:	2001; 166:140-5.

Title:

A short-term, multicentre, randomized double-blind dose titration study of the efficacy and anticholinergic side effects of transdermal compared to immediate release oral oxybutynin treatment of patients with urge urinary incontinence

Abstract:
This paper reports the results of the work of the Transdermal Oxybutynin Study Group. Volunteers with detrusor instability responding to oral immediate release oxybutynin underwent a 2-week wash-out phase, and those with recurrent symptoms underwent a confirmatory cystometrogram and subsequent randomisation to transdermal or oral treatment. There were placebo arms to both the patch and oral groups. Outcome measures included changes in incontinence episodes on urinary diary, anticholinergic symptom questionnaire and visual analogue scale for efficiency. 74 patients completed 4 weeks of treatment, mean age 63 (oral) and 64 (transdermal). Daily incontinent episodes decreased in both groups: 7.3 to 2.4 (transdermal) and 7.4 to 2.6 (oral), with no difference on visual analogue efficiency scales. Importantly, dry mouth occurred in significantly fewer patients in the transdermal group (38%) compared to the oral group (94%, p<0.001). In this patch group 67% noted a reduction in dry mouth severity from previous oral treatment. The authors conclude that transdermal oxybutynin resulted in comparable efficacy and significantly improved side-effect profile compared to oral administration. Dry mouth is the principal side effect of anticholinergic therapy and this appears to represent a genuine development in the treatment of urinary urge incontinence, although larger scale studies replicating these results would be welcome. It would be interesting to compare transdermal oxybutynin to the modified release (once-daily) preparations of oxybutynin and tolterodine.

Reviewer: Steve Garnett

Journal:	BJU International
Authors:	Milsom I, Abrams P, Cardozo L, Roberts RG, Thuroff J and Wein AJ.	Issue:	2001; 87: 760-6

Title:

How widespread are the symptoms of an overactive bladder and how are they managed? A population-based prevalence study.

Abstract:
This important paper, funded by the Pharmacia Corporation, reports on a survey conducted by the Sifo/Gallop network across 6 European countries, investigating the prevalence of overactive bladder symptoms. In total 16,776 interviews were conducted, the vast majority by telephone. There has never previously been a large-scale attempt to assess the prevalence of the overactive bladder, as distinct from incontinence problems, and this paper therefore represents a major advance. The survey aimed to determine the prevalence of urinary frequency (defined as >8 micturitions/ 24 hours), urgency and urge incontinence in men (42%) and women (58%) aged ³ 40 in France, Germany, Italy, Spain, Sweden, and the UK. The level of treatment seeking and current/previous management received was also investigated. Random samples were obtained from current telephone number listings and screening questions designed to exclude individuals whose only complaint was UTI were employed. The overall prevalence of overactive bladder symptoms (over age 40) was 16.6%. Range: from 12% (France) to 22% (Spain). Frequency was the most commonly reported symptom (85%). Prevalence increased with increasing age, and there were only minor differences between the sexes in the overall prevalence. Extrapolation of the results indicated that the number of people over 40 years with overactive bladder symptoms in these countries would be over 22 million. Of those aged 40-74 years with symptoms, 60% had consulted a medical practitioner about their symptoms. Significantly, >65% of those with symptoms reported that their condition adversely affected their daily life. This study represents a very major undertaking and a significant advance in our understanding of the prevalence of overactive bladder symptoms. However, it must be accepted that only urodynamic studies can diagnose bladder (detrusor) overactivity, and that there may be other explanations contributing to these prevalence findings.

Reviewer: Steve Garnett

Journal:	European Urology
Authors:	Soulie M, Cuvillier X, Benaissa A, Mouly P, Larroque JM, Bernstein J, Soulie R, Tollon C, Brucher P, Vazzoler N, Seguin P, Pontonnier F, Plante P.	Issue:	2001; 39 (6): 709-715.

Title:

The Tension-Free Transvaginal Tape Procedure in the Treatment of Female Urinary Stress Incontinence: A French Prospective Multicentre Study.

Abstract:
The tension-free vaginal tape procedure (TVT) has become widely popular since its first description by Ulmsten and Petros in 1995. To date, only early results of long-term outcome have been reported. This French multi-centre trial studied 52 consecutive women with stress urinary incontinence (SUI) from 5 centres who underwent the TVT procedure over a 2.5-year period with a mean follow-up of 15.2 months, involving 9 urologists. This study represented patients with all 3 grades of SUI on the Ingelman-Sundberg scale, with urethral hypermobility in 67.3%, isolated intrinsic sphincter deficiency (ISD) in 32.6% and pelvic organ prolapse in 8 cases. 55.8% had recurrent SUI after 1-4 previous procedures. The results of the TVT in this study reported a cure rate of 83%, increasing to 88% in those with a MUCP >30 cmH20. 17% reported significantly decreased leakage. This compared well with previously reported cure rates of around 90% and an improvement rate of 6%. The investigators encountered complications of bladder perforation in 11.5% and transient urinary retention in 17%, but no sling infection or erosions. The bladder perforation did not have any clinical consequence (all were recognised operatively with a 700 cystoscope and corrected), and was not repeated by any one surgeon, which indicated a learning curve. In 7.7% a transient postoperative dysuria was reported which did not require treatment. The transient urinary retention required intermittent self-catheterisation for 2-10 days. The authors suggested avoidance of this complication by more careful patient selection with exclusion of hypocontractile bladders and avoidance of tension on the sling intraoperatively. Interestingly, they reported a 66% improvement in preoperative urge incontinence as well (8 of 12 of these patients had detrusor instability). This is a good paper, which reported on a heterogeneous group of women with SUI. It reinforces the encouraging, albeit relatively short-term results with this procedure. The editorial comment on this paper rightly emphasised the need for long-term reports of outcome following TVT, particularly the long-term consequences of Prolene-induced peri-urethral fibrosis in the context of its effects on urethral function and revision surgery.

Reviewer: Jay Khastgir

Journal:	Journal of Urology
Authors:	Yossepowitch O, Gillon G, Baniel J, Engelstein D and Livne PM.	Issue:	2001, 165:1441-5

Title:

The effect of cholinergic enhancement during filling cystometry: can edrophonium chloride be used as a provocative test for overactive bladder?

Abstract:
This paper reports a prospective study of the effect of edrophonium chloride (EC), a potent cholinesterase inhibitor, on 27 patients undergoing urodynamic evaluation for lower urinary tract symptoms. The EC was given as 10mg intravenously, and filling cystometry was performed before and after administration. The study population comprised 19 women and 8 men, aged 21-78 (mean 59). History of cardiac arrhythmia, asthma or epilepsy was excluded. The response to EC was defined as significant change in sensation and decreased bladder capacity, the induction or amplification of involuntary detrusor contractions, or significantly reduced compliance. Findings were compared between responders and non-responders. The study identified 11 responders and 16 non-responders. A response rate of 78% was found in patients with symptoms suggesting bladder overactivity, whilst no one responded in the group without symptoms suggesting bladder overactivity. The authors conclude that EC may serve as a novel drug for provocative cystometry, and by increasing cystometric sensitivity would facilitate the identification of the subset of patients with overactive bladder who are currently classified with sensory urgency. Little comment is made regarding unpleasant side-effects, other than noting a high rate of intestinal response. Obviously the low number of patients involved makes this a pilot study. However, more importantly, close inspection of the results of the "responders" group shows that 5 of the 11 did not respond with the induction or amplification of involuntary detrusor contractions - the only response that could alter the diagnosis from that of sensory urgency to detrusor overactivity. This significantly diminishes the usefulness of the test: it is of academic interest only that EC alters bladder capacity or compliance (as would be expected). On the evidence of this paper provocative cystometry with edrophonium will remain a research tool only.

Reviewer: Steve Garnett

Journal:	Journal of Urology
Authors:	Govier F, Litwiller S, Nitti V, Kreder K, Rosenblatt P	Issue:	2001, 165,1193-1198

Title:

Percutaneous afferent neuromodulation for the refractory overactive bladder: Results of a multicenter study

Abstract:
This paper reports a prospective multi-centre (5 sites) clinical trial undertaken to determine the safety and efficacy of percutaneous peripheral afferent nerve stimulation for the treatment of refractory idiopathic overactive bladder dysfunction. The study enrolled 53 patients who had failed conventional therapy (pelvic floor exercises, biofeedback, medical therapy). All completed a variety of pre-study questionnaires, 3-day voiding diary, history, examination, urodynamics and cystoscopy. These patients then underwent 12 weekly neuromodulation sessions. This was performed via bilateral 34 gauge needles placed near the Tibial nerve, 3 finger breadths above the medial malleolus. Proper needle placement was confirmed by plantar toe flexion. Stimulation was titrated from 0-10mA with fixed pulse 200 microseconds at 20Hz. 47 patients (89%) completed the 12-week study. Re-assessment was by questionnaire, voiding diary and urodynamics. A total of 71% of the patients were classified as treatment successes and were started on long-term treatment. Mean reduction in daytime and nocturnal voiding frequencies were 25% and 21% respectively. There was an average 35% reduction in urge incontinence. No significant adverse events were noted. The authors conclude that this method represents a safe, minimally invasive and effective treatment for managing refractive overactive bladder dysfunction. This study is thorough, but lacks a placebo arm and a large placebo response is acknowledged in the treatment of the overactive bladder: a placebo arm could be constructed and would add greatly to the impact of these results. The number of patients is relatively low for a multicentre trial and the goal of 50% of patients having 25% improvement in symptoms is modest. This technique is relatively novel, although good results have been seen before with percutaneous stimulation of the sacral roots and their branches. It would be interesting to know if a transcutaneous technique works as effectively.

Reviewer: Steve Garnett

Journal:	Journal of Urology
Authors:	Govier SE, Litwillier S, Nitti V, Kreder KJ Jr, Rosenblatt P.	Issue:	2001, 165:1193-1198

Title:

Percutaneous afferent neuromodulation for the refractory overactive bladder: Results of a multicenter study

Abstract:
Perhaps because there is little to offer patients failing conservative therapy for detrusor instability, other than surgical treatment, there has been interest in the percutaneous tibial nerve stimulator, SANS. Although the neurological pathways for success with this device are difficult to explain, there is some evidence from animal studies that it inhibits detrusor instability. This paper reports a prospective study on the use of SANS in 53 patients in five different centres in the USA, treated for 12 weeks. The tibial nerve was stimulated via needle insertion for 30 minutes, once a week for 12 weeks. 47 patients completed the treatment. The primary outcome measures were day and night-time voiding frequency, based on voiding diaries. Quality of life (QOL) was also assessed. There was a mean reduction in day-time voiding frequency of 25% and night-time voiding frequency of 21%. There was a 20% improvement in QOL. Some patients experienced minor discomfort, but this did not result in any patient discontinuing the treatment. The authors have demonstrated that the technique is safe, but this is obviously a time-consuming procedure, open to a placebo response. Comparison with bladder training exercises or a sham procedure would be beneficial.

Reviewer: Andrea Cannon

Journal:	British Journal of Obstetrics and Gynaecology
Authors:	Bidmead J, Cardozo L, McLellan A, Khullar V and Kelleher C.	Issue:	2001, 108: 408-413

Title:

A comparison of the objective and subjective outcomes of colposuspension for stress incontinence in women.

Abstract:
The success of incontinence surgery can be measured using objective forms of assessment. However, of equal importance are patient-orientated subjective methods of evaluation. This study sets out to assess the treatment of genuine stress incontinence by colposuspension using videocystourethrography (VCU) and a condition specific questionnaire developed locally ("Kings Health questionnaire"). It aims to evaluate the impact of colposuspension on QOL and the use of the previously validated questionnaire as a form of outcome measure. A total of 83 patients with proven genuine stress incontinence diagnosed by VCU and who had failed a course of conservative treatment were enrolled into the study and divided into those whose procedure was primary (51) and those that were secondary (32). Both outcome measures were assessed at 6 and 12 months post procedure. Objective cure was demonstrated in 92% of patients undergoing primary procedure with an 8% incidence of de-novo detrusor instability and 10% incidence of voiding difficulties. In the secondary procedure group, the objective cure rate was 81% without any de-novo instability and a 6% incidence of urinary difficulties. Overall, QOL scores improved in 95%. Of these women, 70% improved by 25% and in a further 28% by over 50%. Significantly, 2.4% of women who recorded deterioration in QOL had objectively successful stress incontinence surgery whilst 11 patients with objective recurrence of stress incontinence on repeat VSU had significantly improved QOL scores. The authors conclude that colposuspension appears to provide good objective and subjective results and that validated questionnaires are a useful form of assessment when used in conjunction with more objective measures. In addition, their data demonstrate that objective failure need not necessarily equate to subjective failure and vice-versa. They stress the importance of both in the measurement of surgical success, in particular relating to more subtle undesirable sequelae from colposuspension such as difficulty voiding and wound pain. These complications would have been largely overlooked by more objective measurements. This study reinforces the importance of using subjective patient-orientated forms of assessment in evaluating any procedure, be it experimental or established. Furthermore, questionnaires such as the one used in this study provides a simple and practical form of auditing the results of incontinence surgery on a day-to-day basis. Finally, it promotes more detailed pre-operative selection of patients who would benefit most from the procedure.

Reviewer: Akhlil Abdul-Hamid

Journal:	Journal of Urology
Authors:	Shafik A, El-Sibai O	Issue:	2001, 165: 887-9

Title:

Effect of vaginal distention on vesicourethral function with identification of the vagino-vesicourethral reflex

Abstract:
This interesting paper from Egypt describes an experiment performed with healthy volunteer women to evaluate the effect of vaginal distension (used to mimic sexual intercourse) on the function of the bladder and urethra. This involved 26 sexually active premenopausal women with no past urinary or gynaecological problems and normal physical examination and urinalysis. Urethral and vesical pressure was measured by a 2-channel microtip catheter connected to a strain gauge pressure transducer while the vagina was distended by a condom tied on to the distal part of a 6 Fr catheter and introduced into the vagina. The catheter was connected to a CO2 source and inflated incrementally to 80ml causing the condom to take on the shape of an erect penis. The investigators found that there was a significant decrease in bladder pressure with increase in urethral pressure during vaginal distension greater than 30ml. This pressure response lasted about 4 seconds and returned to normal after a latent period of about 5 seconds despite continued distension. This response was abolished by prior anaesthetisation of the bladder, urethra or vagina. The authors conclude that this constant vesicourethral pressure response is a reflex response, which they call the vagino-vesicourethral reflex. They postulate that this reflex occurs during coitus and causes momentary vesical dilatation and increased urethral pressure to prevent urinary leakage, and that disorders of this reflex may cause coital urinary incontinence in some neuropathic conditions. This study represents a brave attempt to tackle a difficult subject. However, how closely a slowly inflating stationary object placed in the vagina during a laboratory investigation resembles intercourse is open to debate, and such a short-lived pressure response would seem unlikely to be protective against urinary loss throughout coitus.

Reviewer: Steve Garnett

Journal:	Journal of Urology
Authors:	Van Kerrebroeck P, Kreder K, Jonas U, Zinner N, Wein A; Tolterodine Study Group	Issue:	2001 Mar; 57:414-21

Title:

Tolterodine once-daily: superior efficacy and tolerability in the treatment of the overactive bladder.

Abstract:
This paper reports the findings of a large double blind, multi-centre, randomised placebo controlled trial aimed at evaluating the efficacy of an extended release (ER) 4 mg once daily preparation of Tolterodine in comparison to the immediate release (IR) 2mg twice-daily formulation and placebo for the treatment of the overactive bladder. 1529 patients were recruited into the three arms of the study and were well matched for demographics and disease characteristics. Previous anti-muscarinic treatment did not exclude recruitment into the study. The primary efficacy variable was the number of incontinent episodes as judged by micturition diaries and the secondary outcome was tolerability and safety as judged by the evaluation of adverse events. 84% of patients (1342) completed the 12 week study period. When compared to baseline values, ER (-71% ) and IR (-60%) preparations significantly reduced the number of urge incontinent episodes in comparison to placebo (-33%). The ER formulation was 18% more effective than the IR formulations. The incidence of dry mouth using ER was 23% lower than IR and severe dry mouth accounted for only 1.8% of the group. The authors conclude that Tolterodine ER is an effective and safe treatment for bladder instability with superior tolerability and efficacy in comparison to the IR preparation. This is a large and well designed trial. However, it does not compare the efficacy of the new Tolterodine ER preparation with other extended release anti-muscarinic agents such as Ditropan XL, although it is encouraging to observe that similar levels of efficacy are reproduced in both ER and IR study groups to those reported by earlier trials comparing IR tolterodine and oxybutynin. This study provides evidence for the use of ER by comparison with IR, not only to promote better compliance, but also to improve efficacy and side effect profile. It would have been interesting to note the efficacy of the ER preparation in patients whose previous anti-muscarinic treatments had failed, in particular because of adverse side effects either due to tolterodine IR or other anti-muscarinic agents. Finally, it is tempting to extrapolate these data to suggest that tolterodine ER be more effective by comparison with Ditropan XL. However, it would be inappropriate to do so without more direct evidence. What is required is a large trial similar to the one above, specifically comparing different anti-muscarinic agents.

Reviewer: Akhlil Abdul-Hamid

Journal:	Journal of Urology
Authors:	Venn SN, Greenwell TJ and Mundy AR	Issue:	2000, 164: 702-707

Title:

The long-term outcome of artificial urinary sphincters

Abstract:
Artificial urinary sphincters are successfully employed in the management of stress urinary incontinence. Whilst short-term success is good, there are concerns as to failure in the longer term with respect to device failure, cuff erosion or chronic infection. This paper reviews long-term outcome of sphincter implantation in a London Urological Institution. The case notes of 100 patients were reviewed, 70 male and 30 female. In 36 patients, the original device remained in situ after a median follow up of 11 years. Of these, the device was functioning in 32. In 27 cases, the device had been replaced due to mechanical failure. In 23 cases, the sphincter was removed due to infection. In 14 cases, the sphincter was removed due to erosion. The continence rates at 10 years were 92% and 84% in males with bulbar urethral and bladder neck cuff respectively and 73% in females. The authors concluded that there was a satisfactory outcome in 84% of patients after 10 years of follow up. Male post prostatectomy incontinence seemed especially amenable to treatment with a sphincter. Female stress incontinence was not as successfully treated and the authors suggest this may be due to recurrent bladder neck operations. They suggest there should be an early recourse to sphincter implantation in women who have failed one previous continence procedure.

Reviewer: Paul Bulmer

Journal:	Urology
Authors:	Lemack GE and Zimmern PE	Issue:	2000, 56: 223-227

Title:

Sexual function after vaginal surgery for stress incontinence: results of a mailed questionnaire.

Abstract:
This paper aims to elucidate the impact of continence surgery on sexual function. The concept of altered sexual function following surgery is an important issue which should be discussed with women pre-operatively thus allowing informed consent to be given. Previous authors have suggested that there is a deterioration in sexual function as a result of altered vaginal axis, development of prolapse or dyspareunia. Others suggest an improvement in sexuality resulting from improved continence and therefore confidence during sexual intercourse. The authors publish the outcome of 93 women who underwent a “modified four-corner bladder neck suspension” or a “simple anterior vaginal wall suspension (AVWS)”. A questionnaire regarding sexuality was given to the women before and after surgery. The conclusions of the study were that around 40% of women undergoing an AVWS for stress urinary incontinence were sexually active prior to surgery and approximately the same number were sexually active 2 years later. The majority of sexually inactive women attributed this inactivity to the lack of a partner or partner related sexual dysfunction. The authors are to be congratulated in addressing this important consequence of continence surgery. It is difficult however as a clinician to draw too much of relevance from these particular results. I say this for several reasons. The first is something that the authors themselves rightly address which is the use of a non-standardised non-validated questionnaire. Questionnaire design and validation is a difficult and lengthy process though it is essential if it is to produce reproducible and meaningful data. The second point is the choice of surgical procedures used in this study. The AVWS is not described in the paper and whilst the modified four corner bladder neck suspension has been described in the literature its use is far from common. In order for the majority of us to be able to inform our patients of potential post-operative sexual dysfunction we need to study operations used more universally e.g. the Burch colposuspension.

Reviewer: Paul Bulmer

Journal:	Journal of Urology
Authors:	Amundsen CL, Guralnick ML and Webster GD	Issue:	2000, 164: 434-437

Title:

Variations in strategy for the treatment of urethral obstruction after a pubovaginal sling procedure.

Abstract:
Pubovaginal sling procedures for the treatment of stress urinary incontinence (SUI) are thought to be more obstructive than bladder neck suspension procedures such as colposuspension. The development of obstructive voiding symptoms following sling surgery may be more bothersome to patients than their initial incontinence. This paper investigates the treatment of such women. Thirty-two women who had voiding symptoms following a sling procedure were evaluated. Twenty were performing intermittent self catheterisation for significant residual urinary volumes. Six had an indwelling catheter. Thirty women had new onset or worsening of urge incontinence. In all cases surgery was attempted via the vaginal route initially and if possible the sling was identified and transected. In a large proportion of patients this led to adequate urethral mobility. In others (especially those with autologous sling material), the sling was hard to visualise or transection did not achieve adequate urethral mobility and in these cases more lateral vaginal dissection or mobilisation from a suprapubic approach was necessary. Five women also underwent a repeat fascia lata sling after the original sling had been taken down. Thirty out of 32 women voided successfully after sling take down. Urge incontinence resolved in 20 cases. All repeat slings successfully treated SUI. SUI developed in 3 women after sling take down but severity was not enough to warrant further intervention. The authors conclude that sling take down successfully treats voiding dysfunction following sling procedures for SUI. They do comment that only one third of women had obstruction confirmed on urodynamics prior to sling take down. Urethral mobilisation is achieved in a variety of ways that appears to be mainly dependent on which sling material has been used.

Reviewer: Paul Bulmer

Journal:	Journal of Urology
Authors:	Tebyani N, Patel H, Yamaguchi R and Aboseif SR	Issue:	2000, 163: 1510-1512

Title:

Percutaneous needle bladder neck suspension for the treatment of stress urinary incontinence in women: Long term results.

Abstract:
In this article, the authors evaluated long-term results of needle suspension in the treatment of stress incontinence. Forty-two women were treated and completed follow up. The needle suspension was performed using permanent monofilament sutures, which were secured superiorly using bone anchors. The procedure was performed under local anaesthetic with intravenous sedation. Average follow up was 29 months. At this time, 5% were subjectively cured, 12% had improvement and 83% had failed. In addition, 15% reported postoperative dyspareunia and 29% had urinary urgency. Of those patients with failed treatment, video urodynamics revealed that there was persistent urethral hypermobility in 88%.The authors conclude that percutaneous bladder neck suspension using bone anchors is associated with a high risk of long-term failure. The results support the concept that strong fixation superiorly to the pubic bone does not prevent failure since the cause of failure is most likely weakness of the periurethral tissue.

Reviewer: Paul Bulmer

Journal:	BJU International
Authors:	Cammu H, Van Nylen M and Amy JJ	Issue:	2000, 85: 655-658

Title:

A 10 year follow up after Kegel pelvic floor muscle exercises for genuine stress incontinence.

Abstract:
Pelvic floor re-education is an accepted therapy for the treatment of genuine stress incontinence. In the short term (< 2years) cure rates of 25% and improvement rates of 50-70% have been quoted. The purpose of this study was to subjectively assess women after completing 10 years of pelvic floor exercises. Forty-five women completed the 10 year follow up. These women had pelvic floor re-education with a physiotherapist and were assessed by a questionnaire at 5 and 10 years. When pelvic floor exercises had been successful in the short term, they remained successful in two thirds of women 10 years later. Of those women whose pelvic floor exercises had not been initially successful, after 10 years 52% had undergone surgery and only 24% (who had not undergone surgery) considered their incontinence to be acceptable. The authors conclude that if pelvic floor exercises are initially effective, there is an excellent chance that surgery can be avoided in the subsequent decade. Only 2 of the 24 patients initially successful using pelvic floor exercises underwent surgery, while more than half of the 21 patients initially dissatisfied with exercise did so.

Reviewer: Paul Bulmer

Journal:	British Journal of Obstetrics and Gynaecology
Authors:	Gorton E and Stanton S	Issue:	2000, 107: 316-319

Title:

Ambulatory urodynamics: do they help clinical management?

Abstract:
Ambulatory urodynamics are said to be more sensitive than conventional static urodynamics for the detection of detrusor instability. An alternative view of ambulatory studies is that they are able to diagnose detrusor instability in asymptomatic women. This paper considers whether this investigation improves our clinical management of women with urinary incontinence. A retrospective case note review was performed on 71 women, 80% of whom had been referred for ambulatory studies after a conventional cystogram had been reported as normal. Detrusor instability was diagnosed in 32 women of which, 20 were given anticholinergic treatment. Of 37 women who were found to have a stable bladder, 9 were treated with anticholinergics. Less than half of both groups of women treated improved with such drug treatment. No woman with detrusor instability was offered surgical treatment. The authors conclude that although the diagnosis of detrusor instability is increased, this does not necessarily lead to more effective management. They suggest a randomised controlled trial of ambulatory urodynamics versus empirical treatment of women who have had a normal static urodynamic test.

Reviewer: Paul Bulmer

Journal:	British Journal of Obstetrics and Gynaecology
Authors:	Colombo M, Vitobello D, Proietti F and Milani R	Issue:	2000, 107: 544-551

Title:

Randomised comparison of Burch colposuspension versus anterior colporrhaphy in women with stress urinary incontinence and anterior vaginal wall prolapse

Abstract:
Anterior colporrhaphy was, until relatively recently, a common treatment for female stress urinary incontinence (SUI). Poor short and long term results compared with suprapubic urethropexy have led to its use diminishing. It does however, remain a useful treatment for anterior vaginal wall prolapse. This paper addresses the problem of managing women with concurrent SUI and anterior vaginal wall prolapse. The aim was to assess outcome of both incontinence and prolapse after intervention with either Burch colposuspension or anterior colporrhaphy. Thirty-five women had a colposuspension after total abdominal hysterectomy. Thirty-three women underwent anterior colporrhaphy after a vaginal hysterectomy. Women were assessed before and after intervention by history and urodynamics (performed at 6 months). Objective cure rates of SUI were 74% for the colposuspension group and 42% for the anterior colporrhaphy group. Thirty-four percent of women in the colposuspension group had recurrence of a significant cystocele compared to 3% of the anterior colporrhaphy group. The authors thus conclude that neither colposuspension nor anterior colporrhaphy should be used to treat women with SUI and concurrent moderate to large cystocele. They speculate that for such women a combined abdomino-vaginal approach may be more appropriate.

Reviewer: Paul Bulmer

Journal:	Seminars in Urologic Oncology
Authors:	Wei JT and Montie JE	Issue:	2000, 18(1): 76-80

Title:

Comparison of patients' and physicians' rating of urinary incontinence following radical prostatectomy.

Abstract:
Reported incontinence rates following a radical prostatectomy have been quite variable. It has been demonstrated that the physician's assessment of a patient's symptom does not correlate with the patient's own assessment. To further explore the differences in the reported outcomes between physicians and patients, the assessment of urinary incontinence in a cohort of men undergoing radical prostatectomy was evaluated. A total of 145 individuals completed a brief urinary continence questionnaire post-operatively at the 1-year anniversary of their operation and also had the physicians' assessment of incontinence documented in the medical record. Patient-reported incontinence rates varied from 13% to 65% depending on the definition of incontinence applied and the greatest agreement was seen when the physicians' assessment of incontinence was compared with the patient's report of pad use and urinary bother. These comparisons resulted in only moderate to good levels of agreement, which suggests that a more reliable and accurate means to evaluate urinary incontinence following radical prostatectomy needs to be developed.

Reviewer: Matthias Winkler

Journal:	Journal of Urology
Authors:	Chaikin D, Groutz A and Blaivas J	Issue:	2000, 163: 531-534

Title:

Predicting the need for anti-incontinence surgery in continent women undergoing repair of severe urogenital prolapse

Abstract:
Most gynaecologists are aware that the surgical correction of major urogenital prolapse can often leave women with urinary stress incontinence, which was not present prior to surgery. It is thought that prolapse causes bladder outlet obstruction and this masks sphincteric incontinence. The authors suggest a way to identify which women with prolapse will be incontinent after surgical reduction so that a concurrent anti-incontinence procedure can be performed. Twenty four women with severe urogenital prolapse, but no incontinence, were seen for evaluation. Urodynamic testing was performed on all women before and after reducing the prolapse with a vaginal ring pessary. Reduction of the prolapse unmasked sphincteric incontinence in 14 women (58%) and these women had a pubovaginal sling procedure as well as an anterior colporrhaphy. The remaining 10 continent women underwent colporrhaphy only and they remained dry postoperatively. Of those who had a pubovaginal sling procedure, 2 (14%) developed stress incontinence postoperatively. It seems that reduction of genitourinary prolapse with a ring pessary is useful to identify which women may benefit from concomitant anti-incontinence procedure at the time of prolapse repair. It is not clear from this study what the ideal continence procedure is.

Reviewer: Paul Bulmer

Journal:	American Journal of Obstetrics and Gynaecology
Authors:	Sand PK, Winkler H, Blackhurst DW and Culligan PJ	Issue:	2000, 182: 30-34

Title:

A prospective randomised study comparing modified Burch retropubic urethropexy and suburethral sling for treatment of genuine stress incontinence with low-pressure urethra.

Abstract:
The authors report their outcome after standard Burch urethropexy for the treatment of genuine stress incontinence in women. They found failure rates of 54% in those women with a urethral closure pressure of <20 cm H2O compared to failure rates of 18% in those with a urethral closure pressure >20 cm H2O. It has been suggested that women with low-pressure urethras would be better treated with a sling procedure. Sling procedures are however associated with a higher incidence of post operative voiding dysfunction. Anecdotal evidence has suggested that this subgroup of women could be successfully treated by a modified Burch procedure in which the sutures were tied more tightly. This study compares this modified approach with a standard sling in the treatment of women with GSI and low urethral closure pressure. Women with GSI, urethral hypermobility and urethral closure pressure of < 20 cm H2O were randomised to receive either procedure. Sling procedures were performed using a Gore-Tex patch. At 3 months the Burch group had an objective cure rate of 90% and subjective cure of 95%. The sling group had a 100% objective and subjective cure rate. It was not possible to adequately assess voiding dysfunction due to the small numbers of subjects involved (19 Burch, 17 sling). The authors conclude that, in the short term at least, a modified Burch appears as successful as a sling in the treatment of this subgroup of women. In the long term, it will be interesting to see how each procedure deteriorates with time.

Reviewer: Paul Bulmer

Journal:	British Journal of Obstetrics and Gynaecology
Authors:	James M, Jackson S, Shepherd A and Abrams P	Issue:	1999, 106: 1255-1258

Title:

Pure stress leakage symptomatology: is it safe to discount Detrusor instability?

Abstract:
This paper seeks to discover whether it is possible to diagnose stress incontinence from detailed history taking combined with a urinary diary, rather than resorting to invasive urodynamic testing. The study was a retrospective review of urodynamic records of women attending for assessment over a 5-year period. Of 5193 women, 555 had symptoms of pure stress incontinence along with a normal urinary diary and it was these women who were studied. Of these women, 81% had urinary incontinence objectively confirmed on urodynamic evaluation. Seventy-two percent were found to have genuine stress incontinence. However, 9% of them had incontinence secondary to Detrusor instability. In addition, Detrusor instability was found in another 10% of the study population. This study raises 2 points: first, that conventional cystometry failed to demonstrate incontinence in 19% of women with symptoms of stress leakage, and second that 9% of women with symptoms of pure stress leakage were actually found to have incontinence secondary to Detrusor instability. This is obviously an important distinction to make since these women would be inappropriately treated by bladder neck surgery. The authors conclude that whilst urodynamic investigation is not necessary prior to conservative treatment of stress incontinence, it is mandatory prior to surgical procedures.

Reviewer: Paul Bulmer

Journal:	BJU International
Authors:	Brown K and Hilton P	Issue:	1999, 84: 961-965

Title:

The incidence of Detrusor instability before and after colposuspension: a study using conventional and ambulatory urodynamic monitoring

Abstract:
Longitudinal studies using conventional cystometry have shown that 4-18% of women having continence surgery will have Detrusor instability (DI) after a colposuspension that was not detected beforehand. It is not clear whether this represents development of de novo DI or whether there was a failure of diagnosis preoperatively. Ambulatory monitoring has been shown to detect a higher incidence of DI than static cystometry in various patient groups. One of the aims of this study was to see whether ambulatory monitoring (AM) might identify preoperatively which patients were more likely to have postoperative urgency and perhaps select them for alternative surgical procedures. Fifty-six patients had cystometry and AM before and after colposuspension. Symptoms were also recorded using questionnaires. The authors found that the incidence of DI on AM was significantly higher than on cystometry both before and after surgery. However, the preoperative urodynamic finding of increased DI on AM does not exclusively predict its presence postoperatively on AM or cystometry. In addition, a patient history of urgency does not correlate well with the urodynamic findings before or after surgery. AM is therefore not recommended in the routine investigation of stress incontinence.

Reviewer: Paul Bulmer

Journal:	Journal of Urology
Authors:	Das S	Issue:	1999, 162: 469-473

Title:

Dynamic suburethral suspension with pedicled external oblique aponeurosis in the management of female urinary incontinence

Abstract:
Suburethral sling procedures in the UK are often reserved for women who have failed previous continence surgery. In The United States the various sling procedures which have been described are often used in the primary treatment of stress incontinence, particularly in women with intrinsic sphincter deficiency (ISD). This study describes yet another technique that appears to offer excellent results in the population studied. The technique is well described in the text and was performed on 25 patients. Fourteen patients had failed previous continence surgery (only 8 of these had a colposuspension or Marshall Marchetti Krantz). Six patients were said to have ISD based on low abdominal leak point pressures with no apparent urethral hypermobility. The remainders were said to have urethral hypermobility based on pelvic examination, cotton swab test, lateral cystogram and cystoscopy. All 25 women were followed up for a mean of 26 months by a 10 point questionnaire. Stress incontinence was "cured" in 100%. Three patients had detrusor instability pre-op which persisted post-op. Eighteen patients had urgency symptoms pre-op and in 12 these resolved after the procedure. One patient developed de novo urgency symptoms. Twenty three patients were said to be satisfied with the outcome of surgery and would undergo it again if necessary. Postoperative complications included pulmonary embolism in 1, abdominal panniculectomy, inguinal hernia in 2 and persistent groin pain needing release of ilioinguinal nerve entrapment in 1. This sling procedure seems to offer another good option for women, in terms of successful outcome for stress incontinence. The study may be slightly flawed however because of the absence of objective data such as pad testing and postoperative urodynamics, and also because subjective data were not collected pre and postoperatively by recognised, validated symptom and quality of life questionnaires. In addition, the authors failed to qualify the term "cure". Subjects also seemed to suffer a high incidence of significant post operative complications requiring reoperation although this was an evolving new procedure.

Reviewer: Paul Bulmer

Journal:	Obstetrics and Gynecology
Authors:	Athanasiou S, Khullar V, Boos K, Salvatore S and Cardozo L	Issue:	1999, 9: 295-301

Title:

Imaging the urethral sphincter with three-dimensional ultrasound

Abstract:
The authors describe the technique of urethral sphincter imaging by three-dimensional ultrasound and compare sphincter size in women with genuine stress incontinence and continent controls. Images are obtained via a transvaginal probe inserted in the distal vagina. The images are stored and later manipulation reveals detailed morphologic assessment of the urethra at different levels. The length, thickness and volume of the urethral rhabdosphincter were measured. Forty-six women with genuine stress incontinence and 48 continent controls were studied. The incontinent group underwent videocystourethrography and their incontinence was graded as mild, moderate or severe (these definitions were not further clarified). Women with genuine stress incontinence had significantly shorter, thinner, and smaller volume striated urethral sphincters compared with continent women. There was also a good correlation between the urethral sphincter volume and the severity of incontinence assessed by videocystourethrography. This technique is an interesting addition to existing techniques of urethral measurement. It would be interesting to see whether there is a relationship between sphincter volume and maximal urethral closure pressure. It may also be a useful technique to assess which patients have a poorer outcome following a bladder neck suspension procedure for the treatment of genuine stress incontinence.

Reviewer: Paul Bulmer

Journal:	British Journal of Obstetrics and Gynaecology
Authors:	Maher C, Dwyer P, Carey M and Gilmour D	Issue:	1999, 106: 719-724

Title:

The Burch colposuspension for recurrent urinary stress incontinence following retropubic continence surgery

Abstract:
The authors retrospectively reviewed 53 women who had undergone a Burch colposuspension following a previous failed retropubic continence procedure. They described their technique of a low pfannenstiel incision along with a Cherney incision to detach the rectus abdominus muscles from their insertion on the pubis. This was performed to improve access to the fibrosed retropubic space to facilitate sharp dissection mobilising the bladder, bladder neck and urethra. The vagina was then suspended within 3-4 cm of the ipsilateral ilio-pectineal ligament by three number 1 Ethibond sutures. Patients were evaluated by assessing pre and post-operative symptom assessment and urodynamics and a patient determined satisfaction score. Subjectively, 89% of women had no or occasional (<1 episode per week) stress or urge incontinence. Objectively, 72% had no urinary leakage due to genuine stress incontinence or detrusor instability on repeat urodynamic testing. There was a trend towards a poor surgical outcome in women with poor bladder neck mobility though the trend was not significant. Sling procedures are the most commonly described surgical treatment for recurrent urinary stress incontinence. The authors of this paper have described an alternative that appears to be safe, successful and has a low incidence of post-operative storage and voiding dysfunction. The study would have been improved with better pre and post-operative data regarding symptom scores and quality of life. Such tools however, which are now widely used, were not available when this study began in 1993. It seems logical that the next step should be a prospective randomised controlled trial comparing colposuspension with a sling procedure. The question is which sling procedure?

Reviewer: Paul Bulmer

Journal:	British Journal of Obstetrics and Gynaecology
Authors:	Jackson S, Shepherd A, Brookes S and Abrams P	Issue:	1999, 106: 711-718

Title:

The effect of oestrogen supplementation on post-menopausal urinary stress incontinence: a double blind placebo controlled trial

Abstract:
This trial set out to answer the question of whether oestrogen treatment is beneficial in the treatment of post-menopausal urinary stress incontinence. Many similar trials in the past have appeared to compromise between trying to give an adequate dosage of oestrogen replacement without stimulating proliferation of the endometrium. This has led investigators to be accused of under treating women when they have found no benefit from treating with oestrogen replacement. This trial randomised women to receive 2 mg of oestradiol valerate or placebo for a total of 6 months. Sixty-seven were recruited and 62 completed. Adequate oestrogen replacement was confirmed by serum oestradiol estimation after six months of treatment. Women were assessed pre and post-treatment subjectively and objectively by the use of questionnaires, pad tests and urodynamics. Six women receiving oestrogen were "unblinded" because of breakthrough vaginal bleeding necessitating the use thereafter of cyclical progestogens. The results showed no significant difference in outcome, subjective or objective, between the two groups leading the investigators to surmise that oestrogen has no effect on post-menopausal urinary incontinence. The investigators are to be congratulated for their sound methodology in this trial which, along with others, suggest that oestrogen replacement is not a valid treatment for post menopausal urinary stress incontinence. The only potential flaw in this and other similar studies is the absence of pre-morbid data to show exactly when women became incontinent. Only with this data would investigators know for certain that they are treating women with true post-menopausal onset stress incontinence.

Reviewer: Paul Bulmer

Journal:	American Journal of Obstetrics and Gynaecology
Authors:	Stephenson KR, Cholhan HJ, Hartmann DM, Buchsbaum GM and Guzick DS	Issue:	1999, 181: 35-38

Title:

Lower urinary tract injury during the Burch procedure: Is there a role for routine cystoscopy?

Abstract:
Burch colposuspension is a procedure performed commonly by Gynaecologists and Urologists alike for the treatment of genuine stress incontinence. The procedure produces excellent success rates with an apparent low level of morbidity and mortality. Routine intraoperative inspection of the bladder has been recommended before to detect iatrogenic injury, however, few surgeons have actually adopted this in their clinical practice. The authors of this paper reviewed the records of 109 consecutive patients who had undergone an abdominal urethropexy procedure along with an intraoperative cystoscopy. The incidence of bladder and ureteric injury was measured. Six patients were found to have a transvesical suture and 1 patient had a ureteric obstruction noted on cystoscopy. Removal of the offending suture was all that was required in these patients. One patient had ureteric obstruction which was not recognized at the time of cystoscopy. Ureteric obstruction was diagnosed by the failure to see dye emerging from each ureteric orifice after an intravenous injection of indigo carmine dye. In the case of the unrecognised obstruction, dye effluent was noted to be "sluggish". In all other non-obstructed cases, dye effluent was described as "vigorous". The authors conclude that their incidence of ureteric obstruction (1.8%) and bladder injury (7.3%) is comparable with other series, which have routinely screened for iatrogenic damage. Studies reviewing postoperative complications of injury to the lower urinary tract without intraoperative screening, report an extremely low incidence of injury of about 0.3%. They therefore recommend that cystoscopy is effective in the detection of lower urinary tract injuries during urethropexy procedures. They also conclude that the efflux of dye from the ureteric orifice should be "vigorous" otherwise the passage of a ureteric stent is recommended.

Reviewer: Paul Bulmer

Journal:	British Journal of Urology
Authors:	Kane L, Chung T, Lawrie H and Iskaros J	Issue:	1999, 83: 1010-1014

Title:

The pubofascial anchor sling procedure for recurrent genuine urinary stress incontinence

Abstract:
The authors evaluate the outcome of a new modified pubovaginal sling procedure in women with recurrent genuine stress incontinence (GSI). The procedure involves harvesting a 5 cm strip of rectus sheath, placing it beneath the bladder neck and suspending it with Prolene sutures to bone anchors in the symphysis pubis. Thirteen women with urodynamically proven GSI and a stable bladder were treated and followed up for a total of 19-38 months. While all became subjectively continent, 2 out of the 12 women who had repeat urodynamics were shown to have stress incontinence and a positive pad test. None developed de novo detrusor instability. The authors are to be congratulated for their successful follow up of their entire study group over a long period of time. The procedure appears to have been extremely successful in the selected patient population. To be able to compare this with other continence procedures for recurrent GSI, it might have been useful if they had published additional urodynamic information such as was the bladder neck mobile or fixed and what were the urethral closure pressures preoperatively. Only 3 of the women had previously undergone a colposuspension (the remainder had an anterior repair or needle suspension procedure). It would be interesting to see the outcome of this new procedure following a failed colposuspension which remains the "gold standard" in the first line surgical treatment of GSI.

Reviewer: Paul Bulmer

Journal:	Urology
Authors:	Galloway NT, El-Galley RE, Sand PK, Appell RA, Russell HW and Carlan SJ	Issue:	1999, 53: 1108-1111

Title:

Extracoporeal magnetic innervation (ExMI) therapy for stress urinary incontinence

Abstract:
The authors describe this new technique for the stimulation of pelvic floor muscles. Patients sit on a special chair, fully clothed, for 20 minutes twice a week for 6 weeks. The chair delivers a rapidly changing magnetic field flux to the muscles of the pelvic floor and sphincters. This in turn induces a flow of electrical current through the tissues, especially the nerves. This causes a propagating impulse that will release neurotransmitters at the motor end plates and provoke muscle contraction. Eighty three women have been recruited so far. Fifty patients have been followed up for longer than 3 months. Objective measures included bladder diaries, dynamic pad weight testing, urodynamic studies, and quality of life survey. Of the 50 women followed up for three months, 34% were dry and used no pads, 32% were not using more than one pad per day and 34% were using more than one pad per day. The average number of pads used per day fell from 2.5 to 1.3. The frequency of leak episodes per day fell from 3.3 to 1.7. The dynamic pad weight test was reduced from 20g to 15g eight weeks after treatment. ExMI therapy appears to offer a new approach to pelvic floor stimulation for the treatment of stress incontinence. The technique is painless and neither a probe nor undressing is needed. As the authors point out, it would be desirable to compare this treatment with existing electrical treatment as well as conventional pelvic floor exercises and placebo. It will also be interesting to see whether improvement will continue with prolonged treatment and whether the improvement will be sustained.

Reviewer: Paul Bulmer

Journal:	Obstetrics and Gynecology
Authors:	Zivkovic F, Tamussino K, Pieber D and Haas J	Issue:	1999, 93: 753-755

Title:

Body mass index and outcome of incontinence surgery

Abstract:
Clinicians who perform surgical treatment for female genuine stress incontinence often have strong views as to the importance of their patient's weight. Some feel strongly that overweight patients should diet preoperatively to improve short and long term success rates. Others feel that women are unlikely to lead a more active lifestyle and lose weight if activity causes urine leakage. In addition, delaying surgery for long periods of time pending weight loss is merely prolonging their suffering. This paper compares the outcome of continence surgery in normal (BMI 20-25), overweight (BMI 26-30) and obese (BMI >30) women after 5 years. Women were selected to undergo anterior repair with or without bladder neck needle suspension, or Burch colposuspension and 291 women underwent surgery. All were invited back for follow up after 5 years and 187 (64%) attended. Objective postoperative cure was defined as no evidence of leakage during coughing at a bladder volume of 300ml. The results showed no significant difference in continence rates among the 3 BMI groups for each procedure. The authors point out however, that the power of the study was only 26%. Perhaps it is time for those clinicians with reservations about operating on overweight women to randomise them to either a waiting list pending weight loss or to surgery. Objective cure rates as well as quality of life comparisons could then be made between those who had surgery despite being overweight, those who had dieted to an ideal target weight and then had surgery and those who remained on a waiting list trying to lose weight. We may then discover whether we are being "cruel to be kind" by insisting women lose weight prior to continence surgery.

Reviewer: Paul Bulmer

Journal:	Urology
Authors:	Al-Hijji J and Batra S	Issue:	53(3): 637-641

Title:

Downregulation by estrogen of nitric oxide synthase activity in the female rabbit lower urinary tract

Abstract:
Mature female rabbits were ovariectomised and, following recovery, were either untreated (control) or given estrogen for 8 weeks. After this time, tissue from the urinary tract was harvested to measure cytosolic and particulate nitric oxide synthase (NOS). NOS activity was also measured. Estrogen caused no alteration in NOS from the upper urinary tract. In the lower urinary tract however, estrogen caused a significant reduction in cytosolic NOS of the bladder, trigone and urethra. The authors conclude that this estrogen-dependent down regulation of NOS supports the use of estrogen in post menopausal stress incontinence, since a reduction in urethral NOS would lead to increased muscular tone. They do however add that this would be disadvantageous in the bladder in urge incontinence.

Reviewer: Jon Cartledge

Journal:	British Journal of Urology
Authors:	F Jamil, M Williamson, YS Ahmed and SCW Harrison	Issue:	1999, 83(4): 396-9

Title:

Natural-fill urodynamics in chronically catheterised patients with spinal cord injury.

Abstract:
The authors determine whether an indwelling catheter on free drainage provides a constantly low intravesical pressure in spinally injured patients with a neuropathic bladder. Thirty patients who had complete spinal cord injury managed with an indwelling catheter (with or without addition of anticholinergic agents) were assessed using natural-fill cystometry. Any anticholinergic medication was stopped 24 hours prior to the assessment. Upper tracts were evaluated for scarring with ultrasound. Detrusor contractions causing intravesical pressure rises of more than 40cm H20 were seen in 11 patients. Renal scarring was seen in 6 out of 9 patients with detrusor contractions greater than 40cm H20, while only 2 out of 21 patients with normal kidneys had such pressure rises. The authors conclude that an indwelling urinary catheter does not guarantee a low residual urine and low intravesical pressure, and they postulate the possible role of these findings in renal scarring.

Reviewer: Andrew Elves

Journal:	Obstetrics and Gynecology
Authors:	Sander P, Thyssen H, Lose G and Thorup Andersen J	Issue:	1999, 93: 407-411

Title:

Effect of a vaginal device on quality of life with urinary stress incontinence

Abstract:
The investigators aimed to assess the effect of a vaginal device (Continence Guard) on urine leakage and quality of life (QOL). Fifty-five women entered the trial and 41 (74.5%) completed the three month study. They were assessed by 24-hour pad tests, incontinence impact questionnaires, and the Short Form 36 general health questionnaire before and after three months of treatment. The fourteen women who withdrew did so because of local discomfort or problems retaining the device. The mean urinary pad test leakage with the device in place decreased significantly from 77.5 g to 23.5 g per 24 hours. The QOL score measured by the incontinence impact questionnaire improved significantly after three month's use of the device. The Short Form 36 revealed no significant change from baseline. At least 2 points can be raised by this study: (i) the Continence Guard vaginal device significantly reduces urinary leakage as measured by 24 hour pad test, and (ii) incontinence related QOL questionnaires are necessary to measure improvement in patient well-being following intervention for urinary incontinence. General health questionnaires like the Short Form 36 score seem not to be sensitive enough in detecting clinical improvement in urinary symptoms and patient well-being.

Reviewer: Paul Bulmer

Journal:	Journal of Urology
Authors:	Hautmann RE, de Petriconi R, Gottfried HW, Kleinschmidt K, Mattes R and Paiss T	Issue:	1999, 161: 422-428

Title:

Ileal neobladder: complications and functional results in 363 patients after 11 years of follow-up

Abstract:
Hautmann et al. present the complications and functional results of ileal neobladder in 363 patients. Perioperative death occurred in 11 patients (3%), while early neobladder related complications occurred in 56 patients (15.4%) and late complications in 85 patients (23.4%) with an early and late re-operation rate of 0.3 and 4.4% respectively. The re-operation rate for neobladder unrelated early and late complications was 12.1% and 12.4% respectively. A total of 3.9% of patients required intermittent self-catheterisation, while unacceptable day and night time incontinence (defined as more than one pad required per day or night) was 4.1% and 5% respectively.

Reviewer: Andrew Elves

Journal:	Journal of Urology
Authors:	Romanzi LJ, Chaikin DC and Blaivas JG	Issue:	1999, 161: 581-586

Title:

Effect of genital prolapse on voiding

Abstract:
Romanzi et al. performed video urodynamic studies on 60 women with genital prolapse (grade 1-4) and repeated leak point pressure, and uroflowmetry in those with severe prolapse after insertion of a ring pessary. Bladder outlet obstruction was demonstrated in 4% of those patients with grade 1-2 cystocele and 58% of those with grade 3-4 cystocele. Insertion of a ring pessary resulted in 94% of those women with grade 3-4 cystocele reverting to normal uroflowmetry. Detrusor instability and urethral hypermobility both correlated with degree of prolapse, though no correlation was observed with detrusor contractility or intrinsic sphincter deficiency.

Reviewer: Andrew Elves

Journal:	British Journal of Urology
Authors:	Kuczyk MA, Klein S, Grunewald V, Machtens S, Denil J, Hofner K, Wagner T and Jonas U.	Issue:	1998, 82: 174-180

Title:

A questionnaire-based outcome analysis of the Stamey bladder neck suspension procedure for the treatment of urinary stress incontinence: the Hannover experience.

Abstract:
The needle bladder neck suspension continues to receive a "bad press". However it must be remembered that many patients are not ideal candidates for alternative pelvic surgery. This review paper concludes that there may still be a role for the Stamey procedure in those women looking for a minimally invasive procedure as long as they are aware of overall long term success rates.

Reviewer: Jonathan Glass

Journal:	Journal of Urology
Authors:	Conrad S, Pieper A, de la Maza SF, Busch R and Huland H.	Issue:	1997, 157: 1672-1677.

Title:

Long-term results of the Stamey bladder neck suspension procedure: a patient questionnaire based outcome analysis.

Abstract:
Reported success rates following Stamey bladder neck suspension vary between 39% and 91%. Varied follow-up and patient selection explain this disparity in part. This study evaluated success and complication rates by patient questionnaire after Stamey needle suspension of the bladder neck. Of 130 patients with incontinence due to hypermobility or intrinsic sphincter deficiency 50% of patients were completely continent, 11.5% never became continent and 38.5% had recurrent incontinence 6-10 months post-operatively after initially regaining continence. Mean follow-up was 66 months. No statistically significant pre-operative risk factors associated with a poor outcome were identified. The number of previous deliveries, prior continence procedures, duration of history of incontinence, number of pads used and Stamey grade of incontinence were more common in patients with primary or secondary failure though none reached statistical significance.

Reviewer: Mark Feneley

Journal:	European Urology
Authors:	Barbalias G, Liatsikos E and Barbalias D.	Issue:	1997, 31: 394-400.

Title:

Use of slings made of indigenous and allogenic material (goretex) in type III urinary incontinence and comparison between them.

Abstract:
This randomised prospective study shows that goretex slings (n=16) used in vesicourethral suspension procedures to treat type III incontinence have better long term results than fascial slings obtained from the rectus abdominis fascia (n=32). However, there were more urethral erosions and more patients suffered with bladder storage symptoms when goretex grafts were used.

Reviewer: Mark Feneley

Journal:	British Journal of Urology
Authors:	Hosker GL, Kilcoyne PM, Lord JC and Smith ARB.	Issue:	1997, 79: 159-162.

Title:

Urodynamic services, personnel and training in the United Kingdom.

Abstract:
One hundred and sixty-three of 281 centres which were sent this postal questionnaire replied and were available for this study. Of these 42% were attached to urology, 23% to gynaecology and 16% to urogynaecology. Thirty-four percent of investigations were performed by a doctor, 30% by a doctor with nurse, 15% by a nurse alone and 20% by others including radiologists and technicians. The finding which most concerned the authors was that 50% of respondents felt that urodynamic training was inadequate. The paper concludes that consideration should be given to requiring a minimum standard of training for personnel performing urodynamics.

Reviewer: Mark Feneley

Journal:	Journal of Urology
Authors:	Herschorn S, Steele DJ, and Radomski SB.	Issue:	1996, 156: 1305-9.

Title:

Followup of intraurethral collagen for female stress urinary incontinence.

Abstract:
This study examined patient selection parameters and durability of response to intraurethral glutaraldehyde cross-linked collagen injections in 187 women for female stress incontinence. Previous incontinence surgery had been performed in 63% of the patients. All patients had been incontinent for longer than 2 years before treatment. Treatment outcome was determined by a change in the individual incontinence grades before and after injection according to the methods of Stamey and Blavias. Twenty three percent were cured and 52% were improved while injection failed in 25%. No difference in outcome was observed with regard to patient age, pretreatment grade of incontinence or hypermobility. The probability of patients cured by intraurethral injection remaining dry at three years was 46%.

Reviewer: Mark Feneley

Journal:	Journal of Urology
Authors:	Eastham J A, Kattan M W, Rogers E, Goad J R, et al.	Issue:	1996, 156: 1707-1713.

Title:

Risk factors for urinary incontinence after radical prostatectomy

Abstract:
While it is reassuring to know from the preceding paper that urinary continence can be improved following radical prostatectomy, this paper attempts to identify the risk factors associated with the development of incontinence allowing preventive measures to be taken during surgery. Factors identified include patient age, weight, degree of obstructive voiding symptoms, prior TURP, resection of the neurovascular bundles, post-anastomotic stricture and method of vesico-urethral anastomosis. However only age, technique of anastomosis, preservation of neurovascular bundles, and absence of anastomotic stricture were independent risk factors. The surgical modified technique advocated by the authors is described.

Reviewer: Mark Feneley

Journal:	Journal of Urology
Authors:	Klutke C G, Nadler R B, Tiemann D and Andriole G L.	Issue:	1996, 156: 1703-1706.

Title:

Early results with antegrade collagen injection for post-radical prostatectomy stress urinary incontinence

Abstract:
The incidence of urinary incontinence following radical prostatectomy is 5-40%. Previous experience with retrograde injection of collagen in this group of patients has been disappointing. This paper reports the results of antegrade injection of collagen via a suprapubic approach after retrograde filling of the bladder with a flexible cystoscope in 20 men with post-radical prostatectomy stress incontinence. Degree of incontinence was assessed by patients on a subjective scale. The technique is described in detail. At a mean follow-up of 8.5 months, 9 out of 20 patients (45%) had significant subjective improvement and 5 (25%) were totally dry.

Reviewer: Mark Feneley

Journal:	British Journal of Urology
Authors:	Black NA & Downs SH.	Issue:	1996, 78: 497-510.

Title:

The effectiveness of surgery for stress incontinence in women: a systematic review.

Abstract:
This is a review of 76 studies involving comparisons between colposuspension, anterior colporrhaphy, needle suspension and sling procedures for stress incontinence. The authors were critical of the methodologies of the 31 prospective studies, of which only 11 were randomised. In particular, data on complications were lacking, so the safety of the procedures was unclear. They considered that colposuspension was more effective and long-lasting than the other procedures, with cure reported in 75-85%, compared to 43-67% for needle suspensions and 37-70% for anterior colporrhaphy.

Reviewer: Mark Feneley

Journal:	Lancet
Authors:	Ruud JL and Groen J.	Issue:	1996, 348: 717-719.

Title:

Treatment of refractory urge urinary incontinence with sacral spinal nerve stimulation in multiple sclerosis patients.

Abstract:
Incontinence in multiple sclerosis (MS) patients may be caused by detrusor hyperreflexia, due to spinal pathology interrupting the spinobulbospinal pathways of the micturition reflex. Patients who do not respond to anticholinergics are difficult to manage. This Dutch group found that by electrically activating somatic afferents of the S3 spinal nerve of six MS patients, the mean number of leakage episodes reduced from 4 to 0.3 per 24 hours. The neuroprosthesis is implanted under local anaesthesia and follow-up was 2 years.

Reviewer: Mark Feneley