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THE JOURNAL OF FEMALE
URINARY INCONTINENCE

Commented Abstracts

 
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  • "Long-Term results of colpocystourethropexy for persistent or recurrent stress urinary incontinence".

  • NITAHARA, K.S.; ABOSEIF, S.; TANAGHO, E.A.
    Department of Urology, University of California Scholl of Medicine and Mount Zion Medical Center, San Francisco, California. J.Urol, v.62, p.138-141, 1999.
ABSTRACT

Purpose: We review the long-term outcome of colpocystourethropexy for persistent or recurrent stress urinary incontinence after suspension procedure failure.

Materials and Methods: Medical records and preoperative were reviewed of 60 patients (mean age 60.8 years) who had undergone colpocystourethropexy after at least 1 suspension procedure (range 1 to 8, mean 2.7). Patient responses to a standardized questionnaire regarding overall health, degree of satisfaction with colpocystourethropexy, presence or absence of leakage, and pattern and degree of leakage were elicited by telephone or mail and compared with preoperative status. Results were graded according to the degree of satisfaction and number of pads used daily. Patients with persistent incontinence were reevaluated with video urodynamic studies.

Results: Mean interval since colpocystourethropexy was 6.9 years. Successful results (greater than 80% satisfaction and the use of 1 or no pad daily) were reported by 41 patients (69%), who were signicantly younger at the time of surgery than those with unsatisfactory results. In the latter group significant urge incontinence was present in 61% before the repair and in 63% postoperatively, suggesting na additional nonanatomical cause, which was confirmed by postoperative video urodynamic studies.

Conclusions: When colpocystourethropexy was used for persistent urinary incontinence after previous surgical repair two-thirds of the patients had excellent long-term results. In patients with less satisfactory results a nonanatomical cause of urinary incontinence was a major factor.

EDITORIAL COMMENT

The authors discuss the surgical results of 60 patients that were submitted to colpocystourethropexy by the technique described by Tanagho1 and which consists in a Burch2 Technique modification 2. In this technique the author uses two pairs of Dixon stitches No 1 which are given in the whole width of the anterior vaginal wall and the Cooper ligament. The most distal point is found in the medium urethra region and the most proximal point at the level of the bladder neck. In the original description the author emphasizes the need that the suture is situated very laterally to the urethrovesicle structures to avoid the compression of the urethra against the Symphysis pubis.
We must emphasize that these were patients that had already been submitted to earlier attempts of surgery for stress Urinary Incontinence (SUI), so constituting an unfavorable group as to the expectation of incontinent cure.
Of the 60 patients, 41 (69%) considered themselves satisfied with the result of the surgery. Meanwhile, among those 41 patients the authors also included patients that needed to use at least one pad a day (there is no reference to the number of cases) which means that some still presented a certain degree of Urinary Incontinence.
This is an important aspect in the evaluation of the results of the treatment of SUI, this means, a clear definition of the cure criteria. If we consider the absence of Urinary loss a cure criteria, we would have to alter the 69% percentage of good results admitted by the authors to less favorable values.
Another important aspect to be considered is surgical treatment of SUI relapse is the technique choice to be indicated in each case. In a last analysis we try to establish a propaedeutic protocol, the most complete possible, to try to identify with precision which is the residual anatomic defect which must be corrected. The non attendance of this condition will certainly enlarge the percentile of failures in the post-surgery.
The authors report the most frequent cases that lead to corrective surgery failures of SUI 1. In some cases the urethrovesicle follow up is poorly or inappropriately, supported allowing that the initial anatomical defect persist; 2) in other cases the urethrovesicle follow up is initially well supported but yields again and becomes excessively changeable; 3) Fibrosis and abnormal fixation of the urethra with persistence or a new appearance of detrusor instability and lesion of the intrinsic musculature of the sphincter.
In the cases where there is an abnormal fixation of the urethra with a sphincterian musculature lesion leading to the opening of the bladder neck the only adequate correction, in the opinion of the authors, is the creation of a compression by a sling and an auto intermittent catheterization. Meanwhile if the sphincterian musculature is working badly due to fibrosis and the abnormal fixation of the urethra it would be a possible solution to remove the fibrosis and the adequate mobilization of the urethra with a correct repositioning of the urethrovesicle connection. In these cases the retropubic approach would have na advantage over the transvaginal, allowing an ample dissection of the anterior vagina wall and exposing an inferior portion of the bladder and urethrovesicle connection, making possible and adequate setting of the sutures to obtain correct positioning of these structures. Another frequent problem in the postoperative of these patients is the persistence or new appearance of urgency or Incontinence urination urgency.
The authors refer 16% of these cases mainly in patients that had already presented these post operative symptoms. In literature the amount varies between 6 and 27%. Those cases demand a careful urodynamic evaluation in the pre operative, even though the physiopathology of those symptoms have not been perfectly made clear. They may be caused by anatomical enervation, disturbance of the bladder or by obstructive processes of the urethra resulting from surgical techniques that were used.
A more profound consideration about this article permits the verification that the frequency of failures in SUI surgeries reveals numbers that are not low, putting into evidence the complexity of this pathology and the difficulty in identifying the main causes of Urinary incontinence in women. This reinforces the conviction that there is a need to establish a rigorous propaedeutic protocol, using new technologies to try to identify, in each case, which is the anatomical defect that must be corrected and from this evidence indicate the most adequate surgical technique to treat the respective case.

José Carlos Souza Trindade


1. Tanagho, E.A.: Colpocystouretropexy; the way we do it. J Urol, 116:751-53, 1976.
2. Burch, J.: Urethrovaginal fixation to Cooper’s ligament for correction of stress incontinence and prolapse. AM. J. Obstet Gynecol 81:281-290, 1961.

 
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