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Michael E Albo,
Heather J Litman,
Holly E Richter,
Gary E Lemack,
Larry T Sirls,
Toby C Chai,
Peggy Norton,
Stephen R Kraus, Halina Zyczynski,
Kimberly Kenton,
E Ann Gormley,
John W Kusek
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ABSTRACT: PURPOSE: Longer term comparative efficacy information regarding transobturator and retropubic mid urethral slings is needed. We report 24-month continence rates, complications and symptom outcomes from a randomized equivalence trial. MATERIALS AND METHODS: Primary outcomes were objective (negative stress test, negative pad test and no re-treatment for stress urinary incontinence) and subjective (no self-report of stress urinary incontinence symptoms, no leakage episodes on 3-day bladder diary and no re-treatment for stress urinary incontinence) success at 24 months. The predetermined equivalence margin was ±12%. RESULTS: Of 597 randomized participants 516 (86.4%) were assessed. Objective success rates for retropubic and transobturator mid urethral slings were 77.3% and 72.3%, respectively (95% CI for difference of 5.1% was -2.0, 12.1), and subjective success rates were 55.7% and 48.3%, respectively (CI for difference of 7.4% was -0.7, 15.5). Neither objective nor subjective success rates met the prespecified criteria for equivalence. Patient satisfaction (retropubic 86.3% vs transobturator 88.1%, p = 0.58), frequency of de novo urgency incontinence (retropubic 0% vs transobturator 0.3%, p = 0.99) and occurrence of mesh exposure (retropubic 4.4% vs transobturator 2.7%, p = 0.26) were not significantly different. The retropubic mid urethral sling group had higher rates of voiding dysfunction requiring surgery (3.0% vs 0%, p = 0.002) and urinary tract infections (17.1% vs 10.7%, p = 0.025), whereas the transobturator group had more neurological symptoms (9.7% vs 5.4%, p = 0.045). CONCLUSIONS: Objective success rates met the criteria for equivalence at 12 months but no longer met these criteria at 24 months. Subjective success rates remained inconclusive for equivalence. Patient satisfaction remained high and symptom severity remained markedly improved. Continued surveillance is important in women undergoing mid urethral sling surgery.
The Journal of urology 10/2012; · 4.02 Impact Factor
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Joseph Schaffer,
Charles W Nager,
Fang Xiang,
Diane Borello-France,
Catherine S Bradley,
Jennifer M Wu,
Elizabeth Mueller,
Peggy Norton,
Marie Fidela R Paraiso, Halina Zyczynski,
Holly E Richter
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ABSTRACT: To identify factors that may predict success and satisfaction in women undergoing nonsurgical therapy for stress urinary incontinence.
Baseline demographic and clinical characteristics of women participating in a multicenter randomized trial of pessary, behavioral, or combined therapy for stress urinary incontinence were evaluated for potential predictors of success and satisfaction. Success and satisfaction outcomes were assessed at 3 months and included the Patient Global Impression of Improvement, stress incontinence subscale of the Pelvic Floor Distress Inventory, and Patient Satisfaction Questionnaire. Logistic regression was performed to identify predictors, adjusting for treatment and other important clinical covariates. Adjusted odds ratios (ORs), 95% confidence intervals (CIs), and associated P values are presented.
Four hundred forty-six women were randomized. College education or more and no previous urinary incontinence surgery predicted success based on the stress subscale of the Pelvic Floor Distress Inventory (adjusted OR 1.61, 95% CI 1.01-2.55, P=.04 and adjusted OR 3.15, 95% CI 1.04- 9.53, P=.04, respectively). Menopausal status predicted success using the Patient Global Impression of Improvement (adjusted OR 2.52 postmenopausal compared with premenopausal, 95% CI 1.29-4.95; adjusted OR 1.32 unsure menopausal status compared with premenopausal, 95% CI 0.65-2.66; P=.03 across all three groups). Fewer than 14 incontinence episodes per week predicted satisfaction with the Patient Satisfaction Questionnaire (adjusted OR 1.97, 95% CI 1.21-3.19; P=.01). These predictors did not differ across the three treatment groups.
Menopause, higher education, no previous urinary incontinence surgery, and lower incontinence frequency were found to be predictors of success and satisfaction with nonsurgical therapy for stress urinary incontinence. This information may help better-align provider and patient expectations with nonsurgical treatment outcomes.
Obstetrics and Gynecology 07/2012; 120(1):91-7. · 4.73 Impact Factor
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ABSTRACT: To determine whether concomitant surgeries affected outcomes in a randomized trial comparing retropubic midurethral sling (MUS) vs transobturator MUS.
Subjects (n = 597) were stratified into 4 groups based on type of concomitant surgeries: group I had anterior/apical with or without posterior repairs (n = 79, 13%); group II had posterior repairs or perineorrhaphy only (n = 38, 6%); group III had nonprolapse procedures (n = 34, 6%); and group IV had no concomitant surgeries (n = 446, 75%). Complication rates, voiding dysfunction, objective and subjective surgical failure rates, and changes in urodynamic values (postop minus preop) were assessed and compared in these 4 groups.
There were no differences in complications, voiding dysfunction, and subjective failure outcomes between these 4 groups. Group I had lower odds ratio of objective surgical failure compared with group IV (OR 0.38, 95% CI 0.18-0.81, P = .05). The OR of failure of all patients undergoing concomitant surgeries (groups I-III) was lower than group IV (OR 0.57, 95% CI 0.35-0.95, P = .03). The change in Pdet@Qmax (from pressure-flow) was significantly higher in group III vs IV (P = .01). The change in Q(max.) (from uroflowmetry) was significantly less in groups I and II vs group IV (P = .046 and .04, respectively).
Concomitant surgeries did not increase complications. Subjects who underwent certain concomitant surgeries had lower failure rates than those undergoing slings only. These data support safety and efficacy of performing concomitant surgery at the time of MUS.
Urology 04/2012; 79(6):1256-61. · 2.43 Impact Factor
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ABSTRACT: The objective of this study was to determine if differences exist in pelvic symptom distress and impact on women randomized to pessary versus behavioral therapy for treatment of stress urinary incontinence (SUI).
Change in symptom and condition-specific health-related quality-of-life (HRQOL) measures were compared between pessary and behavioral groups 3 months after randomization in the Ambulatory Treatments for Leakage Associated With Stress Incontinence trial. Four hundred forty-six women with symptoms of SUI were randomized to continence pessary, behavioral therapy (pelvic floor muscle training and continence strategies) or combination therapy. Validated measures utilized included urinary, prolapse, and colorectal scales of the Pelvic Floor Distress Inventory; urinary, prolapse, and colorectal scales of the Pelvic Floor Impact Questionnaire; and Stress and Urge scales of the Questionnaire for Urinary Incontinence Diagnosis. Student t test and analysis of variance were used to compare scores within and between groups.
Mean age of participants was 49.8 (SD, 11.9) years; 84% were white, and 10% were African American. One hundred forty-nine were randomized to pessary, and 146 to behavioral therapy. Baseline symptoms and HRQOL scores were significantly reduced within treatment arms at 3 months after randomization, but there was no statistically significant difference between groups.
There was no difference in pelvic floor symptom bother and HRQOL between the pessary and behavioral therapy arms in women undergoing conservative treatment for SUI. Individualized preference issues should be considered in the approach to the nonsurgical treatment of SUI.
Journal of Pelvic Medicine and Surgery 03/2012; 18(2):118-21.
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Charles W Nager,
Larry Sirls,
Heather J Litman,
Holly Richter,
Ingrid Nygaard,
Toby Chai,
Stephen Kraus, Halina Zyczynski,
Kim Kenton,
Liyuan Huang,
John Kusek,
Gary Lemack
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ABSTRACT: We determined whether baseline urodynamic study variables predict failure after mid urethral sling surgery.
Preoperative urodynamic study variables and postoperative continence status were analyzed in women participating in a randomized trial comparing retropubic to transobturator mid urethral sling. Objective failure was defined by positive standardized stress test, 15 ml or greater on 24-hour pad test, or re-treatment for stress urinary incontinence. Subjective failure criteria were self-reported stress symptoms, leakage on 3-day diary or re-treatment for stress urinary incontinence. Logistic regression was used to assess associations between covariates and failure controlling for treatment group and clinical variables. Receiver operator curves were constructed for relationships between objective failure and measures of urethral function.
Objective continence outcomes were available at 12 months for 565 of 597 (95%) women. Treatment failed in 260 women (245 by subjective criteria, 124 by objective criteria). No urodynamic variable was significantly associated with subjective failure on multivariate analysis. Valsalva leak point pressure, maximum urethral closure pressure and urodynamic stress incontinence were the only urodynamic variables consistently associated with objective failure on multivariate analysis. No specific cut point was determined for predicting failure for Valsalva leak point pressure or maximum urethral closure pressure by ROC. The lowest quartile (Valsalva leak point pressure less than 86 cm H2O, maximum urethral closure pressure less than 45 cm H2O) conferred an almost 2-fold increased odds of objective failure regardless of sling route (OR 2.23, 1.20-4.14 for Valsalva leak point pressure and OR 1.88, 1.04-3.41 for maximum urethral closure pressure).
Women with a Valsalva leak point pressure or maximum urethral closure pressure in the lowest quartile are nearly 2-fold more likely to experience stress urinary incontinence 1 year after transobturator or retropubic mid urethral sling.
The Journal of urology 06/2011; 186(2):597-603. · 4.02 Impact Factor
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ABSTRACT: The objective of this study was to describe lower urinary tract symptoms (LUTS) and urinary incontinence (UI) symptoms in women with prolapse.
LUTS were measured with the urinary distress inventory (UDI) and UI symptoms with UDI and the Medical, Epidemiological and Social Aspects of Aging (MESA) in women with POPQ stage >or=I support. UI symptoms were classified as stress- or urge-only, stress-predominant or urge-predominant mixed, or mixed. Bladder function was assessed by urodynamics. Bi- and multivariable analyses were performed.
Three hundred thirty-six women aged 62 +/- 13 years were characterized by UDI scores as having mixed 72% (n = 242), urge-only 24% (n = 80), and stress-only <1% (n = 1) UI symptoms. Of subjects with mixed UI symptoms, 57% (n = 137) were stress-predominant and 43% (n = 105) were urge-predominant. In multivariable regression models, advancing age and prolapse were associated with less reported distress related to stress UI symptoms. Prior hysterectomy was associated with higher total UDI scores. Similar findings were noted with MESA.
Mixed UI symptoms are the predominant symptom type in women with POP.
International Urogynecology Journal 06/2010; 21(6):665-72. · 1.83 Impact Factor
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ABSTRACT: This study seeks to determine the impact of prolapse surgery on body image in women with pelvic organ prolapse.
Case-control study of 76 sexually active women with greater than or equal to stage II prolapse planning reconstructive surgery and 67 women with lesser than or equal to stage I prolapse. Questionnaires/examinations were completed at baseline and 6 months postoperatively for cases and at baseline for controls: Body Exposure During Sexual Activity Questionnaire (BESAQ), Body Image Quality of Life Inventory (BIQLI), Pelvic Floor Distress Inventory (PFDI)/Pelvic Floor Impact Questionnaire (PFIQ), and Pelvic Organ Prolapse-Incontinence Sexual Function Questionnaire-12 (PISQ-12), and the Pelvic Organ Prolapse Quantification (POPQ) examination.
Baseline and 6-month data were available for 64 case women with mean age of 60 +/- 8 years, mean body mass index of 28 +/- 5 kg/m(2), 96% Caucasian, and 83% postmenopausal. Baseline POPQ stage distribution was: stage II 14%, stage III 78%, and stage IV 8%. BESAQ, BIQLI, PFDI/PFIQ, and PISQ-12 postoperative scores significantly improved compared to preoperatively (all p <or= 0.001).
Body image, sexual function, and pelvic floor symptoms improve after prolapse surgery.
International Urogynecology Journal 05/2010; 21(8):919-25. · 1.83 Impact Factor
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Holly E Richter, Kathryn L Burgio,
Linda Brubaker,
Ingrid E Nygaard,
Wen Ye,
Alison Weidner,
Catherine S Bradley,
Victoria L Handa,
Diane Borello-France,
Patricia S Goode, Halina Zyczynski,
Emily S Lukacz,
Joseph Schaffer,
Matthew Barber,
Susan Meikle,
Cathie Spino
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ABSTRACT: To compare the effectiveness of a continence pessary to evidence-based behavioral therapy for stress incontinence and to assess whether combined pessary and behavioral therapy is superior to single-modality therapy.
This was a multisite, randomized clinical trial (Ambulatory Treatments for Leakage Associated with Stress Incontinence [ATLAS]) that randomly assigned 446 women with stress incontinence to pessary, behavioral therapy, or combined treatment. Primary outcome measures, at 3 months, were Patient Global Impression of Improvement and the stress incontinence subscale of the Pelvic Floor Distress Inventory. A priori, to be considered clinically superior, combination therapy had to be better than both single-modality therapies. Outcome measures were repeated at 6 and 12 months. Primary analyses used an intention-to-treat approach.
At 3 months, scores from 40% of the pessary group and 49% of the behavioral group were "much better" or "very much better" on the Patient Global Impression of Improvement (P=.10). Compared with the pessary group, more women in the behavioral group reported having no bothersome incontinence symptoms (49% compared with 33%, P=.006) and treatment satisfaction (75% compared with 63%, P=.02). Combination therapy was significantly better than pessary as shown on the Patient Global Impression of Improvement (53%, P=.02) and Pelvic Floor Distress Inventory (44%, P=.05) but not better than behavioral therapy; it was therefore not superior to single-modality therapy. Group differences were not sustained to 12 months on any measure, and patient satisfaction remained above 50% for all treatment groups.
Behavioral therapy resulted in greater patient satisfaction and fewer bothersome incontinence symptoms than pessary at 3 months, but differences did not persist to 12 months. Combination therapy was not superior to single-modality therapy.
ClinicalTrials.gov, www.clinicaltrials.gov, NCT00270998.
Obstetrics and Gynecology 03/2010; 115(3):609-17. · 4.73 Impact Factor
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ABSTRACT: We sought to describe change in sexual function 2 years after surgery to treat stress urinary incontinence.
This analysis included 655 women randomized to Burch colposuspension or sling surgery. Sexual activity was assessed by the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) among those sexually active at baseline and 2 years after surgery.
Mean PISQ-12 total score improved from baseline 32.23 +/- 6.85 to 36.85 +/- 5.89. After surgery, fewer subjects reported incontinence (9% vs 53%; P < .0001), restriction of sexual activity as a result of fear of incontinence (10% vs 52%; P < .0001), avoidance of intercourse because of vaginal bulging (3% vs 24%; P < .0001), or negative emotional reactions during sex (9% vs 35%; P < .0001). Women with successful surgery had greater improvement PISQ-12 scores (5.77 vs 3.79; P < .006). Sexually active women were younger, thinner, and had lower Medical, Epidemiological, and Social Aspects of Aging scores (total and urge subscale) than sexually inactive women.
Sexual function improves after successful surgery and does not differ between Burch and sling.
American journal of obstetrics and gynecology 04/2009; 200(5):562.e1-7. · 3.28 Impact Factor
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International Urogynecology Journal 03/2009; 20(2):269. · 1.83 Impact Factor
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ABSTRACT: To estimate whether perioperative and postoperative outcomes after Burch colposuspension or pubovaginal sling for stress urinary incontinence (SUI) differed with age.
This study was a prospective secondary analysis of the Stress Incontinence Surgical Treatment Efficacy Trial. Baseline characteristics, adverse events, and 2-year outcomes of women at least 65 years old were compared with those younger than 65 years using chi(2) and t tests. Multivariable analyses were performed, including age and outcomes that differed between age groups on univariable analysis, adjusting for variables that differed by age group at baseline and by surgical treatment group.
Six-hundred fifty-five women were included in analyses of perioperative events and 520 for 2-year outcomes. Mean age (+/-standard deviation) was 69.7 (+/-3.7) years in the older group and 49.4 (+/-8.2) in the younger group. Older women had slightly longer time to normal activities (50 days compared with 42 days, P=.05), but there was no difference in time to normal voiding (14 days compared with 11 days, P=.42). Older women were more likely to have a positive stress test at follow-up (odds ratio [OR] 3.7, 95% confidence interval [CI] 1.70-7.97, P=.001), less subjective improvement in stress (8 point lesser decrease, 95% CI 1.5-14.1, P=.02), and urge incontinence (7 point lesser decrease, 95% CI 1.5-12.2, P=.01) by the Medical and Epidemiologic Social Aspects of Aging questionnaire, and were more likely to undergo surgical retreatment for SUI (OR 3.9, 95% CI 1.30-11.48). Perioperative adverse events and length of stay did not differ between groups.
Older women undergoing surgery for stress incontinence can expect to do as well as younger women with respect to perioperative outcomes, but experience 2-year outcomes that are worse.
Obstetrics and Gynecology 10/2008; 112(3):621-9. · 4.73 Impact Factor
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Gary E Lemack,
Stephen Krauss,
Heather Litman,
Mary Pat FitzGerald,
Toby Chai,
Charles Nager,
Larry Sirls, Halina Zyczynski,
Jan Baker,
Keith Lloyd,
W D Steers
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ABSTRACT: Urodynamic studies have been proposed as a means of identifying patients at risk for voiding dysfunction after surgery for stress urinary incontinence. We determined if preoperative urodynamic findings predict postoperative voiding dysfunction after pubovaginal sling or Burch colposuspension.
Data were analyzed from preoperative, standardized urodynamic studies performed on participants in the Stress Incontinence Treatment Efficacy Trial, in which women with stress urinary incontinence were randomized to undergo pubovaginal sling surgery or Burch colposuspension. Voiding dysfunction was defined as use of any bladder catheter after 6 weeks, or reoperation for takedown of a pubovaginal sling or Burch colposuspension. Urodynamic study parameters examined were post-void residual urine, maximum flow during noninvasive flowmetry, maximum flow during pressure flow study, change in vesical pressure at maximum flow during pressure flow study, change in abdominal pressure at maximum flow during pressure flow study and change in detrusor pressure at maximum flow during pressure flow study. The study excluded women with a preoperative post-void residual urine volume of more than 150 ml or a maximum flow during noninvasive flowmetry of less than 12 ml per second unless advanced pelvic prolapse was also present.
Of the 655 women in whom data were analyzed voiding dysfunction developed in 57 including 8 in the Burch colposuspension and 49 in the pubovaginal sling groups. There were 9 patients who could not be categorized and, thus, were excluded from the remainder of the analysis (646). A total of 38 women used a catheter beyond week 6, 3 had a surgical takedown and 16 had both. All 19 women who had surgical takedown were in the pubovaginal sling group. The statistical analysis of urodynamic predictors is based on subsets of the entire cohort, including 579 women with preoperative uroflowmetry, 378 with change in vesical pressure, and 377 with change in abdominal and detrusor pressure values. No preoperative urodynamic study findings were associated with an increased risk of voiding dysfunction in any group. Mean maximum flow during noninvasive flowmetry values were similar among women with voiding dysfunction compared to those without voiding dysfunction in the entire group (23.4 vs 25.7 ml per second, p = 0.16), in the Burch colposuspension group (25.8 vs 25.7 ml per second, p = 0.98) and in the pubovaginal sling group (23.1 vs 25.7 ml per second, p = 0.17). Voiding pressures and degree of abdominal straining were not associated with postoperative voiding dysfunction.
In this carefully selected group preoperative urodynamic studies did not predict postoperative voiding dysfunction or the risk of surgical revision in the pubovaginal sling group. Our findings may be limited by the stringent exclusion criteria and studying a group believed to be at greater risk for voiding dysfunction could alter these findings. Additional analysis using subjective measures to define voiding dysfunction is warranted to further determine the ability of urodynamic studies to stratify the risk of postoperative voiding dysfunction, which appears to be limited in the current study.
The Journal of urology 10/2008; 180(5):2076-80. · 4.02 Impact Factor
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ABSTRACT: The safety information of the vaginal mesh systems upon introduction to a teaching urogynecology service is limited to date. To determine the frequency of perioperative complications associated with the use of Prolift kits (Gynecare/Ethicon, Somerville, NJ, USA) by a teaching urogynecology service, data from the first 100 consecutive women were analyzed. The primary outcome was any deviation from a normal intraoperative or perioperative course. Complications were graded using the Dindo morbidity scale. Univariate analyses were performed to identify risk factors. Complications included bladder perforation (2%), blood transfusion (2%), mesh exposure (4%), and urinary tract infections (28%). Eleven percent of women reported postoperative pain, and 34% required catheterization at discharge for incomplete bladder emptying. Univariate analysis showed no association between morbidities and patient characteristics, attending experience, or fellow involvement. The integration of Prolift kits for prolapse repair into a urogynecology training program can be achieved with few perioperative complications.
International Urogynecology Journal 09/2008; 19(12):1617-22. · 1.83 Impact Factor
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ABSTRACT: The aim of this study is to describe results of reduction testing in stress-continent women undergoing sacrocolpopexy and to estimate whether stress leakage during urodynamic testing with prolapse reduction predicts postoperative stress incontinence. Three hundred twenty-two stress-continent women with stages II-IV prolapse underwent standardized urodynamics. Five prolapse reduction methods were tested: two at each site and both performed for each subject. Clinicians were masked to urodynamic results. At sacrocolpopexy, participants were randomized to Burch colposuspension or no Burch (control). P-values were computed by two-tailed Fisher's exact test or t-test. Preoperatively, only 12 of 313 (3.7%) subjects demonstrated urodynamic stress incontinence (USI) without prolapse reduction. More women leaked after the second method than after the first (22% vs. 16%; p = 0.012). Preoperative detection of USI with prolapse reduction at 300ml was pessary, 6% (5 of 88); manual, 16% (19 of 122); forceps, 21% (21 of 98); swab, 20% (32 of 158); and speculum, 30% (35 of 118). Women who demonstrated preoperative USI during prolapse reduction were more likely to report postoperative stress incontinence, regardless of concomitant colposuspension (controls 58% vs. 38% (p = 0.04) and Burch 32% vs. 21% (p = 0.19)). In stress-continent women undergoing sacrocolpopexy, few women demonstrated USI without prolapse reduction. Detection rates of USI with prolapse reduction varied significantly by reduction method. Preoperative USI leakage during reduction testing is associated with a higher risk for postoperative stress incontinence at 3 months. Future research is warranted in this patient population to evaluate other treatment options to refine predictions and further reduce the risk of postoperative stress incontinence.
International Urogynecology Journal 06/2008; 19(5):607-14. · 1.83 Impact Factor
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Charles W Nager,
MaryPat FitzGerald,
Stephen R Kraus,
Toby C Chai, Halina Zyczynski,
Larry Sirls,
Gary E Lemack,
L Keith Lloyd,
Heather J Litman,
Anne M Stoddard,
Jan Baker,
William Steers
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ABSTRACT: We determined the prognostic value of preoperative urodynamic results in patients with stress urinary incontinence.
In a 9-center surgical trial, women with stress urinary incontinence were randomized to a Burch or pubovaginal sling procedure. Women were eligible for the study if they had predominant stress urinary incontinence symptoms, a positive cough stress test, a bladder capacity more than 200 ml and urethral hypermobility. Preoperative free uroflowmetry, filling cystometry and pressure flow studies were performed in all. Overall treatment success required a negative pad test, no urinary incontinence on a 3-day diary, a negative stress test, no self-reported stress urinary incontinence symptoms and no re-treatment for stress urinary incontinence. Stress specific success required all of the last 3 criteria. We examined urodynamic measures, and whether the presence of urodynamic stress incontinence, the presence of detrusor overactivity and Valsalva leak point pressure would predict surgical success.
Subjects with urodynamic stress incontinence had a 2-fold greater odds of overall success when compared with the No urodynamic stress incontinence group, but this trend did not quite reach statistical significance (OR 2.26; 95% C.I. 0.99, 5.17). Odds of stress specific success did not differ by urodynamic stress incontinence status. Subjects with detrusor overactivity did not have significantly worse success rates. Stratifying by treatment group, there was no difference in mean Valsalva leak point pressure values between surgical successes and failures.
We found a nearly statistically significant trend that women with urodynamic stress incontinence are twice as likely to have a successful overall outcome from surgical management of stress urinary incontinence as women without urodynamic stress incontinence. The level of Valsalva leak point pressure and the presence of detrusor overactivity do not predict the success outcomes after the Burch or autologous fascia sling procedures in women with pure or predominant stress urinary incontinence. The impact of urodynamic studies on surgical outcomes needs further investigation.
The Journal of urology 05/2008; 179(4):1470-4. · 4.02 Impact Factor
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ABSTRACT: To describe how simulated apical support affects the appearance of prolapse in the anterior and posterior vagina using a modification of the Pelvic Organ Prolapse Quantification (POP-Q) examination.
Women with prolapse stage II or greater were examined using the POP-Q. To simulate apical support, the posterior blade of a standard Graves speculum was positioned over the posterior vagina to support the vaginal apex while remeasuring points Aa and Ba and over the anterior vagina to support the apex while remeasuring points Ap and Bp. Change in anterior and posterior POP-Q points and prolapse stage with apical support were calculated.
One hundred ninety-seven women were enrolled with mean age of 62+/-14 years, median parity of 2 (range 0-8), and mean body mass index of 28+/-5 kg/m(2). By standard POP-Q, 36% had stage II prolapse, 54% had stage III, and 10% had stage IV prolapse. With simulated apical support, point Ba changed to stage 0 or I in 55% of cases and point Bp changed to stage 0 or I in 30% (P<.001 for each point). Mean change for point Ba with apical support was 3.5+/-2.6 cm and point Bp was 1.9+/-2.9 cm (P<.001).
When the POP-Q examination is performed with simulated apical support, the critical role of level I vaginal support on the position of the anterior and posterior vagina, particularly the anterior vagina, becomes apparent.
II.
Obstetrics and Gynecology 01/2008; 111(1):152-7. · 4.73 Impact Factor
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ABSTRACT: We compared lower urinary tract and voiding symptoms in women with and without symptoms of stress urinary incontinence who were planning to undergo abdominal sacrocolpopexy for pelvic organ prolapse.
Subjects without stress urinary incontinence included 293 women in the Colpopexy and Urinary Reduction Efforts Trial. Subjects with stress urinary incontinence included 82 women who met trial inclusion criteria except for having stress urinary incontinence symptoms. We assessed symptoms and quality of life using validated measures.
After adjusting for age, race and site subjects with stress urinary incontinence had higher irritative and obstructive symptom subscale scores and reported greater symptom bother, greater impact of colorectal and prolapse symptoms, and poorer physical and mental health.
Women with prolapse and stress urinary incontinence had more lower urinary tract symptoms and reported more functional impact. This is contrary to our hypothesis that women with prolapse and stress urinary incontinence would have fewer irritative, obstructive and voiding symptoms because of the relief valve effect of the less resistant urethra.
The Journal of Urology 10/2007; 178(3 Pt 1):965-9; discussion 969. · 3.75 Impact Factor
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Kathryn L Burgio,
Diane Borello-France,
Holly E Richter,
Mary Pat Fitzgerald,
William Whitehead,
Victoria L Handa,
Ingrid Nygaard,
Paul Fine, Halina Zyczynski,
Anthony G Visco,
Morton B Brown,
Anne M Weber
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ABSTRACT: To identify risk factors for postpartum FI and UI.
Secondary analysis of data from the CAPS study, which estimated the prevalence of postpartum FI and UI in primiparous women with clinically recognized anal sphincter tears after vaginal delivery, compared with women who delivered vaginally without recognized tears or by cesarean before labor. A total of 921 women were enrolled while in the hospital and 759 (82%) were interviewed by telephone 6 months postpartum. FI was assessed using the FISI and UI using the Medical, Epidemiological, and Social Aspects of Aging Questionnaire. FI risk factor analyses were conducted within each group, because of higher prevalence in the tear group. UI analyses were conducted with the groups combined.
In women with sphincter tears, FI at 6 months was associated with white race (OR 6.1, 95% CI 1.3-29.4), antenatal UI (OR 2.2, CI 1.1-4.3), 4th versus 3rd degree tear (OR 2.0, CI 1.0-4.0), older age at delivery (OR 1.6 per 5 yr, CI 1.2-2.1), and higher body mass index (BMI) (OR 1.3 per 5 kg/m(2), CI 1.0-1.7). No factors were associated with FI in the vaginal or cesarean control groups. Across all groups, risk factors for postpartum UI were antenatal UI (OR 3.5, CI 2.4-5.2), less education (OR 2.0, CI 1.4-2.8), and higher BMI (OR 1.2 per 5 kg/m(2), CI 1.1-1.4); cesarean delivery was protective (OR 0.5, CI 0.3-0.9).
Postpartum FI and UI are associated with few modifiable risk factors. However, the presence of antenatal UI and high BMI may help clinicians target at-risk women for early intervention.
The American Journal of Gastroenterology 10/2007; 102(9):1998-2004. · 7.28 Impact Factor
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Kathryn L Burgio,
Diane Borello-France,
Holly E Richter,
Mary Pat FitzGerald,
William Whitehead,
Victoria L Handa,
Ingrid Nygaard,
Paul Fine, Halina Zyczynski,
Anthony G Visco,
Morton B Brown,
Anne M Weber
The American Journal of Gastroenterology 08/2007; 102(9):1998-2004. · 7.28 Impact Factor
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Michael E Albo,
Holly E Richter,
Linda Brubaker,
Peggy Norton,
Stephen R Kraus,
Philippe E Zimmern,
Toby C Chai, Halina Zyczynski,
Ananias C Diokno,
Sharon Tennstedt, [......],
Anne M Stoddard,
Shawn Menefee,
R Edward Varner,
Kimberly Kenton,
Pam Moalli,
Larry Sirls,
Kimberly J Dandreo,
John W Kusek,
Leroy M Nyberg,
William Steers
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ABSTRACT: Many surgical procedures are available for women with urinary stress incontinence, yet few randomized clinical trials have been conducted to provide a basis for treatment recommendations.
We performed a multicenter, randomized clinical trial comparing two procedures--the pubovaginal sling, using autologous rectus fascia, and the Burch colposuspension--among women with stress incontinence. Women were eligible for the study if they had predominant symptoms associated with the condition, a positive stress test, and urethral hypermobility. The primary outcomes were success in terms of overall urinary-incontinence measures, which required a negative pad test, no urinary incontinence (as recorded in a 3-day diary), a negative cough and Valsalva stress test, no self-reported symptoms, and no retreatment for the condition, and success in terms of measures of stress incontinence specifically, which required only the latter three criteria. We also assessed postoperative urge incontinence, voiding dysfunction, and adverse events.
A total of 655 women were randomly assigned to study groups: 326 to undergo the sling procedure and 329 to undergo the Burch procedure; 520 women (79%) completed the outcome assessment. At 24 months, success rates were higher for women who underwent the sling procedure than for those who underwent the Burch procedure, for both the overall category of success (47% vs. 38%, P=0.01) and the category specific to stress incontinence (66% vs. 49%, P<0.001). However, more women who underwent the sling procedure had urinary tract infections, difficulty voiding, and postoperative urge incontinence.
The autologous fascial sling results in a higher rate of successful treatment of stress incontinence but also greater morbidity than the Burch colposuspension. (ClinicalTrials.gov number, NCT00064662 [ClinicalTrials.gov] .).
New England Journal of Medicine 06/2007; 356(21):2143-55. · 53.30 Impact Factor
