W Jäger’s research while affiliated with University of Cologne and other places

Purpose: Current treatments of urgency urinary incontinence (UUI) are aimed to reduce the neurological influence on bladder detrusor muscle function. A previous observation after posterior exenteration led to the hypothesis that UUI is caused by a laxity of the uterosacral ligaments (USL). In a previous Clinical Phase I trial in patients with UUI continence was achieved in 40% of patients by replacement of the USL. The results supported the concept of a Clinical Phase II trial in which only patients who lost urine after urgency (advanced UI) were treated by replacement of the USL. The aim of the study was to evaluate the cause why some patients became continent while others remained incontinent after replacement of the USL. Methods: In this Clinical Phase II trial, patients with advanced UI were included. The USL was replaced by specially designed polyvinylidene fluoride (PVDF) structures. During laparoscopy these structures were fixed at the promontory and at the cervical stump after supracervical hysterectomy (cervicosacropexy, CESA) or at the vaginal stump (vaginosacropexy, VASA). The USL replacing parts of the structures had an identical length of 8.8 cm in CESA and 9.3 cm in VASA. Patients who remained incontinent after tensioning of the vagina were offered a suburethral trans-obturator tape (TOT). Results: 339 patients with advanced urinary incontinence (UI) were evaluable. Continence was re-established in 39% of patients after CESA and in 32.9% after VASA. The statistical analysis revealed that the Continence Rates (CR) after CESA or VASA were significantly (p<0.001) dependent on patients age at surgery (<60 years vs ≥60 years). The respective CR after CESA were 50% vs 26% and after VASA 41.5% vs 28.9%. After an additional transobturator tape (TOT) the overall CR was between 67.5% and 87.5%. Conclusion: The replacement of the USL by PVDF-tapes of defined length led to continence in between 32.9% and 39% of the patients. After the additional placement of a TOT 8/4 the percentage of continent patients increased by 30.5% to 37.3%. These findings support the hypothesis that continence is dependent on the physiological function of the USL and PUL. The observation that the CR after USL replacement decreased in patients ≥60 years indicates that ageing affected some additional other part in the area of the urethra-vesical junction (UVJ). The CR after CESA or VASA (and a TOT) in patients with advanced UI deserve further clinical evaluation.

Objective: Cervicosacropexy (CESA) and vaginosacropexy (VASA) are standardized surgical procedures to elevate and tighten the apical end of the vagina. A combination of CESA or VASA, and a transobturator tape was reported to cure urgency urinary incontinence (UUI). However, the efficacy of CESA or VASA in curing stress urinary incontinence (SUI) has not been investigated. Materials and Methods: Patients with SUI were asked to specify the situation when they urinated involuntarily. All of these patients were never operated on the genital tract before. In all the patients, the uterosacral ligaments were replaced by polyvinylidenefluoride tapes of identical length. The surgical outcomes in terms of vaginal anatomy and urinary incontinence were established several weeks after surgery. SUI was subdivided into SUI 1 (urinary loss while sneezing and coughing) and SUI 2 (urinary loss while performing other activities). Results: In addition to the anatomical effect, the apical fixation of the upper vaginal wall by CESA and VASA led to continence in 57% of the patients. The continence (cure) rate was higher in patients with SUI 1 (73%) than that in patients with SUI 2 (51%). The cure rate decreased with increase in the age of the patient at surgery. Of the 161 patients, 144 (89.4%) patients with SUI 2 were clinically having UUI. CESA and VASA led to continence in 39.1% and 29.3% of these patients, respectively. Conclusion: CESA and VASA can establish urinary continence in 29% to 48% of patients with stress and UUI. Continence rates decreased with patients’ age. © 2021 by the International Society for Pelviperineology / Pelviperineology published by Galenos Publishing House.

Background/aim: Urinary incontinence in women is commonly categorized as stress urinary incontinence (SUI) and urgency urinary incontinence (UUI). SUI occurs due to an increased intra-abdominal pressure caused by an unstable anatomical outlet of the bladder and can be successfully treated surgically. UUI, a combination of a symptom (urgency to void) and urinary incontinence, is considered to be caused by a neurological dysfunction of the bladder. Current treatment options can reduce the feeling of urgency, but effects on restoration of continence are less impressive. However, surgery for pelvic organ prolapse reduction leads to cure UUI, indicating a critical role of pelvic anatomy in the etiology of UUI. We hypothesized that incontinence in patients with UUI is caused by an anatomical instability at the bladder outlet leading to incontinence even under minor physical stress exerted on the bladder base. Patients and methods: Patients with UUI symptoms were asked to specify exactly when (in which body position) they involuntary lose urine after the feeling of urgency to void. Results: In total, 569 patients were evaluated between 2012 and 2020. Overall, 96% of the patients lost urine when they got up from a sitting position on their way to the toilet. Of the total study patients 3% lost urine already in the sitting position when they felt the urgency to void. Conclusion: The current treatment options for UUI are based on the hypothesis that UUI is a neurological disorder. This study demonstrated that urinary incontinence in patients with UUI is dependent on an intact anatomical stability of the urethro-vesical junction under pressure. Therefore, treatment modalities should focus on the anatomical repair or support in that area.

Background: According to the literature, restoration of pelvic organ prolapse also restores urinary continence. However, it is difficult to determine which exact surgical procedure actually led to urinary continence due to a lack of standardisation among these techniques. For example, an apical fixation is broadly defined in terms of type and shape of implanted material, anatomical fixation sides and tensioning. The aim of this study was to evaluate the effect of bilateral uterosacral ligament replacement with alloplastic tapes of defined lengths on symptoms of urinary incontinence. Patients and methods: Patients with urinary incontinence and pelvic organ prolapse underwent an apical suspension. Thereby, both uterosacral ligaments (USL) were replaced by alloplastic structures of defined length. These alloplastic tapes had defined lengths in all patients of 9, 10, or 11 cm in length. They were sutured on both sides of the cervix, placed in the left and right peritoneal fold of the USL, and were sutured laterally to the prevertebral fascial layer of the sacral vertebra at the level of S2. Furthermore, all patients received additional transobturator tape. Pelvic organ prolapse was classified according to the Baden-Walker system, and urinary incontinence symptoms according to validated questionnaires. Results: Four months after bilateral USL replacement, apical suspension was restored in all 31 patients. In addition, urinary continence was re-established in 18 out of these 31 patients (58%). The highest continence rate was observed in patients in which both USL were replaced with alloplastic tapes of 9 cm in length. Conclusion: The findings indicated the importance of USL integrity for urinary continence. In particular, a defined length for both USL seems to be important for (re-)establishing urinary continence.

Background: The aetiology of urgency urinary incontinence is a matter of debate. Current treatment options are based on the hypothesis of a neurological disorder of bladder innervation. However, it has also been hypothesised that one main cause is the reduced function of the bladder-holding apparatus, that is, insufficient suspension of the vesico-urethral junction. This study compared the effects of surgical apical vaginal elevation with those of solifenacin on urgency urinary incontinence in women. Patients and methods: Women with mixed and urgency urinary incontinence were randomised to either an established pharmacological arm (10 mg/day solifenacin) or the surgical arm (bilateral uterosacral ligament replacement, cervicosacropexy, CESA; or vaginosacropexy, VASA. Clinical and objective outcomes were assessed at 4 months after each type of intervention. Results: The study was terminated early; 55 patients were operated on and 41 patients received pharmacological treatment. After surgical treatment, 23 patients (42%, 95% confidence intervaI=29-55%) became continent compared to four patients (10%, 95% confidence intervaI=1-19%) during solifenacin treatment. Conclusion: Compared to pharmacological treatment, the surgical repair of the apical vaginal end restored urinary continence in significantly more patients.