RESUMEN
OBJECTIVES: To evaluate the safety and effectiveness of soft-tissue augmentation of the urethral sphincter with calcium hydroxylapatite (CaHA; Coaptite) compared with glutaraldehyde cross-linked bovine collagen (Contigen) in female patients with stress urinary incontinence due to intrinsic sphincter deficiency and without associated urethral hypermobility. METHODS: This 12-month prospective, randomized, comparative, multicenter, single-blind, parallel, clinical trial of CaHA and collagen for soft-tissue augmentation of the urethral sphincter in the treatment of stress urinary incontinence enrolled 296 women. Up to five injections were performed in the first 6 months of the trial. Twelve-month postinjection efficacy data were available for 231 patients. RESULTS: The results indicated that CaHA and collagen were both well tolerated in this study. No systemic adverse events were observed with either product. We used the Stamey Urinary Incontinence Scale to grade the improvement, which was the primary endpoint of the study. At 12 months, 83 (63.4%) of 131 CaHA patients compared with 57 (57.0%) of 100 collagen patients showed improvement of one Stamey grade or more (P = 0.34). More CaHA patients required only one injection (n = 60; 38.0%) during the study compared with the Contigen patients (n = 36; 26.1%; P = 0.034). Also, the average total volume of material injected during the course of the study was less for CaHA than for collagen (4.0 mL versus 6.6 mL, respectively; P <0.0001). CONCLUSIONS: The results of the study have demonstrated that Coaptite is an appropriate and well-tolerated treatment for patients with incontinence due to intrinsic sphincter deficiency. This new soft-tissue augmentation material has a good safety profile and appears to provide durable improvement.
Asunto(s)
Colágeno/uso terapéutico , Durapatita/uso terapéutico , Calidad de Vida , Incontinencia Urinaria de Esfuerzo/terapia , Adulto , Anciano , Animales , Bovinos , Estudios Cruzados , Femenino , Estudios de Seguimiento , Humanos , Persona de Mediana Edad , Probabilidad , Estudios Prospectivos , Valores de Referencia , Medición de Riesgo , Método Simple Ciego , Resultado del Tratamiento , Incontinencia Urinaria de Esfuerzo/diagnóstico , UrodinámicaRESUMEN
OBJECTIVES: To determine the safety of the use of Durasphere in patients receiving warfarin anticoagulation. METHODS: This case series included patients requiring long-term anticoagulation who also had intrinsic sphincteric deficiency or mixed urinary incontinence, and bladder outlets without hypermobility. All patients, with the exception of the 1 man in the study, were treated under local anesthesia with periurethral carbon bead injections, while receiving therapeutic doses of warfarin. RESULTS: Between 1999 and 2004, 20 such patients received carbon bead injections, on 36 different occasions, during therapeutic warfarin administration. Two complications related to the anticoagulation were encountered, one minor complication of a small periurethral hematoma and the other more severe, with a patient developing urinary retention and intravesical hemorrhage. CONCLUSIONS: In most cases, the injection of carbon beads under local anesthesia in patients receiving therapeutic warfarin anticoagulation can be safely performed without reversal of the anticoagulation.
Asunto(s)
Anticoagulantes/uso terapéutico , Materiales Biocompatibles/administración & dosificación , Glucanos/efectos adversos , Incontinencia Urinaria/terapia , Warfarina/uso terapéutico , Circonio/efectos adversos , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Inyecciones , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Incontinencia Urinaria/tratamiento farmacológicoRESUMEN
PURPOSE: We assessed the outcome of the in situ anterior vaginal wall sling for stress urinary incontinence, identified any predictors of success and reviewed the current literature on this topic. MATERIALS AND METHODS: We identified all patients who underwent an isolated anterior vaginal wall sling procedure in a 16-month period. Charts were reviewed and telephone interviews were performed to assess the success rate of the procedure and identify parameters that may influence outcome. The pertinent literature was identified. RESULTS: Of the 42 patients identified 39 had evaluable data available. The overall success rate was 79.5% at an average 19-month followup. Abdominal Valsalva leak point pressure 50 cm. water or greater was identified as a significant predictor of success (p = 0.002). The success rate was 93% and 40% in patients with a Valsalva leak point pressure of 50 or greater and less than 50 cm. water, respectively. The pertinent literature was reviewed. CONCLUSIONS: The anterior vaginal wall sling is effective for stress urinary incontinence. In patients with a Valsalva leak point pressure of 50 cm. water or greater the success rate is 93%. We recommend the anterior vaginal wall sling procedure in these patients but different treatment in those with Valsalva leak point pressure less than 50 cm. water.
Asunto(s)
Incontinencia Urinaria de Esfuerzo/cirugía , Femenino , Humanos , Inducción de Remisión , Resultado del Tratamiento , Procedimientos Quirúrgicos Urológicos/métodos , VaginaRESUMEN
PURPOSE: Periurethral bulking agents continue to be used as a minimally invasive alternative for management of stress urinary incontinence in men and women. Agents and delivery techniques will be evaluated and compared. MATERIALS AND METHODS: The only agents currently approved by the United States Food and Drug Administration (FDA) include glutaraldehyde cross-linked collagen, autologous fat, and carbon bead/carrier gel technology. Several other agents are undergoing FDA trial evaluation. These agents differ in material characteristics (particle size, viscosity) that, in some cases, produce different immediate and delayed tissue responses or reactions. RESULTS: Initial subjective cure rates with collagen are acceptable, but the majority of women require reinjection. The risk of allergic phenomena complicates collagen use. Carbon-based material appears to parallel collagen in durability, with the significant advantage of a nonimmunogenic response within host tissues. Autologous fat injection achieves early results similar to those with collagen, but is limited by resorption and fibrous replacement as well as local discomfort associated with harvesting procedures. Experience with newer agents is limited. Patient characteristics also influence response to injectable agents. CONCLUSIONS: Injectable agent materials and delivery techniques continue to evolve. The optimal material is yet to be defined.
Asunto(s)
Materiales Biocompatibles/administración & dosificación , Materiales Biocompatibles/uso terapéutico , Inyecciones/métodos , Incontinencia Urinaria de Esfuerzo/tratamiento farmacológico , Femenino , Humanos , Inyecciones/instrumentaciónRESUMEN
BACKGROUND: Oxybutynin chloride and tolterodine tartrate are anticholinergic agents used to suppress involuntary bladder contractions in urinary incontinence. They act by inhibiting binding of acetylcholine to the muscarinic receptors in the detrusor muscle of the bladder. The same types of muscarinic receptors are found in the salivary glands; thus anticholinergic agents may decrease saliva production and cause dry mouth, a commonly cited reason for discontinuation of therapy. OBJECTIVE: The primary objective of this study was to compare saliva output, which is an objective measure of dry mouth, in subjects taking immediate- or extended-release oxybutynin, tolterodine, or placebo. METHODS: This was a single-site, single-dose, randomized, double-blind, 4-treatment, 4-period crossover study. Subjects were randomly assigned to 1 of 4 treatment sequences that included extended-release oxybutynin 10 mg, tolterodine 2 mg, immediate-release oxybutynin 5 mg, and placebo. Saliva output was measured objectively before dosing with each treatment and at 0.5, 1, 2, 3, 4, 6, 8, 10, and 12 hours after dosing. RESULTS: Thirty-six healthy adult volunteers (22 women and 14 men) participated in the study. They ranged in age from 19 to 42 years (mean, 27 years). Thirty-one were white, 3 Asian, and 2 black. There were no significant differences in predose saliva output between the 4 study groups. With placebo, saliva output increased throughout the day. Saliva output was maintained at predose levels throughout the day with extended-release oxybutynin. Two hours after dosing with tolterodine and immediate-release oxybutynin, saliva output decreased nearly 0.5 g in specimens collected over 2 minutes. All 3 active treatments were associated with lower saliva output compared with placebo. Extended-release oxybutynin and tolterodine were similar with respect to area under the saliva concentration-time curve but were associated with significantly greater saliva output than was immediate-release oxybutynin (P < 0.01). There were no serious adverse events (AEs) in this study. AEs were similar between treatments, although the incidence of headache was higher in the active-treatment groups than with placebo. CONCLUSIONS: Objective assessment of saliva output in healthy adult volunteers indicated that extended-release oxybutynin and tolterodine had less impact on saliva output than did conventional immediate-release oxybutynin, suggesting that they may yield lower levels of dry mouth.
Asunto(s)
Compuestos de Bencidrilo/farmacología , Antagonistas Colinérgicos/farmacología , Cresoles/farmacología , Ácidos Mandélicos/farmacología , Fenilpropanolamina , Salivación/efectos de los fármacos , Tartratos/farmacología , Adulto , Área Bajo la Curva , Compuestos de Bencidrilo/efectos adversos , Antagonistas Colinérgicos/efectos adversos , Cresoles/efectos adversos , Estudios Cruzados , Método Doble Ciego , Femenino , Cefalea/inducido químicamente , Humanos , Masculino , Ácidos Mandélicos/efectos adversos , Saliva/metabolismo , Tartratos/efectos adversos , Tartrato de TolterodinaRESUMEN
OBJECTIVES: To determine the incidence of concomitant procedures performed for pelvic organ prolapse or vaginal reconstruction at the time of surgery for stress urinary incontinence in contemporary practice. METHODS: We recorded all concomitant procedures for pelvic organ prolapse or vaginal reconstruction in 264 women who underwent surgery for stress urinary incontinence at our institution from January 1995 to August 1997. RESULTS: Of 264 women, 111 (42%) had at least one concomitant procedure performed for pelvic organ prolapse or vaginal reconstruction, including 87 cystocele repairs, 31 rectocele repairs, 8 sacrospinous fixations, 5 enterocele repairs, 5 abdominal sacrocolpopexies, 4 perineoplasties, 3 urethral diverticulectomies, and 1 vaginal hysterectomy. Furthermore, 9% of patients had two or more procedures. CONCLUSIONS: We found that women who undergo surgery for stress urinary incontinence have a high incidence (42%) of associated pelvic organ prolapse requiring surgical repair. These additional repairs contribute to the overall success of surgery and should not be overlooked.
Asunto(s)
Pelvis/cirugía , Procedimientos de Cirugía Plástica/estadística & datos numéricos , Incontinencia Urinaria de Esfuerzo/cirugía , Técnicas de Diagnóstico Obstétrico y Ginecológico , Femenino , Hernia/epidemiología , Herniorrafia , Humanos , Incidencia , Prolapso , Procedimientos de Cirugía Plástica/métodos , Enfermedades de la Vejiga Urinaria/epidemiología , Enfermedades de la Vejiga Urinaria/cirugía , Incontinencia Urinaria de Esfuerzo/diagnóstico , Vagina/cirugíaRESUMEN
Previously available antimuscarinic therapies for overactive bladder are poorly tolerated due to a high incidence of adverse events, notably dry mouth. Tolterodine is a bladder-selective, antimuscarinic agent for the treatment of frequency, urgency, and urge incontinence that characterize overactive bladder. In a 9-month open-label study, the safety, tolerability, and clinical efficacy of tolterodine 2 mg twice daily was evaluated in 854 patients with overactive bladder symptoms who had completed one of four 12 week randomized, controlled trials of tolterodine. Safety and tolerability were assessed in terms of adverse events and clinical/laboratory variables. Efficacy was assessed using micturition diaries and patient perception of their bladder condition. In all, 70% of patients remained on treatment for 9 months. Dry mouth was the most frequently reported adverse event, occurring in 28% of patients (intensity: 19% mild, 7% moderate, 2% severe). A total of 9% of patients withdrew due to adverse events. Dosage reduction occurred in 13% of patients. Significant improvements (P < 0.0001) in micturitions per 24 h (-22%), urge incontinence episodes per 24 h (-76%) and volume voided per micturition (+22%) were observed after 9 months of treatment, with 65% of patients reporting an improvement in perception of their bladder problems. The incidence of adverse events and improvements in micturition diary variables during open-label treatment were comparable with those observed during a 12 week randomized treatment. It was concluded that tolterodine is well tolerated and maintains its clinical efficacy during 9 months of treatment. The high proportion of patients remaining on treatment indicates that tolterodine is an effective long-term treatment for overactive bladder.
Asunto(s)
Compuestos de Bencidrilo/administración & dosificación , Cresoles/administración & dosificación , Antagonistas Muscarínicos/administración & dosificación , Fenilpropanolamina , Trastornos Urinarios/tratamiento farmacológico , Adulto , Anciano , Anciano de 80 o más Años , Compuestos de Bencidrilo/efectos adversos , Cresoles/efectos adversos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Antagonistas Muscarínicos/efectos adversos , Tartrato de Tolterodina , Resultado del TratamientoRESUMEN
PURPOSE: We determined the reported prevalence of infectious osseous complications due to the use of bone anchors for suture fixation in female pelvic reconstructive procedures. In addition, the type and method of bone anchors as well as the reported pathogens associated with osseous infections were reviewed. MATERIALS AND METHODS: Primary reported series of female pelvic reconstructive procedures involving bone anchor suture fixation referenced in Index Medicus from January 1990 to July 2000 were extracted using the MEDLINE bibliographic database on English language articles involving humans. All case reports of infectious osseous complications due to bone anchor use in female reconstructive procedures were also reviewed during this period. RESULTS: Since the inception of bone anchor suture fixation for female pelvic reconstructive procedures 10 years ago, the overall prevalence of related infectious complications has been 6 cases in 1,018 procedures (0.6%). This type of adverse event developed between followup weeks 1 and 24. The prevalence of suprapubic bone anchors has been 6 cases in 698 procedures (0.86%). For transvaginal bone anchor procedures no infectious cases have been reported in the combined series of 314 procedures and the same is true for 1 reported case of sacral bone anchor placement in 6 procedures. No statistical difference was noted in regard to the prevalence of infection in procedures involving suprapubic bone anchors and transvaginal bone anchor combined with sacral bone anchor placement (Fisher's exact test p = 0.19). The organisms reported in case reports suggest a coliform, skin or hematogenous source for contamination of the bone anchor site. CONCLUSIONS: An infectious bone anchor complication in female pelvic reconstructive procedures is an uncommon event with a reported prevalence of 0.6%. Currently there is no evidence of differences in the prevalence of osseous complications after transvaginal versus suprapubic bone anchor fixation. Preoperative broad-spectrum antibiotics are recommended to decrease the potential of infectious bone anchor complications.
Asunto(s)
Enfermedades Óseas Infecciosas/etiología , Procedimientos Quirúrgicos Ginecológicos , Fijadores Internos/efectos adversos , Femenino , Humanos , Osteomielitis/etiología , Procedimientos de Cirugía Plástica , Estudios RetrospectivosRESUMEN
OBJECTIVE: To compare the efficacy and tolerability of extended-release oxybutynin chloride and tolterodine tartrate at 12 weeks in participants with overactive bladder. SUBJECTS AND METHODS: The OBJECT (Overactive Bladder: Judging Effective Control and Treatment) study was a prospective, randomized, double-blind, parallel-group study conducted between March and October 2000 at 37 US study sites. Participants who had between 7 and 50 episodes of urge incontinence per week and 10 or more voids in 24 hours received extended-release oxybutynin, 10 mg/d, or tolterodine, 2 mg twice daily. The outcome measures were the number of episodes of urge incontinence, total incontinence, and micturition frequency at 12 weeks adjusted for baseline. RESULTS: A total of 315 women and 63 men were randomized and treated, and 332 participants (276 women, 56 men) completed the study. At the end of the study, extended-release oxybutynin was significantly more effective than tolterodine in each of the main outcome measures: weekly urge incontinence (P=.03), total incontinence (P=.02), and micturition frequency episodes (P=.02) adjusted for baseline. Both drugs improved symptoms of overactive bladder significantly from baseline to the end of the study as assessed by the 3 main outcome measures (P<.001). Dry mouth, the most common adverse event, was reported by 28.1% and 33.2% of participants taking extended-release oxybutynin and tolterodine, respectively (P=.32). Rates of central nervous system and other adverse events were low and similar in both groups. CONCLUSIONS: Extended-release oxybutynin was more effective than tolterodine as measured by end-of-study urge incontinence, total incontinence, and micturition frequency episodes. Both groups had similar rates of dry mouth and other adverse events.
Asunto(s)
Compuestos de Bencidrilo/administración & dosificación , Cresoles/administración & dosificación , Ácidos Mandélicos/administración & dosificación , Antagonistas Muscarínicos/administración & dosificación , Fenilpropanolamina , Tartratos/administración & dosificación , Vejiga Urinaria Neurogénica/tratamiento farmacológico , Incontinencia Urinaria de Esfuerzo/tratamiento farmacológico , Anciano , Compuestos de Bencidrilo/efectos adversos , Cresoles/efectos adversos , Preparaciones de Acción Retardada , Método Doble Ciego , Esquema de Medicación , Femenino , Estudios de Seguimiento , Humanos , Masculino , Ácidos Mandélicos/efectos adversos , Persona de Mediana Edad , Antagonistas Muscarínicos/efectos adversos , Enfermedades del Sistema Nervioso/inducido químicamente , Probabilidad , Estudios Prospectivos , Valores de Referencia , Índice de Severidad de la Enfermedad , Estadísticas no Paramétricas , Tartratos/efectos adversos , Tartrato de Tolterodina , Resultado del Tratamiento , Vejiga Urinaria Neurogénica/complicaciones , Vejiga Urinaria Neurogénica/diagnóstico , Incontinencia Urinaria de Esfuerzo/diagnóstico , Incontinencia Urinaria de Esfuerzo/etiología , Trastornos Urinarios/diagnóstico , Trastornos Urinarios/tratamiento farmacológico , Trastornos Urinarios/etiología , Xerostomía/inducido químicamenteRESUMEN
Two agents for the control of overactive bladder-tolterodine (TOL) and extended-release oxybutynin (Oxy-XL)-have been evaluated in a number of studies for their efficacy in urge incontinence. Studies have demonstrated that TOL achieved a 20% reduction in the frequency of voiding and a 45% reduction in urge incontinent episodes. Efficacy was comparable between TOL and immediate-release oxybutinin (Oxy-IR), the standard anticholinergic comparator. There is a delay of some weeks in achieving relief with TOL, but thereafter there is a continued decrease in the total number of both micturitions and incontinent episodes in 24 hours. Trials demonstrated that there were no safety concerns at all with TOL. In particular, there was a lower incidence of dry mouth with TOL than with Oxy-IR. Dose-ranging studies established that TOL produced the lowest incidence of side effects while maintaining efficacy. In a long-term, community-use study of Oxy-XL, there was a very low incidence of central nervous system side effects, including mental acuity and memory. Among elderly nursing home patients, Oxy-XL achieved a 90% reduction in weekly urge incontinence episodes and an 86% decrease in pad use. Oxy-XL was shown to cause a significantly lower reduction in salivary output than Oxy-IR and TOL. In a recent head-to-head comparison study, there were significant differences found between Oxy-XL and TOL. Other studies have shown that the administration of Oxy-XL results in a significantly lower production of the metabolites responsible for anticholinergic side effect, particularly dry mouth, than with the standard release form, owing largely to the elimination of a first-pass effect. A long-acting form of TOL resulted in a 53% reduction in incontinent episodes. Both these anticholinergic agents have been shown to have excellent efficacy and tolerability. But the future of OAB therapy lies in targeting other mechanisms responsible for incontinence.
Asunto(s)
Colágeno/uso terapéutico , Estudios Multicéntricos como Asunto , Ensayos Clínicos Controlados Aleatorios como Asunto , Uretra/efectos de los fármacos , Uretra/cirugía , Incontinencia Urinaria de Esfuerzo/tratamiento farmacológico , Incontinencia Urinaria de Esfuerzo/cirugía , Colágeno/administración & dosificación , Femenino , Humanos , Inyecciones , Satisfacción del Paciente , Calidad de VidaRESUMEN
Stress urinary incontinence remains one of the most prevalent conditions encountered by urologists. In many cases, surgical correction of this condition is carried out using a pubovaginal sling procedure. Bone anchors were initially used in transvaginal needle suspension procedures to improve stabilization of the bladder neck. This technology has been extended to sling procedures, allowing completion of these procedures by an entirely transvaginal approach. Early results of these procedures are encouraging, and overall morbidity appears much less when compared with conventional pubovaginal sling procedures. In this article, the application of bone anchors in female urology is reviewed. Techniques of pubovaginal sling and abdominal sacrocolpopexy using bone anchors and potential complications of bone anchor implantation are discussed. Surgeons performing procedures for the treatment of stress incontinence should be aware of the benefits and potential risks of bone anchor implantation.
Asunto(s)
Hueso Púbico/cirugía , Incontinencia Urinaria de Esfuerzo/cirugía , Clavos Ortopédicos/efectos adversos , Femenino , Estudios de Seguimiento , Humanos , Osteomielitis/etiología , Infección de la Herida Quirúrgica/etiología , Técnicas de Sutura , Resultado del Tratamiento , Vagina/cirugíaRESUMEN
Periurethral bulking agents have been used for decades. The only currently available agents (in the United States) include glutaraldehyde cross-linked collagen, autologous fat, and carbon bead technology. Initial subjective cure rates with collagen are acceptable, but with the majority of women requiring reinjection. The risk of allergic phenomena complicates collagen use. Autologous fat injection is initially effective in >50% of women, but resorption and fibrous replacement hamper the stability of the transplanted graft. Polytetrafluoroethylene and silicone are not currently approved by the US Food and Drug Administration because of particle migration. Materials in development include biologic agents such as allogeneic human collagen and autologous cartilage. Developmental synthetic agents include microballoon technology, hyaluronic acid with or without microsphere technology, hydroxylapatite, and a variety of polymeric technologies. Patient selection and material characteristics influence the optimal choice for injectable agent.
Asunto(s)
Materiales Biocompatibles/administración & dosificación , Prótesis e Implantes , Incontinencia Urinaria de Esfuerzo/terapia , Tejido Adiposo/trasplante , Materiales Biocompatibles/efectos adversos , Carbono/administración & dosificación , Cartílago/trasplante , Colágeno/administración & dosificación , Colágeno/efectos adversos , Femenino , Vidrio , Humanos , Ácido Hialurónico/administración & dosificación , Hipersensibilidad/diagnóstico , Hipersensibilidad/etiología , Masculino , Tamaño de la Partícula , Selección de Paciente , Politetrafluoroetileno/administración & dosificación , Politetrafluoroetileno/efectos adversos , Prótesis e Implantes/efectos adversos , Siliconas/administración & dosificación , UrodinámicaRESUMEN
Continued developments in the understanding of lower urinary tract function have led to improvements in the pharmacologic manipulation of bladder dysfunction. Drug delivery changes have produced drugs that provide better efficacy and tolerability, thus improving patient compliance. Improvements in drug delivery systems have altered drug bioavailability and pharmacokinetics. Active current investigation in new agents and delivery systems for intravesical delivery has yielded intriguing early results that may substantially add to the armamentarium for the management of the overactive bladder (urgency, frequency, urge incontinence). New developments in the understanding of the neuropharmacology of the bladder, peripheral pelvic nerves, and sacral cord may provide agents with entirely new drug effects, either as primary agents or agents to be used in combination with currently available drugs. We herein review newer agents and drug delivery systems.
Asunto(s)
Fenilpropanolamina , Incontinencia Urinaria/tratamiento farmacológico , Antagonistas Adrenérgicos alfa/uso terapéutico , Anciano , Animales , Antidepresivos Tricíclicos/uso terapéutico , Compuestos de Bencidrilo/uso terapéutico , Bencilatos , Benzofuranos/uso terapéutico , Bloqueadores de los Canales de Calcio/uso terapéutico , Antagonistas Colinérgicos/uso terapéutico , Cresoles/uso terapéutico , Preparaciones de Acción Retardada , Vías de Administración de Medicamentos , Femenino , Humanos , Ácidos Mandélicos/administración & dosificación , Persona de Mediana Edad , Antagonistas Muscarínicos/uso terapéutico , Relajantes Musculares Centrales/uso terapéutico , Nortropanos/administración & dosificación , Pirrolidinas/uso terapéutico , Tartrato de Tolterodina , Incontinencia Urinaria/fisiopatologíaRESUMEN
Pulsed magnetic technology has been developed for pelvic floor muscle strengthening for the treatment of urinary incontinence. This report includes an update of the prospective multicenter study of extracorporeal magnetic innervation (ExMI) therapy for stress incontinence and a discussion of the possible mechanisms of action. Issues of patient selection for ExMI therapy will also be discussed. One hundred and eleven women with demonstrable stress urinary incontinence were studied. The mean age was 55 +/- 13 years, and the mean duration of symptoms was 11 years. Ninety-seven completed ExMI therapy and analysis. Evaluation before treatment included bladder diaries, dynamic pad weight test, urodynamics, and a quality-of-life survey. For treatment the patients were seated fully clothed in a Neocontrol chair with a magnetic field therapy head in the seat. Treatment sessions were for 20 minutes, twice a week, for 6 weeks. After ExMI therapy, all of the measures were repeated at 8 weeks, including the dynamic pad weight testing and quality-of-life survey. At 6 months, further data were added, including repeat bladder diary, pad use, and quality-of-life survey. Forty-seven women completed 6 months of follow-up; of the 47, 13 patients were completely dry (28%) and 25 used no pad or less than 1 pad per day (53%). Pad use was reduced in 33 patients (70%). The median number of pads was reduced from 2.16 to 1 per day (Wilcoxon signed rank test, P <0.005). The frequency of leak episodes was reduced from 3.0 to 1.7 at 6 months (Wilcoxon signed rank test, P = 0.004). Detrusor instability was demonstrated in 10 before and 6 after ExMI (P <0.05). ExMI offers an alternative approach for the treatment of urinary incontinence. ExMI therapy is effective for both stress and urge incontinence. The best results are achieved in those patients who use no more than 3 pads a day and have had no prior continence surgery.
Asunto(s)
Magnetismo/uso terapéutico , Incontinencia Urinaria de Esfuerzo/terapia , Adulto , Anciano , Análisis de Varianza , Campos Electromagnéticos , Femenino , Estudios de Seguimiento , Humanos , Persona de Mediana Edad , Estudios Prospectivos , Calidad de Vida , Resultado del TratamientoAsunto(s)
Becas , Ginecología , Procedimientos de Cirugía Plástica , Enfermedades Urológicas/cirugía , Femenino , Humanos , Medicina , Especialización , Estados UnidosAsunto(s)
Incontinencia Urinaria de Esfuerzo/cirugía , Actividades Cotidianas , Femenino , Humanos , Incontinencia Urinaria de Esfuerzo/etiología , Incontinencia Urinaria de Esfuerzo/fisiopatología , Procedimientos Quirúrgicos Urológicos/clasificación , Procedimientos Quirúrgicos Urológicos/métodos , Prolapso Uterino/complicacionesRESUMEN
INTRODUCTION: Recent reviews have noted failures of transvaginal surgical procedures designed to cure female stress urinary incontinence (SUI). Slings for SUI appear to sustain continence over time but have been reserved for the more complex cases of intrinsic sphincteric deficiency because of the perception by many surgeons of increased technical difficulty and complication rates. However, this very success in complex cases of SUI bespeaks the need to develop modifications to simplify sling surgery so as to encourage sling use in all women with SUI. Modifications continue to be applied, including anchoring the supporting sutures to the pelvic bones and reducing the transvaginal dissection to prevent further prolapse. I review the use of the in situ anterior vaginal wall sling using bone anchoring techniques with preservation of the endopelvic fascia. TECHNICAL CONSIDERATIONS: The in situ sling is performed with the patient in the dorsal lithotomy position under regional or general anesthesia, with a 16F Foley catheter placed in the bladder and a weighted vaginal speculum on the posterior vaginal wall. An anterior vaginal suburethral patch is supported by nonabsorbable sutures anchored to the pubic bone. CONCLUSIONS: The use of bone anchoring techniques with preservation of the endopelvic fascia appears to enhance the success rate of autologous vaginal wall slings without increasing the risk to the patient and, as minimally invasive procedures, these techniques appear to reduce surgical time and length of hospitalization, thus reducing costs.
Asunto(s)
Incontinencia Urinaria de Esfuerzo/cirugía , Procedimientos Quirúrgicos Urológicos/métodos , Vagina/cirugía , Femenino , Humanos , Técnicas de SuturaRESUMEN
PURPOSE: We present the experience of the North American UroLume Multicenter Study Group with removal of the UroLume endoprosthesis. MATERIALS AND METHODS: A total of 160 neurologically impaired patients were enrolled in the North American UroLume Multicenter Study Group for detrusor external sphincter dyssynergia application. Analysis was performed in 2 groups of patients in which the device was removed during insertion and after implantation, respectively. RESULTS: Device retrieval was required during insertion in 21 patients (13%) mainly due to misplacement or migration in 17. Extraction was done with minimal complications and in all but 2 cases subsequent UroLume implantation was successful. Of 158 men with the device in place 31 (19.6%) required removal. In 34 procedures 44 devices were removed, mainly due to migration. Time from implantation to removal ranged from 4 days to 66 months (mean 22 months). The UroLume was removed en bloc in 20 cases and in parts or wire by wire in 19. The majority of patients had no or minimal complications after extraction. Only 2 patients had serious temporary complications, including bleeding and urethral injury, with no lasting consequences. No malignancy developed as a result of UroLume insertion. CONCLUSIONS: While there is a potential for urethral injury and bleeding, UroLume endoprosthesis removal is largely a simple procedure with minimal complications and consequences.
Asunto(s)
Stents/efectos adversos , Vejiga Urinaria Neurogénica/cirugía , Humanos , Masculino , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugía , Diseño de Prótesis , ReoperaciónRESUMEN
PURPOSE: Detrusor instability initiated by increased intra-abdominal pressure that results in incontinence has always been difficult to treat. This form of incontinence may be due to traction on the pelvic nerves when increased abdominal pressure is applied to already weakened pelvic supportive tissue. In most patients pharmacological attempts to correct this problem fail. We describe a pubovaginal sling designed to stabilize the urethrovesical junction during the Valsalva maneuver, which is our treatment of choice for such patients. MATERIALS AND METHODS: From 1994 to 1998 we treated 36 patients with a pubovaginal sling procedure for Valsalva induced detrusor instability diagnosed on preoperative urodynamics. The sling material was in situ vaginal wall in 20 cases, free swing vaginal wall in 6, rectus fascia in 4, cadaveric fascia in 3 and synthetic material in 3. Urodynamic evaluation was performed preoperatively in all patients. Followup of 6 months to 4 years involved subjective questions and objective examination. RESULTS: Cure was achieved in 33 of the 36 patients (92%), of whom leak point pressure was less than 50, 50 to 100 and greater than 100 cm. water in 9, 17 and 7, respectively. In the 3 failed cases leak point pressure was 50 to 100 cm water, including 2 in which cotton swab test results were less than 30 degrees. Urge incontinence resolved in 75% of the patients. CONCLUSIONS: The pubovaginal sling procedure may cure Valsalva induced detrusor instability. Leak point pressure does not determine which patients do well. Evaluation for hypermobility may help to predict the success or failure of a procedure by identifying those in whom Valsalva induced detrusor instability results from traction on the pelvic nerves.