UROLOGICAL SURVEY
Female urology
Stress incontinence surgery for patients presenting with mixed incontinence and a normal cystometrogram
Osman T
Urology Department, Ain Shams University, Cairo, Egypt
BJU Int. 2003; 92: 964-8
OBJECTIVE: To evaluate the outcome of surgery for stress urinary incontinence (SUI) in patients presenting with a combination of stress and sensory urge UI.
PATIENTS AND METHODS: The study comprised 75 women presenting with mixed incontinence; the most important inclusion criterion was a negative cystometrogram for detrusor overactivity. Based on random selection, a third of the patients received a 6-month course of anticholinergic treatment (group 1) and 50 (group 2) had surgery for SUI. The surgical procedure depended on the Valsalva leak point pressure (VLPP); those with a VLPP of > ou = 90 cm H2O underwent Burch retropubic bladder neck suspension (group 2a, 24 patients) while 26 (group 2b) with a VLPP of < 90 cm H2O had pubovaginal sling (PVS) surgery. A further group of 20 patients with pure SUI (no urge UI) underwent surgery (PVS in 12 and Burch in eight) as a control group (group 3). After at least 6 months of follow-up (mean 9.3, SD 1.7), 68 patients were evaluable; they were assessed subjectively and objectively for dryness, and by a urodynamic evaluation and quantitative assessment using the SEAPI scoring system.
RESULTS: In group 1 none of the patients became completely dry; there was persistent stress with and without urge UI in nine (43%) and 12 (57%) of the available 21 patients, respectively. Only three of those who had persistent SUI with no urge in the whole study group were satisfied and chose to continue anticholinergic therapy despite SUI. In this group the mean (SD) improvement in the subjective and objective SEAPI score was 3.4 (1.0) and 2.3 (3.8), respectively. In group 2a, 20 of the available 23 patients (87%) became completely dry (both stress and urge continent). The mean improvement in the SEAPI scores was 7.8 (0.9) and 7.8 (1.3), respectively. In group 2b, 20 of the 24 (83%) became completely dry, with mean improvements in SEAPI scores of 8.2 (0.4) and 7.9 (0.3), respectively. The improvement was statistically significant after surgery, vs. anticholinergic therapy, for all variables (P < 0.05). The incidence of persistence urge UI was highest in group 1 (43%), being 13% in group 2 (13% and 12% in 2a and b, respectively). In group 3 there was de novo urge UI in four of the 20 patients, and not significantly different from that in group 2.
CONCLUSION: Most patients with mixed stress and urge UI and a normal cystometrogram were cured of both symptoms by surgery. The incidence of residual urge in such patients was no higher than that of de novo urge after surgery in patients with genuine SUI.
Editorial Comment
This is a randomized study to evaluate the outcome of surgery for stress urinary incontinence (SUI) in a population of women who had a combination of SUI and symptoms of urinary urge incontinence combined with a preoperative cystometrogram that had no evidence of uninhibited detrusor contractions. The study involved 3 basic groups: the first group of 25 patients had their therapy limited to anticholinergic medication for over 6 months; the second was a surgical group of 50 patients which was divided into 3 subgroups of which one group had a Burch retropubic suspension on the basis of a urodynamically proven Valsalva leak point pressure of > 90 cm H2O and a second subgroup of patients who underwent a pubovaginal sling with a criteria of a Valsalva leak point pressure of < 90 cm H2O; lastly, the third group was a control group of patients who had stress urinary incontinence but no complaints of urinary urge incontinence who also underwent a pubovaginal sling or a Burch depending on their preoperative VLPP determination. After at least 6 months of follow-up, the patients were assessed subjectively and objectively on the basis of a SEAPI score. Conclusions of the authors based on their findings included the observation that anti-incontinence surgery has an excellent cure rate for both symptoms in those patients with both stress and symptoms of urinary urge incontinence and that clinical efficacy and patient satisfaction of medical therapy was sub-optimal. In addition, the authors noted that the rate of postoperative urinary urge incontinence was similar between the group of patients who had preoperative symptoms of urinary urge incontinence combined with their stress urinary incontinence and the control group who had only stress urinary incontinence and no complaints of urinary urge incontinence.
This is a valuable paper for the interested in female urology. It is notable that the incidence of post operative urinary urge incontinence was similar in both the surgical group of patients who had preoperative urinary urge incontinence and the control group who had no preoperative urinary urge incontinence. Also of specific interest is that though the patients who preoperatively complained of urinary urge incontinence had negative cystometrograms, 9 of 10 patients had cystometric evidence of detrusor overactivity when plagued with postoperative urinary urge incontinence. In addition, other noteworthy urodynamic changes noted in the study group was a diminution in the maximum flow rate in the patients who had persistent urinary urge incontinence. The authors through their documentation of these urodynamic parameters and their noted difference in the pre- and post-operative patients raised a valuable point: is the etiology of preoperative urinary urge incontinence different from the etiology of postoperative urinary urge incontinence? The authors lead us to believe that this is definitely possible with postoperative urinary urge incontinence potentially being related to an infravesical outlet obstruction as opposed to a preoperative idiopathic condition.
The discussion section by Dr. Osman is of great value and warrants careful reading both for the facts, which it presents as well as the questions that it raises with regard to the etiology of this most troublesome malady. It would be of genuine interest if the author could expand on the urodynamic differences pre and postoperatively between the group that underwent a Burch urothropexy vs. those who underwent a suburethral pubovaginal sling secondary to the historical claim of the potentially obstructive nature of a suburethral sling.
In conclusion, the paper's findings are along the same line as those voiced by Dr. McGuire in the past in that the finding of detrusor instability on a preoperative cystometrogram does not preclude a good result (1). Interested readers should consider other landmark papers of great value on this topic (1,2).
References
1. McGuiure E: Bladder instability and stress incontinence. Neurourol Urodyn. 1988; 7: 563-7.
2. McGuire EJ, Savastano JA: Stress incontinence and detrusor instability / urge incontinence. Neurourol Urodyn. 1985; 4: 313-6.
Dr. Steven P. Petrou
Associate Professor of Urology
Mayo Medical School
Jacksonville, Florida, USA
Publication Dates
-
Publication in this collection
21 May 2004 -
Date of issue
Feb 2004
