Costantini.qxp 16/10/08 02:02 Page 76
Incontinence and Overactive Bladder
laxity leads to the activation of stretch receptors in the bladder neck, repair.
32
Forty-seven women suffering from POP and UI were randomly
triggering an inappropriate micturition reflex and the failure of pelvic floor assigned to abdominal POP repair and concomitant BC (group A: 24
musculature and ligaments, leading to POP.
26
patients) or POP repair alone without any anti-incontinence procedure
(group B: 23 patients). We found that in group A 13/24 patients (54.2%)
However, given their complexity, UI and POP may be considered were still incontinent after surgery compared with 9/23 (39.1%) in group
two sides of the same coin. Recently, a comprehensive theory, i.e. B. The intra-group difference was significant (p=0.003 for group A,
the ‘trampoline theory’, has been developed to encompass all of the p=0.0001 for group B), but there was no significant inter-group
factors that play a role in female pelvic floor disorders.
27
The difference (p=0.459 for A versus B). We concluded that BC does not
reconstructive surgeon has three options regarding continent patients provide any additional benefit in POP repair in patients with UI. We found
suffering from POP: first, to perform a routine anti-incontinence that the continence rate was lower in patients who received concomitant
operation, with the risk that some patients will be overtreated; second, BC, casting doubts on whether BC should be performed during POP
not to perform the anti-incontinence operation and to follow up the repair in women suffering from pre-operative UI.
patient, reserving a second operation for women whose SUI symptoms
warrant it; and third, to predict which patients will have troublesome We realise that these results are difficult to explain. One potential
post-operative SUI. In incontinent patients with POP the surgeon has to explanation could be that the degree of anterior wall support provided by
offer surgery to the patient that repairs the anatomical defect and our technique of sacropexy alone may be adequate for continence in a
corrects incontinence. subset of patients, and that Burch suspension is highly variable in outcome
and difficult to control for reliable continence. We adopted the surgical
Generally, the BC operation along with other reconstructive surgeries has technique as it is an integral POP reconstruction and includes wide
been recommended for treating co-existing SUI and POP. BC has long been preparation of the anterior and posterior vaginal walls and the anterior mesh
considered as one of the most effective operations for treating genuine SUI, placement at the urethral level, which could in itself correct any potential
and even today is still regarded by some urologists and gynaecologists as the incontinence. Our findings seem to be in line with data from Cosson et al.,
‘standard’ surgical procedure for treating SUI associated with urethral who reported that only 34% of patients with prolapse and pre-operative SUI
hypermobility. BC is associated with a high cure rate, but long-term follow- achieved complete correction of urinary dysfunction with a BC procedure
ups have recently shown that the continence rate declines with time, and during sacrocolpopexy.
33
BC is associated with several adverse effects that result in anatomical and
functional pelvic floor dysfunctions.
28
However, even in our best series (group B), 40% of patients remained
incontinent, and one could conclude that POP repair alone failed to
Interesting questions concerning patients with SUI and concomitant POP are correct UI. However, these patients presented with light incontinence and
whether POP repair by itself can achieve a continent status and whether BC, received behavioural and/or medical treatment; nobody required adjuvant
when associated with an abdominal POP repair, changes the outcome of surgical procedures.
POP by acting on the bladder and urethra. Langer et al. and Meltomaa et al.
found that when associated with hysterectomy, BC did not influence post- Conclusion
operative bladder and urethra function and the overall cure rate of SUI The risk remains unclear regarding post-operative UI in patients who
obtained by BC.
29,30
On the other hand, Snooks et al. and Parson et al. underwent surgery for urogenital prolapse. The onset of post-operative
showed that concomitant abdominal surgeries caused impairment of lower stress UI after the reparation of severe POP in previously continent
urinary tract function.
31
Unfortunately, none of these studies are up to date, women represents a challenge, and several prophylactic procedures have
the follow-ups are short and the question of the impact of BC on bladder been developed to prevent it. Although some investigators advise
and urethra function remains unsolved. concomitant SUI operations in all patients with severe POP – regardless
of whether demonstrable incontinence is present – we suggest a prudent
Recently, we investigated the impact of BC as an anti-incontinence case-specific policy of concomitant incontinence surgery only when
measure in patients with UI undergoing abdominal surgery for POP clearly indicated. ■
1. Brown JS, Waetjen LE, Subak LL, et al., Am J Obstet Gynecol, 1318–25. 1996;175:326–33.
2002; 186:712–16. 13. De Tayrac R, Chevalier N, Chauveaud-Lambling A, et al., Eur J 24. Brubaker L, Cundiff GW, Fine P, et al., N Engl J Med,
2. Subak LL, Waetjen LE, van den Eeden S, et al., Obstet Gynecol, Obstet Gynecol Reprod Biol, 2007;130: 258–61. 2006;354:1557–66.
2001;98:646–51. 14. Costantini E, Lazzeri M, Porena M, Lancet, 2008;371(9610): 25. Costantini E, Zucchi A, Giannantoni A, et al., Eur Urol,
3. Kesharvarz H, Hillis SD, Kieke BA, Marchbanks PA, MMWR Surveill 383–4. 2007;51:788–94.
Summ, 2002;51(SS05):1–8. 15. Neuman M, Lavy Y, Int Urogynecol J, 2007;18:889–93. 26. Petros PE, Ulmsten UI, Acta Obstet Gynecol Scand Suppl,
4. Jelovsek JE, Barber MD, Am J Obstet Gynecol, 2006;194: 16. Bergman A, Koonings PP, Ballard CA, Am J Obstet Gynecol, 1990;153:7–31.
1455–61. 1988;158:1171–5. 27. Daneshgari F, Moore C, BJU Int, 2006;98 (Suppl. 1):8–14.
5. Abrams P, Cardozo L, Fall M, et al., Urology, 2003;61:37–49. 17. Nygaard IE, McCreery R, Brubacker L, et al., Obstet Gynecol, 28. Kjolhede P, Wahlstrom J, Wingren G, Acta obstet Gynecol Scand,
6. Melville JL, Katon W, Delaney K, Newton K, Arch Intern Med, 2004;104:805–23. 2005;84:902–8.
2005; 165:537–42. 18. Bhatia NN, Bergman A, Gunning JE, Am J Obstet Gynecol, 29. Sivaslioglu AA, Haberal A, Dolen I, Deveci ZS, J Obstet Gynecolo
7. Swithinbank LV, Donovan JL, du Heaume JC, et al., Br J Gen 1983;147:876–84. Res, 2007;33:181–5, 17.
Pract, 1999;49: 897–900. 19. Karram MM, Int Urogynecol J Pelvic Floor Dysfunct, 30. Meltomaa SS, Haarala MA, Taalikka MO, et al., Int Urogynecol J
8. Vessey MP, Villard-Mackintosh L, McPherson K, et al., Br J Obstet 1999;10:1–21. Pelvic Floor Dysfunct, 2001;12:3–8.
Gynaecol, 1992;99:402–7. 20. Stanton SL, Hilton P, Norton C, Cardozo L, Br J Obstet Gynecol, 31. Snooks SJ, Badenoch DF, Tiptaft RC, Swash M, Br J Urol,
9. Farquhar CM, Steiner CA, Obstet Gynecol, 2002;99:229–34. 1982;89:459–63. 1985;57:422–6.
10. DeLancey JO, World J Urol, 1997;15:268–74. 21. Borstad E, Rud T, Acta Obstet Gynecol Scand, 1989;68:545–9. 32. Costantini E, Lazzeri M, Bini V, et al., J Urol, 2008;180:1007–12
11. Altman D, Granath F, Cnattingius S, Falconer C, Lancet, 22. Borstad E, Skrede M, Rud T, Acta Obstet Gynecol Scand, 33. Cosson M, Boukerrou M, Narducci F, et al., Int Urogynecol J,
2007;370:1494–99. 1991;70:501–6. 2003;14:104–7.
12. Thakar R, Ayers S, Clarkson P, et al., N Engl J Med, 2002;347: 23. Bump RC, Hurt WG, Theofrastous JP, Am J Obstet Gynecol,
76 EUROPEAN UROLOGICAL REVIEW
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92 |
Page 93 |
Page 94 |
Page 95 |
Page 96 |
Page 97 |
Page 98 |
Page 99 |
Page 100 |
Page 101 |
Page 102 |
Page 103 |
Page 104 |
Page 105 |
Page 106 |
Page 107 |
Page 108 |
Page 109 |
Page 110 |
Page 111 |
Page 112 |
Page 113 |
Page 114 |
Page 115 |
Page 116 |
Page 117 |
Page 118 |
Page 119 |
Page 120 |
Page 121 |
Page 122 |
Page 123 |
Page 124 |
Page 125 |
Page 126 |
Page 127 |
Page 128 |
Page 129 |
Page 130 |
Page 131