SELECTED ABSTRACTS

Poster Session 5: Urinary Incontinence

P043

Short Term Results of Minimally Invasive Outpatient Local Anaesthetic Administration of Botulinum Toxin-A for Idiopathic Detrusor Overactivity (IDO)

R.B. POPAT*, A. APOSTOLIDIS*, G. GONZALES*, T. YAP*, C.J. FOWLER* and P. DASGUPTA†
*Department of Uro-Neurology, The National Hospital for Neurology; †GKT School of Medicine and Guys & St. Thomas Hospital, UK

INTRODUCTION

We have been using a flexible cystoscope to inject Botulinum toxin-A as an outpatient procedure into the detrusor muscle and present our results of treating patients with severe IDO.

METHOD

Under antibiotic cover, 200 units of Botox® diluted in 20 ml of normal saline were injected over 20 injection sites along the dome, lateral and posterior walls of the bladder, sparing the trigone. The procedure took 20 min and patients were asked to rate discomfort on a scale of 0-10.

RESULTS

Eighteen patients (10 men) have been treated, mean age 47.0 ± 1.08 years. The mean discomfort score was 3.09 ± 0.28. There was a statistically significant improvement in the LUTS at 4 (n = 17) and 16 weeks (n = 14). One patient developed a UTI and two patients have needed to start CISC. The maximum cystometric capacity (ml) increased form 196.9 ± 23.6 to 385.8 ± 41.7 at 4 weeks and to 355.0 ± 44.5 at 16 weeks. The maximum detrusor pressure (cmH₂O) during filling reduced from 65.5 ± 10.4 to 38.1 ± 7.97 at 4 weeks and to 35.4 ± 5.77 at 16 weeks. The leak episodes in 24 hours reduced from 5.03 ± 1.19 to 0.63 ± 0.21 at 4 weeks and to 0.57 ± 0.3 at 16 weeks. The frequency of voiding reduced from 13.6 ± 0.96 to 7.71 ± 0.73 at 4 weeks and to 7.6 ± 0.82 at 16 weeks. The beneficial effects last for 9 months when injections are repeated.

CONCLUSION

Injections of botulinum toxin are well tolerated using our technique and is an effective alternative treatment for patients with intractable IDO.

P044

Short Term Results of Minimally Invasive Outpatient Local Anaesthetic Administration of Botulinum Toxin-A for Neurogenic Detrusor Overactivity (NDO)

R.B. POPAT*, A. APOSTOLIDIS*, T. YAP*, G. GONZALES*, C.J. FOWLER* and P. DASGUPTA†

*Department of Uro-Neurology, The National Hospital for Neurology; †GKT School of Medicine and Guys & St. Thomas Hospital, UK

INTRODUCTION

We have been using a flexible cystoscope to inject botulinum toxin-A as an outpatient procedure into the detrusor muscle and present our results of treating patients with severe NDO.

METHOD

Under antibiotic cover, 300 units of Botox® diluted in 30 mL of normal saline were injected over 30 injection sites along the dome, lateral and posterior walls of the bladder, sparing the trigone. The procedure took 20 minutes and patients were asked to rate discomfort on a scale of 0-10.

RESULTS

Thirty-two patients (9 men) have been treated, mean age 49.2 ± 2.08 years. The mean discomfort score was 3.09 ± 0.28. There was a statistically significant improvement in the LUTS at 4 (n = 29) and 16 weeks (n = 20). Two patients developed a UTI and 2 patients have needed to start CISC. The rest of the patients already performed CISC. The maximum cystometric capacity (mL) increased from 232.8 ± 25.6 to 534.4 ± 28.9 at 4 weeks and to 405.9 ± 32.4 at 16 weeks. The maximum detrusor pressure (cmH₂O) during filling reduced from 56.8 ± 6.9 to 27.0 ± 3.76 at 4 weeks and to 26.7 ± 3.63 at 16 weeks. The leak episodes in 24 hours reduced from 3.89 ± 0.63 to 0.5 ± 0.17 at 4 weeks and to 0.8 ± 0.23 at 16 weeks. The frequency of voiding reduced from 12.6 ± 0.74 to 6.32 ± 0.72 at 4 weeks and to 7.09 ± 0.8 at 16 weeks.

CONCLUSION

Injections of botulinum toxin are well tolerated using our technique and is an effective alternative treatment for patients with intractable NDO.

P045

Changes in Human Bladder Suburothelial Innervation Following Treatment of Detrusor Overactivity with Intra-detrusor Botulinum Toxin Injections

A. APOSTOLIDIS*, R. POPAT*, J.B. DAVIS†, P. DASGUPTA‡, C.J. FOWLER* and P. ANAND§

*National Hospital for Neurology, Department of Uro-Neurology; †Neurology and GI Centre, GlaxoSmithKline, Harlow; ‡Guy's and St. Thomas Hospitals, Department of Urology; §Hammersmith Hospital, Imperial College London, UK

INTRODUCTION

We aimed to examine the mechanism of action of intra-detrusor injections of botulinum toxin type A (BoTx/A) in intractable detrusor overactivity (DO) by studying the immunohistochemical changes in the suburothelial innervation in treated patients.

PATIENTS AND METHODS

Flexible cystoscopic bladder biopsies were obtained from 36 patients (22 neurogenic DO, 14 idiopathic DO) before and during sustained improvement at 4 and 16 weeks after treatment with BoTx/A injections. Control tissue was obtained from 11 stable bladders. Specimens were incubated with specific antibodies to the pan-neuronal marker PGP9.5, the afferent marker TRPV1 (vanilloid receptor), and the cholinergic marker acetylcholinesterase (AChE). P-values <0.05 were considered statistically significant.

RESULTS

Mean ± SEM density of PGP9.5 (+) fibres remained unchanged at 4/52 post BoTx/A (1.85 ± 0.22 vs pre: 2.04 ± 0.24, P = 0.39), and at 16/52 (1.63 ± 0.22, P = 0.35). No change was found in AChE (+) nerve fibres at 4/52 (0.91 ± 0.15 vs baseline: 0.96 ± 0.14) or at 16/52 follow-up (0.68 ± 0.16, P=0.18; controls: 0.72 ± 0.25). However, TRPV1- expressing fibres decreased at 4/52 post- BoTx/A (0.47 ± 0.11 vs 0.27 ± 0.05), but more significantly at 16/52 (0.11 ± 0.04, P = 0.0004) to controls' levels (0.17 ± 0.09).

CONCLUSIONS

Absence of substantial suburothelial neuronal or cholinergic fibre degeneration, together with the significant decrease of TRPV1 expressing fibres, or of their level of TRPV1 expression, in overactive bladders successfully treated with BoTx/A suggest that the clinical response of such patients may be partly the result of alterations in the suburothelial afferent mechanisms.

P046

Urgemeter Cystometry - Urodynamic Assesment of Urgency and the Relationship of Urge to Detrusor Overactivity

J.A. MOORE*, J.G. NOBLE* and A.F. BRADING†
*Churchill Hospital, Oxford; †University of Oxford, UK

INTRODUCTION

Bladder sensations are difficult to evaluate because of their subjective nature. The aim of this experiment is to develop better methods for assessing patient's sensations, particularly urgency, during urodynamics and evaluate the relationship between urgency and intravesical pressure change without the need for clinician to patient dialogue which may introduce bias and error.

PATIENTS AND METHODS

We designed the urgemeter which consists of a compressible hand held device connected by air filled cystometry tubing to a spare pressure transducer inputting to standard urodynamic hardware. Patients were instructed to squeeze the device if they experienced urgency and the stronger the urge the harder they should squeeze. This gave a continuous tracing of the patients urge alongside other cystometric data during artificial filling using standard urodynamic techniques.

RESULTS

22 patients with overactive bladder underwent urgemeter cystometry. Patients found the device extremely simple to use and the relationship between urgency and intravesical pressure was easy to interpret. 13/22 patients had urgency during filling with no increase in P_det. Interestingly nine of these complained of urge incontinence for which one might expect unstable contractions. 7/22 patients had urgency, five of which demonstrated a close temporal relationship between phasic increases in P_det and urgency, urge preceding pressure rise in all. Two patients had normal cystometrograms and no urgency.

CONCLUSIONS

This prototype facilitates patient recording of urgency during cystometry and introduces objectivity into the assessment of sensation during artificial filling. For the majority of patients detrusor pressure increase was not prerequisite for the sensation of urgency.

P047

Comparison of Transurethral Collagen Injection and Perineal Bone-anchored Male Sling for the Treatment of Intrinsic Sphincter Deficiency

A. SINGLA and R. ONUR
Wayne State University, Department of Urology

PURPOSE

In the present study we compared the efficacy of collagen injection and bone-anchored male sling in the treatment of post-prostatectomy incontinence.

PATIENTS AND METHODS

Two cohorts of men, one which received transurethral collagen injection (group 1) and one perineal bone-anchored male sling (group 2) using In-Vance bone drill (American Medical Systems, Minnetonka, MN, USA) were examined. Patient characteristics, mean injection of collagen, mean cumulative volume, post-operative outcome and complications were noted. Efficacy of the procedures were compared between two groups.

RESULTS

A total of 34 incontinent patients (mean age 69), received a mean of 2.1 injections of collagen (mean cumulative volume injected 9 ml.) whereas, thirty-seven men, (mean age 71) underwent male sling. Preoperatively, patients required a mean of 5.5 and 4.2 (1-10) pads per day, respectively. Mean follow-up was 15 vs. 18 months. There was no difference between two groups with respect to postoperative complications, i.e. urinary retention, de novo urge/urge incontinence, infection and urethral erosion (P < 0.001). Postoperatively, five patients (15%) were dry and 4 (12%) were improved in group 1, whereas 15 (41%) patients in group 2 were cured and 13 (35%) improved. The success rates for collagen and male sling were 27% and 76%, respectively. There was a significant difference between two groups (P < 0.05).

CONCLUSION

Our results demonstrate that patients who undergo male sling placement for mild to moderate incontinence are more likely to be completely continent and also have a much higher rate of improvement compared with patients treated with collagen injections. However, further studies are needed to define long term success.

P048

Sling Surgery for Stress Urinary Incontinence: Feasibility and Safety of a Day-case Approach

S.K. GIRI*, J. MAC DONALD*, J.P. HICKEY*, H.P. REDMOND†, J. DRUMM* and H.D. FLOOD*
*Regional Hospital and NIHS, University of Limerick, Ireland; †University College Hospital, Cork, Ireland

AIM

To assess in a prospective fashion the feasibility for discharge at 10 h following xenograft (Pelvicol) pubovaginal sling procedure.

MATERIALS AND METHODS

Between June 2003 and November 2003, 30 consecutive patients with stress urinary incontinence (SUI) were enrolled prospectively. Patients were admitted with a planned overnight stay and returned to the ward after operation without urinary catheter. Patients were assessed at 4, 10 and 24 h postoperatively. Time interval to first spontaneous void (TIFV), emptying efficiency (EE) and suitability for discharge were assessed. The EE was calculated as EE = VV x 100/ VV + PVR %; VV = voided volume, PVR = post void residual. Patients were considered ready for discharge from hospital when EE was >= 75% or when self-catheterizing confidently.

RESULTS

The mean TIFV was 7.1 h (median 6, 95% CI = 5.2-8.5). The mean EE at 10 h was 65.5% (median 60%, 95% CI = 56.8-76.2 %). Twelve patients (40%) achieved EE >= 75% at 10 h and another 3 (10%) were able to perform self-catheterization. Thus, overall 15 patients (50%) would have been dischargeable at 10 h. Non-dischargeable patients were more likely to be older (>60years) and to have the Valsalva leak point pressure of <60 cm of H₂O.

CONCLUSIONS

These data show that 50% of patients are suitable for day-case sling surgery. Early postoperative emptying inefficiency and inability to perform self-catheterization are the main limiting factors. Careful patient selection based on age and urodynamic findings may improve the feasibility of daycase sling surgery.

P049

Prospective Randomized Trial of Xenograft Versus Rectus Fascia Pubovaginal Sling in the Treatment of Stress Incontinence

S.K. GIRI, O. CLYNE, J.P. HICKEY, G. NARASIMHULU, J. DRUMM and H.D. FLOOD
Regional Hospital and NIHS, University of Limerick, Ireland

INTRODUCTION AND OBJECTIVE

The pubovaginal fascial sling operation has become the first line surgical treatment for stress urinary incontinence (SUI). We compared the early morbidity and longer term efficacy of the rectus fascia sling with that of the xenograft sling in the treatment of SUI.

METHODS

Between January 2001 and March 2002, 65 patients with SUI were randomly assigned to either rectus fascia sling (group 1, n = 31) or xenograft sling (Pelvicol, group 2, n = 34). Mean age was 49 years. Minimum follow-up was 18 months (range 18-30). At follow-up each patient was evaluated by a blinded assessor. Outcome measures included postoperative visual analogue pain score (VAS) (0=no pain, 10=maximum pain), length of stay, postoperative complications, time to return to work, persistence or recurrence of SUI, urge symptoms and subjective improvement.

RESULTS

The groups were well matched for age, type of SUI and urge symptoms. The mean postoperative VAS was 6.18 in group 1 and 2.1 in group 2 (P < 0.001, Wilcoxon rank sum test). The mean length of stay was 4.9 days vs. 2.8 days (P < 0.01) and the mean time to return to work was 9.1 weeks vs. 4.5 weeks (P < 0.001) in group 1 and group 2 respectively. Overall SUI was cured or significantly improved in 26 patients (83.8%) in group 1 and 27 patients (79.4%) in group 2 (P > 0.05).

CONCLUSIONS

The xenograft sling offers significant reduction in early morbidity without compromising longer term efficacy when compared with the autologous rectus fascia sling.

P050

Are TVT Polypropylene Slings Colonized by Muscular Fibres? A Histopathological Evaluation of Resected Tapes for Voiding Dysfunction

J.F. HERMIEU, M. TOUBLANC, B. LHOEST, V. DELMAS, V. RAVERY, L. BOCCON GIBOD and C. BICHAT
Clinique Urologique, Hopital Bichat, Paris, France

PURPOSE

Tension free vaginal tapes (TVT) made of polypropylene mesh are increasingly used in the treatment of female stress urinary incontinence (SUI). It is claimed by the manufacturer that the tape will be over time colonized by muscular fibres which will add their own effect to the simple mechanical suspension of the distal urethra. This study was undertaken to check this hypothesis.

PATIENTS AND METHODS

15 consecutive patients submitted to a TVT for SUI and suffering from voiding dysfunction (obstruction/de novo urgency) were treated by tape resection, 6 to 40 month after implantation. The resected tapes were submitted to hispathologic evaluation using standard stain (HPS) and immunohistochemistry (Vimentin, Actin, CD8) to detect the presence of fibroblast and muscle fibres.

RESULTS

Fibroblast and macrophages were detected around the fibres of every tape in a quantity inferior to what is normally seen in foreign body inflammatory reaction. 13/15 tapes were colonized by muscular fibres considered to be rare to abundant with no special relationship between the duration of implantation and the number of fibres.

CONCLUSION

This study shows that indeed TVT meshes are colonized by muscular fibres and induce only a limited inflammatory reaction. This explains the good tolerance usually observed. The exact contribution of muscular fibres to the recovery of continence remains to be investigated.

P051

Single Centre Experience of the Monarc™ Subfascial Hammock for the Treatment of Female Stress Urinary Incontinence (SUI)

G.H. URWIN and S. HEATON
York Hospital, UK

INTRODUCTION

The tension-free vaginal tape has become the most commonly used technique for the treatment of female SUI. However, its blind needle passage has been associated with complications. The transobturator approach avoids the retropubic space and should result in decreased complication rates but with equivalent efficacy.

PATIENTS AND METHODS

Between April and December 2003, 48 patients with SUI were implanted with the Monarc™ subfascial hammock. Effectiveness was evaluated objectively by physical examination, urodynamics, 1-h pad weight test and subjectively by patient-completed Urogenital Distress Inventory Short Form (UDI-6).

RESULTS

Mean age of patients was 55.6 years (range 33-84) 13 patients (27%) had undergone previous incontinence surgery. The mean operative time was 20 minutes and all patients went home without a catheter. Patients used on average 3.9 pads/day preoperatively. Pad use decreased to 0.6 pads/ day at 6 weeks and 0.4 pads/day at 3 months. Preoperative 1-h pad weight tests showed a mean pad weight of 69 g. Pad weight decreased to 4.3 g at 6 weeks and 3.9 g at 3 months. Mean UDI-6 scores were 70.1, 17.9 and 15.7 preoperatively, 6 weeks and 3 months, respectively. One urethral perforation was sustained and 3 patients developed de novo detrusor overactivity. 2 patients reported slight voiding difficulties at 3 months.

CONCLUSIONS

These early results demonstrate that the Monarc™ sub fascial hammock is an effective and safe operation in the treatment of female SUI and avoids the potential risk of vascular or intestinal injury particularly in patients who have had previous pelvic surgery. Further follow up however, is needed.

P052

Evaluation of the Periurethral Adjustable Continence Therapy (ACT™) Device for the Treatment of Post Prostatectomy Incontinence
Results at 1 year

P.J. GILLING, D. BELL, K.M. KENNETT, A.M. WESTENBERG and M.R. FRAUNDORFER
Promed Urology, Tauranga, New Zealand

INTRODUCTION AND OBJECTIVES

The adjustable continence therapy (ProACT™) device has been designed to provide extrinsic compression of the membraneous urethra. It consists of two contralateral balloons each placed periurethrally, and attached via a conduit to a subcutaneous port placed in the scrotum. This enables postoperative balloon adjustment. We aimed to assess the efficacy of this device in the treatment of postprostatectomy incontinence.

MATERIALS AND METHODS

16 post radical prostatectomy (8 perineal and 8 retropubic) and 7 post transurethral prostatic resection or holmium enucleation patients have been enrolled and treated to date. Subjective and objective parameters including the Incontinence Quality of Life questionnaire (I-QoL) and pad usage were measured at baseline and followed up at 1, 3, 6 and 12-month intervals. Urodynamics studies were conducted at baseline and at 6 months. Perioperative data, number and volume of adjustments and adverse events were also recorded.

RESULTS

9 of 14 patients were either cured or significantly improved at 3 months. No difficulties were encountered with balloon placement and there were no perioperative complications. Mean OR time was 27 (13-48) min. I-QoL scores increased from a mean of 51.8 (13.6-94.3) at baseline to 82.4 (29.5-96.6) at 12 months, representing a significant improvement. Pad usage dropped from a mean of 2.9 (1-12) at baseline to 0.28 (0-1) at 12 months. 13 out of 20 patients required a one time balloon adjustment and 7 out of 20 required a secondary adjustment, one required no adjustment. Two patients did not respond, and had an AUS placed. There were 3 infections necessitating implant removal.

CONCLUSIONS

Most patients (80%) are cured or have a significant improvement following ACT device placement for post-prostatectomy incontinence.