New approaches improve incontinence management

August 15, 2007

The array of devices and procedures available to treat urinary incontinence and bladder dysfunction appears to be growing nonstop.

Shlomo Raz, MD, director of female urology, urodynamics, and reconstructive surgery at the UCLA Medical Center, summarized and analyzed the meeting's most important take-home messages in female urology and incontinence for Urology Times.

A transobturator male sling for mild to moderate stress urinary incontinence supports the dorsal surface of the sphincter complex by repositioning it proximally.

A new transobturator sling system known as AdVance (American Medical Systems, Minnetonka, MN) has shown some promise in this regard. In a cohort of 28 incontinent men, the procedure managed to reduce total pad usage per day from an average of 5.6 pads per patient to 0.6 pads. Twenty-four patients (86%) were down to 0 to 1 pad per day, while 17 (61%) were completely dry. Pre and postoperative flow rates were essentially the same. No patient suffered from retention.

"While the initial results of the procedure can be encouraging, we need long-term data," said Dr. Raz, noting that 10 patients had 6 months of follow-up, 10 others had 3 months follow-up, and the remaining eight were observed at discharge on the second postoperative day.

The use of neuromodulation is growing worldwide, and is generating data on long-term outcomes. Efficacy rates are very high in retention attributed to Fowler's syndrome.

Neuromodulation works relatively well for overactive bladder, but a team of British researchers reported encouraging results in the use of neuromodulation in patients with urinary retention from Fowler's syndrome, as well.

Follow-up was 84.2 months for patients who had undergone single-stage sacral neurostimulation and 11.7 months for two-stage patients. Rates of spontaneous voiding (>200 mL) were 70% and 73% in the two groups, respectively. Fewer than 10% of patients in either group required continued clean intermittent self-catheterization.

"Recent studies using PET scans show that the mechanism of action of neuromodulation for urinary retention is in the brain stem and cingulated cortex, which indirectly control the sacral root reflexes," Dr. Raz said.

Complications were prevalent in the study. The most common were box site pain, leg pain or numbness, lead migration, and new-onset pelvic pain, suggesting a need for careful patient counseling and selection prior to implementation.

Obstructive voiding symptoms correlate poorly with urodynamic evaluation of obstruction in prolapse, and high bother correlates poorly with urodynamic evidence of obstruction.

Investigators from UCLA examined 75 consecutive patients with grade 4 cystocele using videourodynamics and patient self-assessment. They found that while obstructive voiding symptoms were common in this population, patients were not necessarily bothered by them.

Moreover, they observed, videourodynamics had significant limitations when it came to diagnosing obstruction. Only patients with high bother scores seemed likely to benefit from urodynamic evaluation.

"This paper challenges the usefulness of urodynamic evaluation in patients with severe cystocele," Dr. Raz said. "There was no correlation between patient complaints of difficulty to empty and post-void residuals, and findings of urodynamic obstruction.

"What, therefore, is obstruction in a patient with severe cystocele? We don't have a clear answer, but we can say that if a patient complains of obstruction and the urodynamic findings don't show it, the patient may be still be obstructed. We should rely more on patient symptoms than the results of a test."

Long-term response to botulinum toxin A (Botox) injections in wet and dry overactive bladder is 70% to 80%, respectively, with repeat injections needed in about one-third of patients by 11 months.