FEMALE UROLOGY

Effective treatment for mixed urinary incontinence with a pubovaginal sling
Chou EC, Flisser AJ, Panagopoulos G, Blaivas JG
Department of Urology, School of Medicine, China Medical College and China Medical College Hospital, Taichung, Taiwan
J Urol. 2003; 170 (2 Pt 1): 494-7

• Purpose: We assessed the results of autologous fascia pubovaginal sling (PVS) in women with mixed incontinence using a validated outcome score and identified risk factors for failure.
• Materials and Methods: A total of 131 women who received a PVS for sphincteric incontinence (SUI) confirmed by history, physical examination and/or videourodynamic study (VUDS) were identified from a database during the accrual dates 1995 to 2001. Patients with a urethral diverticulum, neoplasm or urinary fistula were excluded. Patients with SUI who also complained of urinary urge incontinence (UUI) and/or had detrusor instability that reproduced incontinence symptoms during VUDS were diagnosed with mixed incontinence (MUI). Patients completed a urological questionnaire, 24-hour voiding diary, pad test, VUDS and cystoscopy preoperatively. The diagnosis of SUI and UUI was further confirmed by physician interview. In patients with MUI detrusor overactivity was classified according to urodynamic criteria. At least 1 year postoperatively the validated Urinary Incontinence Outcome Score (UIOS) was calculated from a 24-hour diary, pad test and questionnaire, and outcomes in patients with SUI and those with MUI were compared. The study was powered a priori to detect a 20% difference in outcome score. Cured patients (UIOS 0) were compared with those who were not cured (UIOS 1 or greater) and univariate analysis was applied to identify the correlates of failed PVS.
• Results: Of the 131 patients evaluated 33 with a diverticulum or fistula were excluded and 98 underwent PVS. Patient age was 45 to 84 years (median 66). Followup was 1 to 7 years (median 3). A total of 46 patients (48.5%) had simple SUI and 52 (51.5%) had MUI. Two patients were lost to followup (2%) and the procedure was presumed to have failed. There were no differences in age, hormone status, previous surgery or pelvic organ prolapse between patients with SUI and MUI. The cure/improved rate was 97% in 44 SUI cases and 93% in 47 MUI cases, which was a nonsignificant difference (p = 0.33). Analysis of the MUI group showed that patients who were cured and not cured had similar age, parity, urethral angle, bladder capacity, leak point pressure and pad tests. Patients with MUI who were cured had a higher number of voids in 24 hours on preoperative voiding diary (12 vs 8, p = 0.01), while those who were improved or in whom treatment failed had a greater number of urgency (5.6 vs 4.1, p < 0.05) and UUI (5.1 vs 3.0, p < 0.01) episodes. Univariate analysis of MUI cases showed that an increasing number of preoperative urgency and urge incontinence episodes correlated directly with PVS failure (r = 0.33, p = 0.038 and r = 0.35, p = 0.048, respectively). In contrast, an increasing number of voids correlated with successful PVS (r = 0.4, p = 0.01).
• Conclusions: Women with SUI and concurrent urge incontinence or detrusor instability have a successful PVS outcome at a rate comparable to that in women with simple SUI, in contrast to our previous findings. Increasing episodes of urgency and urge incontinence on the preoperative voiding diary correlated directly with surgical failure, while voiding frequently was associated with cure.
  
• Editorial Comment
  The authors review 131 patients who underwent an autologous rectus fascial pubovaginal sling performed by the same surgeon. Pre-operatively, the patients completed a urologic questionnaire, 24 hour voiding diary, pad test, video urodynamics and cystoscopy. One year postoperatively the patients completed a 24 hour voiding diary, pad test, questionnaire and physical examination with a full bladder. In addition, they completed a validated urinary incontinence outcome score (UIOS) (1). The treatment outcome in patients with the preoperative diagnosis of stress urinary incontinence was compared to the outcome in patients with preoperatively diagnosed mixed urinary incontinence.
  This is a very elegant and well written paper. It offers multiple points to ponder for those surgeons treating urinary incontinence. The data the paper presents is very fair, unbiased and clear. The use of the Urinary Incontinence Outcome Score draws very firm lines between what is considered a cure, improved, and a failure (1). I use this outcome score as well when analyzing data and urge the reader to consider using it in his practice. One of the true highlights of this paper is in the discussion section, especially reviewing the outcome data presented and pondering whether a selection bias may have been found in the authors of this paper in view of their impressive previous research into this population group. The caveats they extend to the reader for the use of a pubovaginal sling with mixed urinary incontinence should be strongly reviewed and considered.

Reference
1. Groutz A, Blaivas JG, Rosenthal JE: A simplified urinary incontinence score for the evaluation and treatment outcomes. Neurourol Urodynam. 2000; 19: 127-35.

Dr. Steven P. Petrou
Associate Professor of Urology
Mayo Medical School
Jacksonville, Florida, USA