Abstract
The aim of the study was to introduce an anatomical classification for the management of urinary dysfunction based on the Integral Theory, a new connective tissue theory for female incontinence. Eighty-five unselected patients, aged 27–83 years, 12 with pure stress symptoms and 73 with mixed incontinence symptoms, were classified as having laxity in the anterior, middle or posterior zones of the vagina, using specific symptoms, signs and urodynamic parameters summarized in a pictorial algorithm. Special ambulatory surgical techniques, which included the creation of neoligaments, repaired specific connective tissue defects in the anterior (intravaginal slingplasty (IVS),n=85), middle (cystocele repair,n=6), or posterior zones (uterine prolapse repair,n=31, or infracoccygeal sacropexy,n=33). Almost all patients were discharged within 24 hours of surgery, without postoperative catheterization, returning to fairly normal activities within 7–14 days. At (mean) 21-month follow-up cure rates were: stress incontinence 88% (n=85), frequency 85% (n=42), nocturia 80% (n=30), urge incontinence 86% (n=74), emptying symptoms 50% (n=65). Mean objective urine loss (cough stress test) was reduced from 8.9 g preoperatively to 0.3 g postoperatively, and mean residual urine >50 ml from 110 ml to 63 ml,P=<0.02. Pre- and postoperative urodynamics indicated that detrusor instability was not associated with surgical failure. Two new directions, based on the Integral Theory, are presented for the management of female urinary dysfunction, an anatomical classification which delineates three zones of vaginal damage, and a series of ambulatory surgical operations which repair these defects. The operations are fairly simple, safe, effective and easily learnt by any practising gynecologist.
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EDITORIAL COMMENT: This study is very interesting and opens a series of stimulating concepts. The authors report 85 cases of women with incontinence due to different etiologies; most of these individuals underwent ambulatory surgery that strengthened the supporting structures of the urethra using an artificial tape without elevating the bladder neck. The tape was implanted at the level of the midurethra in the retropubic area, without being sutured to surrounding structures. The procedure also ‘tightened the vaginal hammock’ and corrected other pelvic support defects when necessary. This group of patients had a high success rate (>80%) for cure and/or improvement of their incontinence, urgency, frequency and nocturia. All this was hypothesized to be the conseqeunce of correcting ‘laxity of the vagina and its supporting ligaments’. This group of patients had a wide spectrum of lower urinary tract pathologies and with the data presented in this manuscript the conclusions of the authors goes beyond the available evidence. The high success rate, easy technique, low morbidity and the short recovery time make this procedure very attractive for the practising gynecologist and urologist. We would like to see the data presented in this article confirmed by prospective comparative studies.
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Papa Petros, P.E. New ambulatory surgical methods using an anatomical classification of urinary dysfunction improve stress, urge and abnormal emptying. Int Urogynecol J 8, 270–277 (1997). https://doi.org/10.1007/BF02765483
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DOI: https://doi.org/10.1007/BF02765483