Surgery of Female Incontinence

In this book we have expert urologists and gynaecologists on the two sides of the Atlantic working together with a common interest, the inadequate female urethra. What makes this volume so valuable is that it is not restricted to one speciality or one cult, but bravely (and systematically) presents established principles and practice. Not only is the current knowledge of the anatomy and function of the continence mech­ anisms defined by experts carefully selected by the two authorities in the field, but this infor­ mation is directly applied to clinical problems for the reader to use in the care of patients. Because the basics are presented first, and followed by the methods of diagnosis, the sec­ tions describing each form of treatment, whether medical or surgical, are set on rational bases. These are not cookbook directions. This background is especially valuable because the incontinent female usually has a complicated disorder, each case being different, so that the responsible gynaecologists or urologists must apply as much understanding as technique if their efforts are to achieve dryness. The clear descriptions and illustrations in this book, then, act as guides as much as directives. This second edition builds on the success of the first. All of us trying to help these unfortu­ nate women will do more for them from having this new edition at hand.

1 The Mechanism of Continence.- Embryology of the Lower Urinary Tract.- Development of the Embryonic Plate.- Formation of the Cloaca.- Partitioning of the Cloaca.- Development of Nephrogenic Mesoderm.- Formation of the Bladder, Urethra and Trigone.- Epithelium of the Bladder Base and Urethra.- Anatomy of the Lower Urinary Tract.- The Bladder.- The Urethra.- Pubourethral Ligaments.- Neurological Control of Micturition.- Innervation of the Detrusor.- Innervation of Urethral Smooth Muscle.- Innervation of Striated Muscle.- Central Nervous Connections of the Lower Urinary Tract.- Physiology of the Lower Urinary Tract.- The Behaviour of the Bladder.- The Urethra.- The Normal Micturition Cycle.- Pathophysiology of Urinary Incontinence.- General Considerations.- Genuine Stress Incontinence.- The Effects of Incontinence Surgery on Urethral Function.- Conclusions.- 2 Investigation of Incontinence.- Classification of Incontinence.- Adverse Factors.- Indications for Urodynamic Studies.- Clinical Assessment.- History.- Examination.- Investigations.- Urethrocystoscopy.- Uroflowmetry.- Urethral Function Tests.- Cystometry.- Radiology.- Electromyography.- Ultrasound.- Perineal Pad Test.- The Future.- 3 Congenital Causes of Incontinence.- Assessment of the Wet Girl.- General.- History Taking.- Physical Examination.- Investigations.- Ureteric Ectopia.- Embryology.- Duplex System Ureteric Ectopia.- Single System Ureteric Ectopia.- Urogenital Sinus Abnormalities.- Vaginal Atresia and Wide Urethra.- Vaginal Confluence with Wide Bladder Neck.- Cloaca.- Exstrophic Anomalies.- Embryology.- Bladder Exstrophy.- Epispadias.- Cloacal Exstrophy.- Congenital Neuropathic Bladder.- Presentations.- Classification and Pathophysiology.- Investigation.- Management.- 4 Anterior Repair.- Pre-operative Evaluation.- Patient Selection.- Contraindications.- Pre-operative Preparation.- Operative Technique.- Post-operative Management.- Care.- Complications.- Follow-up Assessment.- Results.- Mechanism of Failure.- 5 The Marshall-Marchetti-Krantz Procedure.- Indications and Contraindications.- Pre-operative Evaluation.- Operative Technique.- Post-operative Management.- Complications.- Follow-up Assessment.- Results.- Summary.- 6 Colposuspension.- Terminology.- Indications and Contraindications.- Pre-operative Evaluation.- Pre-operative Preparation.- Operative Technique.- Post-operative Management.- Complications.- Follow-up Assessment.- Results.- Causes of Failure.- 7 Sling Procedures.- Indications.- Classification.- Pre-operative Evaluation.- Operative Technique.- Inguinovaginal Fasciai Sling.- Dural and Alloplastic Sling.- Post-operative Management.- Complications.- Follow-up Assessment.- Results.- Summary.- 8 Endoscopic Suspension of the Vesical Neck.- Indications and Contraindications.- Pre-operative Evaluation.- Operative Technique.- Abdominal Incision.- Vaginal Incision.- Stamey Needles.- Use of Endoscopy.- The New Pereyra-Lebherz Suspension.- Post-operative Management.- Care.- Complications.- Follow-up Assessment.- Results.- Summary.- 9 Abdominoperineal Urethral Suspension: The Zacharin Procedure.- Indications and Contraindications.- Pre-operative Investigations and Preparation.- Operative Technique.- Post-operative Management.- Complications.- Follow-up Assessment.- Results.- Mechanism of Failure.- Conclusions.- 10 Neourethra: Rationale, Surgical Technique and Indications.- Anatomical Considerations and Rationale for Operation.- Indications.- Pre-operative Evaluation.- Operative Technique.- Tanagho Technique (Anterior Bladder Flap).- Leadbetter Technique (Trigonal Tube).- Post-operative Management.- Complications.- Case Examples.- Results.- Mechanism of Failure.- Summary.- 11 Artificial Sphincter.- Developmental History.- The First Model, AS 721.- Sphincter with Pressure-Regulation Balloon, AS 761.- Automatic Reflation Sphincter AS 742.- Automatic Reflation Sphincter AS 791/792.- Model AS 800; Controlled Activation and Deactivation.- Indications.- Pre-operative Evaluation.- Selection of Model.- Operative Technique.- Aseptic Technique.- Patient Position.- Instrumentation.- Surgical Procedure.- Selection of Cuff Size.- Cuff Implantation.- Selection of Balloon Pressure Reservoir.- Post-operative Management.- Results and Discussion.- Summary.- 12 Urinary Diversion.- Classification of Patients.- Choice of Diversion.- Ileal Loop.- Pre-operative Management.- Technique.- Post-operative.- Ureterocolic Anastomosis.- Pre-operative Management.- Technique.- Post-operative.- Continent Heal Pouch.- 13 Urethrotomy.- Methods of Investigation.- Techniques.- Urethral Dilatation.- Internal Urethrotomy.- Bladder Neck Procedures.- Alternative Techniques.- Bladder Drainage.- Conclusions.- 14 The Management of Vesicovaginal and Urethral Fistulae.- Aetiological Groups.- Obstetric.- Surgical Trauma.- Pelvic Malignancy.- Clinical Presentation.- Pre-operative Care.- Early Management.- Associated Conditions.- Concurrent Rectovaginal Fistulae.- Local Assessment.- Surgical Repair.- General.- Vaginal Route.- Abdominal Route.- Post-operative Management.- Complications.- Results.- Management of Failure.- 15 Ureterovaginal Fistulae.- Operative Injuries.- Obstetric Laceration.- Invasion by Growth.- Time of Occurrence.- Early.- Intermediate.- Late.- Recognition of Fistula.- Confirmation of Urinary Leakage.- Confirmation of Ureteric Fistula.- Spontaneous Closure of Fistulae.- Timing of Operative Intervention.- Pre-operative Investigation and Preparation.- Identification of the Side of the Fistula.- Recognition of Level.- Operative Procedures.- Objectives.- Exploratory Laparotomy.- Selection of Procedure.- Direct Reimplantation.- Indirect Reimplantation.- Bilateral Ureteric Injuries.- Primary Nephrectomy.- Urinary Diversion.- Post-operative Complications.- Leakage.- Stenosis.- Urinary Infection.- Reflux.- Late Recurrence of Ureterovaginal Fistula.- Summary.- 16 Pharmacology of the Bladder and Urethra.- Pharmacology of the Lower Urinary Tract.- Principles of Pharmacological Therapy.- Specific Methods of Pharmacological Therapy.- Therapy to Facilitate Bladder Emptying.- Therapy to Facilitate Urine Storage.- Effect of Tricyclic Antidepressants.- Effects of Other Pharmacological Agents.- 17 Electrostimulation.- Sacral Root Stimulation.- Background.- Animal Studies.- Human Studies.- Electrode Implantation.- Pre-operative Evaluation.- Method.- Accomplishments from Human Implantations.- Other Applications of Percutaneous Sacral Root Implantation.- Summary.- 18 Post-operative Voiding Dysfunction.- Pathophysiology.- Problems of Inhibition—the Large Bladder.- Problems of Facilitation—the Unstable Bladder.- Surgical Causes.- Prevention.- Treatment.- Long-term Management.- 19 Post-operative Catheter Drainage.- Indications.- Suprapubic Versus Urethral Drainage.- Technique.- Urethral.- Suprapubic.- Conclusion.- 20 Choice of Surgery.- I.- Coexistent Gynaecological Conditions.- Urodynamic Contraindications.- Urodynamic Factors.- Bladder Neck Elevation.- Urethral Alignment.- Urethral Resistance.- Choice of Surgery.- II.- Differential Diagnosis.- Treatment.- Problems in Management.