Journal of Clinical Urology

To evaluate the complication rates and long-term results of tension-free vaginal tape (TVT) placement for a single surgeon, in terms of objective assessment and patient reported outcome.

Data are presented for 118 cases treated between 1998 and 2004. All patients had proven urodynamic stress incontinence (USI) and were asked to complete a postal symptom questionnaire at a median of 62 months post-procedure.

Mean duration of incontinence was 6.6 years, and 18.6% of patients had undergone previous incontinence surgery. Median hospital stay was 24 h. Complications were bladder perforation in 6.8%, failure to void 11%, haemorrhage 0.8% and late bladder, urethral and vaginal erosions in 3.4%, 0.8% and 1.7%, respectively. Overall continence rates were 86.4% (102/118) at a mean follow-up of 14.5 months. At a mean of 62 months post-operatively (range 31–102 months), questionnaire response rate was 54/118 (45.8%). 72.2% (30/54) of patients reported cure or improvement in symptoms, and 43/52 (82.7%) would recommend this procedure to a friend with similar symptoms.

The outcomes reported compare favourably with published series and confirm the benefit of TVT as a procedure for USI. Patient satisfaction is high and morbidity low.

To assess the long-term effectiveness of polydimethylsiloxane (PDS, Macroplastique™) perisphincteric injections in treating male sphincter weakness incontinence (SWI) caused by spinal cord injury (SCI).

Fourteen male patients with SCI underwent PDS injection to the external urethral sphincter for SWI (mean age: 50.1 years; range: 32–79 years). A single surgeon at a specialist spinal injury unit managed all patients. Complete cure was defined as cessation of pad usage with no evidence of leakage on video cystometrogram (VCMG). Partial cure with improvement was defined as >50% reduction in the number of pads used with incontinence present on VCMG.

Twelve of the 14 patients had a mean (range) follow-up of 8.7 (6.8–10.5) years. One patient was lost to follow-up at 2 years and one other died at 19 months from an unrelated chest infection. Four patients required repeat injections. Cure was achieved in three patients (25%); two were completely dry at 7.5 years while one was partially dry at 8.7 years. The remaining nine patients required further interventions to achieve continence.

The use of PDS can be contemplated as first-line treatment in SWI in SCI patients. The long-term effect can, however, be non-durable and repeat injections may be required.

We report the outcomes of transvaginal (TVT)/transobturator (TOT) tape in women with multiple or complex urogynaecological intervention and persistent stress urinary incontinence (SUI).

Thirty-seven patients with multiple procedures (median 3) or complex urogynaecological intervention for SUI, McGuire classified on videourodynamics, underwent TVT (n = 26) or TOT (n = 11) placement. Patients categorised outcome as excellent, good or poor. Excellent was defined as dry, asymptomatic and completely satisfied. Good was defined as no SUI but residual or de novo urgency, or lack of complete satisfaction. Poor was defined as minimal improvement of symptoms. All patients with residual symptoms underwent repeat video-urodynamics.

Mean follow-up was 37 months. Thirty-two patients (86%) were cured of SUI. According to the outcome definitions 46% were excellent, 30% good and 24% poor. Of six patients with McGuire type III SUI, five (83.3%) had persistent SUI, accounting for all with persistent SUI. Bladder perforation and de novo urgency occurred in 11.5% and 19.2% of TVT, but none of those with TOT. Temporary voiding difficulty occurred in 11.5% TVT and 9.1% TOT. Protracted retention occurred in two TVT cases, of which one required tape division.

TVT/TOT cured SUI in 86% of patients with multiple SUI procedures or complex urogynaecological intervention, with minimal morbidity. Subjective outcomes were less than objective outcomes mainly due to urgency. The TOT route reduced the risk of bladder injury and de novo urgency. Type III SUI on preoperative urodynamics predicted failure.

In the United Kingdom, radiotherapy as opposed to cystectomy has been the preferred treatment modality in invasive bladder cancer [Bower M, Ma R, Savage P, Abel P, Waxman J. British urological surgery practice. 2. Renal, bladder and testis cancer. BJU 1998;81:513–7]. However, there appears to have been a recent shift from this approach in favour of radical cystectomy. Against this background, we conducted to postal survey of all full UK urologists to ascertain their practice.

The aim of the study was to find out about the current practice of management of muscle invasive bladder cancer in the UK, in particular the shift from radiotherapy to radical surgery as the preferred method of treatment.

A 19-point questionnaire on management of muscle invasive bladder cancer was posted to all UK based full BAUS members.

478 questionnaires were sent and 139 valid responses received. Ninety percent used CT as the staging investigation; only 43% requested a bone scan. Eighty two percent offered radical cystectomy as the treatment of choice, of these 94% also undertook limited or extended pelvic node dissection. Five percent used neo-adjuvant radiotherapy. Sixty nine percent routinely undertook an ileal conduit diversion; 31% discussed other forms of diversion and only 6% undertook ortho-topic bladder reconstruction routinely. Recurrence after radiotherapy was treated by salvage cystectomy by 87%. The majority of respondents offered life-long follow-up.

Radical cystectomy is the favoured treatment of UK urologists for muscle invasive bladder cancer. Ileal conduit is still the preferred method of diversion and only a small minority offer orthotopic reconstruction.

Perhaps better patient education as well as better reconstructive training opportunities for cancer urologists will make neobladders a favoured option in the future.