Ultrasound imaging of the lower urinary system in women after Burch colposuspension

Transcription

1 Ultrasound Obstet Gynecol 2001; 17: Ultrasound imaging of the lower urinary system in Blackwell Original Paper Science, Ltd women after Burch colposuspension A. MARTAN, J. MASATA, M. HALASKA and R. VOIGT* Department of Obstetrics and Gynecology, Charles University, Prague, Czech Republic and *Frauenklinik, Robert-Koch-Krankenhaus Apolda, Germany KEYWORDS: Female urinary incontinence, Perineal ultrasound, Burch colposuspension, Urinary bladder neck ABSTRACT Objective Most of the relevant surgical procedures employed in the management of genuine stress urinary incontinence (GSI) involve the technique of bladder neck elevation. The appropriate level of suspension is an important (but frequently overlooked) consideration as the clinical consequences of overcorrection of the posterior angle are voiding dysfunction and urgency symptoms. The aim of our study was to compare ultrasound characteristics in women with GSI with those of women before and after Burch colposuspension. The findings of our study should have implications for GSI management. Design Prospective randomized clinical study at the Department of Obstetrics and Eynecology, Charles University, Prague, Czech Republic. Setting Department of Obstetrics and Gynecology, Charles University, Prague, Czech Republic. Methods Seventy women with previously untreated GSI (preoperative group) and 52 women (42 of whom had been in the preoperative group) who were studied 3 12 months after receiving Burch colposuspension (postoperative group) took part in the study. The standard transperineal and introital ultrasound scans were performed. The mobility of the bladder neck was assessed transperineally with a curved array probe after instillation of 300 ml of saline. The bladder was then evacuated and the thickness of the urinary bladder wall in the sagittal plane in defined regions (base, vertex and anterior wall) was measured. Results We found significant differences in bladder neck position, mobility, and in bladder wall thickness. Where symptoms of urgency occurred, the average bladder wall thickness was > 5 mm, the gamma angle < 40, and lower bladder neck mobility was evident. Conclusion These findings supported our hypothesis that signs of urgency follow over-elevation of the bladder neck. These results helped us significantly to refine our GSI management. INTRODUCTION The prevalence of urinary incontinence increases from 5% among young women up to 50% in the older female population. By definition, genuine urinary stress incontinence (GSI) is the involuntary leakage of urine due to increased intra-abdominal pressure. The peak prevalence is between the 40th and 54th year of life 1,2. Poor anatomical support of the urinary bladder neck and proximal urethra results in its descent and hypermobility 3 5. This phenomenon is considered to be the main reason for GSI Most relevant surgical procedures describe well the technique of bladder neck suspension, but the desirable grade of the elevation is usually addressed only vaguely A hyper-correction can result in disturbing voiding difficulties and in urgency 17. The aim of our study was to analyze the anatomical setting of the lower urinary tract in patients with GSI before and after surgery. The results should serve as feedback for GSI management. PATIENTS AND METHODS Seventy women with previously untreated GSI (preoperative group) and 52 women, 3 12 months after receiving Burch colposuspension (postoperative group) took part in the study. Of the preoperative group, we operated on 42 women who then made up part of the postoperative group. The postoperative group (n = 52) included 40 women from our department, where the effect of the operation was satisfactory and we did not register any symptoms of urgency. Two patients still with urgency symptoms came from our department and 10 women with urgency symptoms were sent to our department after surgery at other hospitals. Their inclusion was important in order to enlarge the group with urgency symptoms and the postoperative group as a whole. The mean age in the preoperative group was 53.1 years (SD 10.5), the mean weight was 71.2 kg (SD 11.3) and mean parity was 2.1 (SD 0.6). The mean values in the postoperative group 3 12 months after colposuspension were 49 years (SD 10.8), 70.8 kg (SD 13.5) and parity 2.0 (SD 0.8), respectively. The diagnosis of GSI was reached by urodynamic examination, stress test and pad-weight test. After informed consent Correspondence: Dr A. Martan, Department of Obstetrics and Gynecology, Charles University, Unemocnice 2, Prague 2, Czech Republic ( martan@vfn.cz) Received , Revised , Accepted ORIGINAL PAPER

2 Table 1 Ultrasound of the lower urinary tract x distance. Summary statistics and K S test x distance (mm) Mean value Median Mode Standard deviation K-S test Figure 1 Ultrasound parameters. X, axis of symphysis; Y, perpendicular to axis X in the inferior point of symphysis; p, distance between the inferior point of symphysis with the bladder neck and the axis of symphysis (X); x, distance between UV junction and axis Y; y, distance between UV junction and axis X; γ angle, angle between the line connecting the inferior point of symphysis with bladder neck and the axis of symphysis. The position of UVJ on the axis X, Y is indicated + or. was obtained, the bladder of a patient in supine position was filled with 300 ml of sterile saline. Then a 5-MHz curved array probe was used to assess the bladder neck mobility from a perineal approach. The measurement was performed at rest, during Valsalva (during maximal increasing of intra-abdominal pressure, which was rehearsed during urodynamic examination) and during maximum squeezing of pelvic floor 18. The direction of movement of the urethrovesical junction (UVJ) on the axis X, Y was indicated + or (Figure 1). After voiding, a 7-MHz sector vaginal probe was used for the rest of the examination. The bladder wall thickness in the base, vertex and anterior wall were measured 19. The urodynamic examination was repeated only in patients suffering from urgency. For the statistical evaluation, the t-test, 95% confidence interval and difference rows were used. The variables were normally distributed (tested by Kolmogorov Smirnov test); only in parameters x, y, p DIFF.1 and DIFF.2 in the group of women without urgency were they not. RESULTS Significant differences were found in bladder neck position and mobility between those women with GSI and those who had undergone Burch colposuspension. Twelve women in the postoperative group (n = 52) suffered from urgency, and a statistically significant larger distance x and shorter distance y were found, at rest and during Valsalva, compared with the same distances in women after Burch colposuspension and without urgency symptoms (P = 0.001) (Tables 1 3, Figures 2 4). The direction of movement of the UV junction during increased intra-abdominal pressure in women with urgency symptoms is forward (P = ). We noticed a slight paradoxical diminishing of the gamma angle during the Valsalva maneuver (Table 4, Figures 5 and 6). Where symptoms of urgency occurred, the average bladder wall thickness was > 5 mm (Table 5, Mean value Median Mode Standard deviation K-S test Mean value Median Mode Standard deviation K-S test x, distance between UV junction and axis Y (the perpendicular to axis X in the inferior point of symphysis); y, distance between UV junction and axis X (the axis of symphysis); p, distance between the inferior point of symphysis and bladder neck; DIFF.1, the difference between distance (x, y, p) during Valsalva and distance (x, y, p) during squeezing; DIFF.2, the difference between distance (x, y, p) during Valsalva minus distance (x, y, p) during rest. Table 2 Ultrasound of the lower urinary tract y distance. Summary statistics and K S test y distance (mm) Mean value Median Mode Standard deviation K-S test Mean value Median Mode Standard deviation K-S test Mean value Median Mode Standard deviation K-S test Ultrasound in Obstetrics and Gynecology 59

3 Table 3 Ultrasound of the lower urinary tract p distance. Summary statistics and K S test p distance (mm) Mean value Median Mode Standard deviation K-S test Mean value Median Mode Standard deviation K-S test Mean value Median Mode Standard deviation K-S test Confidence interval for mean X Y p X Y p X Y p Figure 2 Confidence interval for mean x distance. 60 Ultrasound in Obstetrics and Gynecology

4 Figure 3 Confidence interval for mean y distance. Figure 4 Confidence interval for mean p distance. Table 4 Ultrasound of the lower urinary tract the γ angle. Summary statistics and K S test The γ angle Mean value Median Mode Standard deviation K-S test Mean value Median Mode Standard deviation K-S test Mean value Median Mode Standard deviation K-S test Confidence interval for mean The γ angle is the angle between the line connecting the inferior point of symphysis with the bladder neck and the axis of symphysis. DIFF.1, the difference between the γ angle during Valsalva and the γ angle during squeezing; DIFF.2, the difference between the γ angle during Valsalva minus the γ angle during rest. Ultrasound in Obstetrics and Gynecology 61

5 Figure 5 Ultrasound of the lower urinary tract the γ angle. Confidence interval for mean. Table 5 Urinary bladder wall thickness. Summary statistics and K S test Anterior wall (mm) Base (mm) Vertex (mm) Sample size Mean value Median Mode Standard deviation K-S test Sample size Mean value Median Mode Standard deviation K-S test Sample size Mean value Median Mode Standard deviation K-S test Confidence interval for mean Anterior wall Base Vertex Figure 6 (a) Ultrasound parameters hypercorrection of γ angle. x, axis of symphysis; γ angle, angle between the line connecting the inferior point of symphysis with the bladder neck and the axis of symphysis. (b) Ultrasound parameters hypercorrection of gamma angle. Anterior wall Base Vertex Anterior wall Base Vertex Ultrasound in Obstetrics and Gynecology

6 Figure 7 Urinary bladder wall thickness. Confidence interval for mean. Figure 9 Position of UV junction in women with GSI and in women after Burch colposuspension at rest., women with GSI;, women after Burch colposuspension without urgency;, women after Burch colposuspension with urgency. Table 6 Uroflowmetry Maximum flow rate (ml/s) Average flow rate (ml/s) Residual volume (ml) Sample size Mean value Median Mode Standard deviation Minimum Maximum K-S test Figure 8 (a) Ultrasound parameters normal position of UV junction after Burch colposuspension. (b) Ultrasound parameters normal position of UV junction after Burch colposuspension. Figure 7), the gamma angle was < 40 and lower bladder neck mobility was discovered. In women after Burch colposuspension and without urgency, the direction of movement of the UV junction during increased intra-abdominal pressure was backwards (P = ) (Figures 8 and 9). These findings support our hypothesis that signs of urgency follow slight over-elevation of the bladder neck. In patients suffering from urgency we did not register detrusor instability (DI) and changes in bladder capacity during urodynamic examination, but the mean maximum flow rate was 14.6 ml/s (SD 1.29), the mean average flow rate was 4.8 ml/s (SD 1.35) and the mean residual volume was 63 ml (SD 22.73) (Table 6). These data indicate that these patients suffered from partial obstruction of the urethra. DISCUSSION The most frequent complication of Burch colposuspension is new symptoms of urgency, which has been published by several authors The reason for urgency is not completely understood. Possible explanations include a partial denervation Ultrasound in Obstetrics and Gynecology 63

7 of the bladder neck and partial obstruction of the urethra, but the latter is not always connected with urgency. Symptoms of urgency persisting for 3 or more months after operation could become a serious prognostic factor for the long-term results of the treatment. There is a slight paradoxical diminishing of the gamma angle during the Valsalva maneuver. In cases where urgency occurred, the average bladder wall thickness was > 5 mm and the gamma angle < 40. Where the gamma angle was around 50 60, the effect of the procedure was satisfactory and we did not register any symptoms of urgency. These data support the hypothesis that urgency is the result of over-correction of the gamma angle. A slight paradoxical diminishing of the gamma angle during the Valsalva maneuver was noticed, which is the reason for partial obstruction of the urethra. The US evaluation of the lower urinary tract proved to be a good tool for evaluation of the effect of the Burch colposuspension CONCLUSIONS Implementing routine US evaluation can give good feedback to surgeons and might help to prevent symptoms of urgency in a significant number of patients. When urgency occurs after Burch colposuspension carrying out US examination is a logical step in its management. ACKNOWLEDGMENT This work was supported by the Grant Agency of the Ministry of Health of Czech Republic, grant no REFERENCES 1 Simeonova Z, Bengtsson C. Prevalence of urinary incontinence among women at a Swedish primary health care centre. Scan J Prim Health Care 1990; 8: Thomas TM, Plymat KT, Blannin J, Meade TW. Prevalence of urinary incontinence. Brit Med J Clin Res 1980; 281: Aronson MP, Bates SM, Jacoby AF, Chelmow D, Sant GR. Periurethral and paravaginal anatomy: an endovaginal magnetic resonance imaging study. Am J Obstet Gynecol 1995; 173: Hol M, Bolhuis C, Vierhout ME. Vaginal ultrasound studies of bladder neck mobility. Br J Obstet Gynaecol 1995; 102: Vierhout ME, Van Bolhuis C, Hol M. Standardization of vaginal ultrasound or the study of female bladder neck mobility. Presented at the 22nd Annual Meeting of I.C.S., Halifax, Canada, September 1 4, Demirci F, Fine PM. Ultrasonography in stress urinary incontinence. Int Urogynecol J 1996; 7: Dietz HP, Clarke B. The urethral pressure profile and ultrasound parameters of bladder neck mobility. Neurol Urodynamics 1998; 17: Haadem K. The effects of parturition on female pelvic floor anatomy and function. Curr Opin Obstet Gynecol 1994; 6: Koelbl H, Hanzal E, Bernaschek G. Sonographic urethrocystography methods and application in patients with genuine stress incontinence. Int Urogynecol J 1991; 2: Kuo HC. Transrectal sonography of the female urethra in incontinence and frequency urgency syndrome. Ultrasound Med 1996; 15: Martan A, Halaska M, Voigt R, Drbohlav P. Sonographie des Blasenhals-Urethra Überganges vor und nach Beckenbodentraining mit Kolpexin. Zbl Gynäk 1994; 116: Mouritsen L, Rasmussen A. Objective parameters for describing bladderneck mobility in continent and incontinent women. Neurol Urodynamics 1991; 10: Alcalay M, Monga A, Stanton SL. Burch colposuspension: a year follow up. Br J Obstet Gynaecol 1995; 102: Bergman A, Elia G. Three surgical procedures for genuine stress incontinence: Five year follow-up of a prospective randomized study. Am J Obstet Gynecol 1995; 173: Gosling JA. The structure of the bladder neck, urethra and pelvic floor in relation to female urinary continence. Int Urogynecol J 1996; 7: Halaska M, Martan A, Voigt R, Koleska T. Follow-up of incontinence surgery from 1985 to Presented at the 27th Annual Meeting I.C.S., Yokohama, Japan, September 23 26, Vierhout ME, Mulder AFP. De novo detrusor instability after Burch colposuspension. Acta Obstet Gynecol Scand 1990; 71: Petri E, Koelbl H, Schaer G. What is the place of ultrasound in urogynecology? A written panel. Int Urogynecol J 1999; 10: Khullar V, Cardozo LD, Salvatore S, Hill S. Ultrasound: a noninvasive screening test for detrusor instability. Br J Obstet Gynaecol 1996; 103: Khullar V, Athanasiou S, Cardozo LD, Salvatore S. Urinary sphincter volume and urodynamic diagnosis. Neurol Urodynamics 1996; 15: Martan A, Masata M, Halaska M, Voigt R. Ultrasound of the urethral sphincter. Neurol Urodynamics 1997; 16: Schaer GN, Koechli OR, Schuessler B, Haller U. Improvement of perineal sonographic bladder neck imaging with ultrasound contrast. Medium Obstet Gynecol 1995; 86: Schaer G, Koelbl H, Voigt R, Merz E, Anthuber Ch, Niemeyer R, Ralph G, Bader W, Fink D, Grischke E, Hanzal E, Koechli OR, Koehler K, Munz E, Perucchini D, Peschers U, Sam C, Schwenke A. Recommendations of the German Association of Urogynecology on functional sonography of the lower female urinary tract. Zbl Gynäk 1994; 116: Voigt R, Halaska M, Michels W, Voight P, Martan A, Starker K. Examination of the urethrovesical junction using perineal ultrasonography compared to urethrocystography using a bead chain. Int Urogynecol J 1994; 5: Ultrasound in Obstetrics and Gynecology