KEYWORDS: cystocele; laparoscopic Burch colposuspension; ultrasound cystourethrography; urodynamic stress incontinence; voiding function

Transcription

1 Ultrasound Obstet Gynecol 2005; 25: Published online in Wiley InterScience ( DOI: /uog.1838 Dynamic morphological changes in the anterior vaginal wall before and after laparoscopic Burch colposuspension in primary urodynamic stress incontinence J.-M.YANG*,S.-H.YANG andw.-c.huang *Division of Urogynecology, Department of Obstetrics and Gynecology, Mackay Memorial Hospital, School of Health and Nutrition, Taipei Medical University and Department of Obstetrics and Gynecology, Cathay General Hospital, Taipei, Taiwan, ROC KEYWORDS: cystocele; laparoscopic Burch colposuspension; ultrasound cystourethrography; urodynamic stress incontinence; voiding function ABSTRACT Objective To evaluate dynamic morphological changes in the anterior vaginal wall in primary urodynamic stress incontinence before and after laparoscopic Burch colposuspension and to explore the related effects on urethral and voiding functions. Methods Ultrasound cystourethrography and urodynamic study were performed in 112 patients with primary urodynamic stress incontinence before and 3 months after laparoscopic Burch colposuspension. Ultrasound assessment included measurement of the bladder neck positions at rest and during straining, the bladder wall thickness at the dome and trigone, and observation of the motion of the bladder neck in addition to the development of cystocele on Valsalva maneuver. On ultrasonography, a cystocele was defined as prolapse or descent of the bladder base below the bladder neck at rest, on Valsalva, or both. Results After laparoscopic Burch colposuspension, ultrasound cystourethrography revealed significant differences in the bladder neck position at rest and during stress (preoperative median 93 vs. postoperative 70 at rest and preoperative 160 vs. postoperative 81 during stress, P < 0.001, respectively) and rotational angle (preoperative median 58 vs. postoperative 10, P < 0.001). A laparoscopic Burch operation corrected 50% (5/10) of the preoperative cystoceles. However, a residual cystocele developed postoperatively in 29% (30/102) of the women who did not have one previously. Postoperative ultrasonographic and urodynamic studies did not reveal any differences between those women with or without postoperative cystocele except for the residual urine volume, detrusor opening pressure, and straining and rotational angles of the bladder neck (P < 0.001, 0.032, and < 0.001, respectively). Conclusions Laparoscopic Burch colposuspension may correct a pre-existing cystocele, but in other patients a cystocele may persist or be disclosed. After laparoscopic Burch operation a persistent cystocele is not associated with urethral compression or voiding impairment. Copyright 2005 ISUOG. Published by John Wiley & Sons, Ltd. INTRODUCTION The complex relationship between anterior vaginal wall defect and lower urinary tract symptoms has yet to be clearly defined. It has been known that women with mild and moderate pelvic floor relaxation often complain of stress incontinence, whereas women with severe uterovaginal prolapse rarely complain of incontinence 1 3. By causing urethral kinking, obstruction or narrowing, prolapsing cystocele was one of the anatomical factors responsible for the continent mechanism in severe uterovaginal prolapse 1 3. Different types of cystocele may have a different impact on voiding 2,3. On ultrasound cystourethrography, a cystocele with opening of the retrovesical angle during stress was associated with improved voiding, whereas a cystocele with intact retrovesical angle had the opposite effect 2. Burch colposuspension is a well-accepted procedure for treating stress urinary incontinence secondary to urethral hypermobility 4. The Burch procedure gives rise to a typical configuration of the bladder and urethra on ultrasound 5 7. The bladder neck is anteriorly and Correspondence to: Dr W.-C. Huang, Department of Obstetrics and Gynecology, Cathay General Hospital, 280 Jen-Ai Road, Section 4, Taipei 106, Taiwan, ROC ( huangwc0413@hotmail.com) Accepted: 1 November 2004 Copyright 2005 ISUOG. Published by John Wiley & Sons, Ltd. ORIGINAL PAPER

2 290 Yang et al. superiorly elevated with a decreased retrovesical angle and urethral inclination at rest in addition to diminished urethral mobility during stress. On Valsalva, the bladder base may, in some cases, protrude and descend below the bladder neck, then develop as a cystocele 1,5 7. Is this bladder base descent or prolapsing cystocele a pathological condition reflecting anterior vaginal wall laxity or defect aggravated by Burch operation or just a physiological alteration representing the compensatory abnormality secondary to Burch operation? This question cannot be answered. An ultrasound study had previously demonstrated that irritative symptoms after Burch colposuspension were secondary to surgical overcorrection 8. However, a study carried out by Dietz et al. 6 did not support this finding. Additionally, Skala et al. 9 had even reported that an uncorrected anatomical defect disclosed by ultrasound was also related to these symptoms. This study was designed to test the following hypotheses: (1) laparoscopic colposuspension can cure a cystocele that descends further than the bladder neck on Valsalva and, therefore, (2) failure to cure cystocele is associated with distinct changes in the urethral or voiding function because of varying effects of the preoperative equivalent reported on urodynamic studies 1 3. METHODS A prospective study was conducted in 130 consecutive women presenting over a 4-year period with primary urodynamic stress incontinence managed by laparoscopic Burch colposuspension alone or in conjunction with other gynecological surgery. All the women were evaluated by means of clinical history, clinical examination, urinalysis, multichannel urodynamic study and ultrasound cystourethrography before and 3 months after laparoscopic Burch colposuspension. Sonographic scans and urodynamic examinations were obtained from consenting women participating in a local ethics committee-approved study concerned with morphological and functional change before and after laparoscopic Burch colposuspension. Clinical examination The evaluation included documentation of the patients complaints regarding their lower urinary tract symptoms, pelvic pain and any physical findings. The patients were examined in the dorsal lithotomy position using a split speculum. Pelvic support was assessed and graded when the patient was straining maximally as each individual site (urethra, bladder, cervix/cuff, cul-de-sac and rectum) was identified. For subjects who complained of deep dyspareunia and/or chronic pelvic pain the focus was on the absence or presence of a symptomatic uterine descent. Ultrasound cystourethrography The lower urinary tract was assessed by introital sonography with a Toshiba SSA-260A scanner (Toshiba Medical Systems Co. Ltd, Tokyo, Japan) and a 5-MHz vaginal probe or a Voluson 730 ultrasound scanner (GE Medical Systems, Zipf, Austria) equipped with a 5 9-MHz vaginal probe with patients in the supine position. The morphological characteristics of the lower urinary tract were evaluated at rest and during maximal Valsalva maneuver 7. These included measurement of the bladder neck position and observation of the motion of the bladder neck in addition to the development of cystocele. Motion of the bladder neck may comprise a posterior inferior (rotational) descent with the lower border of the symphysis pubis as the pivot during stress or a sliding (vertical) descent along the urethral axis 5,10.On ultrasonography, a cystocele, also referred to as isolated or true cystocele 11 or posterior bladder suspension defect 12, was defined as prolapse or descent of the bladder base below the bladder neck at rest or on Valsalva 10.Based on the change of retrovesical angle during stress 2,7,13, the development of cystocele was stratified into two types: Type I, a cystocele with opening of the retrovesical angle (Figure 1) and Type II, a cystocele with intact retrovesical angle (Figure 2). The images were frozen at rest and at maximal Valsalva maneuver for measurement of the bladder neck position. The position of the bladder neck was designated as the angle between the bladder neck symphyseal line and the midline of the symphysis pubis. The rotational angle of the bladder neck was defined as the difference between the angle for resting and straining bladder neck positions. After the bladder was emptied, bladder wall thickness at the trigone and dome was measured at the thickest part, perpendicular to the luminal surface 10,14. All ultrasound cystourethrography procedures were performed by either J.-M.Y. or W.-C.H. Urodynamic study A full urodynamic study included a 1-h pad test, spontaneous uroflowmetry, filling and voiding phase cystometry and a urethral pressure profile on both resting and straining. Cystometry was performed at a filling rate of 80 ml/min with the patient lying supine in a birthing chair. The intravesical pressure was measured with a fluidfilled catheter (4.5 Fr) and the intra-abdominal pressure was measured transrectally with a latex rectal catheter. During filling, provocative maneuvers such as coughing, standing, heel bouncing and hearing running water were performed. At the maximal cystometric capacity the patient stood up, and a stress test followed with the legs apart to the breadth of the shoulders. If the stress test was positive, the Valsalva leak point pressure was measured by asking the patient to strain, and the intravesical pressure was recorded at the point of visible urine loss. The lowest pressure obtained on two attempts was used. A voiding study was then carried out with the patient seated and the catheters still in place. After voiding, residual urine

3 Anterior vaginal wall 291 (c) sp U Cystocele at rest on Valsalva Figure 1 Development of cystocele with opening of the retrovesical angle (Type I cystocele). Ultrasonography (a) at rest and (b) during stress and (c) a schematic drawing showing rotational descent of the bladder neck with prolapse and descent of the bladder base (cystocele) (arrows) below the bladder neck on Valsalva maneuver before laparoscopic Burch colposuspension. E, external urethral meatus; sp, symphysis pubis; U, urethra. volume was measured and the bladder was refilled with 200 ml 0.9% saline solution. A microtransducer catheter with two sensors 5 cm apart (Gaeltec, Dunvegan, UK) was introduced through the urethra with both sensors within the bladder oriented at the 9 o clock position. The rate of transducer withdrawal and chart recording was 2 mm/s. The resting and stress urethral pressure profiles were then measured with the patients sitting at 45. Data were recorded continuously on a MMS UD-2000 multichannel recorder (Medical Measurement System, Enschede, The Netherlands). The maximum flow rate centile was calculated according to an established formula derived from the Liverpool nomograms 15.The curves for resting and stress urethral pressure profiles were divided into four quartiles along the functional profile length (Q 1, 0 25%; Q 2, 26 50%; Q 3, 51 75%; Q 4, %). The highest pressure, the resting urethral closure pressure and the pressure transmission ratios (the increment in urethral pressure on stress as a percentage of the simultaneously recorded increment in intravesical pressure) were measured in each quartile. The methods and definitions employed conform to the recommendation of the International Continence Society. Surgical techniques All operations were performed with the patient in the dorsal lithotomy position under general anesthesia and conducted by J.-M.Y. or W.-C.H or both these operators. Bladder neck suspension Laparoscopic Burch colposuspension was performed using a transperitoneal approach. The authors adhered to the 2-cm rule 16. Thus, a No. 2 Ethibond Excel TM suture (Ethicon Inc., Somerville, NJ, USA) was placed 2 cm lateral to the urethra at the level of the proximal urethra 1 cm distal to the urethrovesical junction. A double bite incorporating the entire thickness of the anterior vaginal wall (excluding the vaginal epithelium) was taken, and then the suture was passed through the ipsilateral Cooper s ligament. The suture was tied down with a series of extracorporeal knots using an endoscopic knot pusher. When tying the suture, excessive tension on the vaginal wall was avoided by the following method. A probe with 1-cm marks for calibration was used to ensure that the distance between the upper edge of the indwelling Foley balloon (filled with 12 ml of water) and the superior border of the symphysis pubis was not less than 2 cm. An additional suture was then placed in a similar fashion at the level of urethrovesical junction, approximately 2 cm lateral to the bladder edge on the same side. The procedure was repeated on the opposite side. Uterine suspension Laparoscopic shortening and plication of uterosacral ligaments were performed to correct the symptomatic uterine descent. Uterosacral ligament plication was

4 292 Yang et al. (c) sp U Cystocele at rest on Valsalva Figure 2 Development of cystocele with intact retrovesical angle (Type II cystocele). Ultrasonography (a) at rest and (b) during stress and (c) a schematic drawing showing restricted vertical descent of the bladder neck with prolapse and descent of the bladder base (cystocele) (arrows) below the bladder neck on Valsalva maneuver after laparoscopic Burch colposuspension. sp, symphysis pubis; U, urethra. performed using one No. 2 Ethibond Excel suture with three good bites. The first bite began with the left uterosacral ligament, at the mid-position between its insertion to the uterus and the pelvic sidewall. Then the second bite was put in the posterior surface of cervix, at the level of the insertion of uterosacral ligaments. Finally, the third bite was placed at the right uterosacral ligament, opposite the first bite. Statistical analysis Statistical analysis was performed using SPSS 10.0 for Windows (SPSS Inc., Chicago, IL, USA). Descriptive statistics for measured variables were calculated for the overall sample and for each study group. The Mann Whitney U-test or paired t-test was used to test the differences between study groups for continuous, measured variables when appropriate. To test the differences of categorical variables between study groups, the chi-square or Fisher exact test was used. The Spearman rank correlation (rho) test was used to examine the association between postoperative cystocele and explanatory variables. When significant relationships were found, they were further analyzed using multivariate analysis. A value of P < 0.05 was considered significant. RESULTS Of the 130 women with primary urodynamic stress incontinence who underwent laparoscopic Burch colposuspension, 18 were excluded from the study because of Table 1 Concomitant surgical procedures in women undergoing laparoscopic Burch colposuspension (n = 112) Concomitant surgical procedures n (%) Posterior colporrhaphy 87 (78) Uterine suspension 59 (53) Laparoscopic-assisted vaginal hysterectomy 17 (15) Unilateral/bilateral adnexectomy 4 (4) Myomectomy 2 (2) concomitant anterior colporrhaphy or paravaginal repair. There were therefore 112 patients available for evaluation, and 14 (13%) had a laparoscopic Burch operation only and 98 underwent additional procedures (Table 1). All hysterectomies were performed for benign gynecological conditions. The mean patient age, mean gravidity, mean parity and mean body mass index were 46.4 (range, 28 71) years, 4.3 (range, 1 10), 2.9 (range, 1 7) and 24.5 (range, ) kg/m 2, respectively. There were 27 (24%) postmenopausal subjects and eight (7%) had previously undergone a hysterectomy before the laparoscopic Burch operation. Of the 65 subjects with symptomatic uterine descent, 59 (91%) had laparoscopic uterine suspension and the remaining six cases did not because of severe pelvic adhesion and/or endometriosis. None of the 112 study subjects had Grade 3 or 4 cystocele on physical examination preoperatively. Ultrasound cystourethrography revealed 98 (88%) subjects having

5 Anterior vaginal wall 293 rotational descent of the bladder neck and 10 (9%) having cystocele on Valsalva. All of the preoperative cystoceles were Type I. There were no significant demographic and urodynamic differences between those women with or without cystocele on Valsalva. Patients with cystocele had a significantly greater bladder neck symphysis angle during both resting and straining and a greater rotational angle than did those without cystocele (Table 2). The mean follow-up of this study group was 20.4 (range, 3 48) months. At the follow-up visit 3 months after the operation none of the 112 patients had subjective complaints and objective evidence of stress urinary incontinence (negative stress test). Effect of laparoscopic Burch colposuspension Preoperative and postoperative comparison revealed significant differences in the bladder neck position at rest and during stress (median 93 vs. 70 at rest and 160 vs. 81 during stress, P < 0.001, respectively) and rotational angle (median 58 vs. 10, P < 0.001), average flow rate (median 12 vs. 10 ml/min, P = 0.035), volume at first desire to void (median 160 vs. 190 ml, P = 0.015), maximum cystometric capacity (median 325 vs. 380 ml, P = 0.007) and average pressure transmission ratio (median 82% vs. 102%, P < 0.001). The laparoscopic Burch operation corrected preoperative cystocele in 5/10 cases. However, a residual cystocele developed postoperatively in 30/102 (29%) patients who had not had one preoperatively. After Burch operation, 35/112 (31%) study subjects had cystocele and 108/112 (96%) had vertical descent of the bladder neck on Valsalva. All of the postoperative cystoceles were Type II. Effect of postoperative cystocele There were no significant demographic and urodynamic differences between those with or without a postoperative cystocele except for the residual urine volume and detrusor opening pressure (P < and 0.032, respectively) (Table 3). On ultrasound cystourethrography, subjects who had cystocele postoperatively had significantly smaller straining and rotational angles of the bladder neck than did those who did not (P = and < 0.001, respectively). Factors associated with postoperative cystocele Postoperative cystocele was not correlated with any preoperative factors (demographic and preoperative ultrasonographic variables) but was weakly and negatively associated with concomitant uterine suspension procedure (r = 0.238, P = 0.036) and postoperative straining and rotational angles of the bladder neck (r = 0.308, P = and r = 0.393, P < 0.001). Multivariate Table 2 Comparison of ultrasonographic and urodynamic findings in subjects with and without preoperative cystocele* Preoperative cystocele Parameter Absence (n = 102) Presence (n = 10) P Ultrasound cystourethrography BSAatrest( ) 91 (81 107) 105 (90 136) BSA during stress ( ) 155 ( ) 192 ( ) < Rotational angle ( ) 57 (36 81) 93 (47 107) Urodynamic study Free uroflowmetry MFR (ml/s) 27 (20 31) 21 (19 23) MFR centile 34.6 ( ) 19.4 ( ) 0.06 RU (ml) 13 (10 85) 12 (9 77) Urethral pressure profile MUCP (cmh 2 O) 69 (49 95) 56 (40 68) FPL (cm) 2.7 ( ) 2.6 ( ) PTR Q 1 (%) 99 (85 113) 100 (94 112) Q 2 (%) 95 (77 112) 85 (79 103) Q 3 (%) 80 (52 99) 75 (48 96) Q 4 (%) 38 (12 72) 47 (20 97) Pressure flow study Q max (ml/s) 22 (19 28) 28 (20 29) P detqmax (cmh 2 O) 26 (19 33) 23 (20 30) P det.op (cmh 2 O) 20 (15 27) 17 (16 22) R (cmh 2 O/(mL/s) 2 ) ( ) ( ) *Data presented as median (interquartile range). The Mann Whitney U-test was used to test for differences between study groups. Rotational angle = BSA during stress BSA at rest. BSA, bladder neck symphyseal angle; FPL, functional profile length; MFR, maximum flow rate; MUCP, maximum urethral closure pressure; P det.op, detrusor opening pressure; P detqmax, detrusor pressure at peak flow rate; PTR, pressure transmission ratio; Q 1,Q 2,Q 3,Q 4, PTR in first, second, third and fourth quartiles of urethra; Q max,peakflowrate;r,minimal urethral resistance; RU, residual urine.

6 294 Yang et al. Table 3 Comparison of preoperative ultrasonography, postoperative voiding trials and postoperative 3-month urodynamic and ultrasonographic findings in subjects with and without postoperative cystocele* Postoperative cystocele Parameter Absence (n = 77) Presence (n = 35) P Preoperative ultrasound cystourethrography BSAatrest( ) 95 (85 107) 90 (76 104) BSA during stress ( ) 153 ( ) 148 ( ) Rotational angle ( ) 53 (33 87) 45 (35 79) Postoperative voiding trials Spontaneous voiding (day) 2 (2 3) 2 (2 2) Removal of catheter (day) 3 (3 4) 4 (3 4) Postoperative 3-month ultrasound cystourethrography BSAatrest( ) 75 (58 87) 74 (64 83) BSA during stress ( ) 98 (83 113) 77 (71 85) Rotational angle ( ) 19 (12 30) 5 (1 7) < Bladder wall thickness At trigone (mm) 6.0 ( ) 6.0 ( ) At dome (mm) 7.0 ( ) 5.5 ( ) Postoperative 3-month urodynamic study Free uroflowmetry MFR (ml/s) 24 (18 33) 21 (15 25) MFR centile 18.4 ( ) 24.0 ( ) RU (ml) 10 (3 27) 0 (0 2) < Urethral pressure profile MUCP (cmh 2 O) 94 (76 106) 82 (66 108) FPL (cm) 2.9 ( ) 2.7 ( ) PTR Q 1 (%) 114 ( ) 116 ( ) Q 2 (%) 116 (95 136) 119 (99 128) Q 3 (%) 112 (90 138) 102 (82 127) Q 4 (%) 67 (28 138) 68 (53 110) Pressure flow study Q max (ml/s) 20 (16 26) 23 (19 29) P detqmax (cmh 2 O) 29 (22 33) 37 (26 58) P det.op (cmh 2 O) 26 ( ) 37 (35 55) R (cmh 2 O/(mL/s) 2 ) ( ) ( ) *Data presented as median (interquartile range). The Mann Whitney U-test was used to test for differences between study groups. Rotational angle = BSA during stress BSA at rest. BSA, bladder neck symphyseal angle; FPL, functional profile length; MFR, maximum flow rate; MUCP, maximum urethral closure pressure; P det.op, detrusor opening pressure; P detqmax, detrusor pressure at peak flow rate; PTR, pressure transmission ratio; Q 1,Q 2,Q 3,Q 4, PTR in first, second, third and fourth quartiles of urethra; Q max,peakflowrate;r,minimal urethral resistance; RU, residual urine. analysis revealed that straining angle of the bladder neck was the independent factor (P = 0.006). DISCUSSION On ultrasound cystourethrography, hypermobility of the bladder neck is presumed to be etiologically associated with stress urinary incontinence 6,7,10,13, funneling of the bladder neck signifies the possible coexistence of poor urethral closure pressure 7,17 and cystocele may associate with urethral obstruction or urethral narrowing 1 3,7,13. Clinically, cystocele is defined as a bulging anterior vaginal wall with overhanging bladder demonstrable during a pelvic examination and is common and not specific for any particular bladder anomaly. In the present study, for reasons of clarity, cystocele was defined as descent or prolapse of the bladder base below the bladder neck on ultrasound cystourethrography. Cystocele with opening of the retrovesical angle on stress (Type I cystocele) is usually associated with severe anterior vaginal wall prolapse 7,10.13, whereas cystocele with intact retrovesical angle (Type II cystocele), a high cystocele, is commonly recognized after bladder neck suspension procedures 5,6. In a survey of 1049 females with lower urinary tract symptoms, ultrasound cystourethrography revealed that 33% had Type I cystocele during stress, including 40% with urodynamic stress incontinence and 27% with detrusor overactivity. It was also found in 6% of asymptomatic women 10. In the present study, the low incidence of preoperative cystocele (9%) on ultrasonography was attributed to the inherent prejudice in the selection of subjects with asymptomatic or a lesser degree of cystocele for laparoscopic Burch operation. Subjects with Grade 3 or 4 cystocele on clinical examination frequently necessitating concomitant anterior colporrhaphy and/or paravaginal repair 18 (which

7 Anterior vaginal wall 295 may interfere with the dynamic change of anterior vaginal wall) were excluded from this study. In the present study, 50% (5/10) of the subjects with preoperative cystocele had this corrected by laparoscopic Burch operation. However, 29% (30/102) of the subjects without preoperative cystocele developed cystocele postoperatively. By strictly adhering to the 2- cm rule 16, the persistence or development of cystocele postoperatively was not a result of overcorrection from the Burch operation because there was no difference in the preoperative and postoperative resting positions of the bladder neck in those women with or without postoperative cystocele. Persistent cystocele after a Burch procedure may imply a pre-existing defect that is not corrected by the procedure 19. A persistent cystocele may also be an effect of the realignment of bladder neck and bladder base anatomy by a colposuspension ridge following a Burch procedure 6,19,20. Thus there may be more deformation of the trigone and posterior bladder than before 6. Prolapse or descent of the bladder base may then be relatively more perceptible or even aggravated postoperatively 19. It has also been reported that a cystocele with intact retrovesical angle may suggest a central defect of the endopelvic fascia 7,13 In the present study, a weak association was found between the uterine suspension procedure and non-appearance of postoperative cystocele. The authors speculate that correction of uterine descent by plication of bilateral uterosacral ligaments may, in some cases, revise the concomitant central defect of a cystocele. This issue is worthy of further investigation. A cystocele with opening of the retrovesical angle on stress, resembling the initial acts of spontaneous voiding, does not affect the urinary flow 2. Conversely, a cystocele with intact retrovesical angle and significant bladder neck descent may lead to marked urethral kinking and result in voiding impairment 2,7. In the present study there were significant differences in the residual urine volume and detrusor opening pressure on laboratory urodynamics between those women with or without postoperative cystocele. The configuration of the postoperative cystocele (intact retrovesical angle and restricted descent of the bladder neck) might interfere with the initiation of spontaneous voiding, but the resultant higher detrusor opening pressure seemed to promote a good sustainability of detrusor power to expel the urine. Because urethral kinking was prevented by a relative fixation of the bladder neck in the Burch procedure, postoperative cystocele, even with intact retrovesical angle, did not affect the voiding trials and urethral and voiding functions. In conclusion, cystocele may persist or be disclosed following the laparoscopic Burch procedure. The configuration of intact retrovesical angle and restricted bladder neck descent in the postoperative cystocele does not lead to urethral compression or voiding impairment. ACKNOWLEDGMENT This study was supported by Mackay Memorial Hospital (Research Grant No. 9360). REFERENCES 1. Marinkovic SP, Stanton SL. Incontinence and voiding difficulties associated with prolapse. J Urol 2004; 171: Dietz HP, Haylen BT, Vancaillie TG. Female pelvic organ prolapse and voiding function. Int Urogynecol J Pelvic Floor Dysfunct 2002; 13: Cosimo O, Pierluigi P, Angelo ZM, Santa U, Gabriele F, Salvatore M. A clinical and urodynamic study of patients with varying degrees of cystocele. Maturitas 1997; 27: Bidmeal J, Cardozo L. Retropubic urethropexy (Burch colposuspension). Int Urogynecol J Pelvic Floor Dysfunct 2001; 12: Petri E, Koelbl H, Schaer G. What is the place of ultrasound in urogynecology? 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