Feriha UYGUR, Selçuk ÖZDEN, Cemalettin ÖZARPACI, Vedat DAYICIOĞLU

Üriner inkontinans olgularında perineal ultrasonografi ve ürodinamik incelemenin cerrahi yöntem seçimi ve başarısındaki önemi

Amaç: Üriner inkontinansın tanısında, medikal ve cerrahi yöntemlerle tedavi seçiminde ve cerrahi sonrası başarının değerlendirilmesinde perineal ultrasonografi (USG) ve ürodinamik incelemelerin önemini değerlendirmek. Materyal ve Metod: Çalışmamız üriner inkontinans (Üİ) tanısıyla tedavi uygulanan 60 olgu üzerinde prospektif olarak yapıldı. Cerrahi tedavi öncesinde tüm olgulara perineal USG ve ürodinamik çalışma yapıldı. 56 olgu opere edildi, 4 olguya medikal tedavi uygulandı. Tedaviden ortalama 5 ay sonra, 49 olguda üretra mobilitesi perineal USG ile değerlendirildi, 42 olguda ürodinamik çalışma yapılabildi. Bulgular: Olgularımız ağır ve hafif Üİ olarak gruplandırıldığında demografik özelliklerin, inkontinans ağırlığını etkilemediği gözlendi. Ürodinamik çalışma 'gold standart' alındığında, anamnez ile doğru tanı koyma başarısı, GSl (Gerçek Stres İnkontinans)'da %28, Dİ (Detrüsör İnstabilitesi)'de %100, Mİ (Mikst İnkontinans)'de %87 idi. Cerrahi tedavinin başarısı perineal USG ile değerlendirildiğinde, ilk 5 ayda kolporafi anterior + Kelly Kennedy grubunda %63.6, Burch grubunda %77.4, Sling grubunda ise %85.7 bulundu. Burch ve Sling grubunda 10 olguda Dİ'e bağlı inkontinans devam etmekteydi; 6'sı medikal tedaviyle düzeldi. Sonuç: Erken dönemde saptanmış nüks etyolojisinde, persiste ve/veya de novo Dİ'nin, anatomik defekte uygun cerrahinin seçilememiş olması, cerrahi teknik yetersizliğin rol oynadığı düşünüldü. Perineal USG ve ürodinamik incelemenin Üİ'nin tipinin doğru tanısı, uygun medikal ve cerrahi tedavinin seçimi ve cerrahi tekniğin başarı ve başarısızlığının saptanmasında etkin yöntemler olduğu görüşüne varıldı.

Anahtar Kelimeler:

İdrar kaçırma, İleriye dönük çalışma, Ürodinamik, Ultrasonografi

The value of perineal nitrasonography and urodynamic evaluation in choice of surgical method and its success in cases with urinary incontinence

Objective: To evaluate the significance of perineal ultrasonography (USG) and urodynamic test in the diagnosis of the type of urinary incontinence (I/I), the choice of medical or surgical treatment and evaluation of the success of the surgical method . Materials and methods: The study was performed prospectively on 60 cases of UI. Cases were evaluated by perineal USG and urodynamic testing before the surgical treatment. 56 cases were operated and 4 cases were treated medically. 49 of the cases were re-evaluated by perineal USG and 42, by urodynamic test after 5 months. Results: As grouped as mild and severe UI, no relation was determined between these groups with respect to demographic properties. When urodynamic test considered as 'gold standart' the predictive value of history taking for diagnosis of GSI (Genuine Stress Incontinence), Dl (Detrusor Instability); MI (Mix Incontinence) was found to be %28, %100, %87, respectively. The success rate of reconstruction in 5 months evaluated by perineal USG was found to be %63.6 in colporaphy anterior and Kelly Kennedy group, %77A in Burch group and %85.7 in sling operation group. Ten cases of incontinence due to DI were detected after Burch and Sling operations, six of which were treated successfully with medical therapy. Conclusion: Persistent and/or de novo DI, incorrect choice of surgical method and poor surgical technique were proposed to be responsible for the early recurrence of UI. Perineal USG and urodynamic testing were effective methods in diagnosis of the type of UI and choice of suitable surgical and/or medical therapy and evaluation of the success and failure of the surgical treatment of UI cases.

Keywords:

Urinary Incontinence, Prospective Studies, Urodynamics, Ultrasonography,

___

1. Milsom I, Ekelund P, Molander U. The Influence of age, parity, oral contraception, hysterectomy and menopause on the prevalence of urinary incontinence in women. J Urol 1993; 149: 1459-1462
2. JWG Yarnell, Richards CJ. et al. The prevalence and severity of urinary incontinence in women. J
Epidemiol Community Health 1981; 335: 71-4
3. NIH Consensus Development Conference
Urinary Incontinence in Adults. JAMA 1989; 261;2685
4. Turan C,Zorlu G, Ekin M, et al. Urinary inconti¬ nence in women of reproductive age.Gynecol Obstet Invest 1996;41:132-4
5. Demirci F.,Özden S.,Yücel N,ve ark. Türkiye'de menopozdaki kadınlarda üriner inkontinans prevalansı.İstanbul Jinekoloji dergisi, 1999 6. Green TH. Urinary stress incontinence differential diagnosis,pathophysiology and management. Am J Obstet Gynecol 1972;39:333
7. Wang AC. Burch Colposuspension vs. Stamey Bladder Neck Suspension: A Comparison of complications with special emphasis on detrusor instability and voiding dysfunction. J Reprod Med 1996;41:529-533
8. Jensen JK, Nielsen FR, Ostergard DR. The role of the patient history in the diagnosis of urinary incontinence. Obstet Gynecol.1994; 83: 904-910
9. De Lancey JL. Stress Urinary Incontinence: where are we now, where should we go? Am J Obstet Gyncol 1996;175:311-319
10. Demirci F, Kuyumcuoğlu U, Kekovalı M et al
Perineal ultrasonography in postoperative assess¬ ment of two different surgical procedures for stress urinary incontinence, Int Urol Nephrol 1995;27:289-297
11. Schaer GN, Koechli OR, Schuessler B et al
Perineal ultrasound for evaluating the bladder neck in urinary stress incontinence. Obstet Gynecol 1995; 85:220-4
12. Peschers U, Schaer G, Anthuber C, De Lancey JOL. Changes in the vesical neck mobility following vaginal delivery. Obstet. Gynecol 1996;88: 1001-1006
13. Demirci F, Kuyumcuoğlu U, Eren S, et al
Comparison of preoperative and postoperative urethrovesical junction mobility in the cases operated with the anterior colporraphy and Burch techniques. Int J Gynecol Obstet 1996;8:59-66
14. Thomas T, Pymat KR, Blanin J, et al. Prevalance of urinary incontinence. Brit Med J. 1990,281: 1243-1245
15. Hording U, Pedersen K, Sidenius K, et al
Urinary incontinence in 45 year old women. Scand J Urol Nephrol 1986; 20:183-186
16. Burgio K, Mathews AK, Engel BT. Prevalance, incidence and correlates of urinary incontinence in healthy middle aged women. J Urol 1991;146: 1255-1259
17. Ma SSY. The prevalance of adult female urinary incontinence in Hong Kong Chinese. Int Urogynecol J.1997;8:327-331
18. Iosif S, Henriksson L, Ulmstein U. The frequency of disorders of the lower urinary tract
Urinary incontinence evaluated by questionnarie survey in a gynecological healthy control popula¬ tion. Acta Obstet Gyecol Scand.l981;60:71-75
19» Diokno AC, Brown MB, Brock MB. Clinical and cystometric characteristics of continent and inconti¬nent noninstutionalised elderly. J Urol 1988;145:567-570
20. Bump RC, McClish DK. Cigarette smoking and urinary incontinence in womeen. Am J Obstet Gynecol 1992;167:1213-1218
21. Mommsen S, Foldspong A. Body mass index and adult female incontinence. World J Urol 1994;12, 319-322
22. Farrar DJ, Whiteside CG, Osborne JL
Urodynamic analysis of micturition symptoms in the female. Surg Gynecol Obstet 1975;141:875-81
23. Bates CP, Loose H, Stanton SL. The objective study of incontinence after repair operations. Surg Gynecol Obstet 1975;136:17-22
24. Webb RJ, Ramsden PU, Neal DE. Ambulatory monitoring and electronic measurement of urinary leakage in the diagnosis of detrusor instability and incontinence. Br J Urol 1991;68:148-52
25. Bergman A, Ballard CA, Platt LD. Ultrasonic evaluation of urethrovesical junction in women with stress urinary incontinence, J Clin Ultrasound 1988;16:295-300
26. Hoekstra JW, van Den Mejden APM, Smons A.J, et al. Transvaginal ultrasonography and urodynamic evaluation after suspension operations: Comparison among Gittes, Stamey and Burch suspensions.} Urol 1991;146:132-136
27. White RD, McQuown D, McCarthy TA, Ostergard DR. Real.time ultrasonography in the evaluation of urinary incontinence.Am J Obstet Gynecol 1980;138:235-239
28. Wijma J, Dick JT, VisserGHA. Perineal ultrasonography in women with stress urinary incontinence and controls in the role of the pelvic floor muscles. Gynecol Obstet Invest 1991 ;32: 176-179
29. Wall LL: Incontinence prolapse and disorders of pelvic floor. In:Berek JS (ed) Novak's Gynecology
Baltimore: Williams and Wilkins,1996;619-676
30. James MC, Abrams P: Recent analysis of surgical outcomes for incontinence, Current Opinion in Urology 1997;7:215-218
31. Vierhout ME and Mulder AF. De novo detrusor instability after Burch colposuspension. Acta Obstet Gynecol Scand.l992;71: 812-822
32. Sand P, Bowers LW, Ostergard DR. The effect of retropubic uretropexy on detrusor instability
Obstet Gynecol 1988;71:818-822
33. Cardozo LD, Stanton LS, Williams JE. Detrusor instability following surgery for genuine stress incontinence. Br J Urol 1979;51:204-207
34. Chaikin CD, Rosenthal J, Blaivas JG
Pubovaginal fascial sling for all types of stress urinary incontinence long-term analysis. J Urol 1998;160:1312-1316
35. Me Guire EJ, Lytton B, Pepe V. Stress Incontinence. Obstet. Gynecol.l976;47:255