ABSTRACT

Background:

Previously published flow mechanics and finite element model works demonstrated that the intraurethral resistance to flow in normal micturition was exponentially determined and that the detrusor pressures required for expulsion of urine were by two orders of magnitude beyond normal available voiding pressures. Xray and EMG studies indicated the presence of directional vectors which most likely contacted against the cardinal/uterosacral ligament complex.

Objectives:

A prospective pilot study to test the hypotheses that voiding dysfunction in the female may be caused by lax cardinal/uterosacral ligaments preventing traction of the opening vectors and so is potentially curable by surgical reinforcement of these ligaments.

Patients and Methods:

The mean patient age was 61 yrs., mean BMI 23. Inclusion criteria: symptoms of emptying dysfunction, residual urine >40ml and apical/uterine prolapse to the halfway mark (stage2, Baden Walker). Exclusion criteria: nil. The TFS (Tissue Fixation System), an adjustable tape which shortens and reinforces loose ligaments was applied to the cardinal and uterosacral ligaments for cure of symptomatic uterine/apical prolapse (n=36). The sample size (n=36) was double the number required to give a 95% confidence interval with 1% significance for 50% cure rate of the “obstructed micturition”. A two-tailed Student’s ttest was used.

Results:

34/36 patients were reviewed at 12 months. Emptying symptoms were cured or improved beyond a VAS self-assessed >80% level in 76% of patients (p>0.001); mean emptying time improved from 52 to 26 secs. (p.0.001); mean residual volume from 201ml to 39ml (p>0.001).

Strengths of the study:

The results appear to indicate that competent cardinal/uterosacral ligaments may be important for adequate bladder emptying.

Weakness of the study:

Single centre, non-randomized, no control group.

Conclusions:

The surgical methods described appear to have the potential to improve “obstructed micturition”, a major as yet insoluble problem in older females. The results are best explained by reference to an external striated muscle mechanism reliant on firm ligamentary insertion points for the vector forces to open the urethral tube. Further more rigorous studies are required.