Modification of bladder thermodynamics in stress urinary incontinence patients submitted to trans-obturator tape: A retrospective study based on urodynamic assessment

Hui-Hsuan Lau, Cheng-Yuan Lai, Hsien-Yu Peng, Ming-Chun Hsieh, Tsung-Hsien Su, Jie-Jen Lee, Tzer-Bin Lin, Hui-Hsuan Lau, Cheng-Yuan Lai, Hsien-Yu Peng, Ming-Chun Hsieh, Tsung-Hsien Su, Jie-Jen Lee, Tzer-Bin Lin

Abstract

Importance: It needs to be clarified whether trans-obturator tape (TOT)-enhanced urethral resistance could impact the voiding function. Objective: Although TOT has been well-recognized for enhancing urethral resistance to restore continence in stress urinary incontinence (SUI) patients, whether the bladder's voiding functions adapt to the TOT-enhanced resistance has not been adequately investigated. This study thereby aimed to investigate whether TOT impacts the bladder's thermodynamic efficacy during the voiding phase. Design: A retrospective analysis of urodynamics performed before and after TOT was assessed. Setting: A tertiary referral hospital in Taiwan. Participants: A total of 26 female SUI patients who underwent urodynamic investigations before and after TOT. Main outcomes and measures: The area enclosed by the pressure-volume loop (Apv), which represents the work performed by the bladder during voiding, in a pressure-volume analysis established by plotting the detrusor pressure versus intra-vesical volume was retrospectively analyzed. Paired Student's t-tests were employed to assess the difference in values before and after the operation. Significance in difference was set at p < 0.05. Results: TOT increased Apv in 20 of 26 (77%) patients and significantly increased the mean Apv compared to the preoperative control (2.17 ± 0.18 and 1.51 ± 0.13 × 103 cmH2O-ml, respectively p < 0.01). TOT also increased the mean urethral resistance (1.03 ± 0.30 vs. 0.29 ± 0.05 cmH2O-sec/ml, p < 0.01) and mean voiding pressure (25.87 ± 1.72 and 19.30 ± 1.98 cmH2O p < 0.01) but did not affect the voided volume and voiding time. Moreover, the TOT-induced Apv increment showed a moderate correlation with the changes in urethral resistance and voiding pressure (both r > 0.5) but no correlation with changes in voided volume or voiding time. It is remarkable that the TOT-induced urethral resistance increment showed a strong correlation with changes in voiding pressure (r > 0.7). Conclusion and Relevance: The bladder enhances thermodynamic efficacy by adapting the voiding mechanism to increased urethral resistance caused by TOT. Further studies with higher case series and longer follow-ups should assess whether this effect could be maintained over time or expire in a functional detrusor decompensation, to define diagnostic criteria that allow therapeutic interventions aimed at its prevention during the follow-up. Clinical Trial Registration: (clinicaltrials.gov), identifier (NCT05255289).

Keywords: pressure-volume (P-V) loop; stress urinary incontinence (SUI); thermodynamics; trans-obturator tape (TOT); urodynamics.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2022 Lau, Lai, Peng, Hsieh, Su, Lee and Lin.

Figures

FIGURE 1
FIGURE 1
Pressure-flow study and derived voiding parameters. (A) representative cystometry tracings showing the vesical pressure (Pves), abdominal pressure (Pabd), detrusor pressure (Pdet), urethral flow (Flow), voided volume (Vvod), infused volume (Vinf), and intra-vesical volume (Vive). Although, coughs (arrows) and Valsalva maneuvers (triangles) induce marked fluctuations in the Pves and Pabd, they exhibit low effect on the Pdet. The Pdet, Flow, Vvod, Vinf, and Vive marked by the red bar at the bottom are showed using a faster time-base below. (B) derived voiding parameters including the mean voiding pressure (Pv), the voided volume (Vv), and the voiding time (Tv).
FIGURE 2
FIGURE 2
Pressure-flow/-volume analyses of a voiding. (A) a representative cystometry of a SUI patient. Arrows on the top indicate coughs. Pves is the vesical pressure, Pabd abdominal pressure, Pdet detrusor pressure, Flow urethral flow, Vvod voided volume, Vinf infused volume, and Vive is intra-vesical volume. (B) a pressure-volume analysis established by plotting the Pdet versus Vive. The trajectory of pressure-volume data moves counterclockwise and shapes an enclosed loop representing a voiding cycle. Four phases are identified in the pressure-volume loop, namely (Abrams et al., 2003) filling (F) (Abrams et al., 2002), iso-volumic contraction (IVC), (Sahin et al., 2022), emission (E), and (Kaya et al., 2015) is iso-volumic relaxation (IVR). Orthogonal projections of the top and bottom trajectories onto the abscissa represented the voided and infused volumes of a voiding cycle. Although coughs induce marked fluctuations in the vesical and abdominal pressure in the cystometry, they exhibit low influence on the pressure-volume trajectory.
FIGURE 3
FIGURE 3
Pressure-flow/-volume analyses in response to the TOT surgery. (A,B) representative cystometry of a SUI patient measured pre- and postoperatively (PRE and POST, respectively). Pves is the vesical pressure, Pabd abdominal pressure, Pdet detrusor pressure, Flow urethral flow, Vvod voided volume, Vinf infused volume, and Vive is intra-vesical volume. (C,D) Pressure-volume analyses measured before and after the TOT surgery, respectively. (E) the loop-enclosed area (Apv) of each SUI patient measured pre- and post-operatively. (F) summarized Apv of SUI patients before and after the TOT surgery (**p < 0.01 vs. PRE; N = 26).
FIGURE 4
FIGURE 4
Individual and summarized data of voiding parameters in response to TOT surgery. (A–D) individual (left) and summarized (right) data of the mean voiding resistance (Rv), mean voiding pressure (Pv), voided volume (Vv), and voiding time (Tv), respectively. (**p < 0.01, NS p > 0.05 vs. PRE; N = 26).
FIGURE 5
FIGURE 5
Correlation analyses of the TOT-associated change in Apv and changes in voiding parameters. (A–D) correlation analyses of the TOT-associated change in the loop-enclosed area (ΔApv) and changes in the mean voiding resistance (ΔRv; r > 0.5, N = 26), the mean voiding pressure (ΔPv; r > 0.5, N = 26), the voided volume (ΔVv; r < 0.3, N = 26), and the voiding time (ΔTv; r < 0.3, N = 26), respectively. (E) correlation analysis of ΔRv and ΔPv (r > 0.7, N = 26).
FIGURE 6
FIGURE 6
Thermodynamic processes in a pressure-volume loop of a voiding. (A) during the filling (F), an amount of potential energy represented by the area under the trajectory along the volume change is stored, that is, the output work is negative (−; red). (B) in the isovolumic contraction (IVC), the bladder performs no mechanical work, that is, the output work is zero (0). (C) in the emission (E), the bladder performs a mechanical work characterized by the integration of the trajectory along this stage to repulse fluid, that is, the output work is positive (+; green). (D) in the isovolumic relaxation (IVR), the bladder gains no mechanical work, that is, the work output is zero (0). (E) the net work done in the entire cyclic process is given by the area enclosed by the loop trajectory of a voiding cycle (net; green).

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