- Email: [email protected]
The Pereyra procedure in the management of urinary stress incontinence
The Pereyra procedure in the management of urinary stress incontinence JOSEPH
C.
PORTNUFF,
F.R.C.S.(C), SAMUEL Santa
F.R.C.O.G.,
F.A.C.S. C.
Clara
M.D.,
BALLON,
and Stanford,
M.D. California
Results are presented and discussed of 186 consecutive patients with well-documented urinary stress incontinence who were treated by Pereyra urethrovesical neck suspension combined with a vaginal plastic procedure. The technique combines simglicity and low morbidity and yields a success rate comparable to that of the standard abdominal operations for stress incontinence.
I N 1 9 5 4 , Ullery?” published a collective review listing 50 surgical procedures for the correction of urinary stress incontinence. The number of existing operations clearly pointed to the confusion that existed in this field. Much progress has since been made in the diagnosis of this condition.3-7p I31 l4 Discussion continues, however, about the exact nature of the anatomical defect producing urinary stress incontinence, its cause, and hence its correction.*, “3 I*, lo The studies of Jeffcoate’“, I7 in Great Britain and of Hodgkinson,*op I2 Greens* g and others’, l5 on this continent have shed new light on the subject. Hodgkinson’s” 1970 review summarized the innovations of the last decade and convincingly outlined a plan for diagnosis and treatment based on the literature From the Departments of Obstetrics and Gynecology, Kaiser Hospital, Santa Clara, and Stanford University Hospital, Stanford. Presented by invitation to the San Francisco Gynecological Society, March 14, 1972. y9e;$ved
for publication
August
16,
;4;;;pted
for publication
August
28,
Reprint requests: Dr. Samuel C. Ballon, Dept. of Gynecology and Obstetrics, Stanford University Medical Center, Stanford, California 94305.
and his own excellent studies of some 3,400 cases. Hodgkinson’s studies and his masterful review are most impressive. His recommendations for surgical management suffer, however, from his admitted lack of experience with the Pereyra procedure. Both he and Green state that retropubic urethrocystopexy produces consistently surer results than a vaginal plastic operation. We heartily agree with this statement. We do believe, however, that this need not be accomplished via the abdominal route in all cases. has described a technique of Pereyra’* combined urethrovesical suspension an d vaginourethroplasty for the surgical correction of urinary stress incontinence. In 1967, he and Lebherz19 reported a 94.8 per cent cure rate in 172 patients followed for one to seven years. Despite these encouraging figures, his procedure has not met with widespread acceptance. Material
and
methods
From February, 1966, to April, 197 1, Pereyra urethrovesical neck suspensions combined with vaginal plastic procedures were performed on 186 consecutive patients with documented symptomatic urinary stress incontinence at the Kaiser-Permanente Medical Center, Santa Clara, California. The pur-
408
February 1, 1973 Am. J. Ohrtet. Gynecol.
Portnuff and Ballon
pose of this communication is to report the results of this study. Our definition of stress incontinence is in agreement with that of Hodgkinson. For the diagnosis to be made, the complaint of incontinence had to be of such magnitude that the loss of urine was socially inconvenient or embarrassing. The Pereyra procedure was studied for three reasons : (1) It seemed technically simple; (2) it provided for the combination of a vaginoplasty with a urethrovesical suspension in one vaginal operation; (3) it was hoped that this procedure could provide uniformly high cure rates regardless of patient age, parity, or prior experience with attempted surgical correction of stress incontinence. Diagnosis was made on the basis of history, physical examination, exclusion of other types of incontinence, and the characteristic loss of the normal posterior urethrovesical angle in association with straining on bead chain cystourethrogram. Rotational descent of the urethra was also noted, and the patients were classified as Green Type I or II, in an attempt to determine if patients with this added anatomical derangement were different in their response to the Pereyra procedure. Resulfs Forty patients demonstrated simple loss of the normal posterior urethrovesical angle. Of these, 37, or 92.5 per cent, were cured. Three failures, 7.5 per cent, occurred. One hundred and forty-six patients demonstrated an additional rotational descent of the urethra. One hundred and thirty-three, or 91.0 per cent of this group, underwent successful procedures. Thirteen of these patients, 9.0 per cent, were not improved. Over all, 16 cases were ultimate failures. Fifteen patients were cured after previous attempts at surgical correction of their stress incontinence had failed. Nine of these had undergone one prior procedure; 6 had multiple attempts at repair. The failures are listed in Table I. One of these was a failure in technique. One was
subsequently cured by urethral sling. Six patients had temporary remission of symptoms with subsequent recurrence. Nine were never improved. Seventy patients underwent chain cystograms in the immediate postoperative period. Sixty-two of these patients had clinically sucIn all these cases there cessful procedures. was restoration of both the posterior urethrovesical angle and the angle of inclination between urethra and symphysis pubis. X-rays were obtained in 8 patients whose repairs were considered immediate failures. In all of these cases there was failure to restore the normal posterior urethrovesical angle. In one patient whose symptoms recurred after one year, immediate postoperative films demonstrated a normal posterior urethrovesical angle. When symptoms of urinary stress incontinence returned, a repeat chain cystourethrogram reveaied ioss of this angIe. Morbidity from the procedure was low. Twenty-three patients developed urinary Eighteen patients experitract infections. enced prolonged urinary retention, There were 3 cases of stab wound abscess. Seven patients developed vaginal hematomas. There was one case of bladder penetration, one urethrovaginal fistula, one case of pneumonitis, and one nonfatal pulmonary embolus.
Nineteen patients were either lost to follow-up or seen for less than 3 months postoperatively. One hundred and sixty-seven patients were followed for one to five years. Only 6 patients who were felt to be cured initially were subsequently classed as failures. Comment Hodgkinson has pointed out that the success of a procedure depends on the skill of the operator and that often the failure to cure is the result of the failure to perform actually the intended operation. At least in the 6 cases which showed no radiologic evidence of cure, our surgical technique was faulty. However, it must be pointed out that the results reported here represent the work of 15 gynecologists and 15 residents, to many of whom this was a new procedure. With this background, we believe that our success rate
Pereyra
procedure
409
Table I. Failures Previous
Procedure A and
P and
P
A and A and VH-A A and VH-A A and VH-A
P and P and and P and and P and and
P P P and P P P and P P P and P
A and P and A and P and A and P and A and P and VH-A and VH-BSO-A VH-A and VH-A and A and va.@nal
P P P P P and P and P and P and P P and P
P and hysterectomy.
P = anterior TAH
P
operation
Never
-
A A A A -
P
-
and P and P and P
-
Recurrent Recurrent Never cured Never cured Never cured Never rured Subsequent cure sling Recurrent Recurrent Recurrent Recurrent Never cured Never cured Never cured Never cured
and
A and
3.
4. 5. 6.
Vaginal -
abscess
Cuff hematoma Technical failure
P
posterior repair and Pereyra total abdominal hysterectomy.
REFERENCES
2.
-
Bailey, K. V.: J. Obstet. Gynaecol. Br. Emp. 61: 291, 1954; 63: 663, 1956; 79: 947, 1963. Ball, T. L., Knapp, R. C., Nathanson, B., and Lagasse, L. D.: AM. J. OBSTET. GYNECOL. 94: 997, 1966. Beck, R. P., Thomas, E. A., and Maughan, G. B.: AM. J. OBSTET. GYNECOL. 100: 483, 1968. Calatroni, C. J., Poliak, A., and Kohan, A.: AM. 1. OBSTET. GYNECOL. 83: 649. 1962. Canton, J. N.: AM. J. OESTET. GY&COL. 99: 401, 1967. Dutton, W. A.: Canad. Med. Assoc. 83: 1242, 1960.
procedure. BSO =
A and P = anterior bilateral salpingoophorectomg.
and
posterior
_
cured
-
speaks well for the relative simplicity of the Pereyra operation. Where multiple surgical procedures exist for the treatment of a single condition, it becomes evident that none of these is definitive. The work of the past decade does seem to suggest that surgical cures of urinary stress incontinence are likely to follow operations which elevate the urethrovesical junction above the pubic symphysis while preserving or restoring the normal posterior urethrovesical angle. Retropubic urethropexy can easily be accomplished via the abdominal route. When an abdominal operation is being performed, the Marshall-Marchetti-Krantz procedure
1.
Results
TAH-A and P-12 yr. ago. A and P-l yr. ago VH-A and P-l yr. ago VH-A and P-l yr. ago A and P
and =
Complication.3
repair.
by
VH
=
yields excellent results and is performed by us in cases of stress incontinence without coincident prolapse, cystocele, or rectocele. The vaginal approach, however, has yielded acceptable results and has obviated the need for an abdominal incision in those cases requiring vaginoplasties. Morbidity was both low grade and infrequent. Patients classified as Green Type II responded equally well to the Pereyra procedure. Bead chain cystourethrograms proved invaluable in both preoperative diagnosis and postoperative prognosis. Clinical diagnosis and results correlated well with the radiologic status of the posterior urethrovesical angle.
12.
Gardiner, S. H., Campbell, J. A., Garrett, R. A., and Schell, H. R.: AM. J. OBSTET. GYNECOL. 82: 1112, 1961. Green, T. H., Jr.: AM. J. OBSTET. GYNECOL. 83: 632, 1962. Green, T. H., Jr.: Obstet. Gynecol. Survey 23: 603, 1968. Hodgkinson, C. P.: AM. J. OBSTET. GYNE~OL. 65: 560, 1953. Hodgkinson, C. P.: AM. J. OBSTET. GYNE<:oI;.. 108: 1141, 1970. Hodgkinson, C. P.: Surg. Gynecol. Obstet.
13.
Hodgkinson,
7.
a. 9.
10. 11.
120: 595, 1965. OBSTET.
C. GYNECOL.
P., and Colbert, N.: 79: 648, 1960.
AM.
J.
410
14. 15. 16. 17.
Portnuff
and
Hodgkinson, W. T.: Clin. Hutch, J. A.: Jeffcoate, T. 1965. Jeffcoate, T. OBSTET.
E‘rbrual-y 1. l!lTi Am. J. Obstrt. Gynrrnl.
Ballon
C. P., Doub, H. P., and Kelly, Obstet. Gynecol. 1: 668. 1958. Obstet. eynecol. 30: 309, 1967. N. A.: Br. J. Urol. 37: 633,
18. 19. 20.
N.
A., and Roberts, H.: GYNECOL. 59: 685, 1952.
AM.
J.
Pereyra, A. J.: W. J. Surg. 67: 223. 1959. Pereyra: A. J., and Lebherz, Gynecol. 30: 537, 1967. Ullery, J. C.: Surg. Gynecol. 1954. (Abst.)
Obstet. T. Obstet.
Gynecol. B.:
Obstet. 98: 427,
C.
PORTNUFF,
F.R.C.S.(C), SAMUEL Santa
F.R.C.O.G.,
F.A.C.S. C.
Clara
M.D.,
BALLON,
and Stanford,
M.D. California
Results are presented and discussed of 186 consecutive patients with well-documented urinary stress incontinence who were treated by Pereyra urethrovesical neck suspension combined with a vaginal plastic procedure. The technique combines simglicity and low morbidity and yields a success rate comparable to that of the standard abdominal operations for stress incontinence.
I N 1 9 5 4 , Ullery?” published a collective review listing 50 surgical procedures for the correction of urinary stress incontinence. The number of existing operations clearly pointed to the confusion that existed in this field. Much progress has since been made in the diagnosis of this condition.3-7p I31 l4 Discussion continues, however, about the exact nature of the anatomical defect producing urinary stress incontinence, its cause, and hence its correction.*, “3 I*, lo The studies of Jeffcoate’“, I7 in Great Britain and of Hodgkinson,*op I2 Greens* g and others’, l5 on this continent have shed new light on the subject. Hodgkinson’s” 1970 review summarized the innovations of the last decade and convincingly outlined a plan for diagnosis and treatment based on the literature From the Departments of Obstetrics and Gynecology, Kaiser Hospital, Santa Clara, and Stanford University Hospital, Stanford. Presented by invitation to the San Francisco Gynecological Society, March 14, 1972. y9e;$ved
for publication
August
16,
;4;;;pted
for publication
August
28,
Reprint requests: Dr. Samuel C. Ballon, Dept. of Gynecology and Obstetrics, Stanford University Medical Center, Stanford, California 94305.
and his own excellent studies of some 3,400 cases. Hodgkinson’s studies and his masterful review are most impressive. His recommendations for surgical management suffer, however, from his admitted lack of experience with the Pereyra procedure. Both he and Green state that retropubic urethrocystopexy produces consistently surer results than a vaginal plastic operation. We heartily agree with this statement. We do believe, however, that this need not be accomplished via the abdominal route in all cases. has described a technique of Pereyra’* combined urethrovesical suspension an d vaginourethroplasty for the surgical correction of urinary stress incontinence. In 1967, he and Lebherz19 reported a 94.8 per cent cure rate in 172 patients followed for one to seven years. Despite these encouraging figures, his procedure has not met with widespread acceptance. Material
and
methods
From February, 1966, to April, 197 1, Pereyra urethrovesical neck suspensions combined with vaginal plastic procedures were performed on 186 consecutive patients with documented symptomatic urinary stress incontinence at the Kaiser-Permanente Medical Center, Santa Clara, California. The pur-
408
February 1, 1973 Am. J. Ohrtet. Gynecol.
Portnuff and Ballon
pose of this communication is to report the results of this study. Our definition of stress incontinence is in agreement with that of Hodgkinson. For the diagnosis to be made, the complaint of incontinence had to be of such magnitude that the loss of urine was socially inconvenient or embarrassing. The Pereyra procedure was studied for three reasons : (1) It seemed technically simple; (2) it provided for the combination of a vaginoplasty with a urethrovesical suspension in one vaginal operation; (3) it was hoped that this procedure could provide uniformly high cure rates regardless of patient age, parity, or prior experience with attempted surgical correction of stress incontinence. Diagnosis was made on the basis of history, physical examination, exclusion of other types of incontinence, and the characteristic loss of the normal posterior urethrovesical angle in association with straining on bead chain cystourethrogram. Rotational descent of the urethra was also noted, and the patients were classified as Green Type I or II, in an attempt to determine if patients with this added anatomical derangement were different in their response to the Pereyra procedure. Resulfs Forty patients demonstrated simple loss of the normal posterior urethrovesical angle. Of these, 37, or 92.5 per cent, were cured. Three failures, 7.5 per cent, occurred. One hundred and forty-six patients demonstrated an additional rotational descent of the urethra. One hundred and thirty-three, or 91.0 per cent of this group, underwent successful procedures. Thirteen of these patients, 9.0 per cent, were not improved. Over all, 16 cases were ultimate failures. Fifteen patients were cured after previous attempts at surgical correction of their stress incontinence had failed. Nine of these had undergone one prior procedure; 6 had multiple attempts at repair. The failures are listed in Table I. One of these was a failure in technique. One was
subsequently cured by urethral sling. Six patients had temporary remission of symptoms with subsequent recurrence. Nine were never improved. Seventy patients underwent chain cystograms in the immediate postoperative period. Sixty-two of these patients had clinically sucIn all these cases there cessful procedures. was restoration of both the posterior urethrovesical angle and the angle of inclination between urethra and symphysis pubis. X-rays were obtained in 8 patients whose repairs were considered immediate failures. In all of these cases there was failure to restore the normal posterior urethrovesical angle. In one patient whose symptoms recurred after one year, immediate postoperative films demonstrated a normal posterior urethrovesical angle. When symptoms of urinary stress incontinence returned, a repeat chain cystourethrogram reveaied ioss of this angIe. Morbidity from the procedure was low. Twenty-three patients developed urinary Eighteen patients experitract infections. enced prolonged urinary retention, There were 3 cases of stab wound abscess. Seven patients developed vaginal hematomas. There was one case of bladder penetration, one urethrovaginal fistula, one case of pneumonitis, and one nonfatal pulmonary embolus.
Nineteen patients were either lost to follow-up or seen for less than 3 months postoperatively. One hundred and sixty-seven patients were followed for one to five years. Only 6 patients who were felt to be cured initially were subsequently classed as failures. Comment Hodgkinson has pointed out that the success of a procedure depends on the skill of the operator and that often the failure to cure is the result of the failure to perform actually the intended operation. At least in the 6 cases which showed no radiologic evidence of cure, our surgical technique was faulty. However, it must be pointed out that the results reported here represent the work of 15 gynecologists and 15 residents, to many of whom this was a new procedure. With this background, we believe that our success rate
Pereyra
procedure
409
Table I. Failures Previous
Procedure A and
P and
P
A and A and VH-A A and VH-A A and VH-A
P and P and and P and and P and and
P P P and P P P and P P P and P
A and P and A and P and A and P and A and P and VH-A and VH-BSO-A VH-A and VH-A and A and va.@nal
P P P P P and P and P and P and P P and P
P and hysterectomy.
P = anterior TAH
P
operation
Never
-
A A A A -
P
-
and P and P and P
-
Recurrent Recurrent Never cured Never cured Never cured Never rured Subsequent cure sling Recurrent Recurrent Recurrent Recurrent Never cured Never cured Never cured Never cured
and
A and
3.
4. 5. 6.
Vaginal -
abscess
Cuff hematoma Technical failure
P
posterior repair and Pereyra total abdominal hysterectomy.
REFERENCES
2.
-
Bailey, K. V.: J. Obstet. Gynaecol. Br. Emp. 61: 291, 1954; 63: 663, 1956; 79: 947, 1963. Ball, T. L., Knapp, R. C., Nathanson, B., and Lagasse, L. D.: AM. J. OBSTET. GYNECOL. 94: 997, 1966. Beck, R. P., Thomas, E. A., and Maughan, G. B.: AM. J. OBSTET. GYNECOL. 100: 483, 1968. Calatroni, C. J., Poliak, A., and Kohan, A.: AM. 1. OBSTET. GYNECOL. 83: 649. 1962. Canton, J. N.: AM. J. OESTET. GY&COL. 99: 401, 1967. Dutton, W. A.: Canad. Med. Assoc. 83: 1242, 1960.
procedure. BSO =
A and P = anterior bilateral salpingoophorectomg.
and
posterior
_
cured
-
speaks well for the relative simplicity of the Pereyra operation. Where multiple surgical procedures exist for the treatment of a single condition, it becomes evident that none of these is definitive. The work of the past decade does seem to suggest that surgical cures of urinary stress incontinence are likely to follow operations which elevate the urethrovesical junction above the pubic symphysis while preserving or restoring the normal posterior urethrovesical angle. Retropubic urethropexy can easily be accomplished via the abdominal route. When an abdominal operation is being performed, the Marshall-Marchetti-Krantz procedure
1.
Results
TAH-A and P-12 yr. ago. A and P-l yr. ago VH-A and P-l yr. ago VH-A and P-l yr. ago A and P
and =
Complication.3
repair.
by
VH
=
yields excellent results and is performed by us in cases of stress incontinence without coincident prolapse, cystocele, or rectocele. The vaginal approach, however, has yielded acceptable results and has obviated the need for an abdominal incision in those cases requiring vaginoplasties. Morbidity was both low grade and infrequent. Patients classified as Green Type II responded equally well to the Pereyra procedure. Bead chain cystourethrograms proved invaluable in both preoperative diagnosis and postoperative prognosis. Clinical diagnosis and results correlated well with the radiologic status of the posterior urethrovesical angle.
12.
Gardiner, S. H., Campbell, J. A., Garrett, R. A., and Schell, H. R.: AM. J. OBSTET. GYNECOL. 82: 1112, 1961. Green, T. H., Jr.: AM. J. OBSTET. GYNECOL. 83: 632, 1962. Green, T. H., Jr.: Obstet. Gynecol. Survey 23: 603, 1968. Hodgkinson, C. P.: AM. J. OBSTET. GYNE~OL. 65: 560, 1953. Hodgkinson, C. P.: AM. J. OBSTET. GYNE<:oI;.. 108: 1141, 1970. Hodgkinson, C. P.: Surg. Gynecol. Obstet.
13.
Hodgkinson,
7.
a. 9.
10. 11.
120: 595, 1965. OBSTET.
C. GYNECOL.
P., and Colbert, N.: 79: 648, 1960.
AM.
J.
410
14. 15. 16. 17.
Portnuff
and
Hodgkinson, W. T.: Clin. Hutch, J. A.: Jeffcoate, T. 1965. Jeffcoate, T. OBSTET.
E‘rbrual-y 1. l!lTi Am. J. Obstrt. Gynrrnl.
Ballon
C. P., Doub, H. P., and Kelly, Obstet. Gynecol. 1: 668. 1958. Obstet. eynecol. 30: 309, 1967. N. A.: Br. J. Urol. 37: 633,
18. 19. 20.
N.
A., and Roberts, H.: GYNECOL. 59: 685, 1952.
AM.
J.
Pereyra, A. J.: W. J. Surg. 67: 223. 1959. Pereyra: A. J., and Lebherz, Gynecol. 30: 537, 1967. Ullery, J. C.: Surg. Gynecol. 1954. (Abst.)
Obstet. T. Obstet.
Gynecol. B.:
Obstet. 98: 427,