Int Urogynecol J (2014) 25 (Suppl 1):S1–S240 DOI 10.1007/s00192-014-2429-3

2014 AUGS-IUGA Scientific Meeting, July 22–26, 2014, Washington DC: Oral Presentations

# The International Urogynecological Association 2014

Podium Presentations PP 01 A RANDOMIZED COMPARISON OF INCONTINENCE PROCEDURES PERFORMED CONCOMITANTLY WITH ABDOMINAL SACRAL COLPOPEXY: THE BURCH VERSUS MID-URETHRAL SLING TRIAL E. C. TRABUCO1, C. J. KLINGELE 1, R. BLANDON 2, J. A. OCCHINO 1, M. E. MCGREE 3, A. L. WEAVER 3, M. A. LEMENS 1, J. B. GEBHART 1; 1 OBSTETRICS AND GYNECOLOGY, Mayo Clinic, Rochester, MN, 2OBSTETRICS AND GYNECOLOGY, SAINT LUKE’S Hosp. OF KANSAS CITY, Univ. OF MISSOURI KANSAS CITY SCHOOL OF MEDICINE, KANSAS CITY, MO, 3DIVISION OF BIOMEDICAL STATISTICS AND INFORMATICS, Mayo Clinic, Rochester, MN. Introduction: The CARE trial demonstrated that stress continent women have significantly less bothersome stress incontinence symptoms following sacrocolpopexy combined with a Burch urethropexy compared to sacrocolpopexy alone.1 However, it is not clear which surgical approach to address urinary incontinence is optimal in women who have symptomatic SUI and are undergoing sacrocolpopexy. Objective: To compare the efficacy and safety of Burch retropubic urethropexy and retropubic mid-urethral sling (MUS) in women with symptomatic stress (SUI) or stress predominant mixed incontinence (MUI) undergoing concomitant pelvic floor repairs with a sacrocolpopexy. Methods: IRB-approved, randomized, single-blinded trial comparing Burch with MUS in women with symptomatic urinary incontinence and prolapse undergoing a sacrocolpopexy. Patients were randomized using a dynamic allocation approach to achieve balance between intervention groups regarding age, BMI, history of prior

incontinence surgery, pre-operative diagnosis, and prolapse stage. Two primary outcomes were assessed at 6 weeks and 6 months during a medical visit and with completion of validated questionnaires. Patients were objectively continent if at follow-up they 1) had a negative standardized stress test performed by a masked observer; 2) no interim re-treatment for stress urinary incontinence; and 3) no self-reported urinary incontinence (International Consultation on Incontinence Questionnaire2- short form score of 0). As SUI surgery is not meant to address urge incontinence, patients were considered to have stress-specific continence if they fulfilled criteria 1 and 2 above and 3) had no self-reported stress-related leakage of urine (“never” or “rarely” response to all 6 questions from the SUI subscale of the Medical, Epidemiological, Social Aging questionnaire).3 Comparisons were evaluated using the chi-square test or Fisher’s exact test, as appropriate. Results: There was no difference in age, BMI, history of prior incontinence surgery, pre-operative diagnosis, prolapse stage, or baseline incontinence severity between groups. Six-month follow-up was available on 104 patients (92 %) of the 113 patients randomized (53/57 MUS and 51/56 Burch). Although there was no difference in Objective: continence between MUS and Burch patients with complete 6-month follow-up (66.0 % (35/53) vs. 54.9 % (28/51), p=0.25), patients who had a MUS had higher stress-specific continence at 6 months (81.1 % (43/ 53) vs. 62.7 % (32/51); p=0.04). The findings remained consistent when the patients lacking follow-up were classified as failures for each outcome (Objective: continence: 61.4 % (35/57) vs. 50.0 % (28/56), p=0.22; stress-specific continence: 75.4 % (43/57) vs. 57.1 % (32/56), p=0.04). There was no difference in the rate of de novo urge incontinence between MUS and Burch (10.7 % (3/28) vs. 7.7 % (2/26), p=0.99). Amongst patients with baseline urgency urinary incontinence (answered “a few times a month” or worse to question 6 of the overactive bladder


symptom score [22 MUS and 22 Burch]), 77.3 % of the MUS patients had improvement in, 13.6 % reported no change, and 9.1 % had exacerbation of their symptoms, compared to 59.1, 27.3, and 13.6 %, respectively, for the Burch patients (p=0.52). Patients who had a MUS procedure had higher satisfaction (answered “somewhat” or “completely”: 93.8 % vs. 72.3 %: p=0.005), higher patient perception of improvement (rated 10 on 10-point VAS: 71.4 % vs. 51.1 %, p=0.04) and were more likely to report having had a successful surgery for SUI (rated 10 on a 10-point VAS: 72.3 % vs. 47.8 %; p=0.02). There was no difference in patient global impression of severity, the rate of complications or mesh exposures between groups. Conclusions: In women with baseline SUI undergoing concomitant prolapse repairs with a sacrocolpopexy, MUS resulted in greater patient satisfaction and higher urinary continence rates compared to Burch retropubic urethropexy. References: 1. L. Brubaker et al., N Engl J Med 354, 1557 (Apr 13, 2006). 2. K. Avery, J. Donovan, T. Peters, et al., Neurourol Urodyn 23, 322 (May 24, 2004). 3. A. Diokno, B. Brock, M. Brown, et al., J Urol 136, 1022 (Nov, 1986). Disclosure Block: Emanuel Trabuco: No disclosures. CHRISTOPHER KLINGELE: No disclosures. ROBERTA BLANDON: No disclosures. JOHN OCCHINO: No disclosures. MICHAELA MCGREE: No disclosures. AMY WEAVER: No disclosures. MAUREEN LEMENS: No disclosures. JOHN GEBHART: Elsevier: Book royalties, Royalty. UpToDate: Royalties, Royalty.

PP 02 ASSESSMENT OF VOIDING AFTER SLING (AVAS): A RANDOMIZED TRIAL OF TWO METHODS OF POST-OPERATIVE CATHETER MANAGEMENT AFTER MIDURETHRAL SLING SURGERY FOR STRESS URINARY INCONTINENCE IN WOMEN E. TUNITSKY-BITTON1, A. M. MURPHY 2, M. D. BARBER 1, H. B. GOLDMAN 2, S. VASAVADA 2, J. JELOVSEK 1; 1 Center for Female Pelvic Medicine and Reconstructive Surgery, Cleveland Clinic, Cleveland, OH, 2Center for Female Urology and Reconstructive Pelvic Surgery, Cleveland Clinic, Cleveland, OH. Introduction: Midurethral sling (MUS) surgery is an effective treatment for stress urinary incontinence (SUI). About 35 % of patients are discharged home with an indwelling catheter (1). The challenge for surgeons is avoiding postoperative urinary retention while minimizing the use of catheters and their associated risks. A commonly described

Int Urogynecol J (2014) 25 (Suppl 1):S1–S240

voiding trial uses a low post-void residual (PVR) as specific criterion for discharge without a catheter. This method has never been directly compared to alternative Methods: of catheter management. A single observational study evaluated participants who underwent retrograde fill and after voiding were asked to give a subjective evaluation of their force of stream (FOS) utilizing a visual analog scale (2). Despite variable post-void residual volumes, none of the 114 participants re-presented with urinary retention concluding that the FOS method of voiding evaluation was safe for outpatient MUS surgery. Objective: This was a double-blinded randomized trial comparing two Methods: of assessing voiding function after outpatient MUS surgery: a standard voiding trial (SVT) compared to subjective assessment of FOS. The primary outcome was the rate (%) of catheterization in the 6-week postoperative period. Secondary outcomes were post-operative pain, satisfaction with the surgery, and efficacy of treatment using validated questionnaires. Methods: Patients undergoing outpatient MUS surgery were recruited for this study. Participants were randomized immediately after the surgery in the post anesthesia recovery unit. All participants underwent a standard protocol in the recovery room that involved backfilling the bladder with 300 ml of fluid and allowing the patient to void within 30 min. Voided volume (VV) was measured and PVR volume was determined using a bladder scanner. All participants were also asked to assess their voiding using a FOS visual analog scale. Participants in the SVT group were discharged without the catheter if the VV was over 200 ml and PVR volume was ≤1/3 of the total volume. Participants in the FOS group were discharged without a catheter if their subjective evaluation of the FOS was ≥50 % of baseline (scale range: 0–120 %). Participants’ characteristics and baseline validated questionnaires (ISI and UDI-6) were collected assessing urinary symptoms. Participants also answered telephone questionnaires that assessed post-operative pain, analgesic medication use, urinary symptoms, and satisfaction at 2–4 days, 7–9 days and 6 weeks postoperatively. A sample size of 51 participants per group was determined to provide 80 % power to detect a 10 % difference in the rate of catheterization between the two groups. Results: 106 participants enrolled in the study (54 in the SVT group and 52 in the FOS group). 56 % percent of participants underwent a retropubic sling while 46 % had a transobturator sling with no difference between the groups (56 % TVT in SVT group; 52 % in FOS group, p=0.69) (Table 1). The overall postoperative catheterization rate was 27 % (FOS: 26.9 %; SVT: 24.1 %; p=0.76). All participants had their catheter removed 7–9 days postoperatively. None of the participants in either group who were discharged without a catheter required catheter reinsertion at a later point after the surgery. Three participants


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underwent sling revision (1 in FOS and 2 in SVT group). FOS score demonstrated moderate correlation with voided volume amounts (Spearman rho = 0.52, p0.99


11 (10.0)

5 (4.5)


















C Concomitant POP

−6.05±1.82 44

−5.92±2.56 54

0.62 0.23

VH ± A/P or AP




Ant Mesh or ASC



Post only ± mesh



Table 2: subjective Objective: and functional outcomes after Miniarc Monarc at 24 m


0.58 0.46 0.90 1 (1,2)

0.89 4.2±4.4

1 (1,2) 3 (3,3) 2 (1,2)

1 (1,2)

9 (5,12) 0 (0,5)

1 (1,2)


9 (5,13)

3 (2,3)


IIQ 7 #


24 h Pad M ± sd

1 (1,2)

23 (20.4) 21/83 (25.3) 21 (18.8) Not Sexually active

26/95 (27.4) 25/103 (24.3)

0 (0,4)

33 (28,37) PISQ 12 #

0 (0,3)

33 (29,38) 37 (33,41) 36 (33,40)

5 (3,8) ICIQ OAB #

37 (35,41)

5 (3,8) 3 (2,5) 3 (2,5)

17 (14.4) OAB Meds

3 (1,4)

14 (10,16)

16 (14.2 %)

4 (0,8)

10/56 (17.9)

4 (0,7)

10/92 (10.9)

13 (10,16) ICIQ UI SF #

4 (0,6)



0.48 0.62 0.64

0.70 1 (0,3) 0 (0,3)

23/75 (30.7) 22/95 (23.2) 29/103 (28.2)

0 (0,3)


0.27 0.06 38 (34,42) 38 (33,41) 39 (33,41)



0.26 0.57 3 (2,5) 3 (2,5)



3 (2,5)


0.61 0.77


3 (0,6)

9/56 (16.1)

3 (0,6)

15/95 (15.8)

3 (0,6)

14/96 (14.6)

82/95 (86.3) 51/57 (89.5) 84/89 (94.4) 77/95 (81.1) Obj Cure

73/90 (81.1) 95/103 (92.2) 105/110 (95.5) Subj Cure

5/87 (5.70)


1.0 0.43

73/83 (87.9)

44/50 (88.0)

97/103 (94.2)

87/90 (96.7)

99/107 (92.5)


Between groups 24 m

Between groups 6m 0.4 24 m 12 m

Between groups 12 m 0.78

P value Monarc Monarc

6m Baseline N=113 24 m


12 m

Miniarc Miniarc

Baseline 6 m N=112 (#Median (25 %,75 %)




P value

P value

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Disclosure Block: Joseph Lee: AMS: investigator led RCT, contracted research, Grant/Research Support. BSCI: investigator led RCT, contracted research, Grant/Research Support. anna rosamilia: AMS: Research grant, Grant/Research Support. Boston Scientific: research grant, Grant/Research Support. astellas: Speaker, Honoraria. Peter Dwyer: Allergan: Advisory Committee Member, Consulting Fee. American Medical Systems: research grant to urogyn dept for support RCT, Grant/Research Support. Yik Lim: American Medical Systems: Member of research team, Grant/Research Support. Boston Scientific: Member of research team, Grant/Research Support. Daniela Ulrich: Astellas: Speaker, Travel Grant.

PP 04 REPEAT TREATMENTS WITH ONABOTULINUMTOXINA PROVIDE LONG-TERM IMPROVEMENTS IN SYMPTOMS OF OVERACTIVE BLADDER IN FEMALE PATIENTS WITH URINARY INCONTINENCE WHO ARE INADEQUATELY MANAGED BY AN ANTICHOLINERGIC T. RECHBERGER1, M. PARSONS 2, S. GUARD 3, Y. ZHENG 4, D. GINSBERG 5; 1 Med. Univ., Lublin, Poland, 2Birmingham Women’s Hosp. NHS Fndn. Trust, Birmingham, United Kingdom, 3Allergan., Ltd, Marlow, United Kingdom, 4Allergan, Bridgewater, NJ, 5 USC Inst. of Technology, Los Angeles, CA. Introduction: Overactive bladder (OAB) with urinary urgency incontinence (UUI) is disproportionately more common in women than in men.1 Anticholinergics are the first-line pharmacotherapy for OAB; however, nearly 70 % of patients discontinue treatment within a year of initiation, most commonly due to insufficient efficacy and/or intolerable side effects.2 OnabotulinumtoxinA 100U was found to be effective and well tolerated in the treatment of OAB patients with urinary incontinence (UI) who were inadequately managed by an anticholinergic therapy, in 2 large placebo-controlled multicenter phase 3 trials, and is presently the only approved botulinum toxin for the treatment of OAB. Objective: To evaluate the long-term efficacy and safety of onabotulinumtoxinA 100U in the female subpopulation of patients from an interim analysis of a large multicenter extension study of the two placebo-controlled phase 3 trials. Methods: Patients who completed either of the two phase 3 studies (in which they received up to 2 onabotulinumtoxinA treatments) could enter a 3-year extension study in which they received multiple intradetrusor onabotulinumtoxinA 100U treatments (each treatment administered as 20 injections of 0.5 mL/injection). Treatment schedules were dependent upon


individual patient request/need for retreatment; hence, the number of treatments needed to maintain symptom control varied for each patient. Data were integrated across the phase 3 and extension studies and were analyzed by onabotulinumtoxinA treatment cycle (number of onabotulinumtoxinA treatments received). Change from study baseline at week 12 in OAB symptoms of UI episodes (coprimary endpoint), micturition frequency, and urgency were evaluated in the female subpopulation. Volume voided/ micturition, duration of treatment effect, adverse events (AEs) and use of clean intermittent catheterization (CIC) were also assessed. Results: A total of 749 female patients entered the extension study, with 502 patients followed for 2 years or more. As of June 2013, median follow-up was 127 weeks (2.4 years). Discontinuation rates due to AEs/lack of efficacy were low (4.3 %/4.5 %). Results are presented for treatment cycles 1–5 since they provide a sufficient number of patients to yield an interpretable result as of this interim analysis. The mean baseline voiding parameters were: 5.58 UI episodes/day, 11.59 micturitions/day and 8.42 urgency episodes/day. Reductions in UI episodes/day were consistently observed at week 12 following repeat onabotulinumtoxinA 100U treatments: reductions were −3.32, −3.71, −3.87, −3.21, and −3.25 (treatment cycles 1–5). The proportions of patients who achieved ≥50 % reduction in UI episodes/day with repeat treatment in cycles 1–5 were 68.1, 70.9, 72.1, 64.5, and 63.3 %, respectively. Other OAB symptoms were also consistently reduced over repeated onabotulinumtoxinA treatments; reductions in the frequency of micturition episodes were −2.59, −2.94, −2.83, −2.41 and −2.82, and reductions in urgency episodes were −3.87, −4.11, −4.22, −3.62 and −3.96 (treatment cycles 1–5). A consistent increase in volume voided/micturition was noted with repeat treatment: 53.5, 58.7, 57.9, 52.0 and 52.7 mL over 5 treatment cycles, respectively. Median duration of effect was 24.1, 33.4, 27.9, 24.3, and 23.7 weeks (treatment cycles 1–5). Urinary tract infection was the most common AE in each treatment cycle (29.6, 28.8, 28.4, 21.3, and 19.5 %), and no change was observed in the AE profile over time. CIC rates were 4.1, 3.6, 4.3, 4.5 and 3.1 % (treatment cycles 1–5). Conclusions: Repeat treatment with onabotulinumtoxinA 100U provided consistent and sustained improvements in OAB symptoms in female OAB patients with UI who were inadequately managed by an anticholinergic therapy. OnabotulinumtoxinA was well tolerated, with a consistent safety profile over repeated treatments with no new safety signals. References: 1. World J Urol (2003) 20: 327–336. 2. Scan J Urol (2013) Epub ahead of print; doi:10.3109/ 21681805.2013.814707.

Int Urogynecol J (2014) 25 (Suppl 1):S1–S240

Disclosure Block: Tomasz Rechberger: Astellas: Advisory Committee Member, Consulting Fee. Allergan: Advisory Committee Member, Consulting Fee. [email protected]: Speaker, Honoraria. Matthew Parsons: Pfizer: Consultant, Travel Grant. Steven Guard: Allergan Ltd: Employee, Salary. Yan Zheng: No disclosures. David Ginsberg: Allergan: Scientific Medical Advisor, Consulting Fee. Allergan: Speaker’s Bureau, Honoraria.

PP 05 2014 COCHRANE REVIEW: MINIMALLY INVASIVE SYNTHETIC SUBURETHRAL SLING OPERATIONS FOR STRESS URINARY INCONTINENCE IN WOMEN A. FORD1, L. ROGERSON 2, J. OGAH 3; 1 Gynaecology, Bradford Royal Infirmary, Bradford, United Kingdom, 2Urogynaecology, Leeds Teaching Hosp., Leeds, United Kingdom, 3Gynaecology, Univ. Hosp. of Morecambe Bay Trust, Barrow-In-Furness, United Kingdom. Introduction: Urinary incontinence (SUI) is a common condition affecting up to 30 % of women. Minimally invasive synthetic suburethral sling operation is increasing the primary surgical method to treat. Objective: This meta-analysis of Randomised Controlled Trials summarises the evidence of the effects of minimally invasive sub-urethral sling surgery in the management of stress urinary incontinence in women. This is a major update of the 2009 review Methods: All Randomised Controlled Trials that evaluated the surgical interventions for stress urinary incontinence, and were published or presented prior to February 2014, were identified from MEDLINE, CINAHL, the Cochrane Central Register of Controlled Trials (CENTRAL) hand searching of journals, major conference proceedings. Exclusions were traditional, single incision slings, and colposuspension. Data was extracted independently by two reviewers, a meta-analysis was performed and evidence based conclusions were made Results: Eighty-four randomised controlled trials were included (8946 women). When transobturator route (TOR) was compared with retropubic route (RPR) in the short-term (12 months), subjective cure rate was similar at 1792/2215 (81 %) after TOR as compared to 1818/2194 (83 %) following RPR (RR 0.98, 95 % CI 0.95 to 1.00), in 28 trials. There was also no significant difference in short-term Objective: cure rate (RR 0.98, 95 % CI 0.96 to 1.00), in 34 trials that assessed this outcome. Medium and long-term (≥60 months) cure rates (RR 0.98, 95 % CI 0.93 to 1.04) & (RR 1.00, 95 % CI 0.94 to 1.08) respectively also demonstrated no significant difference. Bladder perforation was less likely to occur at 5/2685 (0.2 %) after TOR as compared to 132/2646 (5 %) following RPR (RR


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0.13, 95 % CI 0.08 to 0.21). Less likely to occur with TOR was major vascular injury (RR 0.31, 95 % CI 0.16 to 0.62) and postoperative voiding dysfunction (RR 0.49, 95 % CI 0.39 to 0.63). The mean operating time, blood loss and length of hospital stay were shorter with the TOR. There were significantly higher rates of groin pain at 75/1373 (5.5 %) after TOR as compared to 33/1348 (2.5 %) following RPR (RR 2.14, 95 % CI 1.45 to 3.15). There were similar rates of tape extrusion (RR 1.10, 95 % CI 0.73 to 1.64), de novo urgency/urgency incontinence (RR 1.00, 95 % CI 0.81 to 1.23), and repeat incontinence surgery (RR 1.26, 95 % CI 0.81 to 1.95). We were unable to perform meta-analysis for the impact on women’s quality of life (Qol) due to the use of a wide variety of Qol assessment tools. When ‘Inside-out’ (medial-lateral) transobturator route was compared with the ‘Outside-in’ (lateral-medial) transobturator routes there were no significant differences in the outcomes of relevance for either method in the short or medium-term. Six studies with 507 women assessed short-term subjective cure rates (RR 1.00, 95 % CI 0.94 to 1.06) and seven studies with 819 women assessed short-term Objective: cure rates (RR 0.99, 95 % CI 0.95 to 1.04). Six studies with 794 women assessed bladder perforation rates and found for ‘inside out’ approach the rate was 0.2 % compared with 1 % for ‘outsidein’ (RR 0.38, 95 % CI 0.07 to 1.9). Three studies assessed vaginal perforation rates with a significantly lower rate (3 %) found in the ‘inside-outside’ tapes compared to 12 % in the ‘outside-inside’ (RR 0.25, 95 % CI 0.12 to 0.53). Seven studies with 930 women assessed postoperative voiding dysfunction rates and found ‘inside out’ had a 6 % voiding dysfunction rate compared with 4 % for ‘outside-in’ (RR 1.48, 95 % CI 0.85 to 2.58). Seven studies with 835 women assessed tape extrusion showing the rate for ‘inside out’ was 1.2 % compared with 2.4 % for ‘outside-in’ (RR 0.52, 95 % CI 0.20 to 1.40). Similarly no significant difference between the rates of groin pain and de novo urgency/urgency incontinence at 12 % vs. 10 % (RR 1.18, 95 % CI 0.77 to 1.82), & 8 % vs. 6 % (RR 1.33, 95 % CI 0.66 to 2.68) respectively was proven Conclusions: The availability of medium term and more recently some long term data; there is evidence that monofilament macroporous transobturator tapes are as effective as their retropubic tapes with lower rate of bladder perforation and postoperative voiding dysfunction but higher rates of groin pain. Of note is that these complications in most cases are of short duration. ‘Inside-out’ transobturator tapes are as efficacious as the ‘outside-in’ transobturator tapes. Higher rates of vaginal perforations with the ‘outside-in’ tapes did not translate into more tape extrusions. In the few trials which evaluated Qol there was evidence of improvement when compared to baseline scores with no difference between the groups. Reporting of more long-term evidence from the included trials is to be encouraged to alert us to long-term efficacy and the

presence or absence of late complications from the insertion of these tapes. References: 1. Cochrane Database Syst Rev 2009;CD006375 2. Neurourol Urodyn. 2011 Mar;30(3):284–91 Disclosure Block: ABIGAIL FORD: No disclosures. LYNNE ROGERSON: Astellas: Fully paid for meeting to Berlin to EUGA, Fully paid for meeting to Berlin to EUGA. JOSEPH OGAH: No disclosures.

PP 06 A RANDOMIZED CONTROL STUDY COMAPRING TENSION FREE VAGINAL TAPE (TVT) AND MONARC TRANS-OBTURATOR TAPE IN THE TREATMENT OF WOMEN WITH URODYNAMIC STRESS INCONTINENCE (USI) AND INTRINSIC SPHINCTER DEFICEINCY (ISD) WITH A MEAN FOLLOW UP OF 60 MONTHS J. ALVAREZ1, L. SCHIERLITZ 1, P. DWYER 1, A. ROSAMILIA 2, C. MURRAY 1, J. LEE 1; 1 Mercy Hosp. for Women, Melbourne, Australia, 2Monash Hlth., Monash Univ. & Cabrini Hospita, melbourne, Australia. BACKGROUND: Stress urinary incontinence (SUI) is a condition which greatly affects a women’s quality of life. The most severe type of SUI is considered to be the one associated with intrinsic sphincter deficiency (ISD). Currently the main line of treatment is the mid-urethral slings being the retropubic and transobturator the most commonly used. The aim of the study is to compare the long term efficacy of these two slings among the most severe group. OBJECTIVE: The aim of this study is to compare the efficacy of tension-free vaginal tape (TVT) versus trans-obturator tape in the treatment of women with stress urinary incontinence (SUI) and intrinsic sphincter deficiency at 5-year follow-up. METHODS: From Feb. 2004 to Feb. 2007, 164 women were randomized to either TVT or transobturator tape after diagnosis of urodynamic stress incontinence and intrinsic sphincter deficiency. Intrinsic sphincter deficiency was diagnosed by a Maximum urethral closure pressure of

Abstracts of the 2014 AUGS-IUGA Scientific Meeting, July 22-26, 2014, Washington DC.

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