- Integral theory: 3 supports of proximal/midurethra — pubourethral ligaments, suburethral vaginal hammock, pubococcygeus muscle.
- ISD = primary underlying cause of female SUI; hypermobility is secondary. All SUI patients have some ISD; not all have hypermobility.
- ALPP <60 cm H₂O or MUCP <20 cm H₂O = ISD; ALPP >90 = little/no ISD.
- VALUE (NEJM 2012): preop office evaluation alone NOT inferior to evaluation with UDS in uncomplicated SUI.
- CARE trial: in women with prolapse without preop SUI undergoing sacrocolpopexy, concomitant Burch significantly reduces postop SUI.
- SISTEr (NEJM 2007): autologous rectus fascia PVS vs. Burch — PVS higher success rate but higher voiding dysfunction (63% vs. 47%), UTI, voiding difficulty, postop urgency incontinence.
- MUS is placed loosely at the midurethra; PVS is placed under mild tension at the bladder neck.
- Retropubic MUS > transobturator MUS in ISD; results similar overall with normal urethral function.
- Macroporous polypropylene monofilament mesh with pore size >75 μm = current standard MUS material.
- MUS contraindicated with concomitant urethral diverticulectomy, urethrovaginal fistula repair, urethral mesh excision.
- Bladder trocar injury higher with retropubic MUS (2.7–23.8%) vs. transobturator (0–1.3%).
- Sling release in midline through single vertical vaginal incision is preferred management for persistent voiding dysfunction within first 3 months after MUS; cut within 4 weeks of surgery.
- Most groin pain after MUS resolves by postop day 2; transobturator groin pain persists longer.
- PVS autologous fascia is gold standard for ALL forms of SUI — minimal inflammation, negligible urethral erosion.
- Synthetic PVS no longer used — 15× urethral perforation and 14× vaginal exposure vs. autologous/allograft/xenograft.
- Martius flap blood supply (3): superior — external pudendal; lateral — obturator; inferior — posterior labial (branch of internal pudendal).
- Martius flap preferred for low/distal VVF involving trigone/bladder neck/urethra; peritoneal flap for high post-hysterectomy VVF; omentum useful in infection/inflammation.
- POP-Q stages: 0 (Aa, Ba, Ap, Bp all at −3), 1 (>1 cm above hymen), 2 (within ±1 cm of hymen), 3 (>1 cm below hymen but not total eversion), 4 (complete eversion, ≥2 cm < tvl).
- POP loss of support by level: I → apical prolapse; II → cystocele/anterior; III anteriorly → urethral mobility; III posteriorly → distal rectocele or perineal descent.
- Complete uterine prolapse (procidentia) can cause bilateral ureteral obstruction — correction relieves obstruction.
- 2011 FDA safety communication on transvaginal mesh for POP — excluded slings and transabdominal mesh for prolapse.
- Urinary continence definition (AUA IPT 2019): not requiring a pad or protective device to stay dry (pad-free).
- Risk factors for IPT after RP (5): older age, larger prostate, shorter membranous urethral length, lack of bilateral NVB preservation, prior pelvic radiation.
- Most men reach maximum continence after RP by 12 months; 90% continent at 6 months after RALP, only +4% afterward.
- Surgical timing for IPT: 12 months (or 6 months if no improvement and severe SUI).
- AUS = gold standard (AMS 800) for male SUI — effective across spectrum of severity.
- Standard bulbar AUS PRB: 61–70 cm H₂O; cuff size most commonly 4 or 4.5 cm; single-cuff perineal approach preferred.
- AUS failure rates: ~24% at 5 years, ~50% at 10 years.
- Urethral atrophy is most common cause of gradual return of incontinence and AUS revision.
- AUS infection: S. epidermidis most common; urgent explant; do not reimplant for at least 3 months.
- AUS cuff erosion management: explant + urethral catheter for few weeks; no reimplant for at least 3 months; confirm urethral healing on urethrography.
- Bladder neck AUS contraindicated after radical prostatectomy; preferred for myelomeningocele.
- Most common surgical cause of rectourethral fistula = radical prostatectomy (although incidence is low, <1–2% rectal injury).
- York-Mason procedure = transrectal transsphincteric approach for rectourethral fistula — effective with low morbidity.
- Most common cause of VVF in industrialized world = hysterectomy (>75%); in developing world = obstructed labor.
- Most common cause of ureterovaginal fistula = hysterectomy with injury to distal 1/3 ureter.
- Most common cause of vesicouterine fistula = Cesarean section.
- Pneumaturia = most common presenting symptom of colovesical fistula; Gouverneur syndrome = suprapubic pain + frequency + dysuria + tenesmus.
- CT with contrast = most sensitive/specific for colovesical fistula; 3 findings: bladder wall thickening adjacent to thickened colon, air in bladder, colonic diverticula.
- Most common cause of ureteroenteric fistula = IBD (Crohn's), usually right-sided involving terminal ileum.
- Most common cause of pyelovascular fistula = PCNL; renovascular fistula → embolization or expectant management (70% close in 18 months after biopsy-induced).
- Most congenital bladder diverticula are near the ureterovesical junction (lateral/posterior to ureteral orifice); ~13% associated VUR.
- Acquired bladder diverticula in men >60 with BPH (~70%); in women → look for BOO etiology.
- Hutch diverticulum = superolateral to ureteral orifice without trigone involvement in neuropathic bladder with VUR.
- Most common malignant histology in bladder diverticulum = urothelial carcinoma; aggressive due to absent muscularis propria.
- Bladder diverticulum tumor is an indication for timely cystectomy (2015 CUA NMIBC).
- Most acquired female urethral diverticula originate from infection of periurethral (Skene) glands.
- Female urethral diverticulum ostium: postero/ventrolaterally at 4 and 8 o'clock in mid- or distal urethra in >90%.
- Most common malignant histology in urethral diverticulum: adenocarcinoma; in female urethral cancer: squamous; in male urethral cancer: urothelial.
- Female urethral lymphatic drainage: proximal → external iliac; distal → superficial inguinal.
- Male urethral lymphatic drainage: posterior → pelvic; anterior → superficial inguinal.
- Synthetic mesh contraindicated synchronous with urethral diverticulectomy (erosion/infection risk).