stress urinary incontinence ( sui ) , which is a complaint of involuntary urine leakage on effort , exertion , sneezing , or coughing , is a common functional disease in women .
understanding of the physiopathological concepts of female sui has steadily developed and the application of this improved understanding has led to improved surgical procedures aimed at correcting this disorder . since the tension - free vaginal tape ( tvt ) procedure was first reported by ulmsten et al .   in 1996 ,
midurethral sling procedures have been considered safe and effective for treating female sui . in 2002 , delorme et al .   described the transobturator technique for a midurethral sling in which they passed the tape through the obturator foramen from outside to inside .
de leval   demonstrated a transobturator midurethral sling procedure in which the sling passes the obturator foramen from inside to outside . in long - term follow - up studies ,
the transobturator technique has similar efficacy and safety compared with that of tvt . despite the popularity of these procedures , prognostic factors for the surgical outcome of correcting sui are still debated .
valsalva leak point pressure ( vlpp ) is defined by the international continence society ( ics ) as the intravesical pressure generated by the valsalva maneuver at which urine leakage occurs owing to increased abdominal pressure in the absence of detrusor contraction .
clinical application of vlpp remains controversial , however , and the effect of vlpp on treatment outcome of distal polypropylene sling procedures or pubovaginal sling procedures is undetermined .
only a few studies have examined outcomes of transobturator midurethral slings stratified by the preoperative severity of urinary incontinence .
additionally , few studies have assessed the relationship between incontinence severity and validated disease - specific quality of life .
thus , we designed this study to assess the influence of preoperative vlpp and stamey grade on quality of life and surgical outcome from transobturator midurethral tape implantation for treating sui in women .
a total of 204 female patients who underwent transobturator midurethral sling placement for the treatment of urodynamic sui from march 2008 to february 2012 were included in this retrospective study .
the preoperative evaluation consisted of a detailed history , urologic physical examination , and a urodynamic study ( uds ) .
the physical examination included a pelvic organ prolapse quantification system classification , q - tip test , and a stress test in the lithotomy position at physiological maximum bladder capacity .
all patients underwent a preoperative uds , including uroflowmetry , provocative cystometry , and urethral profilometry . the stamey incontinence score ( grade 0 , continent ; grade 1 , loss of urine with sudden increase in abdominal pressure such as from coughing , sneezing , or laughing ; grade 2 , leaks with lesser degrees of physical stress such as walking , standing erect from a sitting position , or sitting up in bed ;
grade 3 , total incontinence , urine is lost without any relation to physical activity or position ) was checked to represent sui severity in all enrolled patients . in cases of grade 3 ,
we executed cystoscopy or a radiological evaluation to rule out the possibility of a fistula . patients were then stratified by stamey incontinence score into three groups ( grades 1 , 2 , 3 ) .
all surgery was performed under spinal or general anesthesia according to the decision of the anesthesiologist .
suburethral tape was inserted via an inside - out transobturator midurethral sling ( tvt - o ; gynecare , chaska , mn , usa ) by the same experienced surgeon in all patients ( s.o.k . ) .
the follow - up examination at 6 months included a physical examination with a stress test , an interview for signs and symptoms , and assessment of patient satisfaction with the procedure .
the procedure for this study complied with the guidelines provided by the declaration of helsinki .
patients were excluded from this study according to the following criteria : patients who had undergone previous spine or brain surgery , patients with concomitant high - grade pelvic organ prolapse ( > grade iii ) , patients with a history of urinary retention with residual urine > 200 ml , and patients with active urinary tract infection ( confirmed by nlaton catheterization and urinalysis ) and other urologic disease .
patients using drugs that could have an impact on bladder and urethral function , such as alpha - adrenergic receptor agonists or antagonists , were also excluded .
the incontinence quality of life questionnaire ( i - qol ) , a self - reported quality of life measure specific to urinary incontinence , was completed , and the objective cure rate of incontinence was measured by a stress test before and 6 months after surgery .
cure was defined as no leakage of urine postoperatively both subjectively and objectively , and improvement was defined as no urine leakage on a subjective exam with subjective urine leakage sometimes but with overall satisfaction , whereas failure was defined as objective loss of urine during the stress test .
we compared the pre- and postoperative i - qol scores and cure rates according to preoperative vlpp and stamey grade .
the bladder was filled at a constant rate of 50 ml / min by using normal saline solution at room temperature for standard uds .
vlpp was obtained with the subject seated when the total infused volume of sterile water reached 200 ml by asking the patient to perform a valsalva maneuver until urine loss was directly observed .
the vlpp , a measurement of the lowest abdominal pressure required to produce urine leakage , was recorded and was repeated to verify the initial finding .
if a urine leak was not noted with the valsalva maneuver , the patient was asked to cough .
patients were categorized into three groups on the basis of preoperative vlpp : group 1 ( vlpp60 cm h2o ) , group 2 ( 60<vlpp90 cm h2o ) , and group 3 ( vlpp>90 cm h2o ) .
17 ( spss inc . , chicago , il , usa ) was used for the statistical analyses .
data were analyzed by one - way analysis of variance and bonferroni 's post hoc test .
a total of 204 female patients who underwent transobturator midurethral sling placement for the treatment of urodynamic sui from march 2008 to february 2012 were included in this retrospective study .
the preoperative evaluation consisted of a detailed history , urologic physical examination , and a urodynamic study ( uds ) .
the physical examination included a pelvic organ prolapse quantification system classification , q - tip test , and a stress test in the lithotomy position at physiological maximum bladder capacity .
all patients underwent a preoperative uds , including uroflowmetry , provocative cystometry , and urethral profilometry . the stamey incontinence score ( grade 0 , continent ; grade 1 , loss of urine with sudden increase in abdominal pressure such as from coughing , sneezing , or laughing ; grade 2 , leaks with lesser degrees of physical stress such as walking , standing erect from a sitting position , or sitting up in bed ;
grade 3 , total incontinence , urine is lost without any relation to physical activity or position ) was checked to represent sui severity in all enrolled patients . in cases of grade 3 ,
we executed cystoscopy or a radiological evaluation to rule out the possibility of a fistula . patients were then stratified by stamey incontinence score into three groups ( grades 1 , 2 , 3 ) .
all surgery was performed under spinal or general anesthesia according to the decision of the anesthesiologist .
suburethral tape was inserted via an inside - out transobturator midurethral sling ( tvt - o ; gynecare , chaska , mn , usa ) by the same experienced surgeon in all patients ( s.o.k . ) .
the follow - up examination at 6 months included a physical examination with a stress test , an interview for signs and symptoms , and assessment of patient satisfaction with the procedure .
the procedure for this study complied with the guidelines provided by the declaration of helsinki .
patients were excluded from this study according to the following criteria : patients who had undergone previous spine or brain surgery , patients with concomitant high - grade pelvic organ prolapse ( > grade iii ) , patients with a history of urinary retention with residual urine > 200 ml , and patients with active urinary tract infection ( confirmed by nlaton catheterization and urinalysis ) and other urologic disease . patients using drugs that could have an impact on bladder and urethral function , such as alpha - adrenergic receptor agonists or antagonists , were also excluded .
the incontinence quality of life questionnaire ( i - qol ) , a self - reported quality of life measure specific to urinary incontinence , was completed , and the objective cure rate of incontinence was measured by a stress test before and 6 months after surgery .
cure was defined as no leakage of urine postoperatively both subjectively and objectively , and improvement was defined as no urine leakage on a subjective exam with subjective urine leakage sometimes but with overall satisfaction , whereas failure was defined as objective loss of urine during the stress test .
we compared the pre- and postoperative i - qol scores and cure rates according to preoperative vlpp and stamey grade .
the bladder was filled at a constant rate of 50 ml / min by using normal saline solution at room temperature for standard uds .
vlpp was obtained with the subject seated when the total infused volume of sterile water reached 200 ml by asking the patient to perform a valsalva maneuver until urine loss was directly observed .
the vlpp , a measurement of the lowest abdominal pressure required to produce urine leakage , was recorded and was repeated to verify the initial finding . if a urine leak was not noted with the valsalva maneuver , the patient was asked to cough .
patients were categorized into three groups on the basis of preoperative vlpp : group 1 ( vlpp60 cm h2o ) , group 2 ( 60<vlpp90 cm h2o ) , and group 3 ( vlpp>90 cm h2o ) .
spss ver . 17 ( spss inc . , chicago , il , usa ) was used for the statistical analyses .
data were analyzed by one - way analysis of variance and bonferroni 's post hoc test .
the mean age of the patients was 52.89.6 years , and the duration of disease was 61.458.0 months .
three patients had a hormonal therapy history , and no patient had undergone radiation therapy .
incontinence was the pure sui type in 171 patients ( 83.8% ) , whereas 33 patients ( 16.2% ) showed a mixed type of stress and urgency urinary incontinence .
the numbers of patients with stamey grades i , ii , and iii were 99 ( 48.5% ) , 84 ( 41.2% ) , and 21 ( 10.3% ) , respectively , and 30 ( 14.7% ) , 87 ( 42.6% ) , and 87 patients ( 42.6% ) showed vlpp60 cm h2o , 60<vlpp90 cm h2o , and vlpp>90 cm h2o , respectively .
table 2 shows the objective cure rate and changes in i - qol scores according to preoperative vlpp .
no significant difference was observed in objective cure rate ( p=0.860 ) , preoperative i - qol ( p=0.327 ) , postoperative i - qol ( p=0.560 ) , or changes in i - qol ( p=0.924 ) between the groups when we compared outcome by preoperative vlpp .
measuring outcome by preoperative stamey grade also did not make a significant difference in objective cure rate ( p=0.985 ) or postoperative i - qol ( p=0.944 ) .
however , preoperative i - qol scores were significantly different ( p=0.001 ) between the groups .
a significantly lower i - qol score was found and the score improved remarkably after surgery ( p=0.001 ) when patients had a high preoperative stamey grade ( table 3 ) .
we found that vlpp was not related to the cure rate or quality of life after the midurethral sling operation for treating sui . however ,
preoperative quality of life was significantly different between the groups , with a significantly lower i - qol score and pronounced improvement after surgery when patients had a high preoperative stamey grade .
these results suggest that stamey grade rather than vlpp is important for predicting subjective satisfaction and improved incontinence - related quality of life after midurethral sling surgery in women .
vlpp has been used as an objective determination of sui severity in women to distinguish between intrinsic sphincter deficiency and urethral hypermobility as a cause of sui .
women with low vlpp on uds have been considered to be at increased risk for surgical failure after anti - incontinence surgery .
vlpp has been used to predict the surgical outcome of midurethral sling surgery for correcting sui and to choose an optimal surgical treatment in each woman .
these findings were confirmed by o'connor et al . , who reported that 77% of patients with a preoperative vlpp>60 cm h2o were cured compared with 25% of patients with vlpp60 cm h2o .
similarly , romancik et al .   specifically investigated vlpp as an outcome - predicting factor in 65 patients who underwent tot and found cure and success rates to be significantly higher in patients with vlpp>60 cm h2o ( 78% and 100% , respectively ) than in patients with vlpp60 cm h2o ( 25% and 78% ; p<0.005 and p=0.025 , respectively ) .
in contrast , rodriguez et al .   reported a different result in a recent investigation into preoperative vlpp as a predictor of outcome after the urethral sling procedure .
they evaluated 174 patients who underwent a distal urethral sling procedure in four groups according to vlpp values ( group 1 , no leakage ; group 2 , vlpp>80 cm h2o ; group 3 , vlpp 30 - 80 cm h2o ; group 4 , vlpp<30 cm h2o ) .
regardless of the vlpp , the overall objective cure rates were similar in all groups ( 95% , 92% , 93% , and 92% , respectively ) as were patient - reported outcomes and the number of daily pads used , even though patients with low vlpp had used more pads per day before surgery .
consistent data were reported in a study on 75 consecutive patients with urodynamically proven sui who underwent tvt surgery . when stratified according to preoperative vlpp , 36 patients ( 48% ) had vlpp60 cm h2o and 39 patients ( 52% ) had vlpp>60 cm h2o . when cure rates were compared with preoperative vlpp , no significant difference emerged at a mean follow - up of 21.6 months ( 89.7% vs. 88.9% , respectively ) .
furthermore , a multicenter well - powered study confirmed that vlpp does not predict outcome success after burch or an autologous fascia lata sling procedure in women with pure or predominant sui at a 24-month follow - up .
thus , consensus is lacking on whether preoperative vlpp predicts outcome from anti - incontinence surgery , but the current trend on this issue is that surgical outcome is not associated with preoperative vlpp .
reports suggesting that all types of incontinence can be treated by a similar surgical method and that a distal urethral sling cures incontinence without correcting urethral hypermobility support the results of the present study .
however , our results showed that stamey grade rather than vlpp was important for predicting baseline subjective score of quality of life and improvement in incontinence - related quality of life after midurethral anti - incontinence surgery in women with sui .
the necessity and usage of preoperative uds is still questioned , and related studies have been conducted .
nager et al .   recently reported in their multicenter randomized study that a preoperative office evaluation alone is not inferior to a uds for surgical outcome in women with uncomplicated , demonstrable sui .
the national institutes for health and clinical excellence advised against routine uds in women with a clearly defined clinical diagnosis of pure sui , although some organizations recommend routine uds before surgery for sui .
moreover , it is not easy to use vlpp to assist in choosing the surgical method or surgical decision because the methodology is not standardized .
many related factors such as catheter size , bladder volume , patient position , and valsalva method or cough could influence the vlpp measurement , and all clinicians must recognize this fully when they analyze the results .
we could not address the role of vlpp in women with more challenging issues including urgency - predominant incontinence , incontinence combined with neurologic disease , previous surgery , or sui concomitant with pelvic organ prolapse .
we included some patients with mixed urinary incontinence , and the urgency component of incontinence was not completely excluded when we analyzed the data , which possibly affected the results .
stamey grade rather than vlpp was related with preoperative baseline quality of life and improvement of quality of life after surgery .
 purposewe investigated whether the valsalva leak point pressure ( vlpp ) is valuable for predicting postoperative outcome measurement after transobturator suburethral tape ( tvt - o ) implantation for treating stress urinary incontinence ( sui ) in women.materials and methodsa total of 204 female patients who underwent tvt - o placement for treatment of sui from march 2008 to february 2012 were enrolled in this retrospective study . 
 all patients completed the incontinence quality of life questionnaire ( i - qol ) , a self - reported quality of life measure specific to urinary incontinence , and the cure rate of incontinence was measured before and 6 months after surgery . 
 cure was defined as no leakage of urine postoperatively both subjectively and objectively . 
 we compared pre- and postoperative i - qol scores according to preoperative vlpp and stamey grade.resultsthe numbers of patients with stamey grades i , ii , and iii were 99 ( 48.5% ) , 84 ( 41.2% ) , and 21 ( 10.3% ) , respectively . 
 a total of 30 ( 14.7% ) , 87 ( 42.6% ) , and 87 patients ( 42.6% ) showed vlpp60 , 60<vlpp90 , and vlpp>90 cm h2o , respectively . 
 preoperative vlpp was not significantly different according to preoperative i - qol or change in i - qol after surgery . however , i - qol after surgery improved in patients with a high preoperative stamey grade ( p=0.001).conclusionsvlpp was not a factor related to surgical outcome from the midurethral sling procedure . 
 stamey grade rather than vlpp was important for predicting subjective quality of life and improved incontinence - related quality of life after surgery . 
INTRODUCTION
MATERIALS AND METHODS
1. Subjects and study design
2. Exclusion criteria
3. Outcome measure
4. Measurement of VLPP
5. Statistical analyses
RESULTS
DISCUSSION
CONCLUSIONS