Evaluation of holmium laser for managing mesh/suture complications of continence surgery.

OBJECTIVES: • To evaluate transurethral endoscopic excision using the holmium laser (TEEH) for the management of lower urinary tract mesh or suture complications of continence intervention. • To compare the outcomes, complications and recurrence rates of TEEH with the published results from studies using other techniques. PATIENTS AND METHODS: • A retrospective review of six patients who underwent TEEH for eroded mid-urethral tape or suture into the urethra or bladder. • Patients with urethral and bladder exposure of mesh or suture material managed by TEEH were identified from the operating records, electronic data records and the Holmium Laser Registry at our institution. • Outcome variables included resolution of the presenting symptoms and continence status, recurrent mesh or suture exposure, and symptoms or other morbidity, including haematoma, urinary sepsis, voiding dysfunction and recurrent stress incontinence. • A literature review on the available evidence on holmium laser for lower urinary tract complications of continence surgery was undertaken. RESULTS: • Between September 2006 and March 2010, six women underwent TEEH. All presented with bladder storage symptoms and/or haematuria with recurrent cystitis. The interval between surgery and the diagnosis of erosion was 1-13 years. • Four women had previously undergone retropubic mid-urethral tape, one colposuspension and one a suprapubic arc procedure followed by a transobturator tape insertion. • Complete excision with TEEH was achieved in all cases. • Two women had postoperative haematuria, which resolved after 2 weeks. There were no other immediate complications. • Four patients had recurrent erosion at follow-up. Two of them were symptomatic, requiring repeat TEEH. One was asymptomatic and managed expectantly. In one case, recurrent mesh erosion occurred at the bladder neck in the submucosal layer. This was considered unsuitable for further TEEH. A laparotomy and open excision was undertaken. CONCLUSIONS: • TEEH is a minimally invasive technique, with minimal morbidity and complications, compared to open vaginal or abdominal excision of mesh or suture exposure into the lower urinary tract. Open urethrotomy involves risks of damage to the continence (sphincter) mechanism, with subsequent stress incontinence. In addition, anterior wall scarring may lead to dyspareunia, vaginal pain, urethral stricture and/or fistula. When mesh erosion involves the bladder, transabdominal open or laparoscopic excision may be required. • Although the recurrence rates in our series are high, the majority of them were managed easily by repeat TEEH, with minimal morbidity or expectantly if asymptomatic. • In selected patients, TEEH is an acceptable novel technique for the first-line management of this complication of continence interventions, although longer or pooled prospective studies evaluating TEEH are now required.

Long-term outcomes of modified high uterosacral ligament vault suspension (HUSLS) at vaginal hysterectomy.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to prospectively evaluate long-term outcomes of a modified high uterosacral ligament suspension (HUSLS) at vaginal hysterectomy for pelvic organ prolapse (POP). METHODS: POP was assessed 5 years postoperatively in 42 women who underwent vaginal hysterectomy and HUSLS for POP. Bladder, bowel, sexual function and quality of life (QoL) were evaluated. RESULTS: Preoperatively, 27/42 women had at least BW grade 2 uterine prolapse. At a mean follow-up period of 59.4 months (range: 40-79 months), two women had undergone surgical intervention for vault prolapse, 33 had no vault prolapse and six grade 1 vault prolapse. One woman declined vaginal examination. Twenty women were sexually active and 18 completed the PISQ-31. The mean total score for all domains was 91/125. On QoL assessments high scores were noted in all domains. CONCLUSIONS: Modified HUSLS at vaginal hysterectomy is associated with satisfactory long-term objective and subjective outcomes, sexual function and quality of life scores.

Prospective evaluation of combined local bupivacaine and steroid injections for the management of chronic vaginal and perineal pain.

PURPOSE: Vaginal/perineal pain is common following obstetric trauma or vaginal surgery for prolapse and may have a serious impact on sexual function and quality of life. Local injections of corticosteroids, local anaesthetic and hyaluronidase are treatment options for chronic pain; however, there are no published studies to support their efficacy. The objective of this study was to evaluate prospectively the efficacy of perineal/vaginal injections for chronic localised pain following childbirth or vaginal surgery. METHODS: Consecutive women with chronic vaginal/perineal pain were recruited in this prospective series (audit). Pain severity and sexual function were determined using a visual analogue scale (VAS 0-10) and the abbreviated sexual function questionnaire (ASFQ) respectively. Patients underwent local injections with a combination of 0.5% bupivacaine (10 ml), hydrocortisone (100 mg) and hyaluronidase (1,500 IU). Follow-up was undertaken at four-weekly intervals. Further injections were performed as clinically indicated. RESULTS: Fifty-three women underwent ≥1 injections [mean: 1.86 (range: 1-4)]. Mean interval from index childbirth [43/53 (81%)] or surgical intervention [10/53 (19%)] was 8 months (range 12 weeks-20 years). Twenty-seven women (51%) were sexually active. All reported dyspareunia. Fifteen (28%) women required 1 and 31(59%) two injections. Pre treatment VAS pain scores were 6.1 versus 4.1 after first injection (p = 0.0002, 95% CI 1.01-3.05) and mean ASFQ scores increased from 18.1 to 29.1 (p = 0.01, 95% CI -17.2 to -2.3) 4 weeks post-injection. There were no adverse events or morbidity. 24/27 (89%) sexually active women with dyspareunia resolved and 18/26 (69%) sexually inactive women resumed satisfactory sexual activity 8 weeks post-injection. CONCLUSION: In our series, this treatment was well tolerated and significant improvements in pain scores and sexual function were observed.

High uterosacral ligament vault suspension at vaginal hysterectomy: objective and subjective outcomes of a modified technique.

AIMS: To evaluate the outcomes of a modified high uterosacral ligament suspension (HUSLS) performed at vaginal hysterectomy for uterine prolapse. METHODS: Prolapse was assessed pre- and postoperatively in 53 consecutive women, using Baden-Walker Halfway and Pelvic Organ Prolapse Quantification systems. Sexually active women completed the Prolapse and Incontinence Sexual Function Questionnaire at follow up. The technique involves placement of one HUSLS suture on each side without a fascial reconstruction. RESULTS: Preoperatively, 37 (66%) women had at least Grade 2 prolapse of the cervix. At mean follow-up of 15 months, 45 (85%) had no vault prolapse and 7 (13%) had Grade 1 prolapse. Nineteen (36%) women were sexually active at follow up and completed the Prolapse and Incontinence Sexual Function Questionnaire. Mean scores for pain, vaginal tightness, partner perception of tightness and vaginal length were 2.8, 3.2, 4.0, and 3.8 respectively, indicating excellent function. CONCLUSIONS: We report excellent objective, subjective and sexual function outcomes following this modified HUSLS.

A modified technique for the surgical correction of urethral diverticula using a porcine xenograft.

We report a case of urethral diverticulectomy re-enforced with a porcine xenograft to prevent the risk of recurrence or fistula in the presence of a large urethral communication. The use of porcine small intestinal submucosal xenograft (SIS, Surgisis, Cook, Ireland) material has a low graft rejection rate and erosion is rare as the material is degraded after 3 to 6 months. In this case, xenograft achieved tension-free closure of the urethral defect without any postoperative complications.

Evaluation of outpatient cystoscopy in urogynaecology.

OBJECTIVE: Prospective evaluation of outpatient cystoscopy in a Urogynaecology Unit. DESIGN: Prospective observational series. SETTING: St. George's Hospital, London. Department of Pelvic Reconstructive Surgery and Urogynaecology. POPULATION: A total of 131 consecutive women, who underwent outpatient rigid cystoscopy over a 24-month-period. MATERIALS AND METHODS: Prospective data collection included cystoscopic findings, microbiology data, uroflowmetry and radiological results. An Immediate Feedback Questionnaire was completed at the end of the procedure. MAIN OUTCOME MEASURES: Success rates of the procedure, cystoscopy findings, requirements for additional investigations, including inpatient cystoscopy and patient satisfaction rates. RESULTS: The mean age was 56.4 years (range 20-87 years). A total 126 women (96.2%) had a successful outpatient cystoscopy. In five (3.8%) women the procedure had to be abandoned because of inability to insert the cystoscope. Eleven women (8.7%) experienced pain but were able to tolerate the discomfort. Fifty-three (42.7%) women had abnormalities detected at cystoscopy. Thirty-seven women had trabeculations. Focal vesical lesions were found in 21 women. Thirty-nine (30.9%) women did not require any additional treatment. Six (6.9%) women were scheduled for repeat cystoscopy under general anaesthetic to facilitate a bladder biopsy. Fifteen women (17.2%) were referred for urodynamics or renal imaging. Three women (3.4%) were referred to a urologist. More than 75% reported high satisfaction with the care they received. Four women had symptoms of UTI and two had positive urinary cultures and required antibiotics. CONCLUSIONS: The benefits of outpatient cystoscopy include high levels of tolerability and patient satisfaction, shorter waiting time, quicker implementation of treatment strategies, avoidance of the risks of general anaesthesia and lower procedural cost.

Are voiding symptoms really associated with abnormal urodynamic voiding parameters in women?

OBJECTIVES: To examine the relationship between voiding symptoms and objective measurements of voiding dysfunction. METHODS: We prospectively collected data from 116 consecutive women attending for urodynamic investigations. Symptoms of voiding dysfunction and objective voiding parameters including uroflowmetry and post-void residual volume were evaluated. RESULTS: Sixteen (14%) patients reported a symptom of straining, 21 (18%) double voiding, 32 (27%) post-micturition dribbling, 10 (8%) poor stream and 34 (29%) incomplete emptying. Using receiver-operator curves we were unable to determine a cut-off value for flow or residual volume where symptoms became more prevalent. Poor stream was, however, a good predictor for a residual volume of >100 mL and >150 mL. Strain predicted a residual volume of >100 and >150 mL and it correlated with maximum flow rate <15 mL/s. The other three symptoms did not correlate with any of the cut-off values. CONCLUSIONS: Poor steam and strain are weakly predictive of abnormal voiding function.

Is there an alternative to pad tests? Correlation of subjective variables of severity of urinary loss to the 1-h pad test in women with stress urinary incontinence.

OBJECTIVE: To compare the 1-h pad test in women who have urodynamically confirmed stress incontinence (USI) with a patient-based 3-point symptom severity scale and validated quality of life (QoL) questionnaires. PATIENTS AND METHODS: In all, 98 women with USI were prospectively recruited; all had a 1-h pad test and completed the validated disease-specific QoL questionnaires, including short forms of the International Consultation on Incontinence Questionnaire (ICIQ-SF), Urogenital Distress Inventory (UDI-6), and Incontinence Impact Questionnaire (IIQ-7). In addition, the severity of incontinence was determined using the Stamey grading scale, a visual analogue scale (VAS) score, and a patient-based 3-point symptom severity scale. RESULTS: The VAS, symptom severity scale, Stamey grade, UDI-6, and IIQ-7 failed to correlate significantly with the 1-h pad test. Only the ICIQ-SF correlated significantly with this test. CONCLUSION: The ICIQ-SF is easy to administer and, in this study, correlated best with the 1-h pad test in women with pure primary or secondary USI. It incorporates both symptom severity and QoL variables. We recommend its routine use in clinical practice.

Is Doppler planimetry a valid technique for the evaluation of postpartum urinary bladder volume?

The objective of this prospective study was to evaluate the accuracy of conventional 2D ultrasound (CUS) versus doppler planimetry (DP) in the assessment of postpartum urinary bladder volume compared to a true estimate using urethral catheterisation. Fifty-two women were assessed within 24 hours of delivery. Evaluation of bladder volume was performed using CUS (1-estimate) and DP (6-estimates). CUS had a higher correlation (r=0.796) with the true volume and lower % error than DP in the postpartum group. DP readings were highly reproducible (ICC 0.81) but tended to overestimate the true value especially with smaller volumes. DP was suboptimal for the assessment of the postpartum PVR. Postpartum evaluation using CUS is more accurate in calculating the true urinary volume.

Female urethral diverticula.

Urethral diverticula are frequently under-diagnosed. The pathogenesis of this condition is poorly understood, and these lesions represent a spectrum of disorders ranging from isolated suburethral cysts to herniation of the urethral lining into the vaginal mucosa. Women with this disorder frequently complain of a host of symptoms referable to the lower urinary and genital tracts. Accurate diagnosis is based on history and clinical evaluation. Perineal ultrasound and MRI are often helpful. Repeated courses of antibiotics and urethral dilatation often fail to resolve the problem, and definitive intervention usually requires surgical excision to provide relief. This chapter describes the current management of this condition, and it heralds a re-look at the patho-aetiology in view of recent MRI findings of symptomatic non-communicating microcystic lesions.

Tension-free vaginal tape exposure presenting as a recurrent sterile paraurethral abscess.

We report a case of tension-free vaginal tape (TVT) exposure presenting as a recurrent sterile paraurethral abscess at 25 months and 40 months following successful continence surgery and describe the management of this problem.

The tension-free vaginal tape in older women.

OBJECTIVE: To evaluate peri-operative morbidity, continence outcome and patient satisfaction in older women (>/=65 years) compared with younger women undergoing tension-free vaginal tape. DESIGN: Case controlled study. SETTING: Tertiary Urogynaecology Unit. SAMPLE: Women undergoing tension-free vaginal tape for urodynamic stress incontinence between July 1999 and July 2002 were included. Those with detrusor overactivity, voiding difficulty at urodynamics or requiring concomitant prolapse surgery were excluded. METHODS: Older women were case matched to a younger cohort for BMI, parity, mode of anaesthesia and whether it was a primary or secondary continence procedure. MAIN OUTCOME MEASURES: Operative morbidity and continence outcome were assessed at six weeks. After a minimum six months follow up, patient satisfaction and continence outcome were assessed using the Genitourinary Treatment Satisfaction Score (GUTSS). RESULTS: The median hospital stay was one day and overall urinary tract infection rate was similar in both groups. Post-operative voiding difficulty rates were 3% in older versus 15% in younger women (P= 0.09). At six weeks, 65% of older versus 79% of younger women were dry (P= 0.2). At a median of 12 months, 15 (45%) of older versus 24 (73%) of younger women had no urinary symptoms (P= 0.05). Median GUTSS scores for satisfaction with continence outcome were lower for older 90% compared with 100% in younger women (P= 0.003). CONCLUSIONS: Tension-free vaginal tape is an effective continence intervention in older women but has a lower continence satisfaction rate compared with younger women.

The role of synthetic and biological prostheses in reconstructive pelvic floor surgery.

PURPOSE OF REVIEW: Uterovaginal prolapse and urinary incontinence are common problems whose pathogenesis remains unclear. As life expectancy increases, significantly greater numbers of women will present with pelvic floor prolapse and incontinence requiring surgical intervention. Currently, the lifetime risk of undergoing prolapse or continence surgery in the USA is one in 11, and up to 30% of patients will require repeat prolapse and 10% repeat continence surgery. In an attempt to improve surgical outcomes and to preserve vaginal capacity and coital function, a number of synthetic and biological prostheses have been developed. This review aims to look at the controversies that exist as the 'ideal' prosthetic material is developed. RECENT FINDINGS: The recent literature has reflected the increasing interest in the use of biological prostheses (Allograft/Xenograft) and synthetic absorbable meshes. There has been a focus on the risk factors for erosion seen with the use of synthetic non-absorbable material and a review of techniques for the reduction and management of this complication. The advent of mesh placement in minimally invasive continence surgery (tension-free vaginal tape, intravaginal sling, and Supra Public ARC) is now seeing surgical success to 5 years, but the reporting of complications remains inconsistent. SUMMARY: The use of prosthetics in pelvic floor and continence surgery is an evolving field. Further randomized controlled trials are required to evaluate the role of both biological and synthetic prostheses in reconstructive surgery, to determine which type of prosthesis is most suitable for specific procedures. Prosthetic reinforcement should not be used to replace good surgical techniques.

Stress urinary incontinence after delayed primary closure of genitourinary fistula: a technique for surgical management.

OBJECTIVES: Our purpose was to evaluate the anatomic pathology of severe incontinence after fistula closure and assess a surgical technique for correction of this problem. STUDY DESIGN: Twenty-two women with severe urinary incontinence after fistula closure were recruited, and clinical and urodynamic assessment was performed. A technique combining retropubic urethrolysis, pubovaginal sling, and omental graft was performed in women with genuine stress incontinence (GSI), and continence outcome was assessed at 4 weeks and 14 months. RESULTS: On urodynamic assessment, 9 (41%) had severe GSI with normal compliance, 3 (14%) GSI and poor compliance, 9 (41%) GSI and detrusor instability, and 1 (4%) voiding dysfunction with overflow incontinence. Nine women (41%) with pure GSI underwent continence surgery. Continence outcomes were 78% at 4 weeks and 67% at 14 months. CONCLUSION: The anatomic pathology of GSI after fistula surgery is complex. The surgical technique described is promising with low morbidity and improved continence rates at 4 weeks and 14 months compared with previous techniques.