Endometrial ablation with the neodymium:Yag laser.

The current study was designed to evaluate Nd:Yag laser endometrial ablation as an alternative to hysterectomy in women with uncontrolled benign uterine bleeding. The subjects were candidates for hysterectomy, had benign endometrial histology, had failed hormonal therapy and/or D&C, and did not desire future childbearing. Medication was given to render the endometrium atrophic, and treatment was carried out using a "touch" technique. Forty-two treated patients have been followed 3-36 months, with a success rate of 81%. Fourteen (33%) are amenorrheic and 13 (31%) estimate that they have less than 25% of their pretreatment flow. Those with uterine size over 10 cm or large submucous fibroids were usually excluded because of technical difficulty in performing the procedure. Treatment outcome was not related to patient weight, uterine size, or small intrauterine abnormalities. Twelve patients had medical conditions that were relative contraindications for hysterectomy, and 11 were treated successfully. Endometrial ablation with the Nd:Yag laser is an effective alternative to hysterectomy in patients with uncontrolled benign uterine bleeding.

Suburethral abscess: a complication of periurethral collagen injection therapy.

BACKGROUND: Urinary tract infection after collagen injection is well documented. Other adverse reactions are rare. CASES: Three women experienced suburethral abscess after repeat periurethral injections. All patients received local skin preparation and postprocedural antibiotics. Symptoms failed to resolve with antibiotics. The first two patients presented after 5 weeks and 10 days with irritative voiding symptoms and a tender suburethral swelling. The first patient was treated with excision. Spontaneous rupture into the urethra occurred with the second. The third woman presented with acute urinary retention at 102 days. A large suburethral mass was drained successfully in the office. CONCLUSION: Suburethral abscess may be a delayed complication of periurethral collagen injections, not preventable by postprocedural antibiotics. Drainage is required.

Clinical and urodynamic predictors of delayed voiding after fascia lata suburethral sling.

OBJECTIVE: To determine the time to resumption of normal voiding after a fascia lata sling and whether any clinical, operative, or urodynamic variables predict it. METHODS: Between January 1993 and September 1996, 62 women underwent fascia lata suburethral sling operations for intrinsic sphincter deficiency or recurrent stress incontinence. The demographic, operative, and urodynamic data of 61 of these patients were analyzed. RESULTS: The mean number of days to resumption of normal voiding was ten. Three patients (5%) developed permanent retention. Patients 65 years and older were more likely than younger patients to have prolonged catheterization (16 versus 7 days, P=.008). Women who had additional procedures voided at a mean of 15 days compared to nine days for those having slings only (P=.029). A preoperative urine flow rate less than 20 mL/sec was associated with late voiding. There was no significant relationship between preoperative voiding mechanism and voiding time. CONCLUSION: Resumption of normal voiding occurred earlier than reported by others. Age over 65 years, additional surgical procedures, and low peak flow rates were risk factors for delayed voiding. Time to normal voiding was independent of the preoperative voiding mechanism.

Randomized trial of antibiotic prophylaxis for combined urodynamics and cystourethroscopy.

OBJECTIVE: To determine the efficacy of prophylactic nitrofurantoin in preventing bacteriuria after urodynamics and cystourethroscopy. METHODS: We assumed that nitrofurantoin prophylaxis would decrease the rate of infection after urodynamics and cystourethroscopy from 19% to 5%. All women presenting for urodynamics and cystourethroscopy during a 27-month period were offered enrollment, and 142 were randomly assigned to receive two doses of long-acting nitrofurantoin 100 mg (n = 74), or two doses of placebo (n = 68). Nitrofurantoin and placebo capsules were identical, and subjects and physicians were masked to group assignment. Differences were assessed using Student t test for continuous data and chi2 analysis for dichotomous data. RESULTS: There were no statistical differences in demographic characteristics or final diagnoses between groups. Seven women (5%) who had bacteriuria on initial urine culture were not included in the final analysis. The frequency of bacteriuria in the postinstrumentation urine cultures was 6% overall, 7% in the treatment group, and 5% in the controls, a nonsignificant difference ([relative risk] 1.49, [confidence interval] 0.37, 5.95). The power of the study was 33% to detect a significant difference. CONCLUSION: Bacteriuria after combined urodynamics and cystourethroscopy was not improved by a 1-day course of nitrofurantoin.

A suburethral sling procedure with polytetrafluoroethylene for the treatment of genuine stress incontinence in patients with low urethral closure pressure.

One indication for suburethral sling procedures has been recurrent genuine stress incontinence after previous incontinence surgery. Patients with low urethral closure pressures (20 cm H2O or less) in association with genuine stress incontinence are at particular risk for failure of standard anti-incontinence procedures. Urodynamic evaluation was used to select 17 patients with genuine stress incontinence and low urethral closure pressures for surgical treatment with a sling procedure using polytetrafluoroethylene. The technique of the procedure, cure rate, and postoperative complications were assessed. An 85% subjective and objective cure rate was found on urodynamic testing three months postoperatively. Complications included wound seroma, urinary tract infection, and urinary retention.

Massive evisceration: a complication following sacrospinous vaginal vault fixation.

This report describes a spontaneous vaginal vault prolapse in association with massive evisceration following sacrospinous vaginal vault fixation. Careful attention to surgical technique is critical to the success of the operation. In particular, good apposition of the vaginal vault to the sacrospinous ligament and adequate repair of an enterocele should avoid this complication.

Evaluation of pressure transmission ratios in women with genuine stress incontinence and low urethral pressure: a comparative study.

OBJECTIVE: To determine whether women with genuine stress incontinence and low urethral closure pressure (20 cm H2O or lower) had more severely impaired pressure transmission to the urethra than women with stress incontinence and normal urethral pressures. METHODS: Seventy-six women who underwent multichannel urodynamic testing were included for comparative analysis. They were classified into the following groups: genuine stress incontinence with low urethral pressure (N = 20), genuine stress incontinence without low urethral pressure (N = 32), and continent controls (N = 24). Urodynamic indices and pressure transmission ratios were calculated from static and stress urethral pressure profiles, respectively. Multiple demographic cofactors, urethral mobility, and previous surgeries were correlated for associations with urodynamic results. RESULTS: Women with stress incontinence and low urethral pressure were significantly older (57.6 years, P < .0071). There were no differences with regard to urethral mobility and previous surgeries. Mean maximum urethral closure pressure and the distance from the proximal margin of the urethra to the point of maximum urethral closure pressure were statistically less in women with low urethral pressure. There were no differences in pressure transmission ratios between any of the study groups. CONCLUSION: Because there are no differences in pressure transmission ratios between women with genuine stress incontinence with and without low urethral closure pressure, the higher risk for surgical failure with low urethral pressure appears to result from another pathophysiologic process.

Uterosacral ligament: description of anatomic relationships to optimize surgical safety.

OBJECTIVE: To determine the optimal site in the uterosacral ligament for suspension of the vaginal vault with regard to adjacent anatomy and suspension strength. METHODS: Fifteen female cadavers were evaluated between December 1998 and September 1999. Eleven hemisected pelves were dissected to better define the uterosacral ligament and identify adjacent anatomy. Ureteral pressure profiles with and without relaxing incisions were done on four fresh specimens. Suture pullout strengths also were assessed in the uterosacral ligament. RESULTS: The uterosacral ligament was attached broadly to the first, second, and third sacral vertebrae, and variably to the fourth sacral vertebrae. The intermediate portion of the uterosacral ligament had fewer vital, subjacent structures. The mean +/- standard deviation distance from ureter to uterosacral ligament was 0.9 +/- 0.4, 2.3 +/- 0.9, and 4.1 +/- 0.6 cm in the cervical, intermediate, and sacral portions of the uterosacral ligament, respectively. The distance from the ischial spine to the ureter was 4.9 +/- 2.0 cm. The ischial spine was consistently beneath the intermediate portion but variable in location beneath the breadth of the ligament. Uterosacral ligament tension was transmitted to the ureter, most notably near the cervix. The cervical and intermediate portions of the uterosacral ligament supported more than 17 kg of weight before failure. CONCLUSION: Our findings suggest that the optimal site for fixation is the intermediate portion of the uterosacral ligament, 1 cm posterior to its most anterior palpable margin, with the ligament on tension.

Prospective study utilizing transdermal scopolamine in detrusor instability.

Ten patients with pure detrusor instability were treated in a prospective fashion with transdermal scopolamine. Seventy percent of patients experienced moderate to severe untoward symptoms requiring discontinuation of medication. Three of 10 patients (30%) demonstrated a subjective improvement although only 1 was able to tolerate the medication. No objective change in detrusor instability was demonstrated.

Serum gonadotropin and ovarian steroid levels in women during administration of a norethindrone-ethinylestradiol triphasic oral contraceptive.

We studied the inhibitory effect of a triphasic oral contraceptive (OC) regimen on the pituitary and ovarian function in 29 normal, healthy women. ORTHO* 7/7/7 Tablets contain a constant low dose of ethinylestradiol (EE) and a step-wise increasing level of norethindrone (NE). The pills for the first, middle and last weeks of the 21-day regimen contained, respectively, 0.5, 0.75, and 1.00 mg NE, and all contained 0.035 mg EE. The subjects were divided into 3 groups on the basis of their histories of OC use. Ten had not taken an OC in the previous 2 months, 10 were switched to this study from a fixed-dosage combination OC containing 0.050 mg estrogen, and 9 had been taking ORTHO 7/7/7 Tablets for 5 or more cycles. Serum levels of FSH, LH, estradiol and progesterone were measured and statistically compared with those from 5 normal, untreated women. The results from all study cycles showed that the four hormone profiles were significantly suppressed as compared to the normal patterns. Thus, one mode of action of this new triphasic OC is to inhibit ovulation by suppression of pituitary-ovarian function. This OC treatment appeared to be equally effective among women with varying prior histories of OC therapy.

Etiology and management of detrusor instability and mixed incontinence.

The cause of detrusor instability and mixed incontinence remains elusive. Although DI is most prevalent at the extremes of age, GSI becomes more common with aging and child bearing, and therefore mixed incontinence is common, especially after menopause. Cystometry is used to diagnosis detrusor instability, but urethral closure pressure profilometry is required for assessment of mixed incontinence. DI is managed initially by behavioral therapy, and if this is not satisfactory then FES should be used depending upon availability. Drug therapy should start with oxybutynin at 2.5 to 5 mg twice-daily and increased as necessary to control symptoms. If the effects of therapy are minimal or side effects are too great, other medications or medication combinations should be tried. When the patient does not respond to this level of therapy, transvesical phenol injections should be considered, or, alternatively, a sacral selective neurolysis or neurectomy should be considered. Finally, invasive procedures will have to be considered starting with bladder transection, especially for the patient showing response to medication but intolerant of side effects. Mixed incontinence should be approached with conservative measures for each component. FES or imipramine therapy may help both conditions. If conservative therapy is not beneficial, surgical correction for GSI should be undertaken, with the knowledge that 35 to 50 per cent of patients will also have cure of DI, while the remainder can be treated medically for the DI.

Surgical management of urinary incontinence.

Surgery for stress incontinence is selected according to specific problems in each patient. Patients with ISD can be identified and selected for sling surgery or collagen injection therapy. Other patients may be managed successfully by retropubic urethropexy, either open or laparoscopic. Diagnostic evaluation should be thoughtful and extensive, with good correlation of findings and presenting symptoms to apply therapy in a specific manner to each patient.

Genital prolapse with and without urinary incontinence.

Procidentia, vaginal vault prolapse and severe cystocele may be associated with potential urinary incontinence, which becomes overt only after surgical repair of the genital prolapse. The normal support of the pelvic organs is provided by the pelvic diaphragm (levator ani and coccygeus muscles). The levator plate is a firm, muscular plate between the coccyx and anus formed by fusion of the levator ani muscles on each side. Recent investigators have indicated that the main mechanism for weakening the pelvic muscles occurs as a result of childbearing, when stretch injury of the pudendal nerve causes denervation of the muscles. This injury is aggravated with the changes of aging and has effects on anogenital prolapse and stress incontinence. There may be iatrogenic causes of both prolapse and stress incontinence when an operation produces a change in the direction of tissue forces or removes a prior barrier to incontinence. The evaluation of patients must include the actual and potential aspects of genital prolapse and incontinence. Testing for stress incontinence must be performed before and after reduction of the genital prolapse. Surgical repair should be planned carefully to correct all the significant and potential defects in the urogenital tract. Ideally a normal vaginal axis with adequate length will be restored, and urinary function will not be compromised.

Fascia lata suburethral sling vs. Burch retropubic urethropexy. A comparison of morbidity.

OBJECTIVE: To compare morbidity from the fascia lata sling to that from the Burch procedure. STUDY DESIGN: The charts of 64 consecutive patients undergoing the two procedures were reviewed for perioperative, immediate postoperative and delayed postoperative complications. RESULTS: Mean age was significantly older and prior surgery more common in the sling group, but parity and weight were comparable for the two groups. Operative time, estimated blood loss, change in hematocrit, incidence of transfusion, use of narcotics and hospital stay were not statistically different. Duration of catheter use was 2.2 days longer in the sling group (8.96 vs. 6.75 days, P = .387). Comparison of the sling vs. Burch, respectively, showed persistent urge incontinence in 42.8% and 40.0%, new urge incontinence in 22.2% and 16.6%, and cystotomy in 11% and 0%. CONCLUSION: The fascia lata sling procedure has morbidity comparable to that of Burch retropubic urethropexy. Urge incontinence needs to be specifically addressed preoperatively in both groups of patients.

Delayed reaction to the Dacron buttress used in urethropexy.

Eleven patients developed a delayed reaction to the Dacron buttress used in Stamey urethropexy. The reaction was characterized by pain, dyspareunia, vaginal discharge and/or bleeding, induration of the abdominal incision, vaginal granulation tissue and draining abdominal or vaginal sinus tracts. This complication occurred in 5% of the 163 patients we treated with the Stamey procedure for stress urinary incontinence. Treatment consisted of removal of the nylon suture and Dacron buttress. None of the 11 patients developed recurrent incontinence. The subjective cure rate for stress urinary incontinence was 92% using the Stamey procedure.

Stress incontinence and low urethral closure pressure. Correlation of preoperative urethral hypermobility with successful suburethral sling procedures.

Forty-eight women with genuine stress incontinence and low urethral closure pressure were treated with a suburethral sling procedure using polytetrafluoroethylene. All patients underwent a preoperative clinical evaluation and multichannel urodynamic testing. The clinical examination included a "Q-tip" test to determine the presence or absence of urethral hypermobility. Urethral hypermobility was defined as a maximal angle change of greater than or equal to 30 degrees from the horizontal, measured during straining or coughing in the lithotomy position. Thirty-four patients underwent repeat multichannel urodynamic testing three months postoperatively to determine the objective surgical success. Ninety-three percent of patients (27/29) with a positive preoperative Q-tip test were cured. Of patients with a negative preoperative Q-tip test, only 20% (1/5) were cured. Preoperative urethral hypermobility was a good prognostic indicator of operative success when a suburethral sling procedure was used to treat genuine stress incontinence and low urethral closure pressure.

Recurrent stress incontinence. Causes and treatment in the female patient.

Recurrent urinary incontinence after surgery requires complete evaluation, including urodynamic testing, to make an accurate diagnosis. Documented genuine stress incontinence, if mild to moderate, may respond to nonsurgical treatment, but more severe cases require surgery. Numerous effective surgical procedures have been developed.

Management of recurrent genuine stress incontinence.

Recurrent stress incontinence is frequently a result of incomplete preoperative evaluation. Evaluation of surgical failures must include an assessment of urethral sphincter function by endoscopy, UCPP, or video-urodynamics. Patients with GSI and a mobile urethovesical junction and normal urethral closure pressure should be corrected by a Burch sling or MMK. Patients with low urethral closure pressure and normal or borderline UVJ mobility should have a suburethral sling procedure. Patients with a nonfunctioning urethral sphincter respond best to an artificial urinary sphincter.

The contribution of urethrocystoscopy to evaluation of lower urinary tract dysfunction in women.

The aim of this study was to determine whether the evaluation of lower urinary dysfunction with urodynamics and urethrocystoscopy provides unique information that is missed by urodynamics alone. Eighty-four women underwent multichannel urodynamics and urethrocystoscopy. Retrospective analysis included evaluation of the relationships between lower urinary tract lesions and risk factors using chi2 and Fisher's exact tests. Urethrocystoscopic findings changed the diagnosis and management in 6 patients. New urethrocystoscopic findings included papillary transitional-cell carcinoma, cystitis glandularis, an intravesical suture and a urethral diverticulum. Clinical parameters were not predictive of these findings. Urethrocystoscopic findings also contributed to the final diagnosis in 10 patients with intrinsic sphincter deficiency. Considered alone, maximum urethral closure pressure < or =20 cmH2O had a sensitivity of only 20% and a positive predictive value of 40% for this diagnosis. Urodynamics without urethrocystoscopy would have missed important diagnoses in 19% of women. Urethrocystoscopy and urodynamics complement one another, and both have a role in the evaluation of women with lower urinary tract dysfunction.

Sling incision with associated vaginal wall interposition for obstructed voiding secondary to suburethral sling procedure.

Obstructed voiding is a well recognized complication following a suburethral sling procedure. Current methods of transvaginal and transabdominal urethrolysis have had variable success rates in relieving the obstruction, and do not restabilize the urethra to prevent potential postoperative stress incontinence. We report on a procedure used in 4 cases which addresses both of these issues. All patients had persistent urinary retention beyond 8 weeks after a suburethral sling procedure. An oupatient procedure consisting of sling incision and associated tissue interposition (vaginal wall in three cases and fascia lata in one) was successful in relieving the obstruction. Continence status was maintained in 3 of the 4 patients. There were no major complications of this outpatient procedure.