Urodynamic and clinical effects of transvaginal mesh repair for severe cystocele with and without urinary incontinence.

OBJECTIVE: To demonstrate the urodynamic and clinical effects of transvaginal polypropylene mesh repair (TVM) for severe cystocele with or without stress urinary incontinence (SUI). METHODS: One hundred women with severe cystocele who underwent transvaginal cystocele repair using a tension-free polypropylene mesh were included in a retrospective study. A simultaneous transobturator tape (TOT) procedure was performed in 24 patients with concurrent urodynamic stress incontinence (USI). Postoperative follow-up examinations included urodynamic testing, pelvic organ prolapse quantification, and urogynecologic questionnaire. RESULTS: Mean follow-up was 35 months (range, 13-68 months). At 3-6 months after surgery, 2 (8.3%) of the 24 patients with USI who had undergone TVM and TOT had persistent SUI. Of the 30 women with occult USI who had undergone TVM alone, 6 (20%) developed symptomatic SUI and 9 (30%) had asymptomatic SUI. Thirteen (28.3%) of the 46 patients without USI developed postoperative SUI. The 1-year results showed de novo SUI in 10 (10%) women, recurrent cystocele in 6 (6%), and mesh erosions in 5 (5%). Four (13.3%) of the 30 patients engaging in sexual activity had dyspareunia. CONCLUSION: TVM is effective and safe in patients with severe cystocele, but may have an impact on voiding and sexual activity.

Concomitant tension-free vaginal tape for urinary incontinence during laparoscopic hysterectomy.

OBJECTIVE: To evaluate the effectiveness and safety of placing tension-free vaginal tape (TVT) during a laparoscopically assisted vaginal hysterectomy (LAVH) in women with stress urinary incontinence and coexistent benign gynaecological disease. DESIGN: Retrospective clinical study (Canadian Task Force classification II-2). SAMPLE: Thirty patients diagnosed with genuine stress incontinence and benign gynaecological disease were studied. METHODS: All the patients underwent LAVH and concomitant TVT procedure. RESULTS: There was no significant difference in urodynamic parameters before and after surgery. All patients were followed postoperatively for a mean duration of 24.6 +/- 11.5 months (range 12-40). The cure rate of stress urinary incontinence was 96.7%. CONCLUSIONS: Concomitant placement of tension-free vaginal tape during a laparoscopically assisted vaginal hysterectomy proved to be an efficacious and safe procedure for women with benign gynaecological disease and coexistent stress urinary incontinence.

Ultrasound assessment of mid-urethra tape at three-year follow-up after tension-free vaginal tape procedure.

OBJECTIVES: To evaluate the anatomic changes in the polypropylene mesh sling after a tension-free vaginal tape (TVT) procedure using introital ultrasonography in a prospective study. METHODS: Eighty women with genuine stress incontinence but without pelvic relaxation syndrome underwent surgery. Introital ultrasound evaluation of the mid-urethra TVTs was performed after surgery. RESULTS: Of the 70 women available for evaluation at postoperative year 3, 62 (88.5%) were objectively cured and 6 had improvement; in 2 patients, the procedure had failed. The measurement of the tape position from the bladder neck at the first and third year compared with the tape position at 1 month revealed no statistically significant differences. The tapes were located at the mid-urethra in 60 patients (85.7%) and at the proximal urethra in 10. The measurement of the tape from the lower margin of the symphysis pubis using the rectangular coordinate system showed the tape had a downward descent of 1.7 mm at 3 years of follow-up. The rate of descent decreased during the study period. The mean thickness and width of the tape increased with time. A urethral knee angulation during maximal straining was found in 60 patients (92%), with the tape positioned at the mid-urethra for the follow-up period. CONCLUSIONS: The observations of the tape position and characteristics suggest that shrinkage and compromise of the TVT sling does not occur. The TVT sling fixes to its original implanted site along the urethra and appears to slowly descend with the surrounding tissue with time. The urethra dynamic kinking contributes to the postoperative urinary continence when the TVT sling is placed at the mid-urethra.

Awake fiberoptic intubation for cesarean section in a parturient with odontoid fracture and atlantoaxial subluxation.

We report on the anesthetic experience of a 38-week pregnant patient in labor with an upper cervical spinal cord injury after an unusual trauma. She was transferred from a district hospital to our medical center with acute quadriplegia and sensory loss. Plain cervical spine x-ray and computed tomographic scan showed a C2 odontoid (dens of axis) process type II fracture and atlantoaxial (C1-C2) subluxation. Due to having regular uterine contractions and labor pain, she was scheduled for an urgent cesarean section. The instability of her cervical spine precluded the use of regional anesthesia; so awake nasal fiberoptic endotracheal intubation followed by general anesthesia was performed. The anesthetic course was uneventful, and the outcome of the parturient and newborn was good. We discuss our anesthetic considerations, intubation techniques and a review of the literature.