Outcomes following treatment for pelvic floor mesh complications.

INTRODUCTION AND HYPOTHESIS: Our aim was to determine symptoms and degree of improvement in a cohort of women who presented following treatment for vaginal mesh complications. METHODS: This study was a follow-up to a multicenter, retrospective study of women who presented to four tertiary referral centers for management of vaginal-mesh-related complications. Study participants completed a one-time follow-up survey regarding any additional treatment, current symptoms, and degree of improvement from initial presentation. RESULTS: Two hundred and sixty women received surveys; we had a response rate of 41.1 % (107/260). Complete data were available for 101 respondents. Survey respondents were more likely to be postmenopausal (p = 0.006), but otherwise did not differ from nonrespondents. Fifty-one percent (52/101) of women underwent surgery as the primary intervention for their mesh complication; 8 % (4/52) underwent a second surgery; 34 % (17/52) required a second nonsurgical intervention. Three patients required three or more surgeries. Of the 30 % (30/101) of respondents who reported pelvic pain prior to intervention, 63 % (19/30) reported improvement, 30 % (9/30) were worse, and 7 % (2/30) reported no change. Of the 33 % (33/101) who reported voiding dysfunction prior to intervention, 61 % (20/33) reported being at least somewhat bothered by these symptoms. CONCLUSIONS: About 50 % of women with mesh complications in this study underwent surgical management as treatment, and <10 % required a second surgery. Most patients with pain preintervention reported significant improvement after treatment; however, almost a third reported worsening pain or no change after surgical management. Less than half of patients with voiding dysfunction improved after intervention.

Randomised trial of laparoscopic Burch colposuspension versus tension-free vaginal tape: long-term follow up.

OBJECTIVE: To compare the long-term efficacy of laparoscopic Burch colposuspension with tension-free vaginal tape (TVT) for the treatment of urodynamic stress urinary incontinence (SUI). DESIGN: Long-term follow up from a prospective randomised trial. SETTING: Academic tertiary referral centre. SAMPLE: Seventy-two women with urodynamic SUI from two institutions. METHODS: Subjects were randomised to either laparoscopic Burch or TVT from August 1999 to August 2002. Follow-up evaluations occurred 6 months, 1 year, 2 years, and 4-8 years after surgery. MAIN OUTCOME MEASURES: Subjects completed the Incontinence Severity Index, Urogenital Distress Inventory 6 (UDI-6), Incontinence Impact Questionnaire (IIQ-7), and Patient Global Impression of Improvement (PGI-I) scales. RESULTS: Median follow-up duration was 65 months (range 12-88 months) with 92% completing at least one follow-up visit. Seventy-four percent of subjects had long-term (4-8 years) follow up. Fifty-eight percent of subjects receiving laparoscopic Burch compared with 48% of TVT subjects reported any urinary incontinence 4-8 years after surgery (Relative Risk (RR):1.19; 95% CI: 0.71-2.0) with no significant difference between groups. Bothersome SUI symptoms were seen in 11 and 8%, respectively, 4-8 years after surgery (P = 0.26). There was significant improvement in the postoperative UDI-6 and IIQ-7 scores in both groups at 1-2 years that were maintained throughout follow up with no significant differences between the groups. CONCLUSIONS: TVT has similar long-term efficacy to laparoscopic Burch for the treatment of SUI. A substantial proportion of subjects have some degree of urinary incontinence 4-8 years after surgery; however, the majority of incontinence is not bothersome.

The Q-tip test: standardization of the technique and its interpretation in women with urinary incontinence.

Q-tip tests were carried out on 63 women to determine optimal placement and the effects of bladder fullness and significant anterior vaginal wall relaxation. Significantly higher maximum straining angles were observed when the tip of the Q-tip was placed at the urethrovesical junction or the proximal urethra, compared with placement in the bladder (P less than .05), midurethra (P less than .01), or distal urethra (P less than .01). Bladder fullness did not alter the results significantly. There were no significant differences in resting or maximum straining angles when patients with significant anterior vaginal wall relaxation and genuine stress incontinence were compared with continent women who had significant anterior vaginal wall relaxation. However, in the absence of significant anterior vaginal wall relaxation, women with genuine stress incontinence had significantly higher maximum straining angles than those with bladder instability (P less than .05) or control subjects (P less than .05). The Q-tip test, if performed correctly, is an easy, inexpensive, and reliable method of quantifying mobility of the bladder neck and proximal urethra in continent or incontinent women with or without pelvic relaxation.

Patch procedure: modified transvaginal fascia lata sling for recurrent or severe stress urinary incontinence.

Ten patients with either recurrent or severe stress urinary incontinence were treated with a new procedure, using a patch of fascia lata to support the bladder base and the urethra. Nine of the ten patients are objectively continent of urine 1-2 years postoperatively. When pre- and postoperative urodynamics were compared, we noted significant increases in urethral closure pressure, functional urethral length, and abdominal pressure transmission to the proximal urethra. Intraoperative and postoperative morbidity was minimal. The procedure is easily performed and requires no more expertise than does a transvaginal needle bladder neck suspension.

Transvaginal needle bladder neck suspension procedures for stress urinary incontinence: a comprehensive review.

Transvaginal needle bladder neck suspension procedures for surgical correction of stress incontinence are increasing in popularity among genitourinary surgeons. Since 1959, three main modifications of the originally described procedure have emerged as representing various needle suspension procedures, ie, the modified Pereyra procedure among gynecologic surgeons and the Stamey and the Raz procedures among urologic surgeons. The overall success rate of 85% (range 40-100%) among a total of 1967 surgical procedures reported in the published literature may be misleading; the majority of reported studies relied upon subjective clinical cures rather than objectively demonstrable cures of urinary incontinence. The majority of studies lacked long-term follow-up of successfully treated patients. Few studies reported urodynamic changes after needle suspension procedures in terms of increased functional urethral length and improved pressure transmission to the proximal urethra. A 20-50% incidence of postoperative voiding difficulties has been reported in various studies. This publication reviews the controversies in the nomenclature of various needle suspension procedures, indication, suture materials, procedural details, and results of previously published needle suspension procedures and their modifications. Differences among commonly performed procedures are pointed out and analyzed for their role in the correction of stress urinary incontinence.

Management of coexistent stress and urge urinary incontinence.

Fifty-two patients with objective evidence of pressure equalization incontinence and detrusor instability were evaluated retrospectively to compare nonsurgical modes of therapy with retropubic surgery. Based on the patient's desire for surgery and her overall medical condition, 27 women were treated primarily with retropubic urethropexy (modified Burch procedure) and 25 with various combinations of oxybutynin, imipramine, and estrogen. Thirty-two percent of the patients treated medically were cured and 28% were markedly improved, whereas 59% of patients treated surgically were cured and 22% improved. There was no statistically significant difference in the results between medical and surgical therapy. All failures in the surgically treated group were due to persistent detrusor instability after surgery. We identified no preoperative urodynamic criteria that consistently and accurately predicted surgical outcome in patients with combined stress and urge incontinence. Patients with combined stress incontinence and detrusor instability should initially be managed medically, as this will reduce the incidence of surgical intervention.

Transvaginal repair of vault prolapse: a review.

OBJECTIVE: To provide a critical assessment of the published literature on transvaginal reconstructive techniques used to suspend a prolapsed vaginal vault. DATA SOURCE: A Medline data base search and a bibliographic review of the relevant articles were conducted to identify all English-language articles on repair of vaginal vault prolapse. METHODS OF STUDY SELECTION: Our literature search identified 34 articles published in peer-review journals and one article reported in another format, describing five different techniques. TABULATION, INTEGRATION AND RESULTS: The size of each study population, modifications of the original surgical technique, complications, and results were tabulated and summarized for each surgical approach. Only sacrospinous ligament vaginal vault suspension and endopelvic fascia vaginal vault fixation had a sufficient number of cases to allow an informative evaluation of their effectiveness in managing vaginal vault prolapse. Of the 1229 patients who had undergone sacrospinous ligament suspension, 1062 were available for varying periods of follow-up; 193 (18%) of these developed recurrent pelvic relaxation--including 32 vaginal vault eversions, 81 anterior vaginal wall defects, 24 posterior vaginal wall prolapses, and 56 support defects at unspecified or multiple sites. Of the 367 patients who had undergone endopelvic fascia vaginal vault fixation, 322 were available for follow-up ranging from 1 to 12 years; 34 (11%) of these patients developed recurrent pelvic relaxation including nine vaginal vault prolapses, two anterior vaginal wall defects, 11 posterior vaginal wall relaxations, and 12 support defects at unspecified or multiple sites. CONCLUSION: Published experience suggests that sacrospinous ligament suspension and endopelvic fascia fixation are effective in managing vaginal vault prolapse. Because of study limitations--including an absence of standardized outcome evaluation, relatively short follow-up periods, a substantial number of patients lost to follow-up, concomitant surgical procedures, and failure to assess visceral and sexual functions--the true efficacy of these two procedures remains inconclusive.

Role of antibiotic prophylaxis in retropubic surgery for stress urinary incontinence.

The effectiveness of prophylactic antibiotics was studied prospectively in 26 women undergoing retropubic urethropexy for genuine stress incontinence. Each of the 14 patients in the antibiotic prophylaxis group received three 1-g doses of intravenous cefazolin administered before, during, and 6-8 hours after surgery. Twelve women served as a control group and did not receive prophylactic antibiotics. Postoperative febrile morbidity and hospital stay were significantly less (P less than .01 and P less than .05, respectively) in patients who received prophylactic antibiotics.

Periurethral collagen injection for stress incontinence with and without urethral hypermobility.

OBJECTIVE: To compare the use of periurethral collagen injection in the treatment of female stress urinary incontinence due to intrinsic sphincter deficiency in women with and without urethral hypermobility. METHODS: A retrospective review was performed of 60 periurethral collagen injections performed on 40 consecutive women from January 1996 to December 1997. A review of the office chart and operative notes was performed to obtain demographic, urodynamic, and procedural data. Outcome data were obtained by personal or telephone interview, using patients' subjective assessments including an analog satisfaction scale. RESULTS: Nine of 40 patients (23%) had urethral hypermobility. Compared with patients without hypermobility, patients with hypermobility required a similar number of procedures (a mean of 1.9 compared with 1.4, P = .13) and required similar amounts of collagen on the first injection (5.6 mL compared with 5.3 mL, P = .69). Preoperative urodynamic parameters were similar in both groups. Rates of subjective dryness were equivalent in patients with and without hypermobility at 1 month (76% and 46%, P = .24) and at 6 months (71% and 32%, P = .09) following initial injection. A post hoc power analysis was performed to evaluate the primary study measures of continence at 1 and 6 months, and number of collagen injections. This revealed that a sample size of 40 patients would be sufficient to detect a 2.5-fold difference in number of injections and a 3-fold difference in subjective dryness. CONCLUSION: Coexisting urethral hypermobility should not preclude the use of collagen injections in women with stress urinary incontinence.

Factors affecting detrusor contraction strength during voiding in women.

OBJECTIVE: To compare voiding mechanisms in continent and stress incontinent women and to assess the effects of aging, childbirth, menopausal status, and anterior vaginal wall relaxation on detrusor contraction strength during voiding. METHODS: Thirty-eight asymptomatic female volunteers underwent a thorough evaluation including multichannel urodynamic testing and instrumented pressure-flow voiding studies. The voiding mechanisms and detrusor contraction strengths, available in 30 women, were compared with those of 70 women evaluated previously with objective evidence of genuine stress urinary incontinence. The effect of age, parity, bladder neck mobility, and anterior vaginal wall relaxation on maximum detrusor pressure was assessed using chi2 and linear regression analyses. Detrusor pressures in premenopausal and postmenopausal women and continent and stress incontinent women were also compared. RESULTS: Four types of voiding mechanisms were identified. All 30 of the continent women voided with a detrusor contraction, compared with 59 (84%) of genuine stress incontinent subjects. The mean +/- standard deviation [SD]) detrusor contraction was significantly stronger in continent women than incontinent women (20.3 +/- 14.2 cm H2O compared with 12.3 +/- 11.0 cm H2O; P < .01). In continent and incontinent subjects, maximum detrusor pressure did not correlate significantly with increasing age, parity, bladder neck mobility, or degree of anterior vaginal wall relaxation. Premenopausal women had significantly higher mean (+/- SD) maximum detrusor pressures than postmenopausal women (16.3 +/- 13.0 cm H2O compared with 11.5 +/- 11.0 cm H2O; P < .01). CONCLUSION: Women with genuine stress urinary incontinence may be more likely to void with a weak or absent detrusor contraction than continent women. Menopausal status was the only factor identified that significantly affected maximum detrusor pressure during voiding.

Vaginal correction of pelvic organ relaxation using local anesthesia.

OBJECTIVE: To describe the technique and complications of vaginal repair of advanced pelvic organ prolapse using intravenous sedation, pudendal nerve block, and local anesthesia. METHODS: A retrospective review of the gynecologic surgical records of 20 patients was performed. Patient demographics, surgical procedure, surgical time, estimated blood loss, and complication rate were examined. RESULTS: All 20 patients reviewed had their operations completed without the need for general anesthesia. The surgical procedures included three anterior colporrhaphies, five anterior and posterior colporrhapies, eight vaginal enterocele repairs with anterior and/or posterior repair, and four LeFort partial colpocleises. General anesthesia was contraindicated in all patients. Patients had a mean age of 80 years (range 67-92), a mean parity of 2.7, a mean estimated blood loss of 153 mL, and a mean hospital stay of 2.1 days. One intraoperative and three postoperative complications were reported. CONCLUSION: All 20 patients had successful surgical repair under local anesthesia without the need for general induction. Surgical correction of severe pelvic organ relaxation can be performed rapidly and safely using local anesthesia, thus limiting the potential risks of general anesthesia.

Voiding after Burch colposuspension and effects of concomitant pelvic surgery: correlation with preoperative voiding mechanism.

OBJECTIVE: To determine if concomitant abdominal hysterectomy, posterior colporrhaphy, or preoperative voiding mechanism adversely affect the duration of voiding dysfunction experienced after Burch colposuspension. METHODS: A retrospective review was conducted of 154 consecutive women with genuine stress incontinence managed by Burch colposuspension over 4 years. Fifty-three (35%) women underwent colposuspension alone, 33 (22%) underwent colposuspension with posterior colpoperineorrhaphy, and 68 (44%) underwent colposuspension with total abdominal hysterectomy (TAH). A suprapubic Foley catheter was placed after all operations and removed when the post-void residual urine reached 20% or less of the volume voided on two consecutive attempts. RESULTS: Women who underwent colposuspension alone, colposuspension with posterior colpoperineorrhaphy, and colposuspension with TAH required a mean duration of 4.3, 4.3, and 4.8 days of postoperative bladder drainage, respectively. These differences were not statistically significant. Women who voided with Valsalva maneuver without a detrusor contraction took significantly longer to resume normal micturition than did those who voided with a detrusor contraction with or without Valsalva maneuver, or urethral relaxation alone (mean 9.0 days compared with 3.6, 4.7, and 4.8 days, respectively; P < .001). CONCLUSION: Concomitant abdominal hysterectomy or posterior colpoperineorrhaphy did not prolong voiding dysfunction after colposuspension. Women who voided with Valsalva maneuver and without a detrusor contraction took significantly longer to resume normal micturition after Burch colposuspension with or without concomitant TAH.

Ultrasound and hookwire needle placement for localization of a hydrocele of the canal of Nuck.

BACKGROUND: Hydrocele of the canal of Nuck is a mobile mass entity that can be difficult to locate and excise. We report the use of ultrasound scan and a hookwire needle to localize and stabilize this mass, making its excision easier. CASE: A 24-year-old white female presented with a 6-month history of a painful vulvar mass associated with increased discomfort with prolonged standing. Thorough evaluation revealed a suspected hydrocele that was easily palpable in the standing position but not in the lithotomy position. Translabial ultrasonography and a hookwire needle were used to localize and stabilize the mobile vulvar mass, eliminating the need for extensive surgical exploration. CONCLUSION: Ultrasound scanning and needle localization is a useful technique to identify and stabilize a mobile mass, making its surgical excision possible without extensive exploration and trauma.

A critical appraisal of the methods of measuring leak-point pressures in women with stress incontinence.

OBJECTIVE: To determine whether leak-point pressures can be measured using an intravaginal catheter, and to assess whether leak-point pressures are affected by the provocation method, bladder volume, and the presence of a transurethral-intravesicle catheter. METHODS: Thirty women with genuine stress incontinence had leak-point pressure studies performed, using both cough and Valsalva maneuvers at specific bladder volumes. Intravaginal pressure measurements were compared with intravesicle pressure measurements. The effect of an 8-Fr transurethral-intravesicle catheter on leak-point pressures was also assessed. RESULTS: Leak-point pressures were demonstrated in all 30 patients by cough and/or Valsalva maneuver. There was no significant difference between intravesicle and intravaginal pressure measurements. Subjects who demonstrated leak-point pressures by both cough and Valsalva maneuver had significantly higher cough leak-point pressures at all bladder capacities. Seventeen women with measurable Valsalva leak-point pressures at 150 mL bladder capacity had significantly lower pressures at 300 mL, and 15 women had significantly lower leak-point pressures at 400 mL or more. Valsalva maneuver and cough leak-point pressures decreased significantly when the 8-Fr transurethral-intravesicle catheter was removed and the pressures were measured using only an intravaginal catheter. CONCLUSION: Bladder volume, provocation method, and the presence of a transurethral-intravesicle catheter affect leak-point pressure measurements. Further standardization of leak-point pressure measurement technique is necessary before determining the clinical applicability of these tests.

Vesicouterine fistula: a rare complication of vaginal birth after cesarean.

BACKGROUND: Vesicouterine fistula is rare. We report a vesicouterine fistula that was the direct result of a vaginal delivery in a patient with a history of lower uterine segment cesarean delivery. CASE: A woman developed a vesicouterine fistula during vaginal delivery after a previous cesarean. An anterior uterine wall defect was noted immediately after the delivery. Continuous bladder drainage was unsuccessful in managing her fistula, and surgical correction was necessary. CONCLUSION: Although rare, a vesicouterine fistula can occur as a complication of vaginal delivery in patients with a history of cesarean delivery.

Mesh erosion after abdominal sacrocolpopexy.

OBJECTIVE: To report our experience with erosion of permanent suture or mesh material after abdominal sacrocolpopexy. METHODS: A retrospective chart review was performed to identify patients who underwent sacrocolpopexy by the same surgeon over 8 years. Demographic data, operative notes, hospital records, and office charts were reviewed after sacrocolpopexy. Patients with erosion of either suture or mesh were treated initially with conservative therapy followed by surgical intervention as required. RESULTS: Fifty-seven patients underwent sacrocolpopexy using synthetic mesh during the study period. The mean (range) postoperative follow-up was 19.9 (1.3-50) months. Seven patients (12%) had erosions after abdominal sacrocolpopexy with two suture erosions and five mesh erosions. Patients with suture erosion were asymptomatic compared with patients with mesh erosion, who presented with vaginal bleeding or discharge. The mean (+/-standard deviation) time to erosion was 14.0+/-7.7 (range 4-24) months. Both patients with suture erosion were treated conservatively with estrogen cream. All five patients with mesh erosion required transvaginal removal of the mesh. CONCLUSION: Mesh erosion can follow abdominal sacrocolpopexy over a long time, and usually presents as vaginal bleeding or discharge. Although patients with suture erosion can be managed successfully with conservative treatment, patients with mesh erosion require surgical intervention. Transvaginal removal of the mesh with vaginal advancement appears to be an effective treatment in patients failing conservative management.

Use of magnetic resonance imaging in the diagnosis of cortical blindness in pregnancy.

Magnetic resonance imaging (MRI) may be helpful in the assessment of eclampsia and preeclampsia with central nervous system symptomatology such as cortical blindness. We describe a rare case of complete binocular blindness postpartum with no other neurologic deficits, in which MRI abnormalities were undetected on computed tomography. The better soft-tissue discrimination of MRI may visualize important but subtle lesions which ultimately may help to explain the underlying pathophysiologic mechanism in such cases.

Urodynamic changes following hormonal replacement therapy in women with premature ovarian failure.

The mechanism by which estrogen supplementation improves the symptom of stress incontinence in postmenopausal women is unclear. Six women with proved premature ovarian failure were studied urodynamically before and after administration of oral and vaginal estrogen to study estradiol's effects on lower urinary tract function. Regardless of the mode of administration, estrogen supplementation did not produce any significant change in urethral pressure, functional length, or cystometric parameters. However, a significant increase in pressure transmission ratio (P less than .05) to the proximal and mid-urethra was noted after the administration of vaginal estrogen cream. We conclude that estrogen alone, in the absence of aging and other known precipitating factors for stress incontinence, is of minimal significance in maintaining normal urinary tract physiology.

Open compared with laparoscopic approach to Burch colposuspension: a cost analysis.

OBJECTIVE: To compare postoperative course and hospital charges of an open versus laparoscopic approach to Burch colposuspension for the treatment of genuine stress urinary incontinence. METHODS: A retrospective chart review was performed to identify all patients undergoing open or laparoscopic Burch colposuspension by the same surgeon over a 2-year period. Patients undergoing additional surgical procedures at the time of colposuspension were excluded from the study. Twenty-one patients underwent open Burch colposuspension and 17 patients underwent laparoscopic colposuspension. Demographic data including age, parity, height, and weight were collected for each group. Both groups also were compared with regard to operative time, operating room charges, estimated blood loss, intraoperative complications, change in postoperative hematocrit, time required to resume normal voiding, length of hospital stay, and total hospital charges. RESULTS: The laparoscopic colposuspension group had significantly longer operative times (110 versus 66 minutes, P < .01) and increased operating room charges ($3479 versus $2138, P < .001). There was no statistical difference in estimated blood loss or change in postoperative hematocrit between the two groups. No major intraoperative complications occurred in either group. Mean length of hospital stay was 1.3 days for the laparoscopic group and 2.1 days for the open group (P < .005). However, total hospital charges for the laparoscopic group were significantly higher ($4960 versus $4079, P < .01). CONCLUSION: Laparoscopic colposuspension has been described as a minimally invasive, cost-effective technique for the surgical correction of stress urinary incontinence. Although the laparoscopic approach was found to be associated with a reduction in length of hospital stay, it had significantly higher total hospital charges than the traditional open approach because of expenses associated with increased operative time and use of laparoscopic equipment.