Mid-urethral sling revision for mesh exposure-long-term outcomes of two surgical techniques from a comparative clinical retrospective cohort study.

OBJECTIVE: To compare vaginal closure with versus without sling excision in the management of vaginal sling exposure following mid-urethral sling (MUS). DESIGN: Clinical retrospective cohort study. SETTING: Tertiary urogynaecological centre in Australia. POPULATION: Women with urodynamic stress urinary incontinence (SUI) who had a MUS (n = 2823) during 1999-2017 with a follow-up period up to December 2018. Thirty-three women (1%) had sling exposure and 31 required surgical intervention (1%). METHODS: Clinical review with analysis of surgical database and patient records. MAIN OUTCOME MEASURES: The primary outcome was successful closure and resolution of exposure-related symptoms without the need for re-surgery. Secondary outcomes were repeat procedure and recurrent incontinence following revision. RESULTS: Mean follow up was 103 months. Of the 20 women with a primary excision and closure approach, 19 had successful closure. Seven of 11 women with simple vaginal closure without excision needed another surgery for recurrent mesh exposure. Recurrence of stress incontinence did not occur in any of the four who had 'successful' closure without excision. Of those who had sling division/removal without a concomitant stress continence procedure, 32% (7/22) required further surgery. CONCLUSION: Sling excision and repair have better outcomes with less recurrence of sling exposure compared with simple closure. Following sling removal, one of three women will develop SUI recurrence and require surgery. TWEETABLE ABSTRACT: #Slingexcision &repair leads to less recurrence of exposure versus #simpleclosure for #slingmeshexposure.

Extraperitoneal uterosacral suspension technique for post hysterectomy apical prolapse in 472 women: results from a longitudinal clinical study.

OBJECTIVES: The study aims to evaluate the long-term results of the extraperitoneal uterosacral ligament suspension (bilateral) technique in women with apical prolapse following hysterectomy. DESIGN: Longitudinal clinical follow up conducted between June 2002 and December 2017. SETTING: Tertiary urogynaecology centre in Melbourne, Australia. POPULATION: A total of 472 women with symptomatic vault prolapse who underwent bilateral extraperitoneal uterosacral ligament suspension (EPUSLS). Of these patients, 61% (287/472) had previously had a procedure for pelvic organ prolapse (POP). METHODS: Follow up using structured, standardised questionnaires and examination by POP-Q and Baden-Walker system pre- and postoperatively. MAIN OUTCOME MEASURES: Functional and anatomical results and surgical complications. RESULTS: Mean follow-up duration was approximately 5 years. The objective success rate at vaginal cuff support was 89% (420/472). Only 4% needed revision surgery for vault recurrence. There was improvement in bladder, bowel, and sexual symptoms after the procedure. Mesh exposure rate was 17% (of the 138 having mesh augmentation), with the majority of cases managed conservatively or with minor interventions. The ureteric injury rate was 1% and mainly occurred in patients operated early on in the series. No women had buttock pain. CONCLUSION: EPUSLS is an effective, suture-based procedure for vault prolapse with few complications even on long-term follow up. This technique avoids the need to open the peritoneum vaginally and has a low risk of ureteric injury and gluteal pain. TWEETABLE ABSTRACT: Bilateral extraperitoneal USL suspension of vault is effective with low morbidity and a high success rate.

What can we learn from the vaginal mesh story?

The use of vaginal mesh in prolapse surgery has created enormous controversy and unprecedented media interest; it has become the most emotive topic in urogynecology today. The US Food and Drug Administration 510(k) system allowed the proliferation of mesh products which were rapidly adopted by surgeons internationally. The importance of a firm understanding of the biomechanical properties of tissue and implants, surgical skill, patient selection, communication skills, informed consent, and high-quality research are all important lessons we can learn from the mesh story. These lessons need to be applied to all novel treatments in the field of urogynecology and beyond.

Long-term outcomes of transobturator tapes in women with stress urinary incontinence: E-TOT randomised controlled trial.

OBJECTIVE: To assess the long-term patient-reported outcomes and adverse events following surgery using transobturator tension-free vaginal tape (TO-TVT). DESIGN: Postal follow-up of the E-TOT randomised controlled trial (RCT). SETTING: A tertiary urogynaecology centre in the UK; all procedures took place in 2005-2007. POPULATION: A total of 341 women were randomised to receive either 'inside-out' TVT-O (Ethicon Inc., Somerville, NJ, USA) or 'outside-in' TOT-ARIS (Coloplast Corp., Minneapolis, MN, USA) procedure. METHODS: Long-term follow-up (median 9 years) using validated symptom severity and quality-of-life (QoL) questionnaires. Statistical analysis was performed using spss 22.0 and GraphPad statistics 2014. MAIN OUTCOME MEASURES: The primary outcome was patient-reported success rate, defined as 'very much/much improved' on the Patient's Global Impression of Improvement (PGI-I) scale. Secondary outcomes included impact on women's QoL and sexual function, adverse events, and re-operations for stress urinary incontinence (SUI). RESULTS: The adjusted response rate was 67.8% and the median follow-up period was 9.2 years. The overall patient-reported success rate was 71.6%, with a further 14% reporting 'improvement', and there was no significant difference between inside-out and outside-in groups (P = 0.76; odds ratio, OR 0.8676; 95% confidence interval, 95% CI 0.4744-1.5865). The success rate showed a significant reduction compared with 1-year results (71.6 versus 80%; P = 0.004), but a clinically insignificant reduction when compared with the 3-year results (71.6 versus 73.1%). A total of 7.96% underwent further continence surgery, the tape extrusion/erosion rate was 4.5%, and groin pain/discomfort was reported in 4.32%, with only 1.4% requiring treatment. CONCLUSIONS: This is the largest and longest follow-up randomised trial of TO-TVT. TO-TVT is associated with 71.6% patient-reported success rate, 4% groin pain/discomfort, and 8% continence re-operation rate at a median of 9 years follow-up. The success rate is almost stable after 3 years. TWEETABLE ABSTRACT: The success rate for TO-TVT is 71% at 9 years, and is almost stable after 3 years; 8% required repeat surgery.

Association of B12 deficiency and clinical neuropathy with metformin use in type 2 diabetes patients.

CONTEXT: Long-term metformin use has been hypothesized to cause B12 deficiency and neuropathy in Type 2 diabetes patients. However, there is a paucity of Indian data regarding the same. AIM: To compare the prevalence of B12 deficiency and peripheral neuropathy in patients with Type 2 diabetes mellitus treated with or without metformin. MATERIALS AND METHODS: We recruited patients with Type 2 diabetes and divided them into metformin exposed and nonmetformin exposed groups. We measured baseline demographic variables like age, sex, vegetarian status, and HbA1c levels in both groups. We compared vitamin B12 levels and severity of peripheral neuropathy (using Toronto Clinical Scoring System (TCSS)) in both groups. Definite B12 deficiency was defined as B12 <150 pg/ml and possible B12 deficiency as <220 pg/ml. The difference in vitamin B12 levels and TCSS was calculated in both groups using independent samples t-test. Spearman's rank correlation between cumulative metformin use and B12 level was calculated. Odds ratio of vitamin B12 deficiency in metformin exposed group was also estimated. RESULTS: Mean serum B12 levels was significantly lower in metformin exposed group (n=84) compared with nonmetformin exposed group (n=52) (410±230.7 versus 549.2±244.7, P=0.0011). Mean neuropathy score was significantly higher in metformin exposed group. (5.72±2.04 versus 4.62±2.12, P=0.0064). Odds ratio for possible B12 deficiency was 4.45 (95% CI 1.24-15.97). There was significant negative correlation between cumulative metformin dose and vitamin B12 level (r=-0.68, P<0.0001). CONCLUSION: Metformin use is associated with vitamin B12 deficiency and clinical neuropathy in Type 2 diabetes patients.

Reproductive outcome following hysteroscopic septal resection in patients with infertility and recurrent abortions.

OBJECTIVES: To evaluate the outcome of hysteroscopic septal resection in patients with infertility and recurrent abortions. MATERIALS AND METHODS: This was a retrospective clinical analysis of 170 patients who underwent hysteroscopic septal resection by monopolar electrode (Collin's) knife. A second-look office hysteroscopy was performed in all cases within 2 months. The mean follow-up period was 28.5 months. RESULTS: The mean age of the patients was 25.6 years. The presenting clinical complaint was recurrent abortions in 68.2% patients, infertility in 17.6% patients and preterm deliveries in 14.1% patients. Final reproductive outcome was assessed for 152 patients, after excluding patients with other confounding factors, interfering in pregnancy outcome. There was a significant difference in reduction of number of miscarriages (91.5% pre-surgery; 12.9% post-surgery: p = 0.02) and increase in term deliveries (2.5% pre-surgery; 79.5% post-surgery: p = 0.01), while the number of preterm deliveries remained almost the same (6.1% pre-surgery; 7.5% post-surgery). Thirteen out of 23 infertile patients (56.5%) conceived after septal resection. The take home baby rate was increased from 8.5 to 87.1%. Cumulative first live birth rate revealed that 51.2% women had their first live birth within 10-15 months. There was an increased incidence (43.2%) of cesarean section in mode of delivery. In 11/170 patients, repeat hysteroscopy suggested the presence of uterine adhesions which needed hysteroscopic adhesiolysis and three patients required repeat septal resection. CONCLUSIONS: Hysteroscopic septal resection for women with history of recurrent abortions, preterm deliveries and in women with infertility is a safe and effective method of choice for improving the obstetric outcome.

Result of suprapubic cystostomy only as primary management of posterior urethral rupture following pelvic fracture.

Forty-five patients with posterior urethral injury following pelvic fractures were managed by suprapubic cystostomy alone as primary management. Simultaneous voiding cystourethrogram with retrograde urethrogram six weeks later revealed non-obliterative stricture in eight and total block in 36. Impotence was seen in 20 patients. Eight patients with non-obliterative stricture responded to optical internal urethrotomy. Out of 36 total block, 30 had long strictures in the posterior urethra and required transpubic urethroplasty. Impotence was not affected by transpubic urethroplasty.

Evaluation of the efficacy of a combination of diltiazem and periprostatic nerve block in pain control during transrectal ultrasonography-guided biopsy of the prostate.

INTRODUCTION: The choice of analgesia during prostate biopsy remains controversial. The pain has dual origin: from the insertion of the probe as well as the biopsy itself. Periprostatic nerve block (PPNB) is currently the gold standard modality for decreasing pain of prostate biopsy but it does not alleviate the pain of probe insertion. A randomised controlled trial was performed to test the efficacy and safety of the combination of topical application of diltiazem gel and PPNB for pain control during transrectal ultrasonography guided prostate biopsy. METHODS: A total of 73 patients who were to undergo their first prostate biopsy were randomised to receive either 2ml of 2% topical diltiazem gel or a placebo 15 minutes before the biopsy. All the patients then had a PPNB using 1% lignocaine. A ten- point visual analogue scale was used to record the pain immediately after the insertion of the probe and during the biopsy. Any adverse effects were also recorded. RESULTS: There was no significant difference in the mean age and prostate volumes between the groups. There was a significantly lower mean pain score due to probe insertion in those patients who received topical diltiazem than in the placebo group (p<0.0001). There was no significant difference between the pain scores during the biopsy itself between the two groups. CONCLUSIONS: Topical diltiazem significantly reduces the pain of probe insertion during prostate biopsy and can be used effectively as an adjuvant to PPNB.

Cystic schwannoma of the pelvis.

Schwannomas are benign tumours that arise from the Schwann cells of nerve fibres. They commonly occur in the head and neck, mediastinum and extremities. They are extremely rare in the pelvis. These are usually slow-growing tumours and are often detected incidentally. Preoperative diagnosis is extremely difficult as there are no definitive signs on imaging. Aspiration biopsy is often inconclusive or misleading. Surgical excision is both diagnostic and therapeutic. As these tumours are often large in size, open excision is most commonly performed. We describe a case of a large, cystic schwannoma of the pelvis causing bladder outlet obstruction and bilateral hydroureteronephrosis. Complete surgical excision was performed laparoscopically.

Surgical reconstruction of penile stump in a patient with Klingsor syndrome.

Self-mutilation of genitalia is an extremely rare entity, usually found in psychotic patients. Klingsor syndrome is a condition in which such an act is based upon religious delusions. The extent of genital mutilation can vary from superficial cuts to partial or total amputation of penis to total emasculation. The management of these patients is challenging. The aim of the treatment is restoration of the genital functionality. Microvascular reanastomosis of the phallus is ideal but it is often not possible due to the delay in seeking medical attention, non viability of the excised phallus or lack of surgical expertise. Hence, it is not unusual for these patients to end up with complete loss of the phallus and a perineal urethrostomy. We describe a patient with Klingsor syndrome who presented to us with near total penile amputation. The excised phallus was not viable and could not be used. The patient was managed with surgical reconstruction of the penile stump which was covered with loco-regional flaps. The case highlights that a functional penile reconstruction is possible in such patients even when microvascular reanastomosis is not feasible. This technique should be attempted before embarking upon perineal urethrostomy.