Anatomic and functional outcome of vaginal paravaginal repair in the correction of anterior vaginal wall prolapse.

Over a 2-year period 45 patients with bilateral paravaginal support defects underwent vaginal paravaginal repair. Postoperative evaluations were conducted and anatomic outcome was determined by vaginal examination, with grading of vaginal wall support. Functional outcome was assessed by a standardized quality of life questionnaire, voiding dairy and standing stress test with a full bladder. Thirty-five patients had long-term follow-up with a mean of 1.6 years (range 1-85). The recurrence rates for displacement cystocele, enterocele and rectocele were 3% (1/35), 20% (7/35) and 14% (5/35), respectively. In no patients did vault prolapse develop or recur. Subjective or objective evidence of persistent stress urinary incontinence was found in 57% of patients (12/21). Vaginal paravaginal repair is a safe and effective technique for the surgical correction of anterior vaginal wall prolapse but has limited applicability in the surgical correction of genuine stress incontinence.

Routine hematocrit after elective gynecologic surgery.

OBJECTIVE: To determine the clinical use and associated costs of routine postoperative hematocrit after elective gynecologic surgery. METHODS: We reviewed the charts of all women who had elective gynecologic surgery over 12 months at a community hospital. Demographic data, estimated blood loss at surgery, pre- and postoperative hematocrits, postoperative symptoms suggesting anemia, and incidence of transfusion were tabulated. Laboratory charges for hematocrit at the hospital were used to develop an economic assessment. Statistical analysis was done with Student t test, Mann-Whitney U test, and Fisher exact test. RESULTS: Among 1105 women who had elective surgery, a single postoperative hematocrit was done in 761 (69%) and two or more postoperative hematocrits (mean 2.4, range 2-6) were done in 201 (18%). The overall incidence of blood transfusion related to elective gynecologic surgery was 1.9% (21 of 1105). Five of those women needed preoperative transfusions, eight needed intraoperative transfusions, and the remaining eight had postoperative transfusions. All women who needed postoperative transfusion showed some sign or symptom of anemia. None received transfusions based solely on hematocrit. Risk factors for postoperative transfusion included low preoperative hematocrit and increased intraoperative blood loss. CONCLUSION: Routine postoperative hematocrit in asymptomatic women after uncomplicated elective gynecologic surgery did not improve outcome.

Pharmacologic causes of female incontinence.

The etiology of female urinary incontinence is complex and multifactorial. Many medications have adverse effects on the lower urinary tract, including the promotion of incontinence in certain women. Medications may cause incontinence through three main mechanisms: decreased intraurethral pressure, increased intravesical pressure, and indirect effects on the lower urinary tract. Careful adjustments of a patient's medications based on a knowledge of pharmacologic mechanisms of action may restore continence in some women.

Teaching the pelvic organ prolapse quantitation system.

OBJECTIVE: The objective of this study was to determine the ease with which the new Pelvic Organ Prolapse Quantitation system could be learned by residents and medical students. STUDY DESIGN: Standardized multiple-choice tests were administered to 51 obstetric and gynecology residents and medical students from 4 community-based and university-based programs. Parallel pretests and posttests were administered in conjunction with a 17-minute video demonstration of the Pelvic Organ Prolapse Quantitation system and with the addition of a visual memory aid. The posttest was repeated 3 months after the video presentation. RESULTS: The use of a 17-minute video significantly enhanced participants' ability to interpret examination findings when expressed in the terminology of the system (mean improvement in scores 33%, P <.0001). Posttest scores were similar regardless of the type of program or exposure to urogynecology faculty. These scores were maintained at the 3-month retesting. CONCLUSION: The Pelvic Organ Prolapse Quantitation system can be effectively taught by means of a public-domain video presentation.

Vaginal paravaginal repair in the surgical treatment of anterior vaginal wall prolapse.

Objective: To describe our technique and report our clinical experience with the vaginal paravaginal repair in the surgical treatment of displacement cystocele.Methods: Forty-five patients with bilateral paravaginal support defects underwent vaginal paravaginal repair during a 2-year period at our institution. The technique of vaginal paravaginal repair will be illustrated through the use of anatomic photographs taken at the time of surgery. Demographic data were collected for each patient. Preoperative evaluation, intraoperative parameters, and postoperative course were reviewed.Results: The technique of vaginal paravaginal repair was standardized with transvaginal entrance into the retropubic space bilaterally. The paravaginal defects were identified and repaired using permanent suture in a 3-point closure incorporating the pubocervical fascia, arcus tendineous, and vaginal wall. Concurrent repairs were performed as appropriate.Mean age of the patients was 65.9 +/- 2 years (range 35-76). Thirty-eight patients had advanced prolapse of the anterior vaginal wall beyond the introitus, and 21 patients had coexisting stress incontinence. Postoperatively, the length of stay was 2.6 +/- 1.1 days (range 1-6) and urethral catheterization was required for a median 7 days. Intraoperative complications included 1 case of bilateral ureteral obstruction, and postoperative morbidity included 1 retropubic hematoma requiring re-exploration, 2 vaginal abscesses, and 2 postoperative transfusions.Conclusion: The vaginal paravaginal repair is a safe and effective technique in the surgical correction of vaginal wall prolapse due to a displacement cystocele. The vaginal approach provides adequate exposure to the relevant anatomy and good clinical results.

Ovarian carcinoma metastases to gastrointestinal tract appear to spread like colon carcinoma: implications for surgical resection.

OBJECTIVE: To profile the incidence of mesenteric lymph node metastases in patients with ovarian carcinoma and metastases to the gastrointestinal tract in order to determine the optimal technique for surgical debulking. METHODS: The slides and charts of all patients with ovarian carcinoma who had undergone bowel resection were retrospectively reviewed and follow-up information was obtained. RESULTS: Of 100 separate bowel resections 44% had penetration of metastases to the muscularis, 18% had invasion through the submucosa, 4% had mucosal perforation, and two patients had clinical perforation. Fifty-five percent of all resections demonstrated lymph-vascular space invasion (LVSI). In the 33 specimens which included pathologic analysis of mesenteric lymph nodes, 79% had positive LVSI, which correlated with the presence of mesenteric lymph node metastases (P = 0.05) but not histologic grade (P = 0.20). When surgery was performed for secondary debulking, the frequency of mesenteric node metastasis was higher (P = 0.15). There was a trend for patients with positive mesenteric nodes to fail sooner (median survival, 20 months vs 32 months). CONCLUSIONS: Because ovarian carcinoma metastases to the gastrointestinal tract are frequently associated with metastases to mesenteric lymph nodes, gynecologic oncology surgeons may wish to consider resection of the mesentery in a wedge fashion similar to current standards of resection for primary bowel carcinoma in cases in which a bowel resection is being performed with the intent to debulk to zero visible residual disease.

Long-term survival with adjuvant whole abdominopelvic irradiation for uterine papillary serous carcinoma.

BACKGROUND: The optimum management of uterine papillary serous carcinoma (UPSC), a clinically aggressive histologic variant of endometrial adenocarcinoma, is a controversial issue. METHODS: Ten patients with UPSC were reviewed who received whole abdominopelvic irradiation (WAP) as adjuvant therapy after a staging laparotomy and debulking surgery. RESULTS: Nine patients had clinical Stage I disease; the tumors in eight of them were upstaged based on laparotomy findings. There was greater than a 50% invasion of the myometrium in four of the hysterectomy specimens, and vascular space invasion was noted in seven patients. Peritoneal washings were positive in three of the nine specimens obtained; two others showed atypical cells. Five patients are alive with no evidence of disease at 102-133 months. Four patients are dead, and one patient is alive with disease. All recurrences were observed within 30 months of the initial diagnosis and were more common in the presence of deep myometrial invasion and vascular space involvement. Three of the four patients who died had pleural effusions that did not respond to hormonal and/or chemotherapy. Local irradiation produced long-term control of recurrences in two patients, including one with supraclavicular lymph node metastases who had no evidence of disease 117 months after radiation treatment to the involved nodes. CONCLUSIONS: These findings suggest that WAP be considered as an adjuvant therapy in the management of UPSC. The patients with the greatest benefit were those with early disease by surgical staging with or without positive peritoneal cytologic findings. For patients at high risk for pleural effusions and pulmonary metastasis, additional adjuvant therapy, such as innovative chemotherapy or low-dose lung irradiation, needs to be considered.