Anal incontinence among women with one versus two complete third-degree perineal lacerations.

OBJECTIVE: To compare the rate of anal incontinence and severe incontinence among women who had 0, 1, and > or =2 additional vaginal deliveries after sustaining a third-degree perineal laceration and between subjects with one versus two third-degree tears. METHOD: A telephone survey was done to assess the anal function of all subjects who sustained a complete third-degree tear as a nullipara. RESULT: The rate of anal incontinence and severe incontinence was similar among women who had 0, 1, and > or =2 additional deliveries (11/65, 11/67, and 12/40, p=0.179; 2/65, 1/67, and 2/40, p=0.811) and between women who had one sphincter tear and no additional delivery versus those with two tears and > or =2 subsequent deliveries (11/65 and 10/37, p=0.225. 2/65 and 2/37, p=0.460). CONCLUSION: Additional vaginal deliveries and a repeat sphincter tear after the initial third-degree laceration were not associated with a higher rate or severity of anal incontinence.

Vaginal configuration on MRI after abdominal sacrocolpopexy and sacrospinous ligament suspension.

An MRI study was conducted to compare the vaginal configuration of women who had undergone sacrospinous fixation with transvaginal needle suspension or abdominal sacrocolpopexy with retropubic colposuspension with that of normal controls. MRI examination demonstrated that in normal controls the lower vagina formed an acute angle (mean 53 degrees) with the pubococcygeal line and intersected the upper vagina at a mean angle of 145 degrees. In the abdominal repair group the lower vagina intersected the pubococcygeal line at a mean angle of 57 degrees and joined the upper segment at a mean angle of 137 degrees. In the vaginal repair group the lower vagina intersected the pubococcygeal line at a mean angle of 54 degrees and joined the upper segment at a mean angle of 220 degrees. Our study demonstrated that abdominal sacrocolpopexy with retropubic colposuspension more closely restored the vagina to its normal configuration, whereas sacrospinous fixation with transvaginal needle suspension creates an abnormal vaginal axis.

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.

A retrospective comparison of abdominal sacrocolpopexy with Burch colposuspension versus sacrospinous fixation with transvaginal needle suspension for the management of vaginal vault prolapse and coexisting stress incontinence.

The objective of this study was to compare the surgical outcome of abdominal sacrocolpopexy and Burch colposuspension with sacrospinous fixation and transvaginal needle suspension in the management of vaginal vault prolapse and coexisting stress incontinence. One hundred and seventeen women with vaginal vault prolapse and coexisting stress incontinence were surgically managed over a 7-year period. The first 61 consecutive women who underwent sacrospinous fixation and transvaginal needle suspension comprised the vaginal group, and the following 56 consecutive women who underwent abdominal sacrocolpopexy and Burch colposuspension comprised the abdominal group. Office records were reviewed to assess the presence of recurrent prolapse and urinary incontinence during postoperative follow-up. Objective follow-up was available for 101 women. Mean duration of follow-up was 24.0 +/- 15 months for the vaginal group, and 23.1 +/- 12.6 months for the abdominal group. The incidence of recurrent prolapse to or beyond the hymen (33% vs. 19%, P=0.0505) and lower urinary tract symptoms (26% vs. 13%, P = 0.0506) were significantly higher in the vaginal group than in the abdominal group. Our data suggest that the combined abdominal approach has a lower incidence of recurrent prolapse and lower urinary tract symptoms than the combined vaginal approach in managing vaginal vault prolapse and coexisting stress incontinence.

Computed tomography comparison of bony pelvis dimensions between women with and without genital prolapse.

OBJECTIVE: To compare bony pelvis dimensions between white women with and without genital prolapse using computed tomography (CT) pelvimetry. METHODS: Thirty-four multiparous white women with vaginal prolapse beyond the hymen and 34 matched white controls with no signs or symptoms of pelvic support defects underwent CT pelvimetry. The anteroposterior and transverse diameters of the pelvic inlet, the interspinous diameter of the midpelvis, and the intertuberous diameter of the pelvic outlet were measured. Post hoc power analysis showed that 22 women were needed in each group to detect a 10% difference in the pelvic dimensions between groups, with an alpha error of 1% and a beta error of 10%, resulting in a 90% power. RESULTS: Mean (+/- standard deviation [SD]) age of the subjects was 63.4+/-8.3 years, compared with 62.9+/-7.8 years for controls. Mean parity of the subjects was 3.3+/-1.7, compared with 3.6+/-1.7 for controls. Mean (+/- SD) anteroposterior (12.5+/-1.3 versus 12.8+/-1.0 cm), interspinous (11.5+/-0.8 versus 11.2+/-0.9 cm), and intertuberous (10.0+/-1.0 versus 9.8+/-0.8 cm) diameters were not significantly different between study groups. Mean transverse diameter of the pelvic inlet was significantly greater in women with prolapse than those without prolapse (12.9+/-0.7 versus 12.4+/-0.6 cm, P = .006). CONCLUSION: Women with advanced vaginal prolapse have larger transverse inlet diameters than do women with normal pelvic support.

Urinary oxalate excretion and its role in vulvar pain syndrome.

OBJECTIVE: This study was undertaken to determine the urinary oxalate excretion patterns in patients with vulvodynia compared with controls and to evaluate antioxalate therapy in women with vulvar pain syndrome (vulvodynia). STUDY DESIGN: A total of 130 consecutive patients with vulvar pain syndrome and 23 volunteers without symptoms collected urine specimens for 24 hours; each voiding was saved in individual labeled containers and refrigerated. The specimens were analyzed individually for oxalate and calculated according to 24-hour concentration, volume, and peak oxalate by hour. A total of 59 patients were treated with low-oxalate diets and calcium citrate for 3 months and evaluated for objective relief of vulvar pain. RESULTS: The 24-hour excretion of oxalate was almost identical in controls and vulvodynia patients. The total 24-hour excretion was directly proportional to the volume of urine excreted (p < 0.001). No significant differences were found in peak oxalate excretion (95% confidence intervals). The number of voidings was higher in the vulvodynia cohort (p < 0.02). The 59 women with elevated oxalate concentrations (> 1 mg/40 dl) were treated with an antioxalate regimen. Fourteen (24%) demonstrated an objective response, but only 6 (10%) could have pain-free sexual intercourse. CONCLUSIONS: Urinary oxalates may be nonspecific irritants that aggravate vulvodynia; however, the role of oxalates as instigators is doubtful.

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.

Comparative morbidity and charges associated with route of hysterectomy and concomitant Burch colposuspension.

OBJECTIVE: To compare the surgical morbidity, postoperative course, and hospital charges of Burch colposuspension performed in conjunction with abdominal versus vaginal hysterectomy. METHODS: Power analysis indicated that 35 women would be needed in each group to detect a 20% difference in hospital charges between groups with a beta error of 20% and an alpha error of 5%. A computerized records search identified 80 women who underwent Burch colposuspension, 40 of whom underwent concomitant vaginal hysterectomy (vaginal group) and 40 of whom underwent concomitant abdominal hysterectomy (abdominal group). All procedures were performed by one of 16 surgeons at either Good Samaritan Hospital, Cincinnati, Ohio, or the Medical Center of Central Georgia, Macon, Georgia, between 1992 and 1996. Data on demographics, perioperative course, uterine weight, and operative and total hospital charges were obtained for each group. RESULTS: There was no statistically significant difference in demographics, surgical history, postoperative hemoglobin and hematocrit decrease, postoperative complications (10 versus 23%), operative charges ($4417 +/- 1200 versus $4731 +/- 1453), mean uterine weight (113.5 +/- 45 versus 125.8 +/- 45 g), and operative times (3.0 +/- 0.8 versus 2.9 +/- 0.7 hours) between the vaginal and abdominal groups, respectively. A post hoc power analysis indicated that each group would require 142 patients to achieve statistical significance for postoperative complication rates. The abdominal group had significantly longer hospital stays (3.1 +/- 1.0 versus 2.6 +/- 0.7 days) and higher charges ($7337 +/- 1828 versus $6342 +/- 1123) than the vaginal group. CONCLUSION: When hysterectomy is performed at the time of colposuspension, the vaginal route should be considered seriously when either surgical approach is clinically appropriate.

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.

Percutaneous suprapubic teloscopy: a minimally invasive cystoscopic technique.

We describe a percutaneous approach to suprapubic teloscopy that may be used to assess bladder-ureteral integrity during laparoscopic surgery. After access is gained to the hollow of the bladder using a percutaneous suprapubic catheter introducer, a telescope is inserted via the access sheath, and bladder integrity and ureteral patency are confirmed. We describe this technique as a viable alternative to traditional cystoscopy at laparoscopic surgery.

Sacrospinous ligament fixation with transvaginal needle suspension for advanced pelvic organ prolapse and stress incontinence.

OBJECTIVE: To assess the results of sacrospinous ligament fixation with transvaginal needle suspension for the correction of advanced pelvic organ prolapse and stress incontinence. METHODS: Ninety-six women who had pelvic organ prolapse to or beyond the hymen with or without stress incontinence were surgically managed over 3.5 years. Objective follow-up was available on 75 women. The subject group comprised 54 of these women who had stress incontinence and underwent sacrospinous ligament fixation with transvaginal needle suspension. The remaining 21 women who did not have stress incontinence underwent sacrospinous ligament fixation and served as controls. Appropriate vaginal repairs were performed as needed in both groups. RESULTS: The mean duration of follow-up was 24 months (range 7-72) for the subjects compared with 24.3 months (range 3-53) for the controls. Eighteen subjects (33%) developed recurrent prolapse to or beyond the hymen. Additionally, five (9%) subjects developed recurrent stress incontinence and nine (17%) complained of urge incontinence. Four (19%) controls developed recurrent prolapse, two of whom also have urge incontinence. There was no statistical difference in the mean duration of follow-up or the incidence of recurrent prolapse between subjects and controls. CONCLUSION: Despite the absence of statistical significance, we believe that the 33% recurrent prolapse rate associated with sacrospinous ligament fixation and transvaginal needle suspension is clinically important.

Incidence of recurrent cystocele after anterior colporrhaphy with and without concomitant transvaginal needle suspension.

OBJECTIVE: Our purpose was to compare the recurrent cystocele rate after anterior colporrhaphy versus anterior colporrhaphy performed in conjunction with transvaginal needle bladder neck suspension. STUDY DESIGN: A retrospective chart review of all patients undergoing anterior colporrhaphy with and without needle bladder neck suspension over a 3-year period was conducted. Preoperatively all patients had symptomatic anterior vaginal wall relaxation. Patients undergoing concomitant needle suspension procedures had genuine stress incontinence. Twenty-seven patients underwent anterior colporrhaphy alone, and 40 patients underwent anterior colporrhaphy with needle suspension. Demographic data including age, parity, menopausal status, and use of estrogen replacement was collected for each group. The recurrence rate of anterior vaginal wall relaxation was determined for each group by reviewing standardized postoperative office notes. RESULTS: There was no significant difference in the duration of follow-up between the two groups (13.2 months in the anterior repair group vs 13 months in the anterior repair-needle suspension group). However, a significant difference in recurrent cystocele rates was found between the two groups (7% [2/ 27] in the anterior repair group compared with 33% [13/40] in the anterior repair-needle suspension group, p < 0.01). CONCLUSION: The incidence of recurrent cystocele is significantly higher after anterior colporrhaphy with concomitant needle bladder neck suspension compared with anterior colporrhaphy alone. This difference may be related to the vaginal retropubic dissection at the time of transvaginal needle bladder neck suspension resulting in an iatrogenic paravaginal defect or denervation of the anterior vaginal wall.

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.

Endometrial ablation: a series of 568 patients treated over an 11-year period.

OBJECTIVE: Our purpose was to retrospectively review the intraoperative and long-term outcomes of 568 patients with abnormal uterine bleeding who were treated by endometrial ablation over an 11-year period. STUDY DESIGN: From 1893 to 1994, 401 endometrial ablations were performed with the neodymium-yttrium-aluminum-garnet laser and another 167 patients were treated by electrosurgery. The majority of the patients were treated for irregular, heavy menses. Fifty-seven had ablation because of abnormal bleeding associated with a serious medical disorder, 12 with a bleeding diathesis, and 50 with morbid obesity. All patients had preoperative endometrial sampling that demonstrated benign histology. Nineteen patients had submucous myomas that were resected at the time of hysteroscopic ablation. All patients received preoperative and postoperative suppression. The minimum follow-up period was 1 year. RESULTS: The average operative time was 32.5 minutes. The mean hospital stay was 8 hours. Four patients who received 32% dextran 70 in dextrose (Hyskon) as the distending medium had pulmonary edema postoperatively. One case of endometritis was also detected. No uterine perforations were observed. Amenorrhea developed in 58% of the patients, 34% reported light or normal menstrual flow, and 8% did not respond (continued heavy flow). CONCLUSION: This study represents one of the largest published series of endometrial ablation, with a mean follow-up of 4.5 years. It demonstrates that hysteroscopic endometrial ablation is a reliable, safe alternative to hysterectomy for the surgical management of abnormal uterine bleeding.

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.

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.

Carbon dioxide laser therapy for benign cervical tumors.

Eight patients underwent carbon dioxide (CO 2) laser excision of benign cervical tumors during a 5-year period. Six patients had symptoms of abnormal vaginal bleeding, and 2 had asymptomatic cervical masses. All but one procedure was performed as outpatient surgery. Blood loss was minimal in 7 patients and less than 50 ml in the other patient. There were no cases of morbidity, and long-term follow-up showed excellent results. The technique to perform CO 2 laser excision of large benign cervical tumors is described.

Quantitative evaluation of the skin and accessory appendages in vulvar carcinoma in situ.

Fifty cases of vulvar carcinoma in situ comprising over 1000 histologic sections were studied. Each case was evaluated to determine the thickness of the neoplastic epidermis and the depth of involved skin appendages. Two precise techniques were used to perform the microscopic measurements. The areas most frequently afflicted with neoplasia were: one or both labia (45%), interlabial folds (27%), perineum-fourchette (15%), and perianal skin (10%). Multicentric disease was observed in 68% of the cases. The epidermal thickness ranged between 0.35-1.66 mm. The mean depth (+/- SD) of the epidermis was 0.93 +/- 0.37 mm. Eighteen of the 50 patients demonstrated involvement of the skin appendages to a mean depth of 1.53 +/- 0.77 mm, suggesting that laser vaporization to a depth of 2.5 mm will, with the anticipated additional thermal necrosis, eliminate appendages involved with carcinoma in situ in 95% of instances. The most common sites of skin appendage involvement were the labia majora or minora and the interlabial folds.

Combined tubal and molar pregnancy: case report.

A patient with combined pregnancy developed an acute condition in the abdomen 9 weeks after surgical removal of a tubal pregnancy. At laparotomy she was found to have bilateral theca-lutein cysts. After operation, the patient went into preterm labor and was delivered of a male fetus. Pathologic examination of the placenta revealed hydropic change and trophoblastic hyperplasia.