A. Reich

Hemorrhagic complications associated with tension-free vaginal tape procedure

OBJECTIVE: We sought to assess the frequency, symptoms, and management of hemorrhagic complications in patients undergoing tension-free vaginal tape (TVT) procedure. METHODS: Over a 5-year period the clinical course of all 336 consecutive patients undergoing TVT procedure in our hospital was recorded, including diagnostic approaches and management strategies for both increased intraoperative blood loss and clinically relevant hematoma. RESULTS: In 87 patients (26%), TVT procedure was combined with other gynecologic surgeries, and 249 patients (74%) underwent TVT alone. In 7 cases (2.1%), increased intraoperative blood loss (250–400 mL) was managed by electro-coagulation, manual compression, tamponade, and/or insertion of a drain. The postoperative course in these patients was uncomplicated. In 14 women (4.1%) who did not show increased bleeding during the operation, retropubic hematoma developed, the volume of which exceeded 300 mL in 4 cases (1.2%). These required surgical intervention. In the first case we performed open laparotomy, whereas in the following cases the hematoma could be successfully drained by endoscopy. Postoperative development of a hematoma did not lead to recurrence of stress incontinence. CONCLUSION: Bleeding complications during or after TVT procedure are rare events. Increased intraoperative bleeding can usually be managed with electro-coagulation, compression, and drainage. LEVEL OF EVIDENCE: II-3

Long-term Results of the Tension-free Vaginal Tape Procedure in an Unselected Group: A 7-Year Follow-up Study

OBJECTIVES To evaluate long-term effectiveness and late complications after treatment of female stress urinary incontinence with tension-free vaginal tape (TVT). METHODS We performed a prospective observational study. Follow-up examinations included a standardized questionnaire, medical history, voiding diary, gynecologic examination with cough test, and introital ultrasound. RESULTS One-hundred-eight women (68.8%) from the initial cohort of 157 patients and 79.6% of those alive and able to cooperate were assessed. The median follow-up time was 102 months (range 85-124). The objective cure rate was 89.8%. The subjective cure rate was 82.4%, 13% had improved, 2.8% regarded the continence situation as unchanged, and 1.8% had an impaired stress urinary incontinence. No late-onset adverse effects of the surgery were found. Urge incontinence was the main reason for dissatisfaction with the surgery (in 90% of discontent patients). CONCLUSIONS Our data showed good results more than 7 years after TVT, demonstrating a high level of long-lasting efficacy for this minimally invasive incontinence procedure.

Haemorrhage and nerve damage as complications of TVT-O procedure: case report and literature review.

The transobturatorial vaginal tape procedure is associated with little complication rate. Bladder perforation, urethral invasion, vaginal erosion, postoperative bladder retention, de novo incontinence and retropubic pain and haematoma are the most reported complications. The aim of this article is to present an uncommon complication in a patient operated by transobturator vaginal tape with an inside–outside route.

Comparison of Transobturator Vaginal Tape and Retropubic Tension-Free Vaginal Tape: Clinical Outcome and Sonographic Results of a Case-Control Study

Objectives: To compare the results and ultrasonographic characteristics of the transobturator vaginal tape (TVT-O) and retropubic (TVT) methods. Methods: 120 patients were treated with TVT-O. These were paired with similar patients treated with TVT. The patients were matched according to age, low-pressure urethra, preexisting mixed incontinence, and additional prolapse repair. The follow-up time was 3 months. Assessment variables included a standardized questionnaire, medical history, voiding diary, urinary stress test, 24-hour pad test, and introital ultrasound. The position of the tape was defined by its location in relation to urethral length (%) and the narrowness by its distance to the hypoechoic center of the urethra (mm). Results: The rates of postoperative complications including bladder perforation, urinary retention, and erosion through the vagina were similar. The number of hematomas occurring after TVT was insignificantly higher than after TVT-O (5 cases vs. 1 case). The rates for cure or improvement of stress incontinence were 77 and 17% after TVT-O and 85 and 14% after TVT (not significant). The sonographic characteristics were identical. Conclusion: In terms of clinical outcome, TVT and TVT-O appear to be equally effective. Complications and sonographic characteristics of the tapes were similar after both procedures.

Retziusscopy: a minimal invasive technique for the treatment of retropubic hematomas after TVT procedure

OBJECTIVES Retropubic hematomas are rare but typical complications during or after the tension-free vaginal tape (TVT) procedure. We investigated the possibility of treating these hematomas with retziusscopy, as an update of a previous study by our group. STUDY DESIGN Over a 10-year period the clinical course of all 685 consecutive patients undergoing the tension-free vaginal tape procedure (TVT, Gynecare) was prospectively recorded, including management strategies for clinically relevant hematomas. We report on 10 patients with hematoma and our following surgical management. RESULTS In twenty-eight patients (4.1%) a symptomatic retropubic hematoma developed. In 10 cases (1.5%) volume exceeded 250 mL (range 250-1000 mL). These patients required surgical intervention because of moderate or severe symptoms. In the first case we performed open laparotomy, whereas in the following cases the hematomas could be successfully drained by retziusscopy. CONCLUSIONS In cases of large masses, intervention may be necessary because of significant discomfort. This can usually be achieved by a minimally invasive retziusscopy.

Voiding Dysfunction after the Tension-Free Vaginal Tape Procedure

Aim: To assess the incidence of voiding dysfunction in women undergoing a tension-free vaginal tape (TVT) procedure and report our experience with nonsurgical and surgical management. Methods: Pre- and postoperative introital ultrasonographic measurement of the residual volume was performed in a prospective observational study. Patients’ perception of micturition and continence status was assessed by questionnaire. Results: Of 478 women, 4 (0.8%) suffered from micturition disturbance within the first 2 weeks. In the mean of 3 months after surgery, 7.1% of the patients had residual volume between 50 and 100 ml, and 2.6% had residual volume >100 ml. 243 women were investigated after 39 months (range 12–74). The rate of residual volume exceeding 50 ml decreased to 6.5% and was approximated to the preoperative period. Conclusion: Incomplete bladder emptying is a possible problem after TVT. In our cohort, 93% of the women had no voiding disturbances or marginally affected voiding after 12–74 months.

Influence of Bladder Volume on Pelvic Organ Prolapse Quantification Results

Aims: To compare the degree of pelvic organ prolapse between examinations performed with full and empty bladder in patients without any prolapse and with pelvic organ prolapse stage I or II using the pelvic organ prolapse quantification (POPQ) system. Methods: A prospective observational study with 120 consecutive patients with and without symptoms of pelvic organ prolapse was evaluated. All women were examined with full and empty bladder. The data were analyzed by Wilcoxon’s signed-rank test. Results: With empty bladder 54% had the same stage, 41% had a one-step higher stage and 5% had a two-step higher stage of prolaps. There was an increase in the extent of prolapse in the empty bladder setting at all six site-specific points (Aa, Ba, C, D, Ap, Bp; p < 0.001) but not in the results of genital hiatus, perineal body and total vaginal length. Conclusion: Our results suggest that the full extent of prolapse may be only assessed with an empty bladder.

Suitable laparoscopic surgery in the treatment of ectopic interstitial pregnancy

Interstitial or cornual pregnancies represent a small fraction of ectopic gestations. They are located in the interstitial part of the fallopian tube. Interstitial pregnancies are especially feared due to their life-threatening intraabdominal hemorrhage. General guide-lines for the clinical management are missing. This article discribes important specialities in the differenciation of interstitial and classical tubal pregnancy and will further offer a special minimal invasive procedure for the safe management of this rare ectopic pregnancy. We favour a special operative endoscopic procedure using a combination of encircling suture and endoloop-technique. This method provides an excellent tourniquet effect resulting in an effective hemostasis. In addition to the different endoscopic treatments, other therapeutic options such as primary methotrexate application will be discussed.

Komplette Netzperforation nach bandunterstützter vorderer Scheidenwandplastik durch Infektion mit multiresistenten Escherichia coli – Fallbericht und Übersicht

Pelvic floor disorders are an increasing problem among elderly women with a high prevalence rate. In the search for new methods to decrease the incidence of recurrent prolapse the use of surgical mesh in pelvic floor surgery has grown in popularity. The use of synthetic materials has resulted in a new spectrum of complications including a mesh erosion rate of up to 19 %. CASE REPORT: A 47-year-old woman was transferred to our clinic under intubation for heavy vaginal bleeding 20 days after vaginal hysterectomy and anterior vaginal wall repair using a transobturator mesh. The mesh was completely visible at the anterior vaginal wall and covered with sanies. The bleeding had ceased by the time of the patients arrival at our clinic. A blood transfusion was given. The microbiological smear revealed multiresistant Escherichia coli, which was the reason that the antibiotic therapy performed shortly after surgery remained unsuccessful. The visible parts of the mesh were surgically removed. The patient was discharged 2 days later. Six weeks later the vaginal walls appeared well fixed with only a very small erosion which was later removed in an outpatient setting. CONCLUSION: Despite the initial enthusiasm accompanying new surgical techniques we should not forget the special risks involved or the possibility to perform classical pelvic floor surgery. In our opinion, as data is still rare, the use of graft materials in vaginal reconstructive surgery should be limited to a carefully selected patient population. We would like to point out the importance of educating patients about the higher complication rates. Considering the increasing numbers of multiresistant germs, microbiological investigation is essential in cases of postoperative infection.

OC135: Evaluation of the tension‐free vaginal tape by ultrasound

Results: 230/7661 (3.1%) tubal EP were diagnosed during the study period. 58/230 (25.2%) were initially managed conservatively – 23 expectantly and 35 with methotrexate. 21/23 (91.3%) were successfully managed expectantly. 2/23 (8.7%) failed expectant management – 1 required methotrexate then surgery and 1 surgery alone. Mean hCG at presentation in the expectant group was 663 IU/L (range 40–3367 IU/L) and mean gestation 43 days (range 13–94 days). 35 women in total were treated with methotrexate initially. 26/35 (74.3%) were treated successfully – 24/26 (92.3%) required single dose only. 9/35 (25.7%) failed medical management. The mean hCG at time of the methotrexate injection was 1271 IU/L (range 111–4239 IU/L) and gestation was 45 days (range 16–68 days). Overall 81% (47/58) of EP managed conservatively had a successful outcome. Conclusion: Conservative management in selected cases of EP is safe and associated with high rates of resolution. We believe that more stable women with EP should be offered conservative management as an alternative to more invasive surgical approaches.