Alex C. Wang

An Assessment of the Early Surgical Outcome and Urodynamic Effects of the Tension-free Vaginal Tape (TVT)

Abstract: Fifty-two women underwent a tension-free vaginal tape (TVT) procedure for genuine stress incontinence (GSI). Preoperative assessment included a detailed medical history, pelvic examination, a 1-hour pad test with a comfortably full bladder, and urinary culture. Thirteen of the 52 women were excluded for various reasons. Both before and 12–24 months postoperatively all patients had a full urodynamic investigation using microtip transducer catheters. The study subjects were instructed to maintain a 1-week baseline urinary diary 1 week before the operation, and postoperative urodynamic assessment as well. The period of follow-up ranged from 12 to 24 months (median 19 months). Another 1-hour pad test with a comfortably full bladder and urinary culture were carried out thereafter. Comparisons of the 39 women pre- and postoperatively found a significantly improved 1-hour pad test (34.9 ± 34.7 vs 8.3 ± 24.0, P<0.001). Analyzing the urodynamic effects of surgery revealed no significant postoperative changes except for the maximal urethral closure pressure (MUCP) at rest. An objective assessment using a pad test revealed the success rate (cure plus improved) to be 90% (35/39) and the failure rate 10% (4/39). TVT can thus be considered a safe and effective procedure for GSI in women. Moreover, the urodynamic effects of surgery were not found to be critical to success.

RANDOMIZED COMPARISON OF LOCAL VERSUS EPIDURAL ANESTHESIA FOR TENSION-FREE VAGINAL TAPE OPERATION

PURPOSE We determine the difference between local anesthesia and epidural blockade for the tension-free vaginal tape operation. MATERIALS AND METHODS Between November 1995 and November 1997, 73 women who had genuine stress incontinence in the absence of pelvic prolapse underwent a prospective randomized study. The study was conducted using a standardized protocol for different types of anesthesia for the tension-free vaginal tape procedure. A formal pain scale was used to determine the pain score for the patients during the operation. Additionally an anxiety scale was used to measure the anxiety level of the subjects immediately after admission to the ward and before discharge from the hospital. RESULTS One woman was excluded from study due to loss at followup. The comparisons of pain score, duration of procedure and anxiety level of the 2 different types of anesthesia were not significantly different in the 72 study subjects. There was no significant difference in the amount of blood loss, while initial spontaneous voiding occurred significantly earlier (3.5 +/- 2.3 versus 5.8 +/- 0.1 hours, p <0.01), the number of patients in whom initial spontaneous voiding occurred more than 6 hours postoperatively was fewer (2 versus 10, p =0.01), amount of post-void residual during hospitalization was significantly less (98 +/- 63 versus 155 +/- 56 ml., p <0.01) and length of hospital stay was significantly shorter (3.4 +/- 1.4 versus 5.5 +/- 1.6 days, p <0.01) in the local anesthesia compared to epidural group. Subjective and objective success rates were not significantly different in these 2 groups. CONCLUSIONS Both anesthetic methods can be equally effectively used for the tension-free vaginal tape operation. Local may be better than epidural anesthesia but its clinical significance needs to be proved by further study.

The techniques of trocar insertion and intraoperative urethrocystoscopy in tension-free vaginal taping: an experience of 600 cases

Background.  To determine the frequency of lower urinary tract (LUT) injury for stress incontinent women undergoing the tension‐free vaginal tape (TVT) procedure with or without concomitant procedures.

Endourologic diagnosis and treatment of ureterouterine fistula

A rare case of ureterouterine fistula following a dilatation and evacuation for elective abortion is presented. According to the literature, most cases are related to elective abortion. A 42-year-old woman, 1-0-5-1, presented with copious watery vaginal discharge from the cervical os. She had had an elective abortion followed by a laparotomy for a suspected uterine perforation with peritonitis 1 months prior to presentation. She underwent another laparotomy, which revealed only adhesion of the terminal ileum, appendix and adnexae based on the hysterogram, which suggested an enterouterine fistula. The right ureterouterine fistula was not diagnosed until an antegrade pyelogram was undertaken. She was subsequently treated with temporary percutaneous nephrostomy drainage followed by ureteroneocystostomy. It was concluded that the ureterouterine fistula was most likely caused by the lateral path of abortion instruments into the retroperitoneal space, with trauma to the right ureter.

Effect of suburethral prolene mesh for suburethral function and histology in a stress urinary incontinence mouse model

To create a mouse model pertaining to mesh‐elicited suburethral functional and histological changes after vaginal distention, and to examine the possible mechanism behind these complications.

An atypical and fatal case of pyometra accompanied by the superficial spread of squamous cell carcinoma of the endometrium and the fallopian tubes

Pyometra, an accumulation of large amounts of purulent material within the uterine cavity, is an uncommon condition that carries a significant risk of morbidity and mortality in elderly women with underlying medical conditions [1e5]. We herein report an extremely rare case of a postmenopausal woman with unruptured pyometra who presented with unusual clinical, imaging, and microbiological findings. The persistence or progressive accumulation of purulent discharge (1200 mL) led to a massive uterine enlargement, which was evident on ultrasound and computed tomography (CT) images. The patient ultimately died from septic shock while she was undergoing uterine drainage. Her blood cultures demonstrated a heavy growth of Staphylococcus epidermidis. Notably, the histopathological examination of the uterus showed the presence of squamous cell carcinoma in situ arranged in a diffuse pattern that had spread superficially into the entire endometrial cavity and the fallopian tubes. Moreover, the patient had multiple foci of invasive squamous cell carcinoma scattered along the myometrium. The upward superficial spread of squamous cell carcinoma extending over the entire surface of the endometrium is a very uncommon clinical presentation (0.1%) [6,7]. A 60-year-old, para 3, woman had noted increasing abdominal girth for approximately 2 months. Upon admission she presented with abdominal distension and a palpable abdominal mass. The patient was in good general conditions and did not suffer a net weight loss of significant proportions. She had no fever and her white blood cell count was normal

Urogynecology in Taiwan: past, present and future.

Thirty years ago, when I was still a resident doctor, once the urinary bladder or ureter was injured during pelvic surgery, the only doctor who would come to the gynecologists’ aid to repair the injury was the urologist. Gynecologists in our hospital were not aware of the basic teachings for the repair of vesicovaginal fistula by Marion Sims [1], the father of gynecology, or Howard Kelly, gynecologist who was the first to successfully repair a cut ureter in 1890 [2]. I started my urogynecologic career with the repair of the iatrogenic lower urinary tract (LUT) injuries since 1983 [3, 4]. Several years later, bead-chain cystourethrography and Marshall–Marchetti–Krantz retropubic urethropexy were introduced to the gynecologists on this island. However, the practice of urogynecology was limited to the diagnosis and treatment of urinary stress incontinence (USI). Meanwhile, the gynecologists still argued over the preference of the surgical procedures used for women with USI. Some felt that anterior colporrhaphy with Kelly plication should be used first, and retropubic urethropexy should only be used if the former fails. Urodynamic testing equipment was also scarcely used at that time; only the urological section of certain medical centers owned the privilege. The first female urinary incontinence clinic in Taiwan was not set up until I returned to Taiwan after finishing my urogynecology training program in Australia in 1984. Since then, cystourethroscopy and transurethral surgery under the guidance of the instrument as well as multiple surgical therapies, including Stanton–Tanagho colpocystourethropexy, fascia lata sling operation, Stamey’s needle suspension, and abdominal perineal urethral suspension, have been introduced and used to treat Taiwanese women with USI. However, there were only a few gynecologists practicing urogynecology at that time.