Alfred E. Bent

Tissue reaction to expanded polytetrafluoroethylene suburethral sling for urinary incontinence: Clinical and histologic study

OBJECTIVE The use of expanded polytetrafluoroethylene suburethral sling for recurrent urinary incontinence has shown an excellent cure rate but a number of complications. This study was designed to evaluate patients who had tissue reaction or removal of the sling, to determine potential causes, clinical course, and eventual outcome. STUDY DESIGN A retrospective review of consecutive charts was completed for 115 patients who had suburethral sling surgery with expanded polytetrafluoroethylene. Patients having tissue reaction or removal of sling material were identified, and eight removed sling specimens were analyzed histologically with Milligans trichrome, hematoxylin and eosin, fibrin, Brown-Brenn bacteria, and Dahls calcium stains. RESULTS Twenty-four patients had reactions to the sling material, and 23 slings were eventually removed. Seventeen of 23 patients having sling removal remained continent. Histologic evaluations revealed gram-positive cocci in all expanded polytetrafluoroethylene patch interstices. Fibrous tissue, fibroblasts, and collagen were present in one half of specimens. CONCLUSION There is a 23% reaction or removal rate for expanded polytetrafluoroethylene suburethral sling procedures. Seventeen of 23 patients remained continent in spite of sling removal. Histologic studies showed gram-positive cocci in the patch interstices, although prophylactic antibiotic coverage did not prevent infection and cultures from the vaginal or abdominal reaction sites did not reveal a significant growth of organisms. Patients need to be aware of the high complication rate for this suburethral sling procedure, and physicians need to work further to modify sling materials and techniques to reduce complications.

Uterosacral ligament: description of anatomic relationships to optimize surgical safety☆

Objective To determine the optimal site in the uterosacral ligament for suspension of the vaginal vault with regard to adjacent anatomy and suspension strength. Methods Fifteen female cadavers were evaluated between December 1998 and September 1999. Eleven hemisected pelves were dissected to better define the uterosacral ligament and identify adjacent anatomy. Ureteral pressure profiles with and without relaxing incisions were done on four fresh specimens. Suture pullout strengths also were assessed in the uterosacral ligament. Results The uterosacral ligament was attached broadly to the first, second, and third sacral vertebrae, and variably to the fourth sacral vertebrae. The intermediate portion of the uterosacral ligament had fewer vital, subjacent structures. The mean ± standard deviation distance from ureter to uterosacral ligament was 0.9 ± 0.4, 2.3 ± 0.9, and 4.1 ± 0.6 cm in the cervical, intermediate, and sacral portions of the uterosacral ligament, respectively. The distance from the ischial spine to the ureter was 4.9 ± 2.0 cm. The ischial spine was consistently beneath the intermediate portion but variable in location beneath the breadth of the ligament. Uterosacral ligament tension was transmitted to the ureter, most notably near the cervix. The cervical and intermediate portions of the uterosacral ligament supported more than 17 kg of weight before failure. Conclusion Our findings suggest that the optimal site for fixation is the intermediate portion of the uterosacral ligament, 1 cm posterior to its most anterior palpable margin, with the ligament on tension.

Transvaginal electrical stimulation for female urinary incontinence

OBJECTIVE Our purpose was to determine the objective and subjective efficacy of transvaginal electrical stimulation for treatment of common forms of urinary incontinence in women. STUDY DESIGN A prospective, double-blind, randomized clinical trial included 121 women with either urinary incontinence caused by detrusor instability or genuine stress incontinence, or both (mixed incontinence). Participants used the assigned device for 8 weeks. Identical preintervention and postintervention assessment included multichannel urodynamic testing, quality-of-life scale, and urinary diaries. RESULTS A total of 121 women completed this study at four North American urogynecology centers. Detrusor instability was cured (stable on provocative cystometry) in 49% of women with detrusor instability who used an active electrical device (p = 0.0004, McNemars test), whereas there was no statistically significant change in the percentage with detrusor instability in the sham device group. There was no statistically significant difference between the preintervention and postintervention rates of genuine stress incontinence for either the active device group or the sham device group. CONCLUSION This form of transvaginal electrical stimulation may be effective for treatment of detrusor overactivity, with or without genuine stress incontinence.

Assessment of intraoperative judgment during gynecologic surgery using the Script Concordance Test

OBJECTIVE We sought to develop a valid, reliable assessment of intraoperative judgment by residents during gynecologic surgery based on Script Concordance Theory. STUDY DESIGN This was a multicenter prospective study involving 5 obstetrics and gynecology residency programs. Surgeons from each site generated case scenarios based on common gynecologic procedures. Construct validity was evaluated by correlating scores to training level, in-service examinations, and surgical skill and experience using a Global Rating Scale of Operative Performance and case volumes. RESULTS A final test that included 42 case scenarios was administered to 75 residents. Internal consistency (Cronbach alpha = 0.73) and test-retest reliability (Lin correlation coefficient = 0.76) were good. There were significant differences between test scores and training levels (P = .002) and test scores correlated with in-service examination scores (r = 0.38; P = .001). There was no association between test scores and total number of cases or technical skills. CONCLUSION The Script Concordance Test appears to be a reliable, valid assessment tool for intraoperative decision-making during gynecologic surgery.

Validation of a Two-item Quantitative Questionnaire for the Triage of Women With Urinary Incontinence

OBJECTIVE: To evaluate the reproducibility, construct validity, and preferences for the 2-item Stress/Urge Incontinence Questionnaire. METHODS: The questionnaire asks a patient to recall the number of stress urinary incontinence and urge urinary incontinence episodes she experienced during the preceding week. The 4-week prospective study included 3 office visits and enrolled women with stress, urge, or mixed urinary incontinence symptoms. The test–retest reproducibility was assessed after 3 days, and the construct validity of the questionnaire was evaluated against a diary and other measures of incontinence severity and effect. The bother associated with completing (patients) or analyzing (physicians) the diary was assessed. Both groups also reported their time requirements and preferences for the questionnaire or diary. RESULTS: Reproducibility for the classification of symptoms was moderately strong (&kgr; = .536). Test–retest agreement was good (64–80%) for all but balanced mixed incontinence (38%). Intraclass correlations revealed good reproducibility for the number of stress (.694), urge (.703), and total (.726) incontinence episodes. Significant (P < .01) correlations with other measures of incontinence established construct validity. Patients and physicians reported it took less time to complete the questionnaire than the diary, but the majority said the completion or analysis of the diary was of little or no bother and preferred the diary. CONCLUSION: The Stress/Urge Incontinence Questionnaire is a valid tool that can be used in clinical practice to differentiate between symptoms of stress and urge urinary incontinence to make an initial diagnosis, especially in primary care where incontinence is not a focus of the practice. LEVEL OF EVIDENCE: III

Evaluation of pressure transmission ratios in women with genuine stress incontinence and low urethral pressure: a comparative study.

Objective: To determine whether women with genuine stress incontinence and low urethral closure pressure (20 cm H2O or lower) had more severely impaired pressure transmission to the urethra than women with stress incontinence and normal urethral pressures. Methods: Seventy‐six women who underwent multichannel urodynamic testing were included for comparative analysis. They were classified into the following groups: genuine stress incontinence with low urethral pressure (N = 20), genuine stress incontinence without low urethral pressure (N = 32), and continent controls (N = 24). Urodynamic indices and pressure transmission ratios were calculated from static and stress urethral pressure profiles, respectively. Multiple demographic cofactors, urethral mobility, and previous surgeries were correlated for associations with urodynamic results. Results: Women with stress incontinence and low urethral pressure were significantly older (57.6 years, P < .0071). There were no differences with regard to urethral mobility and previous surgeries. Mean maximum urethral closure pressure and the distance from the proximal margin of the urethra to the point of maximum urethral closure pressure were statistically less in women with low urethral pressure. There were no differences in pressure transmission ratios between any of the study groups. Conclusion: Because there are no differences in pressure transmission ratios between women with genuine stress incontinence with and without low urethral closure pressure, the higher risk for surgical failure with low urethral pressure appears to result from another pathophysiologic process. (Obstet Gynecol 1994;83:984‐8)

Phosphatidylglycerol determination on amniotic fluid 10,000 × g pellet in the prediction of fetal lung maturity

Phosphatidylglycerol and the lecithin/sphingomyelin (L/S) ratio were determined, and the shake test was performed, as indicators of fetal lung maturity, in more than 600 patients. A clinical review of the outcome was made in all patients who underwent delivery within 2 days after collection of amniotic fluid. Correlation was made phosphatidylglycerol, shake test, and L/S ratio results. L/S ratio had a false positive rate of 5%, and a false negative rate of 58.1%. The shake test had a false positive rate of 1.1%, and a false negative rate of 63.5%. Phosphatidylglycerol determination had a false positive rate of 1.8%, and a false negative rate of 26.9%. Phosphatidylglycerol determination is an accurate predictor of fetal lung maturity, and predicts lung immaturity more correctly than do the L/S ratio and shake test.

Women's ability to assess their urinary incontinence type using the QUID as an educational tool

Introduction and hypothesisLittle evidence is available concerning the ability of women with urinary incontinence (UI) to properly assess their problem. This study compared women’s assessments of their UI type with physicians’ diagnoses.MethodsWomen referred to a urogynecology clinic for UI were asked to anonymously answer a short validated Questionnaire for Urinary Incontinence Diagnosis (QUID) before their physician visit. Women completed the QUID and read a brief explanation of its interpretation, after which they were asked to choose their UI type: stress, urge, or mixed. Physicians, blinded to patients’ answers, conducted routine examinations and indicated their diagnoses of incontinence types. Sample size was representative of typical clinic volumes. Levels of agreement among physician diagnoses, QUID scores, and patient self-assessments of UI type were calculated with kappa (κ) statistics. Physician diagnosis was the gold standard.ResultsWe had 497 patients return the questionnaire; 338 met inclusion criteria. Mean age was 53 (±13) years. Levels of agreement among physician diagnoses and patients’ assessments of UI type (κ = 0.411, p < 0.01) and QUID scores (κ = 0.378, p < 0.01) were significant. Significant level of agreement was found among QUID scores and patients’ assessments of UI type (κ = 0.497, p < 0.001).ConclusionsWith aid of a brief standardized questionnaire, women can accurately assess their UI type. This suggests women could be educated about UI via good-quality Internet health sites and choose appropriate conservative management options.

Concurrent genuine stress incontinence and detrusor instability

Forty-six patients with both genuine stress incontinence (GSI) and detrusor instability (DI), as determined by urodynamic evaluation, were treated with medication or surgery and followed for 6 months. It was found that 60% responded favorably to medical therapy with imipramine hydrochloride, oxybutynin chloride, or dicyclomine hydrochloride. Surgery for stress incontinence was performed in 24 patients, including 17 started initially on medication. Surgical cure was achieved in 38% of these 24 patients, and a further 29% of the surgical group were cured with additional drug therapy. Overall, 85% of patients responded favorably to medication and/or surgery. Patients with combined GSI and DI require detailed urodynamics and may be candidates for surgery, in spite of the coexistent DI.