Angelo Maggioni

A randomized comparison of Burch colposuspension and abdominal paravaginal defect repair for female stress urinary incontinence

OBJECTIVE Our aim was to compare Burch colposuspension and paravaginal repair for success rates, complications, and urodynamic effects when the procedures are used in the treatment of stress urinary incontinence. STUDY DESIGN Thirty-six patients were enrolled. A full urodynamic evaluation was repeated 6 months postoperatively. RESULTS Twelve (67%) and 17 (94%) subjects (Burch colposuspension vs paravaginal repair) voided spontaneously before discharge (p = 0.04). One patient receiving the Burch procedure underwent urethral dilation for urinary retention. Follow-up was for 1 to 3 years. Differences in subjective and objective cure rates favored the Burch colposuspension over the paravaginal repair: 100% versus 72% (p = 0.02) and 100% versus 61% (p = 0.004), respectively. The paravaginal repair did not produce significant modifications in profilometry. Postoperatively, cotton swab tests had negative results in all patients with the Burch operation and in 33% of those with the paravaginal repair (p = 0.01). CONCLUSION Paravaginal repair is not recommended for the treatment of stress incontinence, although it was accompanied by a more immediate resumption of voiding.

Surgery for genitourinary prolapse and stress incontinence: A randomized trial of posterior pubourethral ligament plication and Pereyra suspension

OBJECTIVE Our purpose was to compare two antiincontinence procedures in patients with severe genitourinary prolapse and coexisting clinical or potential stress incontinence. STUDY DESIGN In addition to cystopexy, 109 patients with a urethrocystocele of grade 2 or more and a positive stress test result with prolapse reduction received posterior pubourethral ligament plication or Pereyra suspension. RESULTS Of 55 patients undergoing posterior pubourethral ligament plication, 15 were clinically and 40 potentially incontinent; the same figures were 21 and 33, respectively, among 54 patients undergoing the Pereyra procedure. Follow-up was for 3 to 9 years. Subjective (60% vs 71%, p = 0.72) and objective (27% vs 57%, p = 0.14) cure rates were not statistically different among patients who were clinically incontinent (posterior pubourethral ligament plication vs Pereyra suspension). Among potentially incontinent patients, subjective (85% vs 100%, p = 0.03) and objective (50% vs 76%, p = 0.04) continence rates were higher after the Pereyra procedure. Overall, the cotton swab test had negative results (maximum straining angle < or = 30 degrees) after successful surgery in 79% and 96%, respectively, of patients (p = 0.03). Four subjects (7%) underwent removal of one Pereyra suture because of urinary retention or suprapubic wound infection. CONCLUSION Cystopexy with Pereyra suspension is recommended, particularly for patients with prolapse and potential stress incontinence.

Burch colposuspension versus modified Marshall-Marchetti-Krantz urethropexy for primary genuine stress urinary incontinence: A prospective, randomized clinical trial

OBJECTIVE Our purpose was to compare the effects of the Burch colposuspension with those of the modified Marshall-Marchetti-Krantz urethropexy. STUDY DESIGN Eighty women underwent the two types of operation. A full urodynamic investigation was repeated 6 months after surgery. RESULTS Clinical follow-up continued for 2 to 7 years. Differences in subjective and objective cure rates were not statistically significant (respectively, 92% and 80% for the Burch colposuspension and 85 and 65% for the modified Marshall-Marchetti-Krantz urethropexy). The latter induced a longer hospital stay (7.4 vs 6.3 days, p = 0.001), a later resumption of spontaneous voiding (13.8 vs 8.5 days, p = 0.002), and was associated with considerable complications (one case of blood replacement for retropubic hematoma, one case of severe voiding difficulty, one case of further treatment for stress incontinence, and three cases of symptomatic de novo detrusor instability). CONCLUSION For its high cure rate, short time to resumption of spontaneous voiding, short hospital stay, and low associated morbidity, the Burch colposuspension should remain the procedure of choice for stress incontinence.

A randomized comparison of continuous versus interrupted mass closure of midline incisions in patients with gynecologic cancer

Objective To address the incidence of deep wound dehiscence and incisional hernia formation with two types of mass closure after vertical midline laparotomy performed in patients with gynecologic cancer. Methods Continuous and interrupted mass closures were compared randomly in 632 patients. Both methods were performed with absorbable material. Of the 614 subjects who could be evaluated, 308 underwent a continuous, nonlocking closure with looped polyglyconate suture, and 306 were closed with interrupted polyglycolic acid according to the Smead-Jones technique. Results Three (1%) subjects with the continuous closure and five (1.6%) with the interrupted closure had an abdominal wound infection (P = .50). One patient whose incision was closed with continuous suturing had a deep wound dehiscence (without evisceration). The follow-up period was 6 months to 3 years. No patient had evidence of chronic sinus drainage. Thirty-two (10.4%) of the patients who had the continuous closure and 45 (14.7%) of those who were closed with the interrupted method had evidence of incisional hernia (P = .14). No hernia developed in any patient with a wound infection. Four (1.3%) hernias after the continuous closure and eight (2.6%) after the interrupted closure required surgical repair because of patient discomfort (P = .38). Conclusion The interrupted closure was not superior to the continuous closure for short- and long-term wound security. The continuous method was preferable because it was more cost-efficient and faster.

Prevention of postoperative urinary stress incontinence after surgery for genitourinary prolapse

Objective To compare cystopexy alone versus cystopexy with posterior pubourethral ligaments plication for the occurrence of postoperative stress incontinence after prolapse surgery, and to compare the two surgical series in terms of complications and urodynamic effects. Methods One hundred two continent patients randomly underwent cystopexy alone (N = 52) or cystopexy with posterior pubourethral ligaments plication (N = 50). All had a urethrocystocele grade 2 or greater and a negative stress test with the prolapse repositioned. A full urodynamic investigation was repeated 6 months after surgery. Results Twelve (23%) and 14 (28%) patients (P = .73) required intermittent self-catheterization for 11.1 ± 5.1 and 16.5 ± 11.1 days, respectively (cystopexy alone versus cystopexy with posterior pubourethral ligaments plication, P = .002). Long-lasting difficulties in voiding were present in zero and five (10%) patients (P = .02). One subject receiving posterior pubourethral ligaments plication underwent urethral dilation for complete urinary retention. At 1 year follow-up, four patients (8%) in each series developed postoperative stress incontinence (P = .62). Symptomatic detrusor instability complicated the postoperative course in one patient (2%) of each group. Conclusion Cystopexy alone implied lower morbidity in terms of resumption of spontaneous voiding and long-lasting difficulties in voiding. The procedure could be recommended as an effective and safe treatment for continent patients with severe urethrocystocele. Additional plication of the posterior pubourethral ligaments did not seem superior to cystopexy alone in preventing the postoperative occurrence of stress incontinence.

Platin-based chemotherapy and salvage surgery in recurrent ovarian cancer following negative second-look laparotomy.

AIM To evaluate the role of platin-based chemotherapy followed by salvage surgery in patients with recurrent ovarian cancer after negative second-look laparotomy. METHODS A retrospective chart review was conducted on 38 patients with recurrent ovarian cancer after a pathologic complete response to first-line chemotherapy. After diagnosis of recurrence all patients underwent retreatment with platin-based chemotherapy followed by radical salvage surgery. RESULTS Recurrent disease was diagnosed at a median interval of 22 months after second-look surgery. All patients had complete surgical debulking with no macroscopic tumor at the completion of the surgical procedure. Eight patients (21%) required an intestinal resection but no colostomy was performed. Two operative deaths occurred (5%). Twenty-two patients (58%) experienced a second recurrence after salvage surgery The median survival time for all patients after diagnosis of recurrent disease was 29 months (range 6-96 months), with nine patients (25%) surviving more than three years. Survival time after diagnosis of recurrence was not significantly related either to known prognostic factors of ovarian cancer or to the length of the clinical remission time. CONCLUSION Retreatment with platin-based chemotherapy followed by salvage surgery should be offered to recurrent ovarian cancer patients and would appear to prolong survival in a highly selected group of patients.

A randomized trial of open versus closed vaginal vault in the prevention of postoperative morbidity after abdominal hysterectomy

OBJECTIVE Our purpose was to evaluate the effects of two surgical techniques, closed vaginal vault with two layers of continous 3-0 polyglactin suture versus open vaginal vault with a locking 3-0 polyglactin suture, after abdominal hysterectomy. STUDY DESIGN A prospective, randomized trial was performed. During the hospital stay and 4 to 8 weeks after the operation patients were observed for evidence of morbidity. RESULTS Of the 273 evaluable subjects, 141 had the vaginal vault left open whereas 132 were closed. Ten (7.1%) and eight patients (6.1%) had infections at the operative site (pelvis or abdominal wound) (p = 0.92). A urinary tract infection was diagnosed in three (2.1%) and in four subjects (3.0%) (p = 0.46). A pelvic hematoma developed in two patients of each group (p = 0.66). Vault granulations were recorded in 11% and 12% of subjects (p = 0.97). CONCLUSIONS This study failed to show some benefit in favor of either of the two surgical policies. A careful surgical technique and antibiotic prophylaxis seem to remain the most important factors in the prevention of postoperative morbidity.

K cell activity in ovarian cancer patients given chemotherapy

Abstract K cell activity was evaluated in 20 patients with advanced ovarian epithelial tumours, using 51 Cr -labelled murine lymphoma cells as targets. Cancer patients showed significantly lower K cell activity than 40 sex and age matched controls. Cyclophosphamide, given alone or in combination with adriamycin, did not significantly affect K cell activity per unit number of lymphoid cells, whereas lymphoproliferative responses to phytohaemagglutinin and pokeweed mitogen were markedly suppressed by these agents. Patients showing an objective response to chemotherapy had K cell activity values similar to non responders.

Bladder function following randomization to two different radical hysterectomy procedures: A prospective study

Lower urinary tract function was evaluated by means of clinical and urodynamic assessment in a prospective randomized study including 31 patients undergoing two different types of extended hysterectomy [1] for cervical cancer. In the immediate postoperative period loss of both bladder sensitivity and detrusor voiding activity with reduced compliance was observed in 60% of patients regardless of the operative procedure performed. At 3 months follow-up, the improvement in urethrovesical function was significantly related to a less extensive dissection of pelvic connective tissue (P<0.01).

Pefloxacin in the Treatment of Severe Infections in Gynecological Cancer Patients

Infections often complicate the medical or surgical treatment of hospitalized cancer patients. In these cases, a broad-spectrum antibiotic treatment is necessary before the microbiological results are available. The aim of the present study is to verify the efficacy of pefloxacin as empirical antibiotic therapy in controlling infectious complications induced by surgery, chemotherapy or radiotherapy in female patients with gynecological cancer. To this purpose, 58 hospitalized patients with gynecologic malignancy and severe infectious complications were treated with intravenous pefloxacin at the dosage regimen of 400 mg every 12 hours. In all, 49 (or 91%) of the 54 evaluable patients were cured. The mean duration of successful treatment was 5.9 +/- 2.1 days (ranging 4-13 days). No side effects or clinical laboratory abnormalities requiring reduction or discontinuation of therapy were observed. We conclude that pefloxacin may be considered a first choice, broad-spectrum, single antibiotic for use in the empirical therapy of infections in gynecological cancer patients.