Anna Padoa

Collagen-coated polypropylene mesh in vaginal prolapse surgery: an observational study

OBJECTIVE We evaluated the efficacy and safety of a collagen-coated polypropylene mesh with a trans-obturator approach for cystocele repair. STUDY DESIGN We considered as eligible for our study 97 patients with a stage ≥ 2 cystocele according to the Pelvic Organ Prolapse Staging System (POP-Q), with or without associated apical or posterior vaginal wall prolapse. They were also evaluated pre- and post-operatively using validated questionnaires (P-QoL, Wexner and PISQ-12). Patients underwent cystocele repair using Avaulta Biosynthetic Anterior Support System (CR Bard Inc., Billerica, USA). Objective anatomical cure was defined when points Ba, C and Bp were at stage 0 (good outcome) or stage 1 (satisfactory outcome). The McNemar chi-square test was used to compare categorical variables, the paired t-test for continuous parametric variables, and the Mann-Whitney test for continuous non-parametric variables. RESULTS All patients completed the 1-year follow-up. We observed an anatomical cure rate of 64.9% for anterior vaginal wall prolapse (point Ba<-1), and a statistically significant improvement in storage, voiding, post-micturition and prolapse-related symptoms. Quality of Life and sexuality were also statistically improved, while we found no impact on anorectal function. We also observed the development of vaginal mesh exposure in 21 patients (21.6%). CONCLUSION Our data suggest that the collagen-coated polypropylene mesh, as we used it, gives a high recurrence rate (35.1%) and a high exposure rate (21.6%) at one-year follow-up, and is consequently unsatisfactory for the treatment of anterior vaginal wall prolapse.

High levator myorraphy versus uterosacral ligament suspension for vaginal vault fixation: a prospective, randomized study

Introduction and hypothesisOur study compared high levator myorrhaphy (HLM) and uterosacral ligament suspension (USLS) for vaginal apex fixation from both an anatomical and functional point of view, and assessed the impact of surgery on quality of life (QoL) and sexuality.MethodsTwo hundred twenty-nine patients with symptomatic stage ≥2 apical prolapse were randomized to USLS or HLM. Those patients who also needed cystocele repair additionally underwent an anterior prosthetic reinforcement. We defined as cure no prolapse of stage 2 or greater in any compartments according to the POP-Q system.ResultsCorrection of apical prolapse was observed in 96.6% of the HLM group and 98.3% of the USLS group. However, a persistent anterior wall prolapse occurred in 29.2% of the HLM group and in 35.4% of the USLS group. Both groups reported improvement in storage, voiding, and prolapse-related symptoms. Urodynamics of patients in the HLM group showed post-operative reduction in detrusor pressure at maximum flow and an increase in maximum flow. Both groups saw similar improvement in QoL. We did not encounter any serious side effects, except for nine cases of intraoperative ureteral occlusion following USLS.ConclusionThis study demonstrates similar efficacy of HLM and USLS for vaginal apex suspension; however, USLS has a higher incidence of complications involving the upper urinary tract.

High levator myorrhaphy for transvaginal suspension of the vaginal apex: long-term results.

PURPOSE We evaluated the long-term outcome and complications of high levator myorrhaphy for vaginal apical defects. MATERIALS AND METHODS A total of 286 patients underwent high levator myorrhaphy. Patients underwent preoperative and postoperative urogynecologic assessment, including evaluation of prolapse stage according to the international pelvic organ prolapse staging system and conventional urodynamic testing. Quality of life was evaluated using the prolapse quality of life questionnaire. We considered failure as vaginal prolapse stage 2 or greater according to the pelvic organ prolapse staging system. RESULTS A total of 272 patients with a mean age of 60.4 years were available for analysis. Mean followup was 5 years. In 247 patients we associated tension-free cystocele repair with Marlex mesh. In 50.7% of patients high levator myorrhaphy was done with curative intent, while in the remaining 49.3% it was a preventive measure. Complications included a rectal tear in 2 cases, Marlex mesh erosion in 23 (8.4%), vaginal vault abscess in 1, pararectal hematoma in 2 and buttock pain in 2. Anatomical evaluation at followup revealed a 96.7% cure rate for apical defects and a 26.8% incidence of cystocele. We observed improvement in filling, voiding and post-void symptoms. Quality of life evaluation showed improvement in all domains. We detected a 9.6% incidence of de novo dyspareunia. CONCLUSIONS High levator myorrhaphy is a safe and effective procedure for preventing and curing vaginal apical defects. The simplicity of this surgical procedure, its short learning curve, the lack of severe complications and its low costs combined with symptomatic relief and improvement in quality of life encourage its use for the cure and routine prevention of vaginal apical prolapse.

Long-term follow-up (5-20 years) after uterine ventrosuspension for chronic pelvic pain and deep dyspareunia.

Objective: To examine the long-term outcome of patients undergoing uterine ventrosuspension for chronic pelvic pain and deep dyspareunia. Methods: Eighty-two patients, presenting with retroverted uterus, pelvic pain and deep dyspareunia, underwent uterine ventrosuspension by laparotomy or laparoscopy during the period from 1981 to 1996. Only patients (56) with no pelvic pathologic condition, as identified intraoperatively, participated in the study. At the beginning of the year 2002, 41 out of 56 patients (73.2%) were attained by telephonic questionnaire, and they were asked to refer to the uterine ventrosuspension procedure. Results: Patients’ average age was 32.3 years, and the mean duration of preoperative symptoms was 3 years. The mean follow-up period was 12 (range 5–20) years. The initial improvement in preoperative symptoms was observed in 70.7% of patients, whereas the final improvement was observed in 46.3% of patients, with no significant difference comparing the approach of laparotomy versus laparoscopy. Hysterectomy after uterine suspension was performed in 12.1% of patients (4.3% after laparotomy and 22.2% after laparoscopy). Twenty-three patients (56.1%) would recommend this operative procedure to others. Conclusion: The long-term outcome of patients undergoing uterine ventrosuspesnion approximates to 50% success rate, with no significant difference comparing the approach of laparotomy versus laparoscopy.

Pain during Female Urethral Catheterization: Intraurethral Lubricant Injection versus Catheter Tip Lubrication—A Prospective Randomized Trial

PURPOSE Urethral lubrication during catheterization can be performed by instilling the gel directly in the urethra or by pouring the gel on the catheter tip. In this study we compared the pain level associated with each technique during female urethral catheterization in the setup of a multichannel urodynamic study. MATERIALS AND METHODS A total of 94 women with a mean ± SD age of 55 ± 14 years who were referred for a multichannel urodynamic study were prospectively randomized into 2 groups according to lubrication technique, including 1) instillation of 5 ml 2% lidocaine gel in the urethra 5 minutes before catheterization or 2) lubrication of the distal part of the catheter with 5 ml 2% lidocaine gel. A visual analog pain scale of 0 to 10 was completed at different time points, including prior to gel instillation (baseline), during gel instillation (group 1), during catheterization, and 5 and 30 minutes after the procedure ended. RESULTS The study groups did not differ in demographic, clinical or urodynamic parameters. The mean visual analog scale score during catheterization was 2.3 ± 1.4 and 2.4 ± 1.6 in groups 1 and 2, respectively (p = 0.71). There was no difference in the reported visual analog scale score at the other checkpoints. The mean recorded visual analog scale score during instillation of the lubricant in the urethra in group 1 was 1.9 ± 0.9. CONCLUSIONS The actual act of lubricant instillation in the urethra during catheterization in women causes additional and unnecessary pain. Therefore, it is not recommended. Other than that there is no difference in the urethral pain level between the 2 lubrication techniques.

Management of Associated Pelvic Dysfunctions: External Rectal Prolapse and Genital Prolapse

Genital prolapse, or pelvic organ prolapse (POP), is an emerging problem among women over the age of 65 and is a common disorder in Western countries [1]. Besides age, well-established risk factors include race, genetic predisposition, pregnancy, parity, obstetric trauma, menopause and previous gynaecological surgery. Among these variables, Caucasian women have a higher odds ratio (1.0) than do African Americans (0.6) [2].