Bobby L. Shull

A six-year experience with paravaginal defect repair for stress urinary incontinence

One hundred forty-nine consecutive patients who had surgery from May 1890 through December 1986 were evaluated to assess the functional and anatomic results of the paravaginal defect repair for stress urinary incontinence. All patients had their preoperative assessment, operative procedure, and postoperative follow-up managed by the authors. Twelve percent of the patients had one or more previous surgical procedures for urinary incontinence. Sixteen percent of the patients had the preoperative diagnosis of urinary incontinence with mixed components of true stress incontinence and detrusor instability. Postoperatively, 6% of all patients developed evidence of cuff prolapse; 5% had an enterocele. In none of those patients did the defect prolapse to the hymen. Five percent of the patients had postoperative evidence of a persistent cystocele, all of which were smaller than they had been preoperatively. An assessment of the anatomic results of the repair demonstrates that meticulous attention must be paid to the proper repair of the paravesical defect, to support of the vaginal cuff, and to management of the cul-de-sac of Douglas to minimize postoperative anatomic defects. Ninety-seven percent of patients had excellent functional results with no postoperative complaints of stress urinary incontinence.

A serious complication following placement of posterior Prolift.

A 32-year-old female with Crohns disease experienced a rectovaginal fistula and abscess with rectal expulsion of posterior Prolift. She underwent diagnostic laparoscopy, transanal incision and drainage of abscess, transanal excision of mesh, and laparotomy with loop ileostomy. Weeks later, she underwent colectomy, near-total proctectomy, end ileostomy, and fistula repair.

Tension-free vaginal tape bowel perforation

A 73-year-old para 3 white female with posthysterectomy pelvic organ prolapse and stress urinary incontinence underwent pelvic reconstructive surgery and placement of tension-free vaginal tape. On postoperative day 4, she underwent exploratory laparotomy for small bowel obstruction. She was found to have an injury to the small bowel secondary to a through-and-through perforation by tension-free vaginal tape. The entire tape was removed. Partial small bowel resection and primary anastomosis were performed. Her subsequent recovery was uneventful.

A randomized comparison of bupivacaine versus saline during placement of tension-free vaginal tape.

Objectives To compare postoperative urinary retention and pain control when bupivacaine versus saline for hydrodissection is used while placing tension-free vaginal tape midurethral slings. Methods A prospective, randomized, double-blind trial was performed after institutional review board approval. Sixty women were randomized to receive bupivacaine or saline for hydrodissection. Subjects and research team were blinded to subject assignments. Group characteristics were compared using the Student t test, the &khgr;2 test, and the Mann-Whitney U test. Proportions of subjects with a successful postoperative voiding trial along with measurements of postoperative pain and analgesic use were compared using similar appropriate tests. The study was powered to detect differences in voiding trial success from an estimated 58% to greater than 90% with P < 0.05 and 0.8 power using 25 subjects per group. Results Thirty patients were allocated to each group. One subject in the saline-only group was excluded. Group characteristics were not different. After surgery, pain medication use (20/30 vs 25/29 for bupivacaine vs saline only; P = 0.08), pain scores (36 ± 22 vs 31 ± 24; P = 0.49), and successful voiding trials did not differ (14/30 vs 19/29; P = 0.14), whereas postvoid residuals did differ (225 ± 180 mL vs 140 ± 147 mL; P = 0.043). Conclusions Bupivacaine was not seen to improve immediate postoperative pain after placement of a tension-free vaginal tape. It did not increase the risk of failing a postoperative voiding trial. Without an obvious benefit, the use of an additional medicine is not supported. We suggest saline alone be used for hydrodissection.

Lack of preoperative predictors of the immediate return of postoperative bladder emptying after uterosacral ligament suspension.

Objectives To determine whether preoperative postvoid residual volume (PVR), pelvic organ prolapse quantification (POPQ) stage, patient characteristics, or concurrent operations are predictors of immediate postoperative bladder emptying after uterosacral ligament suspension (USLS). Methods A review of patients undergoing USLS in 2008 and 2009 was performed. The factors analyzed included patient age, body mass index, parity, preoperative PVR, POPQ stage, concurrent anterior repair, posterior repair, hysterectomy and/or sling procedures, and postoperative voiding trial status. Results During the study interval, 151 patients underwent USLS with various combinations of concurrent procedures. The mean preoperative PVR was 90 mL. Seventy-five patients (50%) passed the postoperative voiding trial on postoperative day 1. Patients who passed the postoperative voiding trial and those who failed had similar average preoperative PVR (P = 0.94), similar age (P = 0.14), body mass index (P = 0.45), parity (P = 0.82), and preoperative POPQ stage (P = 0.80). There was no difference (P ≥ 0.14) among concurrent surgical procedures in the proportion of patients who passed the postoperative voiding trial based on univariate analyses. Conclusions In our cohort of patients, preoperative PVR, POPQ stage, and other patient characteristics were not predictors of immediate postoperative bladder emptying after USLS. Postoperative voiding function is one of the most unpredictable aspects of pelvic reconstructive surgery.

Does body mass index impact passing voiding trial after midurethral sling procedures for stress urinary incontinence

Objective: To test the hypothesis that body mass index (BMI) is a factor associated with passing a voiding trial after midurethral sling procedures for stress urinary incontinence (SUI). Study Design: The medical records of 136 consecutive patients who underwent placement of either tension-free vaginal tape (TVT) or transobturator tape (TOT) for SUI during a 1-year period (September 1, 2007 to August 31, 2008) were retrospectively reviewed. Variables assessed were BMI, age, and passing or failing a postoperative urinary voiding trial. Patients with concomitant pelvic organ prolapse surgeries were not included in this analysis. Results: Sixty-seven patients underwent TVT, whereas 69 had TOT procedures. In the TVT group, 30 patients (42%) were unable to void immediately postoperatively compared with 11 patients (16%) in the TOT group (P = 0.0003). The mean (SD) age and BMI of patients who failed or passed voiding trials was 58.6 (12.0) years and 28.0 (4.9) kg/m2 or 53.5 (12.3) years and 29.8 (5.7) kg/m2, respectively. Of 38 patients who did not pass a voiding trial on the day of the procedure, 31 (82%) passed on postoperative day 1, and all patients had passed a voiding trial by postoperative day 11. The mean (SD) BMI for 7 patients who did not pass voiding trial by postoperative day 1 was 28.3 (5.2) kg/m2. Conclusions: Women with higher BMIs were more likely to pass voiding trials after midurethral sling procedures. Patients who had TOT placement had greater success passing a postprocedure voiding trial than did patients who had TVT placement.

Evaluation and management of complete vaginal eversion after retropubic urethropexy

The patient is a 56-year-old woman with severe pelvic pressure and vaginal bulging. She had an abdominal hysterectomy and Burch colposuspension 20 years ago. She then had a history of some recurrent stress and urge incontinence; however, over the past 2 years, this has resolved, and she currently has to reduce her prolapse to empty her bladder. Complete vaginal eversion and a palpable enterocele were found on examination [pelvic organ prolapse quantification Stage IV; Aa +2, Ba +7, C +7, gh 5, pb 3, tvl 7, Ap +1, Bp +7; see Fig. 1a (resting) and b (straining)]. She is sexually active, is not interested in a pessary, and desires surgical correction of her prolapse.

Vaginal Pessaries and Their Use in Pelvic Relaxation

To evaluate the therapeutic usefulness of pessaries in patients with pelvic relaxation, a retrospective study was performed identifying 107 patients who had been fitted with a pessary for symptomatic pelvic relaxation. Of this group, 101 returned or were available for follow-up. Ninety-one had at least one pelvic organ protruding to or beyond the hymen. Specific reasons for using the pessary are cited. Group 1 included 19 patients who were thought to be medically unfit for surgery. Twenty-one percent of this group died within one year of their evaluation for pelvic relaxation. Group 2 was composed of 24 patients who chose to use the pessary only temporarily while awaiting a suitable time for surgery. Group 3 consisted of 58 patients who were offered the option of definitive surgical repair but initially declined. Fifty of the 101 patients have continued to use the pessary. Twenty-six had repairs, and four have died. Only 21 patients have discontinued the pessary, had no surgical repair and thus continue without treatment of their pelvic relaxation. No major complications were associated with use of the pessary.