Brett J. Vassallo

Complications and untoward effects of the tension-free vaginal tape procedure.

OBJECTIVE To report our experience with our first 350 cases of tension-free vaginal tape (TVT), specifically assessing intraoperative complications, postoperative morbidity, and untoward effects of the procedure. METHODS Although increased numbers of reports have documented the efficacy of the TVT procedure, there are minimal data about the incidence of complications and how they are managed. We performed a retrospective review of all patients undergoing the TVT procedure over a 4-year period to report intraoperative complications (bladder perforation and excessive bleeding), postoperative complications (de novo urge incontinence, voiding dysfunction, erosion, nerve injury, urinary retention, hematoma formation), and incidence of reoperation either for voiding dysfunction or for recurrent incontinence. RESULTS A total of 350 patients were included in the study. Fifty-five percent (194) of women underwent the TVT procedure in conjunction with other vaginal surgery, and 45% (156) underwent the TVT alone. Seventy women (20%) had previous antiincontinence surgery. Intraoperative complications included 19 bladder perforations in 17 patients (4.9%) and three cases of significant bleeding (0.9%). Postoperatively, 17 women (4.9%) had voiding dysfunction and 42 (12%) required anticholinergic therapy beyond 6 weeks. Recurrent urinary tract infections developed in 38 (10.9%), erosion or poor healing in three (0.9%), hematoma in six (1.7%), and nerve injury in three (0.9%). Twenty-eight (8%) underwent urethral dilation in the postoperative period for varied amounts of voiding dysfunction. Of these, 82% were either improved or were cured. Six women (1.7%) underwent a takedown of the TVT procedure for continued voiding dysfunction, and two of these (33%) developed recurrent stress incontinence. To date, two patients (0.5%) have undergone another procedure for recurrent or persistent stress incontinence. CONCLUSION The TVT procedure is efficacious for the correction of stress incontinence. Our data show that it is a safe procedure with an acceptable complication rate when performed by surgeons who have experience with retropubic and transvaginal antiincontinence procedures.

Prevalence of persistent and de novo overactive bladder symptoms after the tension-free vaginal tape

OBJECTIVE: The purpose of this study was to assess 1) the proportion of de novo urge incontinence and overactive bladder symptoms after a tension-free vaginal tape (TVT), and 2) the natural history of preoperative urge incontinence and overactive bladder symptoms after a TVT. METHODS: A chart review was performed on all patients who underwent a TVT without concomitant procedures from November 1998 to November 2002. Preoperative and postoperative stress and mixed urinary incontinence symptoms as well as overactive bladder symptoms were assessed subjectively, as was the use of anticholinergics to treat overactive bladder symptoms. Two preoperative and postoperative validated quality-of-life questionnaires, the Incontinence Impact Questionnaire (IIQ-7) and Urinary Distress Inventory (UDI-6), were also compared. RESULTS: Ninety-eight patients were included in the study. Postoperatively, de novo urge incontinence symptoms developed in 9.1%, de novo overactive bladder symptoms developed in 4.3%, and 8.7% started taking anticholinergics for the first time. After a TVT, the urge component resolved in 63.1% of those with preoperative symptoms of mixed incontinence, overactive bladder symptoms resolved in 57.3% of those with preoperative overactive bladder symptoms, and 57.7% of those who used anticholinergics preoperatively no longer needed to do so. There was also a statistically significant improvement in comparing the preoperative and postoperative IIQ-7 and UDI-6 scores. CONCLUSION: The proportion of patients in whom de novo overactive bladder or urge incontinence symptoms developed postoperatively is low, and approximately 57% of patients with preoperative overactive bladder symptoms can expect resolution of these symptoms after a TVT.

Urethral erosion of a tension-free vaginal tape.

BACKGROUND Urethral dilation has been recommended to treat voiding dysfunction that may occur after placement of tension-free vaginal tape (TVT) for the treatment of stress urinary incontinence. We report on a case of urethral erosion by the tape secondary to repetitive urethral dilations after surgery. CASE A urethral erosion by the tape was diagnosed by cystoscopy after three urethral dilations failed to resolve postoperative voiding dysfunction 8 weeks after the initial procedure. A partial tape revision with repair of the urethrotomy was performed, with resolution of the subjects voiding dysfunction. CONCLUSION This report describes a potential complication of a recommended treatment for voiding dysfunction after placement of TVT.

The ability of history and a negative cough stress test to detect occult stress incontinence in patients undergoing surgical repair of advanced pelvic organ prolapse

To determine if a negative preoperative reduction cough stress test is a viable method of detecting occult stress incontinence or urge incontinence in women undergoing surgical repair of advanced pelvic organ prolapse. A retrospective chart review was done on all patients who denied any urinary complaints and had repair of advanced pelvic organ prolapse, grade two or greater, without the addition of an anti-incontinence procedure. Additionally patients had a simple office filling study done at the time of initial examination that failed to show the sign of stress incontinence or detrusor instability. Any urinary dysfunction that developed postoperatively was noted. A total of 53 patients met the inclusion criteria. Of these patients, one patient (1.9%) developed genuine stress incontinence, and one patient complained of urgency (1.9%). Patients without urinary complaints and a negative office filling study, who were present for surgical correction of advanced pelvic organ prolapse, have a low incidence of developing occult stress incontinence. Further work-up would not be cost effective.

The efficacy of the tension-free vaginal tape in the treatment of five subtypes of stress urinary incontinence

Purpose: To determine the efficacy of tension-free vaginal tape (TVT) for the treatment of five sub-types of stress urinary incontinence (SUI).Materials and methods: A retrospective review was performed from November 1998 to November 2001 on all patients with SUI who underwent a TVT procedure either alone or with other reconstructive pelvic procedures. The patients were subdivided into five categories. Intrinsic sphincter deficiency (ISD) was defined by a maximum urethral closure pressure <20 cm H2O or a mean Valsalva leak point pressure <60 cm H2O above baseline. Urethral hypermobility (UH) was defined by a straining Q-tip angle greater than 30° from the horizontal. Cure was defined as the subjective resolution of SUI without the development of voiding dysfunction or de novo urge incontinence. Improvement was defined as the subjective improvement of SUI without complete resolution or the subjective resolution of SUI occurring with the development of prolonged voiding dysfunction lasting greater than 6 weeks or de novo urge incontinence. Failure was defined as the subjective lack of improvement of SUI, the need for an additional procedure to correct SUI or the need for revision or takedown of the TVT for persistent voiding dysfunction or mesh erosion.Results: The cure, improvement and failure rates for each of the following groups are respectively as follows: group 1 (+UH, -ISD) (n=121): 101 (83.5%), 13 (10.7%), 7 (5.8%); group 2 (-UH, +ISD) (n=22): 17 (77.3%), 3 (13.6%), 2 (9.1%); group 3 (+UH, +ISD) (n=32): 26 (81.3%), 4 (12.5%), 2 (6.2%); group 4 (-UH, -ISD) (n=25): 21 (84.0%), 3 (12.0%), 1 (4.0%); group 5 (occult SUI) (n=67): 57 (85.1%), 10 (14.9%), 0 (0%).Conclusion: This study shows that the TVT is effective in treating all five sub-types of SUI.

Paravaginal defects: prevalence and accuracy of preoperative detection

The objective of this study was to determine the prevalence of paravaginal defects and to report the correlation between diagnosing a paravaginal defect preoperatively and observing the presence of one intraoperatively. This was a prospective study in which 77 patients with at least stage 2 prolapse of the anterior vaginal wall who desired surgical correction of their prolapse were assessed pre- and intraoperatively for the detection of a paravaginal defect. In order to differentiate a midline or central defect from a paravaginal defect, an index finger or ring forceps was placed vaginally toward each ischial spine separately. If the prolapse became reduced, the patient was clinically diagnosed with a paravaginal defect on that side. The intraoperative visualization or palpation of the pubocervical fascia detached from the arcus tendineus fasciae pelvis was used as the gold standard in diagnosing a paravaginal defect. The overall prevalence of a paravaginal defect in patients with at least stage 2 prolapse of the anterior vaginal wall was 37.7%. The sensitivities for detecting a left, right and bilateral paravaginal defect were 47.6, 40.0 and 23.5%, respectively, while the specificities for each side were 71.4, 67.3, and 80.0%, respectively. The overall prevalence of a paravaginal defect in patients with anterior vaginal wall prolapse is low. The standard clinical evaluation used to preoperatively detect a paravaginal defect in our hands is a poor predictor for the actual presence of a paravaginal defect.

Pelvic floor muscle function in women presenting with pelvic floor disorders

Introduction and hypothesisThis observational study was undertaken to determine knowledge, prior instruction, frequency of performance, and ability to perform pelvic floor muscle exercises in a group of women presenting for evaluation of pelvic floor disorders.MethodsThree hundred twenty-five women presenting for evaluation of pelvic floor disorders were questioned concerning knowledge and performance of pelvic floor muscle exercises (PMEs) and then examined to determine pelvic floor muscle contraction strength.ResultsThe majority of women (73%) had heard of PMEs, but only 42% had been instructed to perform them and 62.5% stated they received verbal instruction only. Only 23.4% of patients could perform pelvic muscle contractions with Oxford Scale 3, 4, or 5 strengths. Increased age, parity, and stage of prolapse were associated with lower Oxford scores.ConclusionsAlthough most women with pelvic floor disorders are familiar with PMEs, less than one fourth could perform adequate contractions at the time of initial evaluation.

Management of iatrogenic vaginal constriction.

OBJECTIVE To prospectively assess the outcomes of four approaches to the surgical management of iatrogenic vaginal constriction. METHODS A prospective study was initiated to evaluate all women who presented to our practice with the complaint of apareunia or dyspareunia secondary to postoperative vaginal constriction. All participants were initially offered and failed a trial of manual dilation. Between 1997 and 2002, 20 women underwent one of four surgical procedures: Z-plasty, vaginal incision of constriction ring, vaginal advancement, or placement of free skin graft. All 20 participants have been followed postoperatively, including assessment of dyspareunia and postoperative vaginal length and caliber. RESULTS Three patients underwent Z-plasty, eight had incision of vaginal ring or ridge, eight had vaginal advancement, and one underwent placement of a free skin graft. Mean follow-up was 17 months (range, 3–32 months). Subjective cure was defined as resumption of pain-free vaginal intercourse. Objective cure was defined by findings on physical examination. The overall subjective and objective cure rates were 75% and 85%, respectively. CONCLUSION The appropriate surgical procedure depends on the site and extent of the vaginal constriction, the state of the surrounding tissue, and the overall length and caliber of the vagina.

Anterior colporrhaphy: why surgeon performance is paramount

Anterior compartment repair is one of the most challenging issues in reconstructive pelvic surgery. Previous studies using strict anatomic criteria suggested a high failure rate after anterior colporrhaphy, prompting increased use of augmented repairs in the past decade. More recent studies suggest anterior colporrhaphy may provide symptom relief similar to that seen with augmented repairs without the risks associated with placement of mesh. There is a wide range of success rates for anterior colporrhaphy in the literature. The wide variation implies surgeon performance is a key issue in the success or failure of anterior compartment repair. It is critical to begin measuring and reporting surgeon performance in research trials and monitoring surgeon performance in clinical practice in order to make meaningful comparisons of surgical techniques and improve patient care.

ORAL PRESENTATION 2: A Randomized Trial Comparing Methods of Vaginal Cuff Closure at Vaginal Hysterectomy and the Effect on Vaginal Length

OBJECTIVE The objective of the study was to compare the effect of horizontal versus vertical closure of the vaginal cuff during vaginal hysterectomy on vaginal length. STUDY DESIGN Forty-three women were randomized to undergo horizontal (n = 23) or vertical (n = 20) vaginal cuff closure during vaginal hysterectomy at a community hospital. The primary outcome of vaginal length before and after surgery was compared by the Student t test and the paired t test. RESULTS Preoperatively mean vaginal lengths in the horizontal and vertical groups were statistically similar (7.76 +/- 1.23 cm versus 8.28 +/- 1.39 cm, respectively; P = .21). Postoperatively the groups statistically differed (6.63 +/- 1.02 cm versus 7.93 +/- 1.18 cm, P < .001). The mean change in vaginal length was -1.13 +/- 1.15 cm and -0.35 +/- 0.91 cm, respectively (P = .01). Within-group comparisons revealed a statistical difference between pre- versus postmean vaginal length in the horizontal group (7.76 +/- 1.23 cm versus 6.63 +/- 1.02 cm; P < .001) and no difference within the vertical group (8.28 +/- 1.39 cm versus 7.93 +/- 1.18 cm; P = .11). CONCLUSION Closing the vaginal cuff vertically is superior to horizontal closure for the purpose of preserving vaginal length.