Charles A. Ballard

Predicting postoperative urinary incontinence development in women undergoing operation for genitourinary prolapse

A total of 67 female patients with pelvic relaxation (cystocele beyond the vaginal orifice) and with no urinary incontinence were clinically and urodynamically evaluated before and after a reconstructive surgical procedure. Of these, 24 patients had a significant decrease in abdominal pressure transmission to the urethra once the cystocele was reduced by vaginal pessary (abdominal pressure transmission ratio to urethra: bladder of less than 1.0). All 24 had a revised Pereyra procedure in addition to the cystocele repair. The other 43 patients had adequate abdominal pressure transmission to the urethra once the cystocele was reduced by vaginal pessary (abdominal pressure transmission ratio to urethra: bladder of greater than or equal to 1.0). These 43 patients underwent cystocele repair only with no surgical repair to the urethra or urethrovesical junction. Evaluation was repeated at 3 to 6 months after the operation. No patient developed urinary incontinence after operation. All 67 patients had urodynamically good abdominal pressure transmission to the urethra while coughing. Women with significant genitourinary prolapse may be continent in spite of a weak urethral sphincter because of kinking of the poorly supported urethra. Urodynamic testing can identify those women at risk of developing postoperative urinary incontinence so that prophylactic measures can be undertaken.

Comparison of three different surgical procedures for genuine stress incontinence: Prospective randomized study

One hundred seven consecutive patients with clinical and urodynamic findings of genuine stress incontinence not previously treated were prospectively allocated in a randomized manner to one of three surgical procedures: anterior colporrhaphy, revised Pereyra procedure, or Burch retropubic urethropexy. Randomization included the surgical procedure and choice of surgeon (one of the three authors). Clinical and urodynamic evaluations were repeated at 3 months and 1 year after surgery. Differences in cure rates among the three procedures at the 3-month postoperative evaluation were insignificant (82%, 84%, and 92% for the anterior colporrhaphy, Pereyra, and Burch respectively) but became statistically significant at the 1 year postoperative evaluation (cure rates of 65%, 72%, and 91% for the anterior colporrhaphy, Pereyra, and Burch respectively, p less than 0.05). In our hands the Burch procedure stabilized the urethrovesical junction and prevented its descent during straining (evaluated by a postoperative Q-tip test) more effectively than either the Pereyra or anterior colporrhaphy. No procedure resulted in severe postoperative voiding difficulties. The present prospective randomized study demonstrates that in our hands the abdominal retropubic operation for genuine stress incontinence in patients not previously operated on results in a higher cure rate when compared with anterior colporrhaphy or Pereyra procedure.

Ovarian tumors associated with pregnancy termination patients

One hundred adnexal masses were discovered at the time of pregnancy termination among a total of 55,278 pregnancy terminations performed at the Los Angeles County/University of Southern California Medical Center between 1970 and 1982. Seven patients were found to be not pregnant, and 93 masses were associated with pregnancy, for an incidence of one adnexal mass for every 594 (0.17%) terminations. Benign cystic teratoma was the most common lesion found (46;50%). There were two (2.2%) ovarian malignancies, 15 masses were bilateral, 11 masses were associated with pain, and torsion of the adnexa had occurred in seven cases. The preoperative diagnosis was made more commonly in the first trimester (86%) than in the second trimester (29%). Since many ovarian tumors are small, the true incidence is unknown. In a series of 998 abortion hysterectomies, 13 ovarian tumors were found, for an incidence of 1.3%.

Cervicovaginal fistula: An apparent increased incidence with prostaglandin F2α

A rare but difficult to treat complication of midtrimester abortion is cervicovaginal fistula. It has been reported as a consequence of criminal, spontaneous, and induced abortions with either laminaria, Hegar dilatation, puncture of the ovum, or by injection of soap. This condition was recently reported as a consequence of intraamniotic hypertonic saline or prostaglandin (PG) instillation. At the Womens Hospital in Los Angeles, 5291 midtrimester abortions with intraamniotic instillation of hypertonic saline had been performed since the advent of elective abortion. There were 4 cases of central cervical rupture (cervicovaginal fistula) for a net incidence of 1:1000. 3 out of 373 intraamniotic PGF2alpha-treated patients developed cervical fistula for an incidence 10 times higher than saline abortion. Other studies confirm this finding. If all such studies are combined, the net incidence is 9 in 678 cases or 1.3%. High risk patients include those who are pregnant for the 1st time, are less than 21 years old, and are treated with hypertonic saline augmented by oxytocin. The fistula may occur with intraamniotic PGF2alpha alone, but the incidence is greater in patients receiving PGs and oxytocin together. A recurring feature is a moderate to severe cramping pain without cervical response even before oxytocin is started. The use of mechanical dilatation of the cervix with the introduction of either laminaria tents or Foley catheters is suggested for primigravid patients receiving hypertonic saline and intravenous oxytocin augmentation. If cervical spasm is the mechanism of action of PGF2alpha, initial insertion of laminaria should be considered with all primigravid patients. Further study of a larger series should be done to elucidate the role of PGs in the development of cervicovaginal fistula. 7 case reports are presented.

Termination of early gestation with vaginal prostaglandin F2α tablets

The abortifacient activity of prostaglandin F2α was investigated by placing one or two 50 mg tablets of prostaglandin F2α in THAM salt into the vagina of nine women less than 4 weeks pregnant at intervals of 2 to 4 hours for a 24 hour period. Serum levels of HCG, estradiol (E2), progesterone and 17α-hydroxyprogesterone were measured by radioimmunoassay prior to starting therapy and at frequent intervals thereafter for 48 hours. All but two patients had significant side-effects, mainly diarrhea and vomiting, indicating that systemic absorption took place. Although bleeding was induced in 8 of 9 women, only 3 had complete abortions. A D&C was performed on all patients 48 hours after starting therapy. A significant fall in HCG levels was noted only in the patients who aborted. Only 3 of the 9 women had significant changes in steroid levels. A fall in progesterone and 17α-hydroxyprogesterone occurred in the 3 women who aborted and took place following the fall in HCG. Estradiol levels remained in the same range in all subjects. These findings indicate that prostaglandin F2α when administered in this vehicle and this dosage is relatively ineffective as an abortifacient. When effective, its action would appear to be due to contractions of uterine muscle and not secondarily to luteolysis.

Proposed Management of Low Urethral Pressure Type of Genuine Stress Urinary Incontinence

One hundred and twenty-one patients with genuine stress urinary incontinence underwent urodynamic examination before and after Burch colposuspension. They were divided into two groups, one with preoperative urethral pressure of 20 cm water or less (n = 17), and the other with urethral pressure greater than 20 cm water (n = 104). Success rates at 12 months were significantly lower in women with low urethral pressure as compared with those with normal urethral pressure (65 vs. 88%; p less than 0.01). Starting in January 1987, all patients with low urethral pressure preoperatively underwent a surgical procedure which combined the techniques of the Ball and Burch procedures. Short-term cure rate (at 3 months postoperative follow-up) in women with low urethral pressure was 83% as opposed to 70% with the Burch urethropexy (p less than 0.05).

Preservation of ovarian tissue in adnexal torsion with fluorescein

OBJECTIVE Our purpose was to assess the ability of fluorescein to intraoperatively detect viable fallopian and ovarian tissues involved in adnexal torsion. STUDY DESIGN This prospective study was performed at Los Angeles County+University of Southern California Womens Hospital. Participants were female patients 18 to 45 years old with adnexal torsion confirmed at exploratory celiotomy. Five milliliters of 10% fluorescein were injected intravenously, and the involved untwisted adnexa was observed under ultraviolet light. Nonfluorescent tissue was resected and histologically evaluated. RESULTS Eleven patients were entered into the study. Mean age was 25 years (range 15 to 42). Eight patients (72%) had preservation of involved ovarian tissue. No complications were associated with this procedure. Only three patients (28%) underwent oophorectomy. CONCLUSION The use of intravenous fluorescein appears to be a valuable adjunct in the management of adnexal torsion. Application of this technique in reproductive-aged patients resulted in a three-quarter reduction in oophorectomy procedures.

Early secondary repair of third- and fourth-degree perineal lacerations after outpatient wound preparation

Research has shown the feasibility of early secondary repair of third- and fourth-degree perineal laceration dehiscence after a short period of inpatient wound preparation; therefore, we evaluated the feasibility of early closure after outpatient wound preparation. In this case series, 23 patients underwent early repair of third- or fourth-degree perineal laceration after outpatient wound preparation. Twenty-one patients (91%) had a fourth-degree dehiscence, whereas two (9%) had a third-degree dehiscence. We repaired the defects after 4-10 days (mean 7) of outpatient debridement and wound preparation. All repairs were successful (95% confidence interval 85-100%), and no subsequent breakdowns occurred. One patient developed a small rectal-perineal fistula which, after irrigation, closed spontaneously within 3 months. Early repair of third- or fourth-degree dehiscence after outpatient wound debridement and preparation is both practical and effective. Forcing patients to wait the traditional 3-4 months before repairing such defects may be both cruel and unnecessary.

Midtrimester abortion with intramuscular injection of 15-methyl-prostaglandin E2

Abstract An intramuscular injection of 250 μ g of 15-methyl-PGF 2α was given to fifty patients every two hours until the fetus was expelled or for a maximum of twelve injections. Within 27 hours, 90% aborted with a mean injection-abortion time of 13.5 hours. All patients received prophylactic antiemetic and antidiarrheal medication. The side effects consisted of vomiting in 33 patients, diarrhea in 38 patients, flushing in 6 patients, and chills in 2 patients. Three patients had a blood loss ≥ 500 ml but did not require a blood transfusion. The intramuscular route offers the early midtrimester patient an effective and rapid means of abortion.

Successful extraction of cardiac-extending intravenous leiomyomatosis through gonadal vein

OBJECTIVE To report a conservative surgical management of cardiac-extending intravenous (IV) leiomyomatosis. DESIGN Case report. SETTING Tertiary care center. PATIENT(S) A 40-year-old nulligravid with incidentally identified IV leiomyomatosis arising from the right gonadal vein and extending into the right atrium. INTERVENTION(S) First, intraoperative transesophageal echocardiogram was performed that demonstrated the IV leiomyomatosis stalk to be 1.1 cm in diameter without an enlarged tip or adherence to the vessel lumen. Next, the 20-week-size uterus was gently pulled caudally under live visualization of the IV leiomyomatosis tip with transesophageal echocardiogram. As the uterus was pulled caudally, the IV leiomyomatosis tip obviously protruded from the right atrium and down into inferior vena cava. Lastly, the gonadal vein was incised longitudinally and the stalk of the tumor was grasped and extracted through the incision. MAIN OUTCOME MEASURE(S) One-step abdominal surgery for complete tumor resection without sternotomy or cardiac bypass surgery. RESULT(S) To our knowledge, this is the first reported case of a cardiac-extending IV leiomyomatosis successfully extracted through the gonadal vein. CONCLUSION(S) In a selected case with logistic step-by-step approach, conservative surgical treatment via gonadal vein extraction could be a feasible option in the management of cardiac-extending IV leiomyomatosis. Systematic literature review highlights important clinical characteristics and management options for IV leiomyomatosis.