Dieter Kölle

Tension-free vaginal tape operation: results of the Austrian registry.

OBJECTIVE To assess the use of and perioperative complications associated with the tension‐free vaginal tape operation with a central registry. METHODS Fifty‐five gynecology units completed questionnaires on patients undergoing the tension‐free vaginal tape operation. Information was collected on patient, surgical, and postoperative data. RESULTS A total of 2795 patients were entered. Overall, 773 patients (28%) had undergone previous surgery for incontinence or prolapse; 1640 (59%) tension‐free vaginal tapes were performed as isolated operations, and 1155 (41%) were done in combination with other procedures. The median operating time for tension‐free vaginal tapes alone was 30 minutes (range 10–120). Of the isolated tension‐free vaginal tapes, 727 (44%) were performed with local, 711 (43%) with regional, and 193 (12%) with general anesthesia. In patients undergoing tension‐free vaginal tape only, postoperative bladder drainage was obtained with intermittent catheterization in 389 (24%) patients, an indwelling urethral catheter in 1032 (63%), and a suprapubic catheter in 143 (9%). The bladder perforation rate was 2.7% overall (n = 75) and higher in patients with than in those without previous surgery (4.4% compared with 2.0%, P = .01). There were four bladder perforations (3.3%) among the 120 patients with previous colposuspension. Most patients undergoing tension‐free vaginal tape only were able to void the next day (range 0 to over 64). A total of 68 patients (2.4%) required reoperation for reasons related to the tape (39 to loosen, remove, or cut the tape, or to place a suprapubic catheter, 19 for hematoma, one for bowel injury). CONCLUSION The tension‐free vaginal tape has become a frequently performed operation in Austria. There are considerable variations in clinical practice. The risk of bladder perforation was increased in patients with previous surgery. Severe complications were rare.

Restoration of voluntary emptying of the bladder by transplantation of innervated free skeletal muscle.

BACKGROUND On the basis of studies with animals and experience with functioning muscle transfer in plastic surgery, we have developed a surgical technique to restore detrusor function for patients with bladder acontractility in whom there is no treatment alternative. METHODS Three patients (aged 26 years, 28 years, and 68 years) with bladder acontractility as a result of spinal-cord injury (two patients) and chronic overdistension (one patient), who required catheterisation for bladder emptying for 5 years, 2 years, and 2 years, respectively, took part in our study. The patients were treated with microneurovascular free transfer of autologous latissimus dorsi muscle to the bladder to restore detrusor function. Follow-up included clinical and urodynamic evaluation, colour doppler sonography, intravenous urography, and flow-mode computerised tomography. FINDINGS The three patients voluntarily emptied their bladders at 16 weeks, 16 weeks, and 30 weeks after surgery, respectively. There was no need for further catheterisation throughout the follow-up period. On urodynamic assessment at 12 months after the operation bladder capacity was found to be 600 mL, 600 mL, and 650 mL, residual urinary volume 0 mL, 50 mL, 90 mL, and maximum flow rate 26 mL/s, 25 mL/s, and 18 mL/s, respectively. Activity at the transplanted latissimus dorsi was confirmed by ultrasonography and flow-mode computerised tomography. INTERPRETATION Microneurovascular free transfer of latissimus dorsi muscle to functionally restore a deficient detrusor muscle has proved to be successful for the three patients in our study. This technique may also be an option to restore the function of other smooth-muscle organs.

Age-Related Rhabdosphincter Function in Female Urinary Stress Incontinence Assessment of Intraurethral Sonography

Objective. To assess dynamic intraurethral sonography in the diagnostic evaluation of the function of the rhabdosphincter in female patients with urinary stress incontinence in relation to patient age. Methods. Sixty‐two patients with clinically proved urinary stress incontinence were investigated by means of intraurethral sonography with a 12.5‐MHz endoluminal 9F catheter. The omega‐shaped rhabdosphincter was visualized at rest and during voluntary contractions. Changes of muscle thickness and transducer‐sphincter distance were measured and considered as parameters of muscle function. The intraurethral sonographic data were compared with results of standard urodynamic tests. Results. Transducer‐sphincter distance and sphincter muscle thickness showed a significant decrease with positive linear dependency on patient age (P < .001). Patients with grade III urinary stress incontinence had complete loss of sphincter contractility. A negative correlation was revealed between urethral closure pressure and patient age. Conclusions. We found an age‐related decrease in rhabdosphincter function. Our results suggest that the rhabdosphincter is a substantial component of the continence mechanism in female urinary stress incontinence. Unlike urethral pressure profiles, which can only reveal zones of higher intraluminal pressure, transurethral sonography is highly specific for measurement of the function of the rhabdosphincter.

Early diagnosis of tubal pregnancy : changes in tubal blood flow evaluated by endovaginal color Doppler sonography

Objective: To improve the accuracy and speed of diagnosis of an ectopic tubal pregnancy by means of blood flow analysis in the tubal arteries. We hypothesized that invasion of the trophoblast increases blood flow in the tubal artery involved in ectopic pregnancy. Methods: In 394 patients, using an endovaginal triplex color Doppler ultrasonography system, we performed qualitative blood flow analysis in the tubal arteries on both sides. The percentage of the between‐side difference in tubal blood flow was calculated. Results: There was an increase in tubal blood flow on the ectopic pregnancy side, and the mean between‐side difference in tubal blood flow was 20.45% in the ectopic pregnancy group. In the control groups, the between‐side difference was 2.95% (t = 21.5, P < .00001). Using a cutoff point of 8% for the percentage of the between‐side difference in tubal blood flow, the method had a sensitivity of 85% and a specificity of 96% for diagnosing an ectopic pregnancy. The percentage of the between‐side difference in tubal blood flow was independent of gestational age (Pearson correlation coefficient 0.081). Conclusion: The advantages of this new method for diagnosing tubal pregnancy are early detection, noninvasivity, and immediate results. (Obstet Gynecol 1993;82:561‐5)

Adhesion of dendritic cells derived from CD34+ progenitors to resting human dermal microvascular endothelial cells is down-regulated upon maturation and partially depends on CD11a-CD18, CD11b-CD18 and CD36.

DC are sentinels of the immune system. In order to reach the skin, bone‐marrow‐derived DC precursors need to bind and migrate through microvascular endothelial cells. Binding of DC toprimary endothelial cells of the skin has not been investigated. We therefore determined adhesion of DC at different stages of development to human dermal microvascular endothelial cells (HDMEC). DC were derived from CD34+ progenitors in cord blood. To enhance DC maturation, a defined cocktail of IL‐1β+IL‐6+TNF‐α+PGE2 was applied. Adhesion was quantified by fluorimetric and phase‐contrast microscopical assays. Significantly more DC precursors (tested on day 5 after isolation) than mature DC (spontaneously matured or cytokine‐cocktail‐matured and tested on day 13) bound to unstimulated HDMEC. In contrast, the maturation stage of DC had no influence on their binding to human umbilical vein endothelial cells. Pretreatment of HDMEC with TNF‐α and IFN‐γ resulted in an enhanced attachment of both DC precursors and mature DC. Mature DC lacked expression of CD31, CD36, CD45RA and CLA, and expressed lower levels of CD11a, CD11b and CD49d as compared with precursors tested on day 5. mAb against CD18, CD11a, CD11b, and CD36 markedly inhibited DC binding, whereas anti‐CLA, anti‐DC‐SIGN, anti‐CD29 and anti‐CD49 mAb did not. Our data support the hypothesis of immunosurveillance with selective recruitment of blood DC precursors to resting and, more so, to inflamed skin. The data have potential relevance for anti‐cancer immunotherapy strategies favoring the intracutaneous application of mature DC.

Virtual reality of the lower urinary tract in women.

Abstract: Advances in computerized and imaging technology permit both students and doctors to depict the anatomy of the human pelvis more realistically than with previous methods. Further refinements outline fine pelvic structures, such as the nerve plexus, which may as a result be spared during major pelvic surgery, thus preserving the function of the bladder neck and urethra. Dynamic computerized tomography or magnetic resonance imaging, coupled with three-dimensional depiction of the lower urinary tract and its adjacent structures, enable visualization of the whole lower urinary tract and the pelvic floor musculature in both continent and incontinent women. In patients with a reconstructed lower urinary tract computer-assisted image processing shows the postoperatively altered topographical anatomy. This may be clinically useful for interpretation of unexpected findings with conventional imaging modalities, postoperative morbidity, and surgical planning of a lower abdominal reoperation. Examples of our own work regarding the innervation of female pelvic organs, dynamic depiction of the bladder and pelvic floor musculature during straining in normal and incontinent women, and the situation of female patients after undergoing an anterior pelvic exenteration with subsequent orthotopic neobladder procedure, are given. In addition, the data of these patients have been compiled for virtual reality endoscopy, which is useful for patient consent and for teaching residents, students and nurses.

Die gynäkologische Befund erstellung und Begutachtung bei Verdacht auf sexuellen Missbrauch

Die kindergynakologische Begutachtung im Rahmen der Begutachtung des Vorliegens oder Nichtvorliegens eines Missbrauchs an Madchen ist eine extrem schwierige Aufgabe mit weitreichenden Konsequenzen. Checklisten und Untersuchungskits nehmen die organisatorische Spannung, verhindern das »Vergessen« von Untersuchungsteilen und ermoglichen ein einfuhlsames Vorgehen. Es sollte darauf Bedacht genommen werden, moglichst bei der Erstuntersuchung fur das Gericht verwertbare Asservate zu gewinnen und dem Kind eine Zweituntersuchung zu ersparen. Daher empfiehlt es sich auch, fur forensische Fragestellungen im kindergynakologischen Bereich die Erstbeurteilung durch moglichst erfahrene Kollegen durchfuhren zu lassen. Grundsatzlich gilt aber, dass ein unauffalliger Befund trotzdem einen Missbrauch niemals zur Ganze ausschliesen kann, da ja von der Beruhrung bis zur gewaltsamen Penetration eine grose Bandbreite an denkbaren (und undenkbaren) zugrundeliegenden Szenarien vorhanden sein konnen.