Dominic Lee

Transvaginal Mesh Kits—How “Serious” Are the Complications and Are They Reversible?

OBJECTIVE To review the merit of the U.S. Food and Drug Administration-issued warnings on the use of transvaginal mesh in women with pelvic organ prolapse because of escalating complications. MATERIALS AND METHODS On institutional review board approval, we reviewed the data from 2 tertiary institutions managing complications of transvaginal mesh. The data recorded included mesh type, details of surgical removal, and patient-reported clinical outcomes. RESULTS From 2006 to March 2011, 58 women were evaluated. Their mean age was 54.6 years (range 32-80), with a mean follow-up of 13 months (range 6-67). The mean interval to mesh excision surgery from the original prolapse surgery was 21 months (range 2-60). Of the 58 women, 35 (60%) had undergone concurrent midurethral sling surgery with the transvaginal mesh surgery. Also, 21 of the 58 patients (36%) had undergone initial mesh removal attempts before their referral to either tertiary institution. Most women presented with multiple complaints, with mesh extrusion the most frequently reported (n=43 [74%]). Of the 58 women, 17 (29%) required re-excision of residual mesh, 13 once and 4 twice. Five women developed recurrent symptomatic pelvic organ prolapse (7%). The residual rate of dyspareunia and pelvic pain was 14% and 22%, respectively. Fourteen women (24%) were treated successfully, with complete resolution of all presenting symptoms. CONCLUSION As outlined in the Food and Drug Administration notifications, patients should be forewarned that some transvaginal mesh complications are life altering and might not always be surgically correctable.

Suprapubic stab cystostomy: a safer technique

Suprapubic catheters have gained wide acceptance in urology. Although many regard their insertion a simple procedure, morbidity is significant and is probably underreported. We describe a percutaneous technique using intraoperative ultrasonography combined with flexible cystoscopy to ensure safe insertion, minimizing the risk to adjacent viscera.

Meshology: a fast-growing field involving mesh and/or tape removal procedures and their outcomes

Stress urinary incontinence and pelvic organ prolapse are two of the commonest conditions affecting women today. It is associated with significant compromise to quality of life. Through the years, there has been an evolution of technique and graft material to augment repairs for durability. Transvaginal placements of synthetic mid-urethral slings and vaginal meshes have largely superseded traditional tissue repairs in the current era because of presumed efficacy and ease of implant with device ‘kits’. The use of synthetic material has generated novel complications, including mesh extrusion, pelvic and vaginal pain and mesh contraction. In this review, our aim is to discuss the management and outcomes associated with mesh removal. In addition, we will briefly review the safety communications issued by the US FDA on transvaginal mesh placement and a new classification system for complications arising from the use of synthetic graft endorsed by both the International Continence Society and International Urogynecological Association.

Long-Term Functional Outcomes Following Nonradiated Vesicovaginal Repair

PURPOSE We investigated the long-term impact on bladder and sexual symptoms in women with prior vesicovaginal fistula repair, particularly those previously treated before referral. MATERIALS AND METHODS After receiving institutional review board approval we reviewed the charts of women who underwent nonradiated vesicovaginal fistula repair for demographics, surgical approach (vaginal or abdominal) and functional outcomes with a minimum 6-month followup. Patients lost to followup were reached by a structured phone interview and/or mailed validated lower urinary tract questionnaires, including the UDI-6 (Urogenital Distress Inventory-6), IIQ-7 (Incontinence Impact Questionnaire-7) and FSFI (Female Sexual Function Index). Three surgical groups were compared, including naïve-no prior repair, recurrent-1 prior repair and other-more than 2 repairs with the hypothesis of worse outcomes with more repairs. RESULTS From 1996 to 2011 vesicovaginal fistula repair was performed in 66 patients, including in 42 as primary treatment (vaginal vs abdominal approach in 31 vs 11), in 14 as secondary treatment, and in 10 who underwent more than 2 repairs. Mean patient age was 45 years (range 24 to 87), mean body mass index was 29 kg/m(2) (range 19 to 43) and mean followup was 55 months (range 6 to 198). The overall repair success rate was 97%. There was no difference in functional outcomes in questionnaire responders among the 3 groups for lower urinary tract symptoms (62% on UDI-6/IIQ-7). However, for FSFI (33% of patients) there was female sexual dysfunction in patients who underwent transabdominal repair and in women with 2 repairs. CONCLUSIONS Long-term followup of patients with vesicovaginal fistula repair indicated no differences in lower urinary tract outcomes at a mean 7-year followup between primary and recurrent repairs. There was a difference in sexual function, although it was not statistically significant. Sexual activity among responders was low.

A Surprisingly Low Prevalence of Demonstrable Stress Urinary Incontinence and Pelvic Organ Prolapse in Women with Multiple Sclerosis Followed at a Tertiary Neurogenic Bladder Clinic

PURPOSE We report the prevalence of stress urinary incontinence and pelvic organ prolapse in patients with multiple sclerosis referred to a tertiary care neurogenic bladder clinic. MATERIALS AND METHODS We queried an institutional review board approved neurogenic bladder database for urodynamic and demographic data on patients with multiple sclerosis followed for lower urinary tract symptoms in a 12-year period. Demographic information included multiple sclerosis classification, age at initial visit, body mass index, parity and pelvic examination findings. Prolapse was defined as stage 2 prolapse or greater. Stress urinary incontinence was defined as urodynamic stress incontinence and/or incontinence on a supine stress test. RESULTS Included in analysis were 280 women with a mean age of 50 years and a mean 13-year history of multiple sclerosis. Relapse remitting multiple sclerosis was noted in 40% of patients, while 45 (16%) had stress urinary incontinence. Women with stress urinary incontinence had a higher average maximum urine flow (14 vs 9 ml per second, p <0.003), higher voided volume (272 vs 194 cc, p = 0.018) and higher body mass index (30 vs 25 kg/m(2), p <0.005). Overall, 23 women (9%) had pelvic organ prolapse, including 2 (9%) with posterior prolapse only, 8 (35%) with anterior prolapse only and 13 (56%) with posterior and anterior prolapse. There was no difference in age, body mass index or multiple sclerosis subtype between women with vs without pelvic organ prolapse. CONCLUSIONS The 14% prevalence of demonstrable stress urinary incontinence and 9% rate of pelvic organ prolapse are markedly lower than published historical data on an age matched cohort without multiple sclerosis. The surprisingly low prevalence of stress urinary incontinence and pelvic organ prolapse in women with multiple sclerosis may be attributable to decreased activity, a neurogenically enhanced vesicourethral unit or other functional or anatomical etiologies.

Long-term outcomes of autologous pubovaginal fascia slings: Is there a difference between primary and secondary slings?

To report our long‐term pubovaginal slings (PVS) outcomes between primary (PVS1) and secondary (PVS2) autologous fascia PVS, with the hypothesis that outcomes in PVS1 will be better than in PVS2.

Urodynamics: Role in Incontinence and Prolapse: A Urology Perspective

Changes in pelvic floor as well as urethral anatomy and function occur with aging, which can result in prolapse and urinary incontinence. Aside from the socially debilitating impact incontinence has on patients lives, it significantly affects the health care systems economically. Rates of incontinence and pelvic organ prolapse (POP) in women of this age demographic is estimated to be 30% to 94%, and 1 in 8 women may require surgical repair for POP or incontinence by their eighth decade, with a reoperation rate of 30%. This article reviews the role of UDS in the evaluation of urinary incontinence and POP.

Martius labial fat pad procedure: technique and long-term outcomes

Surgical technique in this case used anMLFP after completing a transvaginal urethrolysis to fill the space around the urethra and prevent rescarring. A vertical incision (average 8 cm) is made over the labia majora from the level of the mons pubis down toward the level of the fourchette, depending on the length of fat pad required. The incision is deepened to the level of the labial fat pad, which can be gently grasped with a Babcock clamp and mobilized on an inferior pedicle, providing a posteroinferior blood supply to the graft based on branches from the external pudendal artery. Blood supply for the MFLP varies with description of both superior and inferior blood supplies. We and others have used the posteroinferior blood supply, while others have preferred a superior blood supply. Both approaches seem to provide well-vascularized fat-pad grafts. Dissection is continued laterally and medially with attention to avoid being too superficial medially to prevent skin retraction and secondary deformation. Once a sufficient length is achieved, the flap is gradually divided superiorly. The fat pad graft is then detached posteriorly off the underlying ischiocavernosus and bulbocavernosus muscles, leaving a broad base inferiorly to preserve vascularity. After mobilization is completed, a figure-of-eight absorbable suture is placed at the extremity of the flap to facilitate transfer alongside the vaginal wall (Fig. 1). A vaginal tunnel is created with long Metzenbaum scissors and/or a ring forceps and widened to accept at least two fingers to offset compression of the blood supply. The pedicle graft MFLP once tunnelled can be secured in place with absorbable sutures. The incision is closed in layers over a small labial drain, which is removed within 24–48 h postoperatively (Fig. 2). Labial incision is barely noticeable in the long term (Fig. 3).

Adult Onset Nocturnal Enuresis: Identifying Causes, Cofactors and Impact on Quality of Life

The objectives of the present study were: (i) Evaluate common co‐pathologies associated with, and potentially contributing to adult onset Nocturnal enuresis (NE) in a tertiary referral population; and (ii) quantify its impact on QoL with validated questionnaires.

Midurethral slings in the mesh litigation era

Stress urinary incontinence (SUI) has always been a major health issue for women. With the progression of technology and surgical techniques, mid urethral slings (MUS) used in both transvaginal and transobturator routes have become the gold standard in the treatment of SUI. There is ample short to mid-term data confirming the efficacy and safety in using MUS in treating SUI in women. However, long-term data supporting the use of MUS in women to treat SUI is scarce. There has been much controversy surrounding the US Food and Drug Administrations’ (FDA) public notification of potential complications surrounding the use of transvaginal mesh, which has been magnified and generalised by the media; but despite this there has still been substantial growth and uptake of MUS for treating SUI. In this review, we aim to explore some of the issues with MUS, the factors around litigation with mesh use, the impact of FDA’s notification on the uptake of MUS and ultimately, the results and efficacy of MUS for the treatment of SUI.