Emily E. Cole

Preservation of the Anterior Vaginal Wall During Female Radical Cystectomy With Orthotopic Urinary Diversion: Technique and Results

PURPOSE Orthotopic urinary reconstruction has been shown to be a viable option in women undergoing radical cystectomy. However, due to anatomical differences and technical considerations orthotopic diversion has been performed in a relatively small number of patients. We examined our technique of vaginal wall preservation during female radical cystectomy and orthotopic neobladder construction. MATERIALS AND METHODS We reviewed the records of all patients who underwent radical cystectomy between January 1994 and December 2001. Of these 542 patients we identified 94 females, of whom 25 (27%) underwent orthotopic neobladder substitution. We reviewed perioperative major and minor complications, postoperative care, followup and pathological results. RESULTS Overall 21 of the 25 patients (84%) underwent anterior vaginal wall sparing. Five patients (24%) had minor complications, there were no major perioperative complications and no patients required transfusion. Median estimated blood loss in this group was 575 ml. (range 200 to 1,250). A single neobladder-vaginal fistula developed in a patient early in our series in whom the anterior vaginal wall was incised and repaired during dissection. Of the 21 patients 15 (72%) were continent. Pathological specimens revealed a negative posterior bladder wall and urethral margins in all cases. At a median followup of 12 months 1 patient had local recurrence. CONCLUSIONS Anterior vaginal wall preservation in female radical cystectomy with orthotopic neobladder substitution is technically feasible, maintains vaginal length and support, has an acceptable complication rate and can achieve negative margins. Prospective evaluation is needed to assess the long-term impact on functional outcomes and cancer control.

PATHOLOGICAL FINDINGS OF GYNECOLOGIC ORGANS OBTAINED AT FEMALE RADICAL CYSTECTOMY

PURPOSE Historically anterior pelvic exenteration has been the recommended treatment for invasive urothelial carcinoma in women undergoing radical cystectomy. We evaluated the pathological features of reproductive organs removed during exenteration to determine the incidence of malignant pathology in these organs and the need for removal. MATERIALS AND METHODS We reviewed the records of all patients who underwent radical cystectomy between January 1994 and December 2000. Of these 382 patients, we identified 68 females who underwent radical cystectomy for urothelial carcinoma. We reviewed preoperative, operative and pathological findings, including bladder, lymph nodes, uterine and adnexal pathology, in these female patients. RESULTS Median patient age was 64 years (range 35 to 86). Gynecologic organs were present in 40 of the 68 surgical specimens (59%). The reasons for absent gynecologic pathology were previous hysterectomy in 26 cases and the preservation of organs during orthotopic urinary diversion creation in 2. Malignancy was identified in 3 specimens, including invasive urothelial carcinoma in 2 (5%). In these 2 cases invasion was clearly identified intraoperatively. Low grade stromal sarcoma of the uterus was present in 1 specimen (2%). CONCLUSIONS In the absence of clinical suspicion radical hysterectomy at cystectomy rarely improves cancer control. Furthermore, secondary malignancies are rare. The functional impact of preserving gynecologic organs is a subject of ongoing study.

Safely reducing length of stay after open radical retropubic prostatectomy under the guidance of a clinical care pathway.

Collaborative care pathways have proven to be a safe and effective method of decreasing length of hospital stay (LOS) and costs after radical retropubic prostatectomy (RRP). In the current study, the authors evaluated the safety and efficacy of a pathway transitioning from a 3‐day to a 2‐day LOS.

Histologic comparison of pubovaginal sling graft materials: a comparative study.

OBJECTIVES Little is known about the host response to the various biologic and synthetic graft materials used as substitutes for autologous fascia. We investigated the host response to sling graft materials in humans. METHODS A total of 24 women undergoing sling revision had a portion of the graft material removed for comparative analysis. At exploration, the degree of graft preservation (integrity), encapsulation, infection, and fibrosis was quantified. A histopathologic analysis was performed by systematically examining each specimen for the inflammatory response, neovascularity, and host fibroblast infiltration. RESULTS A total of 24 grafts were explanted at 2-34 months after implantation. The indications for removal were a lack of sling efficacy in 2, urinary retention in 9, and sling obstruction in 13. The types of graft material were polypropylene mesh (PPM) in 10, autologous fascia in 5, porcine dermis in 4, cadaveric dermis in 3, and cadaveric fascia in 2. No graft degradation had occurred in PPM material. Autologous and cadaveric fascia had the most demonstrable graft degradation. No encapsulation had occurred with autologous fascia or PPM. The porcine dermis was the most encapsulated. No host infiltration had occurred with the encapsulated porcine grafts, and only peripheral infiltration of fibroblasts had occurred in the cadaveric grafts. The PPM grafts had the greatest number of fibroblasts throughout the entire graft. Neovascularity was the most prevalent in mesh and was also present in the autologous fascia. Giant cells were seen in two mesh and two porcine grafts. CONCLUSIONS The results of our study have shown that porcine dermis has the potential to encapsulate. The degree of host tissue infiltration was greatest with PPM, and no degradation of the mesh material had occurred with time.

Histopathological evaluation of the uterosacral ligament: is this a dependable structure for pelvic reconstruction?

To explore, by histological examination, whether the uterosacral ligament complex is an adequate support structure for vaginal vault suspension and other reconstructive procedures of the female pelvis.

The effects of isolated posterior compartment defects on lower urinary tract symptoms and urodynamic findings

To determine any significant patterns among subjective and/or objective storage or voiding variables in women with isolated rectoceles or posterior enteroceles.

Radio Frequency Therapy for the Treatment of Female Stress Urinary Incontinence

The demographics of stress incontinence suggest that a significant percentage of the female population is affected by this condition and that the number of women who report discomfort due to stress incontinence is increasing [1– 4] . Stress incontinence is associated with quality of life aberrations that, while often managed by changes in physical activity, lead to treatmentseeking behavior on the part of the sufferer in order to regain normal physical function. Cure of stress incontinence is the ultimate goal of any intervention aimed at this symptom; however, complete symptom resolution often is not attained with therapy. Yet, it is now becoming evident from evolving outcomes analysis research that symptom improvement, when attained after intervention, is viewed as a significant and positive aspect of intervention, even if absolute cure is not obtained [5] . When compared to the welldefined prevalence of stress incontinence, the actual number of surgical procedures (colposuspensions and slings) performed for this condition reveal a significant disparity in absolute numbers of women who actually undergo surgical intervention. This numeric difference implies that women may be reluctant to undergo operative interventions due to concerns about morbidity, recovery times, or other perceived risk/lifestyle issues [2, 6, 7] . Nonsurgical modalities, despite the associated noninvasive nature of these options, are plagued by durability and efficacy concerns [8, 9] . Radio frequency (RF) energy application to the endopelvic fascia has been proposed recently as an option for the treatment of women with less bothersome stress incontinence as a less invasive, initial surgical procedure. RF tissue remodeling has been used for other indications such as fecal incontinence [10] and gastroesophageal reflux disease [11] in which luminal contents pass through a poorly functional anatomic and/or physiological barrier. The goal of the RF energy procedure is to correct the laxity and elasticity of the fascial “hammock” that underlies the proximal urethra and bladder neck and which is thought to contribute to anatomic stress incontinence [12] by creating thermally induced tissue shrinkage and contraction [13] . Focal RF application produces heating of the endopelvic fascia, which denatures collagen fibers, resulting in acute contraction (shrinkage) of the target area and which then results in a chronic fibrotic response [14] . Within 4–6 weeks, collagen ingrowth and fibrosis further shrink and stabilize the endopelvic fascia. These dynamic tissue changes result in a decreased compliance to intraabdominal pressure increases and produce stabilization of the position of the bladder neck [15] . The theory of RF effect subsequently will be reviewed in light of clinical experience. Chapter 9 Radio Frequency Therapy for the Treatment of Female Stress Urinary Incontinence