Felix Flock

Hemorrhagic complications associated with tension-free vaginal tape procedure

OBJECTIVE: We sought to assess the frequency, symptoms, and management of hemorrhagic complications in patients undergoing tension-free vaginal tape (TVT) procedure. METHODS: Over a 5-year period the clinical course of all 336 consecutive patients undergoing TVT procedure in our hospital was recorded, including diagnostic approaches and management strategies for both increased intraoperative blood loss and clinically relevant hematoma. RESULTS: In 87 patients (26%), TVT procedure was combined with other gynecologic surgeries, and 249 patients (74%) underwent TVT alone. In 7 cases (2.1%), increased intraoperative blood loss (250–400 mL) was managed by electro-coagulation, manual compression, tamponade, and/or insertion of a drain. The postoperative course in these patients was uncomplicated. In 14 women (4.1%) who did not show increased bleeding during the operation, retropubic hematoma developed, the volume of which exceeded 300 mL in 4 cases (1.2%). These required surgical intervention. In the first case we performed open laparotomy, whereas in the following cases the hematoma could be successfully drained by endoscopy. Postoperative development of a hematoma did not lead to recurrence of stress incontinence. CONCLUSION: Bleeding complications during or after TVT procedure are rare events. Increased intraoperative bleeding can usually be managed with electro-coagulation, compression, and drainage. LEVEL OF EVIDENCE: II-3

Long-term Results of the Tension-free Vaginal Tape Procedure in an Unselected Group: A 7-Year Follow-up Study

OBJECTIVES To evaluate long-term effectiveness and late complications after treatment of female stress urinary incontinence with tension-free vaginal tape (TVT). METHODS We performed a prospective observational study. Follow-up examinations included a standardized questionnaire, medical history, voiding diary, gynecologic examination with cough test, and introital ultrasound. RESULTS One-hundred-eight women (68.8%) from the initial cohort of 157 patients and 79.6% of those alive and able to cooperate were assessed. The median follow-up time was 102 months (range 85-124). The objective cure rate was 89.8%. The subjective cure rate was 82.4%, 13% had improved, 2.8% regarded the continence situation as unchanged, and 1.8% had an impaired stress urinary incontinence. No late-onset adverse effects of the surgery were found. Urge incontinence was the main reason for dissatisfaction with the surgery (in 90% of discontent patients). CONCLUSIONS Our data showed good results more than 7 years after TVT, demonstrating a high level of long-lasting efficacy for this minimally invasive incontinence procedure.

Haemorrhage and nerve damage as complications of TVT-O procedure: case report and literature review.

The transobturatorial vaginal tape procedure is associated with little complication rate. Bladder perforation, urethral invasion, vaginal erosion, postoperative bladder retention, de novo incontinence and retropubic pain and haematoma are the most reported complications. The aim of this article is to present an uncommon complication in a patient operated by transobturator vaginal tape with an inside–outside route.

Early Feeding Advancement in Very Low-birth-weight Infants With Intrauterine Growth Retardation and Increased Umbilical Artery Resistance

Background To investigate whether intrauterine growth retardation (birth weight <10th percentile), increased umbilical artery resistance (resistance index >90th percentile measured by Doppler velocimetry), or brain sparing (increased umbilical artery resistance and decreased middle cerebral artery resistance index <5th percentile) were associated with early feeding intolerance in very low-birth-weight (VLBW, <1,500 g) infants. Methods From July 1999 to December 2000, 124 inborn VLBW infants were enrolled in a prospective trial evaluating early enteral nutrition after a standardized feeding protocol (daily feeding advancement, 16 mL/kg birth weight). Feeding tolerance was assessed as the age at which full enteral feeds (150 mL/kg daily) were achieved. Data are shown as median, 25th, and 75th percentiles. Results Full enteral feeds were achieved at 15 days (range, 12–21 days) of age for all infants. Intrauterine growth retardation (full enteral feeding achieved at 14 days; range, 12–21 days), increased umbilical artery resistance (full enteral feeding achieved at 14 days; range, 11–16 days), and brain sparing (full enteral feeding achieved at 15 days; range, 14–20 days) were not associated with early feeding intolerance. Conclusion Very low-birth-weight infants with intrauterine growth retardation, increased umbilical artery resistance, and brain sparing tolerated enteral feeding as well as appropriate-for-gestational-age VLBW infants.

Ultrasound assessment of tension-free vaginal tape (TVT).

PURPOSE To date, no standardization for the visualization of tension-free vaginal tape (TVT) has been established in clinical practice. The aim of this prospective observational study was to evaluate the shape and position of the tape using ultrasound and to compare this data with clinical postoperative results. MATERIALS AND METHODS In a three-year period, 296 patients with clinically and urodynamically proven stress urinary incontinence (SUI) were treated with TVT and received follow-up in our department. An additional 12 patients, who were initially treated in other hospitals and had postoperative problems, were included in this study. Depending on the outcome after 3 months, the patients were divided into groups with and without specific disorders. The TVT was evaluated by introital ultrasound. The position of the tape was established by its location in relation to the urethral length and the distance to the hypoechoic center of the urethra (HCU). RESULTS A suitable TVT position was determined in patients without any postoperative disorders. The mean value for the TVT position at rest in relation to the urethral length was 61 %. The distance to the HCU was 4.6 ± 1.5 mm. In patients with persistent SUI, the tape was more often located under the inner (3 % vs. 0 %) or outer quarter (29 % vs. 13 %, p = 0.004). In patients with residual volume, the distance to the urethra was significantly lower (2.7 vs. 4.6, p < 0.001). CONCLUSION TVT may be regularly investigated using ultrasound. In combination with the clinical outcome, it represents an important method of evaluating the tape and assists in the planning of a future therapeutic course of action in cases of postoperative problems.

Comparison of Transobturator Vaginal Tape and Retropubic Tension-Free Vaginal Tape: Clinical Outcome and Sonographic Results of a Case-Control Study

Objectives: To compare the results and ultrasonographic characteristics of the transobturator vaginal tape (TVT-O) and retropubic (TVT) methods. Methods: 120 patients were treated with TVT-O. These were paired with similar patients treated with TVT. The patients were matched according to age, low-pressure urethra, preexisting mixed incontinence, and additional prolapse repair. The follow-up time was 3 months. Assessment variables included a standardized questionnaire, medical history, voiding diary, urinary stress test, 24-hour pad test, and introital ultrasound. The position of the tape was defined by its location in relation to urethral length (%) and the narrowness by its distance to the hypoechoic center of the urethra (mm). Results: The rates of postoperative complications including bladder perforation, urinary retention, and erosion through the vagina were similar. The number of hematomas occurring after TVT was insignificantly higher than after TVT-O (5 cases vs. 1 case). The rates for cure or improvement of stress incontinence were 77 and 17% after TVT-O and 85 and 14% after TVT (not significant). The sonographic characteristics were identical. Conclusion: In terms of clinical outcome, TVT and TVT-O appear to be equally effective. Complications and sonographic characteristics of the tapes were similar after both procedures.

Retziusscopy: a minimal invasive technique for the treatment of retropubic hematomas after TVT procedure

OBJECTIVES Retropubic hematomas are rare but typical complications during or after the tension-free vaginal tape (TVT) procedure. We investigated the possibility of treating these hematomas with retziusscopy, as an update of a previous study by our group. STUDY DESIGN Over a 10-year period the clinical course of all 685 consecutive patients undergoing the tension-free vaginal tape procedure (TVT, Gynecare) was prospectively recorded, including management strategies for clinically relevant hematomas. We report on 10 patients with hematoma and our following surgical management. RESULTS In twenty-eight patients (4.1%) a symptomatic retropubic hematoma developed. In 10 cases (1.5%) volume exceeded 250 mL (range 250-1000 mL). These patients required surgical intervention because of moderate or severe symptoms. In the first case we performed open laparotomy, whereas in the following cases the hematomas could be successfully drained by retziusscopy. CONCLUSIONS In cases of large masses, intervention may be necessary because of significant discomfort. This can usually be achieved by a minimally invasive retziusscopy.

Voiding Dysfunction after the Tension-Free Vaginal Tape Procedure

Aim: To assess the incidence of voiding dysfunction in women undergoing a tension-free vaginal tape (TVT) procedure and report our experience with nonsurgical and surgical management. Methods: Pre- and postoperative introital ultrasonographic measurement of the residual volume was performed in a prospective observational study. Patients’ perception of micturition and continence status was assessed by questionnaire. Results: Of 478 women, 4 (0.8%) suffered from micturition disturbance within the first 2 weeks. In the mean of 3 months after surgery, 7.1% of the patients had residual volume between 50 and 100 ml, and 2.6% had residual volume >100 ml. 243 women were investigated after 39 months (range 12–74). The rate of residual volume exceeding 50 ml decreased to 6.5% and was approximated to the preoperative period. Conclusion: Incomplete bladder emptying is a possible problem after TVT. In our cohort, 93% of the women had no voiding disturbances or marginally affected voiding after 12–74 months.

Influence of Bladder Volume on Pelvic Organ Prolapse Quantification Results

Aims: To compare the degree of pelvic organ prolapse between examinations performed with full and empty bladder in patients without any prolapse and with pelvic organ prolapse stage I or II using the pelvic organ prolapse quantification (POPQ) system. Methods: A prospective observational study with 120 consecutive patients with and without symptoms of pelvic organ prolapse was evaluated. All women were examined with full and empty bladder. The data were analyzed by Wilcoxon’s signed-rank test. Results: With empty bladder 54% had the same stage, 41% had a one-step higher stage and 5% had a two-step higher stage of prolaps. There was an increase in the extent of prolapse in the empty bladder setting at all six site-specific points (Aa, Ba, C, D, Ap, Bp; p < 0.001) but not in the results of genital hiatus, perineal body and total vaginal length. Conclusion: Our results suggest that the full extent of prolapse may be only assessed with an empty bladder.

Suitable laparoscopic surgery in the treatment of ectopic interstitial pregnancy

Interstitial or cornual pregnancies represent a small fraction of ectopic gestations. They are located in the interstitial part of the fallopian tube. Interstitial pregnancies are especially feared due to their life-threatening intraabdominal hemorrhage. General guide-lines for the clinical management are missing. This article discribes important specialities in the differenciation of interstitial and classical tubal pregnancy and will further offer a special minimal invasive procedure for the safe management of this rare ectopic pregnancy. We favour a special operative endoscopic procedure using a combination of encircling suture and endoloop-technique. This method provides an excellent tourniquet effect resulting in an effective hemostasis. In addition to the different endoscopic treatments, other therapeutic options such as primary methotrexate application will be discussed.