George Ralph

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.

The Austrian Tension-Free Vaginal Tape Registry

Abstract: In Austria a central registry for all TVT operations has been established in which more than 800 cases have so far been registered. The registry contains information on pertinent data on the operated patients and intra- and postoperative outcomes of the TVT surgery. No serious complications and no mortality have been registered until now.

Long-term effects of vaginal dissection on the innervation of the striated urethral sphincter.

Objective To study the long-term effects of vaginal dissection on the innervation of the striated urethral sphincter. Methods Perineal nerve terminal motor latency was measured before and 8 weeks and 1 year after anterior colporrhaphy, colpoperineoplasty, and vaginal hysterectomy in 33 women, 19 of whom also underwent endoscopic suspension of the bladder neck. Results In the entire series, the mean perineal nerve terminal motor latency was prolonged before surgery over that in normal continent women and further prolonged 8 weeks and 1 year postoperatively. In the subjects who underwent vaginal hysterectomy and anterior colporrhaphy, perineal motor latencies were not significantly prolonged at the 8-week postoperative follow-up and had almost returned to preoperative values 1 year later. However, in those who underwent additional endoscopic bladder neck suspension, perineal motor latencies were prolonged at both postoperative follow-up examinations. Perineal motor latencies were unchanged 1 year postoperatively in continent patients (N = 19) but were prolonged in incontinent patients (N = 14). Conclusion Vaginal dissection, especially during endoscopic bladder neck suspension, can worsen preexisting perineal neuropathy in patients with pelvic relaxation and stress incontinence.

Five-year results after anti-incontinence operations

OBJECTIVE This study was undertaken to evaluate continence rates 5 years after anterior colporrhaphy, anterior colporrhaphy with needle suspension of the bladder neck, and Burch colposuspension. STUDY DESIGN Among 544 women with stress incontinence who were operated on between 1989 and 1993, 327 women (60%) underwent clinical and urodynamic reevaluation 5 years after the operation. Choice of surgical procedure was made on the basis of clinical and urodynamic findings and of physician preference. Continence was defined as no loss of urine during cystometry or during coughing with the bladder filled to 300 mL. RESULTS The 327 patients underwent a total of 334 operations. The objective overall continence rates at 5 years were 61% (65/107) after anterior repair, 49% (59/121) after anterior repair with needle suspension, and 79% (84/106) after Burch colposuspension. Continence rates after anterior colporrhaphy were 82% (32/39) among patients with mild stress incontinence but 49% (33/68) among those with moderate or severe incontinence (P <.02). Continence rates among patients with moderate or severe incontinence were 49% (59/121) after anterior repair with needle suspension and 79% (84/106) after the Burch operation (P <.02). CONCLUSION Anterior colporrhaphy can cure mild stress incontinence but is inadequate to correct severe incontinence. Additional needle suspension may be of benefit for patients with moderate to severe incontinence. Abdominal colposuspension is superior to the vaginal operations for long-term cure of stress incontinence.

Treatment of unruptured tubal pregnancy by laparoscopic instillation of hyperosmolar glucose solution

Sixty patients with unruptured tubal pregnancy were treated with local laparoscopic instillation of 50% glucose solution. This treatment was successful in 49 (98%) of 50 patients with an initial serum human chorionic gonadotropin level of less than or equal to 2500 mU/ml and in six (60%) of 10 with an initial level greater than 2500 mU/ml. No side effects were seen. The average hospital stay of patients who did not require a second intervention was 5.2 days (range 3 to 10). The average time between glucose instillation and the decline of serum human chorionic gonadotropin levels below the level of detectability was 21.3 (+/- 14.3) and 30.2 (+/- 10.9) days in patients with serum levels less than or equal to 2500 mIU/ml and greater than 2500 mIU/ml, respectively. Five patients (8%) underwent a second laparoscopy (n = 4) or laparotomy (n = 1) because of stable or increasing human chorionic gonadotropin levels and progressing clinical symptoms. We conclude that laparoscopic instillation of hyperosmolar glucose solution is safe, technically simple, and effective in the treatment of unruptured tubal pregnancies associated with a serum human chronic gonadotropin level less than or equal to 2500 mIU/ml.

Pelvic floor exercise alone or with vaginal cones for the treatment of mild to moderate stress urinary incontinence in premenopausal women

The authors compared intensive pelvic floor exercise alone (A) with intensive pelvic floor exercise plus vaginal cones (B) in premenopausal women with mild to moderate stress urinary incontinence. Forty-six patients (mean 43±6 years) were randomized into two training groups and treated for 3 months. Pre- and post-therapy urethral pressure profiles at rest and under stress and subjective results were obtained from 29 patients. The subjective improvement rate of the compliant patients after 12 weeks was 85% in group A and 84% in group B. When the dropouts (9 in group A and 8 in group B) were included in the subjective results an overall improvement rate of 48% in group A and 52% in group B was obtained. In group A one pressure transmission ratio (PTR) improved significantly at 6 weeks and the position of maximum urethral closure pressure was shifted proximally at 12 weeks. In group B one PTR in the midurethra was improved significantly at 6 weeks. The other urodynamic parameters were unchanged. There were no differences between groups A and B in subjective results or urodynamic findings. These results suggest that intensive pelvic floor exercise with or without vaginal cones improves the symptoms of mild to moderate stress incontinence in about 85% of premenopausal women, but that it has little effect on urodynamic parameters. Vaginal cones provided no additional benefit but may be useful for women for whom closely supervised pelvic floor exercise is not available.

Surgical treatment of stress urinary incontinence after radical hysterectomy

Stress urinary incontinence is not infrequent after radical hysterectomy for cervical cancer. Eight women who underwent surgery for correction of stress incontinence after radical hysterectomy were studied with urodynamic techniques before and 1 year after incontinence surgery. Five patients underwent a Marshall-Marchetti-Krantz (MMK) operation, 1 a Burch colposuspension, 1 a sling procedure and 1 an anterior repair. Two patients remained incontinent after an MMK operation, as did the patient who had an anterior repair. The patient who underwent a sling procedure had to practice intermittent selfcatheterization. We conclude that an appropriate operation can cure stress incontinence after radical hysterectomy, but that patients should be selected carefully.

Urethral profilometry in women with uterovaginal prolapse

The aim of the study was to investigate the continence mechanism in women with uterovaginal prolapse by analysing urethral pressure profiles. Twenty-four women (mean age 59.0±11.9 years, mean parity 3.1±1.6) with prolapse underwent urodynamic evaluation. Urethral pressure profiles were obtained with prolapse and after reduction of the prolapse with a swab stick in the posterior vaginal fornix. After reduction the maximum urethral closure pressure (MUCP) and pressure transmission ratios (PTR) in all four quartiles of the urethra decreased, the position of the MUCP was shifted proximally and the functional urethral length was increased. Thirteen women reported a history of continence and 11 reported incontinence. Ten of 13 women (77%) who reported continence with prolapse were incontinent with their prolapse reduced. In these women, MUCP and PTRs in the first three quartiles of the urethra decreased significantly upon prolapse reduction. In the patients who reported incontinence with prolapse, only the MUCP decreased significantly upon prolapse reduction. Comparisons between the historically continent and incontinent women showed a statistically significant difference only for PTRs in the second and third quartiles of the urethra before prolapse reduction. Because the position of maximum urethral closure pressure before reduction was located in the distal half of the urethra in all patients, we conclude that direct pressure of the prolapsed mass on the urethra (rather than kinking) is the mechanism masking incompetence of the urethral closure mechanism in women with uterovaginal prolapse. The 77% rate of latent incontinence in this series suggests that women with severe pelvic relaxation should undergo careful urogynecologic evaluation before an attempt at surgical correction.

Fünf-Jahres-Ergebnisse nach Inkontinenzoperation

Fragestellung: Kontinenzraten 5 Jahre nach Kolporrhaphia anterior mit oder ohne Nadelsuspension des Blasenhalses und nach Kolposuspension nach Burch. Methoden: Es wurden 186/ 291 Patientinnen (64%), die 1989-1990 mit der Diagnose Stressinkontmenz operiert wurden, klinisch und urodynamisch nachuntersucht. Ergebnisse: Die objektiven Kontinenzraten nach Kolporrhaphia anterior waren 80% (20/25), 46% (22/47) und 12,5% (1/8) bei erst-, zweit- und drittgradiger Stressinkontinenz nach Ingelman-Sundberg. Die entsprechenden Kontinenzraten bei Stressinkontinenz Grad II–III waren 59% (29/49) nach zusatzlicher Nadelsuspension und 86% (50/58) nach Burch. Schlussfolgerungen: Die Kolporrhaphia anterior kann eine leichte Stressinkontinenz beheben, ist aber fur eine schwere Stressinkontinenz ungeeignet. Fur eine hohergradige Stressinkontinenz sowie bei Risikofaktoren ist die Kolposuspension nach Burch den anderen Operationen uberlegen. Die Ingelman-Sundberg-Klassifikation kann fur die Indiaktionsstellung der operativen Therapie hilfreich sein.

Unrecognized perforation of the cecum at needle suspension of the bladder neck: a case report

Perforation of the cecum at needle suspension of the bladder neck was detected at abdominal surgery for recurrent stress urinary incontinence 4 years later.