J. Christian Winters

ABDOMINAL SACRAL COLPOPEXY AND ABDOMINAL ENTEROCELE REPAIR IN THE MANAGEMENT OF VAGINAL VAULT PROLAPSE

Vaginal vault prolapse and enterocele represent challenging forms of female pelvic organ relaxation. These conditions are most commonly associated with other pelvic organ defects. Proper diagnosis and management is essential to achieve long-term successful outcomes. Physical examination should be carried out in the lithotomy and standing positions (if necessary) in order to detect a loss of vaginal vault support. With proper identification of the vaginal cuff, one should assess the degree of mobility of the vaginal cuff with a Valsalva maneuver. If there is significant descent of the vaginal cuff, vaginal vault prolapse is present, and correction should be considered. The abdominal sacral colpopexy is an excellent means to provide vaginal vault suspension. This procedure entails suspension of the vaginal cuff to the sacrum with fascia or synthetic mesh. This procedure should always be accompanied by an abdominal enterocele repair and cul-de-sac obliteration. In addition, many patients require surgical procedures to correct stress urinary incontinence, which is either symptomatic or latent (occurs postoperatively after prolapse correction). Complications include: mesh infection, mesh erosion, bowel obstruction, ileus, and bleeding from the presacral venous complex. If the procedure is carried out using meticulous technique, few complications occur and excellent long-term reduction of vaginal vault prolapse and enterocele are achieved. The purpose of this article is to review the preoperative evaluation of women with pelvic organ prolapse, and provide a detailed description of the surgical technique of an abdominal sacral colpopexy.

Collagen injection therapy in elderly women: long-term results and patient satisfaction.

OBJECTIVESnTo evaluate long-term results and patient satisfaction using collagen injection therapy in elderly women.nnnMETHODSnPeriurethral injection of collagen using local anesthesia was performed on 58 women 65 years old or older (range 65 to 86, mean 73. 2) to treat stress urinary incontinence. All patients underwent urodynamic evaluation. Forty-nine patients (84.5%) had intrinsic sphincteric deficiency; 9 patients (15.5%) had genuine stress urinary incontinence. Twenty-one patients (36.2%) had no urethral hypermobility using Q-tip testing, and 37 (63.8%) had urethral hypermobility.nnnRESULTSnAt 2 months after injection, the initial response was assessed: 28 patients (48.3%) were totally dry and 18 (31.0%) were socially continent. Therapy was unsuccessful in 12 (20. 7%). To achieve continence, 1 to 4 injections (mean 1.9) were required. The average total volume to achieve success was 14.6 mL. No significant differences were observed in outcome, volume injected, or number of injections in patients with versus without urethral hypermobility. At a mean follow-up of 24.4 months (range 8 to 43), of the 46 patients who achieved continence, 19 (41.3%) developed recurrent leakage and required reinjection. The average interval to recurrence was 7.9 months (range 2 to 16). Of the 19 patients reinjected, only 8 (42.1%) regained continence. The long-term success rate after repeated injections was 35 (60.3%) of 58. An independent examiner contacted 40 patients for telephone interview. To date, 25 of the patients contacted noted a moderate or maximal level of symptom improvement, and 18 reported continued improvement in quality of life. Thirty-six patients noted minimal difficulty with the procedure, and 34 would recommend the treatment.nnnCONCLUSIONSnCollagen is a safe, moderately effective alternative to manage stress urinary incontinence in elderly women. Elderly patients should be counseled that approximately 40% will experience recurrent leakage, which may not resolve with reinjection.

Recurrent Pelvic Floor Defects After Abdominal Sacral Colpopexy

PURPOSEnThe incidence of site specific pelvic organ prolapse defects following sacral colpopexy is not clearly reported. We evaluated site specific pelvic organ defects after colpopexy and determined its impact on patient satisfaction.nnnMATERIALS AND METHODSnA total of 40 women with vault prolapse underwent abdominal sacral colpopexy, culdeplasty and paravaginal repair. Followup consisted of pelvic examination and satisfaction assessment every 6 months. The Baden-Walker classification was used and prolapse halfway to the introitus (grade II) or greater was considered significant prolapse. Surgical failure was identified as grade III prolapse or greater. Satisfaction was assessed on a scale of 1 to 3 with 3 being highly satisfied and according to whether patients perceived a successful outcome.nnnRESULTSnA total of 40 patients with an average age of 66.5 years (range 48 to 81) had an average followup of 25.5 months (range 18 to 42). Of the 40 patients 22 (55%) did not have significant prolapse, including 14 with no prolapse, and 8 with grade I cystocele and/or rectocele. Of the 40 patients 18 (45%) had recurrent significant prolapse, including cystocele in 8 (grades II and III in 4 each), rectocele in 6 (grades II and III in 2 and 4, respectively), and grade II cystocele and rectocele in 3. There was 1 case of recurrent vault prolapse. Eight of 40 cases (20%) were considered surgical failures. Patients without prolapse were highly satisfied (average score 2.95) and 100% considered surgery to have been successful. The recurrent prolapse group was less satisfied (mean score 2.5) and 66.7% considered the surgery successful.nnnCONCLUSIONSnRecurrent pelvic organ prolapse is not an uncommon finding after colpopexy and it may adversely affect patient satisfaction.

Use of bone anchors in female urology

Stress urinary incontinence remains one of the most prevalent conditions encountered by urologists. In many cases, surgical correction of this condition is carried out using a pubovaginal sling procedure. Bone anchors were initially used in transvaginal needle suspension procedures to improve stabilization of the bladder neck. This technology has been extended to sling procedures, allowing completion of these procedures by an entirely transvaginal approach. Early results of these procedures are encouraging, and overall morbidity appears much less when compared with conventional pubovaginal sling procedures. In this article, the application of bone anchors in female urology is reviewed. Techniques of pubovaginal sling and abdominal sacrocolpopexy using bone anchors and potential complications of bone anchor implantation are discussed. Surgeons performing procedures for the treatment of stress incontinence should be aware of the benefits and potential risks of bone anchor implantation.

Vaginal mesh – the controversy

Pelvic organ prolapse is a condition that can cause significant symptoms that affect a womans quality of life. It is the result of defects in the supporting structures of the vagina and, depending on the location and size, can alter the functions of the organs contained within the female pelvis. Approximately 11% of women will undergo surgical intervention for their prolapse or for incontinence in their lifetime. Unfortunately, one third of these will require reoperation for failed procedures. Pelvic floor surgeons have sought to improve these outcomes. Based largely on the success of midurethral slings (MUS), transvaginal mesh has been implanted, and commercial kits developed with the intent of improving these outcomes. In 2008, the Food and Drug Administration (FDA) issued a Public Health Notification in response to possible increased adverse events associated with the use of mesh compared to traditional repairs. The 2011 update required that further study be conducted for the use of transvaginal mesh. In this article, we wish to discuss the background of mesh use and the evolution of the public health warnings, and focus on future prospects.

Comparison of biomechanical properties of periosteal suture fixation and bone anchor fixation to the pubic bone

OBJECTIVESnTo compare the relative strength of fixation using bone anchors (BAs) compared with direct suture placement into the periosteum.nnnMETHODSnThe anterior bony pelvis was harvested from 21 female cadavers. In each pelvis, BA suture fixation was performed using Cinch anchors on one side of the pubic bone and direct periosteal suture fixation (PSF) on the contralateral side of the same pelvis. We used No. 1 polyproprolene suture for all cases. Using a hydraulic mechanical testing machine, all specimens were loaded in uniaxial tension until failure.nnnRESULTSnFailure modes for BA-fixed pelves were as follows: 11 BA pull-out, 1 midsuture failure, and 9 suture cut by BA. Failure modes for the PSF pelves were as follows: 6 suture pull-outs through the bone, 14 midsuture failures, and 1 suture cut at the bone. PSF pelves required significantly higher loads to induce failure compared with BA pelves (PSF 92.63 +/- 22.62 N, BA 71.32 +/- 19.76 N, P <0.0002). In many cases, both PSF and BA were adequate points of fixation, and the major mechanism of failure was suture rupture. In pelves with suture failure, the load to induce failure was significantly higher in the PSF group (PSF 105.06 +/- 12.55 N, BA 86.06 +/- 7.78 N, P <0.0025). When the suture failed, PSF was better because BA fixation actually broke some sutures. The load required to induce failure was higher in the PSF groups in 19 (90.5%) of 21 pelves.nnnCONCLUSIONSnBiomechanical testing using permanent monofilament suture did not demonstrate a superiority of BA suture fixation to PSF fixation. PSF appears superior, since BAs induced suture failure in many cases.

Surgical repair of pelvic organ prolapse in elderly patients.

Purpose of review Epidemiologic data suggests that our population greater than 65 years of age will nearly double. In addition, the incidence of women undergoing surgery for pelvic organ prolapse will rise. Chronologic age does not preclude a woman from undergoing a reconstructive procedure, yet the preoperative assessment should be approached most judiciously with great care to insure patient is maximally medically prepared for surgery. Recent findings Surgical procedures in this review include: the abdominal sacral colpopexy, anterior repair, posterior repair, sacrospinous ligament fixation, uterosacral suspension, and iliococcygeus fixation. The advent of robotic surgery has decreased the perioperative morbidity of several of these procedures. However, the risk of more severe complications does appear higher following robotic procedures, when compared with vaginal procedures. Summary Intuitively, one would surmise that there is a point where vaginal surgery should be considered as the primary procedure based on age, risk and durability of the surgery – unfortunately that age is not clear. Thus, the proper selection of prevalence of organ prolapse surgery can only be done after careful discussion with the patient and including the patient in the selection process as much as possible.

Study design and outcomes measures: The influence of composite endpoints and other design variables on outcomes in a study of a novel device for stress urinary incontinence

To perform a post hoc analysis of the outcome data from a phase III study of a novel incontinence therapy for female stress incontinence (SUI) and to understand the pitfalls inherent to performing trials in SUI.

Post-Prostatectomy Incontinence

Adenocarcinoma of the prostate is the most frequently occurring cancer in men (1). Recently, the American Urologic Association released guidelines for the management of prostate cancer. These guidelines confirmed that radical prostatectomy is the optimal treatment forlocalized prostate cancer in healthy men (2). Incontinence following prostatectomy is a condition with significant adverse effects on quality of life that all physicians caring for patients with prostate disorders will encounter. Complete knowledge of the etiology of incontinence following prostatectomy and the options of treatment will facilitate treatment of these often distressed patients.