J. Thomas Benson

Vaginal versus abdominal reconstructive surgery for the treatment of pelvic support defects: a prospective randomized study with long-term outcome evaluation.

OBJECTIVES Our purpose was to determine whether a vaginal or abdominal approach is more effective in correcting uterovaginal prolapse. STUDY DESIGN Eighty-eight women with cervical prolapse to or beyond the hymen or with vaginal vault inversion > 50% of its length and anterior vaginal wall descent to or beyond the hymen were randomized to a vaginal versus abdominal surgical approach. Forty-eight women underwent a vaginal approach with bilateral sacrospinous vault suspension and paravaginal repair, and 40 women underwent an abdominal approach with colposacral suspension and paravaginal repair. Ancillary procedures were performed as indicated. Detailed pelvic examination was performed postoperatively by the nonsurgeon coauthor yearly up to 5 years. The women were examined while standing during maximum strain. Surgery was classified as optimally effective if the woman remained asymptomatic, the vaginal apex was supported above the levator plate, and no protrusion of any vaginal tissue beyond the hymen occurred. Surgical effectiveness was considered unsatisfactory if the woman was symptomatic, the apex descended > 50% of its length, or the vaginal wall protruded beyond the hymen. RESULTS Eighty women (vaginal 42, abdominal 38) were available for evaluation at 1 to 5.5 years (mean 2.5 years). The groups were similar in age, weight, parity, and estrogen status, and 56% had undergone prior pelvic surgery. There was no significant difference between the groups in morbidity, complications, hemoglobin change, dyspareunia, pain, or hospital stay. The vaginal group had longer catheter use, more urinary tract infections, more incontinence, decreased operative time, and lower hospital charge. Surgical effectiveness was optimal in 29% of the vaginal group and 58% of the abdominal group and was unsatisfactory leading to reoperation in 33% of the vaginal group and 16% of the abdominal group. The reoperations included procedures for recurrent incontinence in 12% of the vaginal and 2% of the abdominal groups. The relative risk of optimal effectiveness by the abdominal route is 2.03 (95% confidence interval 1.22 to 9.83), and the relative risk of unsatisfactory outcome using the vaginal route is 2.11 (95% confidence interval 0.90 to 4.94). CONCLUSIONS Reconstructive pelvic surgery for correction of significant pelvic support defects was more effective with an abdominal approach.

Transvaginal electrical stimulation for female urinary incontinence

OBJECTIVE Our purpose was to determine the objective and subjective efficacy of transvaginal electrical stimulation for treatment of common forms of urinary incontinence in women. STUDY DESIGN A prospective, double-blind, randomized clinical trial included 121 women with either urinary incontinence caused by detrusor instability or genuine stress incontinence, or both (mixed incontinence). Participants used the assigned device for 8 weeks. Identical preintervention and postintervention assessment included multichannel urodynamic testing, quality-of-life scale, and urinary diaries. RESULTS A total of 121 women completed this study at four North American urogynecology centers. Detrusor instability was cured (stable on provocative cystometry) in 49% of women with detrusor instability who used an active electrical device (p = 0.0004, McNemars test), whereas there was no statistically significant change in the percentage with detrusor instability in the sham device group. There was no statistically significant difference between the preintervention and postintervention rates of genuine stress incontinence for either the active device group or the sham device group. CONCLUSION This form of transvaginal electrical stimulation may be effective for treatment of detrusor overactivity, with or without genuine stress incontinence.

Effects of pudendal nerve injury in the female rat

To test a neurogenic hypothesis for external urethral sphincter (EUS) dysfunction associated with urinary incontinence, the proximal pudendal nerve was crushed in anesthetized retired breeder female rats (n = 5) and compared with a sham lesion group (n = 4). Outcome measures included concentric needle electromyograms (EMGs) from the target EUS, voiding patterns during a 2‐hour dark period, and micturition data over a 24‐hour period. Fast Blue (FB) was introduced to the crush site at the time of injury and Diamidino Yellow (DY) to the EUS at the time the rats were killed (3 months post‐operative), when histological analysis of the nerve and urethra was also performed. EMG records indicated the EUS motor units undergo typical denervation changes followed by regeneration and recovery. Voiding patterns from the crush group show a significant increase of small urine marks in the front third of the cage. At 1–2 weeks post‐op, the frequency of voids was significantly increased in the crush group compared to pre‐op and late post‐op time periods. The mean volume voided in the light phase at the early post‐op time was significantly increased in the sham group. Light and electron microscopic patterns seen in nerve and muscle suggest the regenerating motor units maintain a structural integrity. Motoneurons in the lower lumbar cord were labeled with either DY (14.5 ± 6.8), FB (31.7 ± 23.7), or both (35.0 ± 17.5) tracers, indicating ∼54% of the crushed pudendal neurons regenerated to the EUS. In conclusion, several measures suggest this reversible crush lesion induces mild urinary incontinence. This animal model is promising for further development of hypotheses regarding neural injury, the pathogenesis of incontinence, and strategies aimed at prevention and treatment. Neurourol. Urodynam. 19:53–69, 2000.

Monitoring pudendal nerve function during labor.

Background To determine methodology and feasibility of pudendal nerve monitoring during labor and delivery. Methods With Institutional Review Board approval, 13 low-risk, singleton pregnant women were recruited. The latency and amplitude of the perineal branch of the pudendal nerve compound muscle action potential were recorded during the second stage of labor and after delivery. With the first two patients, a wire electrode was used to stimulate the pudendal nerve continuously at the ischial spine. For the remaining 11 patients, a St. Marks electrode was used to stimulate transvaginally. A urethral ring electrode on a 14 French foley catheter monitored the response from the urethral sphincter. All patients received prophylactic antibiotics. Experience Twelve patients delivered vaginally, and one by cesarean. In two patients, continuous wire stimulation showed a gradual decrease in amplitude. Changes were minimal over 15-minute intervals. Wire electrode placement was technically difficult and dislodged easily. With the remaining 11 patients, all had data available for interpretation, and of the 85 potential perineal branch of the pudendal nerve compound muscle action potentials, 53 were obtained. No patients developed cystitis. Conclusion Intrapartum assessment of pudendal nerve function is feasible. Continuous wire stimulation is technically more difficult and does not provide additional information beyond that available from intermittent stimulation.

Correlation of intraurethral ultrasonography and needle electromyography of the urethra.

Objective To correlate structural intraurethral ultrasound findings with needle electromyography of striated urethral sphincters in young continent nulliparas. Methods Twenty-three nulliparas, each less than 35 years old and without pelvic floor disorders, were recruited at Methodist Hospital in Indianapolis, Indiana, and the University of Louisville in Louisville, Kentucky. Each had concentric needle electromyography of their urethra to localize their striated urethral sphincter. Intraurethral ultrasound was used to identify the needle tip and layer in which it was found, examine the sonographic appearance of periurethral anatomy, and measure the thickness of hypoechoic and outer hyperechoic layers. Results Three layers were seen on intraurethral ultrasound: a mildly hyperechoic inner layer, a hypoechoic middle layer, and a hyperechoic outer layer. The concentric needle tip was seen in all subjects and showed motor unit action potentials when located in the outer hyperechoic layer. The mean thickness of the hypoechoic layer was 2.5 mm, and the mean thickness of the outer hyperechoic layer was 2.6 mm. Conclusion Motor unit action potentials showed that striated muscle was present in the outer hyperechoic layer on intraurethral ultrasound, implying that it contains the striated urethral sphincter.

Urethral sphincter needle electromyography in women: Comparison of periurethral and transvaginal approaches

Needle electromyography (EMG) of the striated urethral sphincter is the only technique that permits detection of individual motor unit action potentials (MUAPs) and is a valuable diagnostic tool in the evaluation of women with urinary incontinence and voiding disorders. The purpose of this study was to compare two methods of urethral needle EMG with respect to the number of MUAPs identified, the amount of patient discomfort, and the duration of the examination. Twenty consecutive women referred for electrodiagnostic testing to evaluate symptoms of urinary incontinence and/or voiding dysfunction underwent both methods of the needle examination in a prospective randomized cross‐over study design with each patient acting as her own control. A full cross‐over analysis was conducted to detect period and sequence effects using analysis of variance with a power of 0.85 and a significance level of P < 0.05. Twice as many MUAPs were identified using the periurethral approach (8.8 versus 3.9) with a mean difference of 5.0 (P = 0.0008). There was a non‐significant trend to greater patient discomfort with the periurethral approach; however, the discomfort was generally rated as mild to moderate. The length of time required to count all identifiable MUAPs did not vary significantly between the two methods. We conclude that the periurethral approach is superior to the transvaginal approach with respect to the quantity of electrodiagnostic information obtained and propose that this method be standardized to characterize more accurately the neurogenic component of urinary incontinence and voiding dysfunction for future electrodiagnostic studies. Neurourol. Urodynam. 17:531–535, 1998.

Vaginal müllerian cyst presenting as an anterior enterocele : a case report

A case is discussed of an extremely large vaginal müllerian cyst that presented as an anterior enterocele. Sonographic and radiologic studies are described. The patient underwent operative excision of the cyst with reconstructive vaginoplasty.

Evaluation of a Minimal-Incision Pubovaginal Suspension as an Adjunct to Other Pelvic-Floor Surgery

In September 1987, Gittes and Loughlin first described a minimal-incision pubovaginal suspension as a modification of the Pereyra needle suspension urethropexy. Thirty-four women who underwent the minimal-incision urethropexy procedure were studied for up to 13 months postoperatively. Although 21 patients also had the anterior vaginal wall opened to perform concomitant pelvic-floor surgery, the principles of minimal suprapubic incision, full-thickness vaginal sutures, and no dissection of endopelvic fascia were followed strictly in all 34 cases. With a mean follow-up of 9.5 months, the objective cure rate was 91% and subjectively, 97% of the patients were either cured or improved. This technically simpler procedure is effective for treating genuine stress urinary incontinence in women who also require surgical repair of other pelvic-floor defects.