Judith Teng Wah Goh

Direct repair vs. overlapping sphincter repair: a randomized, controlled trial.

PURPOSE The aim of this study was to compare the results of two surgical techniques (direct end-to-end vs. overlapping) of delayed repair of a localized anterior defect of external anal sphincter after an obstetric trauma. METHODS During a five-year period, 23 patients were randomly assigned to direct end-to-end repair (n = 12) or overlapping sphincter repair (n = 11), using 2-0 PDS™ sutures. Two patients from each group had an internal anal sphincter defect that also was repaired. All patients had a normal pudendal nerve terminal motor latency preoperatively. Evaluations included endoanal ultrasound, anorectal manometry, and neurophysiologic evaluation. Continence was assessed by the Cleveland Clinic Continence Score (0–20; 0, perfect continence; 20, complete incontinence). RESULTS The two groups were comparable with regard to age (median, 45 years), past history of sphincter repair (n = 2), and posterior vaginal repair. There was no major morbidity. The wound-healing rate was identical between the two groups. However, of the patients undergoing overlapping repair, two had fecal impaction, and one had a urinary retention. Median preoperative continence score was 17 in both the direct-repair group (score, 8–20) and the overlap group (score, 7–20). At a median follow-up of 18 months, the improvement in continence was similar between the two surgical groups, with a median continence score of 3, respectively. In both surgical groups there was a significant and similar improvement in maximum squeeze pressure and in the functional anal canal length postoperatively (P < 0.05), but the mean resting pressure was relatively unchanged. In the overlap group, one patient developed a unilaterally prolonged pudendal nerve terminal motor latency that was persistent 22 months after surgery, and two patients had impaired fecal evacuation postoperatively. CONCLUSIONS This randomized, controlled study suggests that the outcome is similar whether direct end-to-end or overlapping repair of a sphincter defect is performed. Overlapping repair might be associated with more difficulties with fecal evacuation and a prolonged pudendal nerve terminal motor latency postoperatively.

Direct Repair vs. Overlapping Sphincter Repair

AbstractPURPOSE: The aim of this study was to compare the results of two surgical techniques (direct end-to-end vs. overlapping) of delayed repair of a localized anterior defect of external anal sphincter after an obstetric trauma. METHODS: During a five-year period, 23 patients were randomly assigned to direct end-to-end repair (n = 12) or overlapping sphincter repair (n = 11), using 2-0 PDS™ sutures. Two patients from each group had an internal anal sphincter defect that also was repaired. All patients had a normal pudendal nerve terminal motor latency preoperatively. Evaluations included endoanal ultrasound, anorectal manometry, and neurophysiologic evaluation. Continence was assessed by the Cleveland Clinic Continence Score (0–20; 0, perfect continence; 20, complete incontinence). RESULTS: The two groups were comparable with regard to age (median, 45 years), past history of sphincter repair (n = 2), and posterior vaginal repair. There was no major morbidity. The wound-healing rate was identical between the two groups. However, of the patients undergoing overlapping repair, two had fecal impaction, and one had a urinary retention. Median preoperative continence score was 17 in both the direct-repair group (score, 8–20) and the overlap group (score, 7–20). At a median follow-up of 18 months, the improvement in continence was similar between the two surgical groups, with a median continence score of 3, respectively. In both surgical groups there was a significant and similar improvement in maximum squeeze pressure and in the functional anal canal length postoperatively (P < 0.05), but the mean resting pressure was relatively unchanged. In the overlap group, one patient developed a unilaterally prolonged pudendal nerve terminal motor latency that was persistent 22 months after surgery, and two patients had impaired fecal evacuation postoperatively. CONCLUSIONS: This randomized, controlled study suggests that the outcome is similar whether direct end-to-end or overlapping repair of a sphincter defect is performed. Overlapping repair might be associated with more difficulties with fecal evacuation and a prolonged pudendal nerve terminal motor latency postoperatively.

Urinary and faecal incontinence following delayed primary repair of obstetric genital fistula

Objective To evaluate: (1) the factors associated with the development of obstetric genitourinary fistula, (2) the incidence of urinary and faecal incontinence following closure of the fistula and (3) the urodynamic findings in women with persistent urinary incontinence.

A new classification for female genital tract fistula

Neglected prolonged obstructed labour is the most common cause of genital tract fistulae worldwide. Pressure necrosis of soft pelvic tissues occurs between the impacted fetal presenting part and the bony maternal pelvis. Other obstetric reasons for genital tract fistulae include vaginal trauma and laceration from instrumental deliveries or spontaneous vaginal deliveries, from Caesarean sections, symphysiotomies and destructive procedures. It is estimated (probably an underestimation) that over 100 000 new cases of fistulae occur each year and current United Nations Population Fund (UNFPA) data indicates that currently, genital tract fistulae affect at least 2 million women world-wide. In developed countries, over 90% of genital tract fistulae occur following pelvic surgery. Urinary tract injury complicates 1% of all gynaecological procedures and Caesarean sections and the incidence of genitourinary fistula following all hysterectomies is 0.8/1000. Surgery is the mainstay of treatment for the woman with a genital tract fistula. The rate of successful closure is over 85% in experienced hands but there has been a tendency to focus on the surgical closure of the fistula as the successful outcome measure rather than function following surgery. Successful surgical closure of the defect should be called ‘anatomical closure’ rather than ‘cure’, because it is clear many women suffer from ongoing pelvic organ, sexual and psychological dysfunction.

Predicting the risk of failure of closure of obstetric fistula and residual urinary incontinence using a classification system.

The aim of this study is to assess the possibility of predicting the risk of failure of closure and post-fistula urinary incontinence. Women attending the fistula clinics were assessed pre-operatively, and fistulae were staged prospectively, using a previously published classification system. Assessment for fistula closure and residual urinary incontinence was performed, prior to discharge. Of the 987 women who were assessed, 960 had successful closure of their fistulae. Of those with successful closure, 229 complained of urinary incontinence following surgery. Women with fistulae located closest to the external urinary meatus had the highest rate of urinary incontinence following fistula closure. Women with significant vaginal scarring and circumferential fistulae also had significantly higher rates of urinary incontinence and higher risk of failure of closure. The classification used is able to predict women at risk of post-fistula urinary incontinence and failure of closure.

Laparoscopic versus open Burch colposuspension : a randomised controlled trial

Objective  To compare perioperative characteristics, short‐term, and long‐term outcomes for laparoscopic Burch colposuspension (LBC) and open Burch colposuspension (OBC) for the treatment of urinary stress incontinence.

Is levator avulsion a predictor of cystocele recurrence following anterior vaginal mesh placement

Levator avulsion has been shown to be a predictor of cystocele recurrence following anterior colporrhaphy. The aim of this study was to determine if levator avulsion is a risk factor for prolapse recurrence following anterior colporrhaphy with mesh.

Biomechanical properties of raw meshes used in pelvic floor reconstruction

Female urinary incontinence and pelvic organ prolapse are common conditions. The aim of this study was to assess the biomechanical properties of raw meshes commonly used in pelvic floor surgery, particularly the effects of cyclical loading on these meshes. The material properties of nine different types of surgical meshes were examined using uniaxial tensile tests. The strength and extensibility of the mesh designs differed considerably. Most mesh types exhibited curvilinear loading curves. Cyclical loading of mesh samples produced significant permanent deformation in all mesh designs. This non-recoverable extension ranged from about 8.5% to 19% strain. Hysteresis also varied considerably between materials from 30% to 85%. All mesh groups tested for their biomechanical properties displayed differences in results for failure load, stiffness, non-recoverable extension and hysteresis.

Abdominal sacral colpopexy: an independent prospective long‐term follow‐up study

Aims:  The aim of the study was to provide a long‐term follow up of subjective and objective outcomes following sacral colpopexy.

How could management of rectoceles be optimized

A posterior vaginal wall prolapse, also known as a rectocele, is a common condition and is an outpouching of the posterior vaginal wall and anterior rectal wall into the lumen of the vagina. 1−5 Although more common in parous women, rectoceles of over 1 cm in size have been demonstrated in over 40% of nulliparous women. As rectoceles may be asymptomatic, their true prevalence is not clear. Many women with rectoceles present to their gynaecologist who may not ascertain any anorectal symptoms or perform a rectal examination. Conversely, colorectal surgeons often disregard a vaginal examination. 6 Conventionally, gynaecologists have managed rectoceles, but increasingly colorectal surgeons are involved because of the prevalence of anorectal symptoms. There are many surgical techniques for the management of a symptomatic rectocele. There is, however, little data to suggest which is the most effective technique, or whether specific techniques are more appropriate in certain circumstances. 7