Karolynn T. Echols

Urinary tract injury during hysterectomy based on universal cystoscopy.

OBJECTIVE: To estimate the incidence and location of injury to the urinary tract during hysterectomy for benign gynecologic disease. METHODS: This was a prospective clinical study in an academic environment performed at three sites. Diagnostic cystourethroscopy was performed on all patients after hysterectomy for benign disease. RESULTS: Eight hundred thirty-nine patients were enrolled. The incidence of urinary tract injury associated with hysterectomy for benign disease was 4.3% (39 of 839 cases). The rate of bladder injury was 2.9% (24 of 839 cases), and rate of ureteral injury was 1.8% (15 of 839 cases). There were three cases of simultaneous bladder and ureteral injuries, resulting in a cumulative injury rate of 4.3%. The injury detection rate using intraoperative diagnostic cystoscopy was 97.4% (817 of 839 cases). The most common site of injury to the ureter was at the junction of the ureter and the uterine artery in 80% (12 of 15 cases) of ureteral injuries. Transection and kinking injuries were the most frequent type of injury. There were 21 cases of subnormal dye efflux from the ureteral orifices, with no subsequent injury detected on further evaluation. CONCLUSION: Ureteral injury occurred most commonly at the level of the uterine artery, and transection and kinking injuries were most frequent. Diminished dye efflux from ureteral orifices was not associated with injury. LEVEL OF EVIDENCE: III

Digital examination compared to trans-perineal ultrasound for the evaluation of anal sphincter repair

Objective: To assess the adequacy of a third‐ or a fourth‐degree laceration repair by comparing digital and trans‐perineal ultrasound measurements. Method: During a 4‐year period, 34 subjects without prior history of anal sphincter injury or fecal incontinence underwent ultrasound measurements of external anal sphincter muscle diameter and perineal length, which were compared to measurements obtained by digital examination. Results: Pearsons correlation coefficients for comparing the digital external sphincter examination to trans‐perineal ultrasonography, and the digital perineal examination to trans‐perineal ultrasonography were 0.88 and 0.40, respectively. Patients (n=4/34) whose external sphincter was identified as less than 1 cm by digital examination were found to have an external sphincter diameter of less than 1 cm by trans‐perineal ultrasound. Conclusion: The digital perineum examination is a reliable method of measuring the external sphincter thickness and perineal body length immediately after primary repair.

Sling Procedures after repair of obstetric vesicovaginal fistula in Niamey, Niger.

Introduction and hypothesisThe purpose of this paper is to evaluate the results of sling procedures for stress incontinence after repair of vesicovaginal fistulae at the National Hospital in Niamey, Niger.MethodsThis study is a retrospective chart review of 701 women surgically treated for vesicovaginal fistulae. One hundred forty women subsequently underwent a sling procedure for stress incontinence after fistula repair.ResultsThe demographics among the groups were similar. No significant difference was seen in results between the sling types except the risk of erosion was significantly greater in the synthetic sling group. There was a trend towards greater sling success in the fascia lata group.ConclusionsCorrection of incontinence is a common and difficult challenge following repair of obstetric vesicovaginal fistula. Compared to published studies on sling procedures, these patients have higher rates of continued incontinence. This is likely due to the frequent loss of a urethral sphincter as well as high prevalence of detrusor overactivity and decreased bladder capacity.

Sinus formation after insertion of a silicone-coated suburethral sling

We report the case of a 65-year-old woman who developed a sinus tract after a suburethral synthetic silicone mesh sling placement. After removal of the sling material with debridement and reconstruction of the suburethral tissue, fascia lata harvest with a sling to abdominal rectus fascia was performed. Silicone mesh may erode to form a sinus tract if used as suburethral sling material.

Persistence of Delayed Hypersensitivity following Transurethral Collagen Injection for Recurrent Urinary Stress Incontinence

Abstract: Transurethral collagen injection is both safe and effective when used for the treatment of genuine stress urinary incontinence. It is associated with a minimal inflammatory response, and virtually no foreign body reaction. Most allergic reactions occur within 72 hours of treatment (immediate hypersensitivity). Although uncommon, delayed hypersensitivity reactions may occur and it is advisable to administer a collagen skin test 30 days prior to the procedure. Adverse effects may cause long-term sequelae, such as severe trigonal tenderness, urgency, frequency, hematuria, urinary retention and persistent stress urinary incontinence. A case of a prolonged delayed hypersensitivity reaction following negative collagen skin testing after transurethral collagen injection is presented. Treatment of stress incontinence could not be initiated until symptoms decreased significantly after 1 year.

Postoperative urinary retention following vaginal mesh procedures for the treatment of pelvic organ prolapse

Introduction and hypothesisThe objective of the study was to assess vaginal mesh procedures and patient characteristics that are associated with postoperative urinary retention (PUR) following pelvic reconstructive surgery.MethodsThe charts of 142 patients who underwent transvaginal reconstructive surgery with mesh were included in the analysis. Primary outcome was the incidence of PUR following surgery with mesh. Patients were grouped according to discharge from the hospital with or without a catheter based on a standardized voiding trial.ResultsForty-eight patients (34%) developed PUR after surgery. Of those, 30 patients (62.5%) had a combined anterior and posterior repair (p = 0.033). Mean preoperative anterior stage prolapse for patients with PUR compared with no PUR was 2.31 vs. 1.80 (p = 0.002). There was a greater association of PUR among patients with concomitant retropubic slings compared with transobturator slings (OR = 3.6, 95% confidence interval = 1.3–9.8).ConclusionsA higher preoperative anterior stage prolapse, combined anterior and posterior compartment repairs, and retropubic sling procedures appear to be associated with PUR.

Cystoscopic fistulography: a new technique for the diagnosis of vesicocervical fistula.

BACKGROUND Most fistulas communicating with the bladder are large enough to be diagnosed easily, or small enough to close spontaneously without clinical sequel. A vesicocervical fistula is an uncommon event and may be difficult to diagnose. TECHNIQUE During an operative cystourethroscopy procedure, suspicious areas of the bladder can be probed with a cone tip catheter and injected with contrast dye to visualize the suspected fistula communicating with the bladder. EXPERIENCE This technique was employed when a double dye test, an intravenous urogram, a cystogram, a computed tomography scan, and a hysterogram failed to localize the fistulous tract in a patient who was 3 weeks postpartum after a repeat cesarean with complaint of persistent urinary incontinence. CONCLUSION Cystoscopic catherization of suspicious lesions in the bladder may visualize an otherwise elusive fistulous tract.

Pelvic organ prolapse is associated with alteration of sphingosine-1-phosphate/Rho-kinase signalling pathway in human vaginal wall

Pelvic organ prolapse (POP) is a debilitating condition of unknown aetiology affecting > 50% of women over 40 years of age. In POP patients, the vaginal walls are weakened allowing descent of pelvic organs through the vagina. We sought to determine if sphingosine-1-phosphate (S1P) signalling, which regulates smooth muscle contractility and apoptosis via the RhoA/Rho-kinase (ROK) pathway, is altered in the vagina of women with POP. Utilising anterior vaginal wall specimens, we provide novel demonstration of the S1P pathway in this organ. Additionally, comparing specimens from women having pelvic reconstructive surgery for POP and control subjects, we reveal increases in mRNA expression of the three major mammalian S1P receptors (S1P1–S1P3), and RhoA and the ROK isoforms: ROKα and ROKβ in POP patients, which correlates with a decrease in elastic fibre assembly pathway constituents. Taken together, our data suggest the S1P/ROK pathway as a novel area for future POP research and potential therapeutic development.

Surgical treatment of persistent vaginal granulation tissue using CO(2) laser vaporization under colposcopic and laparoscopic guidance.

The authors recommend a CO2 laser, colposcopy, and laparoscopy for the management of recurrent vaginal mesh erosions.

A novel approach to recurrent vaginal vault prolapse in a patient with müllerian agenesis.

Background Vaginal agenesis is a congenital disorder affecting 1 in 4000 to 1 in 10,000 females. Lack of normal vaginal support structures may lead these patients to develop prolapse of the distal rudimentary vagina. Presently, there is no consensus regarding the best surgical option. However, the goal of surgery is to restore normal anatomy and establish normal sexual function. Case We report the case of a 28-year-old woman with müllerian agenesis, diagnosed at age 19 years, who presented with complaints of dyspareunia and vaginal eversion. One year before presentation to our practice, the patient underwent an anterior and posterior repair with mesh and a transobturator sling. After careful evaluation, the patient underwent excision of mesh and a second procedure to elongate and suspend her vagina. Her vaginal length was extended from 4 to 8 cm. Conclusions Prolapse of the neovagina in müllerian agenesis is a rare event; it can occur after nonsurgical or surgical treatments. Although there have been reported cases of abdominal or laparoscopic sacrocolpopexy to correct vaginal vault prolapse in these patients, there is a scarcity of information addressing the vault suspension in cases lacking healthy vaginal tissue. Our case shows how successful anatomical functional correction can be achieved with a simpler technique using an allograft to achieve a normal vaginal length in combination with a sacrocolpopexy.