Linda Brubaker

Outcome after rectovaginal fascia reattachment for rectocele repair

OBJECTIVE This study was undertaken to determine the effects of rectovaginal fascia reattachment on symptoms and vaginal topography. STUDY DESIGN Standardized preoperative and postoperative assessments of vaginal topography (the Pelvic Organ Prolapse staging system of the International Continence Society, American Urogynecologic Society, and Society of Gynecologic Surgeons) and 5 symptoms commonly attributed to rectocele were used to evaluate 66 women who underwent rectovaginal fascia reattachment for rectocele repair. All patients had abnormal fluoroscopic results with objective rectocele formation. RESULTS Seventy percent (n = 46) of the women were objectively assessed at 1 year. Preoperative symptoms included the following: protrusion, 85% (n = 39); difficult defecation, 52% (n = 24); constipation, 46% (n = 21); dyspareunia, 26% (n = 12); and manual evacuation, 24% (n = 11). Posterior vaginal topography was considered abnormal in all patients with a mean Ap point (a point located in the midline of the posterior vaginal wall 3 cm proximal to the hymen) value of -0.5 cm (range, -2 to 3 cm). Postoperative symptom resolution was as follows: protrusion, 90% (35/39; P <.0005); difficult defecation, 54% (14/24; P <.0005); constipation, 43% (9/21; P =.02); dyspareunia, 92% (11/12; P =.01); and manual evacuation, 36% (4/11; P =.125). Vaginal topography at 1 year was improved, with a mean Ap point value of -2 cm (range, -3 to 2 cm). CONCLUSION This technique of rectocele repair improves vaginal topography and alleviates 3 symptoms commonly attributed to rectoceles. It is relatively ineffective for relief of manual evacuation, and constipation is variably decreased.

Pudendal denervation affects the structure and function of the striated, urethral sphincter in female rats

Our aim was to examine the effects of denervation on urethral anatomy and urine voiding pattern. Rats usually void at one end of their cage, which gives a behavioral index of continence. The voiding preference for denervated rats was decreased to 88.8+4.7%,n=32,P<0.001, compared to improvements with time for unoperated (117±10%,n=16) or sham-operated rats (105±8%,n=5). The volume of urine or the frequency of voidings between denervated, unoperated or sham-operated rats did not differ significantly. Urethral sections were analyzed immunochemically and quantified morphometrically. Smooth muscle volume remained constant but skeletal muscle volume decreased after denervation, from 43±2% to 36±3% (P<0.05,n=5). Fiber diameter decreased from 14.3±1.4 μm to 8.5±0.7 μm (P<0.005). We concluded that pudendal nerve transection in female rats causes behavioral alterations in voiding and muscular atrophy of the striated sphincter.

Vaginal topography does not correlate well with visceral position in women with pelvic organ prolapse

The objective was to determine whether vaginal topography accurately predicts the location of the pelvic viscera on fluoroscopy in women with pelvic organ prolapse. Eighty-nine women undergoing preoperative evaluation for reconstructive pelvic surgery at a tertiary care referral practice formed the study population. Each woman completed a comprehensive urogynecologic history and physical examination, which included a quantified (POP-Q) assessment of her vaginal topography, as described by Bump et al. In addition each woman underwent pelvic floor fluoroscopy (PFF). Visceral sites were selected which corresponded clinically to the vaginal sites measured by the POP-Q. The most dependent portion of the bladder, small intestine, rectum and urethrovesical junction was measured. Twenty-five (28%) women had stage II prolapse, 34 (38%) had stage III prolapse, and 28 (32%) had stage IV prolapse. The remaining 2 women were symptomatic, with stage I prolapse. For the entire study population there was no correlation between the fluoroscopic position of the small bowel and/or rectum and any apical or posterior wall POP-Q site (C, Ap or Bp). There was no correlation with the fluoroscopic position of the UVJ at rest or with straining and the corresponding POP-Q site (Aa). The fluoroscopic position of the most dependent portion of the bladder correlated only modestly with the upper (Ba,ρ=0.51) and lower Aa,ρ=0.68) anterior vaginal wall POP-Q sites. In women without prior surgery (n=33) there was only modest correlation between the fluoroscopic position of the bladder and the corresponding POP-Q site (Aa,ρ=0.71). In this unoperated subpopulation there was no correlation with PFF and any other POP-Q site. In women who had undergone prior hysterectomy (n=25) or hysterectomy with anterior and/or posterior colporrhaphy (n=17), there was only a modest correlation of the most dependent portion of the bladder and the upper anterior vaginal wall site (Bb,ρ=0.67 andρ=0.55, respectively). It was concluded that vaginal topography does not reliably predict the position of the associated viscera on PFF in women with primary or recurrent pelvic organ prolapse.

Levator ani muscle in women with genitourinary prolapse: Indirect assessment by muscle histopathology

The objective of this study was to assess the state of innervation in levator ani muscle sites using muscle histopathology.

Sacrocolpopexy and the anterior compartment: Support and function

Abstract OBJECTIVES: This report analyzes the functional and anatomic results of the anterior compartment when Burch retropubic urethropexy or paravaginal repair are performed at the time of sacrocolpopexy. STUDY DESIGN: A retrospective chart review of 65 women undergoing sacrocolpopexy for repair of symptomatic prolapse was performed. Pertinent subjective and objective parameters were abstracted preoperatively and postoperatively. History, including symptoms, physical findings, and urodynamic testing were performed in an identical manner preoperatively and 3 months postoperatively. RESULTS: Sixty-five women (mean age 62 years [range 29 to 89 years]) underwent sacrocolpopexy. Preoperative and postoperative symptoms included protrusion (100% and 3%, respectively), stress urinary incontinence (60% and 16%), urge incontinence (51% and 28%), and voiding dysfunction (14% and 3%). Anterior and apical prolapse protruded beyond the hymen in 85% of patients preoperatively and in 3% postoperatively. Urodynamics diagnoses were assessed preoperatively and postoperatively: genuine stress incontinence (80% and 13%, respectively) and detrusor instability (41% and 42%). The location of cystocele defects preoperatively and postoperatively was combined (38 and 10, respectively), pure lateral (24 and 1), pure midline (2 and 18), and none (1 and 46). CONCLUSIONS: Abnormalities in lower urinary tract function commonly exist in patients with apical support loss. A high cure rate for genuine stress incontinence can be obtained with retropubic repositioning. Cure rates for apical support are excellent, although anterior wall recurrences occur. The preoperative diagnosis of cystocele location appears problematic and warrants further study.

Pubic osteomyelitis and granuloma after bone anchor placement.

Abstract: The use of bone anchors as a superior fixation for suburethral slings is becoming popular. We present a case report of pubic osteomyelitis and granuloma after bone anchor placement. A 71-year-old woman underwent placement of a vaginal wall sling using pubic bone anchors placed through a suprapubic incision. Recurrent swelling of the mons pubis required re-exploration and removal of the anchors from an infected pubic bone. When symptoms persisted over the following 10 months, the patient underwent repeat surgery and excision of a pubic bone granuloma. The use of bone anchors in suburethral sling surgery is associated with possible increase in patient morbidity, and no benefit to the patient has been shown.

A comparison of women with primary and recurrent pelvic prolapse.

OBJECTIVE Our purpose was to identify clinically relevant differences in women with primary and recurrent pelvic organ prolapse. STUDY DESIGN Consecutive women undergoing reconstructive surgery completed a urogynecologic history and physical examination and underwent either multichannel urodynamic testing or pelvic floor fluoroscopy, or both. Two groups were compared: primary (no prior surgery for pelvic organ prolapse) and recurrent. RESULTS One hundred eighty-one consecutive women were studied-103 with primary and 78 with recurrent prolapse. The groups were similar with respect to age, race, weight, vaginal parity, prolapse stage, urodynamic diagnosis, extent of visceral malposition, and common urinary, anorectal, and sexual symptoms. Clinically relevant differences were found, with the recurrent group having shorter vaginal lengths (P =. 0005), being more likely to have had a hysterectomy for a nonprolapse indication (P =.00018) and to be receiving hormone replacement therapy (P =.00003). CONCLUSION The women with primary and recurrent pelvic organ prolapse in this population were remarkably similar in many quantifiable parameters measured. The clinical differences may be related to previous surgery for pelvic organ prolapse.

Urinary Tract Injuries in Pelvic Surgery

In this article, we have reviewed the scope of surgically induced damage to the lower urinary tract. Preventative and reparative techniques have been presented. As pelvic surgeons become more confident in their efforts to safeguard the urinary tract, the chance of an unrecognized injury causing morbidity will diminish.

Simple standing incremental cystometry as a screening method for detrusor instability

One hundred consecutive neurologically normal women complaining of urinary incontinence underwent standing incremental retrograde medium-fill water cystometrograms on two different days followed by sitting and standing continuous retrograde medium-fill water urethrocystometry on a third visit between November 1987 and February 1989. Studies were done to assess the reproducibility, sensitivity, specificity, and predictive values of a simple cystometer. Standing incremental, retrograde cystometry was found to be relatively inexpensive, simple, reproducible, and sensitive. The two cystometrograms yielded similar results in 84% of the patients. The sensitivities were found to be 84.3 and 90.2% for the first and second cystometrograms, respectively. Using both cystometrograms together, we were able to detect detrusor instability with a sensitivity of 92.3% and to predict its absence with a negative predictive value of 86.7%. Detrusor instability was found in 64% of these patients. Based on these results, it was concluded that when multichannel urodynamics are not available in a high prevalence population, standing retrograde incremental water cystometry done on two occasions may offer the physician an accurate alternative for the diagnosis of detrusor instability

Suburethral sling release

Background The suburethral sling is an effective surgical procedure for curing genuine stress incontinence. However, a well-known complication is urinary retention. This report describes a method of modifying sling placement 6 weeks after the initial surgery to ameliorate the complication of urinary retention. Case A 68-year-old woman had undergone suburethral sling placement as part of her pelvic reconstructive surgery. Preoperatively, she had objective, urodynamic evidence of severe genuine stress incontinence, consistent with intrinsic sphincter deficiency. She was unable to void for 6 weeks postoperatively, at which time this procedure was offered. After an uneventful suburethral sling release, the patient had immediate return of voiding function, and symptoms resolved over the next 2 weeks. Conclusion This procedure may be a useful alternative to sling removal in cases of persistent urinary retention after placement of a suburethral sling.