Michael Heit

Release of tension-free vaginal tape for the treatment of Refractory postoperative voiding dysfunction

OBJECTIVE To report our experience with surgical release of tension‐free vaginal tape (TVT) for the treatment of persistent post‐TVT voiding dysfunction. METHODS A total of 1175 women underwent TVT placement for treatment of genuine stress urinary incontinence and/or intrinsic sphincter deficiency over a 2‐year period. Additional procedures and vaginal repairs were performed as indicated. Among these patients, 23 women (1.9%) had persistent voiding dysfunction (urinary retention, incomplete bladder emptying, or severe urgency or urge incontinence) refractory to conservative management. This cohort underwent a simple vaginal TVT release procedure, performed on an outpatient basis. Preoperative characteristics, intraoperative, and postoperative details were assessed by review of operative notes, medical records, and office notes. Continence status was assessed using subjective and objective information. RESULTS Mean age was 67 years (range 46–86 years), and the mean interval between TVT placement and release was 17.3 weeks (range 2–69 weeks; median 8.6 weeks). For the release procedure, there were no intraoperative complications, and all patients were discharged on the day of surgery. All cases of impaired emptying were completely resolved, and all cases of irritative symptoms were resolved (30%) or improved (70%) by 6 weeks. Fourteen (61%) patients remained continent 6 weeks after the release procedure, six (26%) were improved over baseline, and three patients (13%) had recurrence of stress incontinence. CONCLUSION Refractory voiding dysfunction after TVT is a relatively uncommon situation and can be successfully managed with a simple midline release procedure. In most cases, the release procedure does not compromise overall improvement in symptoms of stress incontinence.

Predicting treatment choice for patients with pelvic organ prolapse

OBJECTIVE To evaluate which clinical factors were predictive of treatment choice for patients with pelvic organ prolapse. METHODS One hundred fifty-two patients were enrolled in this cross-sectional study to collect clinical data on potential predictors of treatment choice. Continuous parametric, continuous nonparametric (ordinal), and categoric data were compared with chosen management plan (expectant, pessary, surgery) using analysis of variance, the Kruskal–Wallis test, and the χ2 test for association, respectively. All significant predictors (P < .05) of treatment choice for pelvic organ prolapse identified during univariate analysis were entered into a backward elimination polytomous logistic regression analysis for predicting surgery versus pessary versus expectant management, with surgery as the reference group. RESULTS The probability of choosing expectant management rather than surgery 1) increases as the preoperative pelvic pain score increases (odds ratio [OR] 1.6; 95% confidence interval [CI] 1.07, 2.40; P = .024) and 2) decreases as the prolapse severity increases (OR 0.46; 95% CI 0.29, 0.72; P = .001). The probability of choosing pessary rather than surgery 1) increases as age increases (OR 1.1; 95% CI 1.05, 1.16; P < .001), 2) decreases as the prolapse severity increases (OR 0.77; 95% CI 0.60, 0.99; P = .042), and 3) is less if the participant had prior prolapse surgery (OR 0.23; 95% CI 0.07, 0.76; P = .017). CONCLUSION Age, prior prolapse surgery, preoperative pelvic pain scores, and pelvic organ prolapse severity were independently associated with treatment choices in a predictable way and provide physicians with medical evidence necessary to support a patients decision.

Is Pelvic Organ Prolapse a Cause of Pelvic or Low Back Pain

OBJECTIVE To test the null hypothesis that there is no association between pelvic organ prolapse and pelvic or low back pain. METHODS A total of 152 consecutive patients with pelvic organ prolapse completed a visual faces scale to quantify the amount of pelvic or low back pain present. Pelvic organ prolapse severity was graded by three techniques: 1) pelvic organ prolapse quantification staging; 2) descent of the leading edge of prolapse; and 3) dynamic cystoproctography. Linear and nonlinear associations of pelvic organ prolapse quantification staging, descent of the leading edge of prolapse, and dynamic cystoproctography findings with pelvic or low back pain were assessed. We also characterized the nature of any significant nonlinear associations. RESULTS Descent of the leading edge of prolapse was linearly associated with low back pain. Patients with greater descent of the leading edge of their prolapse reported less low back pain (r = −0.176, P = .034). Bladder descent during dynamic cystoproctography was nonlinearly associated with low back pain (P = .037). Neither of these associations was statistically significant after controlling for patient age and prior prolapse surgery. There were no linear or nonlinear associations between pelvic organ prolapse and pelvic pain. CONCLUSION Based on the data, pelvic organ prolapse is not a cause of pelvic or low back pain.

Rupture of the symphysis pubis during vaginal delivery followed by two subsequent uneventful pregnancies.

BACKGROUND Rupture of the symphysis pubis during vaginal delivery is a rare but debilitating complication. Factors contributing to rupture are poorly defined. CASE A healthy primigravida suffered a rupture of her symphysis pubis during an otherwise uncomplicated vaginal delivery. She experienced significant pain and difficulty walking for 6 months after the injury. Her 5-cm symphyseal separation was managed successfully with physical therapy and activity restriction. The patients two subsequent deliveries (one vaginal and one via cesarean delivery) were uneventful. CONCLUSION Severe symphyseal rupture during vaginal delivery can be managed without surgery. Risk factors for rupture are not well defined. Based on a literature review, there is a significant risk of repeat symphyseal rupture with subsequent vaginal delivery.

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.

Poor Surgical Outcomes after Fascia Lata Allograft Slings

Abstract: The objective of this retrospective case control study was to determine whether our poor surgical outcomes were associated with the material used to construct our pubovaginal slings. Autologous rectus fascia was used in 33 patients and cadaveric fascia lata was used in 12 patients who underwent pubovaginal sling placement for intrinsic urethral sphincter deficiency (ISD). Treatment was successful in 78.8% and 33.3% of patients who underwent rectus fascia and fascia lata allograft slings, respectively (P=0.006). Based on regression analysis, the sling material was found to be strongly associated with surgical outcome after controlling for all confounding variables (β coefficient = 1204.6, P<0.00005). We conclude that fascia lata allografts are a poor choice for pubovaginal slings.

Bacterial Colony Counts During Vaginal Surgery

Objective: To describe the bacterial types and colony counts present before and during vaginal surgery. Methods: A descriptive study was undertaken of patients undergoing vaginal hysterectomy with or without reconstructive pelvic surgery. Aerobic and anaerobic bacterial cultures were obtained immediately before and throughout the surgical cases at preselected time intervals. Standard antimicrobial prophylaxis was administered in all cases. Mean total colony counts and mean anaerobic colony counts were determined by adding all colonies regardless of bacteria type. ‘Contamination’ was defined as ≥ 5000 colony-forming units/ml. Results: A total of 31 patients aged 26 to 82 years (mean age ± SD, 51 ± 15) were included. The highest total and anaerobic colony counts were found at the first intraoperative time interval. On the first set of cultures (30 minutes after the surgical scrub), 52% (16/31) of the surgical fields were contaminated, and at 90 minutes, 41% (12/29) were contaminated. A negligible number of subsequent cultures were contaminated. Conclusions: Any future interventions designed to minimize bacterial colony counts should focus on the first 30 to 90 minutes of surgery.

Effect of anesthesia on voiding function after tension-free vaginal tape procedure.

OBJECTIVE To determine whether the mode of anesthesia used during the tension-free vaginal tape procedure affects postoperative voiding function. METHODS A retrospective cohort study was performed using cases in which tension-free vaginal tape placement was the sole procedure performed. Of the 173 cases reviewed, we were able to use the data from 163. Hierarchal linear regression was used to identify independent predictors of our dependent variable: days to complete voiding. In the first block, established predictors of postoperative voiding dysfunction were entered into the model. In the second block, potential confounders of the relationship between anesthesia type and days to complete voiding identified during univariate analysis (P < .15) were entered into the model. In the third block, anesthesia type was entered into the model to determine whether it added any unique variance after controlling for previously established predictors of postoperative voiding dysfunction. RESULTS The mean days to complete voiding was similar in our local or regional anesthesia (n = 90) and general anesthesia groups (n = 73) (2.3 [0–21] versus 2.3 [0–14], P = 95). Our final regression model (F = 2.74, P = .011) included age, prior pelvic organ prolapse surgery, and preoperative urge symptoms and explained 22.2% of the variance in days to complete voiding. Anesthesia type did not add any predictive improvement after controlling for these variables. CONCLUSION General anesthesia, and therefore lack of a cough-stress test, does not increase the chance of postoperative voiding dysfunction associated with tension-free vaginal tape.

Urethral sphincter morphology in women with detrusor instability

OBJECTIVE To determine whether sonographic urethral sphincter morphology is different in patients with detrusor instability than in those with normal urodynamic testing. METHODS Patients from a population of women presenting for evaluation of urinary incontinence or pelvic organ prolapse underwent intraurethral ultrasonography before multichannel urodynamic testing. Maximal rhabdosphincter thickness, total urethral diameter, total urethral circumference, and longitudinal smooth muscle thickness, diameter, and circumference were measured. For patients with detrusor instability, the strength of the involuntary detrusor contraction and the bladder volume at its onset were recorded. These data were compared with information from history questionnaires and urodynamic evaluations. RESULTS The 17 patients with detrusor instability and 16 patients with normal urodynamic testing did not differ with respect to age, vaginal parity, race, weight, body mass index, prior continence surgery, or maximal total urethral closure pressure. Patients with detrusor instability, had decreased urethral longitudinal smooth muscle thickness (3.0 ± 0.9 mm vs 4.1 ± 0.7 mm, P = .001), total urethral diameter (18.0 ± 1.6 mm vs 19.4 ± 1.4 mm, P = .01), and total urethral circumference (5.65 ± 0.5 cm vs 6.1 ± 0.4 cm, P = .012) compared with those with normal urodynamic tests. A linear relationship between rhabdosphincter thickness and strength of involuntary detrusor contraction was observed (r = .686, P = .002). CONCLUSION Urethral sphincter morphology is different in patients with detrusor instability compared with those who have normal urodynamic tests. These findings provide an anatomic basis for the physiologic findings in patients with “urethrogenic” detrusor instability.

Intraurethral Ultrasonography: Correlation of Urethral Anatomy with Functional Urodynamic Parameters in Stress Incontinent Women

Abstract: To determine whether differences in functional urodynamic parameters can be explained by changes in urethral anatomy, 39 patients underwent intraurethral ultrasonography to obtain a 360° view of the urethra. The point of maximal rhabdosphincter thickness was identified in all patients. The thickness, circumference and area of the urethral smooth and skeletal muscle layers were calculated. Data from patient histories and urodynamic evaluations were compared with this anatomical survey. The urodynamic diagnoses were as follows: 10 patients were normal, 24 had genuine stress incontinence and 5 had intrinsic sphincter deficiency. These patients had decreasing rhabdosphincter thicknesses of 3.91, 3.35 and 2.70 mm (P= 0.048). A weak linear relationship was found between maximal urethral closure pressure and rhabdosphincter (r= 0.40, P= 0.013) and longitudinal smooth muscle (r= 0.35, P = 0.027) thickness. It was concluded that a loss of urethral resistance as measured by maximal urethral closure pressure is associated with changes in urethral anatomy identified by intraurethral ultrasonography.