Michele Meschia

Tension-Free vaginal tape: analysis of outcomes and complications in 404 stress incontinent women.

Abstract: The aim of this prospective multicenter study was to evaluate the safety and efficacy of tension-free vaginal tape (TVT) for the surgical treatment of female stress incontinence. Four hundred and four women underwent the TVT procedure. Their mean age was 57 years (range 31–83). The median follow-up time was 21 months (range 12–35). The subjective and objective cure rates were 92% and 90%, respectively. Another 4% of the women were significantly improved by the procedure. Intra- and postoperative complications were few and included uneventful bladder perforations (6%), retropubic bleeding requiring surgery (0.5%), voiding difficulties (4%) in the postoperative course, and one obturator nerve injury. We conclude that the TVT procedure is associated with a high cure rate and a low morbidity.

Functional and anatomical outcome of anterior and posterior vaginal prolapse repair with prolene mesh

Objective  To evaluate the effects of prolene mesh on urinary, bowel and sexual function in prolapse surgery.

Reproductive factors, family history, occupation and risk of urogenital prolapse.

OBJECTIVE We conducted a case-control study to analyze risk factors for urogenital prolapse requiring surgery. METHODS Cases were 108 women with a diagnosis of II or III degree uterovaginal prolapse and/or third degree cystocele. Controls were 100 women admitted to the same hospitals as the cases, for acute, non-gynecological, non-neoplastic conditions. RESULTS Occupation showed an association with urogenital prolapse: in comparison with professional/managerial women, housewives had an odds ratios (OR) of urogenital prolapse of 3.1 (95% confidence interval (CI), 1.6-8.8). Compared with nulliparae, parous women tended to have a higher risk of genital prolapse (OR 2.6, 95% CI 0.9-7.8). In comparison with women reporting no vaginal delivery, the ORs were 3.0 for women reporting one vaginal delivery (95% CI 1.0-9.5), and 4.5 (95% CI 1.6-13.1) for women with two or more vaginal deliveries. Forceps delivery and birthweight were not associated with risk of prolapse after taking into account the effect of number of vaginal deliveries. The risk of urogenital prolapse was higher in women with mother or sisters reporting the condition: the ORs were, respectively, 3.2 (95% CI 1.1-7.6) and 2.4 (95% CI 1.0-5.6) in comparison with women whose mother or sisters reported no prolapse. CONCLUSIONS Our data support the clinical suggestion that parous women are at a higher risk of prolapse and the risk increases with number of vaginal deliveries. First-degree family history of prolapse seems to increase the risk of prolapse.

Prevalence of anal incontinence in women with symptoms of urinary incontinence and genital prolapse

OBJECTIVE To investigate risk factors and prevalence of anal incontinence among women with pelvic floor dysfunctions. METHODS We evaluated 881 women with symptoms of urinary incontinence and/or genital prolapse. Each completed a bowel questionnaire and underwent a detailed medical, surgical, obstetric, and gynecologic history, and a pelvic examination. Additional testing, when indicated, included office cystometry or multichannel urodynamic evaluation. Multivariable analysis using logistic regression was used to test the overall significance of all variables significantly associated with anal incontinence, using univariate analysis. RESULTS A total of 178 women had anal incontinence (20%). These patients were on average older, had a greater body mass index, and had larger birth weight infants than their anal‐continent counterparts; 511 were diagnosed with urinary incontinence, and 122 (24%) also had anal incontinence. Women with urinary incontinence were more likely to report anal incontinence events than women continent of urine (24% versus 15%, P = .002). The following associations were found with anal incontinence: infant with birth weight 3800 g or greater (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.1, 2.2), rectocele greater than grade 2 (OR 1.9, 95% CI 1.1, 3.3), urinary incontinence (OR 1.9, 95% CI 1.3, 2.8), hemorrhoidectomy (OR 2.7, 95% CI 1.1, 7.0), irritable bowel syndrome (OR 6.3, 95% CI 3.5, 11.5). CONCLUSION Among women with symptoms of urinary incontinence and pelvic organ prolapse, the prevalence of anal incontinence was 20%. Urinary incontinence and severe rectocele were found to be associated with anal incontinence.

Bladder Detrusor Endometriosis: Clinical and Pathogenetic Implications

PURPOSE We examined the pathogenesis of vesical endometriosis, identified the diagnostic signs and defined a successful management strategy. MATERIALS AND METHODS The records of 8 patients with bladder detrusor endometriosis were reviewed. RESULTS Two distinct forms of the condition appear to exist, that is spontaneous and post-cesarean. In the former case the bladder lesion is a manifestation of a generalized pelvic disease, whereas after iatrogenic dissemination growth of ectopic endometrium is usually limited to the bladder wall. The catamenial nature of bladder symptoms (frequency, urgency, dysuria and tenesmus) was pathognomonic. Cystoscopy with biopsy was diagnostic in 3 cases. Ultrasonography revealed an endo-luminal vegetation and ruled out an anterior uterine leiomyoma, whereas magnetic resonance imaging did not add relevant information. Partial cystectomy appears to cure the urinary disturbances. CONCLUSIONS We suggest a high index of suspicion of vesical endometriosis in all premenopausal women complaining of catamenial bladder symptoms with negative urine cultures.

The effect of menopause on blood lipid and lipoprotein levels

There is increasing evidence from epidemiological studies that exogenous estrogen (hormone replacement therapy) protects against the elevated risk of cardiovascular disease in women after the menopause. However, it is still uncertain whether the postmenopausal decrease in endogenous estrogen in itself contributes significantly to this increase in risk. Most of the studies that have provided evidence linking cardiovascular disease with menopause have involved North American women, who may differ significantly from Europeans in terms of lifestyle and diet. ICARUS (Italian Climacteric Research Group Study) is an observational study that involves Italian Menopause Clinics, with the objective of collecting observational data on menopause and its management. The results of a cross-sectional analysis of 9309 women, free from any hormonal treatment and enrolled up to March 1997, are reported here. Data show that the menopause has a marked effect on the circulating levels of lipids and lipoproteins. From pre- to post-menopause there are significant increases in total cholesterol (6.9% before and 4.4% after adjustment for covariates including chronological age, educational level, center, BMI, smoking habits, hypertension and diabetes, previous contraceptive use, and time since menopause), LDL (7.5% before, 4.0% after), and triglycerides (9.0% before, 3.2% (ns) after). However, there is no significant change in HDL. Among postmenopausal women, no effect on lipid profile of time since menopause was observed.

Determinants of age at menopause in Italy: results from a large cross-sectional study

OBJECTIVE To identify the determinants of age at menopause in an Italian population, using data from the Italian Climacteric Research Group Study (ICARUS). METHODS ICARUS is a prospective study of the effect of menopause on womens health that has been running in menopause clinics throughout Italy since 1995. A total of 4300 women with spontaneous menopause, aged 55 years or more and observed for the first time at the participating centres are included in the present analysis. RESULTS The mean age at menopause in the total population was 50.9 years. After taking into account potential covariates, the women reported smoking, had a slightly lower mean age at menopause than non smokers 50.4 versus 50.9 years; P = 0.01. The mean age at menopause in nulliparae was 50.0 years, and, respectively 50.4, 50.6, 50.9, 51.2 and 50.9 years in those reporting 1, 2, 3, 4 and 5 or more births (P < 0.01). A low body mass index and an early age at menarche were associated with early menopause in the crude analysis, but these associations disappeared after taking into account the confounding factors. CONCLUSIONS This study offers an estimate of the mean age at menopause of women attending menopause clinics in Italy, on the basis of the data obtained from a large sample. It also indicates that smoking and nulliparity are associated with early menopause.

Bowel Perforation During Insertion of Tension-free Vaginal Tape (TVT)

Abstract: A 56-year-old non-obese woman with a previous history of pelvic surgery underwent an uneventful TVT procedure for the treatment of genuine stress incontinence. Postoperatively she began to report an acute low abdominal pain and a secondary laparoscopy was performed. The view of the right iliac region showed the tape passing through a loop of the small intestine. The tape was cut in its intraperitoneal portion and the ileum freed and repaired. After the operation the patient recovered well and was discharged on the fifth day after laparoscopy. Despite the section of the tape, 1 year later the patient is objectively cured by the procedure.

The Sacrospinous Vaginal Vault Suspension: Critical Analysis of Outcomes

Abstract: One hundred and three women with a preoperative diagnosis of a pelvic support defect underwent right sacrospinous fixation of the vaginal apex. The procedure was performed either therapeutically (in 63 subjects with vaginal vault eversion) or prophylactically (40 patients with severe uterovaginal prolapse), and was associated with other reconstructive procedures to repair the coexisting cystocele, enterocele or rectocele. Preoperative and postoperative assessments of each vaginal site were compared and the results in the cure of stress urinary incontinence, if present, were evaluated with regard to the type of surgery performed. The overall rate of satisfactory results in the repair of the superior vaginal defect was 94%, and good anatomic results were achieved in the repair of either enterocele or rectocele. Conversely, the repair of the anterior vaginal wall was not as good as in the posterior and superior vaginal sites. Stress urinary incontinence was successfully managed in 72% of the women using different anti-incontinence procedures.

Lipoprotein(a) and other lipids after oophorectomy and estrogen replacement therapy

Objective To assess the effect of surgical menopause and subsequent estrogen replacement therapy (ERT) on lipoprotein(a) [Lp(a)] and common lipids. Methods In 24 healthy premenopausal women, lipids (total cholesterol, low-density lipoprotein [LDL] and highdensity lipoprotein [HDL] cholesterol, and triglycerides) and gonadotropins (FSH, LH) were measured the day before hysterectomy with bilateral oophorectomy and then after 1, 2, and 3 months. Blood was also drawn after 2, 4, 6, and 15 days to exclude the effect of surgery on Lp(a). In 19 women who volunteered for ERT, the lipid profile was assayed again after 3, 6, and 12 months of treatment. Results Lipoprotein(a) levels rose significantly over the 3 months after surgery, from a mean ± standard deviation (SD) 5.7 ± 6.1 mg/dL to 10.4 ± 9.2 mg/dL. Total cholesterol and LDL cholesterol levels increased significantly over the first 2 months; HDL cholesterol decreased significantly during the 3 months of follow-up (by 10, 17, and 20%) (P < .001). Plasma triglycerides did not change after surgery. Three months following ERT, Lp(a) and total cholesterol were significantly decreased (28 and 11%, respectively), as was LDL cholesterol (33%) after 6 months. High-density lipopromein cholesterol increased by 24% after 6 months of treatment, and triglycerides rose significantly in the year of therapy (37%). Conclusion These findings suggest that surgical menopause induces atherogenic changes in the lipid profile in 3 months and that ERT soon reverses them.