Paul Riss

Tension-free vaginal tape operation: results of the Austrian registry.

OBJECTIVE To assess the use of and perioperative complications associated with the tension‐free vaginal tape operation with a central registry. METHODS Fifty‐five gynecology units completed questionnaires on patients undergoing the tension‐free vaginal tape operation. Information was collected on patient, surgical, and postoperative data. RESULTS A total of 2795 patients were entered. Overall, 773 patients (28%) had undergone previous surgery for incontinence or prolapse; 1640 (59%) tension‐free vaginal tapes were performed as isolated operations, and 1155 (41%) were done in combination with other procedures. The median operating time for tension‐free vaginal tapes alone was 30 minutes (range 10–120). Of the isolated tension‐free vaginal tapes, 727 (44%) were performed with local, 711 (43%) with regional, and 193 (12%) with general anesthesia. In patients undergoing tension‐free vaginal tape only, postoperative bladder drainage was obtained with intermittent catheterization in 389 (24%) patients, an indwelling urethral catheter in 1032 (63%), and a suprapubic catheter in 143 (9%). The bladder perforation rate was 2.7% overall (n = 75) and higher in patients with than in those without previous surgery (4.4% compared with 2.0%, P = .01). There were four bladder perforations (3.3%) among the 120 patients with previous colposuspension. Most patients undergoing tension‐free vaginal tape only were able to void the next day (range 0 to over 64). A total of 68 patients (2.4%) required reoperation for reasons related to the tape (39 to loosen, remove, or cut the tape, or to place a suprapubic catheter, 19 for hematoma, one for bowel injury). CONCLUSION The tension‐free vaginal tape has become a frequently performed operation in Austria. There are considerable variations in clinical practice. The risk of bladder perforation was increased in patients with previous surgery. Severe complications were rare.

Updated recommendations on ultrasonography in urogynecology

Ultrasound is a supplementary, indispensable diagnostic procedure in urogynecology; perineal, introital, and endoanal ultrasound are the most recommended techniques. The position and mobility of the bladder neck can be demonstrated. In patients undergoing diagnostic work-up for urge symptoms, ultrasound occasionally demonstrates urethral diverticula, leiomyomas, and cysts in the vaginal wall. These findings will lead to further diagnostic assessment. The same applies to the demonstration of bladder diverticula, foreign bodies in the bladder, and bullous edema. With endoanal ultrasound, different parts of the sphincter ani muscle can be evaluated. Recommendations for the standardized use of urogenital ultrasound are given.

The Austrian Tension-Free Vaginal Tape Registry

Abstract: In Austria a central registry for all TVT operations has been established in which more than 800 cases have so far been registered. The registry contains information on pertinent data on the operated patients and intra- and postoperative outcomes of the TVT surgery. No serious complications and no mortality have been registered until now.

Immunoexpression of B7-H3 in endometrial cancer: Relation to tumor T-cell infiltration and prognosis

OBJECTIVE B7-H3, a member of the B7 family of immune regulatory ligands regulates T cell-mediated peripheral immune response. The purpose of this study was to correlate the expression of B7-H3 and number of lymphocytes in patients with endometrial cancer. MATERIAL AND METHODS A total of 107 patients with primary endometrial carcinoma (type I/endometrioid, n=81; type II, n=18) and endometrial hyperplasia (n=8) were investigated. Expression of B7-H3 in endometrial hyperplasia, endometrial carcinoma, and the endothelium of tumor-associated vasculature was assessed using immunohistochemistry from paraffin-embedded tissue blocks. Detection of CD8-positive tumor-infiltrating lymphocytes (TIL) and CD8-positive tumor-associated lymphocytes (TAL) was correlated with the expression of B7-H3. RESULTS Patients with high grade tumors and patients with type II carcinomas expressed significantly more B7-H3 than low grade and endometrioid tumors (p=<0.0001 and p=0.0001, respectively). The expression of B7-H3 in the endothelium of identified vasculature in the tumor specimens showed similar results with strong relation to high grade tumors (p=0.001) and type II carcinomas (p=0.004). We found a significant correlation between B7-H3 expression on cancer cells and tumor T-cell infiltration (TIL) (p=0.017). In a univariate survival analysis, overexpression of B7-H3 in tumor cells was associated with shortened overall survival (p=0.005). CONCLUSIONS B7-H3 is overexpressed on cancer cells and in the endothelium of tumor-associated vasculature in high grade tumors (G3) and type II carcinomas. B7-H3 expression on cancer cells is correlated with the number of T cells infiltrating the tumor. Endometrium tumor development and progression may be associated with downregulation of T-cell-mediated antitumor immunity through B7-H3.

Quality of life and urinary incontinence in women

Urinary incontinence greatly diminishes quality of life. It is important to diagnose the three main types of urinary incontinence correctly - stress, urge or mixed incontinence - and to evaluate the impact of incontinence on quality of life. After a detailed history, a bladder diary and questionnaires are the most useful tools with which to determine what aspects of quality of life are most impaired - daily, work-related, recreational or sexual activities. In general, urgency and urge incontinence have a worse effect on quality of life than stress urinary incontinence. Measures of quality of life have become essential in developing management plans and in follow-up.

The mesh debate.

The U.S. Food and Drug Administration (FDA) published asecond warning to medical practitioners and patients on“Complications Associated with Transvaginal Placement ofSurgical Mesh for Pelvic Organ Prolapse” in July 2011.Following this, on the advice of legal advisors the researchand ethics committee of one of our hospitals (P.L.D)recommended that no further synthetic mesh be used forany incontinence or prolapse surgery. This recommendationwas a case of “throwing the baby out with the bath water”and was not ratified following further discussion. However,it is an indication of the perfect storm referred to byBrubaker and Shull in this issue of the InternationalUrogynecology Journal [1]. In order to give a range ofopinions we are also publishing in this issue the views ofother well-known gynaecologists on the usage of syntheticgrafts [2, 3].So how did we get to this? Polypropylene syntheticmesh has been used in urogynaecology since the 1960s totreat stress incontinence [4]. However, it was not untilUlmsten and Petros developed the TVT sling with itsadvantages of same-day surgery and less postoperative painand morbidity that the mid-urethral sling became thecommonest stress incontinence operation performed world-wide. This success led to the development of a number ofsimilar slings by many commercial companies. Complica-tions did occur, frequently related to inexperienced trocarpositioning and incorrect placement of tape in the bladder,small bowel or blood vessels. The incidence of polypro-pylene mesh-related complication was low, with a less than1% rate of infection or mesh exposure, although this wasnot the case when non-polypropylene tapes were used,when infection and rejection rates were high. These werethen discontinued, but not until considerable damage hadbeen done.The problem with transvaginal polypropylene mesh wasevident from the beginning. In a prospective randomisedstudy by Julian in 1996 of 24 patients with mesh versusnon-mesh for surgical treatment of recurrent cystocele [5],there was a better anatomical result with no recurrence inthe mesh group but 3 of the 12 patients had mesh exposure.When we reported our 2-year results in 2004, our meshexposure rate was 9% [6]. It was interesting that the resultsof a meta-analysis of recent studies published this year byAbed et al. [7] showed an incidence of 10.3%. Therefore,little progress has been made in this critical area despite theuse of softer, lighter polypropylene meshes.These exposures are often asymptomatic, but maycause symptoms of discharge, bleeding and pain, espe-cially during intercourse, both to the patient and herpartner. Bowel and bladder perforation are rare but occurespecially if these organs have been injured. These meshexposures in most cases require excision of the exposedmesh and vaginal closure, usually under general anaes-thesia as day surgery. In some cases multiple attempts atrepair are required for recurring mesh exposures. Asmesh exposures can occur late, long-term studies(10yearsormore)maybeneededtoknowthetruemesh exposure complication rate. Vaginal exposure of

The POP-Q classification system: looking back and looking forward

Pelvic organ prolapse is one of the most common problems facing every urogynecologist. Understandably, terminology is very important when describing vaginal or uterine descent, for two reasons. First, the physician’s notes must represent the clinical problem so that the physician knows what has been seen and can relate it to a colleague. The second reason is quality assurance and research, where exact terminology is needed to accurately describe changes in pelvic organ prolapse and to be able to make comparisons between institutions and studies. In 1996 Bump et al. published a classification developed by several societies [1]. This POP-Q has been widely adopted and become the de facto standard in clinical medicine and research [2]. After almost 20 years we may ask whether this classification is set in stone or whether it needs modifying? Three areas should be considered:

Nocturia in women.

Nocturia is a common problem in adults, which adversely affects quality of sleep and quality of life. This review summarizes the definition, epidemiology, clinical presentation, pathophysiology, diagnostic evaluation, and the therapeutic options with regard to a female population. Based on the degree of bother nocturia is classified as two or more episodes per night. It is most prevalent in older woman but also affects younger individuals. Voiding during nighttime leads to a disruption of sleep, affecting both sleep onset and maintenance. A clear understanding of its underlying pathophysiology, including diurnal polyuria, nocturnal polyuria, and bladder storage problems is necessary to address symptoms and co-morbid conditions. Diagnostic evaluation includes a detailed patients history, physical examination, laboratory tests, and a voiding bladder diary. For treatment, tailored lifestyle and behavioural changes are able to decrease bother. In addition some patients profit from pharmacological therapy with antimuscarinic agents and analogue of arginine vasopressin, however this strategy is often restricted by side effects.

The posterior intravaginal slingplasty operation: Results of the Austrian registry

OBJECTIVE We set up a registry to assess complications and short-term results of the posterior intravaginal slingplasty operation. STUDY DESIGN A total of 14 gynecology departments in Austria completed questionnaires addressing the patients history, the operation itself and the postoperative course. In the follow-up we asked for information on tape exposure and functional and anatomical results. RESULTS Fourteen centers entered a total of 577 patients operated between 2001 and 2006. 560 (97%) posterior slingplasty operations were done in conjunction with other procedures. Intraoperative complications were reported for 16 (2.8%) procedures. Postoperatively five hematomas required reoperation. 496 (86%) patients were available for follow-up after a median of 7 weeks (range, 1-156). 54 (9.4%) patients required reoperation. Vaginal tape exposure was seen in 50 (8.7%) women. Physicians assessed the functional and anatomical results as excellent or good in 83% and 88% of patients, respectively. CONCLUSION Despite the limitations of a registry and the high rate of concomitant procedures, this study provides data on the complications and results of the posterior intravaginal slingplasty operation.

Moving from case reports to images in urogynecology

Case reports have always been an integral part of the International Urogynecology Journal. Even in the era of evidence-based medicine, case reports have value: readers like them because they widen their clinical horizon and help them sharpen their diagnostic skills [1, 2]. Authors, early in their careers, often submit case reports as an entry into publishing manuscripts, and they often find case reports an opportunity to publish their own clinical experience. In addition, most readers enjoy case reports because they are interesting takes on unique issues in clinical practice. Journals, on the other hand, are often ambivalent in regard to case reports. Case reports take up space in the printed issue and are rarely cited, thus affecting the impact factor negatively. As a consequence, journals do not publish case reports at all, limit the number they publish in an issue, or group them together in a special issue or supplement [3]. Some publishers also offer the option to transfer case reports for publication in a separate special open-access journal. At the International Urogynecology Journal we are aware of these issues and have tried to limit the number of case reports we accept for publication. As a consequence, in 2013, out of the 73 case reports we received only 20 were accepted for publication (27 %). We have also considered various options. After the successful introduction of the “IUJ Video” section, we think that a way forward could be twofold: we would encourage authors to present a series of cases rather than a single case, with discussion of the relevant literature (published as original articles or reviews). Additionally, we would create a new section: “Images in Urogynecology”, which would take the place of individual case reports. There is no doubt that with digital technology the use of images has increased dramatically in social and professional media.Manymedical journals have special sections for images, with some text, to illustrate a teaching point or a special or unusual case. Case reports most frequently include illustrations, so it seems to us a logical step to invite authors to submit their clinical experience as images with some text and explanation of the pictures. The new section will follow the proven format already in use by other journals and familiar to readers [4, 5]. An image in urogynecology will consist of one to three pictures (photographs, diagrams, illustrations) with up to 300 words of text and up to three literature references. Each image must be accompanied by a legend providing further information on the case or technique presented. A short video clip could be added as electronic supplemental material (ESM) but videos must be submitted separately for the “IUJ Video” section. All submissions for the “Images in Urogynecology” section will be peer reviewed andmanaged by one of our editors. Requirements are summarized in the “Instruction for Authors” of the IUJ. We trust this new section will enhance the value of the IUJ. The final image will always be in color in the digital format. Readers should find the new section attractive and relevant. We invite authors to share with us new techniques or special or unusual cases in this new format.