Ralf Tunn

Severe mesh complications following intravaginal slingplasty

OBJECTIVE: Synthetic meshes are increasingly used in the management of stress urinary incontinence and pelvic organ prolapse. This report describes severe complications following anterior and/or posterior intravaginal slingplasties employing a multifilament polypropylene mesh. METHODS: We describe the symptoms, findings, subsequent management, and outcome of 19 consecutive women who have been referred with complications following anterior (n = 11) and/or posterior intravaginal slingplasty (n = 13) employing the multifilament polypropylene tape. RESULTS: The main indications for removal of the 11 anterior intravaginal slings were intractable mesh infection in 6 women, retropubic abscess with cutaneous sinus in one, and vesico-vaginal fistula in one, intravesical mesh and pain syndrome in one, and voiding difficulties and pain syndrome in two. The main indications for removal of the 13 posterior intravaginal slings were intractable mesh infection in three and pain syndrome and dyspareunia in 10 women. Removal of the slings was performed after a median time of 24 months post-slingplasty. At follow-up between 6 weeks and 6 months, in all women genital pain, chronic vaginal discharge and bleeding, voiding, and defecation difficulties had been markedly alleviated (5) or they had ceased (14). Twelve of 17 sexually active women (71%) resumed sexual intercourse without difficulties. Ten women required subsequent surgery for stress incontinence and pelvic organ prolapse. CONCLUSION: Surgeons should be aware of the potential complications of synthetic meshes. Until data on the safety and efficacy of the intravaginal slingplasties are available, these procedures cannot be recommended. LEVEL OF EVIDENCE: III

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.

Racial Differences in the Structure and Function of the Stress Urinary Continence Mechanism

Objective To compare the structure and function of the urethral sphincter and the urethral support in nulliparous black and white women. Methods Eighteen black women (mean age 28.1 years) and 17 white women (mean age 31.3 years) completed this cross-sectional study. The following assessments were made: urethral function using multichannel cystometrics and urethral pressure profilometry, pelvic muscle strength using an instrumented speculum, urethral mobility using the cotton-swab test and perineal ultrasound, and pelvic muscle bulk using magnetic resonance imaging. Results Black women demonstrated a 29% higher average urethral closure pressure during a maximum pelvic muscle contraction (154 cm H2O versus 119 cm H2O in the white subjects; P = .008). Although not statistically significant, black women had a 14% higher maximum urethral closure and pressure at rest (108 cm H2O versus 95 cm H2O; P = .23) and a 21% larger urethral volume (4818 mm3 versus 3977 mm3; P = .06). In addition, there was a 36% greater vesical neck mobility measured with the cotton-swab test (blacks 49° versus whites 36°; P = .02) and a 42% difference in ultrasonically measured vesical neck mobility during a maximum Valsalva effort (blacks = −17 mm versus whites −12 mm; P = .08). Conclusion Functional and morphologic differences exist in the urethral sphincteric and support system of nulliparous black and white women.

Effect of vaginal polypropylene mesh implants on sexual function

OBJECTIVE Published studies report a very high rate of dyspareunia and impairment of sexual function in women who have undergone vaginal mesh repair. The present study investigates these problems with a view to sex therapy. STUDY DESIGN A validated questionnaire was administered to 120 women to explore sex life before and after polypropylene mesh insertion (Apogee/Perigee). Postoperative exploration took place 1 year after surgery. In addition, gynecologic examinations were performed preoperatively and postoperatively to assess urogenital anatomy and function. RESULTS Fifteen women reported dyspareunia before surgery, which was related to vaginal prolapse. No woman complained of dyspareunia at 1-year follow-up. In 40 patients (33.3%), analysis of the validated questionnaires revealed more deeply rooted sexual disorders based on partnership problems and unrelated to surgery. CONCLUSION The results presented here show that vaginal mesh repair does not interfere with a healthy sex life. Our data on sexual function and activities suggests that sexuality is complex and cannot be reduced to mere genital aspects. Sexual dysfunction is only rarely associated with urogynecologic surgery.

Reasons for and treatment of surgical complications with alloplastic slings.

Suburethral slings with tension-free vaginal tapes have become a popular treatment for stress urinary incontinence. Case reports on singleton complications are numerous and of clinical interest. Four European centers for urogynecology report on 328 surgical reinterventions after tension-free slings. Poor surgical technique is the most frequent cause of problems (45%), followed by incorrect indication (38%). The most frequent symptom is functional or anatomical outlet obstruction; perforation or penetration and defect healing are rare, but, apparently more frequent than described in studies or follow-up series previously.

“The cough game”: are there characteristic urethrovesical movement patterns associated with stress incontinence?

This study was carried out to determine whether five experts in female stress urinary incontinence (SUI) could discover a pattern of urethrovesical movement characteristic of SUI on dynamic perineal ultrasound. A secondary analysis of data from a case–control study was performed. Ultrasounds from 31 cases (daily SUI) and 42 controls (continent volunteers) of similar age and parity were analyzed. Perineal ultrasound was performed during a single cough. The five experts, blinded to continence status and urodynamics, classified each woman as stress continent or incontinent. Correct responses ranged from 45.7% to 65.8% (mean 57.4 ± 7.6). Sensitivity was 53.0 ± 8.8% and specificity 61.2 ± 12.4%. The positive predictive value was 48.8 ± 8.2% and negative predictive value was 65.0 ± 7.3%. Inter-rater reliability, evaluated by Cohen’s kappa statistic, averaged 0.47 [95% CI 0.40–0.50]. Experts could not identify a pattern of urethrovesical movement characteristic of SUI on ultrasound.

Childbearing after TVT: how I have my baby when I have a TVT

About 1 million tension-free vaginal tape (TVT) procedures, according to Ulmsten et al. [1], have been performed worldwide, and the total number of interventions is estimated to be about twice that figure if the tension-free tapes from other manufacturers are included. Compared to other surgical techniques used to treat urinary incontinence, TVT plasty is minimally invasive and has excellent longterm results with only few complications. Hence, it is only too understandable that women of reproductive age also favor this therapeutic option. Even if a woman convinces her gynecologist when discussing therapeutic options that she is absolutely positive that her family planning is complete, situations can change, and then we are in a fix. There are those who say that women should not become pregnant after TVT insertion, and that all women of childbearing age should be treated by colposuspension, which has been effectively used for over 45 years in this age group, where lateral defects seem to be the main etiologic factor underlying the development of stress urinary incontinence. Proponents of this approach rely on their vast clinical experience, but hard scientific evidence is lacking. On the one hand, there is no prospective clinical data demonstrating that colposuspension is superior to the TVT procedure in women with stress urinary incontinence and a lateral defect. On the other hand, it has been demonstrated that TVT plasty is equally successful in treating all six types of stress urinary incontinence [2]. This success not only contradicts the original concept of midurethral stabilization and replacement of the pubourethral ligaments but also the observation, at least based on magnetic resonance imaging criteria, that the lateral defect is not repaired by TVT insertion [3]. A second group is equally adamant that primary cesarean section should be performed in women with a TVT because this is what has always been recommended for deliveries after incontinence surgery. Well, let us just say that the literature on this subject is rather meager [4–6], and the scientific discussion is not very deep. One important fact should not be forgotten: The rate of cesarean sections is on the rise, and many countries allow elective cesareans since its safety has dramatically improved and is now on par with spontaneous delivery. Just think of breech delivery. Not so long ago, it was a skilled and highly competent obstetrician who mastered vaginal delivery, whereas today, we are liable to be sued for malpractice if we do not perform primary cesarean section. When two people quarrel, a third rejoices, and if he comes from a research background, he will search the medical database. Unfortunately, he is out of luck because only a handful of case reports turn up. Some early reports describe successful cesarean sections after TVT with preservation of continence [7], while other braver souls report the first successful spontaneous deliveries with maintained continence [8], well, at least, for a couple of weeks after delivery. Why so pessimistic? Consider the EPINCONT study [9], which identified a fairly high risk of becoming incontinent by the age of 64 in multiparous women who delivered spontaneously. I say: “We will never know whether this is different after TVT.” Other scientists say at the end of every lecture: “We need prospective randomized studies to obtain definitive proof.” Our team has performed about 2,000 TVT procedures. In our population, we had one patient who carried a pregnancy to term and delivered by cesarean section, and then became Int Urogynecol J (2006) 17:553–554 DOI 10.1007/s00192-006-0212-9

Standardization of dynamic magnetic resonance imaging measurements of pelvic organ prolapse: can the PICS line help?

Dynamic magnetic resonance imaging (MRI) of the pelvis has been rapidly introduced into urogynecological research and practice in recent years mainly to address the shortcomings of clinical assessment systems in women with pelvic organ prolapse (POP). The primary objective was to better select candidates for surgical intervention and choose the appropriate procedure in order to reduce recurrences by allowing accurate identification and objective measurement of prolapse and simultaneous topographic assessment of the pelvis at rest and straining [1–5]. MRI is particularly indicated in women with multi-compartment POP and in those who had undergone previous repair, as imaging can reveal more extensive prolapse than physical examination alone with detection rates similar to other conventional fluoroscopic and ultrasound methods [1, 3, 4]. Staging of POP using MRI has also been suggested by measuring the perpendicular distance between several reference points and lines in each compartment at rest and after straining [1–5]. The two most commonly used lines are one connecting the inferior aspect of the pubic symphysis to the last coccygeal joint, the pubococcygeal line (PCL), and one extending caudally along the long axis of the symphysis pubis, the midpubic line (MPL). Several MRI staging systems have been published for both of these lines [1, 3, 4]. Despite the widely accepted role of MRI in supplementing clinical evaluation and management of women with POP, this imaging modality has certain limitations. Most importantly, so far, there has been no standardized technique for performing MRI examination of the pelvis. Imaging protocols vary according to patient positioning, filling media, pelvic organ opacification, patient maneuvers (i.e., rest, Kegel, Valsalva, evacuation) and MRI sequences and planes [1–5]. Most of the available imaging systems are unable to demonstrate the full extent of POP because patients are examined in a supine position promoting current efforts to image patients in the sitting and upright position using open-magnet MRI units [1, 3–5]. In fact, sagittal plane images of women with POP that are commonly displayed in the literature as if taken in the upright position had been made in the supine position [6]. A further major problem with MRI studies of the pelvis is the incomplete reproducibility and lack of standardization of the patient effort exerted during straining [3–5]. The anatomical landmarks used for pelvic measurements are easily identified inMRI and this is expected to increase the validity of measurement [5]. The intraand inter-observer reliability of most MRI measurements is, however, rarely described in POP studies [2]. Furthermore, the reference line used for MRI interpretation of POP is not consistent in all studies as this is often based on radiologist experience and referring physician preference [1, 5]. In a recent systematic review, seven different reference lines in relation to a wide variety of reference points have been used in different studies with imprecise definition or interchangeable use of some lines, e.g. “MPL/hymenal line” and “PCL/sacrococcygeal inferior pubic point line” [2]. Although the MPL corresponds anatomically to the level of the hymen on cadaveric dissection, the landmark used for clinical staging of POP, the reliability of MRI using the MPL versus clinical findings in women with POP was lower than that of the PCL in most reports [1, 2]. It is obvious that we lack a proper validation system for interpreting MRI measurements of POP and we urgently need to reach a consensus on a more standardized and scientifically robust MRI protocol for examination of the pelvis. Betschart et al. review this topic further in a seminal Clinical Opinion D. E. E. Rizk Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Cairo, Egypt

Urogynecological training, testing and treatment among gynecologists in Germany

OBJECTIVE A survey was conducted to evaluate the urogynecology training of German gynecologists and the diagnostic tests and therapeutic options offered to women with incontinence or prolapse in hospital departments and private practices. STUDY DESIGN Questionnaires were mailed to 3000 gynecologists in private practice and to 500 consultants in gynecology departments. The questionnaire included items on urogynecological training, diagnostic workup as well as conservative and surgical treatment options. RESULTS The response rate was 16.8% with 589 of the 3500 questionnaires being returned. Less than one third of the respondents (28.6%) regard their training in urogynecology as good, 41% rate their training as moderate and 30.4% state that their urogynecology training during residency was inadequate. Male physicians significantly more often consider themselves well trained than women (p=.00006). The majority of gynecologists in private practice (74.7%) refer patients to a gynecological clinic for assessment of urogynecologic symptoms, 37.7% refer their patients to urologists in private practice, 10.4% to other gynecologists in private practice, and 10.4% to a urological clinic (percentages add up to more than 100% because multiple answers were allowed). Among the gynecologists who offer surgery, 81.2% perform retropubic TVT-operation and 80.1% colposuspension. Seventy-seven percentage of the gynecologists in private practice who do operations on an inpatient basis still perform anterior colporrhaphy to treat stress urinary incontinence compared to 62% of consultants in gynecological clinics (p<.05). CONCLUSION One third of German gynecologists consider themselves inadequately trained in urogynecology. The results of our survey show that there is a need for improved general training during residency and for subspecialist training.

Birth Trauma and Incontinence

6.1 Morphological Changes of the Continence Controlling System of Urethra and Anus Caused by Pregnancy and Delivery . . . . . . . 88 6.1.1 Urethra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 6.1.2 Levator ani Muscle . . . . . . . . . . . . . . . . . . . . . . 88 6.1.3 Endopelvic Fascia . . . . . . . . . . . . . . . . . . . . . . . 89 6.1.4 Anal-Sphincter System . . . . . . . . . . . . . . . . . . . 89