Roger Lefevre

Functional Disorders: Rectocele

The baseline prevalence of rectocele is not well defined as many women are asymptomatic and do not seek medical help. Gynecologists tend to perform posterior wall repairs more commonly than colorectal surgeons because they also address patients with vaginal symptoms in addition to those with defecatory dysfunction. Overall, surgical correction success rates for rectocele correction are quite high when using a vaginal approach. Vaginal dissection, as opposed to transrectal or transperineal approaches, results in better visualization and access to the endopelvic fascia and levator musculature, allowing for more firm anatomic correction. In addition, the maintenance of rectal mucosal integrity may reduce the risk of postoperative complications such as infection and fistula formation. With the rapidly growing popularity of synthetic and biologic implant kits in the field of pelvic reconstruction, outcomes data reporting is increasing and allowing surgeons to better understand the effect of various surgical techniques on vaginal, sexual, and defecatory symptoms.

Diabetes, Glycemic Control, and Urinary Incontinence in Women.

Objectives To estimate the association between urinary incontinence and glycemic control in women ages 20 to 85 years. Methods We included 7270 women from the 2005 to 2010 National Health and Nutrition Examination Survey, stratified into three groups of glycemic control defined by hemoglobin A1c (HbA1c): (i) those below the diagnostic threshold (HbA1c < 6.5%), (ii) those with relatively controlled diabetes (HbA1c, 6.5–8.5%), and (iii) those with poorly controlled diabetes (HbA1c > 8.5%) to allow for a different relationship between glycemic control and urinary incontinence within each group. The primary outcomes were the presence of any, only stress, only urgency, and mixed urinary incontinence. We calculated adjusted risk ratios using Poisson regressions with robust variance estimates. Results The survey-weighted prevalence was 52.9% for any, 27.2% for only stress, 9.9% for only urgency, and 15.8% for mixed urinary incontinence. Among women with relatively controlled diabetes, each one-unit increase in HbA1c was associated with a 13% (95% confidence interval, 1.03–1.25) increase for any urinary incontinence and a 34% (95% confidence interval, 1.06–1.69) increase in risk for only stress incontinence but was not significantly associated with only urgency and mixed incontinence. Other risk factors included body mass index, hormone replacement therapy, smoking, and physical activity. Conclusions Worsening glycemic control is associated with an increased risk for stress incontinence for women with relatively controlled diabetes. For those either below the diagnostic threshold or with poorly controlled diabetes, the risk may be driven by other factors. Further prospective investigation of HbA1c as a modifiable risk factor may motivate measures to improve continence in women with diabetes.

Atypical Graft Infection Presenting as a Remote Draining Sinus

BACKGROUND: Synthetic materials are being used increasingly in reconstructive pelvic surgery. Multifilament polypropylene mesh in particular has been associated with healing abnormalities and other postoperative complications. This article describes an atypical infection presenting as a draining sinus tract to the lower extremity after intravaginal slingplasty. CASE: An otherwise healthy 75-year-old-woman presented with recurrent leg cellulitis 18 months after posterior intravaginal slingplasty for vaginal vault prolapse. A 35-cm fistulous tract draining from the pelvis to the lower thigh was identified. The patient underwent surgical debridement and was treated with 12 weeks of intravenous antibiotics with complete healing and no recurrence of symptoms. CONCLUSION: Complications associated with the multifilament mesh used in the intravaginal slingplasty tunneler device include pain, erosion, localized abscess, and genitourinary fistula.

“Eyeball” POP-Q examination: shortcut or valid assessment tool?

Introduction and hypothesisThe objective of this study was to compare the results of the Pelvic Organ Prolapse Quantification (POP-Q) examination by visual estimation to measurement.MethodsWomen with pelvic organ prolapse underwent both “eyeball”/estimated and measured POP-Q examinations by two trained examiners in a randomized order. POP-Q points and stage were analyzed using the paired t test, chi-square, Pearson’s correlation, and kappa statistics.ResultsFifty subjects had a mean age of 60, mean BMI 27.8, and median parity of 2. The POP-Q stages by the measured technique were 18% (9/50) stage 1, 38% (19/50) stage 2, 44% (22/50) stage 3, and 0% (0/50) stage 4. The POP-Q stages based on estimation and measurement were highly associated (p < 0.05). Individual points did not differ significantly between the techniques and did not differ significantly between examiners (all p > 0.05).ConclusionAmong examiners who routinely perform POP-Q examinations, there is no significant difference between “eyeball”/estimated and measured POP-Q values and stage.

56: Tensioning of retropubic suburethral slings with Babcock versus Kelly clamp

McCall’s uterosacral ligament cuff suspensions, and 6 concurrent posterior repairs (PR). Twenty-three additional posterior repairs, 2 vaginal para vaginal repairs (VPVR), and 2 bilateral sacrospinous ligament colpopexies (SSLC). Preoperative POP-Q scores measuring level 1 and level 2 support ranged from -2 to +6. POP-Q scores obtained 1 to 60 months (median 1⁄4 46) postoperatively revealed durable global level 1 and 2 support with most at -3 scores. Two anatomical failures to anterior or apical -1 scores, but only 1 symptomatic case needed reoperation. No significant surgical or product complications were identified. CONCLUSION: Secondary to procurement inconsistencies associated with synthetic and cadaveric products, and the risk of erosion, fibrosis, retraction, or dyspareunia with synthetic materials, our preliminary data shows that Matristem xenografts offers a safe and efficacious alternative in the surgical repair of level 1 and 2 POP.

Management of Urinary and Fecal Incontinence in Patients With Complex Regional Pain Syndrome.

Background Urinary voiding dysfunction is reported in many patients with complex regional pain syndrome (CRPS). However, there is a gap in the literature for treating patients with CRPS who develop incontinence symptoms. Case We report a case describing the use of sacral neuromodulation therapy in a patient with urgency urinary and fecal incontinence who had a previously implanted spinal cord stimulator for type 1 CRPS, formerly known as reflex sympathetic dystrophy. Despite initial hesitation and treatment delay, sacral neuromodulation therapy was successful and effective in controlling both fecal and urgency urinary incontinence symptoms for the patient. This intervention continues to provide her with an improved quality of life 10 months after her procedure. Conclusions In this case, there was significant hesitation from the provider and patient to use invasive treatments for incontinence symptoms when the patients pain symptoms have been well controlled with an existing spinal device. However, in this patient with type 1 CRPS, even in the setting of an existing spinal cord stimulator, sacral neuromodulation therapy was an effective treatment.