S Ludwig

Surgical Treatment of Urgency Urinary Incontinence, OAB (Wet), Mixed Urinary Incontinence, and Total Incontinence by Cervicosacropexy or Vaginosacropexy

We previously developed a standardized surgical method to replace the uterosacral-ligaments in patients with genital prolapse. These cervicosacropexy (CESA) or vaginosacropexy (VASA) operations were effective in treating genital prolapse and urinary incontinence. In this study, we investigated the effects of these operations in combination with a transobturator tape (TOT) 8/4 procedure for the treatment of urgency urinary incontinence (UUI), overactive bladder (OAB), mixed urinary incontinence (MUI), and total incontinence (TI) in patients without symptomatic prolapse. Material and Methods: Patients with UUI, OAB, MUI, and TI were eligible for the study and an informed consent was obtained. Patients with genital prolapse POP-Q stage>I were excluded. The USLs in all the patients were replaced by standardized polyvinylidene fluoride structures by CESA/VASA. If patients remained incontinent, they received a TOT 8/4. Main outcome analysis was performed 4 months after the previous surgery. Data were analyzed retrospectively. Results: 133 patients were operated by CESA (n=57) or VASA (n=76). Subsequently, continence was reestablished in 57 patients (43%). The respective continence rates ranged from 27% (CI [5-49%]) in patients with TI to 73% (CI [54-92%]) in patients with UUI. After 75 patients received an additional TOT 8/4, the overall continence rates were 33% and 86% for patients with TI and those with UUI, respectively. Conclusion: The results of this study strongly support the hypothesis that urinary continence is based on the anatomical changes of the different levels of the holding apparatus of the bladder. The bilateral suspension of level I by CESA/VASA cured 66%-72% of the patients with UUI and OAB. In patients with MUI, an additional repair of level III by a TOT 8/4 was necessary to achieve a cure rate of 76%. Only patients with TI demonstrated a success rate of 33% after the suspension of the levels I and III indicating an additional problem of level II.

TOT 8/4: A Way to Standardize the Surgical Procedure of a Transobturator Tape.

Suburethral tapes are placed “tension-free” below the urethra. Several studies reported considerable differences of the distance between urethra and tape. These distances ranged from 1 to 10 mm amongst different patients. This either caused urethral obstruction or had no effect on urinary incontinence. Therefore, we decided to standardize the procedure by placing a Hegar dilator of 8-millimeter diameter in the urethra and another Hegar dilator of 4-millimeter diameter between the urethra and the tape during transobturator tape placement. Using that simple technique, which we named “TOT 8/4,” we observed that 83% of the tapes were placed in the desired distance between 3 and 5 millimeters below the urethra.

Does the Patients Age have an Influence on the Outcome of CESA (Cervico-Sacropexy) and VASA (Vagino-Sacropexy) for the Treatment of Urinary Incontinence in Women?

About 40% of all women will develop urinary incontinence during their life, usually starting around the age of 50 years. It usually starts with the spontaneous undesired loss of urine during increased intra-abdominal pressure (coughing or sneezing) and will continue in even shorter time intervals to reach the toilet “just in time”. In its ultimate form the patient has no control anymore about her voiding function and is “always wet”. While previously only SUI, the “mild” form of urinary incontinence, could effectively be treated by the replacement of the PUL using suburethral tapes we now have the chance to cure also the moderate and severe forms of urinary incontinence. With the bilateral replacement of the USL by the CESA and VASA operations over 50% of all patients were cured. When the remaining patients received an additional TOT 8/4 the cure rate was increased up to more than 80% of the patients. We observed that the number of cured patients decreased with increasing age. While patients younger than 60 years have a nearly 90% chance of cure this chance decreases down to 65% for those patients older than 70 years. The fact that continence could be reestablished by CESA / VASA and a TOT 8/4 demonstrates that urinary incontinence can be cured by surgery in most patients. We are not certain which ageing effects were responsible for the diminishing cure rate with increasing age. As all our other calculations did not indicate any responsible factor for this observation, we probably did not measure the responsible factor so far.

Laparoscopic bilateral cervicosacropexy (laCESA) and vaginosacropexy (laVASA) – new surgical treatment option in women with pelvic organ prolapse and urinary incontinence

Abstract Objective: Sacrocolpopexy (SCP) is the gold standard for apical prolapse treatment. However, the technical performance of each SCP is strongly dependent on the surgeons own discretion and comparison of clinical outcomes with respect to urinary incontinence (UI) is difficult. We developed a comprehensible laparoscopic surgical technique for the treatment of apical prolapse with UI. Methods: A total of 120 women with UI underwent laparoscopic bilateral SCP for apical prolapse. Thereby, the uterosacral ligaments (USLs) were bilaterally replaced by polyvinylidene fluoride (PVDF) tapes of identical length and shape, which were fixed at defined anatomical landmarks (cervix/vaginal vault and S1). Results: The restoration of apical vaginal support was achieved in 116 patients (97%); restoration failed in the first 4 patients owing to the use of fast-absorbable sutures. Seventy-eight patients (65%) with mixed and urgency UI symptoms before surgery achieved continence. The mean hospitalization was 3 days; no major complications were observed intraoperatively. Conclusion: The advantage of laparoscopic cervicosacropexy (laCESA) and laparoscopic vaginosacropexy (laVASA) lies in the comprehensible surgical technique (clearly defined technique) and the minimal amount of material used (no polypropylenes). The possibility of a short operating time and short hospitalization depicts this laparoscopic bilateral USL replacement as one treatment alternative in patients with apical prolapse suffering from UI.

A successful multidisciplinary approach for treatment and for preserving the reproductive potential in a rare case of acute lymphocytic leukemia during pregnancy

Abstract Leukemia in pregnancy is a rare condition with the prevalence of 1 in 75,000–100,000 pregnancies. In this case report, we present a successful multidisciplinary management strategy for treatment and for preserving the reproductive potential in a rare case of acute lymphocytic leukemia (ALL) during pregnancy. Several complex challenges existed and necessitated a multidisciplinary approach with strong coordination and collaboration between oncologists, gynecologists, reproductive cryobiologists, obstetricians, and neonatologists in order to improve the maternal and fetal outcome. Pregnancy in the second trimester is neither a contraindication for ALL treatment nor for emergency fertility preservation via ovarian tissue extraction and further cryopreservation.

PD54-09 FIRST RESULTS – THE URGE 1 STUDY - RANDOMIZED TRIAL TO COMPARE SOLIFENACIN AND BILATERAL MESH REPLACEMENT OF THE UTEROSACRAL LIGAMENTS IN THE TREATMENT OF URGENCY URINARY INCONTINENCE

cephalosporin group (36%), p1⁄40.042. On multivariable regression analysis, predictors of post-procedure UTI included single IM dose of prophylaxis (OR 2.80, 95% CI 1.2-6.5, p1⁄40.016) and positive preprocedure urine culture (OR 1.31, 95% CI 1.03-1.66, p1⁄40.027). Age, BMI and diabetes were not associated with post-procedure UTI. CONCLUSIONS: In our series comparing two different antibiotic prophylaxis regimens for Botox injection, we found a significantly lower rate of UTI when patients received a three-day course of an oral fluoroquinolone as opposed to a single IM dose of a third-generation cephalosporin. Patients with a positive pre-procedure culture may benefit from longer duration of antibiotics at the time of Botox injection.

V2-09 LAPAROSCOPIC CERVICOSACROPEXY AND VAGINOSACROPEXY TECHNIQUES AS TREATMENT OF PELVIC ORGAN PROLAPSE AND URINARY INCONTINENCE

INTRODUCTION AND OBJECTIVES: Female urethral strictures are rare and occur in less than 1% of women. Common causes are trauma, iatrogenic injury, inflammatory diseases or idiopathic. Diagnosis is suspected when a patient reports obstructive symptoms, urodynamics shows outlet obstruction and/or cystourethroscopy reveals urethral narrowing or fibrosis. Surgical treatment depends on location and length of the stricture, and the optimal approach is not well established. In this video, the technique for female urethroplasty with a dorsal onlay buccal mucosal graft is demonstrated. METHODS: A 48-year-old female patient presented with longstanding, symptomatic urethral stricture disease. She previously failed conservative management with urethral dilations and elected to pursue urethroplasty with buccal mucosal graft. Following informed consent, video recording of intraoperative surgical procedure was performed. Video editing and narration was standardized to highlight key steps of the procedure. RESULTS: The patient was taken to the OR for urethroplasty with a dorsal onlay buccal mucosal graft. First, a cystoscopy was performed and a suprapubic tube was placed to allow for sufficient postoperative healing. The buccal mucosal graft was harvested, defatted and soaked in normal saline. Circumferentially around the urethral meatus hydrodissection is used with care taken to avoid the clitoral tissue and nerves. The urethra was dissected to the level of the bladder neck and the full extent of the stricture was identified then incised. Stay sutures were placed in the superior and inferior apices to facilitate placement of the graft. Superior apical sutures were threaded through the graft and additional interrupted sutures were placed circumferentially. The graft was trimmed to size, threaded with the inferior apical stay sutures and secured in place. The surgical bed and graft were joined to enhance revascularization. The patient did well postoperatively, with no recurrence of stricture and healthy buccal mucosa graft on cystoscopy. CONCLUSIONS: Urethroplasty with dorsal buccal mucosal graft placement can be a feasible and effective treatment for female urethral strictures.

There is a Chance to Cure Urinary Incontinence in all Women

UI usually starts with the loss of some drops of urine during coughing or sneezing, i.e. when the intra-abdominal pressure increases. It is a characteristic finding that this urinary “stress urinary incontinence” usually presents as the first symptom of UI. In most patients that starts in their forties [2]. After an undefined time interval of few years most patients have increasing problems to reach the toilet without loosing urine. In order to prevent this involuntary loss of urine these patients increase their voiding frequency and get up from the bed at night.

Die operative Behandlung des weiblichen Genitalprolapses mit CESA/VASA

Der Deszensus von Uterus und Scheidenstumpf ist Ausdruck defekter Uterosakralligamente (USL). Mit dem CESA/VASA Operationsverfahren werden erstmals die USL ersetzt und anatomiegetreu rekonstruiert. Uber die Effekte auf die Anatomie und Physiologie wird im Folgenden berichtet. Patientinnen mit Deszensus von Uterus oder Scheidenstumpf (POP-Q Stadium II, III und IV) wurden mit dem CESA (cerviko-sakrale Fixation) oder VASA (vagino-sakrale Fixation) Operationsverfahren operiert. Die USL wurden mittels alloplastischen Bandeinsatz (PVDF, CESA/VASA DynaMesh®) rekonstruiert. Deszensusmessungen wurden analog zum POP-Q Klassifikationssystems vor und nach OP durchgefuhrt. Inkontinenzsymptome wurden mittels eines Fragebogens erfasst (Items aus BBUSQ-22, ICIQ-SF, PGI-I und KHQ). 41 Patientinnen mit Deszensus von Uterus oder Scheidenstumpf (POP-Q Stadium II, III und IV) wurden mit dem CESA oder VASA operiert. Praoperativ deszendierten das apikale Scheidenende zwischen -1 und +6 cm Abstand zum Hymenalsaum. Nach CESA/VASA war dieses bei allen Patientinnen im POP-Q Stadium 0. Das Scheidenende war zwischen -5 cm und der maximalen Scheidenlange (8 bis 12 cm) frei beweglich. Praoperativ zeigten 48% (n = 22) der Patientinnen erhohte Restharnbildung, postoperativ keine mehr. Praoperativ lagen Punkt Aa und Ba bei > 70% der Patientinnen ≥-1 cm. Postoperativ lagen Punkt Aa und Ba bei 60% der Patientinnen bei -3 cm. Praoperativ klagten > 60% der Patientinnen uber Misch- und Dranginkontinenzsymptome, postoperativ nur 20%. Die CESA/VASA Operationen sind standardisierte Verfahren zur Behandlung des weiblichen apikalen Deszensus. Neben der Anatomie wird auch die Physiologie wiederhergestellt: die Scheide bleibt beweglich, Dyspareunien verschwinden und eine erhohte Restharnbildung bleibt aus. Des Weiteren zeigt sich ein positiver Einfluss auf Harninkontinenzsymptomatik. Banderosionen wurden nicht beobachtet.