Salvatore Scalambrino

Surgery for genitourinary prolapse and stress incontinence: A randomized trial of posterior pubourethral ligament plication and Pereyra suspension

OBJECTIVE Our purpose was to compare two antiincontinence procedures in patients with severe genitourinary prolapse and coexisting clinical or potential stress incontinence. STUDY DESIGN In addition to cystopexy, 109 patients with a urethrocystocele of grade 2 or more and a positive stress test result with prolapse reduction received posterior pubourethral ligament plication or Pereyra suspension. RESULTS Of 55 patients undergoing posterior pubourethral ligament plication, 15 were clinically and 40 potentially incontinent; the same figures were 21 and 33, respectively, among 54 patients undergoing the Pereyra procedure. Follow-up was for 3 to 9 years. Subjective (60% vs 71%, p = 0.72) and objective (27% vs 57%, p = 0.14) cure rates were not statistically different among patients who were clinically incontinent (posterior pubourethral ligament plication vs Pereyra suspension). Among potentially incontinent patients, subjective (85% vs 100%, p = 0.03) and objective (50% vs 76%, p = 0.04) continence rates were higher after the Pereyra procedure. Overall, the cotton swab test had negative results (maximum straining angle < or = 30 degrees) after successful surgery in 79% and 96%, respectively, of patients (p = 0.03). Four subjects (7%) underwent removal of one Pereyra suture because of urinary retention or suprapubic wound infection. CONCLUSION Cystopexy with Pereyra suspension is recommended, particularly for patients with prolapse and potential stress incontinence.

Burch colposuspension versus modified Marshall-Marchetti-Krantz urethropexy for primary genuine stress urinary incontinence: A prospective, randomized clinical trial

OBJECTIVE Our purpose was to compare the effects of the Burch colposuspension with those of the modified Marshall-Marchetti-Krantz urethropexy. STUDY DESIGN Eighty women underwent the two types of operation. A full urodynamic investigation was repeated 6 months after surgery. RESULTS Clinical follow-up continued for 2 to 7 years. Differences in subjective and objective cure rates were not statistically significant (respectively, 92% and 80% for the Burch colposuspension and 85 and 65% for the modified Marshall-Marchetti-Krantz urethropexy). The latter induced a longer hospital stay (7.4 vs 6.3 days, p = 0.001), a later resumption of spontaneous voiding (13.8 vs 8.5 days, p = 0.002), and was associated with considerable complications (one case of blood replacement for retropubic hematoma, one case of severe voiding difficulty, one case of further treatment for stress incontinence, and three cases of symptomatic de novo detrusor instability). CONCLUSION For its high cure rate, short time to resumption of spontaneous voiding, short hospital stay, and low associated morbidity, the Burch colposuspension should remain the procedure of choice for stress incontinence.

A randomized comparison of continuous versus interrupted mass closure of midline incisions in patients with gynecologic cancer

Objective To address the incidence of deep wound dehiscence and incisional hernia formation with two types of mass closure after vertical midline laparotomy performed in patients with gynecologic cancer. Methods Continuous and interrupted mass closures were compared randomly in 632 patients. Both methods were performed with absorbable material. Of the 614 subjects who could be evaluated, 308 underwent a continuous, nonlocking closure with looped polyglyconate suture, and 306 were closed with interrupted polyglycolic acid according to the Smead-Jones technique. Results Three (1%) subjects with the continuous closure and five (1.6%) with the interrupted closure had an abdominal wound infection (P = .50). One patient whose incision was closed with continuous suturing had a deep wound dehiscence (without evisceration). The follow-up period was 6 months to 3 years. No patient had evidence of chronic sinus drainage. Thirty-two (10.4%) of the patients who had the continuous closure and 45 (14.7%) of those who were closed with the interrupted method had evidence of incisional hernia (P = .14). No hernia developed in any patient with a wound infection. Four (1.3%) hernias after the continuous closure and eight (2.6%) after the interrupted closure required surgical repair because of patient discomfort (P = .38). Conclusion The interrupted closure was not superior to the continuous closure for short- and long-term wound security. The continuous method was preferable because it was more cost-efficient and faster.

Marshall-Marchetti-Krantz procedure and Burch colposuspension in the surgical treatment of female urinary incontinence

Summary. Urinary stress incontinence was treated by the Marshall‐Marchetti‐Kranz (MMK) procedure in 42 and by Burch coloposuspension in 44 women. All were assessed preoperatively and for <1 year postoperatively, both clinically and by urodynamic tests. Cure of incontinence was achieved to a similar extent by both procedures, in 71% after the MMK and 79% after the Burch operation. Results were better than average if there was no prolapse and if the bladder was stable preoperatively.

Double-blind crossover comparison of flavoxate and oxybutynin in women affected by urinary urge syndrome

This double-blind multiclinic crossover study was performed in order to compare the efficacy and tolerance of a 4-week treatment course with flavoxate, given orally at 1200 mg/day, with that of oxybutynin, 15 mg/day orally, in women with idiopathic motor or sensory urgency. Fifty patients were included in the study: 41 (20 affected by sensory urgency and 21 by motor urgency) completed both courses of treatment and were evaluated for efficacy utilizing clinical and urodynamic criteria. Diurnal and nocturnal frequency, diurnal incontinence, urgency, dysuria, and daily utilization of pads were comparably reduced by both treatments. A statistically significant improvement in all urodynamic parameters was present at the end of both treatment courses. The effect on the urodynamic parameters of the two treatments was comparable. According to the patients, flavoxate cured or greatly improved the syndrome in 81.6% of cases, while oxybutynin produced the same effects in 78.9%. The difference in efficacy between the two treatments was not statistically significant. Of the 41 patients who received both treatment courses, 11 (26.8%) experienced adverse reactions with flavoxate, and 37 (90.2%) with oxybutynin treatment. Moreover, 5 patients, not included in the efficacy evaluation, interrupted the treatment because of side effects while taking oxybutynin, whereas no patients stopped while taking flavoxate. The severity of the side effects recorded during oxybutynin treatment was significantly greater than during treatment with flavoxate. Flavoxate showed comparable efficacy to oxybutynin in relieving the urge syndrome, but was associated with fewer and milder side effects.

Pre-operative morphological and colour Doppler features of borderline ovarian tumours

Objective To evaluate pre‐operatively the sonographic morphology and colour Doppler findings of borderline ovarian tumours and to compare these findings to those of benign and malignant tumours.

A randomized trial of open versus closed vaginal vault in the prevention of postoperative morbidity after abdominal hysterectomy

OBJECTIVE Our purpose was to evaluate the effects of two surgical techniques, closed vaginal vault with two layers of continous 3-0 polyglactin suture versus open vaginal vault with a locking 3-0 polyglactin suture, after abdominal hysterectomy. STUDY DESIGN A prospective, randomized trial was performed. During the hospital stay and 4 to 8 weeks after the operation patients were observed for evidence of morbidity. RESULTS Of the 273 evaluable subjects, 141 had the vaginal vault left open whereas 132 were closed. Ten (7.1%) and eight patients (6.1%) had infections at the operative site (pelvis or abdominal wound) (p = 0.92). A urinary tract infection was diagnosed in three (2.1%) and in four subjects (3.0%) (p = 0.46). A pelvic hematoma developed in two patients of each group (p = 0.66). Vault granulations were recorded in 11% and 12% of subjects (p = 0.97). CONCLUSIONS This study failed to show some benefit in favor of either of the two surgical policies. A careful surgical technique and antibiotic prophylaxis seem to remain the most important factors in the prevention of postoperative morbidity.

Bladder function following randomization to two different radical hysterectomy procedures: A prospective study

Lower urinary tract function was evaluated by means of clinical and urodynamic assessment in a prospective randomized study including 31 patients undergoing two different types of extended hysterectomy [1] for cervical cancer. In the immediate postoperative period loss of both bladder sensitivity and detrusor voiding activity with reduced compliance was observed in 60% of patients regardless of the operative procedure performed. At 3 months follow-up, the improvement in urethrovesical function was significantly related to a less extensive dissection of pelvic connective tissue (P<0.01).

Pefloxacin in the Treatment of Severe Infections in Gynecological Cancer Patients

Infections often complicate the medical or surgical treatment of hospitalized cancer patients. In these cases, a broad-spectrum antibiotic treatment is necessary before the microbiological results are available. The aim of the present study is to verify the efficacy of pefloxacin as empirical antibiotic therapy in controlling infectious complications induced by surgery, chemotherapy or radiotherapy in female patients with gynecological cancer. To this purpose, 58 hospitalized patients with gynecologic malignancy and severe infectious complications were treated with intravenous pefloxacin at the dosage regimen of 400 mg every 12 hours. In all, 49 (or 91%) of the 54 evaluable patients were cured. The mean duration of successful treatment was 5.9 +/- 2.1 days (ranging 4-13 days). No side effects or clinical laboratory abnormalities requiring reduction or discontinuation of therapy were observed. We conclude that pefloxacin may be considered a first choice, broad-spectrum, single antibiotic for use in the empirical therapy of infections in gynecological cancer patients.