Shwu Huey Yang

Dynamic Interaction Involved in the Tension-Free Vaginal Tape Obturator Procedure

PURPOSE We explored the static and dynamic morphological characteristics of the tension-free vaginal tape obturator procedure by ultrasound cystourethrography. MATERIALS AND METHODS From July 2005 to December 2006, 98 consecutive women who had undergone the tension-free vaginal tape obturator procedures alone or with concomitant pelvic surgery were evaluated. Preoperative and postoperative morphological assessments of lower urinary tract and tension-free vaginal tape obturator procedure tape were performed by introital ultrasound. RESULTS The resting and straining bladder neck angles as well as the resting tape angle gradually increased postoperatively while the resting bladder neck distance and total urethral length decreased. The vector of the tension-free vaginal tape obturator procedure tape was significantly correlated with the resting tape distance (r = 0.55, p <0.01). The tension-free vaginal tape obturator procedure tape migrated distally with time but remained in the same position relative to the urethra (60th percentile). Concomitant pelvic surgery did not affect the position and motion of the bladder neck or tension-free vaginal tape obturator procedure tape except for mesh reinforcement anterior colporrhaphy in which the tape was displaced proximally. Postoperatively 5 types of urethral descent in relation to the tape during stress were seen. One type of vertical and 1 type of rotational urethral descent during straining were observed in women in whom surgery failed, while 2 other types of vertical and 1 of rotational descent were not associated with failure. CONCLUSIONS The dynamic interaction between the tension-free vaginal tape obturator procedure tape and urethra depends on the proximity of the tape and the type of urethral descent.

Correlation of Morphological Alterations and Functional Impairment of the Tension-Free Vaginal Tape Obturator Procedure

PURPOSE We explored the morphological features associated with functional impairment in patients undergoing the tension-free vaginal tape obturator procedure. MATERIALS AND METHODS We retrospectively reviewed the records of 98 women who underwent the tension-free vaginal tape obturator procedure alone or with concomitant pelvic surgery. Postoperative assessment included a symptom questionnaire, ultrasound cystourethrography and a cough stress test. During followup the measures of postoperative functional impairment included a positive cough stress test, new onset voiding dysfunction and the worsening or progression of urge symptoms. RESULTS Median followup was 22 months. During followup 11 women had a positive cough stress test, 22 had voiding dysfunction and 12 had worsening or new onset urge symptoms. Failure was associated with 4 variables on multiple logistic regression analysis, including absent urethral encroachment at rest (OR 16.63, 95% CI 1.87-147.85, p = 0.01), bladder neck funneling (OR 8.27, 95% CI 1.99-34.26, p <0.01), a urethral location of less than the 50th percentile (OR 6.01, 95% CI 1.43-25.25, p = 0.01) and a resting tape angle of less than 165 degrees (OR 5.21, 95% CI 1.15-23.54, p = 0.03). A resting tape distance of less than 12.0 mm (OR 3.00, 95% CI 1.44-6.26, p <0.01) and urethral encroachment at rest (OR 2.86, 95% CI 1.30-6.30, p <0.01) were the variables predictive of postoperative voiding dysfunction. Bladder neck funneling was the only risk factor for postoperative urge symptoms (p <0.01). CONCLUSIONS The tension-free vaginal tape obturator procedure achieves its effectiveness in a process of biological reaction and mechanical interaction between the tape and urethra. When this mechanical interaction is too great or too little, there is functional impairment after the procedure.

Biologic Correlates of Sexual Function in Women with Stress Urinary Incontinence

INTRODUCTION Stress urinary incontinence (SUI) has a great impact on the quality of life and sexual function. We hypothesized that specific risk factors for SUI may be correlated with reduced sexual function in women with SUI. AIMS To explore significant associations between the risk factors for SUI and female sexual function. METHODS Women with SUI (N=223) were surveyed about their sexual function. Demographic data and clinical findings on pelvic examination and the 1-hour pad test were recorded. Sexually active respondents completed the short form of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). MAIN OUTCOME MEASURE PISQ-12 and the correlation of the risk factors for SUI with PISQ-12 scores. RESULTS Of the 223 subjects, 68 (30%) reported no sexual activity for 6 months or more prior to the interview and did not respond to the PISQ-12. In comparison with the 155 (70%) of women who were sexually active, sexually inactive respondents were older and more likely to be postmenopausal and had a higher parity and more severe prolapse (all P<0.01). Among those completing the PISQ-12 questionnaire, the same factors (age, parity, severity of prolapse, menopausal status) were significantly associated with lower PISQ-12 scores. The scores were not correlated with body mass index, delivery mode, genital hiatus length, and total vaginal length by the short form of the Pelvic Organ Prolapse Quantification (POP-Q) system, or estrogen therapy. Lower points Ba and C of the POP-Q system were associated with lower PISQ-12 scores (r= -0.200, P=0.026; r= -0.191, P=0.035, respectively). Multivariate analysis identified parity as the only factor independently predictive of sexual dysfunction (r= -0.225, P=0.013). CONCLUSIONS Anatomic and biologic pathology does not satisfactorily predict the level of sexual functioning in women with SUI.

Reliability of Real-Time Ultrasound to Detect Pelvic Floor Muscle Contraction in Urinary Incontinent Women

PURPOSE We determined the reliability of real-time ultrasound for detecting involuntary or reflex pelvic floor muscle contraction. MATERIALS AND METHODS A total of 118 women with the symptomatic and urodynamic evidence of stress urinary incontinence were recruited in a 3-year period from tertiary referral urogynecology clinics. Under the oral instruction of strong coughing involuntary pelvic floor muscle contraction was detected using introital ultrasound in real-time and cine loop modes. Two dynamic imaging features were considered involuntary pelvic floor muscle contraction, including an inward clitoral motion and a superior-anterior anorectal lift before or during coughing. RESULTS Real-time ultrasound had good reliability to detect involuntary pelvic floor muscle contraction. For interobserver and intra-observer reliability Cohens kappa was 0.645 to 0.679. Of the 118 women real-time ultrasound before or during coughing showed an inward clitoral motion in 100 (93%) and an anorectal lift in 108 (92%). Neither type of contraction during coughing was identified in 2 women. Although the 2 contraction patterns were synchronized in 88% of women, for this synchronization kappa was only 0.159, indicating poor coordination between these 2 involuntary activities. CONCLUSIONS Real-time ultrasound is a reliable tool for detecting involuntary pelvic floor muscle contraction.

Clinical and pathophysiological correlates of the symptom severity of stress urinary incontinence

Introduction and hypothesisThe pathophysiology of stress urinary incontinence (SUI) is multifactorial. The aim of this study was to explore the factor determining the symptom severity of SUI.MethodsOne hundred twenty-four women with SUI were retrospectively investigated. Clinical data for analyses included demographics, pelvic organ prolapse quantification, SUI severity using a 4-point Likert scale, ultrasound, 1-h pad tests, and urodynamic studies. Data were analyzed using the Spearmans rho test and Kruskal–Wallis test.ResultsThe symptom severity was not correlated with risk factors of SUI or the morphologic manifestations representing urethral support defect, but was significantly correlated with urine loss on 1-h pad test, Valsalva leak point pressure (VLPP) grading, and maximum urethral closure pressure (MUCP). Women with higher SUI severity had greater urine loss on 1-h pad tests, worse VLPP grading, and lower MUCP.ConclusionsUrethral sphincter function appears to be an important determinant for the symptom severity of SUI.

Transvaginal repair of ureterovaginal fistula by Latzko technique

Ureterovaginal fistula is an uncommon but serious sequela of unrecognized distal ureteral injury during pelvic operations. Traditionally, it is managed either by endoscopic internal ureteral stenting or by ureteral reimplantation. We report a case of ureterovaginal fistula that failed to respond to ureteral stenting. Because the patient had a history of several laparotomies and intra-abdominal abscesses, she was at high risk for complications with a transabdominal operation. Therefore, we used transvaginal Latzko partial colpocleisis and successfully resolved the ureterovaginal fistula.

Reliability of a new method for assessing tension and configuration of transobturator suburethral tapes using four-dimensional ultrasound.

We conducted this study to evaluate the intra- and interobserver reliability of a new method in assessing the tension and configuration of transobturator suburethral tape (TOT) at different tape points using 4-dimensional (4D) ultrasound. We randomly recruited 20 women following TOT procedures. Postoperative ultrasound datasets acquired during rest, straining, and coughing were digitally stored and analyzed offline by 2 independent and blinded investigators. The assessed parameters included axial tape-urethral distance, axial urethral central echolucent area, axial tape angle, and coronal tape angle at 5 equidistant tape points. For most parameters, the intraclass correlation coefficient and 95% confidence interval for intra- and interobserver reliability was higher than 0.70. 4D ultrasound can provide a quantitative method that meets minimal standards for reliability coefficients in assessing the tension and configuration of TOT. The reliability of the current method could be further evaluated when a whole new ultrasound examination was performed.

Matched-pair analyses of resting and dynamic morphology between Monarc and TVT-O procedures by ultrasound.

OBJECTIVE To determine morphologic differences between Monarc and TVT-O procedures in axial and coronal planes by three- and four-dimensional (3D and 4D) ultrasound. STUDY DESIGN Retrospective chart audits and ultrasound analyses were conducted on 128 women who had undergone either Monarc or TVT-O procedures for urodynamic stress incontinence. Thirty matched pairs of the two successful procedures were randomly selected and compared. Matched variables were age, parity, body mass index, cesarean status, menopausal status, and primary surgeries. Six-month postoperative 3D and 4D ultrasound results obtained at rest, on straining, and during coughing in these 60 women were analyzed. Assessed ultrasound parameters included the axial tape urethral distance (aTUD), axial central urethral echolucent area (aUCEA), axial tape angle (aTA), and coronal tape angle (cTA), all of which were measured at three equidistant points along the tapes. Paired t-tests were used to compare differences in ultrasound parameters between women after the two procedures and a P value <0.004 was considered significant after Bonferroni correction. RESULTS At rest, women subjected to Monarc procedures had a significantly wider aTA at one-fourth of the tape and a wider cTA at one-, two-, and three-fourths of the tape than did those subjected to TVT-O procedures. There were no significant differences in other resting ultrasound parameters between these two procedures. Additionally, after both procedures women had comparable straining and coughing ultrasound manifestations as well as respective dynamic changes. CONCLUSION Despite flatter resting tape angulations in women following Monarc procedures, both Monarc and TVT-O tapes had equivalent dynamic patterns and changes assessed by 4D ultrasound.

Applications of Ultrasonography in Female Lower Urinary Tract Symptoms: Diagnosis and Intervention

Summary Lower urinary tract symptoms (LUTS) are a common health problem causing considerable inconvenience to many women. Moreover, they are non-specific and can be caused by a large number of disorders. A thorough evaluation, including physical examination, imaging studies, and urodynamic investigation of the lower urinary tract, is crucial for appropriate management of bothersome symptoms. Ultrasonography has the advantages of non-invasiveness, reproducibility, no radiation exposure, and low cost. With the use of a high-resolution transducer, pelvic organs can be demonstrated clearly on ultrasonography. In addition, three-dimensional sonography provides a clear demonstration of the spatial orientation of the female lower urinary tract. Both color and power Doppler scanning can not only reveal the vascular flow in pelvic organs, but also demonstrate urinary flow. Ultrasonography has dual functions in the management of female LUTS: diagnosis and intervention. It may help physicians to recognize the anatomic characteristics of specific pelvic floor disorders, to explore the pathophysiologic mechanism responsible for pelvic floor dysfunction, and to assist in the surgical management of LUTS with minimal invasion. Since female LUTS may originate from gynecologic or nongynecologic conditions, it is more convenient and helpful to obtain transvaginal and introital sonograms at the same time by using an endovaginal probe.

Pelvic floor muscle functions are improved after successful transobturator vaginal mesh procedures

To explore functional changes of pelvic floor muscle (PFM) after successful Perigee procedures.