Stefano Uccella

Female Urinary Incontinence During Intercourse: A Review on an Understudied Problem for Women's Sexuality

INTRODUCTION Coital urinary incontinence is a frequently underreported symptom, with a relevant impact on womens sexuality and quality of life. AIM This article will review the available evidence on incidence, pathophysiology, and treatment of coital urinary incontinence with the attempt to present the current state of the art. METHODS PubMed was searched for reports about coital urinary incontinence that were published from 1970 to 2008, and the most relevant articles were reviewed. MAIN OUTCOME MEASURES Review on epidemiology, pathophysiology, diagnosis, and treatment of coital incontinence. RESULTS The incidence of coital incontinence in incontinent women has been reported to range between 10% and 27%. At present, some evidence suggests an association between urinary leakage at penetration and urodynamic stress (USI) incontinence as well as urinary leakage during orgasm and detrusor overactivity (DO). When treatment for these conditions are based upon urodynamic findings, pelvic floor muscle training, surgery, and pharmacotherapy show satisfactory cure rates. CONCLUSIONS Coital urinary incontinence deserves much more attention in clinical practice: women should be specifically interviewed for this disturbance because it has a very negative impact on their sexuality. If a reliable urodynamic diagnosis is made, coital urinary incontinence at penetration can be cured in more than 80% of cases by surgery in the presence of USI. The form of coital incontinence during orgasm is curable by antimuscarinic treatment in about 60% of cases when associated with DO.

Vaginal cuff closure after minimally invasive hysterectomy: our experience and systematic review of the literature

OBJECTIVE To determine the incidence of vaginal cuff dehiscence after minimally invasive hysterectomy, we reported our series of total laparoscopic hysterectomies with transvaginal colporraphy. STUDY DESIGN We then conducted a systematic search of PubMed to retrieve published series of laparoscopic and robotic hysterectomies, in which different techniques for vaginal cuff closure were used. RESULTS In our study group, vaginal cuff dehiscence occurred in 2 of 665 (0.3%) patients. Our literature search identified 57 articles, for a total of 13,030 endoscopic hysterectomies. Ninety-one postoperative vaginal separations were reported (0.66%). The pooled incidence of vaginal dehiscence was lower for transvaginal cuff closure (0.18%) than for both laparoscopic (0.64%; odds ratio [OR], 0.28; 95% confidence interval [CI], 0.12-0.65) and robotic (1.64%; OR, 0.11; 95% CI, 0.04-0.26) colporraphy. Laparoscopic cuff closure was associated with a lower risk of dehiscence than robotic closure (OR, 0.38; 95% CI, 0.28-0.6). CONCLUSION Current evidence indicates that transvaginal colporraphy after total laparoscopic hysterectomy is associated with a 3- and 9-fold reduction in risk of vaginal cuff dehiscence compared with laparoscopic and robotic suture, respectively.

Vaginal cuff dehiscence in a series of 12,398 hysterectomies: effect of different types of colpotomy and vaginal closure.

OBJECTIVE: To investigate the risk of vaginal cuff dehiscence after different routes of hysterectomy and methods of cuff closure. METHODS: A multi-institutional analysis of 12,398 patients who underwent hysterectomy for both benign and malignant disease between 1994 and 2008 was performed. We analyzed how different routes of hysterectomy and approaches to cuff suture may influence the risk of development of vaginal dehiscence. RESULTS: Women who had total laparoscopic (n=3,573), abdominal (n=4,291), and vaginal (n=4,534) hysterectomies experienced 23 (0.64%), 9 (0.2%), and 6 (0.13%) cases of vaginal cuff dehiscence, respectively. Total laparoscopic hysterectomy was associated with a higher incidence of cuff separations, compared with abdominal hysterectomy (0.64% compared with 0.21%, P=.003) and vaginal hysterectomy (0.64% compared with 0.13%, P<.001). Within the endoscopic group, patients who underwent vaginal closure with laparoscopic knots had a higher rate of cuff dehiscence than patients who had suture with transvaginal knots (20 of 2,332 [0.86%] compared with 3 of 1,241 [0.24%], P=.028). When vaginal suture was performed transvaginally, no statistical difference in vaginal cuff dehiscence rate was observed compared with both abdominal hysterectomy (0.24% compared with 0.21%, P=.83) and vaginal hysterectomy (0.24% compared with 0.13%, P=.38). Use of monopolar energy at the time of colpotomy and reducing the power of monopolar energy from 60 watts to 50 watts when colpotomy was performed at the end of total laparoscopic hysterectomy did not alter the rate of cuff separations. CONCLUSION: Transvaginal suturing appears to reduce the risk of vaginal dehiscence after total laparoscopic hysterectomy. LEVEL OF EVIDENCE: II

Robot-assisted Sacrocolpopexy for Pelvic Organ Prolapse: A Systematic Review and Meta-analysis of Comparative Studies

CONTEXT Surgery represents the mainstay of treatment for pelvic organ prolapse (POP). Among different surgical procedures, abdominal sacrocolpopexy (SC) is the gold standard for apical or multicompartmental POP. Research has recently focused on the role of robot-assisted sacrocolpopexy (RASC). OBJECTIVE To conduct a systematic review on the outcomes of RASC. EVIDENCE ACQUISITION PubMed, Scopus, and Web of Science databases as well as ClinicalTrials.gov were searched for English-language literature on RASC. A total of 509 articles were screened; 50 (10%) were selected, and 27 (5%) were included. Studies were evaluated per the Grading of Recommendations, Assessment, Development, and Evaluation system and the European Association of Urology guidelines. EVIDENCE SYNTHESIS Overall, data on 1488 RASCs were collected from 27 studies, published from 2006 to 2013. Objective and subjective cures ranged from 84% to 100% and from 92% to 95%, respectively. Conversion rate to open surgery was <1% (range: 0-5%). Intraoperative, severe postoperative complications, and mesh erosion rates were 3% (range: 0-19%), 2% (range: 0-8%), and 2% (range: 0-8%), respectively. Surgical-related outcomes have improved with increased experience, with an estimated learning curve of about 10-20 procedures. Laparoscopic SC is less costly than RASC, although the latter has lower costs than abdominal SC. CONCLUSIONS RASC is a safe and feasible procedure for POP; it allows the execution of complex surgical steps via minimally invasive surgery without medium- and long-term anatomic detriments. Further prospective studies are needed to confirm these findings. PATIENT SUMMARY We looked at the outcomes of robotic sacrocolpopexy for prolapse. We found that the use of robotic technology is safe and effective for the treatment of prolapse in women.

Prospective study to assess risk factors for pelvic floor dysfunction after delivery

Background. To identify obstetric risk factors for de novo pelvic floor disorders after vaginal delivery. Methods. Antenatally asymptomatic women who delivered vaginally were interviewed on urinary, anal and sexual disorders antenatally, 6 and 12 months postpartum. Results. Of 967 women, 336 were included for final analysis. Urinary symptoms occurred in 27 and 23% of women at 6 and 12 months postpartum: univariate analysis showed a significant relation to the use of epidural analgesia (p =0.04) and to a second stage of labour >1 h (p =0.02), the latter was confirmed significant by multivariate analysis. Anal incontinence occurred in 7.1 and 6.8% of women at 6 and 12 months postpartum, respectively. Dyspareunia was reported by 24% at 6 months, decreasing to 8% at 12 months (p <0.0001). Conclusions. Our study shows that a second stage longer than 1 h is associated with the development of postpartum urinary incontinence. Except for dyspareunia, pelvic floor dysfunction rarely resolves spontaneously.

Surgical treatment for female stress urinary incontinence: what is the gold-standard procedure?

In the last few years, the Burch colposuspension and the fascial slings were often defined from the pages of the most relevant journals of general medicine, as gold-standard procedures for the surgical treatment of stress urinary incontinence (SUI), whereas mid-urethral slings (tension-free vaginal tape (TVT) and tension-free vaginal tape obturator) were attributed a marginal and almost experimental role in this field. This poorly reflect the current scenario of the surgical management of SUI: Recently, a number of meta-analysis have demonstrated that TVT is significantly more effective if compared to colposuspension and that it is followed by significantly lower perioperative morbidity if compared to pubovaginal slings. It is not realistic to suggest to general practitioners that the surgical gold standard for SUI includes the performance of a wide laparotomy, long hospital stays and a high risk of long-lasting intermittent self-catheterisation. This would inevitably discourage women from embarking on surgical treatment, which instead could actually improve their quality of life.

Postoperative pain after laparoscopic and vaginal hysterectomy for benign gynecologic disease: a randomized trial

OBJECTIVE To compare postoperative pain after laparoscopic and vaginal hysterectomy for benign disease. STUDY DESIGN A prospective randomized trial was designed to compare laparoscopic hysterectomy and vaginal hysterectomy in patients with uterine volume <or=14 weeks of gestation. Postoperative pain was measured using the visual analog scale (VAS) at 1, 3, 8, and 24 hours postoperatively. Intra- and postoperative outcomes were carefully recorded, including the need for postoperative rescue doses of analgesia. RESULTS A total of 82 patients were enrolled. Patients who underwent vaginal hysterectomy complained of higher postoperative pain at each VAS evaluation (VAS-1 hour, P < .0001; VAS-3 hour, P < .0001; VAS-8 hour, P < .0001; VAS-24 hour, P = .0003) with a higher need for rescue analgesia (P < .0001) and a longer hospitalization (P = .001). The other perioperative characteristics were comparable between the 2 groups. CONCLUSION Laparoscopic hysterectomy provides an advantage over vaginal hysterectomy in terms of postoperative pain, need for rescue analgesia and hospital stay, with similar perioperative outcomes.

Cosmetic outcomes of various skin closure methods following cesarean delivery: a randomized trial

OBJECTIVE The objective of the study was to compare scar quality associated with different types of wound closure methods after cesarean section (CS). STUDY DESIGN Patients were randomized to have skin closure following CS with either staples or 3 different types of subcuticular sutures. Scar quality was evaluated 2 and 6 months postoperatively. The Vancouver Scar Scale, the Patient and Observer Scar Assessment Scale (POSAS), and a visual analog scale were used as scar assessment tools. RESULTS Of the 180 patients who were recruited, 123 successfully completed the study. No difference in both subjective and objective scar rating was detected across groups at either 2 months or 6 months. In the overall study population, objective scores correlated with patient rating, and correlation was strongest between the observer and patient components of the POSAS (r = 0.48). CONCLUSION In women undergoing CS, stapled wounds and those closed with subcuticular sutures result in equivalent cosmetic appearance of the scar.

Sexual Function after Radical Hysterectomy for Early-Stage Cervical Cancer: Is There a Difference between Laparoscopy and Laparotomy?

INTRODUCTION Surgical treatment for cervical cancer is associated with a high rate of late postoperative complications, and in particular with sexual dysfunction. AIM To evaluate sexual function in women who underwent radical hysterectomy (RH), in comparison with a control group of healthy women, using a validated questionnaire (Female Sexual Function Index [FSFI]). Then we tried to evaluate the possible differences between laparoscopic RH and abdominal RH in terms of their impact on sexuality. METHODS Consecutive sexually active women, who underwent RH for the treatment of early-stage cervical cancer between 2003 and 2007, were enrolled in this study (cases) and divided into two groups, according to the surgical approach. All women were administered the FSFI. The results of this questionnaire were compared between patients who underwent laparoscopic RH (LPS group) vs. women who underwent laparotomic RH (LPT group). The cases of RH were also compared with a control group of healthy women, who were referred to our outpatient clinic for a routine gynecologic evaluation. MAIN OUTCOME MEASURES FSFI questionnaire on six domains of female sexuality (desire, arousal, lubrication, orgasm, satisfaction, pain). RESULTS A total of 38 patients were included. We also enrolled 35 women as healthy controls. FSFI score was significantly higher in the healthy controls vs. the cases of RH. In the LPS group, the total score and all the domains of the FSFI were lower in comparison with the healthy controls, whereas three of the six domains (arousal, lubrication, orgasm) and the total score of FSFI were lower in the LPT group if compared with the controls. There were no significant differences between LPS and LPT group. CONCLUSIONS RH worsens sexual function, regardless of the type of surgical approach. In our experience, laparoscopy did not show any benefit on womens sexuality over the abdominal surgery for cervical cancer.

A randomized trial of preinduction cervical ripening: dinoprostone vaginal insert versus double-balloon catheter

OBJECTIVE We sought to compare the efficacy of a double-balloon transcervical catheter to that of a prostaglandin (PG) vaginal insert among women undergoing labor induction. STUDY DESIGN In all, 210 women with a Bishop score ≤6 were assigned randomly to cervical ripening with either a double-balloon device or a PGE2 sustained-release vaginal insert. Primary outcome was vaginal delivery within 24 hours. RESULTS The proportion of women who achieved vaginal delivery in 24 hours was higher in the double-balloon group than in the PGE2 group (68.6% vs 49.5%; odds ratio, 2.22; 95% confidence interval, 1.26-3.91). There was no difference in cesarean delivery rates (23.8% vs 26.2%; odds ratio, 0.88; 95% confidence interval, 0.47-1.65). Oxytocin and epidural analgesia were administered more frequently when a double-balloon device was used. Uterine tachysystole or hypertonus occurred more frequently in the PGE2 arm (9.7% vs 0%, P = .0007). CONCLUSION The use of a double-balloon catheter for cervical ripening is associated with a higher rate of vaginal birth within 24 hours compared with a PGE2 vaginal insert.