Thais V. Peterson

Are There Predictors of Outcome Following Rectovaginal Fistula Repair

BACKGROUND: Rectovaginal fistula is a distressing condition for patients and for physicians who are continuously challenged in providing durable treatment options. The aim of this study is to assess the results of rectovaginal fistula repair and identify predictive factors for poor outcome. METHODS: Retrospective analysis of patients who underwent rectovaginal fistula repair from 1988 to 2008 was performed. &khgr;2 tests and logistical regression analysis were used to study treatment outcomes according to the following fistula characteristics: etiology, size, location, and number of prior attempts at fistula repair. In addition, patient factors such as age, body mass index, smoking history, comorbid condition of diabetes, use of steroid and immunosuppressive medications, number of prior vaginal deliveries, and presence of a diverting stoma were analyzed. RESULTS: A total of 184 procedures were performed in 125 patients. Inflammatory bowel disease was the most common indication for surgery (45.6%), followed by obstetric injury (24%) and surgical trauma (16%). The mean duration of fistula presence was 31.2 months. The procedures performed included endorectal advancement flap (35.3%), gracilis muscle interposition (13.6%), seton placement (13.6%), and transperineal (8.7%) and transvaginal repair (8.1%). The overall success rate per procedure was 60%, with no difference in recurrence rates based on the type of repair. Patients with Crohns disease had more recurrent fistulas (44.2% success per procedure; P < .01), although 78% eventually healed after an average of 1.8 procedures. Patients with obstetric injuries had an 89% success rate after an average of 1.3 procedures per patient, which is similar to the success rate for traumatic fistulas. Pouch vaginal fistulas had a 91% success rate after an average of 1.6 procedures per patient. The overall success rate per patient was 88% after multiple procedures with a mean follow-up of 16.3 months. Age, body mass index, diabetes, use of steroids and immunosuppressive agents, size and location of the fistula, number of vaginal deliveries, time interval between a recurrent episode and subsequent repair, and the presence of fecal diversion did not affect outcomes. The presence of Crohns disease and a smoking history are strongly associated with rectovaginal fistula recurrence (P = .02). CONCLUSIONS: Despite a relatively low initial success rate (60%), most rectovaginal fistulas can be successfully repaired with subsequent operations. Crohns disease and smoking are associated with adverse outcomes.

Anterior Repair With or Without Collagen Matrix Reinforcement: A Randomized Controlled Trial

OBJECTIVE: To compare outcomes of anterior colporrhaphy alone to that reinforced with bovine pericardium graft. METHODS: Women with anterior vaginal wall prolapse were enrolled in a randomized fashion in this grafted compared with nongrafted repair study. Outcome measures included pelvic organ prolapse quantification data, quality-of-life assessment, healing abnormalities, and complications. RESULTS: Ninety-four patients were enrolled. Seventy-two (77%) provided 1-year data, and 59 (63%) supplied 2-year data. Demographics and stage of prolapse were similar between groups at baseline. Postoperative complications consisted basically of low urinary tract infection and were low in both groups (10 in bovine pericardium graft and 16 in anterior colporrhaphy alone). One year after surgery, successful anterior vaginal wall support was obtained in 85.7% of the bovine pericardium graft group and 78.4% of anterior colporrhaphy–alone group (P=.544). For the cohort that comprised 2-year analyses, the success rate was 76.5% for the bovine pericardium graft group and 63% for anterior colporrhaphy–alone group (P=.509). Postoperative Urogenital Distress Inventory-6 and Pelvic Organ Prolapse–Urinary Incontinence Sexual Function Questionnaire-12 scores were uniformly improved over baseline in both groups. CONCLUSION: The use of bovine pericardium graft for anterior vaginal prolapse does not have higher complication rates or healing difficulties. At 1- and 2-year follow-up, anterior colporrhaphy with bovine pericardium reinforcement did not show a statistically significant improvement over colporrhaphy alone. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00860912 LEVEL OF EVIDENCE: I

Validation of a global pelvic floor symptom bother questionnaire

Introduction and hypothesisThis study aimed to validate a symptom questionnaire to assess presence and patient bother as related to common pelvic floor disorders.MethodsThe validation of the Pelvic Floor Bother Questionnaire (PFBQ) included evaluation of internal reliability, test-retest reliability, and validity of the items.ResultsA total of 141 patients with mean age of 61.8 ± 13.2 were included in the study. Twenty-four percent of patients complained of stress urinary incontinence, 14.9% mixed incontinence, 14.9% urge incontinence, 10% fecal incontinence, 5.7% obstructed defecation, 28.4% pelvic organ prolapse, and 2.1% dyspareunia. The PFBQ demonstrated good reliability (α = 0.61-0.74; ICC = 0.94). There was a strong agreement beyond chance observed for each question (k = 0.77-0.91). PFBQ correlated with stage of prolapse (ρ = 0.73, p < 0.0001), number of urinary and fecal incontinence episodes (ρ = 0.81, p < 0.0001; ρ = 0.54, p < 0.0001), and obstructed defecation (ρ = 0.55, p < 0.0001).ConclusionThe PFBQ is a useful tool that can be easily used for identification and severity or bother assessment of various pelvic floor symptoms.

“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.

Cistoadenocarcioma mucinoso de ovário e esclerose sistêmica

O câncer de ovario e a terceira causa de morte entre as neoplasias malignas em mulheres e o cistoadenocarcinoma mucinoso e uma neoplasia maligna originaria do epitelio ovariano e que pode adquirir grandes dimensoes. Alguns estudos sugerem um aumento do risco de neoplasia em pacientes com esclerose sistemica (ES), mas a associacao com neoplasia de ovario, principalmente do subtipo mucinoso, nao e comum. Os autores descrevem um caso de cistoadenocarcinoma mucinoso de ovario em uma mulher branca de 52 anos com diagnostico de ES difusa ha seis anos, tratada previamente com D-penicilamina e ciclofosfamida, que procurou o servico medico com queixa de dor e aumento do volume abdominal ha tres meses. Ao exame fisico apresentava facies esclerodermica, membros superiores com diminuicao da elasticidade e enxerto bitibial em membros inferiores; no abdome havia a presenca de uma massa endurecida estendendo-se da regiao suprapubica ate o epigastrio. Foi realizada laparotomia exploradora onde se encontrou uma massa cistica no ovario direito, com peso de 3.300 gramas. Em seguida procedeu-se exerese do tumor com histerectomia total e ooforectomia bilateral. O exame histologico confirmou tratar-se de um cistoadenocarcinoma mucinoso sem invasao de capsula.