Tsia-Shu Lo

Ultrasonographic and urodynamic evaluation after tension free vagina tape procedure (TVT)

Background. This study was carried out to evaluate the urodynamic and ultrasonographic findings after tension‐free vagina tape (TVT) procedure on stress urinary incontinent women.

Pessary test to predict postoperative urinary incontinence in women undergoing hysterectomy for prolapse.

OBJECTIVE: We sought to demonstrate that a positive pessary test could predict postsurgical stress urinary incontinence in women with severe pelvic organ prolapse and that performing tension-free vaginal taping (TVT) could effectively prevent its occurrence. METHODS: Among the 79 patients evaluated for severe pelvic organ prolapse without symptoms of stress urinary incontinence, all underwent meticulous urogynecologic evaluations and pessary testing. In group 1, 32 patients had positive pessary tests and underwent vaginal hysterectomy, anterior and posterior colporrhaphy, and TVT. In group 2, 47 patients (17 of whom had positive pessary tests and 30 of whom had negative pessary tests) underwent vaginal hysterectomy and anterior and posterior colporrhaphy alone. A comparison in terms of surgical outcome and clinical manifestations was made between these 2 groups of patients. RESULTS: After surgery, a small proportion of patients had de novo idiopathic detrusor overactivity (7.6%, n = 6), urinary tract infections (7.6%, n = 6), mild recurrent prolapse (5.1%, n = 4), and urinary retention (3.8%, n = 3). Eleven (64.7%) of 17 patients with positive pessary tests who did not undergo TVT had urine leakage after their hysterectomies in contrast with the 30 patients who had negative pessary test, none of whom developed symptomatic stress urinary incontinence after vaginal hysterectomy. Among the 32 patients with positive pessary tests who had TVT with their hysterectomies, 3 developed urine leakage later; the cure rate was 90.6%. CONCLUSION: Continent patients suffering from severe pelvic organ prolapse but with a positive pessary test are considered to be at high risk of developing postoperative symptomatic stress urinary incontinence. Among the patients in our medium-range study, TVT effectively prevented postsurgical urinary incontinence. LEVEL OF EVIDENCE: II-1

Tension-free vaginal tape procedure after previous failure in incontinence surgery.

OBJECTIVES To study the efficacy of the tension-free vaginal tape (TVT) procedure for patients with recurrent genuine stress incontinence. METHODS Forty-one women, including 11 with urethral sphincter incompetence (mean age 49.6 years, range 37 to 66), were treated for recurrent genuine stress incontinence with TVT procedure under local or regional anesthesia. Urodynamic studies, a 1-hour pad test, introital ultrasonography on the urethra, a cotton swab test, and subjective symptom analysis were documented before the procedure and at 1 year postoperatively. RESULTS Of the 41 women, 34 (82.9%) were cured, 2 improved, and 5 (12.2%) had treatment failure. Among the women with failure, three had urethral sphincter incompetence with a fixed urethra. No major surgical complications occurred. Four bladder perforations were noted. The 1-hour pad test reduced from a mean of 27.3 to 1.7 g (P <0.001). The operating time was 22 minutes (range 15 to 44), and the postoperative hospital stay was 22.4 hours (range 12 to 72). Spontaneous voiding with adequate postvoid residual urine volume was noted for all patients by the fourth day postoperatively. The preoperative and postoperative cotton swab result was 40.0 degrees (range 10 degrees to 80 degrees ) and 38.7 degrees (range 10 degrees to 76 degrees ), respectively, without statistically significant changes. Of the 36 cured and improved patients, 31 (86.1%) had a cotton swab test result of 30 degrees or more before and after the TVT procedure. Urodynamic parameters related to the voiding dysfunction showed no significant difference before and after the surgery. Urodynamic assessment showed no significant difference in the filling, voiding, and urethral pressure profile (dynamic and static) variables, except for significant increases in the maximal flow rate, bladder volume at the first desire to void, and cystometric capacity, which were measured preoperatively and postoperatively. No de nova detrusor instability or micturition disturbances were found in the cystometric study. CONCLUSIONS The TVT procedure for the treatment of recurrent genuine stress incontinence is a safe, effective, and minimally invasive option requiring only a short hospital stay. However, the immobile urethra seems to be a risk factor for failure. Long-term follow-up is needed to determine whether this surgery achieves long-lasting results.

Tension-free vaginal tape procedure on genuine stress incontinent women with coexisting genital prolapse

Objective.  To study the efficacy of performing the tension‐free vaginal tape (TVT) procedure concurrently with vaginal pelvic relaxation surgeries in the management of genuine stress incontinence with genital prolapse.

Use of intravenous anesthesia for tension-free vaginal tape therapy in elderly women with genuine stress incontinence.

OBJECTIVES To study the efficacy of the tension-free vaginal tape (TVT) procedure for elderly patients. METHODS Forty-five women, 65 years old or older (mean 69.1; range 65 to 85), were treated for genuine stress incontinence with the tension-free vaginal tape procedure under intravenous anesthesia with heavy sedation. Urodynamic studies and 1-hour pad test were performed before the procedure and at 1 year postoperatively. Vigorous manual pressure against the abdominal wall and ensuring no lifting of urethra by intraoperative introital ultrasonography were used to position and adjust the vaginal taping. RESULTS Forty-one (91%) were cured, one improved, and three failed. No major surgical complications occurred. Two bladder perforations were noted. The pad test disclosed a reduction in urine leakage from a mean of 28.9 to 1.6 g/hr (P <0.001). The average blood loss was 72 mL (range 30 to 250), operating time was 21 minutes (range 18 to 35), and postoperative hospital stay was 24.2 hours (range 12 to 72). Spontaneous voiding with an adequate volume of postvoid residual urine was noted for all patients by the fourth day postoperatively. Urodynamic parameters related to the voiding dysfunction showed no significant difference before and after surgery. De novo detrusor instability was observed in 2 patients. CONCLUSIONS With modifications of the technique and the aid of intraoperative ultrasonography, the TVT procedure can be performed under intravenous anesthesia with heavy sedation. The procedure is safe, effective, and minimally invasive for elderly patients. However, long-term follow-up is needed to determine whether this surgery achieves long-lasting results.

Bladder Injury after LAVH: A Prospective, Randomized Comparison of Vaginal and Laparoscopic Approaches to Colpotomy During LAVH

STUDY OBJECTIVE To compare results of a vaginal approach to colpotomy (type IA) and laparoscopic-assisted abdominal colpotomy (type ID) in performing a laparoscopic-assisted vaginal hysterectomy (LAVH). DESIGN Prospective, randomized study (Canadian Task Force classification I). SETTING Tertiary teaching hospital. PATIENTS Five hundred forty-one women, 274 in group 1 (type 1D) and 267 in group 2 (type 1A). INTERVENTION LAVH with follow-up for 3 months to 5 years. MEASUREMENTS AND MAIN RESULTS There were no statistically significant differences in age, preoperative and postoperative hemoglobin values, or postoperative hospital stay between groups. Operating time and estimated blood loss were significantly reduced in group 2 (p <0.001 and <0.001, respectively). Women in group 1 had nine urinary tract injuries (3.28%), including eight cases of intraoperative bladder injury (2.91%) and one vesicovaginal fistula (0.36%), but no ureteral injury. The bladder injury rate in group 2 was 0.37%, which was significantly lower (p = 0.038). There were no significant differences in ureteral or bowel injuries, pelvic hematomas, or pelvic abscesses. CONCLUSION LAVH type IA achieved better results than type ID in preventing bladder injury.

Repair of recurrent vaginal vault prolapse using sacrospinous ligament fixation with mesh interposition and reinforcement

Objective.  Our goal was to study the efficacy of performing the repeated sacrospinous ligament fixation with mesh interposition and reinforcement in women with recurrent vaginal vault prolapse.

Expression of matrix metalloproteinase-2 and tissue inhibitors of metalloproteinase-1 (TIMP-1, TIMP-2 and TIMP-3) in women with uterine prolapse but without urinary incontinence

OBJECTIVE To investigate the activities of matrix metalloproteinase-2 (MMP-2) and its inhibitors, tissue inhibitor of metalloproteinase-1, -2 and -3 (TIMP-1, TIMP-2 and TIMP-3), in the pelvic support and nonsupport tissue of women with uterine prolapse but without urinary incontinence. STUDY DESIGN Paired samples of uterosacral ligament and cervical tissue were obtained from 11 postmenopausal and 8 premenopausal women with severe uterine prolapse. Nine premenopausal women without prolapse were selected as normal controls. Immunoreactivity of MMP-2 and TIMPs was demonstrated by immunohistochemistry. Steady state of MMP-2 as well as TIMPs messenger RNA (mRNA) expression was analyzed by polymerase chain reaction (PCR) with quantitative expression determined by multiplex PCR. RESULTS A significantly higher expression of MMP-2 mRNA and lower expression of TIMP-2 mRNA were found in uterosacral ligament in uterine prolapse women compared to controls. In the cervical tissue, however, the MMP-2 and TIMPs mRNA expression was comparable between prolapse and control groups. With regard to menopausal status, there was no significant difference in MMP-2 and TIMPs mRNA expression between premenopausal and postmenopausal women with uterine prolapse. CONCLUSIONS An increase in MMP-2 mRNA and a decrease in TIMP-2 mRNA expression in uterosacral ligament are related to uterine prolapse in women without urinary incontinence.

Comparison between Elevate Anterior/Apical system and Perigee system in pelvic organ prolapse surgery: clinical and sonographic outcomes

ObjectiveThe aim of this study was to assess the incidence of de novo stress urinary incontinence (SUI) and sonographic features of implanted transvaginal mesh in continent women treated with Elevate™ anterior/apical [single-incision mesh (SIM-A)] or Perigee™ [transvaginal mesh with sacrospinous fixation (TVM + SSF)] in extensive pelvic organ reconstruction surgery.MethodsThis prospective observational study was done from May 2010 to January 2013. Patients were recruited from two tertiary centers, and the Elevate™ and Perigee™ systems were compared. Patients who had overt or occult SUI, previous prolapse or mesh insertion were excluded.ResultFifty-seven patients in the SIM-A group and sixty-one in the TVM + SSF group were analysed. All completed a minimum of 1-year follow-up. Groups were demographically and statistically similar. There was a significantly high incidence of de novo SUI postoperatively in the SIM-A group. The objective and subjective cure rate of pelvic organ prolapse (POP) were comparable between groups, with incidence of mesh erosion in the SIM-A group and three in the TVM + SSF group. Sonographic evaluation showed significant increase in mesh length in the SIM-A group.ConclusionElevate™ a offered lower incidence of mesh erosion and comparable results on anatomical POP correction; however, incidence of de novo SUI was high. There is an apparent lengthening of implanted Elevate® mesh sonographically.

Successful management of chylous ascites after laparoscopic presacral neurectomy

Laparoscopic presacral neurectomy is a safe, effective, and well-established surgical procedure to relieve intractable dysmenorrhea and chronic pelvic pain. In one woman, substantial lymphatic leakage occurred due to damaged lymphatic vessels. Adequate exposure and coagulation of the presacral lymphatic zone through the laparoscope resolved the problem, and a substantial amount of chylous ascites was removed. The patient fully recovered after the intervention.