Is transobturator suburethral sling effective for treating female urodynamic stress incontinence with low maximal urethral closure pressure?

ObjectiveTo assess retrospectively the efficacy and safety of MONARC (American Medical Systems) transobturator suburethral slings in the treatment of female urodynamic stress incontinence with and without low maximal urethral closure pressure (MUCP).Materials and MethodsSeventy-three women with urodynamic stress incontinence, fitted with the transobturator suburethral sling at a medical center in central Taiwan, participated in the study. Objective postoperative evaluations, including a 1-hour pad test, cough stress test, uroflowmetry, and residual urine volume, were conducted 6 months after operation. Subjective outcomes were evaluated by telephone interview. Charts were reviewed for perioperative complications, urinary retention, and requirements for postoperative medication for symptoms of urgency. The mean follow-up was 48 months.ResultsObjective cure rate was 80.8% (dry pad test and negative stress test), 82.4% for MUCP less than 30 cmH₂O, and 80.4% for MUCP greater than 30 cmH₂O (p = 1.000). Mean pad weight gain changed from 25.8 g preoperatively to 1.8 g postoperatively (p < 0.05). There was no significant change in urinary flow rate or residual volume. Subjectively, 98.6% of subjects experienced complete improvement; only one patient found no improvement. Very few perioperative complications occurred. Immediate postoperative difficulty in voiding occurred in 6.8% of patients. Postoperative de novo urgency was 2.7%.ConclusionsThe MONARC transobturator suburethral sling is a safe and highly effective treatment for stress urinary incontinence even in women with low MUCP at a mean follow-up of 48 months. Evaluation of the outcomes after a longer follow-up period is necessary.     

Is the cough-stress test necessary when placing the tension-free vaginal tape?

OBJECTIVE: To estimate whether the mode of anesthesia (and the resultant ability or inability to perform the cough-stress test) used during the tension-free vaginal tape (TVT) procedure affects postoperative continence. METHODS: A cohort of 170 women who underwent the TVT procedure without any other concomitant surgery completed the short form of the Urogenital Distress Inventory (UDI-6) to assess their continence status preoperatively and postoperatively. Chi-squared, t, and Mann-Whitney U tests were used to determine the association between these data and anesthesia type during univariate analysis. RESULTS: Both anesthesia groups showed significant improvement from their preoperative UDI-6 scores to their postoperative scores. However, when comparing the change from pre- to postoperative UDI-Stress Symptoms subscale scores between the 2 groups, we found a significant difference. Mean improvement in the local group was 58.3 (+/- 33.8) compared with 41.7 (+/- 39.4) in the general group (P = .02). CONCLUSION: Women who undergo TVT show significant improvements in incontinence severity regardless of anesthesia type. However, greater improvements in stress incontinence, as measured by the UDI-Stress Symptoms subscale, are seen when the TVT is placed while using the cough-stress test under local analgesia. LEVEL OF EVIDENCE: II-2.     

Does the tension-free vaginal tape stay where you put it?

OBJECTIVE: The tension-free vaginal tape (TVT) is a widely used procedure for the surgical treatment of urodynamic stress incontinence. Long-term follow-up data remain scarce. It has been speculated that scar formation leads to tape shortening and stiffening. This study was designed to longitudinally investigate tape position and mobility. STUDY DESIGN: An observational clinical study was performed using ultrasound parameters of tape position and mobility on Valsalva maneuver as main outcome parameters. RESULTS: Of 92 women eligible for a minimum of two postoperative assessments, 72 (78%) attended at least twice after TVT placement, at a median interval of 1.6 years. Sixty-eight data sets remained after exclusion of 4 patients who had undergone tape division. At the last visit, the tape was found to be more caudal, at rest (P <.001) and on Valsalva maneuver (P =.002). Tape mobility on Valsalva maneuver remained virtually unchanged. CONCLUSION: The TVT does not seem to contract or shorten over a median observation period of 1.6 years. On the contrary, it appears to slowly migrate caudally.     

Bladder perforation during tension-free vaginal tape surgery: does it matter?

OBJECTIVE: To analyze the incidence, possible risk factors, preoperative morbidity and outcome results in tension-free vaginal tape (TVT) cases complicated by lower urinary tract injury in a large, heterogeneous, consecutive group of women. STUDY DESIGN: Four hundred sixty consecutive women who underwent TVT surgery for correction of urodynamically proven stress urinary incontinence were enrolled prospectively. All the procedures were performed at 1 center by 3 experienced surgeons. RESULTS: In this series, 3.9% cases of lower urinary tract injury occurred. Most of the injuries occurred during the learning curve. TVT-related urinary tract injury was not associated with increased perioperative morbidity. The cure rates were similar with and without injury. De novo urge and persistent urge incontinence were slightly more common in patients with bladder perforation. CONCLUSION: Lower urinary tract injury during the TVT procedure is directly related to the inexperience of the surgeon. However, TVT-related lower urinary tract injury does not appear to affect medium-term outcome results.     

The use of prophylactic antibiotics in the tension-free vaginal tape procedure: is it indicated?

The tension-free vaginal tape (TVT) surgical procedure is well established in the treatment of female urinary stress incontinence. The operation is based on a midurethral Prolene tape support. TVT is accepted as an easy-to-learn and safe minimally invasive surgical technique. Postoperative infections have been described following other surgical methods for correcting female urinary stress incontinence. Hence, prophylactic antibiotics are commonly also used in TVT to minimise this surgical complication. The aim of this analysis was to evaluate the occurrence of infection in relation to TVT and the need for prophylactic antibiotics. Out of 524 patients undergoing TVT and followed for up to 68 months, only three suffered surgical field infections within the postoperative period. The three infective processes developed with a background of retropubic haematoma formation. The literature is reviewed, and the justification for prophylactic antibiotics in the TVT operation is discussed.     

Is treatment with vaginal pessaries an option in patients with a sonographically detected short cervix?

OBJECTIVE: The purpose was to determine the effect of vaginal pessaries in patients at risk for spontaneous preterm birth (SPB). STUDY DESIGN: Transvaginal sonography (TVS) was longitudinally performed to measure cervical length (CL) in 258 singleton at risk for SPB and 282 twin pregnancies. Pairs with or without treatment were matched for gestational age and the CL at examination. RESULTS: In 4 singleton and 7 twin pregnancies the CL was < 15 mm before 24 weeks, the mean interval between pessary insertion and delivery was 13 + 2 and 12 + 5 weeks respectively. For the matched control analysis, 12 pairs with singleton and 23 pairs with twin pregnancies were compared. For singleton pregnancies, the mean interval between TVS and delivery was 99 (70-134) days in the treatment and 67 (2-130) days in the control group (p = 0.0184), the mean gestational age at delivery was 38 (36 + 6-41) and 33 + 4 (26-38) weeks respectively (p = 0.02). For twin pregnancies, the interval was 85 (43-129) days in the treatment and 67 (21-100) days in the control group (p = 0.001), gestational age at delivery was 35 + 6 (33-37 + 4) and 33 + 2 (24 + 4-37 + 2) respectively (p = 0.02). Within singleton pregnancies with pessary, there was no SPB < 36 weeks compared to 6/12 cases in the control group (p < 0.001). Within twin pregnancies, the rates were 8/23 cases with SPB < 36 weeks but none < 32 weeks, compared to 12/23 cases with SPB < 36 weeks and 7/23 cases < 32 weeks in the control group (p < 0.001). CONCLUSIONS: Insertion of a vaginal pessary may be a cost-effective preventive treatment in patients at risk for SPB. Prospective controlled trials are needed.     

Transvaginal evisceration after hysterectomy: Is vaginal cuff closure associated with a reduced risk?

OBJECTIVE: To evaluate the overall incidence of transvaginal evisceration following hysterectomy and to assess the risk associated with indication, route of surgery, age and vaginal cuff closure technique. MATERIALS AND METHODS: A database was used to identify all patients undergoing hysterectomy from 1995 to 2001 at our institution and all the patients admitted for vaginal evisceration during the same period. Each vaginal evisceration was analyzed for time of onset, trigger event, presenting symptoms, details of prolapsed organs and type of repair surgery. RESULTS: Of the 3593 patients enrolled in the study, 63.5% underwent abdominal hysterectomy, 33.0% vaginal hysterectomy, and 3.5% laparoscopic hysterectomy. Ten patients (0.28%) presented to the emergency room with vaginal evisceration. No statistical differences in evisceration rates were seen according to the route of surgery. No differences were found between the 1440 patients who had closure of the vaginal cuff and the 2153 who had an unclosed cuff closure technique. CONCLUSIONS: Our data suggest that, in young patients, sexual intercourse is to be considered the main trigger event before the complete healing of the vaginal cuff while, in elderly patients, the evisceration is a spontaneous event. Uterine prolapse was not associated with a higher rate and the route of surgery or vaginal cuff closure technique did not influence the dehiscence rate.     

Is induction of labor with continuous release dinoprostone vaginal pessary a viable option in patients with preeclampsia?

Objective: To evaluate the role of dinoprostone vaginal pessary (DVP) for induction of labor in preeclampsia.Methods: This is a prospective review of 94 patients with preeclampsia, who delivered from July 1995 to December 1996 at a university center. Of these, 25 received DVP, 22 oxytocin, 11 intracervical prostaglandin E₂, and 36 received no pharmacologic agents. Patients receiving DVP and oxytocin induction were compared for outcome of pregnancy and cesarean section rate. Statistical analysis was carried out by Student t test, χ² test with Yates correction.Results: The two groups were comparable with respect to parity and 5-minute Apgar scores.      

14.

How are tension-free vaginal tapes (TVT) used in the United Kingdom?     

Julian?W.?BarringtonEmail author  Mohammed?Abdel-fattah  Farida?Bano 《Gynecological surgery》2004,1(3):199-200

Objective The purpose was to ascertain how tension-free vaginal tape (TVT) slings are used in the United Kingdom.Methods A postal questionnaire was sent to all 446 gynaecologists and urologists thought to be using TVT sling surgery in the UK.Results There was wide variation in technique amongst the 236 respondents. These varied with respect to the type of anaesthetic and place of surgery, use of cystoscopy and cough test and postoperative management.Conclusion Although there is a wide variation in technique, it does not appear to affect outcome since results are broadly comparable from different units.     

15.

Is octreotide treatment useful in patients with congenital chylothorax?     

Horvers M  Mooij CF  Antonius TA 《Neonatology》2012,101(3):225-231

     

16.

What determines a successful tension-free vaginal tape? A prospective multicenter cohort study: results from The Netherlands TVT database     

Koops SE  Bisseling TM  van Brummen HJ  Heintz AP  Vervest HA 《American journal of obstetrics and gynecology》2006,194(1):65-74

     

17.

Is urethral pressure profilometry a useful diagnostic test for stress urinary incontinence?     

A M Weber 《Obstetrical & gynecological survey》2001,56(11):720-735

Urethral pressure profilometry is commonly used as a diagnostic test for stress urinary incontinence. The objective of this article is to review the published literature on urethral pressure profilometry to summarize its usefulness. MEDLINE was used to search the published English literature from 1966 to October 2000 for full-length original research articles on urethral pressure profilometry and stress urinary incontinence in women. Terms related to urethral pressure profilometry are defined consistently but techniques are not standardized, introducing variation in test results. Reproducibility of urethral pressure profilometry parameters is poor, both because of biological variation and variation within the test procedure itself (related in part to lack of standardization). Parameters of urethral pressure profilometry do not distinguish between continent and incontinent women and do not characterize the severity of incontinence or urethral incompetence. It is, therefore, concluded that urethral pressure profilometry is not a useful diagnostic test for stress urinary incontinence in women. Its use in clinical management is not supported by current evidence.     

18.

Does vaginal closure force differ in the supine and standing positions?     

Morgan DM  Kaur G  Hsu Y  Fenner DE  Guire K  Miller J  Ashton-Miller JA  Delancey JO 《American journal of obstetrics and gynecology》2005,192(5):1722-1728

OBJECTIVE: This study was undertaken to quantify resting vaginal closure force (VCF(REST)), maximum vaginal closure force (VCF(MAX)), and augmentation of vaginal closure force augmentation (VCF(AUG)) when supine and standing and to determine whether the change in intra-abdominal pressure associated with change in posture accounts for differences in VCF. STUDY DESIGN: Thirty-nine asymptomatic, continent women were recruited to determine, when supine and standing, the vaginal closure force (eg, the force closing the vagina in the mid-sagittal plane) and bladder pressures at rest and at maximal voluntary contraction. VCF was measured with an instrumented vaginal speculum and bladder pressure was determined with a microtip catheter. VCF(REST) was the resting pelvic floor tone, and VCF(MAX) was the peak pelvic floor force during a maximal voluntary contraction. VCF(AUG) was the difference between VCF(MAX) and VCF(REST). T tests and Pearson correlation coefficients were used for analysis. RESULTS: VCF(REST) when supine was 3.6 +/- 0.8 N and when standing was 6.9 +/- 1.5 N--a 92% difference (P < .001). The VCF(MAX) when supine was 7.5 +/- 2.9 N and when standing was 10.1 +/- 2.4 N--a 35% difference (P < .001). Bladder pressure when supine (10.5 +/- 4.7 cm H2O) was significantly less (P < .001) than when standing (31.0 +/- 6.4 cm H2O). The differences in bladder pressure when either supine or standing did not correlate with the corresponding differences in VCF at rest or at maximal voluntary contraction. The supine VCF(AUG) of 3.9 +/- 2.7 N, was significantly greater than the standing VCF(AUG) of 3.3+/-1.9 N. CONCLUSION: With change in posture, vaginal closure force increases because of higher intra-abdominal pressure and greater resistance in the pelvic floor muscles.     

19.

Is assisted hatching beneficial in patients with recurrent implantation failures?     

Rufas-Sapir O  Stein A  Orvieto R  Avrech OM  Kotler N  Pinkas H  Bar J  Fisch B 《Clinical and experimental obstetrics & gynecology》2004,31(2):110-112

PURPOSE: To assess the possible role of assisted hatching in patients with recurrent implantation failure during IVF cycles. DESIGN: Prospective randomized study. SETTING: IVF unit of an academic medical center. PATIENTS: Women who underwent IVF after at least three failed IVF-ET attempts. INTERVENTIONS: Patients were prospectively randomized to undergo assisted hatching of their embryos prior to their replacement by mechanical partial zona dissection. RESULTS: The study (assisted hatching) and control groups included 104 and 103 patients, respectively. There were no significant between-group differences in patient age, cause of infertility, mean number of previous IVF trials, number of oocytes retrieved, fertilization rate, or number of embryos transferred. No difference in pregnancy rate was noted on comparison of the whole study group, to the whole control group (21% and 27%, respectively). However, when the results were re-analyzed by age groups, assisted hatching was found to be harmful in the youngest group (< 34 years), significantly decreasing pregnancy rates (15% vs 35%, p < 0.05). CONCLUSION: Repeated implantation failure alone is not an indication for assisted hatching. Although assisted hatching appears to be effective in a selected group of older patients, in younger patients it may further hamper implantation and should be avoided.     

20.

Is blastocyst transfer useful as an alternative treatment for patients with multiple in vitro fertilization failures?   总被引：5，自引：0，他引：5  

J R Cruz  A K Dubey  J Patel  D Peak  B Hartog  P R Gindoff 《Fertility and sterility》1999,72(2):218-220

OBJECTIVE: To determine whether blastocyst transfer is of benefit to patients with multiple IVF failures. DESIGN: Retrospective cohort study. SETTING: The George Washington University Medical Center. PATIENT(S): Patients undergoing IVF between October 1, 1997, and November 30, 1998, who had previously undergone three or more unsuccessful IVF cycles. Patients who had at least three embryos at the 8- to 12-cell stage available on day 3 were eligible for the study. INTERVENTION(S): Patients were given the option of day 3 ET (group A) or blastocyst transfer (group B). MAIN OUTCOME MEASURE(S): Blastocyst-formation rate, clinical pregnancy rate (PR) per transfer, and implantation rate per transfer. RESULT(S): Groups A and B were similar in terms of age, the number of previous failed IVF cycles, fertilization rate, and the number of fertilized oocytes per cycle. The blastocyst-formation rate was 51.0%. Clinical pregnancy and implantation rates per transfer were statistically significantly higher in the blastocyst-transfer group. There were no multiple pregnancies after blastocyst transfer. CONCLUSION: Blastocyst transfer increases implantation rates and PRs in patients with multiple failed IVF cycles, without increasing the risk of multiple pregnancy.     

How are tension-free vaginal tapes (TVT) used in the United Kingdom?

Objective The purpose was to ascertain how tension-free vaginal tape (TVT) slings are used in the United Kingdom.Methods A postal questionnaire was sent to all 446 gynaecologists and urologists thought to be using TVT sling surgery in the UK.Results There was wide variation in technique amongst the 236 respondents. These varied with respect to the type of anaesthetic and place of surgery, use of cystoscopy and cough test and postoperative management.Conclusion Although there is a wide variation in technique, it does not appear to affect outcome since results are broadly comparable from different units.     

Is urethral pressure profilometry a useful diagnostic test for stress urinary incontinence?

Urethral pressure profilometry is commonly used as a diagnostic test for stress urinary incontinence. The objective of this article is to review the published literature on urethral pressure profilometry to summarize its usefulness. MEDLINE was used to search the published English literature from 1966 to October 2000 for full-length original research articles on urethral pressure profilometry and stress urinary incontinence in women. Terms related to urethral pressure profilometry are defined consistently but techniques are not standardized, introducing variation in test results. Reproducibility of urethral pressure profilometry parameters is poor, both because of biological variation and variation within the test procedure itself (related in part to lack of standardization). Parameters of urethral pressure profilometry do not distinguish between continent and incontinent women and do not characterize the severity of incontinence or urethral incompetence. It is, therefore, concluded that urethral pressure profilometry is not a useful diagnostic test for stress urinary incontinence in women. Its use in clinical management is not supported by current evidence.     

Does vaginal closure force differ in the supine and standing positions?

OBJECTIVE: This study was undertaken to quantify resting vaginal closure force (VCF(REST)), maximum vaginal closure force (VCF(MAX)), and augmentation of vaginal closure force augmentation (VCF(AUG)) when supine and standing and to determine whether the change in intra-abdominal pressure associated with change in posture accounts for differences in VCF. STUDY DESIGN: Thirty-nine asymptomatic, continent women were recruited to determine, when supine and standing, the vaginal closure force (eg, the force closing the vagina in the mid-sagittal plane) and bladder pressures at rest and at maximal voluntary contraction. VCF was measured with an instrumented vaginal speculum and bladder pressure was determined with a microtip catheter. VCF(REST) was the resting pelvic floor tone, and VCF(MAX) was the peak pelvic floor force during a maximal voluntary contraction. VCF(AUG) was the difference between VCF(MAX) and VCF(REST). T tests and Pearson correlation coefficients were used for analysis. RESULTS: VCF(REST) when supine was 3.6 +/- 0.8 N and when standing was 6.9 +/- 1.5 N--a 92% difference (P < .001). The VCF(MAX) when supine was 7.5 +/- 2.9 N and when standing was 10.1 +/- 2.4 N--a 35% difference (P < .001). Bladder pressure when supine (10.5 +/- 4.7 cm H2O) was significantly less (P < .001) than when standing (31.0 +/- 6.4 cm H2O). The differences in bladder pressure when either supine or standing did not correlate with the corresponding differences in VCF at rest or at maximal voluntary contraction. The supine VCF(AUG) of 3.9 +/- 2.7 N, was significantly greater than the standing VCF(AUG) of 3.3+/-1.9 N. CONCLUSION: With change in posture, vaginal closure force increases because of higher intra-abdominal pressure and greater resistance in the pelvic floor muscles.     

Is assisted hatching beneficial in patients with recurrent implantation failures?

PURPOSE: To assess the possible role of assisted hatching in patients with recurrent implantation failure during IVF cycles. DESIGN: Prospective randomized study. SETTING: IVF unit of an academic medical center. PATIENTS: Women who underwent IVF after at least three failed IVF-ET attempts. INTERVENTIONS: Patients were prospectively randomized to undergo assisted hatching of their embryos prior to their replacement by mechanical partial zona dissection. RESULTS: The study (assisted hatching) and control groups included 104 and 103 patients, respectively. There were no significant between-group differences in patient age, cause of infertility, mean number of previous IVF trials, number of oocytes retrieved, fertilization rate, or number of embryos transferred. No difference in pregnancy rate was noted on comparison of the whole study group, to the whole control group (21% and 27%, respectively). However, when the results were re-analyzed by age groups, assisted hatching was found to be harmful in the youngest group (< 34 years), significantly decreasing pregnancy rates (15% vs 35%, p < 0.05). CONCLUSION: Repeated implantation failure alone is not an indication for assisted hatching. Although assisted hatching appears to be effective in a selected group of older patients, in younger patients it may further hamper implantation and should be avoided.     

Is blastocyst transfer useful as an alternative treatment for patients with multiple in vitro fertilization failures?

OBJECTIVE: To determine whether blastocyst transfer is of benefit to patients with multiple IVF failures. DESIGN: Retrospective cohort study. SETTING: The George Washington University Medical Center. PATIENT(S): Patients undergoing IVF between October 1, 1997, and November 30, 1998, who had previously undergone three or more unsuccessful IVF cycles. Patients who had at least three embryos at the 8- to 12-cell stage available on day 3 were eligible for the study. INTERVENTION(S): Patients were given the option of day 3 ET (group A) or blastocyst transfer (group B). MAIN OUTCOME MEASURE(S): Blastocyst-formation rate, clinical pregnancy rate (PR) per transfer, and implantation rate per transfer. RESULT(S): Groups A and B were similar in terms of age, the number of previous failed IVF cycles, fertilization rate, and the number of fertilized oocytes per cycle. The blastocyst-formation rate was 51.0%. Clinical pregnancy and implantation rates per transfer were statistically significantly higher in the blastocyst-transfer group. There were no multiple pregnancies after blastocyst transfer. CONCLUSION: Blastocyst transfer increases implantation rates and PRs in patients with multiple failed IVF cycles, without increasing the risk of multiple pregnancy.