Tension-free transobturator tape procedure for stress urinary incontinence

PURPOSE OF REVIEW: Recent data on the tension-free transobturator tape procedure for the treatment of female stress urinary incontinence are reviewed. RECENT FINDINGS: Although long-term data are not available, the effectiveness and safety of the tension-free transobturator tape procedure as reported during the past 5 years are very promising and this procedure is becoming a popular surgical treatment for female stress urinary incontinence. The continence rates obtained have been similar to those obtained using the retropubic tension-free vaginal tape on short-term follow-up. Clinical data as well as studies on cadaveric dissections suggest that complication rates can be decreased significantly with the transobturator approach. In the original tension-free transobturator tape procedure, the tape is inserted through the obturator foramen from the outside-to-inside direction (skin incision to vaginal incision). The inside-to-outside approach with passage of the tape from the vaginal incision to the obturator foramen has also been described. SUMMARY: The tension-free transobturator tape procedure provides a useful alternative to the retropubic tension-free vaginal tape approach while maintaining the principles of tension-free midurethral support. By avoiding the intrapelvic and retropubic passage, complications can be decreased. The effectiveness of this approach is similar to that of tension-free vaginal tape on short-term follow-up.     

Vaginal reconstruction after total pelvic exenteration using a modification of the Williams' procedure.

The complete rehabilitation of women who have been subjected to ultraradical pelvic surgery should include the reconstruction of a functional vagina. The creation of a vaginal pouch as described by Williams for patients with congenital absence of the vagina or vaginal stenosis may be considered in some of these patients. The principle of his operative procedure can be applied to anatomic conditions in which the vagina and vulva have been resected utilizing perineal tissue structures and skin grafts. This is demonstrated in two patients with different postoperative perineal defects.     

Tension-free Vaginal Tapes and Pelvic Nerve Neuropathy

Obturator nerve neuropathies after tension-free vaginal tape or transobturator tape are considered to be caused by nerve trauma, although it is unclear whether these are accidents or whether these injuries are inherent to the procedure of tape insertion. Two cases show that obturator nerve neuropathy can occur after tension-free vaginal tape without direct trauma to the obturator nerve possibly as a consequence of excessive fibrotic reaction or persisting low-grade inflammation. PubMed Entrez, Cochrane Library, and up-to-date databases were searched for obturator and pudendal neuropathy and for neuropathies associated with tension-free vaginal tape-transobturator tape and the symptoms, diagnosis, and therapy of the pudendal and obturator nerve neuropathies are reviewed. Based on data, our experience, and data available in literature, we can conclude that, if conservative obturator nerve block confirms the diagnosis of obturator nerve neuropathy and symptoms recur shortly thereafter, a laparoscopic neurolysis can be proposed as therapy.     

An unusual long-term complication of transobturator polypropylene mesh

Serious complications associated with surgical mesh for transvaginal repair of POP, as infections, vaginal mesh exposure, painful mesh shrinkage and dyspareunia, are not rare. A 48-year-old woman underwent the Perigee procedure because of a stage 3 anterior wall prolapse. Eleven months after surgery, the patient became suddenly unable to walk because of a strong pain to the left thigh root after running. The MRI revealed an external obturator left muscle hyperintensity consistent with muscular oedema; the patient was treated with oral corticosteroids with a complete resolution of the pain. We could hypothesize that the posterior arm of the mesh caused a laceration of the muscles of the obturator space with consequent oedema and pain. The use of the meshes in prolapse surgery can cause unexpected long-term complications.     

腹腔镜下阴道骶骨固定术应用现况与思考

腹腔镜阴道骶骨固定术已成为中盆腔缺陷的金标准术式,已逐渐取代开腹的阴道骶骨固定术。由于手术方式的改进,手术适应证不断地扩大,它不仅可纠正中盆腔缺陷,同时也可纠正重度膀胱膨出或直肠膨出。长期的临床疗效显示：主、客观治愈率高,阴道顶端脱垂的复发率极低,术后对患者生活质量影响少,网片相关并发症在可接受范围。虽然网片的肠道侵蚀罕见,但应强调术后患者的长期随访。腹腔镜子宫骶骨固定术的长期疗效仍待观察。     

Total vaginal reconstruction with combined 'Split Labia Minora Flaps' and full-thickness skin grafts

PURPOSE: Vaginal reconstruction with split-thickness skin grafts is the most common method for total vaginal reconstruction. Although it has disadvantages like contraction of the graft, foreshortening, donor site morbidity and long-lasting periods of vaginal standing; its easy surgical technique makes it popular. A new method using split labia minora (LM) flaps and full-thickness skin graft is discussed in this study. METHOD: A 19-year-old female was presented with amenorrhea. A total absence of vagina was present and the patient underwent a total vaginal reconstruction for possible sexual intercourse. RESULTS: We observed no contraction and no foreshortening with a patent vaginal cavity up to 11 cm and 4.5 cm width. The need for continuous standing period was as short as 4 weeks and for intermittent standing up to 4 months. Sexual intercourse was encouraged after 4 weeks. During sexual intercourse no external lubrication was reported to be needed. There was no need for further reconstructive intervention. CONCLUSION: Vaginal reconstruction in congenital vaginal agenesis with split LM flaps and full-thickness skin grafts is a simple and effective method, which shortens the standing period and decreases the contraction in neovagina. Total vaginal reconstruction with split LM flaps could also be possible; to achieve this goal, expansion of LM flaps could be a further alternative.     

Vaginal reconstruction in the fibrotic pelvis

Vaginal reconstruction was performed in 7 patients who had developed vaginal stenosis as a result of extensive pelvic fibrosis following either pelvic irradiation (6 patients) or multiple vaginal procedures (1 patient). Six patients received split thickness skin grafts and 1 patient received an amnion graft in the creation of the neovagina. Five patients achieved a satisfactory final result. All of these patients were sexually active and described adequate sexual function. There was no serious morbidity associated with these procedures. Safe and successful vaginal reconstruction can be performed in a patient with a fibrotic pelvis.     

Modifizierter doppelt gestielter VRAM-Lappen zur simultanen Rekonstruktion eines Perineum- und posterioren vaginalen Defekts

The management of locally advanced pelvic tumors regularly requires radical surgical resection. The resection results in significant intrinsic and extrinsic pelvic defects. The advent of composite flaps has revolutionized vaginal and perineal reconstruction. Flaps provide bulky tissue to obliterate dead space, recruit vascularized tissue to an irradiated area and facilitate the skin closure. The authors present a modified vertical rectus abdominis myocutaneous (VRAM) flap for simultaneous reconstruction of a perineal and posterior vaginal defect following radical pelvic and abdominoperineal resection, based on two individual perforators off the inferior epigastric artery and vein with an excellent outcome. The English full-text version of this article is available at SpringerLink (under supplemental).     

Abdominal sacrospinous ligament colposuspension

BACKGROUND: When an abdominal approach is chosen for repair of pelvic prolapse, a paravaginal repair is often used to correct lateral cystoceles and a retropubic urethropexy to correct genuine stress incontinence. If concomitant vaginal vault prolapse exists, an approach for vaginal vault support, which can be done through the space of Retzius, would be beneficial. We describe an abdominal approach to the sacrospinous ligament. TECHNIQUE: The space of Retzius is accessed and important anatomic landmarks, including the obturator canal and neurovascular bundle, paravaginal veins, bladder, and ischial spine, are identified. The sacrospinous ligament complex is palpated and exposed. The superior posterolateral vaginal wall is then fixed to the complex. Often a bilateral repair is possible. EXPERIENCE: Fifty-five women at two centers had abdominal sacrospinous ligament colpopexies for vaginal vault prolapse. All had other repairs for pelvic organ prolapse. No follow-up operations were needed for recurrent vault prolapse, over an average of 23 months follow-up. CONCLUSION: An abdominal approach to the sacrospinous ligament complex can be used, providing pelvic reconstruction surgeons with an alternative technique for vaginal vault support when other space-of-Retzius procedures are required.     

Tension-free vaginal tape obturator: midterm data on an operative procedure for the cure of female stress urinary incontinence performed on 100 patients

STUDY OBJECTIVE: To evaluate the midterm therapeutic results of a minimally invasive anti-incontinence operative procedure, the tension-free vaginal tape (TVT) obturator. DESIGN: With this prospective, observational, and consecutive patient series, the TVT obturator procedure was performed by the same surgeon on 100 patients. Follow-up lasted 30 to 36 months. SETTING: Operative theaters of Assuta medical centers private hospitals. PATIENTS: One hundred female patients with urodynamically proven stress urinary incontinence. INTERVENTIONS: TVT obturator operations were performed for all patients. MEASUREMENTS AND MAIN RESULTS: Demographic and therapeutic aspects of the patient group data were evaluated. Clinical signs for bowel, urethral, or bladder injuries were undetectable with this TVT obturator patient group. Intraoperative bleeding, postoperative field infections, or postoperative pelvic floor relaxations were not noted. The therapeutic failure rate for the TVT obturator procedure was 8.0% (8 of 100 patients) after 1 year, whereas the midterm failure rate was 10.8% (10 of 93 patients). Six of the 10 patients with TVT obturator failure underwent interval TVT operations with satisfactory results. The overall midterm satisfaction rate for this study group of patients was 89.2% (83 of 93 patients), 6 (6.5%) of those patients were improved only, yet still with minimal residual urinary leakage. CONCLUSION: Use of the TVT obturator, a midurethral sling, did not involve bladder penetration and was complicated by a low rate of postoperative outlet obstruction. The midterm therapeutic results and the cost-effectiveness of the TVT obturator appear similar to previously reported midurethral sling operations. Long-term comparative data collection is required to enable drawing solid conclusions regarding the appropriate position of this operative technique within the spectrum of antiincontinence operations.     

A new technique for esophageal reconstruction by combined skin and muscle flaps after failure in primary colonic interposition

A new procedure is presented for esophageal reconstruction using the skin flap combined with the overlying muscle flap in a situation in which preceding cervical esophagostomy and antesternal colostomy have been performed. A conventional musculocutaneous flap may be used for the second stage of the operation. However, our method has several advantages. The skin canal, which is the most important part of this reconstruction, is created using the skin of the anterior chest wall without transferring cutaneous tissue from other places. Therefore, the operative procedure becomes simpler and the blood supply to the skin canal is more assured. While blood of the wall of the canal is supposed to be supplied initially from internal mammary and intercostal arteries, the muscle flap over the canal may subsequently provide more blood to the skin canal. In addition to sufficient blood supply, the length of a suture line for creating the skin canal is minimal, and, thereby, the possibility of postoperative leakage can be diminished. Because both esophagostoma and colostoma are not damaged in the second stage of the operation, strictures at these sites are not likely to occur. Furthermore, the muscle flap serves as a physical protector for the canal, and presents a suitable bed for the split thickness graft. Our two stage operation using combined skin and muscle flaps after antesternal colostomy is a safe, simple and assured technique for the compromised colonic segment at primary esophageal reconstruction. This procedure is also applicable to the patient in whom use of a stomach tube for esophageal replacement is attempted but primary cervical esophagogastrotomy is not possible.     

Buccal mucosal graft for urethral reconstruction.

Urethral reconstruction with graft substances, such as skin and bladder mucosa, has been previously used when primary anastomosis cannot be achieved. However, stricture and meatal prolapse are associated with these grafts. We report the use of buccal mucosa for the reconstruction of urethral defects in 3 patients. One patient with failed operation for hypospadias received tube buccal mucosal graft for urethral replacement. Two patients with urethral necrosis and stricture received onlay buccal mucosal graft. All patients were disease-free during follow-up (range, 12 to 49 months; mean, 36 months). One patient had a pinhole fistula that was successfully managed with simple repair. This technique appears to be useful for urethral reconstruction when a local graft is not available, even in patients with complicated conditions.     

A simple geometric flap for the closure of skin defects.

The Limberg flap is a useful method of closing defects anywhere on the body which are too large for simple closure but where skin grafting is not desirable. It is an easy flap to perform, and it is reliable and safe to use. It must not, however, be used indiscriminately or by rote. Care must be taken in planning both the excision and the flap so that the points which must move farthest are placed where the skin is maximally extensible. With such planning, accurate and precise designing and careful surgical technique, the Limberg flap can be used successfully to solve a number of otherwise extremely difficult problems.     

Vaginal aplasia associated with anatomically and functionally normal uterus

Maldevelopment of the vagina is usually combined with aplasia/hypoplasia of the uterus. Complete vaginal aplasia with a normally developed uterus and cervix is an extremely rare form of developmental failure. The accepted treatment for this kind of maldevelopment is hysterectomy plus creation of a neovagina. We present the case of 12-year-old girl with isolated complete vaginal aplasia. After the creation of a vagina during a first procedure and lysis of pericervical adhesions with implantation of skin graft in a second she now has regular menstrual bleeding.     

Sentinel node detection in patients with vaginal carcinoma

OBJECTIVE: The objective was to describe sentinel ode detection in patients with primary and recurrent vaginal carcinoma. METHOD: Preoperatively 60-mBq technetium-labeled nannocolloid was injected in the mucosa at 3, 6, 9, and 12 o'clock, just adjacent to the vaginal cancer. Sentinel nodes were detected using a laparoscopic or hand-held probe (Navigator) and removed for pathological assessment. RESULTS: Sentinel nodes could be found in two of three patients with primary stage I or II carcinoma of the vagina. In the first patient the sentinel nodes, located in the groin and obturator region, proved to be negative and she was treated with a wide local excision of the tumor, pelvic and groin lymphadenectomy, and adjuvant radiotherapy. The second patient had tumor metastases in the sentinel node, which was found just below of the junction of the iliac vessels, and she underwent combined chemo- and radiotherapy. In a third patient no sentinel node could be detected at lymphoscintigraphy. A last patient with stage III carcinoma of the upper vagina was initially treated by combined chemo-radiotherapy but recurred 6 months later. During a staging procedure the sentinel nodes could be detected in the right obturator fossa and were removed laparoscopically. As they were negative, she underwent a posterior pelvic exenteration with complete resection of the tumor. CONCLUSION: Laparoscopic detection of sentinel nodes using 99mTc-labeled colloid is feasible in patients with primary and recurrent vaginal cancer and may provide important information to direct further management.     

在体盆腔淋巴结切除术数字化三维导航模型的构建和应用初步探讨

目的 构建在体盆腔淋巴结切除术数字化三维导航模型,并探讨其在临床应用中的意义。方法 通过采集1例2014年11月就诊于南方医科大学南方医院妇科拟接受腹腔镜手术治疗的Ⅰb1期宫颈癌患者的CT血管成像DICOM数据集,应用数字化三维重建技术构建该患者的骨盆、盆腔血管、腰大肌、淋巴结及闭孔神经等解剖结构,组建盆腔淋巴结切除术数字化三维导航模型,并应用于腹腔镜下盆腔淋巴结切除术的实时导航。结果 成功地构建了在体盆腔淋巴结切除术数字化三维导航模型,并完成了术中实时导航。在导航模型的导引下,顺利完成盆腔淋巴结切除,同时避免了对变异闭孔静脉的损伤。术中通过比较发现所构建模型包括盆腔血管的走行及与周围组织如骨盆、腰大肌、淋巴结的关系和患者实际的盆腔解剖结构一致。重建双侧淋巴结24个,实际切除淋巴结31个。结论   在体盆腔淋巴结切除术数字化三维导航模型可辅助术者在术前熟悉患者实体解剖结构及变异情况,实时指导手术实施,避免血管等重要组织的损伤,提高手术安全性和成功率。     

Vaginal reconstruction in gynecologic oncology

The improved prognosis for patients with gynecologic malignancies has resulted in an increased concern for their sexual function. Vaginal reconstruction plays an integral role in this rehabilitation. The care of these patients at the University of Michigan is reviewed and their treatment is described. Fifty-one patients were treated with split-thickness skin graft vaginoplasty. Seven repeat vaginoplasties were required, for a total of 58 procedures. Fifty patients were assessed postoperatively, and 47 (94%) ultimately had a satisfactory outcome. Three of the 50 patients had an unsatisfactory final outcome; two had recurrent malignancy and the third patient did not comply with the proposed dilator regimen. Four patients developed fistulas. The split-thickness skin graft provides an acceptable outcome when used for vaginal reconstruction in the patient with a gynecologic malignancy.     

Vaginal reconstruction with a greater omentum–pedicled graft combined with a vicryl mesh after anterior pelvic exenteration. Surgical approach with long-term follow-up

Resection of anterior vaginal wall that occurs with some cases of anterior pelvic exenteration leaves the patient with a small and narrow vagina. This affects their sexual life leading to major psychologic problems, especially in young women. The aim of this study is to evaluate a new technique of vaginal reconstruction following anterior pelvic exenteration with clinical and cytohistologic follow-up. Between March 2002 and November 2004, ten sexually active female patients underwent vaginal reconstruction after radical cystectomy that required en bloc removal of the anterior vaginal wall, with a pedicle graft of greater omentum combined with a vicryl mesh. The mean age of the patients was 38 years. The mean operative time of the reconstructive procedure was 50 min. There were no complications regarding the reconstructive procedure. On follow-up, the neovagina accepted two fingers easily and showed a pink-colored smooth lining. Seven patients reported successful attempts of sexual intercourse. It was concluded that reconstruction of vagina after anterior pelvic exenteration in sexually active women can be done safely with the use of vicryl mesh combined with a pedicled omental graft. It is a simple, reliable, and not time-consuming technique. The long-term follow-up was very beneficial in detection of complete healing, postoperative infections, and hormonal activity of the graft and recurrence of malignancy.     

Tilapia Skin for Neovaginoplasty after Sex Reassignment Surgery

Study ObjectiveTo describe a new technique of neovaginoplasty after a female sex reassignment surgery using a tilapia skin as a graft.DesignStepwise demonstration of a new technique with narrated video of a single case report. The patient provided oral and written informed consent. Moreover, this video report is part of a multicenter, Investigational Review Board–approved study.SettingWomen's university hospital in Campinas, Brazil.InterventionsNeovaginoplasty technique using tilapia skin with the following key strategies: (1) corpus cavernosum removal, (2) vagina tunnel creation, (3) mold coating with tilapia skin, (4) mold fixation, and (5) postoperative care. The patient remained with the mold coated with tilapia skin for 5 days; after this time, the mold was removed, and the tissue graft was adhered and incorporated in the new vaginal canal. After 2 months, the tissue resembled a vaginal mucosa, and the vaginal length was 8 cm. The patient has not had intercourse yet.ConclusionWe introduce an alternative for low-morbidity neovaginoplasty based on the experience of plastic surgery in burned grafts. The procedure described offers an alternative option to develop an anatomic neovagina with tissue similar to mucosa tissue by a simple, low-morbidity minimally invasive procedure.