Value of Maximum Urethral Closure Pressure in Predicting the Outcome of Tension‐Free Vaginal Tape and Transobturator Tape Procedure

Objectives: The short‐term results for the tension‐free vaginal tape procedure (TVT) and the transobturator tape procedure (TOT) for stress urinary incontinence (SUI) were compared using the preoperative maximum urethral closure pressure (MUCP). Methods: A total of 278 patients treated for SUI was considered: 165 who underwent TVT and 113 who underwent TOT retrospectively. The MUCP in a preoperative urodynamic study before and 3 months after surgery were evaluated. Results: At 3 months after TVT, 159 patients (96.4%) were cured and four patients failed. The mean MUCP of the patients who failed was 22.5 ± 5.3 cmH₂O, which was significantly lower than that among the cured patients (P < 0.007). At 3 months after TOT, 100 patients (88.5%) were cured and seven patients failed. The mean MUCP of the patients who failed was 27 ± 6.3 cmH₂O, which was significantly lower than that among the cured patients (P < 0.001). Furthermore, the mean MUCP among the patients who were cured after TOT was significantly higher than that among the patients who were cured after TVT (P < 0.01). A further analysis using a ROC curve indicated that the MUCP value in the successful patients after TVT was ≧ 24 cmH₂O and that in the failures after TOT was ≦ 30 cmH₂O with selection sensitivity at 80%. Conclusion: These results suggest that the failure cases after TVT or TOT are often found in SUI with a low MUCP and that TVT might be superior to TOT in SUI with a MUCP ≦ 30 cmH₂O.     

Severe Thigh Abscess Two Years after Transobturator Sling Operation

Objectives: Tension‐free vaginal tape has gained large popularity owing to the ease of the procedure and its effectiveness. These procedures were initially thought to rarely involve any significant morbid complications. The transobturator tape (TOT) procedure reproduces the natural suspension similar to the tension‐free vaginal tape with a reduction in potential bladder, bowel, and vascular complications by the retropubic approach. However, the TOT procedure is not risk‐free when improperly performed. We report a rare case of abscess formation after TOT. Methods: A 45‐year‐old woman was admitted to the orthopedic department with the chief complaint of right side thigh pain and swelling. Pelvis MRI showed abscess formation and inflammatory changes extending into the soft tissues and muscles between the right gracilis and adductor femoris. During incision and open drainage, the remnant mesh could not be located. On urologic consult, the pelvic examination located the remnant mesh to the right upper vaginal wall. Our patient underwent excision of the mesh material. Results: She had significant improvement of the leg pain and was discharged home in good condition on postoperative day 7. Ultimately, the treatment for this complication was the removal of the mesh. Conclusion: Treatment for thigh abscess after TOT was the removal of the mesh. All patients should be counseled about this potential complication.     

无张力阴道尿道悬吊术治疗老年女性尿失禁六例临床分析

目的 探讨无张力阴道尿道中段悬吊术(TVT)治疗老年女性尿失禁的临床意义和疗效。方法 采用SPRAC吊带系统对6例单纯性压力性尿失禁老年女性进行TVT治疗，分析其疗效及并发症。结果 6例TVT手术均在硬膜外麻醉下完成，平均手术时间31．6min，术中平均出血36．2ml，5例手术后24h内自行排尿，1例合并肥胖和阴道前壁膨出患者留置尿管1周后自行排尿。术后随访10～28个月，5例尿失禁治愈，1例手术后3个月再次发生尿失禁，2例术后伴不同程度的尿频、尿急，1例自觉耻骨后轻度不适。结论 TVT易操作、创伤小、疗效好，对绝经后老年女性合并肥胖和阴道前壁膨出的压力性尿失禁患者治疗有明显疗效。     

Challenge of One‐incision Midurethral Sling for Female Stress Urinary Incontinence: Current Results

As a result of the understanding of the pathogenesis of stress urinary incontinence in females, a tension‐free vaginal tape procedure has been introduced based on integral theory and is now widely used because of its minimal invasiveness and high success rate. Modifications over the last 10 years include changes to mesh type, technique and route of insertion of sling materials. Long‐term efficacy and quality of life data of the different midurethral sling (MUS) procedures are available. However, complications, such as bladder and urethral injury, persistent groin pain, vascular and nerve injury, and voiding difficulty can occur. Recently, one‐incision MUS procedures without tape outlets have been developed to reduce surgical invasiveness and lower the risk of complications. However, few studies have reported the outcomes following one‐incision MUS procedures. The present report reviews studies of one‐incision MUS procedures to determine whether this technique can be used in the place of older techniques. It appears that while one‐incision MUS procedures may be associated with lower complication rates, success rates may also be lower, although the latest results are promising. It takes a long time for the surgeon to become an expert in performing the technique. Proper sling tension and correct surgical plane are very important. At the moment it seems that the one‐incision sling cannot replace older slings. We need to wait for and review the long‐term prospective results of the new and minimally invasive one‐incision sling for the treatment of female stress urinary incontinence.     

Posterior sagittal anorectoplasty in adults

PURPOSE: Posterior sagittal anorectoplasty, regarded as a standard surgical primary repair for anorectal malformations in infancy, was evaluated for effectiveness when performed as a secondary operation for establishing continence in the adult. The purpose of this review was to evaluate our results of performing posterior sagittal anorectoplasty in adult patients and to emphasize the extensive evaluation required to perform proper patient selection. METHOD: From January 1, 1992, to December 31, 1996, eight patients with Grade 3 incontinence underwent posterior sagittal anorectoplasty. The ages ranged from 13 to 40 (mean, 26) years. RESULTS: All patients had diverting stomas at the time of repair and all but one had restoration of intestinal continuity. Of eight patients who underwent posterior sagittal anorectoplasty, one failed secondary to rectal ischemia and retained a diverting stoma. Six patients had restoration of continuity. Five patients were continent and one had incontinence only to gas. DISCUSSION: We have established that posterior sagittal anorectoplasty can effectively be used to establish continence as a secondary procedure for a select group of adult patients.     

Simultaneous Treatment of Female Urethral Diverticulum and Stress Urinary Incontinence with Urethral Diverticulectomy and Suburethral Synthetic Mesh Sling

Objectives: Pubovaginal fascial sling along with urethral diverticulectomy has been advised as the most appropriate anti‐incontinence procedure for female stress urinary incontinence (SUI) with concomitant urethral diverticula (UD). We believe that suburethral synthetic mesh tape sling can also be safely used in some patients with concomitant SUI and UD. Herein, we present our experience for simultaneous treatment of UD and SUI with urethral diverticulectomy and suburethral synthetic mesh tape sling. Methods: From 2003 to 2008, there are three patients with UD and SUI in our institution. They received transvaginal urethral diverticulectomy and suburethral synthetic mesh tape sling simultaneously. Videourodynamics was done before and three months after the surgery. Results: Preoperative pelvis magnetic resonance imaging and videourodynamic study showed UD over distal urethra and SUI in all three patients. Urinalysis disclosed mild pyuria in two of the patients, and they both received intravenous antibiotics treatment to eradicate the infection prior to the surgery. They all underwent urethral diverticulectomy with suburethral synthetic mesh tape sling. The postoperative videourodynamic study showed no recurrence of UD and SUI. With a mean follow up of 33.3 months, there was no infection or exposure of synthetic mesh tape. Conclusions: In patients with UD and SUI, suburethral sling using synthetic mesh can be as effective and safe as facial sling in selected patients.     

Two stage total gastrectomy in a case of multiple bleeding gastric ulcers

A 78-year-old man with severe diabetes mellitus fell into shock due to bleeding from multiple gastric ulcers. Near-total gastrectomy without reconstruction was performed in the initial operation to save his life. After his general condition improved, total gastrectomy with Roux-en-Y esophagojejunostomy was performed in a second procedure. As this two stage total gastrectomy can avoid excessive operative stress, and prevent rebleeding and breakdown at the anastomosis, we consider it a valuable procedure for patients who have multiple bleeding gastric ulcers involving almost the whole stomach, and who have very poor general condition or severe complications at the time of operation.     

Experience with Tension‐free Vaginal Tape (TVT)‐SECUR for Female Stress Urinary Incontinence

Objectives: Tension‐free vaginal tape (TVT)‐SECUR is a technique specifically designed to place a short suburethral mesh sling for the treatment of female stress urinary incontinence (SUI). The aim of the technique is to decrease surgical morbidity. We report our experience of applying this technique on 10 patients. Methods: From June 2007 to July 2007, 10 female patients with SUI underwent TVT‐SECUR placement operation. The sling was inserted in a suprapubic direction over the inner surface of pubic bone (U‐shaped technique). Nine of the patients underwent videourodynamic study (VUDS). The maximal bladder neck decent distance (MBND) by abdominal straining was determined. We identified intrinsic sphincter deficiency (ISD) as a valsalva leak point pressure lower than 60 cm H₂O and hypermobility as MBND more than 2 cm. Results: Two patients had pure ISD, three had hypermobility, and four had both ISD and hypermobility. All patients remained continent for first month after surgery. SUI recurred in five of nine patients at an average of 2.5 months. The recurrence appeared in all three groups of patients. The recurrent SUI was so severe that three patients required repeat surgery using percutaneous prolene tape sling. After surgery, no further SUI was noted in the three patients. During surgery the TVT‐SECUR sling was found to have firmly adhered to perivesical tissue rather than to the pubic bone. Conclusion: Our experience shows that the current design of the TVT‐SECUR results in unpredictable outcomes. Some placed slings may migrate away from the inner surface of the pubic bone. To act as a reliable “hammock”, the sling must be securely fixed on immobile structures independent from the bladder/urethra.     

Gastrothorax mimicking acute tension pneumothorax

We describe a case of respiratory failure due to an acute tension gastrothorax in an elderly patient, secondary to an episode of vomiting. Initially the scout view was interpreted as a tension pneumothorax. Eventually the computed tomography (CT) of the thorax revealed a transdiaphragmatical herniation of the stomach and other visceral organs. An endoscopic desufflation procedure was performed, leading to improvement of the vital signs. Consequently, surgical repair was performed. It is important to be aware of specific radiologic signs, suggesting that the intrathoracic air collection is not caused by a pneumothorax. The initial treatment of a tension gastrothorax is nasogastric or orogastric decompression.     

Anal fistula: intraoperative difficulties and unexpected findings

Anal fistula surgery is a commonly performed procedure.The diverse anatomy of anal fistulae and their proximity to anal sphincters make accurate preoperative diagnosis essential to avoid recurrence and fecal incontinence.Despite the fact that proper preoperative diagnosis can be reached in the majority of patients by simple clinical examination,endoanal ultrasound or magnetic resonance imaging,on many occasions,unexpected findings can be encountered during surgery that can make the operation difficult and c...     

Tension-free vaginal tape for the treatment of stress urinary incontinence in geriatric patients

OBJECTIVE: To evaluate the safety and efficacy of tension-free vaginal tape (TVT) for the treatment of stress urinary incontinence (SUI) in geriatric patients. PATIENTS AND METHODS: Fifty-one women, aged 65-80 (mean 72.3) years, underwent a TVT procedure for genuine SUI from 2001 to 2004. A urodynamic test together with uroflowmetry were performed. The patients' SUI bother score was assessed using a visual analog scale (VAS). RESULTS: The mean operative time was 25 (range 14-29) min and mean hospitalization time was 1.2 (range 1-2) days. Bladder perforation occurred in 3 cases (5.8%) and was managed conservatively. Pre- and postoperative maximum flow rate were not significantly different (p > 0.05). The patients' SUI bother score estimated by the VAS was statistically significantly improved (p < 0.0001). After a mean follow-up of 35.6 (range 14-60) months, 49 patients (96%) had no SUI, while 2 patients (3.9%) had persistent SUI. Also, during the follow-up 5 patients (9.8%) were diagnosed with de novo urgency due to detrusor overactivity and 1 patient (1.9%) had persistent dysuria that was resolved with urethrolysis. CONCLUSIONS: SUI in elderly women can be safely treated with the TVT procedure in the vast majority of the patients. However, bladder perforation during surgery and de novo urgency postoperatively should be taken into account.     

Endosonographic assessment of the anal sphincter after surgical reconstruction

PURPOSE: Patients with anal incontinence attributable to trauma are usually treated by sphincter reconstruction. Failures because of incomplete reconstruction may possibly be detected by anal endosonography which gives detailed information on the anal sphincter muscles. The aim of this study was to describe the endosonographic findings in patients after sphincter reconstruction. MATERIALS AND METHODS: Ten female patients who had undergone surgical sphincter reconstruction using an overlapping technique because of anal incontinence were studied with anal endosonography a median of six months after surgery. Five patients were fully continent, three were incontinent for flatus, and two patients were still incontinent for solid stool at the time of this study. Eight patients had also been studied with endosonography before surgery, and, in these patients, we compared the initial sonograms with the follow-up sonograms. The angular extent of the endosonographic defects in the external sphincter before and after reconstruction was measured in degrees and compared with the outcome of surgery. RESULTS: After reconstruction, continuity of the external anal sphincter was completely restored at all levels in four patients, one of whom still had anal incontinence. Continuity was partially restored in three patients: two were fully continent, while one patient, previously incontinent for stool, was incontinent for flatus. In three patients the continuity was restored at one level but a persisting defect was found at a different level. In two of these patients the grade of incontinence was unchanged. Three patients also had defects in the internal anal sphincter. CONCLUSION: After surgical sphincter reconstruction for anal incontinence, we found sphincteric defects in six patients, including four of five patients who still had some degree of incontinence. Thus, endosonography may be used for postoperative assessment and may explain the unsatisfactory results of surgery in some patients. We recommend that endosonography be also performed preoperatively, whereby the effect of the operation on the size of the sphincteric defect can be assessed.     

Outcome of overlapping anal sphincter repair after 3 months and after a mean of 80 months

BACKGROUND: The aim of this study was to determine the functional results of anal sphincter repair after a long follow-up (mean 80.1 months). METHODS: In the period 1990-2002, 65 sphincter repairs were performed. Obstetric trauma was the cause of incontinence in 72.3% cases, fistulotomy in 13.8%, nonspecific trauma in 9.2%, and war injury in 4.6%. At the time of surgery, 12 patients had undergone an urgent stoma procedure. In all cases, anal manometry, electromyography, and defecography were performed. The severity of incontinence was evaluated preoperatively using the Wexner score system. Anterior sphincteroplasty was performed in 52 cases, lateral in 9 cases, and posterior in 4 cases. RESULTS: The results were determined according to the Wexner score system and the Browning-Parks scale. The Wexner score was calculated 3 months after operation and during every follow-up visit. Preoperative scores and those at the first and last follow-up visits were analyzed. Three months after operation excellent results were achieved in 55.5%, good in 18.5%, fair in 16.9%, and poor in 9.2% patients. After follow-up (mean 80.1 months), 26.8% had excellent results, 21.4% had good results, 12.5% had fair results, and 39.3% of patients had a poor outcome. Results determined by the Wexner score system improved from 17.8 preoperatively to 3.6 three months after operation, but deteriorated over time to 6.3 after longer follow-up (p<0.001). CONCLUSION: Overlapping sphincter repair provides satisfactory results in more than two-thirds of patients initially, but the results tend to worsen over time and are satisfactory in half of patients after longer follow-up.     

Management of Stress Urinary Incontinence in the Neobladder Patient

Considering the intent for provision of near-normal urinary function with an orthotopic diversion, issues with voiding dysfunction and urinary incontinence manifest substantial impact on quality of life for neobladder patients. Following appropriate functional and anatomic evaluation, often employing cystoscopy and urodynamics, multiple treatment strategies are available for treatment of stress incontinence in this complex patient population. Conservative modalities including pelvic floor physical therapy, behavioral therapies, and general education regarding neobladder diversion are foremost. Pharmacologic therapies may be suitable in select circumstances. Minimally invasive treatments such as transurethral bulking agents can provide improvement for women with stress incontinence following orthotopic diversion; however the risk profile may preclude use in many patients. Midurethral tape technologies, including transobturator and single incision slings, represent a comparatively recent iteration of implements to be considered. The pitfalls of fascial pubovaginal sling include navigation of complex anatomy combined with a high rate of urinary retention. In men, artificial urinary sphincter continues to exemplify an effective continence procedure following neobladder diversion with only a modestly elevated complication profile in these high risk patients. Male sling technologies are additionally gaining appreciation as an option for treatment of sphincteric dysfunction following orthotopic neobladder and forgo several drawbacks associated with artificial sphincter placement.     

Optimum age for performing Fontan operation in patients with univentricular heart

The purpose of this study was to determine the optimal age for performing Fontan operation using data from the National Inpatient Sample. Our results showed that although the Fontan operation was most commonly performed at age 2 in the United States, age 3 is the optimum age for this procedure as evident by lower rate of in‐hospital mortality, procedure‐related complications, and rate of nonroutine home discharge when procedure is performed at age 3 years.     

Implantation of microballoons in the management of fecal incontinence

PURPOSE: The implantation of expandable microballoons has proved successful for the treatment of stress urinary incontinence. This led us to test its effectiveness in the treatment of severe fecal incontinence. METHODS: Six patients (four male), of average age of 43 (range, 29–60) years, with severe fecal incontinence, underwent implantation of expandable microballoons in the submucosa of the anal canal. The implantation was performed under intravenous sedation as an outpatient procedure. Anal manometry, endosonography, and incontinence assessment with a scoring system were performed before and after the implantation. RESULTS: With a mean follow-up of 8.6 (range, 7–12) months, the incontinence scores improved in all patients from an average of 16.16 (standard deviation: ± 1.6) before the implantation to an average of 5 (standard deviation: ± 1.26) after the procedure. The anal pressure at rest was not improved in any patient (mean: 50.16 before treatment to a mean of 53 after treatment). No significant adverse events were associated with the procedure, and no serious postim-plantation complications were noted. DISCUSSION: Anal implantation of expandable microballoons seems to be a simple, safe, and effective method that restores the fecal continence without hindering normal defecation.Presented at the Digestive Disease Week, Atlanta, Georgia, May 20 to 23, 2001.     

Prospective Study Comparing the Suprapubic Arc (Sparc) Procedure and the Transobturator (Monarc) Procedure for Treating Female Stress Urinary Incontinence

Objectives: In a comparative trial we evaluated the efficacy and safety of the suprapubic arch (Sparc) and transobturator (Monarc) procedures for the treatment of female stress urinary incontinence (SUI). Methods: Between November 2003 and May 2004, 46 women with SUI who underwent the Sparc procedure and 42 women who underwent the Monarc procedure were analyzed. The preoperative evaluation included history taking, physical examination, voiding diary, stress and 1‐h pad tests and a comprehensive urodynamic examination. Postoperative evaluation included a stress test, 1‐h pad test, and uroflowmetry with postvoid residuals. Results: After 1 year of follow up, the rates of cure and satisfaction were 93.5 and 93.0%, respectively, in the Sparc group. The rates of cure and satisfaction were 95.2 and 85.7%, respectively, in the Monarc group. After 2 years of follow up, the rates of cure (93.5 vs 92.9%) and satisfaction (84.8 vs 83.3%) were similar between the two groups. No bladder injury occurred in the Monarc group. Bladder injury occurred in 6.5% (n = 3) of the patients in the Sparc group. Vaginal wall perforation occurred in 4.8% (n = 2) of the patients in the Monarc group (P > 0.05). Late complications included de novo urge symptoms (8.7 vs 11.9%) and voiding dysfunction (10.9 vs 9.5%). Conclusions: The transobturator Monarc procedure appears to be as efficient and safe as the retropubic Sparc procedure for the treatment of SUI.     

Treatment of Vaginal Cuff Prolapses with Posterior Intravaginal Sling and Evaluation of Efficiency with International Consultation on Incontinence Questionnaire—Vaginal Symptoms Method in the Long Term: Preliminary Results

Objectives: The aim of this study was to research the efficiency of posterior intravaginal sling (PIVS) procedure in vaginal cuff prolapse, together with possible complications, long‐term effects and effects of the method on vaginal and sexual function and quality of life of patients. This retrospective study comprised 21 patients with vaginal cuff prolapse. Methods: PIVS procedure was performed in 21 patients with vaginal cuff prolapse with quantification stages 2, 3, or 4 of pelvic organ prolapse. Patients were assessed according to the International Consultation on Incontinence Questionnaire—Vaginal Symptoms before and after operation. Results: The average follow‐up period was 24.6 months. The rate of surgical success was 100%, the rate of mesh erosion was 14.2% and the rate of dyspareunia was 33.3%. Vaginal symptom, sexual matter and quality of life scores were statistically significant in the postoperative period compared to the preoperative period (P = 0.001, P = 0.001, P = 0.001, respectively). Conclusion: PIVS is an effective and reliable method of treating vaginal cuff prolapse. However, its complication profile is not yet at an acceptable level. We believe that the rate of mesh erosion will regress to a more acceptable level with the improvement of mesh technology and postoperative method. The necessary incontinence surgery is easily performed together with PIVS procedure. PIVS restores the vaginal and sexual functions of patients and increases their quality of life significantly.     

Effects of low‐frequency intravaginal electrical stimulation on female urinary incontinence,quality of life,and urinary symptoms: A pilot study

This study investigated the effects of a low‐frequency home‐based incontinence therapy device on quality of life (QoL) and urinary symptoms in women with urinary incontinence. From May 2017 to February 2018, 34 patients, aged ≥ 20 years, with involuntary urine leakage >2 times/week, were recruited to this study. Patients with severe pelvic organ prolapse, pregnancy, virgin status, and psychological problems were excluded. The incontinence home‐care device treatments were administered in 12‐minute sessions, twice daily for 8 weeks. Simultaneously, hyperthermic conditions of 35°C to 40°C and microvibrations were administered. All patients completed urinary incontinence questionnaires (King's Health Questionnaire [KHQ], Bristol Female Lower Urinary Tract Symptoms [BFLUTS] questionnaire, and the Overactive Bladder Symptom Score [OABSS]) before treatment, as well as 4 and 8 weeks into treatment. Changes in the questionnaire responses over time were compared. Two participants dropped out of the study and there was one screening failure, leaving 31 patients for analysis. After 4 weeks treatment, there were significant improvements in symptoms, such as role limitation, physical limitation, social limitation, personal relationship, emotion, sleep/energy, and severity measures. After 8 weeks treatment, almost all parameters on the KHQ revealed symptomatic improvement. On the BFLUTS, voiding times during activity, nocturia, urgency, urge incontinence, incontinence frequency, stress incontinence, volume leakage, strain to start, intermittency, reduced stream, acute retention, incomplete emptying, and stopping flow showed significant improvements. On the OABSS, almost all storage symptoms improved. Low‐frequency electrical stimulation devices were effective at improving urinary incontinence, which became evident as the duration of treatment increased. Improvement of urgency and frequency was more evident after treatment.     

Urinary incontinence in elderly women: urodynamic evaluation

The objective of this study is to characterize urinary incontinence observed in elderly women and to assess the importance of various parameters used to evaluate urinary incontinence. Two hundred consecutive, ambulatory, outpatient, incontinent women 55 years of age and over who were seen at the Continence Program Clinic and completed a medical and urodynamic protocol are included in this paper. After a thorough medical history and a complete physical examination, urodynamic tests were performed. The urodynamic results showed that 77% of incontinent women had an incompetent urethra. Twenty-five percent had a hyperactive bladder, 8% had "other" types, and 7% had a normal study. Comparison of the clinical diagnosis with the actual urodynamic diagnosis for stress incontinence revealed a 78% accuracy and only a 6% false negative. In contrast, a similar comparison for urge incontinence found only 44% accurate and 45% false negative. Analysis of the urodynamic tests revealed that the simple provocative full-bladder stress test was as effective as the radiographic or electronic pressure measurement in detecting incompetent urethra producing stress urinary incontinence. Provocative upright cystometry was helpful in uncovering 33% of hyperactive bladders not provoked in the supine position. Complex urodynamic tests should be reserved for unexplained incontinence or when symptomatology is complex.