Incidence of recurrent cystocele after anterior colporrhaphy with and without concomitant transvaginal needle suspension

OBJECTIVE: Our purpose was to compare the recurrent cystocele rate after anterior colporrhaphy versus anterior colporrhaphy performed in conjunction with transvaginal needle bladder neck suspension. STUDY DESIGN: A retrospective chart review of all patients undergoing anterior colporrhaphy with and without needle bladder neck suspension over a 3-year period was conducted. Preoperatively all patients had symptomatic anterior vaginal wall relaxation. Patients undergoing concomitant needle suspension procedures had genuine stress incontinence. Twenty-seven patients underwent anterior colporrhaphy alone, and 40 patients underwent anterior colporrhaphy with needle suspension. Demographic data including age, parity, menopausal status, and use of estrogen replacement was collected for each group. The recurrence rate of anterior vaginal wall relaxation was determined for each group by reviewing standardized postoperative office notes. RESULTS: There was no significant difference in the duration of follow-up between the two groups (13.2 months in the anterior repair group vs 13 months in the anterior repair-needle suspension group). However, a significant difference in recurrent cystocele rates was found between the two groups (7% [2/27] in the anterior repair group compared with 33%[13/40] in the anterior repair-needle suspension group, p < 0.01). CONCLUSION: The incidence of recurrent cystocele is significantly higher after anterior colporrhaphy with concomitant needle bladder neck suspension compared with anterior colporrhaphy alone. This difference may be related to the vaginal retropubic dissection at the time of transvaginal needle bladder neck suspension resulting in an iatrogenic paravaginal defect or denervation of the anterior vaginal wall. (Am J Obstet Gynecol 1996;175:1476-82.)     

Anterior colporrhaphy: A randomized trial of three surgical techniques

OBJECTIVE: The purpose of this study was to compare outcomes after anterior colporrhaphy with the use of 3 different surgical techniques. STUDY DESIGN: One hundred fourteen women with anterior vaginal prolapse were randomly assigned to undergo anterior repair by one of 3 techniques: standard, standard plus polyglactin 910 mesh, or ultralateral anterior colporrhaphy. Before and after operation, patients underwent physical examination staging of prolapse; the International Continence Society system was used. Symptoms were assessed by questionnaire and visual analog scales. We defined "cure" as satisfactory (stage I) or optimal (stage 0) outcome at points Aa and Ba. RESULTS: Of 114 patients who were originally enrolled, 109 patients underwent operation, and 83 patients (76%) returned for follow-up. Mean age (+/- SD) was 64.7 +/- 11.1 years. At entry, 7 patients (7%) had stage I anterior vaginal prolapse; 35 patients (37%) had stage II anterior vaginal prolapse; 51 patients (54%) had stage III anterior vaginal prolapse; and 2 patients (2%) had stage IV anterior vaginal prolapse. At a median length of follow-up of 23.3 months, 10 of 33 patients (30%) who were randomly assigned to the standard anterior colporrhaphy group experienced satisfactory or optimal anatomic results, compared with 11 of 26 patients (42%) with standard plus mesh and with 11 of 24 patients (46%) with ultralateral anterior colporrhaphy. The severity of symptoms that were related to prolapse improved markedly (preoperative score, 6.9 +/- 2.7; postoperative score, 1.1 +/- 0.8). Twenty-three of 24 patients (96%) no longer required manual pressure to void after operation. CONCLUSION: These 3 techniques of anterior colporrhaphy provided similar anatomic cure rates and symptom resolution for anterior vaginal prolapse repair. The addition of polyglactin 910 mesh did not improve the cure rate compared with standard anterior colporrhaphy.     

Anatomical and functional assessment of anterior colporrhaphy versus polypropylene mesh surgery in cystocele treatment

Objective

To compare the anatomical and functional results of traditional anterior colporrhaphy and polypropylene mesh surgery in cystocele treatment.Study design: Prospective study conducted in the Urogynecology Clinic of Etlik Zubeyde Hanim Maternity and Women's Health Teaching and Research Hospital between June 2006 and February 2007. Forty patients with stage II and III cystocele according to the Pelvic Organ Prolapse Quantification system were allocated by a computer programme to conventional or mesh surgery. Twenty patients each underwent anterior colporrhaphy (group I) or polypropylene mesh (Sofradim^®, Parieten) surgery (group II). Both groups were followed for 12 months.

Results

At the end of the 12th month, anatomical cure rates were 15/20 (75%) and 19/20 (95%) in groups I and II, respectively, and the difference between the two groups was statistically significant (p < 0.05). De novo stress urinary incontinence developed in one patient in group I. Mesh erosion developed postoperatively in three cases (15%).

Conclusion

In terms of anatomical cure rates, polypropylene mesh surgery was the more successful treatment option when compared with anterior colporrhaphy at the end of 1 year follow-up.     

Ultrasound assessment of the bladder volume after anterior colporrhaphy

In 40 gynecological patients 44 different determinations of the bladder volume were made using ultrasonic methods. The product of bladder depth, height, and width, as determined from transverse and sagittal scans, showed the best correlation with the bladder volume measured by urethral catheter (r = 0.981). For 73% of the measurements the error was under 20% when the true bladder volume was greater than 100 cm3. This method gives a reasonable assessment of the bladder residual volume. It is quick, safe, and repeatable and, therefore, useful in postoperative clinical practice.     

Comparison of anterior colporrhaphy and retropubic urethropexy for patients with genuine stress urinary incontinence

OBJECTIVE: Our purpose was to compare the efficacy of anterior colporrhaphy and retropubic urethropexy performed for genuine stress urinary incontinence.STUDY DESIGN: A retrospective analysis was performed on women who underwent either anterior colporrhaphy or retropubic urethropexy for genuine stress urinary incontinence. Patients were identified by a computer-assisted search, and these women were contacted by telephone. The interview was used to assess current continence status. Variables reviewed included demographic data, medications, hormonal status, current smoking history, significant medical and surgical history, and time to recurrence of incontinence. Operative procedure, prior or concomitant hysterectomy, history of previous incontinence procedures, concomitant surgery for repair of other pelvic floor defects, experience level of the primary surgeon, and duration of postoperative catheterization were also documented.RESULTS: Seventy-six women who had undergone surgery for genuine stress incontinence during a 4-year period were identified and evaluated by telephone interview. Fifty-six had undergone anterior colporrhaphy and 20 retropubic urethropexy. Both groups of patients were comparable in age, social status, race, parity, and weight. The duration of follow-up (mean ± SD) was 66.6 ± 14.2 months (range 48 to 96 months). Concurrent surgery to repair other pelvic floor defects was more common in patients undergoing anterior colporrhaphy than in patients undergoing retropubic urethropexy (p < 0.05). Of the 56 patients treated with anterior colporrhaphy, 26 (46%) were continent at the time of interview versus 15 of 20 (75%) treated with retropubic urethropexy (p < 0.05). Times to recurrence for anterior colporrhaphy and retropubic urethropexy were not significantly different. History of previous incontinence procedures, concomitant hysterectomy, previous hysterectomy, duration of postoperative catheterization, obesity, chronic lung disease, and smoking were not correlated with success for either procedure. Experience of the primary surgeon did have a significant effect on success, with attending staff having a better cure rate than resident surgeons (p < 0.05).CONCLUSION: Retropubic urethropexy was significantly more effective than anterior colporrhaphy for long-term cure of genuine stress urinary incontinence. We believe these conclusions should be tempered because of the complex nature of genuine stress incontinence. Patients having anterior colporrhaphy may represent a high-risk group because nearly all of them had associated pelvic floor defects. Experience of the surgeon seems to enhance the liklihood of success and may reflect subtle modifications of technique.     

Protective effect of suburethral slings on postoperative cystocele recurrence after reconstructive pelvic operation

OBJECTIVE: The purpose of this study was to evaluate the independent effect of suburethral sling placement on the risk of cystocele recurrence after pelvic reconstructive operation. STUDY DESIGN: One hundred forty-eight women with cystoceles to or beyond the hymenal ring underwent pelvic reconstructive operation, with or without incontinence procedures, and were evaluated at 12 and 52 weeks after operation with a standardized pelvic examination. Rates of recurrent prolapse, at all sites, were statistically compared between subjects with and without suburethral slings. A multiple regression analysis was used to determine the independent effect of sling placement on the risk of recurrent cystoceles. RESULTS: Suburethral sling placement was associated with a 54.8% reduction in the mean rate of postoperative cystocele recurrence (P =.004). This protective effect was observed as early as 12 weeks and remained significant at 1-year follow up (42% vs 19%). A markedly reduced risk of cystocele recurrence was observed when women with sling procedures were compared with all other women, with those women who underwent other incontinence operations, and even with those women who had undergone prolapse repair with no incontinence procedure. The protective effect of the sling procedure remained highly significant (odds ratio, 0.29; P =.0003), even after controlling for potentially confounding variables in a multiple logistic regression model. CONCLUSION: Suburethral sling procedures appear to significantly reduce the risk of cystocele recurrence after pelvic reconstructive operation, in contrast with the effect of retropubic urethropexy and needle suspensions. These findings should be considered when the surgical treatment of stress incontinence that accompanies pelvic organ prolapse is being planned.     

An unusual case of bilateral ureteric obstruction after anterior colporrhaphy and vaginal hysterectomy for pelvic organ prolapse

We report a case of bilateral ureteric obstruction after anterior colporrhaphy. The excessive folding of the bladder trigone after anterior colporrhaphy led to occlusion of both ureteric orifices.     

Morbidity and recurrence rates after surgical treatment of malignant melanoma by scalpel versus CO2 laser beam

A retrospective study was carried out on 219 patients who underwent surgical treatment of a malignant melanoma. A scalpel was used in 96 patients in group 1 and CO2 laser beam was used in 123 patients in group 2. The average length of hospitalization for group 2 was longer (16.3 versus 12.8 days for group 1). This was due to failure of the skin graft; 32.5 per cent in group 2 versus 15.6 per cent in group 1 (p = 0.005). The accumulative rate of recurrence for both groups was almost the same although there were significant differences according to the various parameters. Male patients in group 2 had a significantly higher rate of recurrence as compared with female patients in the same group (p less than 0.001) and male patients in group 1 (p = 0.002). In both groups, there was a significantly higher rate of recurrence for ulcerated primary lesions and those lesions more than 1.6 millimeters thick (p = 0.05). Patients in group 2, with lesions more than 3 millimeters in thickness, had a higher rate of recurrence than those in group 1 (54.6 versus 40.6 per cent). In both groups, patients who underwent elective regional dissection of lymph nodes had a lower rate of recurrence (19.4 per cent) than those patients who did not undergo dissection (53.6 per cent) (p = 0.001). It is suggested that thermal damage to the blood and lymph vessels incurred during laser excision may be more extensive than has been reported. These damaged walls may cause the higher rate of distal metastases of malignant melanoma from a primary lesion more than 1.6 millimeters in thickness; primarily in male patients.     

Long-term outcomes of two different surgical techniques for cesarean.

OBJECTIVE: To assess the rate of adhesions and other long-term outcomes of two cesarean delivery techniques. METHODS: A total of 600 women were randomly assigned to either a standard (Pfannenstiel-Kerr) or modified (Joel-Cohen-Stark) technique for first-time cesarean delivery. A total of 124 women were assessed at repeat cesarean delivery. The primary outcome measure was the presence of adhesions. RESULTS: At repeat cesarean delivery, anesthesia-to-delivery time, total duration of surgery, change in hemoglobin level, time to mobilization and oral intake, and postoperative hospital stay were significantly less with the modified technique. Adhesions were found in 7 (11.3%) and 22 (35.5%) of the cases using the modified and standard techniques, respectively (P=0.0026; relative risk 3.14 [95% CI, 1.45-6.82]). CONCLUSION: A modified cesarean delivery technique, including Joel-Cohen incision, exteriorized full thickness suturing of the uterine incision, and non-closure of the peritoneum may reduce long-term morbidities of the procedure.     

A long-term cohort study of surgery for recurrent prolapse comparing mesh augmented anterior repairs to anterior colporrhaphy

Background

There are safety concerns regarding the use of mesh in vaginal surgery with a call for long-term follow-up data. This study was designed to evaluate the long-term safety and efficacy of vaginal repairs performed for recurrent cystocele using Perigee (non-absorbable trans-obturator) mesh.

Methods

A retrospective consecutive cohort of 48 women who underwent surgery for recurrent prolapse between March 2007 and December 2011 in a single centre was reviewed. Satisfaction was assessed using the patient global impression of improvement (PGI-I). Symptoms were assessed with the pelvic floor distress inventory (PFDI). Women were questioned regarding pain, sexual activity and pelvic floor surgery performed since the original procedure and examined for erosion. Women were compared to 25 controls from a consecutive cohort of repeat anterior colporrhapies.

Results

The mean length of follow-up was 6.5 years (78 months; range 48–106). Significantly more women in the mesh group reported that they were “much better” or “very much better” (69 vs 40% p?=?0.02). The rate of mesh erosion at follow-up was 11.6%. Two women in the mesh group required surgical excision of eroded mesh in the operating room (4%). The reoperation rate for a combination of de novo stress incontinence, recurrent prolapse and mesh exposure was similar in each group (33% mesh vs 32% native tissue).

Conclusions

A vaginal mesh repair using a non-absorbable trans-obturator mesh has improved satisfaction compared to an anterior colporrhaphy.

     

Comparing effectiveness of combined transobturator tension-free vaginal mesh (Perigee) and transobturator tension-free vaginal tape (TVT-O) versus anterior colporrhaphy and TVT-O for associated cystocele and urodynamic stress incontinence

Objective

To evaluate the efficacy and safety of transobturator tension-free vaginal mesh (Perigee) and concomitant transobturator tension-free vaginal tape (TVT-O) for treating cystocele with urodynamic stress incontinence (UDSI).

Study design

A retrospective study of 115 patients with symptomatic stages 2-3 cystocele and UDSI who were treated with a Perigee system (Group I, n = 68) plus TVT-O procedure or traditional anterior colporrhaphy (Group II, n = 47) plus TVT-O procedure. All patients were followed up for more than one year. Objective and subjective symptoms were evaluated at one year postoperatively. Statistical analysis was performed using SPSS software.

Results

The objective cure rates for cystocele at one year were significantly higher in Group I than in Group II (98.5% and 86.9%, P = 0.018), respectively. The cure rates for UDSI in the two groups were 91.0% vs. 91.3% (P = 1.000). Symptomatic improvement of frequency was better in Group I than Group II (87.7% vs. 70.0%, P = 0.030). There were no significant differences with regard to intraoperative and postoperative complications between the two groups.

Conclusions

The combination of the Perigee system and TVT-O offers a safe and effective treatment for cystocele with UDSI and may be performed as first-line treatment.     

Reliability of cytological follow-up after conization of the cervix; a comparison of three surgical techniques

Summary. A retrospective analysis was made 154 consecutive conizations between 1974 and 1982. Three surgical methods were compared: (A) Sturmdorf sutures; (B) interrupted vertical sutures; and (C) an 'open' method using only cauterization and no additional stitches. The mean blood loss during conization was not reduced by ligation of descending branches of the uterine arteries. Post-conization haemorrhage occurred in only 3% and did not differ between the three groups. Cervical smears with only ectocervical squamous epithelium or too little material to allow diagnosis were considered inadequate. Unreliable follow-up was defined as inadequacy of more than 25% of a patient's smears. Thirty per cent of all follow-up smears were inadequate (group A 33%; B 41%; C 16%). In 46% of the patients, cytological follow-up was unreliable (group A 48%; B 61%; C 18%) and additional measures such as dilatation of the cervix, endocervical curettage, or hysterectomy were required. The differences between group C and the other two groups were statistically significant ( P <0.01; χ² test).