A case of a large rectovaginal mass presenting as posterior vaginal wall prolapse

A 66-year-old female presented with symptoms suggestive of pelvic organ prolapse, history of fibroid uterus, and rectal pressure. Pelvic examination revealed a large pelvic mass filling the posterior cul-de-sac, occupying the rectovaginal septum, and compressing the rectum. There was a stage II pelvic organ prolapse of the posterior vaginal wall with distal vaginal wall extending to the hymen during valsalva. A CT scan confirmed the large pelvic mass distinct from the uterus measuring 9.4 × 9.8 × 6.2 cm. Colorectal workup revealed adenocarcinoma of colon on screening colonoscopy with biopsies. Patient underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy, colon resection, and abdominal resection of the pelvic mass in the rectovaginal septum and inferior to the uterus. The patient did not require any concomitant pelvic reconstruction and the posterior vaginal wall prolapse resolved after resecting the pelvic mass.     

Primary menouria due to a congenital vesico–vaginal fistula with distal vaginal agenesis: a rarity

We present the case of a female aged 16 years, suffering from cyclical menouria for the last 3 years. Clinical examination revealed the absence of a vagina. Cystoscopy performed while the patient was having menouria revealed an orifice (10 × 8 mm) in the supratrigonal region; blood clots were entering the urinary bladder through this orifice. Magnetic resonance imaging of the pelvis depicted a fluid-filled longitudinal tract distal to the uterus (which was the upper vagina), between the cervix and the bladder. Diagnostic laparoscopy confirmed the presence of a uterus, both ovaries, and the tubal structures. Exploratory laparotomy, correction of the fistulous tract, and sigmoid vaginoplasty were performed. The distal part of the fistulous tract (urinary bladder end) was anastomosed to the proximal end of the sigmoid neo-vagina. The patient is doing well as per her last follow-up at 6 months. She has started menstruating per neo-vagina.     

Influence of interferon-α2b (IFN-α2b) on the prevention of locally advanced bladder carcinoma in mice

In the model of chemically induced bladder carcinoma in mice following application of betahydroxylbutylnitrosamine (BBN) we could not detect a therapeutic influence of systemic treatment with intraperitoneal injection of interferon-α2b (10 × 3 × 10⁵ IU IFN-α2b) on the rate of locally advanced bladder carcinoma (IFN-α2b 37% versus control 41%) nor on the development of tumor precursors (severe dysplasia 100% in both groups). Received: 25 February 1998 / Accepted: 24 February 1999     

Case of longitudinal vaginal septum with pelvic organ prolapse

Longitudinal vaginal septum is a rare mullerian anomaly and its association with pelvic organ prolapse (POP) is unusual. A case of longitudinal vaginal septum with stage IV POP in a 35-year-old multiparous woman is being reported. Examination revealed an incomplete longitudinal vaginal septum (9 × 6 × 2 cm) with stage IV POP. Vaginal hysterectomy with repair and reconstruction was done along with excision of the longitudinal vaginal septum which was technically challenging due to proximity to rectum. This is the only case report of stage IV pelvic organ prolapse associated with a thick longitudinal vaginal septum in a multiparous woman without any obstetric complications. Surgery required increased caution per operatively while dissecting the septum from the vaginal wall and the adjacent organs.     

Bladder exstrophy combined with uterovaginal prolapse and its surgical management: case report and literature review

We describe a case of a postmenopausal woman with a corrected bladder exstrophy (BE) who presented with a uterovaginal prolapse complicated by calcified fibroids and discuss its surgical management. A 51-year-old woman presented with a uterovaginal prolapse. She had previously had one full term delivery by caesarean section 20 years ago. She had an ileal conduit performed for her BE at birth. A computed tomography scan revealed significant pelvic anomaly and the uterus contained multiple calcified fibroids. Due to the complexity of her condition the surgical management was planned in two stages: initial examination under anaesthetic in conjunction with a consultant urologist and then the definitive planned reconstructive surgery. This case describes the need for careful evaluation and planning of complex surgery and the successful surgical management option for correction of uterovaginal prolapse in patients with BE. A vaginal approach seemed to be a most sensible route to correct the prolapse in view of her previous multiple abdominal surgeries.     

Chronic pelvic pain syndromes: clinical, urodynamic, and urothelial observations

Introduction/methods  A cohort of 408 patients with bladder pain syndrome/interstitial cystitis (BPS/IC) was evaluated, and findings were discussed in this retrospective chart review. Results  Based on the chief complaints, they were divided into four subgroups: BPS/IC (n = 157), CPP (n = 98), vulvodynia/dyspareunia (n = 40), and “other” (n = 113). Similar findings were found in all four subgroups: complaints of voiding dysfunction (70%), dyspareunia (54%), mean PUF score of 15.9 ± 6.4, and a positive potassium sensitivity test in 83%. Urodynamics revealed a maximal urethral pressure of 131 cm of water and an abnormal uroflow in 80%. Urothelial therapy in the form of intravesical therapeutic anesthetic cocktails provided benefit in all groups (50%, 67%, 73%, and 77% for vulvodynia, CPP, BPS/IC, “other”). Conclusions  All subgroups had similar findings and response to therapy. Five to 10% of patients with chief complaints of stress or urge incontinence or prolapse were also found to have BPS/IC.     

The latissimus dorsi bladder myoplasty to assist detrusor function

The objective of this study was to evaluate whether an innervated skeletal muscle might augment detrusor function. In four dogs we performed the latissimus dorsi myoplasty, a transfer of the latissimus muscle as an innervated free flap wrapped around the bladder. Stimulation of the latissimus dorsi free flap initially achieved an average bladder pressure of 45.8 ± 8.41 cm H₂O, sufficient for partial evacuation. After 4 months the muscle generated a maximal pressure of 82 cm H₂O, resulting in an evacuation of 27.7%. For selected patients, the latissimus dorsi bladder myoplasty may provide an alternative to intermittent catheterization in the future. Received: 14 March 1997 / Accepted: 12 January 1998     

Robotic-assisted laparoscopic bladder diverticulectomy and concomitant ureteral re-implantation: initial clinical experience

We present our initial clinical experience with robotic-assisted laparoscopic bladder diverticulectomy with associated ureteral re-implantation. A 75-year-old man was referred to us for recurrent urinary tract infections and lower urinary tract symptoms. On computed tomography of abdomen and pelvis the patient was found to have a 13 × 14 × 6 cm diverticulum in the left posterior bladder wall. The patient elected to undergo robotic-assisted laparoscopic removal of the diverticulum. The patient’s preparation, draping, and trocar placement was performed as per standard fashion of robotic-assisted laparoscopic radical prostatectomy. The bladder was mobilized and diverticulum was identified and removed. The left ureter was transected secondary to its passage through the diverticulum, and required re-implantation. After hemostasis was achieved, the repair was tested and confirmed. The operation was completed in 207 min without any complications. Estimated blood loss was 150 cc. On postoperative day 1, the patient was placed on oral analgesic and discharged home. Our initial report of robotic-assisted laparoscopic bladder diverticulectomy and ureteral re-implantation illustrates that this minimally invasive technique is an effective method of treatment of bladder diverticulum. Proximity of the ureter to the diverticulum should not be a deterrent for this approach of repair.     

Monarc transobturator sling system for the treatment of female urinary stress incontinence: results of a post-operative transvaginal ultrasonography

The aim of the study was to determine Monarc (American Medical Systems) sling position after surgical treatment of stress urinary incontinence (SUI) through the transobturator approach. A total of 54 consecutive women with SUI were evaluated post-operatively with transvaginal ultrasound. A concomitant hysterectomy was performed in ten cases and a concomitant prolapse surgery in six cases. Ultrasound measurements include urethral length, the distance between the upper edge of the sling and the bladder neck (BN–S) and the BN–S/U ratio. The mean distance between the transobturator tape and the bladder neck was found to be 12.6 ± 3.2 mm in the group of patients who underwent the transobturator procedure alone, 13 ± 3.1 mm in the transobturator plus hysterectomy group and 12 ± 2.8 mm in the transobturator plus prolapse group. The superior tape margin was at the mid-urethra in 81.5% of patients and always at a distance greater than 7 mm from the bladder neck. Eight patients did not have satisfactory results after the surgery. Only in one out of these eight patients was the transobturator sling not found to be at the mid-urethra. The superior tape margin of the Monarc sling remained at the level of mid-urethra in the majority of cases. It was never located too proximally beneath the bladder neck.     

Effect of renal pelvic distension on the ureteropelvic and ureterovesical junctions and the urinary bladder: the renal pelvivesical reflex

For investigation of the effect of distension of the renal pelvis on the ureteropelvic (UPJ) and uretero vesical junctions (UVJ) and on the urinary bladder, nephrostomy was performed on 14 anesthetized mongrel dogs. The pressure was measured in the UPJ by a catheter with a side port introduced through the nephrostomy and in the UVJ and urinary bladder by two catheters inserted cystoscopically. Likewise, a balloon mounted on the tip of a catheter was introduced into the renal pelvis. It was filled with saline in increments of 1 ml, and the pressure response of the UPJ, the UVJ, and the urinary bladder was determined. The test was repeated on the anesthetized renal pelvis, UVJ, and bladder. Whereas renal pelvic distension with 1 ml of saline effected no pressure response in the UPJ, UVJ or bladder, distension with 2–4 ml produced a significant pressure drop (P < 0.01, P < 0.01, and P < 0.05, respectively). There was no difference in the pressure drops recorded at distensions with 2, 3, or 4 ml of saline (P > 0.05). Distension of the anesthetized renal pelvis produced no pressure response in the UPJ, UVJ, or bladder. Furthermore, renal pelvic distension did not elicit a pressure response in the anesthetized UPJ or the bladder. In conclusion, the opening of the UVJ synchronously with the UPJ upon renal pelvic distension appears to assist the delivery of urine from the renal pelvis to the urinary bladder and to protect both the renal pelvis and the ureter against dilatation. This process is supported by a vesical pressure drop. The opening of the UPJ together with the UVJ and the vesical relaxation observed on renal pelvic distension seem to be reflex in nature. A “renal pelvivesical reflex” is postulated to regulate the flow of urine from the renal pelvis to the urinary bladder, preventing the occurrence of urine collection in, or backflow into, the renal pelvis or the ureter.     

Gastrointestinal Stromal Tumor of the Rectum Resected by Laparoscopic Surgery: Report of a Case

A 53-year-old man visited our hospital with the chief complaint of pain on urination. On digital rectal examination, a rigid immobile tumor mass with a smooth surface was palpated on the anterior wall on the right side of the rectum near the anal canal. Computed tomography (CT) and magnetic resonance imaging (MRI) of the pelvis revealed a heterogeneous tumor mass measuring 6.5 cm in diameter, which occupied the cavity of the lesser pelvis. This rectal tumor was diagnosed to be a gastrointestinal stromal tumor (GIST) based on the results of a transrectal needle biopsy. A laparoscopic abdominoperineal resection of the rectum was performed to remove the mass. The intraoperative findings showed an ambiguous boundary between the tumor and the rectum but clear boundaries between the tumor and the peripheral organs, and the use of a laparoscope allowed for a good separation by providing a good visual field. The bleeding volume was approximately 80 ml and the operative time was 320 min. The macroscopic findings of excised specimens of the mass showed the tumor, measuring 6.5 × 5.5 × 5.0 cm, to be growing extrinsically from the anterior wall on the right side of the rectum. A histological examination of the excised specimens revealed at most 5 mitoses per 50 high-power fields (×400). The tumor mass was diagnosed to be a GIST of low-grade malignancy based on these findings. The postoperative course was favorable, and there were no postoperative complications. The patient was discharged on the 8th hospital day. Laparoscopic surgery is a minimally invasive surgical procedure for rectal GIST, which is excellent in terms of esthetics. Laparoscopic surgery is therefore considered to be useful for a resection of the rectum, because the magnifying effect allows surgical maneuvers with a favorable visual field within the pelvis.     

Does bladder neck descent increase with age?

It is assumed that pelvic organ descent and prolapse increase with age. Epidemiological studies support this assumption. We aimed to define the relationship between age and bladder neck descent (BND) in a retrospective observational study on 790 women referred for evaluation of pelvic floor disorders. Bladder neck descent, cystocele descent and urethral rotation were evaluated on maximal Valsalva manoeuvre, using trans-labial ultrasound. There was a weak negative correlation between bladder neck descent on Valsalva and age (r = −0.154, p < 0.001), which was absent in nulliparous women (n = 107) and stronger (r = −0.213, p < 0.001) in parous women (n = 683). This relationship was evident from the age of 50 years onwards and may be explained by increased tissue stiffness after menopause. The difference observed between parous and nulliparous women is intriguing and raises the issue of obstetric confounders such as historical changes in the likelihood of significant pelvic floor trauma.     

Reconstruction of the Anterior Chest Wall After Subtotal Sternectomy for Metastatic Breast Cancer: Report of a Case

We describe our successful operative management of a solitary metastasis in the sternal body after modified left mastectomy. Because the primary lesion was well controlled and the sternal metastasis was isolated, we performed a subtotal sternectomy, with full-thickness resection of the anterior chest wall, including the sternal body and inferior part of the manubrium (14.5 cm × 8.5 cm × 3.0 cm). A prosthesis was created to fill the defect, by sandwiching molded bone cement (methylmethacrylate) between two layers of Prolene mesh. The prosthesis was fixed to the cut ends of the costal cartilages and the residual manubrium. The patient had an uneventful course, and her respirations were normal without paradoxical movement of the thorax or hypoxemia. The skin covering the prosthesis healed well. Thus, the creation of an artificial chest wall from methylmethacrylate and Prolene mesh is a useful technique for repairing sternal defects.     

Baroreceptor-heart rate reflex sensitivity enhancement after urinary bladder distention in essential hypertensives

Our objective was to determine if urinary bladder distention modifies the sensitivity of the baroreceptor-heart rate reflex in hypertensive and control subjects. The baroreceptor-heart rate reflex sensitivity was measured in 15 male patients (mean age 37 ± 8 years) with mild untreated hypertension (mean 163 ± 8/95 ± 12 mmHg) and 17 age- and sex-matched control subjects before and after urinary bladder distention. Bladder filling was performed infusing saline heated to 37°C via a urinary catheter; the volume infused in each patient corresponded to that which caused the urge to void without reaching the pain threshold. The baroreceptor-heart rate reflex sensitivity was determined correlating the variations of the systolic pressure and of the peak blood flow velocity in the common carotid artery with the variations of the ECG RR′ interval of the following heart beat, both during spontaneous and phenylephrine-induced fluctuations of the haemodynamic variables. After bladder distention the diastolic pressure of the hypertensive subjects increased significantly (95 ± 12 vs. 100 ± 12 mmHg; P < 0.02), whereas the heart rate decreased (RR=873 ± 70 vs. 926 ± 80 ms; P < 0.005). These parameters were unchanged in the normotensive subjects (84 ± 9 vs. 83 ± 8 mmHg and 914 ± 158 vs. 913±140 ms, respectively). The baroreceptor-heart rate reflex sensitivity, measured on the basis of spontaneous pressure and carotid blood flow velocity fluctuations in relationship to RR changes, decreased in the normotensive subjects after bladder distention (10.7 ± 4.6 vs. 9.4 ± 2.7 ms/mmHg; P < 0.05 and 423 ± 99 vs. 356 ± 102 ms/kHz; P < 0.01, respectively), whereas it increased in the hypertensive patients (6.9 ± 3.6 vs. 8.3 ± 2.8 ms/mmHg; P < 0.03, and 332 ± 86 vs. 381 ± 97 ms/kHz; P < 0.03 respectively). After bladder distention and phenylephrine administration the baroreceptor-heart rate reflex sensitivity, measured by the correlation between systolic pressure and RR interval, increased only in the hypertensive group (10.2 ± 5.4 vs. 15.2 ± 7.7 ms/mmHg; P < 0.005). In conclusion urinary bladder distention provokes in hypertensives but not normotensive controls a brisk parasympathetic response of the component of the baroreceptor-heart rate reflex which controls heart rate. Received: 17 June 1998 / Accepted: 20 October 1998     

Irreducible procidentia due to multiple bladder calculi mimicking impacted faecal mass

A case of massive irreducible procidentia with a hard palpable mass in the anterior vaginal wall mimicking an impacted faecal mass in a 57-year-old multiparous, post-menopausal woman is reported. Inability to walk, constipation and urinary incontinence were her primary complaints. Routine CT of the abdomen and pelvis excluded intestinal pathology, but failed to reveal multiple vesical calculi as the procidentia was lying outside the imaging zone of the pelvic CT. However, targeted plain X-ray and ultrasound of the prolapsed mass disclosed the existence of multiple vesical calculi. The patient was managed with single-stage laparotomy and vaginal hysterectomy. Hysterectomy permitted the reduction of the prolapse and facilitated extraperitoneal vesicolithotomy. Laparotomy excluded bowel pathology. No reconstructive surgical steps for repair and reconstruction were combined. Currently, the patient is relieved of all symptoms and her asymptomatic stage II vault prolapse is managed conservatively.     

Fibulin-5 expression is decreased in women with anterior vaginal wall prolapse

The aim of this study was to compare fibulin-5 expression in women with and without anterior vaginal wall prolapse. Vaginal tissues were sampled in a standardized fashion from women with (n = 12) or without (n = 10) anterior vaginal wall prolapse. Quantitative real-time polymerase chain reaction was performed to measure mRNA levels of fibulin-5 (FIB-5). FIB-5 protein expression was assessed by immunohistochemistry. There were no significant differences in demographic data between the two groups. FIB-5 mRNA expression was significantly decreased in women with anterior vaginal wall prolapse compared to women without prolapse [(FIB-5 mean ± SD mRNA expression in relative units) 0.01 ± 0.01 vs. 0.09 ± 0.14, P = 0.04]. Fibulin-5 staining intensity was diminished in women with prolapse compared to women without prolapse [intensity score, median (range), 1 (1–2) vs. 3 (2–3), P = 0.04]. Fibulin-5 expression is decreased in vaginal biopsies from women with prolapse. Changes in fibulin expression may play a role in the development of pelvic organ prolapse.     

Hepatic and Splenic Hydatidosis Managed with Percutaneous Aspiration,Injection, and Reaspiration (PAIR) of the Hepatic Cyst and Laparoscopic Splenectomy

The treatment of hydatidosis traditionally consisted of surgery with a perioperative course of anthelmintic medications. However, percutaneous aspiration, injection, and reaspiration (PAIR) combined with oral albendazole has been recently shown to be as effective as surgery in the treatment of liver hydatidosis. We report a 20-year-old female immigrant from Western Europe who presented with discomfort in her upper abdomen. Computed tomography revealed a 5.7 × 7 × 5.9-cm cyst in segment 7 of the liver and a 17 × 15-cm cyst in the spleen in contiguity with the hilar vessels. Indirect hemaglutination test confirmed hydatidosis. A strategy with two different surgical approaches was designed to treat her condition: laparoscopic splenectomy and ultrasound-guided PAIR of the liver cyst. The patient was discharged on postoperative day 5, and at 18 months follow-up, she is free of symptoms.     

Simultaneous Bilateral Laparoscopic Adrenalectomy for Adrenocorticotropic Hormone-Independent Macronodular Adrenal Hyerplasia: Report of a Case

Cushing's syndrome caused by adrenocorticotropic hormone (ACTH)-independent macronodular adrenal hyperplasia (AIMAH) is an extremely rare disease, which shows bilateral macronodular adrenal hypertrophy and autonomous cortisol production. We herein report a case of AIMAH treated successfully by minimally invasive simultaneous bilateral laparoscopic adrenalectomy. A 73-year-old woman with hypertension, diabetes mellitus, and osteoporosis was referred to our hospital because of an incidentally found huge bilateral adrenal mass. An abdominal computed tomography scan showed large bilateral adrenal glands with multiple nodules. A diagnosis of AIMAH was made and a simultaneous bilateral laparoscopic adrenalectomy was thus performed. The total operation time was 310 min and blood loss was 70 g. Both glands were hypertrophic (right 5 × 3 cm, 48.5 g and left 4 × 2 cm, 39.2 g) and consisted of multiple golden yellow macronodules. The postoperative course was uneventful. A simultaneous bilateral adrenalectomy for AIMAH performed by an experienced surgical team is therefore considered to be a safe and minimally invasive procedure.     

Standards for ultrasound guidance of suprapubic bladder aspiration

 We performed a prospective study of 40 infants with suspected urinary tract infection to determine standards for ultrasound guidance of suprapubic bladder aspiration (SBA). Only transverse bladder diameter showed a significant correlation with bladder volume (r = 0.83, P<0.001). Urine was obtained in 36 patients (90%). The mean transverse diameter was 4.4 ± 0.8 cm (range 3–6.1 cm). In the 4 patients (10%) in whom urine was not obtained, the transverse diameter was 3.2 ± 0.2 cm (range 2.9–3.5 cm). Our findings indicate that a SBA is more likely to be successful when the transverse diameter is above 3.5 cm, whereas when the diameter is lower than 3 cm the procedure is less likely to be successful. Received September 9, 1996; received in revised form and accepted February 20, 1997     

Complications of transvaginal monofilament polypropylene mesh in pelvic organ prolapse repair

Introduction and hypothesis  This study aimed to document intraoperative and postoperative complications associated with the use of transvaginal polypropylene mesh in the repair of pelvic organ prolapse (POP). Methods  This is a retrospective review of 127 cases of transvaginal repair of POP using synthetic mesh. Results  Mean postoperative value (±SD) for pelvic organ prolapse quantification (POPQ) measurements Aa, Ap, and C were: −2.4 ± 1.1 (cm), −2.4 ± 0.9 (cm), and −7.7 ± 1.2 (cm), respectively. The difference between preoperative and postoperative values of these points was significant (p < 0.0001). Mesh erosion rate was 13/127 (10.2%) with significant correlation between mesh erosion and concurrent vaginal hysterectomy (p = 0.008). Combined anterior and posterior vaginal mesh surgery increased the risk of intraoperative bleeding and blood transfusion (p < 0.05). Conclusions  Concurrent vaginal hysterectomy is associated with increased risk of vaginal mesh erosion. Combined anterior and posterior vaginal mesh repair is an increased risk factor for intraoperative bleeding and blood transfusion.