Rising awareness of the complications of synthetic slings

PURPOSE OF REVIEW: This article will review the current literature on the complications of synthetic suburethral slings used in the treatment of stress urinary incontinence and the management of these complications. RECENT FINDINGS: Loosely applied mid-urethral synthetic slings are becoming the treatment of choice in the management of stress urinary incontinence. Despite the ease of carrying out these procedures there is still a learning curve and, whilst the current literature shows there has been a significant reduction in the complication rate in recent years with the use of modern synthetic slings, they still occur and can be a significant cause of morbidity. There has been interest in developing better imaging techniques for both establishing early diagnosis and in assisting in the treatment of complications; magnetic resonance imaging of the urethra has been one of the modalities that has been investigated. Further work is needed to predict those who are more likely to develop complications during the placement of suburethral slings; the use of urodynamic procedures has shown equivocal results. Inevitably with more experience the techniques have evolved for the management of complications, such as the treatment of urethral obstruction with transvaginal sling incision. SUMMARY: Synthetic materials for slings provide an effective and safe method for treating urinary stress incontinence in women, and have delivered improved efficacy; nevertheless, although the incidence of complications has significantly reduced in recent years, they still represent a significant and not unsubstantial morbidity.     

Framing the doctor-patient relationship in chronic illness: a comparative study of general practitioners' accounts

How family doctors conceptualise chronic illness in the consultation has important implications for both the delivery of medical care, and its experience by patients. In this paper, we present the results of a re-analysis of qualitative data collected in a series of studies of British family doctors between 1995 and 2001, to explore the ways in which the legitimacy and authority of medical knowledge and practice are organised and worked out in relation to three kinds of chronic illness (menorrhagia; depression; and chronic low back pain/medically unexplained symptoms). We present a comparative analysis of (a). the moral evaluation of the patient (and judgements about the legitimacy of symptom presentation); (b). the possibilities of disposal; and (c). doctors' empathic responses to the patient, in each of these clinical cases. Our analysis defines some of the fundamental conditions through which general practitioners frame their relationships with patients presenting complex but sometimes diffuse combinations of 'social', 'psychological' and 'medical' symptoms. These are fundamental to, yet barely touched by, the increasingly voluminous literature on how doctors should interact with patients. Moving beyond the individual studies from which our data are drawn, we have outlined some of the highly complex and demanding features of what is often seen as routine and unrewarding medical work, and some of the key requirements for the local negotiation of patients' problems and their meanings (for both patients and doctors) in everyday general practice.     

The decision to have a prosthesis: A qualitative study of men with testicular cancer

The aim of this paper is to understand why some men decide to have a testicular prosthesis while others reject the idea and to explore the extent to which the option of a testicular prosthesis is adequately presented. Forty-five men with testicular cancer were interviewed about all aspects of their illness. Some men decided against a prosthesis for a number of reasons; they thought that the loss of a testicle was not visibly obvious, did not affect self-image, was not a long-term threat to masculinity, and that living with one testicle was comfortable. Some did not want additional surgery and others were concerned about safety issues. The men who decided to have a prosthesis were concerned about self-image and a threat to masculinity. They had a desire to look 'normal' and a wish to keep the orchidectomy secret. Some men felt that the decision had been rushed. Others wished that they had had information about the possibility of implants before the orchidectomy or they considered the information presented inadequate. We conclude that it is important to counsel men with testicular cancer about the advantages and disadvantages of having a testicular prosthesis and to give them time to consider issues such as cosmetic appearance, self-image, comfort, possible short term complications and long-term safety.     

Transurethral implantation of macroplastique for the treatment of female stress urinary incontinence secondary to urethral sphincter deficiency

OBJECTIVE: To assess the results of transurethral implantation of Macroplastique in women with stress incontinence secondary to urethral sphincter deficiency using subjective and objective outcome measures. METHODS: A total of 60 women with genuine stress incontinence secondary to intrinsic urethral sphincter deficiency were treated with transurethral implantation of Macroplastique. The patients had undergone a mean of 1.9 (range 0-7) previous episodes of continence surgery. Up to three treatment episodes were used, if necessary. The outcome was assessed by telephone interview (56 patients, mean follow-up period 19 months) and videocystometry (41 patients, mean follow-up period 16 months). Transurethral ultrasound scanning was performed in a further 9 patients. RESULTS: Symptomatically, 19.6% of the women interviewed by telephone considered themselves cured of their incontinence or were no longer using pads. A further 41.1% said their symptoms had significantly improved. Pad usage was reduced from a median of five to three pads per day (p < 0.001). Videocystometry in 41 women (mean follow-up period 16 months) was normal in 16 patients (39%) and showed genuine stress incontinence in 18 (43.9%) and detrusor instability in 12 patients (29.3%). Overall, 71.4% stated that they would undergo the procedure again under the same circumstances, and 80.4% would recommend this form of treatment to a friend with the same condition. Transurethral ultrasound scanning was performed in 9 patients (5 subjectively improved or cured, 1 patient with persistent symptoms but normal cystometry, and 3 patients with persistent genuine stress incontinence). Hyperechoic foci were seen surrounding the proximal urethra, consistent with implanted Macroplastique boluses. When completely encircling the urethra, the outcome was generally good. A total of 10 patients have undergone or are awaiting open surgery, and 3 are awaiting repeat implantation. CONCLUSION: Sustained improvement or cure of genuine stress incontinence has been achieved using Macroplastique in a large proportion of women with intrinsic sphincter deficiency, often following previous unsuccessful continence surgery. Transurethral ultrasound may prove to be a clinically useful imaging technique for the assessment and subsequent management of treatment failure following Macroplastique implantation.     

A new treatment for urethral strictures: a permanently implanted urethral stent

We describe a new urethral stent, originally developed for endovascular use, that we have implanted into 8 patients with urethral strictures. The stent is woven in the form of a tubular mesh from surgical grade stainless steel wire and is self-expanding when released from its small diameter delivery catheter. All patients have been treated successfully with a good caliber urethra visible on urethrography and direct endoscopy, and with improved urine flow rates. Mean followup of these patients is 8 months (range 6 months to 1 year). Urethroscopy had demonstrated complete epithelial covering of the implant at 4 to 6 months. Although the followup is short it seems that this simple technique may offer a lasting treatment for many urethral strictures.     

Active site-blocked factor Xa prevents thrombus formation in the coronary vasculature in parallel with inhibition of extravascular coagulation in a canine thrombosis model

Factor Xa is a central procoagulant enzyme, linking the intrinsic and extrinsic activation mechanisms to the final common pathway of coagulation. To assess its contribution to pathologic thrombosis, studies were performed in a canine coronary thrombosis model. Thrombus formation was initiated by the application of electric current via a needle electrode placed in the lumen of the left circumflex coronary artery. When 50% occlusion of the vessel developed, the current was stopped and animals received an intravenous bolus of either saline, bovine glutamyl-glycinyl-arginyl-factor Xa (Xai), a competitive inhibitor of factor Xa assembly into the prothrombinase complex, Factor X, or heparin. Animals infused with saline or factor X (300 micrograms/kg) developed total occlusion of the vessel due to a fibrin/platelet thrombus in 70 +/- 11 minutes (36 of 36 animals) and 74 +/- 13 minutes (8 of 8 animals), respectively. In contrast, infusion of Xai prevented thrombus formation completely at a dose of 300 micrograms/kg (8 of 8 animals). As the dose of Xai was decreased, its antithrombotic effect was diminished, with a patency rate of only 2 of 6 animals at a dose of 90 micrograms/kg. Xai at 300 micrograms/kg prevented the accumulation of 125I-fibrinogen/fibrin at the site of the coronary thrombus by approximately 63% and decreased deposition of 111In-labeled platelets by approximately 57%. Hemostatic parameters of animals infused with Xai demonstrated prolongation of the PT and dose- dependent increased extravascular bleeding tendency. These data indicate that factor Xa has a comparably important role in thrombus formation and extravascular hemostasis, and contrast with previous results in this same animal model in which IXai selectively prevented clotting in the coronary vasculature.