Reporting and grading of complications after mid-urethral sling surgeries: Could the “Clavien-Dindo Classification” be adopted?

Background:To construct a modified model for reporting and grading of postoperative complications after the mid-urethral sling (MUS) procedure based on the Clavien-Dindo classification. In addition, complications of three different types of MUS were compared.Materials and methods:A PubMed search for postoperative complication after MUS was carried out for the period between January 1990 and July 2018. Reported complications were stratified in a plate form designed in accordance with grades of the Clavien-Dindo classification. Then, the proposed model was applied on reported complications in 160 females who underwent three different procedures of MUS (transvaginal tape [TVT], transobturator tape [TOT], and autologous fascial sling) with a minimum follow-up of 24 months.Results:The mean ± SD age at time of surgery was 46 ± 7 years. TVT was carried out in 75 (47%) patients, TOT in 40 (25%), and fascial sling in 45 (28%). The total number of complications was 62 in 43 (26.8%) patients. The vast majority of complications were Grade I and Grade II 19 (12%) and 21 (13%) out of 160 patients, respectively. Transient postoperative voiding difficulty (Grade II) and de novo urgency (Grade II) were the most prevalent complications in the fascial sling method (15.4% for each), whereas transient thigh pain (Grade II) was the most frequently reported complication after TOT (10%). Life-threatening vascular injury (Grade IV-a) was a serious complication in TVT cases.Conclusions:Postoperative complications of the MUS could be graded according to Clavien''s classification. The vast majority of complications were Graded I or II. TVT can cause serious life-threatening complications.     

腹膜外入路腹腔镜下膀胱颈悬吊术治疗压力性尿失禁TVT-O术后失败或复发患者的初步经验

目的报道6例经腹膜外途径腹腔镜下膀胱颈Cooper韧带悬吊术(Burch手术)治疗女性压力性尿失禁行经阴道经闭孔尿道中段无张力悬吊术(TVT-O)术后失败或复发患者的初步经验。方法回顾分析2015年6月至2019年9月我们采用经腹腔镜下腹膜外途径Burch手术治疗的6例女性压力性尿失禁TVT-O术后失败或复发患者。自脐下2 cm处切开皮肤并制造腹膜外空间,用2#0薇荞线将尿道旁侧的阴道壁肌层“8字”缝合后再缝合到同侧Cooper韧带上。观察患者手术时间、出血量、住院时间等。结果所有手术均成功,手术时间(37±6)min,术中出血量(17±7)ml,术后住院时间(4.5±0.5)d。6例随访时间3~45个月,所有病例尿失禁症状均消失,均无感染、膀胱损伤、排尿困难、复发等并发症。结论女性压力性尿失禁患者行TVT-O术失败或复发后,选择腹腔镜下经腹膜外途径Burch术安全、有效,可以获得完全尿控,为临床可选方案。     

Erworbene Bauchhöhlenmuskelstörungen

Zusammenfassung Die Bauchhöhle hat ein Faszienskelett, das durch ihren permanenten veränderhchen Ruhetonus verspannt gehalten wird. Zur Bauchhöhle gehören mit der seitlichen Bauchmuskulatur auch das Zwerchfell und der Beckenboden. Willkürliche und reflektorische Tonusänderungen bedingen ihre Verformung und ihren Verschluß oder ihre Eröffnung. Am Versuchstier haben wir diesen Ruhetonus schon in der Schwanzmuskulatur nachgewiesen, von der der Beckenboden des Menschen stammesgeschichtlich abstammt. Der Beckenboden bildet mit den Sphinkteren das anorektale Kontinenzorgan. Es ist, phylogenetisch erklärbar, bei der Frau viel schwächer entwickelt als beim Mann. Diese unterschiedliche Mächtigkeit ist his zu den Kernen des Rückenmarks, die diese Muskulatur steuern, zu verfolgen. Diese Asthenie des weiblichen Kontinenzorgans wird durch das Gebären und die Obstipation noch zusätzlich belastet. Das gleiche gilt für die Bauchdecke der Frau, die, wie hier nachgewiesen wird, nach einer Gravidität die gleichen, bleibenden Denervationserscheinungen ihrer Muskulatur erkennen läß t. Es sind die gleichen Schäden, die der Beckenboden mit den Sphinkteren erleidet. In schwereren Fällen ist neben der Inkontinenz also auch ein Schlotterbauch die Folge dieser Belastungen. Der ruhetonisierte Beckenboden kann das spastische Beckenbodensyndrom, die kontinente Obstipation, zur Folge haben. Sic kann psychotherapeutisch geheilt werden. Davon muß die inkontinente Obstipation unterschieden werden, die manchmal mit einem Mastdarmvorfall einhergeht. Bei ihr liegt das Hindernis im Darm. Sic kann in schweren Fällen durch eine Sigmaresektion gebessert werden. Die Denervationsinkontinenz ist am besten durch das operative Engerstellen des ganzen Levatortrichters zu bessern. Voraussetzung ist: Der gelähmte Beckenboden muß noch eine Restruheaktivität aufweisen.

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Acquired disturbances of muscles of the peritoneal cavity

The peritoneal cavity has a fascial skeleton that is kept under tension by permanent variable resting tone maintained by the abdominal muscles. The lateral abdominal muscles, the diaphragm and the pelvic floor are all components of this fasciomuscular support system. Voluntary and reflective changes in muscle tension allow the entry and exit of matter into and out of the spherical abdominal cavity by opening and closing of specialized wall segments called sphincters. We have previously demonstrated the existence of a resting tone in the tail muscles of mammals from which the human pelvic floor muscles are derived. The pelvic floor and its integrated sphincters form the anorectal organ of continence. This organ is much weaker in females than in males. The spinal centers that govern continence, contain in the female significantly fewer ganglion cells than the corresponding centers in the male. Childbirth and a commonly found tendency to develop constipation are additional stressors for the congenitally weaker female organ of continence. We explain in this paper why the abdominal wall and the pelvic floor may suffer stretch-induced denervation injuries during pregnancy and delivery. Such damage may persist in later life and can give rise to incontinence and flabby abdomen. Based on our work in this field, we found a new differentiation between continent and incontinent constipation. Continent constipation is caused by spasticity of the pelvic floor characterized by abnormally high sphincter activity. This spastic pelvic floor syndrome can be treated successfully by psychotherapeutic techniques. Incontinent constipation, in contrast, is always associated with subnormal activity of the sphincters and may be a cause of rectal prolapse. It can be treated successfully by anterior rectosigmoid resection. Incontinent constipation will also require operative approximation of the levators in many cases. Improvement cannot be expected to result from this procedure, however, unless the pelvic floor shows some residual resting activity.

Korrespondenz an: em. Prof. Dr. Dr. h. c. mult. F. Stelzner     

Day wetting

About 1% of healthy children over the age of 5 years have troublesome daytime wetting. Two-thirds of those who wet by day are reliably dry at night. The problem is more common in girls and is usually the result of urge incontinence. Although the wetting may be exacerbated by giggling and/or stress, pure giggle micturition and isolated stress incontinence are both rare. There is a strong association with bacteriuria (50% prevalence) in girls who wet by day. A potentially important relationship exists between day wetting, infection, reflux and upper tract damage, which is expressed in an extreme form in the syndromes of incoordinated voiding and progressive renal damage. Most children who wet by day have unstable bladders. Many of them adopt characteristic holding postures. There is an increased incidence of emotional disorder compared with children who merely wet the bed. Between 10% and 15% of children who wet by day become dry during the next 12 months. The acquisition of dryness is accelerated by eradication of bacteriuria and a sympathetic and energetic management regime, which should place responsibility on the child and result in the child voiding more frequently and completely. Reminder alarms and other behaviour therapies have proved effective. There is no satisfactory evidence for the efficacy of drugs. More complex behavioural training regimes including biofeedback are valuable for severe cases.     

Pelvic floor exercise alone or with vaginal cones for the treatment of mild to moderate stress urinary incontinence in premenopausal women

The authors compared intensive pelvic floor exercise alone (A) with intensive pelvic floor exercise plus vaginal cones (B) in premenopausal women with mild to moderate stress urinary incontinence. Forty-six patients (mean 43±6 years) were randomized into two training groups and treated for 3 months. Pre- and post-therapy urethral pressure profiles at rest and under stress and subjective results were obtained from 29 patients. The subjective improvement rate of the compliant patients after 12 weeks was 85% in group A and 84% in group B. When the dropouts (9 in group A and 8 in group B) were included in the subjective results an overall improvement rate of 48% in group A and 52% in group B was obtained. In group A one pressure transmission ratio (PTR) improved significantly at 6 weeks and the position of maximum urethral closure pressure was shifted proximally at 12 weeks. In group B one PTR in the midurethra was improved significantly at 6 weeks. The other urodynamic parameters were unchanged. There were no differences between groups A and B in subjective results or urodynamic findings. These results suggest that intensive pelvic floor exercise with or without vaginal cones improves the symptoms of mild to moderate stress incontinence in about 85% of premenopausal women, but that it has little effect on urodynamic parameters. Vaginal cones provided no additional benefit but may be useful for women for whom closely supervised pelvic floor exercise is not available.Editorial Comment: It is becoming increasingly clear from the literature that pelvic floor muscle exercises are effective in improving continence in many women with straightforward stress incontinence. An appropriate quest continues to determine how the exercises can best be taught and done. This article demonstrates that with frequent supervision, similar continence status is achieved both with and without the use of vaginal cones. It would be interesting to compare outcomes with and without cones in women who saw a health care provider only once for their initial teaching. If cones were found to be more effective in this setting, that would be a great aid to primary care physicians.The authors state that there was no correlation between the cone weight and the degree of improvement of symptoms: however, only 2 of the subjects progressed to the next heaviest cone weight. My understanding of the principles of athletic muscles training is that as one increases the resistance the muscle fibers hypertrophy and strengthen. This is the principle behind building biceps. Body-builders or power-lifters continue to increase the amount of weight (resistance) they lift in order to increase bulk and strength. I wonder if this same principle is the reason for the differences in results between this study and the one by Peattie et al. quoted by the authors. My major concern is that people begin to devalue the amount of effort required to perform effective pelvic floor exercises and make assumptions that such exercises are not as good as a permanent surgical cure. I believe that we have not yet begun to develop really effective muscle strengthening regimens for the pelvic floor, and attitudes such as the above will only serve to inhibit our progress.     

Laparoscopic Surgery for Genuine Stress Incontinence

Laparoscopic Burch colposuspension has rapidly become one of the primary surgical treatment options for genuine stress incontinence. The procedure has been modified by some investigators because of technical difficulty with laparoscopic suturing, but should be identical to the conventional open Burch procedure. This article reviews the indications, operative technique, clinical results, complications and learning curve for laparoscopic retropubic surgical procedures.     

Anatomy and physiology of the male urethral sphincter and its preservation in prostatic surgery

Radical prostatectomy is commonly used in the management of localized prostate cancer. Urinary incontinence after prostatectomy is of great concern to many patients. Improved understanding of the anatomy of the external urethral sphincter complex has resulted in a statistically significant decrease in the incidence of postprostatectomy incontinence. Most recent anatomic studies have described the external urethral sphincter complex as consisting of an intrinsic rhabdosphincter surrounding the smooth musculature of the urethra and an extrinsic sphincter incorporating the levator ani muscle and the pelvic floor. Both form a condensed striated muscle ring around the membranous urethra. Preservation of as much as possible of the normal anatomy of the sphincter mechanism and its nerve supply results in an excellent return to continence after radical prostatectomy. Received: 26 February 1999 / Accepted: 20 May 1999     

Fecal incontinence successfully managed by antegrade continence enema in children: A report of two cases

Two children with intractable fecal incontinence after correction of high anorectal malformations were successfully managed by the daily administration of a glycerin enema into the cecum via an appendicocecostomy or tubularized cecostomy, according to the method of Malone's antegrade continence enema (ACE). Fluoroscopic defecography performed during this procedure in each patient disclosed that the glycerin enema promptly evoked cecal peristalsis, which was transmitted to the distal colon and rectum, and squeezed out almost all the fecal matter, evacuating it from the anus. However, two enemas within a short interval were required to achieve a complete washout of feces. Although this report describes only two patients, our experience confirmed that the ACE was very effective and that adding the word continence to antegrade enema was justifiable. Moreover, fluoroscopic defecography was proven to play a significant role in determining the appropriate regimens of this technique to achieve complete washout of the feces.     

Retropublic colpourethropexy with transabdominal anterior and/or posterior repair for the treatment of genuine stress urinary incontinence and genital prolapse

A new operative technique combining retropublic colpourethropexy with transabdominal internal anterior and/or internal posterior repair for the treatment of genuine stress incontinence (GSI) and genital prolapse is described in 75 cases. The overall success rate in correcting GSI was 92.0%, with a 94.8% success rate in the primary surgical group (n=58) and an 82.4% in the secondary group (n=17). Average follow-up has been 1.31 years (range 6 weeks–6 years). There was a 3.4% incidence of residual prolapse. Nine patients also underwent concomitant colpourethropexy. Overall surgical complications include febrile morbidity 4/75 (5.3%), wound infection 1/75 (1.3%), deep vein thrombosis 1/75 (1.3%) and partial ureteric obstruction 1/75 (1.3%). There were no statistically significant changes in multichannel urodynamic studies preoperatively and at 1 year following surgery. Onethird (2/6) of the GSI failures had low MUCP (<20 cm H₂O) prior to surgery and continued so at 1 year follow-up.EDITORIAL COMMENT: Genital prolapse is often present in patients who have GSI. If an operation is performed to correct the GSI, and those areas of weakness in the pelvic support system that are contributing to the genital prolapse are not treated, the genital prolapse will become more severe. In the operation which has been described, the colpopexy sutures will correct any cystourethrocele, and the removal of the wedge of tissue from the anterior superior vaginal wall will correct the cystocele. The removal of the wedge of tissue from the posterior superior vaginal wall will reduce the redundancy of the posterior vaginal fornix, but a culdeplasty of the Moschcowitz or Halban type is recommended to treat or prevent an enterocele and to place the vaginal apex in the hollow of the sacrum. Any coexistent rectocele must always be treated vaginally. If it is not treated, it will appear to be more advanced following elevation of the anterior vaginal wall by retropubic urethropexy and the anterior repair which has been recommended.Genital prolapse is best treated by a vaginal approach. When one must une an abdominal approach, ancillary procedures such as the authors have described should be considered. A bulbous upper vagina is ideal for childbearing but if the apical support system and vaginal wall is weakened it is predisposed to prolapse. If the surgeon, in operating for genital prolapse, which involves the upper vagina, will taper the vaginal apex and support it by obliteration of the cul-desac and shortening and reattachment of the uterosacralcardinal complex, postoperative prolapse will be less likely to recur.