Use of endoscopy in the management of postoperative ureterovaginal fistula

The aim of the study was to evaluate endourological techniques in the management of iatrogenic ureterovaginal fistula. Seventeen patients referred to us after gynecologic surgery were diagnosed as having iatrogenic ureterovaginal fistula. First, retrograde double-J stenting was tried. If this failed, percutaneous nephrostomy using an antegrade double-J stent was performed. If this also failed, open surgical repair was performed. The retrograde double-J stent bypassed the fistula in 2 patients (11.8%). Percutaneous nephrostomy was performed in the remaining 15. The antegrade double-J stent bypassed the fistula in another 2 of these patients (11.8%). Open surgical repair was performed in the remaining 13 patients (67.5%) (direct ureteroneocystostomy) with nipple valve in 11 patients and Boari flap with psoas hitch in 2 patients). Of all patients, 2 had ureteral stricture, one after antegrade double-J stenting and the other after open repair. It was concluded that early intervention is recommended in the treatment of iatrogenic uretrovaginal fistula, causing minimal morbidity and discomfort, and being less expensive. EDITORIAL COMMENT: This is an interesting paper that is worthy of mention because of an important concept in the management of an iatrogenic ureterovaginal fistula. The traditional management of these fistulas has been ureteroneocystostomy [1]. However, recent urologic literature suggests that modern endoscopic treatment is highly successful if the passage of an internal stent is possible [2,3]. This is a concept that must be shared with our urogynecologic colleagues. In this paper, 4 of 14 patients with an iatrogenic fistula underwent placement of an indwelling stent. Of these, two were placed cystoscopically, whereas the other two were placed percutaneously. All four ureterovaginal fistulas healed successfully. However, 1 patient developed a ureteral stricture. It is noteworthy that in the combined series of Selzman [2] and this Tulane group not only were all ureterovaginal fistulas successfully treated with a stent, but only 1 of 11 patients (9%) developed a stricture. Although the sample size is small, this paper supports the conclusion that successful endoscopic placement of a double-J stent does allow the ureterovaginal fistula to heal spontaneously. Therefore, initial endoscopic management of an iatrogenic ureterovaginal fistula is a reasonable recommendation. However, equally important is the development of a ureteral stricture causing ‘silent hydronephrosis’. After stent removal the patient may develop a distal ureteral stricture with a completely asymptomatic hydronephrosis — ‘silent hydronephrosis’. Although the patient may be clinically asymptomatic, the renal units remain in jeopardy. Therefore, routine periodic follow-up with radiologic studies is warranted after stent removal.     

Long-Term Outcomes of Augmentation Enterocystoplasty with a Catheterizable Channel in the Adult Neurogenic Population

Augmentation enterocystoplasty with a continent catheterizable stoma is a common approach to refractory neuropathic bladder, incontinence and end-stage bladder disease that aims to provide a large capacity, low-pressure reservoir and continent stoma. The goal is to not only to prevent renal deterioration, but also provide the patient with an improved quality of life. Several recent studies, reviewed in this chapter, have assessed the long-term outcomes of these procedures, demonstrating durable improvement in bladder capacity, bladder compliance, continence and quality of life. The long-term complications of the surgery include stomal complications such as stenosis and prolapse, channel related complications leading to difficult catheterization, bladder stones, recurrent urinary tract infections, bladder rupture, metabolic derangement and in very rare cases, malignant transformation. Successful surgery and good outcomes depend on proper patient selection, surgeon and center experience with the procedure, and close follow-up.     

A randomized controlled trial of duloxetine alone, pelvic floor muscle training alone, combined treatment and no active treatment in women with stress urinary incontinence

PURPOSE: We primarily compared the effectiveness of combined pelvic floor muscle training (PFMT) and duloxetine with imitation PFMT and placebo for 12 weeks in women with stress urinary incontinence (SUI). In addition, we compared the effectiveness of combined treatment with single treatments, single treatments with each other and single treatments with no treatment. MATERIALS AND METHODS: This blinded, doubly controlled, randomized trial enrolled 201 women 18 to 75 years old with SUI at 17 incontinence centers in the Netherlands, United Kingdom and United States. Women averaged 2 or more incontinence episodes daily and were randomized to 1 of 4 combinations of 80 mg duloxetine daily, placebo, PFMT and imitation PFMT, including combined treatment (in 52), no active treatment (in 47), PFMT only (in 50) and duloxetine only (in 52). The primary efficacy measure was incontinence episode frequency. Other efficacy variables included the number of continence pads used and the Incontinence Quality of Life questionnaire score. RESULTS: The intent to treat population incontinence episode frequency analysis demonstrated the superiority of duloxetine with or without PFMT compared with no treatment or with PFMT alone. However, pad and Incontinence Quality of Life analyses suggested greater improvement with combined treatment than single treatment. A completer population analysis demonstrated the efficacy of duloxetine with or without PFMT and suggested combined treatment was more effective than either treatment alone. CONCLUSIONS: The data support significant efficacy of combined PFMT and duloxetine in the treatment of women with SUI. We hypothesize that complementary modes of action of duloxetine and PFMT may result in an additive effect of combined treatment.     

Nonautologous sling materials

This article provides a comprehensive and updated review of the current nonautologous sling materials available for treatment of stress urinary incontinence. The various materials are described, relevant clinical studies are discussed, and newer materials are outlined. Complications arising from use of different materials also are described.     

Genitourinary spheroidal membrane (GSM) for the treatment of female stress urinary incontinence

Fourteen female patients with stress urinary incontinence were implanted with the genitourinary spheroidal membrane (GSM) device (Bard), a percutaneous implantable spheroidal membrane for the treatment of urinary incontinence through localized tissue expansion. Most patients had undergone previous pelvic surgery and suffered from significant medical problems. The placement of the GSM was performed under local anesthesia, with the help of fluoroscopy, cystoscopy and digital examination. The GSM was inserted and inflated close to the posterior urethra, causing its coaptation. Mean patient follow-up is 33 months. Eight patients are now completely dry (57.1%) and 2 are significantly improved (14.3%), with a success rate of (71.4%). The remaining 4 patients (27.6%) are considered failures. Migration of the GSM into the bladder was noticed on three occasions. Two extrusions into the vaginal wall were encountered. GSM replacements were performed without ill effects. Preliminary findings suggest that the GSM prosthesis may be a simple and safe alternative for the treatment of female stress urinary incontinence. The device is still in the experimental stage and further studies in Europe have been started.     

Pelvic Floor Dysfunction Management Practice Patterns: A Survey of Members of the International Urogynecological Association

The authors report results of a survey of the practice patterns of International Urogynecological Association (IUGA) members in the management of urinary incontinence and pelvic organ prolapse. A questionnaire regarding current urogynecological clinical practice was developed by the Research and Development Committee of IUGA and mailed to all members of IUGA. Age, specialty, and geographic location factors were used for response comparisons. One hundred and fifty-two surveys (30%) were returned, 35% from North America, 51% from Europe/Australia/New Zealand, and 14% from elsewhere. The average age of respondents was 47.2 years (SD = 9.5), 89% were gynecologists and 11% were urologists. Overall, the procedures of choice for stress incontinence (SUI) were tension-free vaginal tape (TVT; 48.8%) and Burch colposuspension (44%). There were significant geographic variations noted. For SUI with low-pressure urethra/intrinsic sphincteric deficiency, TVT was used by 44.6% and suburethral sling by 32.3%. Various materials are used for suburethral slings, including autologous fascia (46.5%), Marlex mesh (27.8%) and cadaveric fascia lata (11.6%). Bulking agent injection therapy is used for ISD by 75% of respondents. Traditional reconstructive procedures are performed by the majority of respondents, including sacrospinous fixation (78%), abdominal sacrocolpopexy (77%), paravaginal repair (65%) and vaginal enterocele repair (93%); 6.5% use defecography in evaluating rectoceles and 44% use the POP-Q. Seventy-two per cent use urodynamic evaluation routinely in prolapse cases with no manifest SUI. Most IUGA members perform commonly accepted procedures for surgical therapy of urinary incontinence and genital prolapse. IUGA members do not frequently use anorectal physiology and fluoroscopic investigations to evaluate rectoceles prior to repair.     

Management of Mesh-Related Pelvic Inflammation

Purpose of Review

To review mesh used for transvaginal surgeries, specifically slings and prolapse repairs, as well as offer a review of management after mesh-induced inflammation occurs.

Recent Findings

There have been changes to FDA notifications regarding vaginal mesh, with continued high-profile press. The inflammatory changes and possible complications vary with different mesh characteristics. Risk for complications due to transvaginal mesh placed for prolapse is higher than that when placed for the treatment of stress urinary incontinence.

Summary

Transvaginal mesh aids in the effective treatment of female stress incontinence and pelvic organ prolapse but holds the possibility for complications. Placement of transvaginal mesh should continue in the hands of specially trained surgeons, who are knowledgeable regarding management of complications.

     

Persistence of injectable collagen in human urethra: Case report

A polypoid lesion was found near the bladder neck during cystoscopy in a woman with urinary incontinence who had undergone periurethral collagen (Contigen) injections 3 years before. She had previously received radiation therapy in addition to a radical vulvectomy for vaginal cancer. On transurethral resection of the lesion, particles of unresorbed collagen material extruded from the capsulated suburothelial space. Histologic evaluation verified the material as the foreign collagen. The persistence of glutaraldehyde cross-linked collagen in our patient was much longer than previously reported and may have been due to effects of previous radiation treatment.