Size of urogenital hiatus as a potential risk factor for emptying disorders after pelvic prolapse repair.

PURPOSE: We correlated urogenital hiatus size and levator ani contraction strength with early postoperative emptying disorders. We also determined whether postoperative emptying disorders could be predicted before anti-incontinence procedures and pelvic organ prolapse repair. MATERIALS AND METHODS: We retrospectively reviewed the charts of 225 consecutive patients after surgery for pelvic organ prolapse and/or stress urinary incontinence. Urogenital hiatus size was evaluated using pelvic organ prolapse quantification. Levator contraction strength was determined by the Oxford 0 to 5 classification scale. Emptying disorders were defined as post-void residual urine volume greater than 100 ml 48 hours postoperatively and/or discharge home with a Foley catheter or on intermittent self-catheterization. RESULTS: Median patient age, post-void residual urine volume and urogenital hiatus size were significantly related to levator contraction strength (each p <0.05). Univariate logistic regression analysis revealed a significant association of urogenital hiatus size (p = 0.001), post-void residual urine volume (p = 0.005) and levator contraction strength (p = 0.001) with emptying disorder status. Multivariate logistic regression analysis showed that levator contraction strength (p = 0.001) and post-void residual urine (p = 0.01) were independent predictors of emptying disorders. CONCLUSIONS: A wide urogenital hiatus, decreased levator ani contraction strength, increasing age and increased post-void residual urine correlated with an increased chance of early postoperative emptying disorders. The most independent predictors of early emptying disorders were decreased levator contraction strength and increased post-void residual urine.

Colpocleisis for advanced pelvic organ prolapse.

OBJECTIVE: To characterize our experience with colpocleisis in a urologic setting because it has not been documented broadly in the urologic literature. METHODS: Retrospective review of demographics, urodynamics, presenting symptoms, complications, and outcomes for patients undergoing colpocleisis from 2001-2010 was performed. A questionnaire including the short forms of the Urinary Distress Inventory and Pelvic Organ Prolapse Distress Inventory (POPDI-6), and the Patient Global Impression of Improvement was sent to consenting patients. RESULTS: Fifty-three patients were identified. Examinations were all POP-Q stage 3 or greater or Baden Walker grade 3 or higher; 73.6% underwent total colpocleisis and 26.4% Le Fort; 60.4% underwent concomitant sling. Complications included 1 patient requiring transfusion, 1 with pulmonary embolus, 1 needing clot evacuation, and 1 requiring intraoperative cystotomy repair. There was no postoperative de novo urgency, no recurrence of prolapse, and no chronic urinary retention. In patients not undergoing urethral sling, stress urinary incontinence persisted in 4 patients and occurred de novo in 1. Mean follow-up was 9.3 months. Twenty-two surveys were returned: 90.9% described their condition as much or very much better on Patient Global Impression of Improvement. The average POPDI-6 score was 9.1. Frequency and urgency were the most common complaints leading to bother on the UDI-6 (33.3%). Most of these responders had a preoperative urge component. CONCLUSION: In a selected patient population, colpocleisis is safe and efficacious. Persistent lower urinary tract symptoms comprise the highest frequency of complaints after colpocleisis, and this must be included in patient counseling. In an aging patient population with expected increase in demand for pelvic floor reconstruction, colpocleisis is a useful approach for the urologist.

Hypertrophic cervical elongation: clinical and histological correlations.

INTRODUCTION AND HYPOTHESIS: The objective of this study is to define the diagnosis of hypertrophic cervical elongation clinically and to perform histochemical and histological evaluations of patients with and without hypertrophic cervical elongation. METHODS: This prospective study was conducted at Louisiana State University between December 2005 and May 2008. Fourteen women with cervical elongation and 28 women without prolapse were studied. RESULTS: The amounts of elastin, collagen, and smooth muscle did not differ between study and control groups. Estrogen and progesterone receptor content in cervical elongation were elevated compared to the cervix of women without prolapse. Hypertrophic cervical elongation was defined as the difference between point C and point D of the Pelvic Organ Prolapse Quantification system greater than 8 cm. CONCLUSIONS: Estrogen and progesterone receptor levels are greater in women with hypertrophic cervical elongation compared with a normal cervix.

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.

Anatomic relationships of the "top-down" mid-urethral sling.

OBJECTIVE: To determine the anatomic relationships between the "top-down" mid-urethral sling (MUS) and pelvic structures. STUDY DESIGN: Placement of the sling needle delivery device was performed in 10 cadaveric hemi-pelves. The distances between major structures in the pelvis and the needle delivery device were recorded. RESULTS: The mean distances are as follows: mid pubis 1.71 (+/- 0.25) cm, bladder neck 1.66 (+/- 0.37) cm, urethral orifice 3.96 (+/- 0.52) cm, obturator foramen 3.90 (+/- 0.43) cm, inferior epigastric vessels 3.50 (+/- 0.62) cm, accessory obturator vessels 3.53 (+/- 0.36) cm and external iliac vein 4.02 (+/- 0.42) cm. CONCLUSION: Major pelvic structures are in close proximity to the needle delivery device in a top-down mid-urethral sling.

Urinary tract injury during hysterectomy based on universal cystoscopy.

OBJECTIVE: To estimate the incidence and location of injury to the urinary tract during hysterectomy for benign gynecologic disease. METHODS: This was a prospective clinical study in an academic environment performed at three sites. Diagnostic cystourethroscopy was performed on all patients after hysterectomy for benign disease. RESULTS: Eight hundred thirty-nine patients were enrolled. The incidence of urinary tract injury associated with hysterectomy for benign disease was 4.3% (39 of 839 cases). The rate of bladder injury was 2.9% (24 of 839 cases), and rate of ureteral injury was 1.8% (15 of 839 cases). There were three cases of simultaneous bladder and ureteral injuries, resulting in a cumulative injury rate of 4.3%. The injury detection rate using intraoperative diagnostic cystoscopy was 97.4% (817 of 839 cases). The most common site of injury to the ureter was at the junction of the ureter and the uterine artery in 80% (12 of 15 cases) of ureteral injuries. Transection and kinking injuries were the most frequent type of injury. There were 21 cases of subnormal dye efflux from the ureteral orifices, with no subsequent injury detected on further evaluation. CONCLUSION: Ureteral injury occurred most commonly at the level of the uterine artery, and transection and kinking injuries were most frequent. Diminished dye efflux from ureteral orifices was not associated with injury. LEVEL OF EVIDENCE: III.

The internal innervation and morphology of the human female levator ani muscle.

OBJECTIVE: The purpose of this study was to describe the microinnervation of the human the female levator ani muscle complex. STUDY DESIGN: Detailed microdissection of 10 fresh female levator ani muscles was performed. Specimens were processed by modified Sihler's staining technique. A composite drawing of the levator ani nerve (LAN) distribution was created. RESULTS: Six hemi-levator ani muscles were stained and digitally reconstructed. The LAN traveled perpendicular to major muscular bundles while progressively branching into finer nerves that eventually entered single muscle fascicles. The LAN continued its course through the iliococcygeous muscle to innervate the puborectalis, puboperinealis, and puboanalis muscles. There was no distinct separation between pubovisceralis and iliococcygeous fibers. There were muscle fibers that could be best described as coccygeoperinealis. CONCLUSION: The utilized staining technique enabled us to visualize the LAN microinnervation of the levator ani muscle that extends to puboperinealis and puboanalis muscles. A blueprint for LAN and levator ani morphology was created.

Outcomes of vaginal reconstructive surgery with and without graft material.

OBJECTIVE: This study was undertaken to evaluate the outcomes of vaginal surgery for pelvic organ prolapse, comparing cases implementing graft augmentation to those without graft augmentation. STUDY DESIGN: This was a retrospective cohort study of 312 patients who underwent vaginal surgery for prolapse from February 1998 to January 2004. RESULTS: Of the 312 patients, 98 (31.4%) had graft augmentation. The median follow-up was 9 months (3-67 months). Graft use was not associated with reduction in recurrent prolapse, recurrent stage 3 prolapse, recurrent incontinence, or additional surgery for prolapse. After controlling for confounders, there was still no difference in surgical outcomes. Complications such as vaginal/graft infection (18.4% vs 4.7%; P < .001) and granulation tissue (38.8% vs 17.3%; P < .001) were more common after cases in which graft was used. CONCLUSION: In the early postoperative period, there was no benefit in using graft for prolapse repair. Graft use leads to a higher rate of postoperative complications.

The incidence of urinary tract injury during hysterectomy: a prospective analysis based on universal cystoscopy.

OBJECTIVE: To evaluate the incidence of urinary tract injury due to hysterectomy for benign disease. STUDY DESIGN: Patients were enrolled prospectively from 3 sites. All patients undergoing abdominal, vaginal, or laparoscopic hysterectomy for benign disease underwent diagnostic cystourethroscopy. RESULTS: Four hundred seventy-one patients participated. Ninety-six percent (24/25) of urinary tract injuries were detected intraoperatively. There were 8 cases of ureteral injury (1.7%) and 17 cases of bladder injury (3.6%). Ureteral injury was associated with concurrent prolapse surgery (7.3% vs 1.2%; P = .025). Bladder injury was associated with concurrent anti-incontinence procedures (12.5% vs 3.1%; P = .049). Abdominal hysterectomy was associated with a higher incidence of ureteral injury (2.2% vs 1.2%) but this was not significant. Only 12.5% of ureteral injuries and 35.3% of bladder injuries were detected before cystoscopy. CONCLUSION: The incidence of urinary tract injury during hysterectomy is 4.8%. Surgery for prolapse or incontinence increases the risk. Routine use of cystoscopy during hysterectomy should be considered.

Levator contraction strength and genital hiatus as risk factors for recurrent pelvic organ prolapse.

OBJECTIVE: To correlate levator ani contraction strength and genital hiatus measurements with surgical failure in prolapse. STUDY DESIGN: This retrospective study involved chart review for documentation of levator contraction strength, genital hiatus measurement, and recurrent pelvic floor disorders in women who underwent surgery for prolapse. RESULTS: The recurrent prolapse rate was 34.6%. Median follow-up interval was 5 months. Diminished levator strength was associated with recurrent prolapse (35.8% versus 0%; P = .017). A genital hiatus 5 cm or greater was associated with recurrent prolapse (44.2% vs 27.8%; P = .034). Inability to contract the levator ani was associated with urinary incontinence (35.1% vs 18.8%; P = .023). Increasing levator contraction strength was associated with a decreased reoperation rate for pelvic floor disorders, whereas genital hiatus correlated best with recurrent prolapse. CONCLUSION: Diminished levator ani contraction strength and a widened genital hiatus correlate with an increase in surgical failures in the early postoperative period. These tools are useful for counseling a patient concerning surgery for prolapse.

The anatomy of midurethral slings and dynamics of neurovascular injury.

The aim of this study was to investigate the course of midurethral slings using tension-free vaginal tape. The TVT procedure was performed on six fresh pelves, measurements were obtained, and the structures were cross-referenced in 16 embalmed pelves. The midurethral sling enters the suburethral tissue 2.2-3 cm caudad to the internal urethral meatus, pierces the paraurethral musculature and vascular plexus, and exits 2+/-0.5 cm from the midline lateral to the point of insertion of the arcus tendineus fasciae pelvis. On the pubic tubercle the sling is 4+/-0.5 cm, 4+/-1 cm and 6+/-1 cm from the accessory obturator, the inferior epigastric and the external iliac vessels, respectively. The critical angle of error resulting in the external iliac vessel injury is 7-15 degrees. A current knowledge of pelvic anatomy may help the surgeon avoid the neural and vascular structures that are in the path of the sling.

Recognition of occult bladder injury during the tension-free vaginal tape procedure.

OBJECTIVE: To identify signs and the etiology of occult bladder injury during the tension-free vaginal tape sling procedure. METHOD: The charts of 140 women who underwent a tension-free vaginal tape procedure were reviewed, and complications were tabulated and analyzed. The tension-free vaginal tape procedure was performed in six fresh-frozen pelves to demonstrate the mechanism of the occult bladder injury. RESULTS: Occult bladder injury was suspected when cystoscopy instillation fluid flowed from the plastic sheath that covers the prolene tape after the extraction of the tension-free vaginal tape trocar. Three of six cases of intraoperative bladder injury had occult bladder injury identified on repeat cystoscopic inspection. The bladder injury caused by the rough edge at the point of attachment of the tension-free vaginal tape to the trocar was reproducible in three of 12 tension-free vaginal tape applications in fresh-frozen pelves. Traction on the tension-free vaginal tape reapproximates the injured bladder edges and potentially promotes spontaneous healing. CONCLUSION: Bladder injuries may go unrecognized during a tension-free vaginal tape procedure. Continuous seepage of water through the prolene plastic sleeve is suggestive of occult bladder injury and requires repeat cystoscopy to identify the potential site of injury.