A nationwide analysis of transvaginal tape release for urinary retention after tension-free vaginal tape procedure.

The role of transvaginal release procedure (TRP) for the treatment of urinary retention after TVT operation in Finland by the end of the year 2002 was evaluated. Questionnaires regarding the TVTs and the TRPs were sent to 56 hospitals. A retrospective review of the records of 48 women undergoing the TRP was available for analysis. TVT was performed on 9040 patients under local (94%), spinal (4%) or general (2%) anesthesia. TRP was made under local (48%), light (48%) or spinal (4%) anesthesia. The number of TRPs was 50/9040 (0.6%) in the whole country. Forty-nine percent of the patients were completely cured of their retention and remained continent after TRP by subjective report and by stress test. The retention following a TVT did not resolve in four patients (12%) who underwent TRP. This nationwide analysis proved that half of the patients remained continent after TRP, which is in our opinion an important information for all proceduralists.

The Rosti sling: a new, minimally invasive, tension-free technique for the surgical treatment of female urinary incontinence-the first 217 patients.

PURPOSE: We evaluated the outcome of a new, innovative, inexpensive tension-free technique, the Rosti sling (RS), for female urinary incontinence. MATERIALS AND METHODS: RS was performed in 217 patients under local (45%), spinal (52%) or general (3%) anesthesia. A 1.5 x 33 cm strip of polypropylene mesh was inserted under the mid urethra from above through small suprapubic stabs down and out through a 1.5 cm midline vaginal incision using the Stamey needle. Of the women 76% had stress urinary incontinence and 24% had mixed incontinence. Patient age was 24 to 90 years (mean 56) and parity was 0 to 6 (mean 2). The diagnosis of incontinence was based on history and physical examinations with a cough stress test. Mean followup was 23 months. RESULTS: Mean operative time was 25 minutes (range 15 to 45) and mean hospital stay was 3 days (range 1 to 12). Perioperative complications were bladder and urethral perforations in 2 and 1 cases, respectively (1.4%), and hematoma in 3 (1.4%). There was postoperative retention with a variable duration in 49 patients (23%), of whom 41 underwent Hegar dilation. Altogether 186 of 215 patients (86.5%) were cured of incontinence. Two patients were lost to followup and 14 (16.3%) had de novo urge incontinence. The cure rates were 87% for stress urinary incontinence and 91% for mixed incontinence. The cure rate in patients treated under local and spinal anesthesia were 82% and 91%, respectively (p = 0.1084). The rates for RS with recurrent vs primary incontinence were 84% vs 87% (p = 0.5800) and for RS with vs without Hegar dilation 80% vs 88% (p = 0.2094). CONCLUSIONS: The technique described is simple, safe and inexpensive. The cure rates are comparable to those of tension-free vaginal tape. However, because of the relatively high rate of postoperative voiding difficulties compared to tension-free vaginal tape, this technique can be criticized. To avoid these problems special attention should be focused on applying the mesh without tension and with precision.

Urogynecologic ultrasound is a useful aid in the assessment of female stress urinary incontinence--a prospective study with TVT procedure.

The aims of the study were to study the suitability of certain urogynecologic ultrasound parameters, e.g. descent of the urethrovesical (UV) junction on Valsalva, posterior urethrovesical (PUV) angle both at rest and on Valsalva, and funneling of the vesical neck, in the pre- and postoperative assessment of stress urinary incontinence (SUI) and to evaluate the efficacy and safety of tension-free vaginal tape (TVT) for the surgical treatment of SUI. Forty-six consecutive women (mean age 61 years) with symptoms of SUI underwent TVT placement. The patients were examined prior to and on average of 11 weeks after the operation with perineal ultrasound. An upright coughing test on standing was performed every time. Operative success rate was 94% in this series. Urogynecologic perineal ultrasound examination seemed strongly to support an anamnestic diagnosis of genuine SUI, and TVT proved to be a safe and effective ambulatory procedure for the surgical treatment of SUI.

Outcome of Burch retropubic urethropexy and the effect of concomitant abdominal hysterectomy: a prospective long-term follow-up study.

A prospective follow-up study was performed to evaluate the effect of a concomitant abdominal hysterectomy with Burch colposuspension. Sixty-five women underwent Burch colposuspension (the Burch group) and 78 women colposuspension with concomitant abdominal hysterectomy (the hysterectomy group) during a 1-year period in Turku University Hospital. Subjective outcome was assessed with three questionnaires: at 6 weeks, 1 year, and a mean of 4.9 years after the operation. Complications related to the operation occurred in 19 patients (29.2%) in the Burch group and in 36 (46.2%) in the hysterectomy group (P = 0.038). No statistically significant difference in the frequency of any subgroup of complications was found. Instead, complications cumulated to fewer patients in the Burch group. During postoperative care in the hospital intermittent catheterization to treat transient urinary retention was needed more frequently in the Burch group than in the hysterectomy group (10.8% vs. 1.3%, P = 0.046). No significant difference was found in subjective short- and long-term outcome. In the long-term follow-up 79% were subjectively cured or improved, 77% in the Burch group and 81% in the hysterectomy group.

Lower urinary tract symptoms in patients with Sjögren's syndrome and systemic lupus erythematosus.

Sjögren's syndrome (SS) and systemic lupus erythematosus (SLE) are autoimmune diseases which have many similarities with interstitial cystitis (IC), a urinary bladder disease with unknown etiology. This survey on the occurrence, severity and nature of lower urinary tract symptoms among patients suffering from SS or SLE showed that these patients have significantly more urinary complaints, especially irritative bladder symptoms, than age- and sex-matched controls. We studied 36 patients with SS, 85 patients with SLE and 121 controls. In these groups, 25%, 29% and 66%, respectively, were free of urinary symptoms. The prevalences of mild symptoms were 61%, 62% and 27%, and severe symptoms 14%, 9% and 7% in the respective groups. SS and SLE patients with urinary complaints reported mostly urinary frequency (27% and 62%) and suprapubic pain (36% and 34%). The most common symptom in the control group was stress urinary incontinence. The frequency of lower urinary tract problems in patients with SS and SLE supports the concept that autoimmune disorders also have bladder affections.

Urinary bacterial flora of women with urethral syndrome and interstitial cystitis.

The aerobic and anaerobic bacterial flora in the first voided and in the midstream urine of healthy females (n = 5) and female patients with either urethral syndrome (US) (n = 5) or interstitial cystitis (IC) (n = 14) were studied. Bacteria were grown on media enabling isolation of fastidious and aerobic as well as obligatory anaerobic species. In healthy females only gram-positive rods were found whereas US patients also harbored streptococci. Patients with IC presented also with Enterobacteriae and anaerobic bacteria. Five IC patients with severe symptoms were treated with metronidazole; 2 out of 3 patients with anaerobic bacteria in the pretreatment specimens had no anaerobes after metronidazole therapy and in 1 patient streptococci disappeared after the therapy. One patient with severe symptoms and Bacteroides fragilis in the midstream urine became symptom-free after 2 weeks of metronidazole treatment. Although there is uncertainty whether the US and IC are not related to an infectious etiology, the bacterial flora in urethral and in midstream urine in these conditions differs considerably from that of healthy females.

Percutaneous sclerotherapy for varicocele embolization.

Varicocele is a common cause of male infertility and can be treated surgically or by angiographic occlusion of the internal spermatic (testicular) vein. The treatment of clinical as well as subclinical varicoceles has been reported to improve sperm parameters. Varicocele also can cause scrotal pain and discomfort. We treated 89 patients using percutaneous sclerotherapy on an outpatient basis. Our technique proved to be simple and effective and was associated with low morbidity. At follow-up only three failures occurred.

Comparison of a 10-mg controlled release oxybutynin tablet with a 5-mg oxybutynin tablet in urge incontinent patients.

Oxybutynin has long been used for the treatment of patients with detrusor overactivity and urinary urge incontinence. The short half-life of oxybutynin administered as a conventional tablet formulation or syrup requires 2-3 times daily dosage to be effective. A new controlled release (CR) tablet for once-daily administration has been developed. The efficacy and tolerability of this new controlled release tablet was compared to that of a 5-mg conventional oxybutynin tablet administered twice daily. Seventeen female incontinent patients were studied in a double-dummy crossover trial. Efficacy and tolerability were assessed by using a voiding diary, pad-weighing test, visual-analogue scale (VAS), and questionnaire. Adverse events were recorded spontaneously on a questionnaire by the patients themselves throughout the study. Serum concentrations of oxybutynin and its active metabolite N-desethyloxybutynin were studied after both a single dose and multiple dosage. There was no difference in efficacy between the two formulations. Depending on the parameters tested, the change from baseline values in a positive direction ranged from 15 to 53%. The incidence of adverse events was similar with both formulations. Oxybutynin or its metabolite showed no cumulation during the multiple dosage with a 10-mg CR tablet. The controlled release tablet formulation is as effective and as well-tolerated as the conventional one, but has the advantage of only once-a-day dosage, enhancing treatment compliance.

Endoscopic colposuspension with simplified extraperitoneal approach.

The retropubic colposuspension (Burch procedure) has been proven an effective treatment for female genuine stress urinary incontinence. During this decade, laparoscopic approach has gained access in continence surgery also. Endoscopic colposuspension can be performed either extraperitoneally or transperitoneally. If there is no need for intra-abdominal procedures the extraperitoneal approach for colposuspension is feasible. Generally a balloon dissection is used to develop the extraperitoneal space, but here we present a modified technique where no balloon is needed. This modification is easy to perform, quicker and decreases the costs of the procedure compared to transperitoneal approach. We also summarize the results of our first 46 patients, 24 of which were operated extraperitoneally and 22 by transperitoneal approach with concomitant pelvic surgery.

Absence of bacterial DNA in the bladder of patients with interstitial cystitis.

PURPOSE: Although bacterial infection has been long considered a possible cause of interstitial cystitis (IC), no definitive proof for or against this hypothesis has been presented so far. We have used 16S rDNA bacterial polymerase chain reaction to study bladder biopsies and sterile urine samples from patients suffering from IC. This method is sensitive and detects all known eubacteria. MATERIALS AND METHODS: Bladder biopsies and sterile urine samples obtained by transabdominal puncture were studied from 11 patients with IC. As controls we studied 4 patients with other urological problems leading to partly similar symptoms and 5 healthy individuals. RESULTS: All samples from the IC patients were negative. One positive sample was obtained from a woman with a history of urinary tract infections who suffered from nonIC ulcerative cystitis. Her sterile urine sample yielded Lactobacillus acidophilus. CONCLUSION: These results indicate that an ongoing bacterial infection is not the cause of interstitial cystitis.

Viruses and interstitial cystitis: adenovirus genomes cannot be demonstrated in urinary bladder biopsies.

Microbes may be involved in the pathogenesis of interstitial cystitis (IC). Adenoviruses and BK virus (BKV) can infect epithelial cells in urinary bladder and they are causative agents for hemorrhagic cystitis. We therefore studied the presence of adenovirus and BKV genomes in urinary bladder tissue specimens of patients with IC using polymerase chain reaction (PCR) and in situ hybridization (ISH). Controls were specimens from cases with transitional cell carcinoma of the bladder. Nucleic acids were extracted from paraffin sections of the bladder tissue for PCR. Primers detecting all adenovirus types were used. In situ hybridization was carried out for the paraffin sections using digoxigenin-labeled DNA probes for adenovirus and BKV. The adenovirus DNA PCR was able to detect one to two infected cells/specimen. All the seven IC cases studied and six controls were negative for adenovirus DNA by PCR and ISH. The ISH test for BKV genomes was also considered negative in IC cases and controls. The specimens which were negative in PCR tests yielded a signal with beta-globin primers, thus being amplifiable. We conclude that adenovirus and BKV do not play a major pathogenetic role in interstitial cystitis.

Vaginal axis after abdominal, vaginal and laparoscopic hysterectomy: a preliminary study with perineal ultrasonography using contrast medium.

Fifteen consecutive women (mean age 44.5 years) without pelvic relaxation underwent total abdominal (5), vaginal (5) and laparoscopic (5) hysterectomy for benign disease. The vaginal axes of the patients were examined prior to and on average 7 weeks (range 3-10) after the operation with perineal ultrasonography enhanced with an ultrasound contrast medium (SHU454/Echovist-300). Transabdominal and vaginal hysterectomies were performed in the classic manner, i.e. the round as well as cardinal and sacrouterine ligaments were attached to the vaginal vault, followed by peritonealization. In laparoscopic hysterectomy the round, broad and outer parts of the uterosacral and the upper parts of the cardinal ligaments were desiccated by bipolar electrocoagulation and cut with laparoscopic scissors. The vagina was closed by interrupted sutures with no specific fixation of the round, cardinal or uterosacral ligaments. Preoperative ultrasound findings showed that in all women the vagina was an angulated organ. The mean preoperative angle between the upper and lower vaginal portions was 108 degrees, in both the supine and the standing positions. Postoperatively this angulated shape remained almost unchanged after vaginal (mean angle 117 degrees ) and laparoscopic hysterectomy (mean angle 130 degrees ), whereas after transabdominal hysterectomy the vaginal axis rotated anteriorly and became an almost straight tube (mean angle 158 degrees). We conclude that the vaginal axis, at least at an early stage after vaginal and laparoscopic hysterectomy remained in almost the same position as preoperatively, in contrast to that after abdominal hysterectomy. A tight attachment of the round ligaments to the vaginal vault in the abdominal approach could explain the outcome of transabdominal hysterectomy, and should be called into question.

Evisceration after enterocele repair: a rare complication of vaginal surgery.

Evisceration is a life-threatening surgical emergency which must be promptly treated. Evisceration following vaginal enterocele operation is so rare that no incidence rate can be established. A review of the literature revealed only 71 cases. The reported women were in general postmenopausal, with only 15% less than 50 years of age. In 18% of cases vaginal rupture occurred while straining at stool. Four patients are known to have died due to evisceration. Of the reported repair operations, 57% were performed transabdominably, 28% transvaginally, and 15% via a combined abdominovaginal route. The authors present 1 more case treated transvaginally, with a review of the literature.

Comparison of the gonadotropin-releasing hormone agonist goserelin acetate alone versus goserelin combined with estrogen-progestogen add-back therapy in the treatment of endometriosis.

OBJECTIVE: To investigate whether the addition of low-dose estrogen-P combination hormone replacement therapy (HRT) to GnRH agonist (GnRH-a) treatment for endometriosis reduces the pharmacologic side effects of such treatment without reducing efficacy and to determine the endocrinologic changes during treatment. DESIGN: Prospective, randomized, double-blind, placebo-controlled, comparative study of two drug regimens: 3.6 mg goserelin acetate in a 28-day SC depot formulation once monthly for 6 months plus either a combination of 2 mg 17 beta-E2 and 1 mg norethisterone acetate (NET) 1 mg or matching placebo tablets once daily for 6 months. SETTING: Multicenter study in three tertiary referral centers at university teaching hospitals and two central hospitals. PATIENTS: Women with laparoscopically confirmed symptomatic endometriosis were included in the study. RESULTS: Of the total of 109 patients screened, 93 were recruited and 88 patients were randomized to either the HRT or the placebo group. Four women were withdrawn because of various medical reasons, and 76 patients were followed-up for a total of 12 months. In terms of efficacy, there was no difference between the two drug regimens for objective or subjective response. There were significantly less postmenopausal symptoms in the patients treated with goserelin plus HRT compared with those treated with goserelin plus placebo. CONCLUSION: Goserelin diminished significantly the symptoms and laparoscopic scores of endometriosis. The addition of HRT did not reduce the efficacy of goserelin but diminished the postmenopausal symptoms during treatment.

p53 protein detected by immunohistochemistry as a prognostic factor in patients with epithelial ovarian carcinoma.

BACKGROUND: The clinical significance of p53 suppressor gene nucleoprotein immunostaining in ovarian epithelial cancer has not been determined. METHODS: p53 protein expression was studied by immunohistochemistry from paraffin embedded tissue in a series of 136 patients with malignant ovarian epithelial tumors. The median follow-up time of the patients still alive was 10 years. RESULTS: Sixty (44%) carcinomas stained clearly positive for p53 protein. Positive staining for p53 protein was associated with the serous histologic type (P = 0.0006), a higher than the median S-phase fraction size determined by DNA flow cytometry (P = 0.02), and poor histologic grade of differentiation (P = 0.04), but not with the International Federation of Gynecology and Obstetrics (FIGO) stage, age at diagnosis, or DNA ploidy. Cancers with positive staining had only 17% 5-year and 9% 15-year survival rates compared with 42% 5-year and 36% 15-year survival rates corrected for intercurrent deaths among the rest of patients (P = 0.002). In a multivariate analysis, positive p53 staining was associated with poor survival (relative risk of death, 1.8, 95% confidence interval [CI], 1.2-2.9) together with less than radical surgery (nonradical vs. radical: RR, 5.5; 95% CI, 2.2-13.6), and advanced FIGO stage (RR, 1.4; 95% CI, 1.0-2.0). CONCLUSION: Although p53 protein immunostaining is associated with several other prognostic factors in epithelial ovarian cancer, it may also have independent prognostic value in this disease.

Sutureless endoscopic colposuspension with fibrin sealant.

Endoscopic colposuspension by using fibrin sealant as a substitute for sutures was performed in 17 women suffering from urodynamically verified type I-II stress urinary incontinence. Two-puncture technique was used with a 10-mm trocar for optics and a 5-mm trocar for instrumentation. The two-component fibrin sealant, Tisseel (1 ml) by using special applicator device, Duploject was applied with tube on both sides of the urethrovesical area. After that the urethrovesical junction was pressed for 5 min against the retropubic periost by the surgeon's index and middle fingers placed in the vagina. The average duration of the procedure was 20 min, excluding learning curve for the first two cases. The indwelling catheter and vaginal packing were removed and all patients discharged on the first postoperative day. All but two patients experienced excellent immediate response. Of the 12 patients followed > 6 months, 10 patients were completely dry and two were markedly improved. In our experience, laparoscopic colposuspension with fibrin sealant appears to be a promising new approach in correcting stress incontinence in women.

Immunohistochemical detection of p53 protein in borderline and malignant serous ovarian tumors.

The p53 suppressor gene protein expression was studied with immunoperoxidase staining in 61 serous tumors of the ovary. Twenty four (53%) of the 45 histologically malignant tumors were positive for p53, whereas neither the six benign nor the 10 tumors of borderline malignancy showed positive staining, except for one borderline tumor with atypia and increased mitotic activity. Therefore, p53 immunostaining may have diagnostic value in discriminating between borderline and malignant serous ovarian tumors. Malignant ovarian tumors with negative staining for p53 were associated with a 67% 3-year crude survival rate as compared with only an 18% 3-year survival rate if p53 staining was positive (p = 0.002). In a multivariate analysis, the p53 staining was the most important prognostic factor, with a relative risk of 4.2 (95% confidence interval, 1.8-9.9) followed by the FIGO stage (2.1, 1.3-3.5). We conclude that immunohistochemical p53 suppressor gene protein expression analysis has both diagnostic and prognostic value.

Functional urethral closure with pubovaginal sling for destroyed female urethra after long-term urethral catheterization.

OBJECTIVE: To assess the pubovaginal sling as therapy for correction of the destroyed female urethra secondary to long-term indwelling Foley catheter management of neurogenic vesical dysfunction. METHODS: Fourteen women with neurologic disease and a patulous and nonfunctioning urethra underwent pubovaginal sling functional urethral closure. The purpose of the procedure is to achieve a dry perineum. Greater tension is applied to the sling suspension for urethral closure than is normally used to ensure continence for patients exhibiting intrinsic sphincter dysfunction without neurogenic vesical dysfunction. RESULTS: Two patients with adequate bladder capacity and compliance underwent only a pubovaginal sling suspension. They were subsequently managed with intermittent catheterization. In 5 patients, a sling operation in conjunction with enterocystoplasty was accomplished. In 5 patients, a sling procedure with an ileocystostomy and a cutaneous urostomy (bladder chimney) was utilized. In 2 patients, suprapubic tube drainage was established at the time of pubovaginal sling placement. All patients have achieved continence, without the need for absorbent pads, with follow-up time of six to sixty months (mean, 24 months). Abdominal wall herniation has not developed in any patient. CONCLUSIONS: The pubovaginal sling cured incontinence and has resulted in a dry perineum with few problems. The sling procedure may be superior to transabdominal or transvaginal bladder neck closure without the risk of fistula formation.