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.

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.

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.

Urinary tract fistulas following abdominal hysterectomy.

Sixteen patients with urinary tract fistulas (14 vesicovaginal and two ureterovaginal) following simple abdominal hysterectomy were treated over a period of 17 years. Most vesicovaginal fistulas were treated by a transvesical technique, which proved to be a comfortable and successful method in our hands. Closure of the fistula followed usually more than four weeks after diagnosis. Earlier repair, which has been forwarded as an alternative therapy, might give equally good results and would save the patient from the severe hygienic problem of continuous urinary leakage. Conservative treatment with an indwelling urinary catheter led to spontaneous closure of the fistula in one patient. Two ureterovaginal fistulas were corrected by an anti-reflux ureteroneocystostomy.

Perineal ultrasound: an alternative for radiography for evaluating stress urinary incontinence in females.

Perineal sonography was used to assess the position and descent of the bladder neck at rest and during straining in 38 female patients with stress urinary incontinence. Twenty nine patients had primary and nine patients recurrent stress incontinence. There was a statistically significant positive correlation between the degree of sonographically determined bladder neck descent and the severity of stress incontinence by urodynamic criteria among the patients with primary but not with recurrent stress incontinence.

Complications of Teflon injection for stress urinary incontinence.

Four significant complications of Teflon injections for stress urinary incontinence are reported in 22 women and eight men. Three of the complications included periurethral abscess, urethral diverticulum, and periurethral Teflon granuloma with urethral wall prolapse occurred in women. These complications needed surgical excision and further surgery for stress incontinence, in two patients the outcome was good. Among the female patients the cure rate for stress incontinence with Teflon injection was only 18% in the 5-year follow-up. One other complication, a Teflon cyst, occurred in a male who had previously undergone radical retropubic prostatectomy. Only two of the eight men (25%) who received Teflon injections had maintained improvement after 1 year.