Transabdominal approach to repair of vaginal vault prolapse.

PURPOSE: To review the preoperative evaluation of women with vaginal vault prolapse and describe the surgical methods of treatment using a transabdominal approach. METHODS: Abdominal sacral colpopexy is the most widely performed method of transabdominal correction of vaginal vault prolapse. The procedure is completed by securing the apex to the vagina to the periosteum of the sacrum with mesh. This procedure is demonstrated in great detail. Successful repair can be achieved by other transabdominal approaches and by laparoscopic approaches. RESULTS: Twenty women (mean age 67.9 years) were evaluated for complex pelvic floor prolapse. Six (30.0%) patients had failed transvaginal sacrospinus ligament fixation. Abdominal sacrocolpopexy utilizing Marlex mesh, Halban culdeplasty, and paravaginal repair was performed on all patients. Five posterior repairs and one anterior repair was done. The average operating time for the colpopexy and enterocele repair alone is approximately 90 minutes. The average blood loss was 284 cc. The average hospital stay was 3.7 days. The mean follow-up is 11.3 months (6-27 months). The vaginal vault is well supported in all patients with no recurrent enterocele or vault prolapse. Three patients have asymptomatic grade II cystoceles, and three patients have asymptomatic grade II rectoceles. There were few complications. No mesh complications have been encountered. CONCLUSIONS: Vaginal vault prolapse can be a difficult problem to diagnose and treat. Successful treatment requires thorough knowledge of the anatomy, methods of diagnosis, and treatment options. The abdominal sacrocolpopexy achieves excellent correction of vaginal vault prolapse with minimal morbidity.

Use of bone anchors in female urology.

Stress urinary incontinence remains one of the most prevalent conditions encountered by urologists. In many cases, surgical correction of this condition is carried out using a pubovaginal sling procedure. Bone anchors were initially used in transvaginal needle suspension procedures to improve stabilization of the bladder neck. This technology has been extended to sling procedures, allowing completion of these procedures by an entirely transvaginal approach. Early results of these procedures are encouraging, and overall morbidity appears much less when compared with conventional pubovaginal sling procedures. In this article, the application of bone anchors in female urology is reviewed. Techniques of pubovaginal sling and abdominal sacrocolpopexy using bone anchors and potential complications of bone anchor implantation are discussed. Surgeons performing procedures for the treatment of stress incontinence should be aware of the benefits and potential risks of bone anchor implantation.

Collagen injection therapy in elderly women: long-term results and patient satisfaction.

OBJECTIVES: To evaluate long-term results and patient satisfaction using collagen injection therapy in elderly women. METHODS: Periurethral injection of collagen using local anesthesia was performed on 58 women 65 years old or older (range 65 to 86, mean 73. 2) to treat stress urinary incontinence. All patients underwent urodynamic evaluation. Forty-nine patients (84.5%) had intrinsic sphincteric deficiency; 9 patients (15.5%) had genuine stress urinary incontinence. Twenty-one patients (36.2%) had no urethral hypermobility using Q-tip testing, and 37 (63.8%) had urethral hypermobility. RESULTS: At 2 months after injection, the initial response was assessed: 28 patients (48.3%) were totally dry and 18 (31.0%) were socially continent. Therapy was unsuccessful in 12 (20. 7%). To achieve continence, 1 to 4 injections (mean 1.9) were required. The average total volume to achieve success was 14.6 mL. No significant differences were observed in outcome, volume injected, or number of injections in patients with versus without urethral hypermobility. At a mean follow-up of 24.4 months (range 8 to 43), of the 46 patients who achieved continence, 19 (41.3%) developed recurrent leakage and required reinjection. The average interval to recurrence was 7.9 months (range 2 to 16). Of the 19 patients reinjected, only 8 (42.1%) regained continence. The long-term success rate after repeated injections was 35 (60.3%) of 58. An independent examiner contacted 40 patients for telephone interview. To date, 25 of the patients contacted noted a moderate or maximal level of symptom improvement, and 18 reported continued improvement in quality of life. Thirty-six patients noted minimal difficulty with the procedure, and 34 would recommend the treatment. CONCLUSIONS: Collagen is a safe, moderately effective alternative to manage stress urinary incontinence in elderly women. Elderly patients should be counseled that approximately 40% will experience recurrent leakage, which may not resolve with reinjection.

Comparison of biomechanical properties of periosteal suture fixation and bone anchor fixation to the pubic bone.

OBJECTIVES: To compare the relative strength of fixation using bone anchors (BAs) compared with direct suture placement into the periosteum. METHODS: The anterior bony pelvis was harvested from 21 female cadavers. In each pelvis, BA suture fixation was performed using Cinch anchors on one side of the pubic bone and direct periosteal suture fixation (PSF) on the contralateral side of the same pelvis. We used No. 1 polyproprolene suture for all cases. Using a hydraulic mechanical testing machine, all specimens were loaded in uniaxial tension until failure. RESULTS: Failure modes for BA-fixed pelves were as follows: 11 BA pull-out, 1 midsuture failure, and 9 suture cut by BA. Failure modes for the PSF pelves were as follows: 6 suture pull-outs through the bone, 14 midsuture failures, and 1 suture cut at the bone. PSF pelves required significantly higher loads to induce failure compared with BA pelves (PSF 92.63 +/- 22.62 N, BA 71.32 +/- 19.76 N, P <0.0002). In many cases, both PSF and BA were adequate points of fixation, and the major mechanism of failure was suture rupture. In pelves with suture failure, the load to induce failure was significantly higher in the PSF group (PSF 105.06 +/- 12.55 N, BA 86.06 +/- 7.78 N, P <0.0025). When the suture failed, PSF was better because BA fixation actually broke some sutures. The load required to induce failure was higher in the PSF groups in 19 (90.5%) of 21 pelves. CONCLUSIONS: Biomechanical testing using permanent monofilament suture did not demonstrate a superiority of BA suture fixation to PSF fixation. PSF appears superior, since BAs induced suture failure in many cases.

Metachronous bilateral torsion of the testicular appendices.

BACKGROUND: Torsion of the appendix testis is a common cause of scrotal pain in children and a common cause for surgical exploration of the pediatric scrotum. The first case of metachronous bilateral torsion of the testicular appendices managed by a non-operative approach is reported. METHODS/RESULTS: A case report and a computer-assisted review of the literature are presented. Physical findings of a tender, mobile mass over the anterior surface of the testis characterize the presentation. Doppler findings of normal blood flow to the testes with increased flow to the adjacent appendix testis can be utilized as an adjunct to diagnosis. Ultrasonographic findings of a pedunculated mass with a central hypoechoic area at the superior aspect of the testis support the diagnosis. Accurate non-operative diagnosis of torsion of the appendix testis permits successful conservative management with non-steroidal anti-inflammatory agents. CONCLUSIONS: Improvements in ultrasonographic and Doppler imaging of torsion of the appendix testis have facilitated the diagnosis of this entity and decreased the need for surgical exploration of the scrotum.

Xanthogranulomatous pyelonephritis in a renal allograft recipient.

Xanthogranulomatous pyelonephritis rarely occurs in renal allografts. This is the fifth reported case. Diagnosis was made by renal biopsy, which is usually performed to evaluate an elevated serum creatinine. Associated patient symptomology is nonspecific, and graft imaging with ultrasonography and computed tomography was not helpful as it would be with native kidney xanthogranulomatous pyelonephritis. Successful treatment with antibiotics may depend on the serum creatinine at presentation. Prognosis, therefore, is guarded, with a common outcome of irreversible renal dysfunction.