Obesity and retropubic surgery for stress incontinence: is there really an increased risk of intraoperative complications?

OBJECTIVE: The objective of the study was to evaluate the impact of obesity on length of surgery, blood loss, and intra- and postoperative complications in women who underwent retropubic surgery for stress urinary incontinence. STUDY DESIGN: Of 449 women participating in a multicenter, randomized trial evaluating antibiotic prophylaxis in women with suprapubic catheters, 250 women underwent retropubic anti-incontinence procedures. This is a prospective nested cohort study of these women, 79 (32%) of whom were obese (body mass index 30 or greater) and 171 (68%) overweight or normal weight (body mass index less than 30). Data collected included demographic variables, past medical history, physical examination, and intraoperative and postoperative complications. Data were analyzed with Fisher's exact for dichotomous variables, Student t tests for continuous variables, and analysis of variance for multivariate analysis. Significance was set at P < .05. RESULTS: Obese women undergoing stress urinary incontinence surgery were younger than nonobese women (48.7 versus 51.9 years, respectively, P < .019). The number and type of additional surgeries performed were similar between groups with the exception that obese women were less likely to undergo abdominal apical suspensions (P = .006) or abdominal paravaginal repairs (P = .001); therefore, estimated blood loss, change in hematocrit, length of stay, surgery, and suprapubic catheterization comparisons are adjusted for the performance of these procedures. Estimated surgical blood loss was greater for obese women (344 versus 284 P = .03); however, change in hematocrit was lower for obese than nonobese women (6.6 versus 7.3, P = .048). Mean length of surgery was 15 minutes longer in obese women (P = .02). Length of hospital stay did not vary between groups (P = NS). Major intraoperative complications were uncommon (14 [5.6%]), with no difference between weight groups. Incidence of postoperative urinary tract infection, wound infections, or postoperative major complications were likewise similar between groups (all P > .05). CONCLUSION: Surgery takes longer for obese patients, but blood loss as recorded by change in hematocrit is lower. Major complications were rare and similar between weight groups, as were infectious complications.

Ball urethroplasty combined with Marshall-Marchetti-Krantz urethropexy versus suburethral sling in patients with intrinsic sphincter deficiency and urethral hypermobility.

OBJECTIVE: It was our goal to compare the efficacy of a suburethral fascial sling with that of a combination of Marshall-Marchetti-Krantz urethropexy and Ball urethroplasty in patients with intrinsic sphincter deficiency and urethral hypermobility. STUDY DESIGN: This study consisted of a retrospective observational evaluation of patients from 2 separate practice sites. Preoperative and postoperative data were collected from patients' medical records. The long-term results were based on a mailed questionnaire addressing bladder symptoms and quality-of-life issues. RESULTS: Among a total of 48 patients, 37 (77. 1%) responded in the group undergoing Marshall-Marchetti-Krantz urethropexy combined with Ball urethroplasty, and 30 out of 35 (85.7%) patients replied in the suburethral fascial sling group. The mean length of follow-up was 2. 7 years (range, 1-5 years). The patients were similar in age, hormonal status, parity, and previous bladder neck surgery. Similar cure and improvement were demonstrated in both groups (86.6% in the suburethral fascia group and 89.2% in the group with the Marshall-Marchetti-Krantz procedure combined with Ball urethroplasty). No significant differences were found in urinary incontinence types, irritable bladder symptoms, voiding difficulties, or quality-of-life measures. CONCLUSIONS: The suburethral fascial sling and a procedure consisting of Marshall-Marchetti-Krantz urethropexy combined with Ball urethroplasty have similar results in patients with intrinsic sphincter and urethral hypermobility.

Stress incontinence in women under 50: does urodynamics improve surgical outcome?

The aim of the study was to determine whether urodynamic testing improves the outcome of retropubic surgery in women aged 50 or younger. A retrospective study was undertaken of 212 women aged 50 or younger who underwent retropubic surgery at a medical school-affiliated hospital between February 1991 and July 1997. Excluded were patients with prior retropubic urethropexy and known low urethral closure pressures. The surgery was performed by one urogynecologist and two urologists. The minimal evaluation by the urogynecologist was a focused incontinence questionnaire, pelvic neurologic examination, pelvic floor grading, cough stress test, urinalysis, postvoid residual, cotton swab test and supine empty stress test. Full urodynamics consisted of uroflowmetry, subtracted cystometry, urethral closure pressure, cough leak-point pressure and cystourethroscopy. Subjective postoperative follow-up at 14 years was by annual questionnaire. The urogynecologist's patients were in group I (95 women with full urodynamic studies) and group II (36 women with minimal testing). The urologists' patients were in group III (81 women with a very minimal workup and cystourethroscopy). A review of seven variables revealed no difference between the groups. In terms of cured, improved and failed, there was also no difference in outcome. There was a difference in postoperative voiding problems (though not stress incontinence) in group III compared to group I (P= 0.005) and group II (P=0.002). Our conclusion was that all women with stress incontinence should undergo a careful minimal evaluation. In women aged 50 or younger urodynamic studies may be avoided unless there is significant stress incontinence, complex symptoms, a positive supine empty stress test, marked prolapse, or a history of prior retropubic urethropexy.

Echoes of things to come. Ultrasound in UK emergency medicine practice.

Ultrasound is widely used in the US and continental Europe in the immediate assessment of patients after blunt abdominal trauma. There are also now other recognised "primary" indications for ultrasound in emergency medicine. In this paper current evidence supporting the implementation and use of emergency ultrasound in these primary conditions and possible other indications are assessed. The issues surrounding introduction of the technology into the practice of emergency medicine in this country are considered. It is accepted that further debate is necessary but the establishment of a robust evidence base in the UK will help to clarify the place of ultrasound.

Cat-scratch disease presenting as neuroretinitis and peripheral facial palsy.

A 40-year-old woman with Cat-scratch disease sought treatment for neuroretinitis OD and right peripheral facial nerve palsy. To our knowledge, this is the first case of an adult with a peripheral facial nerve palsy from Cat-scratch disease and the first case of a patient with both neuroretinitis and peripheral facial nerve palsy.

Factors predictive of cytomegalovirus immune status in pregnant women.

We performed serological tests for antibody to cytomegalovirus on 1989 pregnant women of middle-to-upper socioeconomic status at the time of their first obstetric visit. Fifty percent of the women had antibody to cytomegalovirus. Analysis with a stepwise logistic regression model revealed that seropositivity was independently correlated with nonwhite race, less than 16 years of education, being breast-fed as an infant, the presence of children five to 18 years of age in the home, and maternal age greater than or equal to 30 years. Conversely, women not possessing these risk factors were more likely to be seronegative; 69% of the women without any of the five factors lacked antibody to cytomegalovirus. Serological screening for antibody would be more useful in obstetric practices where the majority of patients lack these risk factors.

The natural history of group B streptococcal colonization in the pregnant woman and her offspring. I. Colonization studies.

A longitudinal study of colonization by group B streptococcus (GBS) was conducted in 93 pregnant women and 92 of their infants. Positive cultures were obtained from vaginal swab specimens on at least one occasion during pregnancy from 20.4% of the women. Three types of carriage were observed: chronic, transient, and intermittent. At the time of delivery, 12.9% of the mothers were colonized by GBS. GBS colonization occurred in 41.7% of the infants of the mothers colonized intrapartum. Only 1.2% of infants intrapartum culture-negative mothers were colonized. Infants colonized at birth were culture negative by 4 months of age. This study suggests that interruption of vertical transmission of GBS from mother to infant not only would influence the incidence of early-onset GBS disease but also might reduce the incidence of late-onset GBS disease.

Failure of penicillin to eradicate group B streptococcal colonization in the pregnant woman. A couple study.

Prophylactic treatment of couples with oral penicillin has been recommended as a means of eradicating GBS from the parturient female. In 1977 and 1978 this hypothesis was tested in an investigation of couples from a middle and upper socioeconomic group in Houston, Texas. A group of 40 women, known to be colonized with GBS during the third trimester of pregnancy, and their husbands were treated simultaneously with oral penicillin. Patients were recultured 3 weeks following completion of therapy and at the time of delivery. At the time of delivery 67% of the women remained colonized with GBS. This percentage does not differ substantially from that obtained in a series of untreated colonized women. This study demonstrates that oral penicillin treatment of couples is not an effective means of reducing maternal colonization at the time of delivery.

Ampicillin prevents intrapartum transmission of group B streptococcus.

Early-onset group B streptococcus (GBS) disease in the infant is acquired by vertical transmission from the mother colonized with GBS. Thirty-four women colonized with GBS were treated with intravenous ampicillin sodium during labor. None of their infants were colonized with GBS at birth or within 48 hours. Twenty-four women colonized with GBS received no antibiotic therapy; 14 (58%) of their infants were colonized with GBS at birth or by 48 hours. This difference was highly significant. Mechanisms by which this may have occurred were temporary suppression of GBS vaginal and rectal colonization, high concentration of ampicillin in the amniotic fluid, and transplacental transport of the antibiotic to the infant. In areas where GBS disease is prevalent, we recommend screening pregnant women (34 to 36 weeks' gestation) and treating those colonized with GBS (with no history of penicillin hypersensitivity) with intravenous ampicillin during labor.