Protective effect of suburethral slings on postoperative cystocele recurrence after reconstructive pelvic operation.

OBJECTIVE: The purpose of this study was to evaluate the independent effect of suburethral sling placement on the risk of cystocele recurrence after pelvic reconstructive operation. STUDY DESIGN: One hundred forty-eight women with cystoceles to or beyond the hymenal ring underwent pelvic reconstructive operation, with or without incontinence procedures, and were evaluated at 12 and 52 weeks after operation with a standardized pelvic examination. Rates of recurrent prolapse, at all sites, were statistically compared between subjects with and without suburethral slings. A multiple regression analysis was used to determine the independent effect of sling placement on the risk of recurrent cystoceles. RESULTS: Suburethral sling placement was associated with a 54.8% reduction in the mean rate of postoperative cystocele recurrence (P =.004). This protective effect was observed as early as 12 weeks and remained significant at 1-year follow up (42% vs 19%). A markedly reduced risk of cystocele recurrence was observed when women with sling procedures were compared with all other women, with those women who underwent other incontinence operations, and even with those women who had undergone prolapse repair with no incontinence procedure. The protective effect of the sling procedure remained highly significant (odds ratio, 0.29; P =.0003), even after controlling for potentially confounding variables in a multiple logistic regression model. CONCLUSION: Suburethral sling procedures appear to significantly reduce the risk of cystocele recurrence after pelvic reconstructive operation, in contrast with the effect of retropubic urethropexy and needle suspensions. These findings should be considered when the surgical treatment of stress incontinence that accompanies pelvic organ prolapse is being planned.

Anterior or posterior sacrospinous vaginal vault suspension: long-term anatomic and functional evaluation.

OBJECTIVE: To compare vaginal anatomy and sexual function after the conventional posterior and anterior sacrospinous vault suspension. METHODS: A retrospective repeated measures cohort study included all 168 consecutive sacrospinous vault suspension procedures between July 1990 and February 1997. The posterior suspension (n = 92) used a posterior vaginal incision and pararectal dissection. Anterior suspension (n = 76) involved an anterior rather than posterior vaginal incision, retropubic perforation, and dissection of a paravaginal-paravesical rather than pararectal space to accommodate the vaginal vault. Two polytetrafluoroethylene (00) sutures anchored the anterior vaginal cuff (for the anterior sacrospinous suspension) or the posterior vaginal cuff (for the posterior sacrospinous suspension) to the ligament. Postoperative evaluation included an examination using the pelvic organ prolapse quantitative system, assessment of vaginal width and axis, and symptom questionnaire. RESULTS: Total vaginal length and apical suspension were slightly greater after the anterior suspension, and recurrent anterior vaginal relaxation was less likely. No differences were found in maximal dilator size or apical narrowing between the two groups. New onset dyspareunia was reported by two subjects in the anterior vault suspension group, and two in the posterior vault suspension group. Three of these four cases of de novo dyspareunia were attributable to either severe atrophy or recurrent prolapse, and none to vaginal narrowing or shortening. CONCLUSION: After anterior sacrospinous vault suspension, vaginal length and apical suspension were slightly increased, and recurrent anterior vaginal prolapse decreased compared with the posterior sacrospinous suspension technique. Upper vaginal caliber and sexual function appear well preserved using either technique.

Prospective randomized trial of polyglactin 910 mesh to prevent recurrence of cystoceles and rectoceles.

OBJECTIVE: Our aim was to evaluate the efficacy of polyglactin 910 mesh in preventing recurrent cystoceles and rectoceles. STUDY DESIGN: In a prospective, randomized, controlled trial, patients undergoing vaginal reconstructive surgery with cystoceles to the hymenal ring and beyond were randomly selected to undergo anterior and posterior colporrhaphy with or without polyglactin 910 mesh reinforcement. Results were evaluated preoperatively and at 2, 6, 12, and 52 weeks postoperatively. RESULTS: A total of 161 women were randomly selected for this study. One woman was excluded at the time of surgery, and 17 women were lost to follow-up. Eighty women received mesh, and 80 did not. Both groups were found to be equivalent with respect to age, parity, concomitant surgery, and menopausal and hormone replacement status. Preoperatively 49 women had a central cystocele to the hymenal ring and 111 women had cystoceles beyond the introitus; 91 women had a rectocele to the mid-vaginal plane, 31 to the hymenal ring, and 22 beyond the introitus. After 1 year, 30 (43%) of 70 subjects without mesh and 18 (25%) of 73 subjects with mesh had recurrent cystoceles beyond the mid-vaginal plane (P =.02). Eight women without mesh and 2 women with mesh had recurrent cystoceles to the hymenal ring (P =.04). No recurrent cystoceles beyond the hymenal ring occurred in either group. Multivariate logistic regression analysis showed concurrent slings to be associated with significantly fewer recurrent cystoceles (odds ratio, 0.32; P =.005), whereas the presence of mesh remained significantly predictive of fewer cystocele recurrences in this analysis. Thirteen recurrent rectoceles were noted 1 year postoperatively, with no differences between groups. CONCLUSION: Polyglactin 910 mesh was found to be useful in the prevention of recurrent cystoceles.

Abnormal spinal curvature and its relationship to pelvic organ prolapse.

OBJECTIVE: Intra-abdominal vector forces have been implicated in the development of genital prolapse. Because the normal spinal curvature appears to protect the pelvic cavity from direct upper abdominal forces, variations in spinal curvature may alter these vector forces and possibly potentiate the development of pelvic organ prolapse. This study was undertaken to evaluate the relationship of spinal curvature and pelvic organ prolapse, specifically, the loss of lumbar lordosis or pronounced thoracic kyphosis. STUDY DESIGN: A total of 363 patients referred for various complaints of urinary incontinence or pelvic organ prolapse were included in this multicenter, prospective, case-control study. All patients underwent a detailed history with site-specific examinations; pelvic organ prolapse was quantitatively assessed according to the POPQ (pelvic organ prolapse quantitation) staging system. Spinal curvature was measured with a flexi-curve malleable rod when patients were in a fully erect position. Spinal curvature was then transferred to graph paper by tracing the flexi-curve. Thoracic and lumbar curvatures were determined by measuring thoracic and lumbar lengths and widths, respectively. RESULTS: Ninety-two patients had abnormal spinal curvature according to the study criteria. Complete loss of lumbar lordosis was found in 69 patients. Of the 92 patients with an abnormal curvature, 84 currently had or previously had pelvic organ prolapse (sensitivity, 91%). When compared with patients with a normal curvature, patients with an abnormal spinal curvature were 3. 2 times more likely to have development of pelvic organ prolapse (odds ratio, 3.18; 95% confidence interval, 1.46 to 6.93; P =.002). There was no difference in the number of vaginal deliveries, weight of largest vaginally delivered infant, or body mass index. Only 11% (8/72) of patients with stage 0 prolapse had an abnormal spinal curvature, which increased to 30% (28/99) in patients with stage III prolapse (P =.042). CONCLUSION: An abnormal change in spinal curvature, specifically, a loss of lumbar lordosis, appears to be a significant risk factor in the development of pelvic organ prolapse.

Energy expenditure and substrate utilization in adults with cystic fibrosis and diabetes mellitus.

BACKGROUND: The onset of cystic fibrosis-related diabetes mellitus (CFDM) is often associated with a decline in clinical and nutritional status. OBJECTIVE: The purpose of this study was to characterize energy expenditure (EE) and substrate utilization during rest, exercise, and recovery from exercise in patients with CF diagnosed with diabetes mellitus. DESIGN: EE, substrate utilization, minute ventilation, tidal volume, and respiratory rate were calculated by indirect calorimetry durng rest; a 30-min, low-to-medium-intensity exercise bout on a treadmill; and a 45-min postexercise recovery period (in reclining position) in 10 CF, 7 CFDM, and 10 control subjects between 18 and 45 y of age. RESULTS: In all 3 periods, minute ventilation was higher in the CF and CFDM groups than in the control subjects (P < 0.01). During rest and exercise, the CF and CFDM groups maintained EE values at the high end of the normal range of the control subjects. However, during recovery, EE was higher in the CF and CFDM groups than in the control group (P < 0.01). CONCLUSIONS: EE may be higher than usual for the patients with CF and CFDM during periods of recovery from mild exercise or activity because of increased work of breathing consistent with higher ventilatory requirements. This information may be useful for patients receiving nutritional counseling who may choose to exercise regularly, but are concerned about possible weight loss.

Pregnancy and intercurrent diseases of the urogenital tract.

Pregnancy, labor, delivery, and the puerperium cause many changes in the urinary and genital tracts. The management of lower urinary tract symptoms, disease, and genital prolapse during and after pregnancy is controversial. Patients treated surgically for incontinence, genital prolapse, and lower urinary tract reconstruction present a challenge to the obstetrician and other doctors caring for them during pregnancy. This article reviews the literature on the effect of pregnancy, labor, delivery, and the puerperium on lower urinary and genital tract disease. Preventive methods to reduce subsequent pelvic floor muscle damage and urinary and fecal incontinence are reviewed. The management of pregnant women with antecedent urinary and genital tract abnormalities also are summarized.

Longitudinal, prospective analysis of dietary intake in children with cystic fibrosis.

OBJECTIVES: Prospective, 3-year longitudinal dietary intakes of 25 prepubertal, pancreatic-insufficient children with cystic fibrosis (CF) and mild lung disease, and the intakes of 26 control children were compared, and relationships among energy intake, nutritional status, and pulmonary function were determined. STUDY DESIGN: Intakes from 3-day weighed food records were compared with CF recommendations, recommended dietary allowances (RDA), and the recommendations of the Third National Health and Nutrition Examination Survey (NHANES III). Energy and nutrient intakes were analyzed by repeated-measures analysis of variance. RESULTS: Children with CF consumed more energy than control children (p = 0.025) in terms of calories per day, percentage of RDA by age and by age and weight, energy adjusted for fat malabsorption, and percentage of NHANES III recommendations. Energy intake was similar between boys and girls with CF. The percentage of energy from fat was greater (p = 0.0004) in the CF group (3-year mean, 33%) than in the control group. Height and weight z scores declined in the CF group (p <0.05) with time. Vitamin and mineral intakes were generally adequate in the CF group. CONCLUSIONS: The children in this sample did not consume the CF recommended intakes of 120% RDA for energy or a high-fat (40% of energy) diet. Energy intakes may be insufficient in this group to meet requirements for optimal growth.

Energy expenditure and genotype of children with cystic fibrosis.

Increased energy expenditure, poor dietary intake, and fat malabsorption in patients with cystic fibrosis (CF) frequently lead to growth failure and malnutrition, which are associated with pulmonary failure and decreased survival. The study purpose was to understand better the energy expenditure and requirements in the mild pulmonary disease state in children. Resting and total energy expenditure were measured in 6- to 9-yr-old, pancreatic-insufficient children with CF (n = 25) and control children (n = 25) of similar age, gender, and weight. The effect of the most common genotype, homozygous delta F508, on energy expenditure was also investigated. Dietary intake, degree of fat malabsorption, body composition, physical activity, and clinical status were determined. The CF group had a 9% increase in resting energy expenditure, which was not related to genotype or severity of lung disease. Both CF genotype subgroups (delta F508 homozygous and all others) had a similar, modest resting energy expenditure increase. Total energy expenditure was increased by 12% in the entire CF group and by 23% in the delta F508 homozygous CF subgroup compared with controls. The total energy expenditure increase in delta F508 homozygous children may be related to increased voluntary physical activity, reflecting no activity reduction associated with lung disease, or to an unidentified genotype-related mechanism. The clinical implication is that a detailed physical activity assessment should be evaluated along with resting energy expenditure, either measured or estimated by equations, when daily energy needs are being determined for children with CF.

Body composition of children with cystic fibrosis with mild clinical manifestations compared with normal children.

Because growth and anthropometric measurements are frequently below normal in patients with cystic fibrosis (CF), the body composition of 23 children (6-9 y of age) who had mild manifestations of CF was examined and compared with a control group of 24 subjects similar in age, sex, and weight. Skinfold measurements, total body water (TBW) by deuterium oxide dilution, and total body electroconductivity (TOBEC) were measured. Skinfold and TBW measurements demonstrated that fat mass and fat-free mass did not differ significantly between the two groups. No significant difference in percent body fat was found by using the skinfold equations of Slaughter et al (13.8% vs 15.3%), although percent body fat (TBW method) differed between the groups (P < 0.05). TOBEC measurements (CF, n = 14) were not used in the group comparison. The majority of the methods demonstrated that the CF group achieved normal growth and body composition, with a possible trend of fat depletion.

Dietary intake of healthy children with cystic fibrosis compared with normal control children.

Because a low calorie intake may result in growth failure and malnutrition in patients with cystic fibrosis (CF), the dietary and energy intakes of 22 children with CF who had mild lung disease and excellent Shwachman scores were examined and compared with those of 23 normal control subjects similar in age (5 to 10 years), gender, and weight. The children with CF consumed significantly more calories than the control subjects. Calorie intake was 111 +/- 19.9% (mean +/- SD) of estimated requirements (World Health Organization recommendations) for the CF group and 97 +/- 18.7% for the control group (P = .014). Calories consumed per kilogram of body weight were 117% of World Health Organization (CF) vs 97% (control) (P = .009). Calorie intake compared to the 1989 Recommended Dietary Allowance was 106 +/- 20.6% for the CF group vs 93 +/- 19.1% for the control group. Fat consumed as a percent of total calories was similar: 33.5% (CF) vs 32.2% (control). All children with CF had pancreatic insufficiency and, on average, consumed a large number of pancreatic enzyme supplements, resulting in dietary fat absorption of 86 +/- 12%. It is concluded that these children with CF were able to maintain normal growth and energy stores on a diet that was relatively high in calories compared to control subjects and moderate in percent fat, along with an aggressive pancreatic enzyme supplement regimen.