Outcomes and complications of transvaginal and abdominal custom-shaped light-weight polypropylene mesh used in repair of pelvic organ prolapse.

STUDY OBJECTIVE: To assess the outcomes and complications of transvaginally placed custom-shaped light-weight polypropylene mesh for repair of pelvic organ prolapse. DESIGN: Retrospective review of medical records (Canadian Task Force classification II-2). SETTING: Two urogynecologic centers. PATIENTS: Between March 2006 and September 2007, 154 women with anterior, posterior, or apical prolapse underwent vaginal reconstructive surgery using custom-shaped transvaginal or abdominal mesh. Surgical procedures were chosen after informed consent. The primary outcome for the study was recurrence of prolapse, defined as POP-Q (Pelvic Organ Prolapse Quantitative) stage II or greater. Secondary end points included perioperative and postoperative complications. INTERVENTIONS: Anterior compartment repair was performed in 94 patients (61%), and posterior compartment repair in 60 (39%). Combined anterior and posterior repairs were performed in 25 patients. Hysterectomy was performed in 27 patients (18%) (abdominal in 1, vaginal in 19, and laparoscopy-assisted in 7). Apical support techniques included sacrospinous fixation in 69 patients (45%), abdominal sacral colpopexy in 30 (19%), and vaginal culdoplasty in 7 (5%). Transobturator sling procedures were performed in 65 patients (42%). MEASUREMENTS AND MAIN RESULTS: Postoperative follow-up exceeded 24 months in all patients. The overall success of these procedures was 97.4%. There were 4 failures (2.6%), defined as stage II prolapse or greater. Comparison of POP-Q points Aa, Ba, C, Ap, and Bp preoperatively and postoperatively revealed statistically significant improvement at each point (p <.001). Complications were observed in 17 patients (11%), with mesh extrusion in 1 (0.7%). CONCLUSIONS: Long-term follow-up demonstrated that use of custom-shaped light-weight polypropylene mesh is safe and effective, with a low rate of complications.

Prevalence of benign microscopic hematuria among women with interstitial cystitis: implications for evaluation of genitourinary malignancy.

OBJECTIVES: To assess the prevalence of benign microscopic hematuria among a cohort of women with clinical interstitial cystitis (IC). METHODS: A total of 100 women were prospectively assessed for microscopic hematuria with postvoid sterile catheterization. The evaluation for all patients included urine culture, potassium sensitivity test (PST), cystoscopy with hydrodistension under general anesthesia, and symptom assessment with the Pelvic Pain and Urgency/Frequency (PUF) questionnaire. RESULTS: The mean age +/- SD was 37 +/- 15 years, with no difference noted in those with or without microscopic hematuria (P = 0.71). Microscopic hematuria was present in 24 (24%) of the 100 women. No patient had gross hematuria, positive urine culture, or cystoscopic findings suspicious for malignancy. The mean PUF score was 17 +/- 6. The PST was positive in 92 (92%) of 100 women, and 8 patients had only cystoscopic findings diagnostic of IC. The likelihood of a positive PST or positive cystoscopic findings among patients with microscopic hematuria was similar to that of patients without microscopic hematuria. The PST results correlated with the cystoscopic findings (P < 0.001). Of 36 patients with positive cystoscopic findings, 28 (78%) had a positive PST, and 28 (30%) of 92 with a positive PST had positive cystoscopy findings. CONCLUSIONS: In this cohort of women with IC, the prevalence of benign microscopic hematuria was 24%. These data suggest that in women at low risk of genitourinary malignancy who have clinical IC, microscopic hematuria may be an incidental finding.

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.

The prevalence of urinary incontinence or prolapse among white and Hispanic women.

OBJECTIVE: Our purpose was to study the distribution of symptoms and disorders of urinary incontinence or prolapse among white and Hispanic women. STUDY DESIGN: Data were collected for all new patients referred to the urogynecology clinic over a 2-year period. One hundred twenty-one Hispanic and 50 white women consecutively referred to the urogynecology clinic as new patients over 2 years were included in the study. All patients underwent a detailed history and physical examination and multichannel urodynamic studies. Differences between the two groups were analyzed for significant differences by use of demographic data, presenting symptoms, urodynamic profiles, and final diagnosis or disorder. RESULTS: The symptoms of stress, urge, or mixed incontinence and prolapse were noted in 26%, 18%, 30%, and 14% of white women, respectively, compared with 41%, 9%, 21%, and 26% of Hispanic women (p=0.019). The diagnosis of genuine stress incontinence, motor urge incontinence, mixed incontinence, and pelvic organ prolapse without incontinence was made, respectively, in 16%, 44%, 6%, and 18% of white women versus 30%, 27%, 5%, and 18% of Hispanic women (p=0.33). The nondiagnostic rate after a complete evaluation for both groups was 10%. Hispanic women were of significantly higher gravidity (5.6 vs 3.8, p=0.001) and parity (4.7 vs 3.0, p=0.0006) than white women but were of comparable age. Medical problems and medications were too infrequent to allow meaningful comparison. White women were much more likely to have undergone a hysterectomy (36% vs 11.5%, p=0.0004, 95% confidence interval 1.8 to 10.3). CONCLUSION: Although the distribution of presenting symptoms of incontinence differs between Hispanic and white women, the final diagnosis after a complete urogynecologic evaluation was similar. Therefore presenting complaints in patients of different ethnic groups appears to be a poor predictor of the type of incontinence. Hispanic women were of higher gravidity and parity than white women were, but white women were more likely to have undergone a hysterectomy. Because the power of this study was limited by the 50 white women, larger prospective and longitudinal studies are needed to determine the significance of possible difference in etiologic factors.

Modification of the Miya hook in vaginal colpopexy.

OBJECTIVE: To evaluate a modification of the Miya hook in performing vaginal sacrospinous ligament fixation. STUDY DESIGN: The modification was performed in over 50 patients. It involves placing the needle through the ligament unloaded; then the hook is back-threaded with the appropriate suture. The hook is then withdrawn, bringing the suture with it. RESULTS: There were no complications as a result of this modification. The technique was faster, used fewer instruments and obviated fraying of the suture. It could also be adapted when retrieving the suture when the classic technique proved difficult. CONCLUSION: The ease of this modification should promote the use of this instrument in performing vaginal sacrospinous ligament fixation.

Angiogenesis in uterine cervical squamous cell carcinoma.

This study tested the hypothesis that increased angiogenesis in squamous cell carcinoma of the cervix is an indicator of poor prognosis. We retrospectively studied 70 cases and related the microvessel count to stage and follow-up. We performed immunohistochemical staining for Factor VIII and counted the number of microvessels in a 400x field in the area of greatest density of vessels. The mean vessel count in stage I was 18.3 +/- 5.4 (26 cases), in stage II 18.0 +/- 6.8 (21 cases), in stage III 17.9 +/- 3.9 (18 cases), and in stage IV 22.2 +/- 13.6 (five cases). We found no correlation between the mean vessel count and stage (p < 0.85) or between mean vessel count and disease status on an average follow-up of 21 months (p < 0.65). With a power of approximately 70%, this study excludes the hypothesis that an increased density of microvessels is associated with a worsened prognosis in cervical squamous cell carcinoma.

Nonfluorescent erythrasma of the vulva.

BACKGROUND: Erythrasma is an uncommon vulvar infection, best diagnosed by its fluorescence under the Wood lamp. This report shows that despite a negative Wood lamp examination, the diagnosis can be made histologically. CASE: A 42-year-old woman was referred to our clinic with a persistent candidal infection. Evaluation included a Wood lamp examination, wet mount, and potassium hydroxide test of the affected skin, all of which were negative. A biopsy of the area demonstrated rods and filamentous organisms in the keratotic layer consistent with a Corynebacterium minutissimum infection. The patient was diagnosed as having erythrasma, and she responded to oral erythromycin. CONCLUSION: Persistent vulvar diseases may be caused by erythrasma despite a negative Wood lamp examination. The diagnosis can be made by biopsy of the lesion.

Effectiveness of repeated gonorrhea cultures in the third trimester.

OBJECTIVE: With the high cost of health care today, the universal prophylactic measures recommended, and the availability of effective treatment should infection occur, the practice of routinely repeating the endocervical gonorrhea (GC) culture in the third trimester of pregnancy may be unwarranted. METHODS: To test this hypothesis, we reviewed charts from patients who had received routine prenatal care during a 2-year period at the Lafayette and Opelousas parish health units. Those charts, which had documented results of both the initial and repeat GC cultures, were then used for retrospective review. The results ofthe initial GC culture were compared with that taken in the third trimester. Other data recorded included age, gravidity, race, and history of gonorrhea, syphilis, or multiple sexual partners. RESULTS: Two hundred fifty charts were available for extraction; 130 of these had documentation of both GC cultures. Of the 130 cultures obtained during the initial prenatal visit, only 6 (4.6%) were positive. Of the repeat cultures taken during the third trimester, none were positive. Thirteen patients (10.0%) had a documented history of GC infection; none of them had positive cultures during the study period. CONCLUSIONS: Screening for GC during pregnancy is important and appropriate. This is commonly accomplished by taking a GC culture during the initial prenatal visit. Based upon the present study, we found that repeating this culture in the third trimester, even in a relatively high-risk population, seems unnecessary, whether the initial culture is negative or not.