Anterior colporrhaphy: why surgeon performance is paramount.

Anterior compartment repair is one of the most challenging issues in reconstructive pelvic surgery. Previous studies using strict anatomic criteria suggested a high failure rate after anterior colporrhaphy, prompting increased use of augmented repairs in the past decade. More recent studies suggest anterior colporrhaphy may provide symptom relief similar to that seen with augmented repairs without the risks associated with placement of mesh. There is a wide range of success rates for anterior colporrhaphy in the literature. The wide variation implies surgeon performance is a key issue in the success or failure of anterior compartment repair. It is critical to begin measuring and reporting surgeon performance in research trials and monitoring surgeon performance in clinical practice in order to make meaningful comparisons of surgical techniques and improve patient care.

Progressive reduction in abdominal hysterectomy rates: impact of laparoscopy, robotics and surgeon factors.

The objective of this study is to describe changes in rates of types of hysterectomy at a tertiary care community teaching hospital since the introduction of laparoscopic and robotic techniques and to determine the effect of surgeon characteristics on route of hysterectomy. This is a retrospective analysis of types of hysterectomies performed for benign disease during five different years (1989, 1994, 1999, 2004, 2009) at a large community teaching hospital. Hospital discharge data was reviewed to identify all hysterectomies performed during the first six months of each year of the study. Hospital charts were reviewed and patient characteristics, indication for surgery, type of hysterectomy and surgeon characteristics were recorded. Hysterectomies performed for malignancy, suspected malignancy, or postpartum hemorrhage were excluded. Types of hysterectomies included abdominal (AH), vaginal (VH), laparoscopic-assisted vaginal (LAVH), total laparoscopic (TLH), laparoscopic supracervical (LSH) and robotic-assisted (RH). The progressive introduction of newer minimally invasive surgical techniques (LAVH, TLH, LSH, and RH) resulted in an overall reduction in the abdominal hysterectomy rate from 77 to 35.2 % during the time of the study. The majority of abdominal, laparoscopic supracervical and robotic hysterectomies were performed by generalists, while the majority of vaginal, laparoscopic-assisted vaginal and total laparoscopic hysterectomies were performed by fellowship trained subspecialists. Minimally invasive hysterectomy techniques significantly reduced the rate of abdominal hysterectomies. The LSH and RH were the techniques utilized by generalists as their most preferred minimally invasive surgical approaches to hysterectomy.

Pelvic floor muscle function in women presenting with pelvic floor disorders.

INTRODUCTION AND HYPOTHESIS: This observational study was undertaken to determine knowledge, prior instruction, frequency of performance, and ability to perform pelvic floor muscle exercises in a group of women presenting for evaluation of pelvic floor disorders. METHODS: Three hundred twenty-five women presenting for evaluation of pelvic floor disorders were questioned concerning knowledge and performance of pelvic floor muscle exercises (PMEs) and then examined to determine pelvic floor muscle contraction strength. RESULTS: The majority of women (73%) had heard of PMEs, but only 42% had been instructed to perform them and 62.5% stated they received verbal instruction only. Only 23.4% of patients could perform pelvic muscle contractions with Oxford Scale 3, 4, or 5 strengths. Increased age, parity, and stage of prolapse were associated with lower Oxford scores. CONCLUSIONS: Although most women with pelvic floor disorders are familiar with PMEs, less than one fourth could perform adequate contractions at the time of initial evaluation.

A randomized trial comparing methods of vaginal cuff closure at vaginal hysterectomy and the effect on vaginal length.

OBJECTIVE: The objective of the study was to compare the effect of horizontal versus vertical closure of the vaginal cuff during vaginal hysterectomy on vaginal length. STUDY DESIGN: Forty-three women were randomized to undergo horizontal (n = 23) or vertical (n = 20) vaginal cuff closure during vaginal hysterectomy at a community hospital. The primary outcome of vaginal length before and after surgery was compared by the Student t test and the paired t test. RESULTS: Preoperatively mean vaginal lengths in the horizontal and vertical groups were statistically similar (7.76 +/- 1.23 cm versus 8.28 +/- 1.39 cm, respectively; P = .21). Postoperatively the groups statistically differed (6.63 +/- 1.02 cm versus 7.93 +/- 1.18 cm, P < .001). The mean change in vaginal length was -1.13 +/- 1.15 cm and -0.35 +/- 0.91 cm, respectively (P = .01). Within-group comparisons revealed a statistical difference between pre- versus postmean vaginal length in the horizontal group (7.76 +/- 1.23 cm versus 6.63 +/- 1.02 cm; P < .001) and no difference within the vertical group (8.28 +/- 1.39 cm versus 7.93 +/- 1.18 cm; P = .11). CONCLUSION: Closing the vaginal cuff vertically is superior to horizontal closure for the purpose of preserving vaginal length.

Various surgical approaches to treat voiding dysfunction following anti-incontinence surgery.

OBJECTIVE: The aims of this study are to report the efficacy of retropubic urethrolysis, vaginal urethrolysis, and cutting of synthetic suburethral slings in treating postoperative voiding dysfunction that occurs after anti-incontinence surgery and to report the recurrence rate of stress urinary incontinence (SUI). METHODS: All patients from January 1996 to October 2003 who presented with voiding dysfunction following an anti-incontinence procedure and who subsequently underwent either retropubic urethrolysis, vaginal urethrolysis, or synthetic suburethral sling takedown were included in the study. Pre- and postoperative irritative symptoms (urinary frequency or urgency), obstructive symptoms (hesitancy, voiding difficulty, and incomplete emptying), and stress urinary incontinence symptoms were obtained in a standardized fashion. The Incontinence Impact Questionnaire and Urogenital Distres Invetory quality of life (QOL) questionnaires were also obtained to objectify these symptoms. Other objective postoperative analysis included simple uroflowmetry, measurement of postvoid residual (PVR), and simple or subtracted cystometry. RESULTS: Forty-four patients were included in the study (suburethral sling takedown = 14, vaginal urethrolysis = 20, and retropubic urethrolysis = 10), 77% of whom had objective follow-up. Preoperatively, 31 patients (70.5%) had irritative symptoms, 41 (93.2%) had obstructive symptoms, and 6 (13.6%) had symptoms of stress urinary incontinence (SUI), while postoperatively, these symptoms were found in 30 (68.2%), 11 (25.0%), and 18 (40.9%), respectively. Postoperatively, 6 patients (17.6%) had a PVR > 100 cc, 5 patients (14.7%) had a bladder contractions, and 16 patients (47.1%) demonstrated the sign or diagnosis of (SUI). Additionally, there was a statistically significant improvement in both QOL questionnaires. CONCLUSIONS: Various surgical approaches may be used to treat voiding dysfunction following an anti-incontinence procedure. Following a vaginal or retropubic urethrolysis or takedown of a synthetic suburethral sling, obstructive symptoms are likely to improve, irritative symptoms may remain unchanged, and almost half will develop recurrence of SUI.

The ability of history and a negative cough stress test to detect occult stress incontinence in patients undergoing surgical repair of advanced pelvic organ prolapse.

To determine if a negative preoperative reduction cough stress test is a viable method of detecting occult stress incontinence or urge incontinence in women undergoing surgical repair of advanced pelvic organ prolapse. A retrospective chart review was done on all patients who denied any urinary complaints and had repair of advanced pelvic organ prolapse, grade two or greater, without the addition of an anti-incontinence procedure. Additionally patients had a simple office filling study done at the time of initial examination that failed to show the sign of stress incontinence or detrusor instability. Any urinary dysfunction that developed postoperatively was noted. A total of 53 patients met the inclusion criteria. Of these patients, one patient (1.9%) developed genuine stress incontinence, and one patient complained of urgency (1.9%). Patients without urinary complaints and a negative office filling study, who were present for surgical correction of advanced pelvic organ prolapse, have a low incidence of developing occult stress incontinence. Further work-up would not be cost effective.

The efficacy of the tension-free vaginal tape in the treatment of five subtypes of stress urinary incontinence.

PURPOSE: To determine the efficacy of tension-free vaginal tape (TVT) for the treatment of five sub-types of stress urinary incontinence (SUI). MATERIALS AND METHODS: A retrospective review was performed from November 1998 to November 2001 on all patients with SUI who underwent a TVT procedure either alone or with other reconstructive pelvic procedures. The patients were subdivided into five categories. Intrinsic sphincter deficiency (ISD) was defined by a maximum urethral closure pressure < 20 cm H2O or a mean Valsalva leak point pressure < 60 cm H2O above baseline. Urethral hypermobility (UH) was defined by a straining Q-tip angle greater than 30 degrees from the horizontal. Cure was defined as the subjective resolution of SUI without the development of voiding dysfunction or de novo urge incontinence. Improvement was defined as the subjective improvement of SUI without complete resolution or the subjective resolution of SUI occurring with the development of prolonged voiding dysfunction lasting greater than 6 weeks or de novo urge incontinence. Failure was defined as the subjective lack of improvement of SUI, the need for an additional procedure to correct SUI or the need for revision or takedown of the TVT for persistent voiding dysfunction or mesh erosion. RESULTS: The cure, improvement and failure rates for each of the following groups are respectively as follows: group 1 (+UH, -ISD) (n = 121): 101 (83.5%), 13 (10.7%), 7 (5.8%); group 2 (-UH, +ISD) (n = 22): 17 (77.3%), 3 (13.6%), 2 (9.1%); group 3 (+UH, +ISD) (n = 32): 26 (81.3%), 4 (12.5%), 2 (6.2%); group 4 (-UH, -ISD) (n = 25): 21 (84.0%), 3 (12.0%), 1 (4.0%); group 5 (occult SUI) (n = 67): 57 (85.1%), 10 (14.9%), 0 (0%). CONCLUSION: This study shows that the TVT is effective in treating all five sub-types of SUI.

Is previous cesarean section a risk for incidental cystotomy at the time of hysterectomy? A case-controlled study.

OBJECTIVE: The purpose of this study was to determine if previous cesarean section is an independent risk factor for incidental cystotomy at the time of hysterectomy. STUDY DESIGN: This is a case-controlled study that evaluated all cases of incidental cystotomy at the time of hysterectomy between January 1998 and December 2001. Five thousand and ninety-two hysterectomies were performed in the time period mentioned above, and 51 cases of incidental cystotomy were identified. Each case of incidental cystotomy was then matched to 3 controls with similar patient characteristics, medical histories, and surgical histories, as well as the absence of incidental cystotomy at the time of hysterectomy. RESULTS: Overall, 5092 hysterectomies were performed during the study period (total abdominal hysterectomy [TAH] 3140 [61.7%], total vaginal hysterectomy [TVH] 1519 [29.8%], laparoscopically-assisted vaginal hysterectomy [LAVH] 433 [8.5%]). Fifty-one cases of incidental cystotomy were identified (TAH: 24 [47.1%], TVH: 19 [37.3%], LAVH: 8 [15.7%]). The overall incidence of cystotomy was 1.0%. When considering TAH, there were 24/3141 (0.76%) cases of incidental cystotomy, with 8 (33%) of these patients with a history of previous cesarean section. During TVH, we encountered 19/1519 (1.3%) cases of incidental cystotomy, with 4 (21%) of these women having undergone a previous cesarean. Finally, during LAVH, there were 8/433 (1.8%) cases of incidental cystotomy. Five (62.5%) of these patients had a previous history of cesarean section. In comparison, 19/72 (26.4%) TAH controls had a previous history of cesarean. Four out of 57 (7.0%) TVH controls had a history of cesarean section. Finally, 2/24 (8.3%) LAVH controls had a history of previous cesarean. CONCLUSION: Previous cesarean section is indeed a significant risk factor for damage to the lower urinary tract at the time of hysterectomy (odds ratio [OR] 2.04; 95%CI 1.2-3.5). When analyzed separately, the OR of incidental cystotomy at the time of TAH, TVH, and LAVH in a woman with a history of previous cesarean was 1.26, 3.00, and 7.50, respectively. Only the value for LAVH was statistically significant (P = .005; 95%CI 1.8-31.4).

Prevalence of persistent and de novo overactive bladder symptoms after the tension-free vaginal tape.

OBJECTIVE: The purpose of this study was to assess 1) the proportion of de novo urge incontinence and overactive bladder symptoms after a tension-free vaginal tape (TVT), and 2) the natural history of preoperative urge incontinence and overactive bladder symptoms after a TVT. METHODS: A chart review was performed on all patients who underwent a TVT without concomitant procedures from November 1998 to November 2002. Preoperative and postoperative stress and mixed urinary incontinence symptoms as well as overactive bladder symptoms were assessed subjectively, as was the use of anticholinergics to treat overactive bladder symptoms. Two preoperative and postoperative validated quality-of-life questionnaires, the Incontinence Impact Questionnaire (IIQ-7) and Urinary Distress Inventory (UDI-6), were also compared. RESULTS: Ninety-eight patients were included in the study. Postoperatively, de novo urge incontinence symptoms developed in 9.1%, de novo overactive bladder symptoms developed in 4.3%, and 8.7% started taking anticholinergics for the first time. After a TVT, the urge component resolved in 63.1% of those with preoperative symptoms of mixed incontinence, overactive bladder symptoms resolved in 57.3% of those with preoperative overactive bladder symptoms, and 57.7% of those who used anticholinergics preoperatively no longer needed to do so. There was also a statistically significant improvement in comparing the preoperative and postoperative IIQ-7 and UDI-6 scores. CONCLUSION: The proportion of patients in whom de novo overactive bladder or urge incontinence symptoms developed postoperatively is low, and approximately 57% of patients with preoperative overactive bladder symptoms can expect resolution of these symptoms after a TVT.

Paravaginal defects: prevalence and accuracy of preoperative detection.

The objective of this study was to determine the prevalence of paravaginal defects and to report the correlation between diagnosing a paravaginal defect preoperatively and observing the presence of one intraoperatively. This was a prospective study in which 77 patients with at least stage 2 prolapse of the anterior vaginal wall who desired surgical correction of their prolapse were assessed pre- and intraoperatively for the detection of a paravaginal defect. In order to differentiate a midline or central defect from a paravaginal defect, an index finger or ring forceps was placed vaginally toward each ischial spine separately. If the prolapse became reduced, the patient was clinically diagnosed with a paravaginal defect on that side. The intraoperative visualization or palpation of the pubocervical fascia detached from the arcus tendineus fasciae pelvis was used as the gold standard in diagnosing a paravaginal defect. The overall prevalence of a paravaginal defect in patients with at least stage 2 prolapse of the anterior vaginal wall was 37.7%. The sensitivities for detecting a left, right and bilateral paravaginal defect were 47.6, 40.0 and 23.5%, respectively, while the specificities for each side were 71.4, 67.3, and 80.0%, respectively. The overall prevalence of a paravaginal defect in patients with anterior vaginal wall prolapse is low. The standard clinical evaluation used to preoperatively detect a paravaginal defect in our hands is a poor predictor for the actual presence of a paravaginal defect.

Management of iatrogenic vaginal constriction.

OBJECTIVE: To prospectively assess the outcomes of four approaches to the surgical management of iatrogenic vaginal constriction. METHODS: A prospective study was initiated to evaluate all women who presented to our practice with the complaint of apareunia or dyspareunia secondary to postoperative vaginal constriction. All participants were initially offered and failed a trial of manual dilation. Between 1997 and 2002, 20 women underwent one of four surgical procedures: Z-plasty, vaginal incision of constriction ring, vaginal advancement, or placement of free skin graft. All 20 participants have been followed postoperatively, including assessment of dyspareunia and postoperative vaginal length and caliber. RESULTS: Three patients underwent Z-plasty, eight had incision of vaginal ring or ridge, eight had vaginal advancement, and one underwent placement of a free skin graft. Mean follow-up was 17 months (range, 3-32 months). Subjective cure was defined as resumption of pain-free vaginal intercourse. Objective cure was defined by findings on physical examination. The overall subjective and objective cure rates were 75% and 85%, respectively. CONCLUSION: The appropriate surgical procedure depends on the site and extent of the vaginal constriction, the state of the surrounding tissue, and the overall length and caliber of the vagina.

Complications and untoward effects of the tension-free vaginal tape procedure.

OBJECTIVE: To report our experience with our first 350 cases of tension-free vaginal tape (TVT), specifically assessing intraoperative complications, postoperative morbidity, and untoward effects of the procedure. METHODS: Although increased numbers of reports have documented the efficacy of the TVT procedure, there are minimal data about the incidence of complications and how they are managed. We performed a retrospective review of all patients undergoing the TVT procedure over a 4-year period to report intraoperative complications (bladder perforation and excessive bleeding), postoperative complications (de novo urge incontinence, voiding dysfunction, erosion, nerve injury, urinary retention, hematoma formation), and incidence of reoperation either for voiding dysfunction or for recurrent incontinence. RESULTS: A total of 350 patients were included in the study. Fifty-five percent (194) of women underwent the TVT procedure in conjunction with other vaginal surgery, and 45% (156) underwent the TVT alone. Seventy women (20%) had previous antiincontinence surgery. Intraoperative complications included 19 bladder perforations in 17 patients (4.9%) and three cases of significant bleeding (0.9%). Postoperatively, 17 women (4.9%) had voiding dysfunction and 42 (12%) required anticholinergic therapy beyond 6 weeks. Recurrent urinary tract infections developed in 38 (10.9%), erosion or poor healing in three (0.9%), hematoma in six (1.7%), and nerve injury in three (0.9%). Twenty-eight (8%) underwent urethral dilation in the postoperative period for varied amounts of voiding dysfunction. Of these, 82% were either improved or were cured. Six women (1.7%) underwent a takedown of the TVT procedure for continued voiding dysfunction, and two of these (33%) developed recurrent stress incontinence. To date, two patients (0.5%) have undergone another procedure for recurrent or persistent stress incontinence. CONCLUSION: The TVT procedure is efficacious for the correction of stress incontinence. Our data show that it is a safe procedure with an acceptable complication rate when performed by surgeons who have experience with retropubic and transvaginal antiincontinence procedures.

Urethral erosion of a tension-free vaginal tape.

BACKGROUND: Urethral dilation has been recommended to treat voiding dysfunction that may occur after placement of tension-free vaginal tape (TVT) for the treatment of stress urinary incontinence. We report on a case of urethral erosion by the tape secondary to repetitive urethral dilations after surgery. CASE: A urethral erosion by the tape was diagnosed by cystoscopy after three urethral dilations failed to resolve postoperative voiding dysfunction 8 weeks after the initial procedure. A partial tape revision with repair of the urethrotomy was performed, with resolution of the subject's voiding dysfunction. CONCLUSION: This report describes a potential complication of a recommended treatment for voiding dysfunction after placement of TVT.

Tension-free vaginal tape: a quality-of-life assessment.

OBJECTIVE: To assess whether tension-free vaginal tape (TVT) results in significant improvements in urinary incontinence and its effect on patients' quality of life (QOL) utilizing two validated questionnaires. METHODS: One hundred sixty-two tension-free vaginal tape procedures were performed at two sites between October 1998 and January 2001. All patients were requested to complete the Incontinence Impact Questionnaire (IIQ-7) and Urinary Distress Inventory (UDI-6) as part of their preoperative assessment. History, physical, and demographic data were also collected. All subjects underwent subtracted cystometry and urethral function tests prior to surgery. A combination of mail and phone follow-up was used to obtain postoperative IIQ-7 and UDI-6 scores in October 2001. Data were analyzed with the Wilcoxon matched-pairs signed-ranks test. RESULTS: One hundred fifty-one patients completed the pre- and postoperative quality-of-life forms and were included in the analysis. Mean follow-up was 22.1 months (range 6.1-49.8). There were significant improvements in postoperative scores for both the IIQ-7 and the UDI-6 (P <.001). Significant improvements were also seen in subscales measuring urge symptoms, stress incontinence symptoms, and symptoms of voiding dysfunction. These improvements were consistent, regardless of type or severity of stress incontinence. CONCLUSION: The IIQ-7 and UDI-6 are validated tools that can be used to provide some objective evidence for the impact of urinary incontinence on patients' lives. Utilizing these two validated quality-of-life tools we show that tension-free vaginal tape results in significant improvement in patient quality of life and symptoms of urgency, stress incontinence, and voiding dysfunction.

Predicting postoperative voiding efficiency after operation for incontinence and prolapse.

OBJECTIVE: The purpose of this study was to determine the postoperative postvoid residual volume that predicts a voiding efficiency after operation for incontinence and prolapse. STUDY DESIGN: Ninety-nine patients met the criteria for inclusion. The patients' bladders were filled retrograde through gravity, through a Foley catheter, with 300 mL of sterile water, or by subjective fullness. The catheter was then removed, and the patient was asked to void spontaneously into a measured urine collection device ("Texas hat"). A postvoid residual was then calculated (amount voided minus amount inserted). The Foley catheter was reinserted for patients with a postvoid residual of >50%. These patients were instructed to follow-up in the office in 1 week, at which time the test was repeated. This process continued until the patient had a postvoid residual of < or = 50% or was taught intermittent self-catheterization. RESULTS: Ninety patients were available for follow-up. The overall failure rate (defined as cases that required reinsertion of a catheter) was 7.8%. No patient with a postvoid residual of < or = 32% required reinsertion of a catheter. CONCLUSION: With the use of this simple bedside test, voiding efficiency was predicted in 92% of patients who voided > or = 50% of the amount inserted and in 100% of patients who voided > or = 68%.