Urogynecologic ultrasound is a useful aid in the assessment of female stress urinary incontinence--a prospective study with TVT procedure.

The aims of the study were to study the suitability of certain urogynecologic ultrasound parameters, e.g. descent of the urethrovesical (UV) junction on Valsalva, posterior urethrovesical (PUV) angle both at rest and on Valsalva, and funneling of the vesical neck, in the pre- and postoperative assessment of stress urinary incontinence (SUI) and to evaluate the efficacy and safety of tension-free vaginal tape (TVT) for the surgical treatment of SUI. Forty-six consecutive women (mean age 61 years) with symptoms of SUI underwent TVT placement. The patients were examined prior to and on average of 11 weeks after the operation with perineal ultrasound. An upright coughing test on standing was performed every time. Operative success rate was 94% in this series. Urogynecologic perineal ultrasound examination seemed strongly to support an anamnestic diagnosis of genuine SUI, and TVT proved to be a safe and effective ambulatory procedure for the surgical treatment of SUI.

Vaginal axis after abdominal, vaginal and laparoscopic hysterectomy: a preliminary study with perineal ultrasonography using contrast medium.

Fifteen consecutive women (mean age 44.5 years) without pelvic relaxation underwent total abdominal (5), vaginal (5) and laparoscopic (5) hysterectomy for benign disease. The vaginal axes of the patients were examined prior to and on average 7 weeks (range 3-10) after the operation with perineal ultrasonography enhanced with an ultrasound contrast medium (SHU454/Echovist-300). Transabdominal and vaginal hysterectomies were performed in the classic manner, i.e. the round as well as cardinal and sacrouterine ligaments were attached to the vaginal vault, followed by peritonealization. In laparoscopic hysterectomy the round, broad and outer parts of the uterosacral and the upper parts of the cardinal ligaments were desiccated by bipolar electrocoagulation and cut with laparoscopic scissors. The vagina was closed by interrupted sutures with no specific fixation of the round, cardinal or uterosacral ligaments. Preoperative ultrasound findings showed that in all women the vagina was an angulated organ. The mean preoperative angle between the upper and lower vaginal portions was 108 degrees, in both the supine and the standing positions. Postoperatively this angulated shape remained almost unchanged after vaginal (mean angle 117 degrees ) and laparoscopic hysterectomy (mean angle 130 degrees ), whereas after transabdominal hysterectomy the vaginal axis rotated anteriorly and became an almost straight tube (mean angle 158 degrees). We conclude that the vaginal axis, at least at an early stage after vaginal and laparoscopic hysterectomy remained in almost the same position as preoperatively, in contrast to that after abdominal hysterectomy. A tight attachment of the round ligaments to the vaginal vault in the abdominal approach could explain the outcome of transabdominal hysterectomy, and should be called into question.

Evisceration after enterocele repair: a rare complication of vaginal surgery.

Evisceration is a life-threatening surgical emergency which must be promptly treated. Evisceration following vaginal enterocele operation is so rare that no incidence rate can be established. A review of the literature revealed only 71 cases. The reported women were in general postmenopausal, with only 15% less than 50 years of age. In 18% of cases vaginal rupture occurred while straining at stool. Four patients are known to have died due to evisceration. Of the reported repair operations, 57% were performed transabdominably, 28% transvaginally, and 15% via a combined abdominovaginal route. The authors present 1 more case treated transvaginally, with a review of the literature.

Mortality after gynaecologic operations in Finland, 1986-1991.

OBJECTIVE: To study the current in-hospital, 30-day and 42-day mortality after conventional gynaecologic procedures in Finland, with special reference to hysterectomy. DESIGN: Nationwide six-year annual study. SETTING: Data were from the Finnish Population Register Centre, the Finnish Cause-of-Death and Hospital Discharge Register, and the Register for Legal Abortions and Sterilisations. SUBJECTS: Gynaecologic operations (n = 299,257) performed between January 1986 and December 1991. MAIN OUTCOME MEASURES: The overall and age-adjusted mortality rates during the initial hospitalisation, as well as 30 and 42 days after the operations. Age-adjusted probability of dying within 42 days after hysterectomy compared with the overall probability of age-matched Finnish female control population. RESULTS: Overall mortality rates per 10,000 hysterectomies increased gradually from 6.0 during initial hospitalisation to 9.1 and 12.9 when calculated 30 and 42 days post-operatively. The overall 42-day mortality rates of radical hysterectomy, curettage and laparoscopy (other than sterilisation) exceeded the post-hysterectomy mortality rate, while the rates after caesarean section, legal abortion and laparoscopic sterilisation did not. No deaths occurred after laparoscopic sterilisation (n = 40,346). The patients who died after radical hysterectomy, curettage and for other laparoscopy than sterilisation were old, and the great majority of them died of cancer. CONCLUSIONS: The mortality rates after gynaecologic procedures in Finland are currently very low and have clearly decreased in recent decades. Patients may be reassured that conventional gynaecologic operations are safe.

Vesicocervical fistula--a rare cause of urinary incontinence.

A vesicocervical fistula is reported. This extremely rare and late sequela of caesarean section, secondary to a lesion in the bladder and unrecognized intraoperatively, was followed with a distressing, long-lasting urinary incontinence unreactive to conservative treatment. Not until 7 years after the primary operation was this lesion diagnosed and treated successfully by vaginal approach. Etiological factors, clinical features and treatment possibilities are discussed.

Retrospective analysis of 711 patients operated on for pelvic relaxation in 1983-1989.

OBJECTIVE: To analyze which factors, including gynecological surgery in particular, contribute to the occurrence of pelvic relaxation. METHOD: A retrospective analysis of 711 consecutive patients treated surgically for pelvic relaxation from 1983 to 1989 at the Department of Obstetrics and Gynecology of Turku University Central Hospital was undertaken. RESULT: The patients who underwent surgery for recurrent pelvic relaxation were significantly older (66.8 vs. 62.1 years) and suffered significantly less (20% vs. 41%) from urinary stress incontinence than patients undergoing primary surgery for pelvic relaxation. Anterior vaginal segment relaxation (i.e. cysto- and urethrocele) was common in patients undergoing the initial operation (n = 684), and posterior vaginal segment relaxation (i.e. rectocele and perineal laceration) in recurrent operations (n = 58). Of the patients studied, 87 had pelvic relaxation, which had developed after partial (n = 46), total abdominal (n = 16) or vaginal (n = 25) hysterectomy. CONCLUSION: Care must be taken in the treatment of the posterior vaginal segment during the initial operation for pelvic relaxation in order to avoid late sequelae. Moreover, when the removal of the uterus is planned, the matter of a stable vaginal vault must be taken into account especially when partial hysterectomy should be performed.