Stress urinary incontinence (SUI) is common in the adult females. Surgical treatment options incl... more Stress urinary incontinence (SUI) is common in the adult females. Surgical treatment options include synthetic mid-urethral sling (MUS), autologous sling, bulking agents, and Burch colposuspension. The autologous pubovaginal sling (PVS) has re-emerged in response to complications of synthetic MUSs and FDA communications regarding the use of vaginal mesh. This resulted in patients' fear related to vaginal mesh and drop in number of patients seeking surgical treatment of SUI. PVS has re-emerged as an option for treatment of primary SUI. The aim of this review is to familiarize, disseminate information, and share tips for the practicing female pelvic surgeons related to the practice of the autologous fascia sling. Methods: We reviewed the literature related to the autologous sling. We used the following data bases and search engines: GoPubMed (Transinsight), Cochrane reviews (Wiley Interscience), google scholar (google), and Scopus (Elsevier). Because it is the most commonly investigated and utilized, we focused on the autologous rectus fascia sling. We also focused on the retropubic sling approach because the literature on transobturator rectus fascia sling is sparse. Results: Out of 307 articles related to the subject found, 22 articles were included and the rest were excluded. Conclusion: ARFS is a valid primary method of treatment for female SUI. Also, it is used in particular indications such as patients with intrinsic sphincter deficiency (ISD), prior pelvic irradiation, failed and/or complicated synthetic MUS, and violated urethral lumen.
Acute urinary retention (AUR) in women is not uncommon. Many reports have been published discussi... more Acute urinary retention (AUR) in women is not uncommon. Many reports have been published discussing the possible theories and pathogeneses of this condition. AUR induced by uterine fibroid is a rare entity that has been mentioned only in case reports. All the reported cases focused mainly on the different approaches for fibroid management. In this study, we present a 52-year-old female with recurrent episodes of urinary retention that was related to periods of menstruation. Pelvic magnetic resonance imaging revealed a markedly enlarged uterus with multiple fibroids. The patient had laparoscopic hysterectomy with postoperative resolution of patient's symptoms and improved uroflow studies. This is the first article that proves the cure of AUR following hysterectomy using an objective tool.
Interstitial cystitis/painful bladder syndrome/(IC/PBS) results in recurring pain in the bladder ... more Interstitial cystitis/painful bladder syndrome/(IC/PBS) results in recurring pain in the bladder and surrounding pelvic region caused by abnormal excitability of micturition reflexes. Spinal cord stimulation (SCS) is currently clinically used for the attenuation of neuropathic and visceral pain. The present study examined whether SCS at upper lumbar segments modulates detrusor overactivity and visceral hyperalgesia associated with cystitis in a rat model of cyclophosphamide (CYP)-induced cystitis. Methods: Cystitis was induced by intraperitoneal injection of CYP (200 mg/kg) in six adult female Sprague Dawley rats 48 h prior to urodynamic recordings. Another six rats served as-controls with saline injection. Cystometry and the external urethral sphincter (EUS) electromyography during bladder infusion were evaluated under urethane anesthesia. The visceromotor reflexes (VMR) obtained from the external abdominal oblique muscle were quantified during bladder infusion and isotonic bladder distension (IBD), respectively. After baseline recordings were taken, SCS was applied on the dorsal surface of L3 for 25 min. Urodynamic recordings and VMR during bladder infusion and IBD were repeated 2 h after SCS. Results: CYP resulted in detrusor overactivity, stronger EUS tonic contractions, and increased VMR. SCS significantly reduced non-voiding contractions, prolonged EUS relaxation, and delayed VMR appearance during bladder infusion as well as significantly decreased VMR during IBD in cystitis rats. and significantly attenuated visceral nociceptive-related VMR during IBD in cystitis rats. SCS may have therapeutic potential for patients with hyperalgesia and IC/PBS. electromyography, external urethral sphincter, neuromodulation, visceral pain Neuromodulation of the sacral nerves and lumbosacral spinal roots has been established as an effective treatment for urge incontinence, urgency-frequency symptoms, non-obstructive urinary retention, and neurogenic bladder. 1 Spinal cord stimulation (SCS) of upper lumbar segments was previously reported to improve the urethral relaxation and promote efficient voiding. 2,3 SCS has also been employed for chronic neuropathic pain and visceral hyperalgesia. The mechanisms Karl-Erik Andersson led the peer-review process as the Associate Editor responsible for the paper.
Purpose: To characterize detrusor properties of myelomeningocele (MMC) bladders which failed conv... more Purpose: To characterize detrusor properties of myelomeningocele (MMC) bladders which failed conventional therapy. Materials and Methods: Bladder strips from five end-stage MMC patients were compared with those from five patients with vesicoureteric reflux. The active and passive properties of the detrusor muscles and the effect of different blocking agents on the transmural nerve stimulation were studied. Results: A significant decrease in contractility (p = 0.003) and increased rigidity (p = 0.019) was found in MMC group. In the control group, atropine blocked 77.7% of the detrusor contractility and tetrodotoxin demonstrated an equal blocking effect. In MMC group, atropine blocked 58.2% and tetrodotoxin blocked 77.4% of the detrusor contractility. Conclusion: MMC bladders showed decreased contractility and increased rigidity. In MMC group, the atropine-resistant component which is blocked by tetrodotoxin signifies the possible existence of non-adrenergic, non-cholinergic neurotransmitters (NANC). Further studies are needed to possibly improve the pharmacological therapy of the myelomeningocele detrusor.
The hyperactive bladder does not always completely empty. The aim of this study was to determine ... more The hyperactive bladder does not always completely empty. The aim of this study was to determine the frequency of detrusor instahility and impaired contractility in 45 patients with benign prostatic hyperplasia. The evaluation consisted of uroflowmetry , residual urine determination, cystometrogram (CMG), and micturition study with stop-flow technique, Detmsor instability is diagnosed urodynamically with the appearance of abnormal contractions either on medium filling CMG and/or on a provocative rapid injection CMG. Iinpaired bladder contractility was diagnoscd by the presence of significant residual urine (250% of capacity) and unsustained bladder contraction with no or little detrusor reserve power. Urodynamic evaluation showed that 21 out of 45 patients had detrusor instability. Seven of these patients showed also impaired contractility. The mean residual urine was 380 ml in this subgroup. On micturition studies five of thesc patients showed low prcssure, low uroflow pattern. Stop-flow technique revealed absence of detrusor reserve power in five patients, while two patients showed little detrusor reserve power. Out of the 24 patients with stable bladders, four showed impaired contractility. Indeed, delrusor instability is not associated exclusively with low residual urine values. The importance of recognizing detrusor instability in combination with poor contractility in patients with benign prostatic hyperplasia is that one can anticipate incomplctc bladder emptying even after prolstate surgery and consider other forms of therapy. Our approach to this specific problem is presented.
Dextranomer/hyaluronic acid copolymer (Zuidex®) is a new bulking agent. There is little data abou... more Dextranomer/hyaluronic acid copolymer (Zuidex®) is a new bulking agent. There is little data about the complications of using this substance as urethral bulking agent for the treatment of urinary stress incontinence. We are presenting a 59-year-old female patient who developed a suburethral mass and urinary retention after zuidex urethral injection. A stepwise approach for treatment was followed. Complete excision of the mass was the only curative procedure that succeeded.
We evaluate transurethral collagen injection as a minimally invasive option in treating stress ur... more We evaluate transurethral collagen injection as a minimally invasive option in treating stress urinary incontinence in men and identify the prognostic factors for success or failure. Transurethral collagen was injected in 35 men with grades III (22) and II (13) incontinence. Of the patients 7 became dry (20%), 11 improved (31.4%) and 17 were considered failures (48.6%). Abdominal leak point pressure increased and the number of pads needed decreased. In the failed group 4 patients had a history of pelvic irradiation, 5 urethral stricture disease and 3 bladder instability before injection. There was 1 case of temporary urinary retention as a complication. Transurethral collagen injection for male stress urinary incontinence is a reasonable option in select patients.
In deciding which surgical approach to use in repairing pelvic organ prolapse (POP), it is essent... more In deciding which surgical approach to use in repairing pelvic organ prolapse (POP), it is essential to have a complete understanding not only of the relevant anatomy, but also of the pathogenesis of POP. A detailed discussion of pelvic floor anatomy and physiology was presented earlier. There is no ideal approach or repair for POP. The choice of operation is made after careful consideration of a series of factors related to the patient’s anatomy, medical history, and goals of surgery. To further complicate matters, laparoscopic and robotic surgery are new techniques available to the pelvic reconstructive surgeon. These newer techniques will be discussed in detail in a later Chapter. Finally, the traditional view that hysterectomy is part of POP repair is being challenged.
Objectives. A simple new technique, using a trapezoid island of vaginal wall, is described for el... more Objectives. A simple new technique, using a trapezoid island of vaginal wall, is described for elderly female patients undergoing transvaginal pelvic prolapse repair and suffering from stress urinary incontinence secondary to intrinsic sphincteric deficiency. Methods. Fifteen elderly women underwent bladder neck prop in association with other pelvic prolapse surgery. The mean follow-up period was 20 months. Results. Twelve of 14 patients (85.7%) were dry. One patient was lost to follow-up. Conclusions. Bladder neck prop provided urethral and bladder neck compression and support. The major advantage of this approach is avoiding extensive dissection and/or abdominal incision in elderly female patients.
Purpose: hbovaginal sling is gaining widespread acceptance as a primary form of treatment for typ... more Purpose: hbovaginal sling is gaining widespread acceptance as a primary form of treatment for types I1 and 111 stress urinary incontinence. However, a major drawback is postoperative obstructed voiding due to excessive force placed on the suspension suture. We describe a simple objective method for intraoperative adjustment of sling tension that can be performed by a single surgeon during pubovaginal sling surgery. Materials and Methods: A cotton swab is inserted into the urethra and placed at the urethrovesical junction after the sling is fixed suburethrally and the vaginal mucosa is closed. The suspension sutures are tied down directly onto the rectus fascia with enough tension to keep the cotton swab angle between 0 and 10 degrees to the horizontal plane. A total of 29 patients with an average age of 62 years underwent pubovaginal sling surgery with rectus and cadaveric fascia using this technique for tension adjustment. Of the patients 21 were diagnosed with types I1 and 111, 5 had type I1 only and 3 had type 111 only incontinence. Preoperative evaluation revealed detrusor instability in 5 patients. Mean postoperative indwelling catheterization period was 6.2 days. Average followup was 15.6 months. Results: To date no permanent urinary retention has occurred. Of the patients 15 voided without difficulty after catheter removal, 13 had urinary difficulty requiring intermittent catheterization for 1 week or less and 1 had retention requiring intermittent catheterization for 10 weeks. Preoperative symptoms of detrusor instability resolved in all cases. De novo detrusor instability in 3 cases was controlled with anticholinergics. Conclusions: Overzealous sling tension adjustment has been recognized as a cause of treatment failure leading to urethral obstruction. Our technique is effective in preventing over adjustment of tension, is reproducible and can be performed by 1 surgeon.
In a pivotal trial we evaluated the effectiveness and safety of Macro-plastique® as minimally inv... more In a pivotal trial we evaluated the effectiveness and safety of Macro-plastique® as minimally invasive endoscopic treatment for female stress urinary incontinence primarily due to intrinsic sphincter deficiency. Materials and Methods: A total of 247 females with intrinsic sphincter deficiency were randomized 1:1 and treated with a transurethral injection of Macroplastique or Contigen®. The latter group served as the control. Repeat treatment was allowed after the 3-month followup. Effectiveness was determined 12 months after the last treatment using Stamey grade, pad weight and Urinary Incontinence Quality of Life Scale scores. Safety assessment was recorded throughout the study. Results: After 12 patients were excluded from study 122 patients received Macroplastique injection and 125 received Contigen injection. Mean patient age was 61 years and the average history of incontinence was 11.2 years. Of the patients 24% had undergone prior incontinence surgery. At 12 months after treatment 61.5% of patients who received Macroplastique and 48% of controls had improved 1 Stamey grade. In the Macroplastique group the dry/cure rate was 36.9% compared to 24.8% in the control group (p Ͻ0.05). In the Macroplastique and control groups the 1-hour pad weight decrease was 25.4 and 22.8 ml from baseline (p ϭ 0.64), and the mean improvement in Urinary Incontinence Quality of Life Scale score was 28.7 and 26.4 (p ϭ 0.49), respectively. Conclusions: Macroplastique injection was statistically more effective than Contigen for stress urinary incontinence primarily due to intrinsic sphincter deficiency with a 12.1% cure rate difference. Macroplastique can be administered on an outpatient basis. It should be considered a primary or secondary treatment option for stress urinary incontinence.
Ilioinguinal nerve entrapment is a documented complication of inguinal herniorraphy, inguinal lym... more Ilioinguinal nerve entrapment is a documented complication of inguinal herniorraphy, inguinal lymph node dissection, and appendectomy. This article reports two clinical histories to illustrate the diagnosis and management, and outlines prevention of ilioinguinal nerve entrapment as a complication of needle suspension procedures for stress urinary incontinence.
A modified Martius graft interposition flap was used in conjunction with the modified pubovaginal... more A modified Martius graft interposition flap was used in conjunction with the modified pubovaginal sling bladder suspension to treat a recurrent vesicovaginal fistula involving the proximal urethra and bladder neck. The patient recovered with no incontinence, voiding dysfunction or dyspareunia. Incontinence should be anticipated with vesicovaginal fistulas involving the internal sphincter and repair should be tailored to include an organic suburethral sling.
The authors report results of a survey of the practice patterns of International Urogynecological... more The authors report results of a survey of the practice patterns of International Urogynecological Association (IUGA) members in the management of urinary incontinence and pelvic organ prolapse. A questionnaire regarding current urogynecological clinical practice was developed by the Research and Development Committee of IUGA and mailed to all members of IUGA. Age, specialty, and geographic location factors were used for response comparisons. One hundred and fifty-two surveys (30%) were returned, 35% from North America, 51% from Europe/Australia/New Zealand, and 14% from elsewhere. The average age of respondents was 47.2 years (SD = 9.5), 89% were gynecologists and 11% were urologists. Overall, the procedures of choice for stress incontinence (SUI) were tension-free vaginal tape (TVT; 48.8%) and Burch colposuspension (44%). There were significant geographic variations noted. For SUI with low-pressure urethra/intrinsic sphincteric deficiency, TVT was used by 44.6% and suburethral sling by 32.3%. Various materials are used for suburethral slings, including autologous fascia (46.5%), Marlex mesh (27.8%) and cadaveric fascia lata (11.6%). Bulking agent injection therapy is used for ISD by 75% of respondents. Traditional reconstructive procedures are performed by the majority of respondents, including sacrospinous fixation (78%), abdominal sacrocolpopexy (77%), paravaginal repair (65%) and vaginal enterocele repair (93%); 6.5% use defecography in evaluating rectoceles and 44% use the POP-Q. Seventy-two per cent use urodynamic evaluation routinely in prolapse cases with no manifest SUI. Most IUGA members perform commonly accepted procedures for surgical therapy of urinary incontinence and genital prolapse. IUGA members do not frequently use anorectal physiology and fluoroscopic investigations to evaluate rectoceles prior to repair.
The objective of this study was to evaluate the impact of obesity on pelvic floor function in wom... more The objective of this study was to evaluate the impact of obesity on pelvic floor function in women. This was a prospective controlled study of 20 morbidly obese female patients planning to undergo gastric bypass surgery and 20 age-matched female controls. Subjects completed symptom and impact questionnaires, including the Incontinence Impact Questionnaire (IIQ-7), Urogenital Distress Inventory (UDI), the Kobashi Prolapse Symptom Inventory and Quality-of-Life Questionnaire (PSI-QOL), and Index of Female Sexual Function. Data were analyzed with Wilcoxon or ratio 2 tests. Results: Mean weight was 295.7 Ϯ 87.9 lbs in the study group and 144.79 Ϯ 33.07 lbs in the control group. Mean BMI was 52.65 Ϯ14.49 kg/m 2 in the study group and 25.11 Ϯ 5.27 kg/m 2 in the control group. According to the IIQ-7, urinary incontinence significantly affected lifestyle in the study group. The total IIQ-7 score was also significantly affected in the study group (p ϭ 0.03). The UDI indicated more urinary leakage with activity (p ϭ 0.04) and more incidents of small amounts of leakage (p ϭ 0.02) in the study group. According to the PSI-QOL, women in the study group experienced constipation more often because of difficulty in emptying the rectum (p ϭ 0.04). The PSI-QOL score was higher in the study group (6.75 Ϯ 6.84) than in the control group (2.65 Ϯ 3.03; p ϭ 0.04). There were no significant differences between groups regarding sexual function. Discussion: Morbid obesity is associated with a significant negative impact on urogenital health. Sexual function did not seem to be affected in women who are morbidly obese.
Stress urinary incontinence (SUI) is common in the adult females. Surgical treatment options incl... more Stress urinary incontinence (SUI) is common in the adult females. Surgical treatment options include synthetic mid-urethral sling (MUS), autologous sling, bulking agents, and Burch colposuspension. The autologous pubovaginal sling (PVS) has re-emerged in response to complications of synthetic MUSs and FDA communications regarding the use of vaginal mesh. This resulted in patients' fear related to vaginal mesh and drop in number of patients seeking surgical treatment of SUI. PVS has re-emerged as an option for treatment of primary SUI. The aim of this review is to familiarize, disseminate information, and share tips for the practicing female pelvic surgeons related to the practice of the autologous fascia sling. Methods: We reviewed the literature related to the autologous sling. We used the following data bases and search engines: GoPubMed (Transinsight), Cochrane reviews (Wiley Interscience), google scholar (google), and Scopus (Elsevier). Because it is the most commonly investigated and utilized, we focused on the autologous rectus fascia sling. We also focused on the retropubic sling approach because the literature on transobturator rectus fascia sling is sparse. Results: Out of 307 articles related to the subject found, 22 articles were included and the rest were excluded. Conclusion: ARFS is a valid primary method of treatment for female SUI. Also, it is used in particular indications such as patients with intrinsic sphincter deficiency (ISD), prior pelvic irradiation, failed and/or complicated synthetic MUS, and violated urethral lumen.
Acute urinary retention (AUR) in women is not uncommon. Many reports have been published discussi... more Acute urinary retention (AUR) in women is not uncommon. Many reports have been published discussing the possible theories and pathogeneses of this condition. AUR induced by uterine fibroid is a rare entity that has been mentioned only in case reports. All the reported cases focused mainly on the different approaches for fibroid management. In this study, we present a 52-year-old female with recurrent episodes of urinary retention that was related to periods of menstruation. Pelvic magnetic resonance imaging revealed a markedly enlarged uterus with multiple fibroids. The patient had laparoscopic hysterectomy with postoperative resolution of patient's symptoms and improved uroflow studies. This is the first article that proves the cure of AUR following hysterectomy using an objective tool.
Interstitial cystitis/painful bladder syndrome/(IC/PBS) results in recurring pain in the bladder ... more Interstitial cystitis/painful bladder syndrome/(IC/PBS) results in recurring pain in the bladder and surrounding pelvic region caused by abnormal excitability of micturition reflexes. Spinal cord stimulation (SCS) is currently clinically used for the attenuation of neuropathic and visceral pain. The present study examined whether SCS at upper lumbar segments modulates detrusor overactivity and visceral hyperalgesia associated with cystitis in a rat model of cyclophosphamide (CYP)-induced cystitis. Methods: Cystitis was induced by intraperitoneal injection of CYP (200 mg/kg) in six adult female Sprague Dawley rats 48 h prior to urodynamic recordings. Another six rats served as-controls with saline injection. Cystometry and the external urethral sphincter (EUS) electromyography during bladder infusion were evaluated under urethane anesthesia. The visceromotor reflexes (VMR) obtained from the external abdominal oblique muscle were quantified during bladder infusion and isotonic bladder distension (IBD), respectively. After baseline recordings were taken, SCS was applied on the dorsal surface of L3 for 25 min. Urodynamic recordings and VMR during bladder infusion and IBD were repeated 2 h after SCS. Results: CYP resulted in detrusor overactivity, stronger EUS tonic contractions, and increased VMR. SCS significantly reduced non-voiding contractions, prolonged EUS relaxation, and delayed VMR appearance during bladder infusion as well as significantly decreased VMR during IBD in cystitis rats. and significantly attenuated visceral nociceptive-related VMR during IBD in cystitis rats. SCS may have therapeutic potential for patients with hyperalgesia and IC/PBS. electromyography, external urethral sphincter, neuromodulation, visceral pain Neuromodulation of the sacral nerves and lumbosacral spinal roots has been established as an effective treatment for urge incontinence, urgency-frequency symptoms, non-obstructive urinary retention, and neurogenic bladder. 1 Spinal cord stimulation (SCS) of upper lumbar segments was previously reported to improve the urethral relaxation and promote efficient voiding. 2,3 SCS has also been employed for chronic neuropathic pain and visceral hyperalgesia. The mechanisms Karl-Erik Andersson led the peer-review process as the Associate Editor responsible for the paper.
Purpose: To characterize detrusor properties of myelomeningocele (MMC) bladders which failed conv... more Purpose: To characterize detrusor properties of myelomeningocele (MMC) bladders which failed conventional therapy. Materials and Methods: Bladder strips from five end-stage MMC patients were compared with those from five patients with vesicoureteric reflux. The active and passive properties of the detrusor muscles and the effect of different blocking agents on the transmural nerve stimulation were studied. Results: A significant decrease in contractility (p = 0.003) and increased rigidity (p = 0.019) was found in MMC group. In the control group, atropine blocked 77.7% of the detrusor contractility and tetrodotoxin demonstrated an equal blocking effect. In MMC group, atropine blocked 58.2% and tetrodotoxin blocked 77.4% of the detrusor contractility. Conclusion: MMC bladders showed decreased contractility and increased rigidity. In MMC group, the atropine-resistant component which is blocked by tetrodotoxin signifies the possible existence of non-adrenergic, non-cholinergic neurotransmitters (NANC). Further studies are needed to possibly improve the pharmacological therapy of the myelomeningocele detrusor.
The hyperactive bladder does not always completely empty. The aim of this study was to determine ... more The hyperactive bladder does not always completely empty. The aim of this study was to determine the frequency of detrusor instahility and impaired contractility in 45 patients with benign prostatic hyperplasia. The evaluation consisted of uroflowmetry , residual urine determination, cystometrogram (CMG), and micturition study with stop-flow technique, Detmsor instability is diagnosed urodynamically with the appearance of abnormal contractions either on medium filling CMG and/or on a provocative rapid injection CMG. Iinpaired bladder contractility was diagnoscd by the presence of significant residual urine (250% of capacity) and unsustained bladder contraction with no or little detrusor reserve power. Urodynamic evaluation showed that 21 out of 45 patients had detrusor instability. Seven of these patients showed also impaired contractility. The mean residual urine was 380 ml in this subgroup. On micturition studies five of thesc patients showed low prcssure, low uroflow pattern. Stop-flow technique revealed absence of detrusor reserve power in five patients, while two patients showed little detrusor reserve power. Out of the 24 patients with stable bladders, four showed impaired contractility. Indeed, delrusor instability is not associated exclusively with low residual urine values. The importance of recognizing detrusor instability in combination with poor contractility in patients with benign prostatic hyperplasia is that one can anticipate incomplctc bladder emptying even after prolstate surgery and consider other forms of therapy. Our approach to this specific problem is presented.
Dextranomer/hyaluronic acid copolymer (Zuidex®) is a new bulking agent. There is little data abou... more Dextranomer/hyaluronic acid copolymer (Zuidex®) is a new bulking agent. There is little data about the complications of using this substance as urethral bulking agent for the treatment of urinary stress incontinence. We are presenting a 59-year-old female patient who developed a suburethral mass and urinary retention after zuidex urethral injection. A stepwise approach for treatment was followed. Complete excision of the mass was the only curative procedure that succeeded.
We evaluate transurethral collagen injection as a minimally invasive option in treating stress ur... more We evaluate transurethral collagen injection as a minimally invasive option in treating stress urinary incontinence in men and identify the prognostic factors for success or failure. Transurethral collagen was injected in 35 men with grades III (22) and II (13) incontinence. Of the patients 7 became dry (20%), 11 improved (31.4%) and 17 were considered failures (48.6%). Abdominal leak point pressure increased and the number of pads needed decreased. In the failed group 4 patients had a history of pelvic irradiation, 5 urethral stricture disease and 3 bladder instability before injection. There was 1 case of temporary urinary retention as a complication. Transurethral collagen injection for male stress urinary incontinence is a reasonable option in select patients.
In deciding which surgical approach to use in repairing pelvic organ prolapse (POP), it is essent... more In deciding which surgical approach to use in repairing pelvic organ prolapse (POP), it is essential to have a complete understanding not only of the relevant anatomy, but also of the pathogenesis of POP. A detailed discussion of pelvic floor anatomy and physiology was presented earlier. There is no ideal approach or repair for POP. The choice of operation is made after careful consideration of a series of factors related to the patient’s anatomy, medical history, and goals of surgery. To further complicate matters, laparoscopic and robotic surgery are new techniques available to the pelvic reconstructive surgeon. These newer techniques will be discussed in detail in a later Chapter. Finally, the traditional view that hysterectomy is part of POP repair is being challenged.
Objectives. A simple new technique, using a trapezoid island of vaginal wall, is described for el... more Objectives. A simple new technique, using a trapezoid island of vaginal wall, is described for elderly female patients undergoing transvaginal pelvic prolapse repair and suffering from stress urinary incontinence secondary to intrinsic sphincteric deficiency. Methods. Fifteen elderly women underwent bladder neck prop in association with other pelvic prolapse surgery. The mean follow-up period was 20 months. Results. Twelve of 14 patients (85.7%) were dry. One patient was lost to follow-up. Conclusions. Bladder neck prop provided urethral and bladder neck compression and support. The major advantage of this approach is avoiding extensive dissection and/or abdominal incision in elderly female patients.
Purpose: hbovaginal sling is gaining widespread acceptance as a primary form of treatment for typ... more Purpose: hbovaginal sling is gaining widespread acceptance as a primary form of treatment for types I1 and 111 stress urinary incontinence. However, a major drawback is postoperative obstructed voiding due to excessive force placed on the suspension suture. We describe a simple objective method for intraoperative adjustment of sling tension that can be performed by a single surgeon during pubovaginal sling surgery. Materials and Methods: A cotton swab is inserted into the urethra and placed at the urethrovesical junction after the sling is fixed suburethrally and the vaginal mucosa is closed. The suspension sutures are tied down directly onto the rectus fascia with enough tension to keep the cotton swab angle between 0 and 10 degrees to the horizontal plane. A total of 29 patients with an average age of 62 years underwent pubovaginal sling surgery with rectus and cadaveric fascia using this technique for tension adjustment. Of the patients 21 were diagnosed with types I1 and 111, 5 had type I1 only and 3 had type 111 only incontinence. Preoperative evaluation revealed detrusor instability in 5 patients. Mean postoperative indwelling catheterization period was 6.2 days. Average followup was 15.6 months. Results: To date no permanent urinary retention has occurred. Of the patients 15 voided without difficulty after catheter removal, 13 had urinary difficulty requiring intermittent catheterization for 1 week or less and 1 had retention requiring intermittent catheterization for 10 weeks. Preoperative symptoms of detrusor instability resolved in all cases. De novo detrusor instability in 3 cases was controlled with anticholinergics. Conclusions: Overzealous sling tension adjustment has been recognized as a cause of treatment failure leading to urethral obstruction. Our technique is effective in preventing over adjustment of tension, is reproducible and can be performed by 1 surgeon.
In a pivotal trial we evaluated the effectiveness and safety of Macro-plastique® as minimally inv... more In a pivotal trial we evaluated the effectiveness and safety of Macro-plastique® as minimally invasive endoscopic treatment for female stress urinary incontinence primarily due to intrinsic sphincter deficiency. Materials and Methods: A total of 247 females with intrinsic sphincter deficiency were randomized 1:1 and treated with a transurethral injection of Macroplastique or Contigen®. The latter group served as the control. Repeat treatment was allowed after the 3-month followup. Effectiveness was determined 12 months after the last treatment using Stamey grade, pad weight and Urinary Incontinence Quality of Life Scale scores. Safety assessment was recorded throughout the study. Results: After 12 patients were excluded from study 122 patients received Macroplastique injection and 125 received Contigen injection. Mean patient age was 61 years and the average history of incontinence was 11.2 years. Of the patients 24% had undergone prior incontinence surgery. At 12 months after treatment 61.5% of patients who received Macroplastique and 48% of controls had improved 1 Stamey grade. In the Macroplastique group the dry/cure rate was 36.9% compared to 24.8% in the control group (p Ͻ0.05). In the Macroplastique and control groups the 1-hour pad weight decrease was 25.4 and 22.8 ml from baseline (p ϭ 0.64), and the mean improvement in Urinary Incontinence Quality of Life Scale score was 28.7 and 26.4 (p ϭ 0.49), respectively. Conclusions: Macroplastique injection was statistically more effective than Contigen for stress urinary incontinence primarily due to intrinsic sphincter deficiency with a 12.1% cure rate difference. Macroplastique can be administered on an outpatient basis. It should be considered a primary or secondary treatment option for stress urinary incontinence.
Ilioinguinal nerve entrapment is a documented complication of inguinal herniorraphy, inguinal lym... more Ilioinguinal nerve entrapment is a documented complication of inguinal herniorraphy, inguinal lymph node dissection, and appendectomy. This article reports two clinical histories to illustrate the diagnosis and management, and outlines prevention of ilioinguinal nerve entrapment as a complication of needle suspension procedures for stress urinary incontinence.
A modified Martius graft interposition flap was used in conjunction with the modified pubovaginal... more A modified Martius graft interposition flap was used in conjunction with the modified pubovaginal sling bladder suspension to treat a recurrent vesicovaginal fistula involving the proximal urethra and bladder neck. The patient recovered with no incontinence, voiding dysfunction or dyspareunia. Incontinence should be anticipated with vesicovaginal fistulas involving the internal sphincter and repair should be tailored to include an organic suburethral sling.
The authors report results of a survey of the practice patterns of International Urogynecological... more The authors report results of a survey of the practice patterns of International Urogynecological Association (IUGA) members in the management of urinary incontinence and pelvic organ prolapse. A questionnaire regarding current urogynecological clinical practice was developed by the Research and Development Committee of IUGA and mailed to all members of IUGA. Age, specialty, and geographic location factors were used for response comparisons. One hundred and fifty-two surveys (30%) were returned, 35% from North America, 51% from Europe/Australia/New Zealand, and 14% from elsewhere. The average age of respondents was 47.2 years (SD = 9.5), 89% were gynecologists and 11% were urologists. Overall, the procedures of choice for stress incontinence (SUI) were tension-free vaginal tape (TVT; 48.8%) and Burch colposuspension (44%). There were significant geographic variations noted. For SUI with low-pressure urethra/intrinsic sphincteric deficiency, TVT was used by 44.6% and suburethral sling by 32.3%. Various materials are used for suburethral slings, including autologous fascia (46.5%), Marlex mesh (27.8%) and cadaveric fascia lata (11.6%). Bulking agent injection therapy is used for ISD by 75% of respondents. Traditional reconstructive procedures are performed by the majority of respondents, including sacrospinous fixation (78%), abdominal sacrocolpopexy (77%), paravaginal repair (65%) and vaginal enterocele repair (93%); 6.5% use defecography in evaluating rectoceles and 44% use the POP-Q. Seventy-two per cent use urodynamic evaluation routinely in prolapse cases with no manifest SUI. Most IUGA members perform commonly accepted procedures for surgical therapy of urinary incontinence and genital prolapse. IUGA members do not frequently use anorectal physiology and fluoroscopic investigations to evaluate rectoceles prior to repair.
The objective of this study was to evaluate the impact of obesity on pelvic floor function in wom... more The objective of this study was to evaluate the impact of obesity on pelvic floor function in women. This was a prospective controlled study of 20 morbidly obese female patients planning to undergo gastric bypass surgery and 20 age-matched female controls. Subjects completed symptom and impact questionnaires, including the Incontinence Impact Questionnaire (IIQ-7), Urogenital Distress Inventory (UDI), the Kobashi Prolapse Symptom Inventory and Quality-of-Life Questionnaire (PSI-QOL), and Index of Female Sexual Function. Data were analyzed with Wilcoxon or ratio 2 tests. Results: Mean weight was 295.7 Ϯ 87.9 lbs in the study group and 144.79 Ϯ 33.07 lbs in the control group. Mean BMI was 52.65 Ϯ14.49 kg/m 2 in the study group and 25.11 Ϯ 5.27 kg/m 2 in the control group. According to the IIQ-7, urinary incontinence significantly affected lifestyle in the study group. The total IIQ-7 score was also significantly affected in the study group (p ϭ 0.03). The UDI indicated more urinary leakage with activity (p ϭ 0.04) and more incidents of small amounts of leakage (p ϭ 0.02) in the study group. According to the PSI-QOL, women in the study group experienced constipation more often because of difficulty in emptying the rectum (p ϭ 0.04). The PSI-QOL score was higher in the study group (6.75 Ϯ 6.84) than in the control group (2.65 Ϯ 3.03; p ϭ 0.04). There were no significant differences between groups regarding sexual function. Discussion: Morbid obesity is associated with a significant negative impact on urogenital health. Sexual function did not seem to be affected in women who are morbidly obese.
Uploads
Papers by Gamal Ghoniem