Degree Of Cystocele Research Articles

Correlation of the type and degree of cystocele with stress urinary incontinence by transperineal ultrasound.

To assess the correlation between the type and degree of cystocele and stress urinary incontinence (SUI) by transperineal ultrasound. A retrospective study evaluated 207 women who were diagnosed with cystocele by transperineal ultrasound. One hundred and six women who were diagnosed with SUI by a full urodynamic study were enrolled in the SUI group, 101 women without SUI were enrolled in the prolapse group, and 100 normal women with neither SUI nor POP were enrolled as the control group. In the transperineal ultrasound study, the bladder neck, the lowest point of the bladder wall, bladder neck funneling, the retrovesical angle, and the urethra inclination angle were observed at rest and Valsalva. It was found that 87.7% of patients in the SUI group were diagnosed with cystourethrocele, which was significantly higher than the 47.5% in the prolapse group. In addition, 93.4% of patients in the SUI group were diagnosed with Grade I or II cystocele and 6.6% were Grade III, which was significantly higher than that in the prolapse group. Bladder neck funneling on ultrasonography had a sensitivity of 59.4% and a specificity of 64.1% for the detection of SUI. It was significantly higher in cystourethrocele than isolated cystocele (P < 0.05). The type and degree of cystocele can be diagnosed by transperineal ultrasound. Cystourethrocele and bladder neck funneling are highly correlated with SUI. Bladder neck funneling may be an important symptom of SUI.

Supine magnetic resonance defecography for evaluation of anterior compartment prolapse: Comparison with upright voiding cystourethrogram

PurposeTo compare utility of supine Magnetic Resonance Defecography (MRD) with upright Voiding Cystourethrogram (VCUG) for evaluation of cystocele and urethral hypermobility (UHM). MethodsThis was an IRB-approved, HIPAA-compliant, retrospective study of 51 consecutive patients with symptomatic pelvic organ prolapse (POP) and lower urinary tract symptoms who underwent both upright VCUG and supine MRD. Cystocele height was defined in centimeters with reference to the inferior edge of the pubic bone on VCUG and the pubococcygeal line on MRD. Urethral angle at rest (UAR) and during straining (UAS) was measured in degrees between the urethral axis and a vertical line at the external meatus. Pairedt-test and simple linear regression were applied to compare VCUG and MRD data sets. p < 0.05 was considered significant. ResultsThe mean cystocele extent was 1.58 cm lower (more inferior to the reference point) (95% CI for the mean difference: 1.21, 1.94;p < 0.0001) on MRD (-2.73 ± 1.99 cm) than on VCUG (-1.16 ± 1.75 cm). Mean UAS on MRD (72.29 ± 26.45) was 31.8 degrees higher compared to that on VCUG (40.45 ± 21.41), (95% CI for mean difference in UAS: 37.57, 26.11; p < 0.0001). Mean UAS-UAR on MRD (74.30 ± 28.50) was 58.6 degrees higher compared to that on VCUG (15.70 ± 11.27) (95% CI for mean difference in UAS-UAR 65.94, 51.26; p < 0.0001). Cystocele size was upgraded in 22 (43.3%) patients on MRD compared to VCUG. Five (9.8%) patients demonstrated UHM on VCUG; 48 (94.1%) patients demonstrated UHM on MRD. The differences between VCUG and MRD scores persisted across the range of VCUG measurements. Cystocele size was significantly larger in POP (+) patients than in POP (-) patients on MRD (p = 0.005) but not on VCUG (p = 0.06). ConclusionsSupine MRD demonstrates significantly higher prevalence and degree of cystocele and UHM than upright VCUG, and alters the grade of bladder prolapse in a significant portion of the patient population. Cystocele size on MRD correlates with clinical presence of prolapse symptoms.

Does the Degree of Cystocele Predict De Novo Stress Urinary Incontinence After Prolapse Repair? Further Analysis of the Colpopexy and Urinary Reduction Efforts Trial.

Cystoceles may cause urethral obstruction by altering the vesicourethral angle. Restoration of normal anatomy after pelvic organ prolapse (POP) repair can relieve this obstruction but may unmask stress urinary incontinence (SUI). The association between the severity of cystocele and developing de novo SUI after prolapse repair, however, is poorly understood. We hypothesized that, in women undergoing prolapse repair, increasing degrees of bladder prolapse would be associated with increasing rates of postoperative de novo SUI. We performed a secondary analysis of the Colpopexy and Urinary Reduction Efforts (CARE) trial data. Using the control arm (women undergoing prolapse repair without a prophylactic SUI procedure), we identified de novo SUI using a composite definition based on original trial criteria. We performed logistic regression to evaluate the relationship between the degree of cystocele and the development of new SUI. Of the 164 women who underwent abdominal sacrocolpopexy alone, 54% developed de novo postoperative SUI. Stratifying by the degree of anterior prolapse (point Ba), we found a linear increase in the rate of SUI with worsening preoperative cystocele. The incidence of de novo SUI based on the POP Quantification stage of anterior prolapse was 41.3%, 52.5%, and 66.1%, for stage 2, early stage 3, and advanced stage 3 or stage 4, respectively. Point Ba was found to be significantly associated with de novo SUI on both univariate (odds ratio = 1.17, P = 0.015) and multivariate analysis (odds ratio = 1.16, P = 0.04). The incidence of de novo SUI after prolapse repair directly correlates to the degree of cystocele on preoperative examination. This simple yet novel relationship should further guide discussions about potential postoperative incontinence.

The Degree of Cystocele and Rectocele with Hiatal Area Levator Ani

Objective: To investigate the degree of cystocele and rectocele with a maximum of levator hiatal area (AHL) during Valsava.&#x0D; Methods: Secondary data analysis of 90 patients with uterine prolapse January 2012 to November 2013 in the clinic Uroginekologi RSCM, Jakarta. 3D/4D ultrasound measurement and pelvic organ prolapse system Quantification (POP-Q) stage I-IV cystocele and rectocelestage I-IV. All statistical analyses were analyzed using Stata 20 for Windows.&#x0D; Results: Significant difference cystocele stage I-II (n = 25) with stage III-IV (n = 65), the maximum AHL with a difference of 4.33 cm2 (p = 0.040). In rectocele stage I-II (n = 64) and stage III-IV (n = 26) of 3.85 cm2 (p = 0.130). AUC values for stage I-II and III-IV cystocele was 0.607 (IK95% from 0.467 to 0.738), and the ROC for rectocele was 0.603 (IK95% from 0.472 to 0.734). The ROC optimal cut point for cystocele stage I-II with III-IV with the highestsensitivity and specificity is 29 cm2 (0.523 sensitivity, specificity 0.520), the rectocele is 30 cm2 (0.538 sensitivity, specificity 0.584).&#x0D; Conclusion: There is a significant relationship between the degree of cystocele and area of the levator ani muscles when Valsava, but there is no relationship at rectocele. The value of maximum area under the curve (AUC) hiatal area of the levatorani muscle in distinguishing stage I-II and III-IV cystocele are relatively similar to rectocele stage I-II and III-IV. Optimal cut point hiatal area of the levatorani muscle in distinguishing stage I-II and III-IV cystoceleis 29 cm2, while for rectocele is 30 cm2 with sensitivity and specificity values were quite good.&#x0D; Keywords: cystocele, levatorani hiatal area, pelvic organ prolapse, rectocele

Incidence of PostOperative Urinary Retention after Pelvic Organ Prolapse Reconstruction

Abstract&#x0D; Objective: To determine the incidence of post-operative urinary retention&#x0D; after pelvic organ prolapse reconstruction and associated&#x0D; factors.&#x0D; &#x0D; Method: This was a prospective cohort study conducted in Dr. Cipto&#x0D; Mangunkusumo and another associate hospital. We recruited women&#x0D; planned for pelvic organ prolapse reconstruction from April&#x0D; 2013 to April 2015. Inclusion and exclusion criteria were women&#x0D; with pelvic organ prolapse (2nd, 3rd and 4th degree) without prior&#x0D; urinary retention, drugs affecting bladder function, and history of&#x0D; bladder injury. After surgery, urinary catheter was applied for 24&#x0D; hours. Six hours apart from urinary catheter released, residual urine&#x0D; was measured. Urinary retention was defined as residual urine more&#x0D; than 100 ml.&#x0D; &#x0D; Result: Of 200 subjects, 59 of them (29.5%) classified as having urinary&#x0D; retention. No association found between age, body mass index&#x0D; (BMI), degree of prolapse, degree of cystocele and urinary tract infection&#x0D; toward urinary retention. Total vagina hysterectomy + anterior&#x0D; colporaphy + colpoperineoraphy + sacrospinous fixation and reconstruction&#x0D; duration more than 130 minutes were associated with&#x0D; urinary retention (relative risk (RR) 3.66; 95% CI 2.91-4.60; p

MP10-10 DOES THE DEGREE OF CYSTOCELE PREDICT DE-NOVO STRESS URINARY INCONTINENCE AFTER PROLAPSE REPAIR? FURTHER ANALYSIS OF THE CARE TRIAL

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Pelvic Prolapse1 Apr 2016MP10-10 DOES THE DEGREE OF CYSTOCELE PREDICT DE-NOVO STRESS URINARY INCONTINENCE AFTER PROLAPSE REPAIR? FURTHER ANALYSIS OF THE CARE TRIAL Michael Davenport, Eric Sokol, and Christopher Elliott Michael DavenportMichael Davenport More articles by this author , Eric SokolEric Sokol More articles by this author , and Christopher ElliottChristopher Elliott More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2340AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Cystoceles may cause urethral obstruction by altering the vesico-urethral angle. Restoration of normal anatomy after vaginal prolapse repair can relieve this urethral “kink”, but may unmask stress incontinence (SUI). The association between the severity of cystocele and developing de-novo SUI after prolapse repair however, is poorly understood. We hypothesized that in women undergoing prolapse repair, increasing degrees of bladder prolapse would be associated with increasing rates of post-operative de-novo SUI. METHODS We performed a secondary analysis of the Colpopexy and Urinary Reduction Efforts (CARE) trial data. Using the control arm (women undergoing prolapse repair without a prophylactic SUI procedure), we identified de-novo SUI using a composite definition based on original trial criteria, including 1) new symptoms of SUI, 2) new physical exam findings of SUI and 3) any treatment for SUI within one year of prolapse repair. We performed logistic regression to evaluate the relationship between the degree of cystocele and the development of new SUI. RESULTS Of the 168 women who underwent abdominal sacrocolpopexy alone, 53% developed de-novo post-operative SUI. Stratifying by the degree of anterior prolapse (point Ba), we found a linear increase in the rate of SUI with worsening preoperative cystocele. The incidence of de-novo SUI based on tertile of anterior prolapse from least to most severe, was 41.7%, 53.3% and 63.3%, respectively (Table 1). Point Ba was found to be significant for predicting de-novo SUI on both univariate (OR=1.17 3, p-value 0.015), and multivariate analysis (OR=1.16, p-value 0.04). CONCLUSIONS The incidence of de-novo SUI after prolapse repair directly correlates to the degree of cystocele on preoperative exam. This simple yet novel relationship should further guide discussions about potential post-operative incontinence with women undergoing prolapse repair. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e105-e106 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Michael Davenport More articles by this author Eric Sokol More articles by this author Christopher Elliott More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PD8-02 UPPER TRACT IMAGING ABNORMALITIES RELATED TO RECURRENT URINARY TRACT INFECTIONS RARELY FOUND IN WOMEN

You have accessJournal of UrologyInfections/Inflammation of the Genitourinary Tract: Kidney & Bladder I1 Apr 2015PD8-02 UPPER TRACT IMAGING ABNORMALITIES RELATED TO RECURRENT URINARY TRACT INFECTIONS RARELY FOUND IN WOMEN Lauren Rego, Alana Christie, and Philippe Zimmern Lauren RegoLauren Rego More articles by this author , Alana ChristieAlana Christie More articles by this author , and Philippe ZimmernPhilippe Zimmern More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.917AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To investigate the rate of upper tract imaging abnormalities as possible source for UTI recurrence in women with documented RUTIs. METHODS Following IRB approval, a prospective database of non-neurogenic women with documented RUTIs (≥ 3 UTI/year) was reviewed for relevant demographic and clinical data (Table 1), as well as radiology-interpreted upper tract imaging study (renal ultrasound (US), CT scan, IVP) findings. Patients were excluded for irretrievable image (3), no imaging study performed (13), an obvious source for RUTI (intermittent catheterization, indwelling catheter, > stage 2 anterior prolapse)(8), or history of pyelonephritis (1). Any upper tract imaging anomaly was recorded. RESULTS From 2006 to 2014, 170 of 280 women with RUTIs were studied, including US alone (N=76), CT alone (N=47), US and CT (N=38), and IVP with US or CT (N=9). Out of total imaging findings (N=84 in 76 women), 81/84 (96.4%) were noncontributory: duplicated systems (10), non-obstructing renal stone (16), renal cyst (46), renal tumor (1), questionable small renal lesion (8). In 3/76 women (3.6%), mild unilateral hydronephrosis appeared related to RUTI; but no clinical parameters (BMI, gravida, parity, immunosuppression, history of urethral dilation or kidney stones, degree of cystocele, infecting strain, post-void residual) were correlated with these upper tract findings. Six of 15 (40%) patients with kidney stone history had stones on imaging (ranging from 1–3 mm) versus 10/155 (6.5%) of patients that did not have such history had stones on imaging (p < 0.0001). CONCLUSIONS In this cohort of predominantly Caucasian post-menopausal women, upper tract imaging yielded a low percentage of significant findings associated with RUTIs, thus questioning the routine practice of upper tract studies in this population. Table 1. Patient demographics (N = 170) N/Total (%) Age (avg. ± std. dev.) 62.7 ± 14.9 BMI (avg. ± std. dev.) 26.4 ± 6.5 Race White 160/170 (94%) Other 10/170 (6%) Diabetes 13/170 (8%) Immunosuppression 7/170 (4%) Post-Menopausal 133/163 (82%) Sexually Active 57/107 (53%) Voiding Dysfunction 72/165 (44%) History of Urethral Dilation 32/169 (19%) History of Kidney Stones 15/169 (9%) Cystocele Stage 0 99/155 (64%) Stage 1 45/155 (29%) Stage 2 11/155 (7%) Current Chemotherapy Yes 2/170 (1%) © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e190 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Lauren Rego More articles by this author Alana Christie More articles by this author Philippe Zimmern More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP75-10 FIFTEEN YEARS EXPERIENCE WITH THE ANTERIOR VAGINAL WALL SUSPENSION PROCEDURE, A NATIVE TISSUE VAGINAL REPAIR FOR STRESS URINARY INCONTINENCE WITH EARLY STAGE ANTERIOR COMPARTMENT PROLAPSE.

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Female Urology II1 Apr 2014MP75-10 FIFTEEN YEARS EXPERIENCE WITH THE ANTERIOR VAGINAL WALL SUSPENSION PROCEDURE, A NATIVE TISSUE VAGINAL REPAIR FOR STRESS URINARY INCONTINENCE WITH EARLY STAGE ANTERIOR COMPARTMENT PROLAPSE. Philippe Zimmern, Alana Christie, Xian-Jin Xie, Chasta Bacsu, Dominic Lee, Benjamin Dillon, Jack Hou, and Feras Alhalabi Philippe ZimmernPhilippe Zimmern More articles by this author , Alana ChristieAlana Christie More articles by this author , Xian-Jin XieXian-Jin Xie More articles by this author , Chasta BacsuChasta Bacsu More articles by this author , Dominic LeeDominic Lee More articles by this author , Benjamin DillonBenjamin Dillon More articles by this author , Jack HouJack Hou More articles by this author , and Feras AlhalabiFeras Alhalabi More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2383AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To report on the mid- and long-term outcome for the anterior vaginal wall suspension (AVWS) procedure (1) for stress urinary incontinence (SUI) with early stage anterior compartment prolapse. METHODS Following IRB approval, the long-term prospective Access database of non-neurogenic women who underwent AVWS for SUI, with a minimum 1 year follow-up, was reviewed in women with complete pre and post-operative records. Preoperative evaluation included detailed history, validated questionnaires, (UDI-6, QoL), physical examination, and standing lateral voiding cystourethrogram (VCUG) with rest (UAR)/strain (UAS) views to evaluate urethral hypermobility and degree of cystocele (Lateral height). Follow-up included examination, questionnaires, and one VCUG around 6-12 months post-operatively. Success was measured by Kaplan-Meier curves using time to reoperation for incontinence. Mixed-effects model least square means were used for baseline versus post-AVWS mean score comparison and for follow-up period mean score comparison (2). RESULTS Between 1996 and 2011, 213 women met inclusion criteria. Mean ± Sd were: age 62.2 (11.0), BMI 26.8 (5.7), parity 2.4 (1.3). 88 (41%) patients underwent AVWS alone and 51 (24%) had prior anti-incontinence procedures. Aa and Ba points, questionnaire results, and QoL consistently improved post-operatively, and remained stable over time (Table 1). VCUG findings also improved for urethral support and cystocele reduction. Additional therapy with sling (4) or injectable agents (8) was required in 12 (6%) women at a median of 3.8 (1.2-10.3) years. CONCLUSIONS The AVWS procedure can durably correct SUI by restoration of anatomical support to the bladder neck and bladder base. Reference: 1. Wilson TS, Zimmern PE: Anterior Vaginal Wall Suspension, Female Urology, Urogynecology, and Voiding Dysfunction, Vasavada, Appell, Sand, and Raz, Section I, Chapter 17, 283-290, Marcel Dekker, 2005 Table 1. Mixed Model Least Square Means for Follow-up Period Mean Score Comparison Patients Baseline Follow-up Period Mean Mean p-value 1-3 Years 3-5 Years >5 Years p-value Physical Exam (n=197/213) (n=80/177) (n=73/147) Aa (-3,+3) 213 -1.0 0.0003 -2.8 -2.8 -2.7 0.1913 Ba (-3,+8) 213 -2.8 0.0003 -2.8 -2.7 -2.7 0.3462 Questionnaires (n=113/122) (n=45/99) (n=41/88) UDI 6 Total (0-18) 122 8.2 0.0045 4.0 4.6 5.1 0.0936 UDI Q2 (UUI) (0-3) 122 1.6 0.0251 0.8 0.9 1.3 0.1112 No OAB Treatment 107 1.6 0.1248 0.8 0.9 1.2 0.2223 OAB Treatment 15 1.5 0.0092 1.0 1.5 1.7 0.2174 UDI Q3 (SUI) (0-3) 122 1.7 0.0023 0.6 0.7 0.9 0.03961 UDI Q5 (Empty) (0-3) 122 1.0 0.0008 0.5 0.6 0.5 0.6151 (n=113/120) (n=45/97) (n=41/87) QoL (0-10) 120 6.2 0.0005 2.2 2.7 2.8 0.2182 UUI = Urge Urinary Incontinence; SUI = Stress Urinary Incontinence; OAB = Overactive bladder 1 1-3 years follow-up and >5 years follow-up is significantly different, p < 0.05 © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e876-e877 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Philippe Zimmern More articles by this author Alana Christie More articles by this author Xian-Jin Xie More articles by this author Chasta Bacsu More articles by this author Dominic Lee More articles by this author Benjamin Dillon More articles by this author Jack Hou More articles by this author Feras Alhalabi More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP3-16 DISMEMBERED PYELOPLASTY IN SYMPTOMATIC PATIENTS WITH EQUIVOCAL OBSTRUCTION: DOES IT MAKE A DIFFERENCE?

INTRODUCTION AND OBJECTIVES: To report on the midand long-term outcome for the anterior vaginal wall suspension (AVWS) procedure (1) for correction of stage II-IV anterior compartment prolapse (ACP). METHODS: Following IRB approval, the long-term prospective Access database of non-neurogenic women who underwent AVWS for ACP, with a minimum 1 year follow-up and complete pre and postoperative records, was reviewed. Preoperative evaluation included detailed history, validated questionnaires (UDI-6, QoL), physical examination, and standing lateral voiding cystourethrogram (VCUG) with rest (UAR)/strain(UAS) views to evaluate urethral hypermobility and degree of cystocele (Lateral height). Follow-up included examination, questionnaires, and one VCUG around 6-12 months post-operatively. Success was measured by Kaplan-Meier curves using time to reoperation for ACP recurrence. Mixed-effects model least square means were used for baseline versus post-AVWS and follow-up period mean score comparisons. RESULTS: Between 1996 and 2012, 169 women met inclusion criteria. Mean Sd were: age 67.7 (9.3), BMI 26.5 (4.5), parity 2.7 (1.5). 78 (46%) patients underwent AVWS alone and 28 (17%) had prior POP procedures. Aa and Ba points increased slightly over time (p1⁄40.01, p1⁄40.02, respectively) (Table 1). VCUG findings also improved significantly for urethral support and cystocele reduction. Recurrence rate based on reoperation using mesh sacrocolpopexy or anterior colporrhaphy was 13/169 (8%) at a median of 1.4 (0.6-7.0) years. CONCLUSIONS: The AVWS procedure can durably correct ACP by restoration of the anatomical support to the bladder neck and bladder base.

MP3-15 LARGE CYSTOCELE REPAIR WITH THE ANTERIOR VAGINAL WALL SUSPENSION PROCEDURE

You have accessJournal of UrologyTrauma/Reconstruction: Trauma & Reconstructive Surgery II1 Apr 2014MP3-15 LARGE CYSTOCELE REPAIR WITH THE ANTERIOR VAGINAL WALL SUSPENSION PROCEDURE Philippe Zimmern, Alana Christie, Xian-Jin Xie, Chasta D. Bacsu, Dominic Lee, Benjamin Dillon, Jack C. Hou, and Feras Alhalabi Philippe ZimmernPhilippe Zimmern More articles by this author , Alana ChristieAlana Christie More articles by this author , Xian-Jin XieXian-Jin Xie More articles by this author , Chasta D. BacsuChasta D. Bacsu More articles by this author , Dominic LeeDominic Lee More articles by this author , Benjamin DillonBenjamin Dillon More articles by this author , Jack C. HouJack C. Hou More articles by this author , and Feras AlhalabiFeras Alhalabi More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.194AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To report on the mid- and long-term outcome for the anterior vaginal wall suspension (AVWS) procedure (1) for correction of stage II-IV anterior compartment prolapse (ACP). METHODS Following IRB approval, the long-term prospective Access database of non-neurogenic women who underwent AVWS for ACP, with a minimum 1 year follow-up and complete pre and post-operative records, was reviewed. Preoperative evaluation included detailed history, validated questionnaires (UDI-6, QoL), physical examination, and standing lateral voiding cystourethrogram (VCUG) with rest (UAR)/strain(UAS) views to evaluate urethral hypermobility and degree of cystocele (Lateral height). Follow-up included examination, questionnaires, and one VCUG around 6-12 months post-operatively. Success was measured by Kaplan-Meier curves using time to reoperation for ACP recurrence. Mixed-effects model least square means were used for baseline versus post-AVWS and follow-up period mean score comparisons. RESULTS Between 1996 and 2012, 169 women met inclusion criteria. Mean ± Sd were: age 67.7 (9.3), BMI 26.5 (4.5), parity 2.7 (1.5). 78 (46%) patients underwent AVWS alone and 28 (17%) had prior POP procedures. Aa and Ba points increased slightly over time (p=0.01, p=0.02, respectively) (Table 1). VCUG findings also improved significantly for urethral support and cystocele reduction. Recurrence rate based on reoperation using mesh sacrocolpopexy or anterior colporrhaphy was 13/169 (8%) at a median of 1.4 (0.6-7.0) years. CONCLUSIONS The AVWS procedure can durably correct ACP by restoration of the anatomical support to the bladder neck and bladder base. Table 1. Mixed Model Least Square Means for Follow-up Period Mean Score Comparison Patients Baseline Follow-up Period Mean (95% CI) Mean p-value 1-3 Years 3-5 Years >5 Years p-value Physical Exam (n=164/169) (n=57/138) (n=44/109) Aa (-3,+3) 169 0.14 0.0003 -2.65 -2.41 -2.42 0.012112 Ba (-3,+8) 169 0.22 0.1054 -2.59 -2.37 -2.30 0.01992 Questionnaires (n=93/97) (n=42/82) (n=29/75) UDI6 Total (0-18) 97 7.87 <0.0001 4.03 4.63 4.33 0.3581 UDI Q2 (UUI)(0-3) 97 1.65 <0.0001 0.93 1.08 0.91 0.4228 No OAB treatment 91 1.61 <0.0001 0.90 1.04 0.89 0.5040 OAB treatment 6 2.23 0.0199 1.61 2.00 1.40 0.8218 UDI Q3 (SUI)(0-3) 97 1.21 <0.0001 0.66 0.74 0.79 0.6173 UDI Q5 (Empty)(0-3) 97 1.17 <0.0001 0.40 0.46 0.72 0.043223 (n=95/98) (n=42/84) (n=30/76) QoL (0-10) 98 6.15 0.0206 1.92 2.10 2.59 0.2513 11-3 years follow-up and 3-5 years follow-up is significantly different, p < 0.05 21-3 years follow-up and >5 years follow-up is significantly different, p < 0.05 33-5 years follow-up and >5 years follow-up is significantly different, p < 0.05 UUI = Urge Urinary Incontinence; SUI = Stress Urinary Incontinence OAB = Overactive Bladder © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e40 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Philippe Zimmern More articles by this author Alana Christie More articles by this author Xian-Jin Xie More articles by this author Chasta D. Bacsu More articles by this author Dominic Lee More articles by this author Benjamin Dillon More articles by this author Jack C. Hou More articles by this author Feras Alhalabi More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Mesh in prolapse surgery: an imaging perspective

Mesh in prolapse surgery: an imaging perspective

An effective short duration postoperative catheterization after vaginal hysterectomy and pelvic floor repair

Background: The most common postoperative problem in the female bladder is atony caused by overdistention and reluctance of the patient to initiate the voluntary phase of voiding. After anterior colporraphy, spasm, edema and tenderness of the pubo-coccygeal muscles may obstruct the process of voiding. For spontaneous voiding to occur, the para sympathetic function of the bladder detrusor must be coordinated with the voluntary motor function of the abdominal wall and elevator muscles. In the past it was customary to insert an indwelling urethral catheter for 5 or more days after vaginal hysterectomy and pelvic floor repair but infect in uncomplicated cases 12- 24 hours post operative bladder catheterization is sufficient. Objective: to study the urinary symptoms, like retention of urine and frequency of micturition, in patients with short duration postoperative catheterization after vaginal hysterectomy and pelvic floor repair. Study design: This is descriptive study, comprised of 257 women, who underwent vaginal hysterectomy and pelvic floor repair under spinal anaesthesia in different districts of Nepal. They were catheterized for 12 to 24 hours and after removal of catheter urinary problems were studied. Results: Despite of different age, different degree of prolepses, different degree of cystocele and different duration of prolepses out of 257 patients only 8 patients developed urinary symptoms including retention of urine in 5 patients and frequency and burning maturation in 3 patients. They were catheterized for 12 to 24 hours. One of the patients who had retention required 5 days catheterization, while other 4 were re catheterized for 24 more hours. In all the cases there was urinary tract infection. Conclusion: Long duration postoperative catheterization 48 to 72 hours is not necessary in patients after uncomplicated vaginal hysterectomy and pelvic floor repair as practiced in many gynecological centers. Age of the patients, degree of uterine prolapse, cystocele, and duration of prolapse do not play major role in development of post catheter removal urinary symptoms. Preexisting or postoperative urinary tract infections have main role in the development of these symptoms. Journal of Institute of Medicine Vol.28(1) 2006

Alteraciones de la fase de llenado vesical y cistocele

To evaluate the clinical and urodynamic characteristics of a series of women with lower urinary tract symptoms (bladder filling phase) presenting various rates of cystocele. 119 female patients were included in this study; mean age was 55.8 yr. (range 15-87). All patients underwent urogynecologic physical examination (cystocele was graded 0-3) and complete urodynamic study. Urodynamic terminology and measurements comply with the ICS (InternationaL Continence Society) standards. Statistical significance was established below 0.05. Quantitative variables were compared by the Student's t and non parametric variables by Pearson's chi-square. The most frequently reported symptom was urinary incontinence when coughing (77/118, 65.3%), followed by urge incontinence (71 patients, 60.2%). The grade of cystocele was 0 in 31.1%, 1 in 25.2%, and 2 in 26.1%, and 3 in 17.6%. There was a statistically significant association between grade of cystocele and the symptom "vaginal bulge" (p=0.00002). The presence of cystocele did not show any statistical association with lower urinary tract symptoms of the filling phase. Mean cystomanometric bladder capacity was 224.8 ml. Involuntary contractions of the detrusor muscle appeared in 38 cases (21.9%), stress urinary incontinence in 19 (16%), mixed incontinence in 8 (6.7%) and absence of evidence of urinary incontinence in 58 (48.7%). Patients with urgency had a lower bladder capacity than patients without it (p = 0.02), as did patients with urge incontinence (p = 0.02). Nocturia (p = 0.05), urgency (p = 0.02) and urge incontinence (p = 0.01) were significantly associated to bladder capacity. The existence of involuntary contractions was statistically associated with urge incontinence (p = 0.01). Patients with involuntary contractions during the filling phase showed increased diurnal voiding frequency (p = 0.02), as well as patients without a stress urinary incontinence (p = 0.04) and cases without a stress urinary incontinence (p = 0.04). The symptom incontinence with coughing had a significant statistical association with the urodynamic diagnosis of stress urinary incontinence (p= 0.01). Bladder capacity was augmented in grade 3 cystocele (p = 0.003). The existence of cystocele was not associated with bladder hyperactivity (p = 0.65), neither was the diagnosis of a stress urinary incontinence (p = 0.37). No relationship has been demonstrated between existence and degree of cystocele and functional lower urinary tract symptoms of the filling phase, on the one hand, and urodynamic evidence of bladder hyperactivity and incontinence on the other hand. This could have important therapeutic implications.

Factores de descompensación miccional y cistocele

To evaluate the clinical and urodynamic features of a series of women with post void residual urine (disbalanced voiding) and various degrees of associated cystocele. 119 female patients were studied by clinical evaluation, urodynamics, and imaging tests (VCUG). All patients underwent history and genitourological examination (evaluating cystoceles from grade o to 3), neuro-urological examination, and complete urodynamic study. Fifty patients (42%) underwent radiological studies of the upper urinary tract. Disbalanced voiding was defined as existence of post void residual greater than 20% of the voided volume. Urethral resistance was measured by URA. Structural obstruction was characterized by PURR (CHESS classification). Functional obstruction was studied by DURR and perineal EMG (associated with flowmetry). Detrusor contractile power was evaluated by W max, W 80-20, and duration of contraction. Urodynamic terminology and measurements complied with the International Continence Society (ICS) standards. Statistical significance was established at 0.05. Statistical analysis was done by Student's t for quantitative variables, and Pearson's chi-square for non parametric variables. 119 patients were enrolled. Mean age was 55.84 yr. (range 15-87). Regarding post void residual (114 valid uroflowmetry studies), 25 patients were classified as voiding disbalance (21.9%) and 89 as balanced (74.8%). Regarding clinical data, there were only significant differences between groups in voiding difficulty. For uroflowmetry, only the percentile of the Maximal flow (Qmax) showed significant differences (35 vs. 22 for balanced/disbalanced voiding respectively, p = 0.02). Pressure/volume studies demonstrated bladder hyperactivity in 16 cases (64%) in the group of disbalanced voiding and 31 cases (34.8%) in the normal voiding group (p = 0.008), which presented associated with increased urethral resistance (URA)(p = 0.01) . In the pressure/flow study, there were significant differences in the URA (14.7 vs. 25.3, p = 0.001). There were statistically significant differences in the degree of constrictive (0.5 vs. 1.1, p = 0.009) and compressive (0.5 vs. 1.1; p = 0.04) obstruction (Chess classification). There were not significant differences in the analysis of isometric contractility (Wmax), but there were in the isotonic contractility (W80-20) and detrusor contraction duration. These latter differences presented significant association with the degree of cystocele. DURR and perineal EMG data did not show differences between groups. Radiological abnormalities of urethral morphology were statistically different between groups, presenting in 10% of the patients with normal voiding and 50% of the disbalanced voiding group, although there was not statistical association with obstruction (p = 0.64). The existence of cystocele did not show a statistical association with these variables either. Disbalanced voiding appeared with organic obstruction of the lower urinary tract (constrictive most significantly), as well as detrusor abnormal contractility, but whereas the first was not significantly associated with presence and grade of cystocele, the second showed such association.

Correction of stress incontinence and cystocele through the utilization of strips of polypropylene

In order to correct stress incontinence and/or cystocele we propose the well-known Burch technique modified by utilizing polypropylene strips (about 5 cm in length and 2 cm in width) for the suspension of the vagina to Cooper's ligaments, and, depending on the degree of cystocele and/or the severity of the uterine pathology, possibly associated hysterectomy and stabilization of the vaginal cupula to the uterosacral and round ligaments (always using the above-mentioned polypropylene strips). The aim of this technique is to avoid the complication considered by many authors to be the most frequent cause of failure in the surgery of stress incontinence and cystocele: tension of the suspension structures and threads. These strips may be used through either laparoscopic or laparotomic approach. The results we obtained could be described as satisfying; complications were rare.

Transvaginal Repair of Enterocele

The urologist actively involved in the treatment of female genitourinary disease must to be able to recognize and treat various forms of pelvic prolapse. Enterocele is commonly seen in conjunction with stress urinary incontinence and cystocele or it may result from surgery to correct these problems. Many techniques to correct enterocele have been developed, including transvaginal repairs as well as intra-abdominal procedures such as the Moschcowitz technique or colpofixation to the sacrum for enterocele with vault prolapse. Surgical management of enterocele must take into account several factors, including the presence of stress urinary incontinence, rectocele, vaginal vault prolapse, prior hysterectomy and the desire to maintain sexual activity. Based on these considerations we discuss our approach to the transvaginal repair of enterocele. In patients without vault prolapse a simple enterocele repair is performed. If vault prolapse is present, then the condition of the anterior vaginal wall is considered. In patients with a cystocele a vault suspension procedure is performed, which involves simultaneous suspension of the uterosacral-cardinal ligament complex and vaginal vault along with the bladder neck and bladder. There are 2 modifications of this technique depending on the degree of cystocele: the 4-corner vault suspension for grades 2 and 3 cystocele, and the vault suspension with grade 4 cystocele repair. Patients with vault prolapse and no cystocele undergo sacrospinous ligament fixation. In elderly patients who are not sexually active, especially if they are in poor medical condition, partial colpocleisis is considered. In these patients partial colpocleisis was not performed as a primary procedure but it was done later in 3 who failed an initial attempt at repair. All coexisting vaginal pathology is fixed at the time of enterocele repair. A total of 83 patients underwent enterocele repair according to this protocol and 81 were available for followup. Mean followup was 15 months (range 3 to 70). Overall a successful result (no recurrence) was achieved in 70 patients (86%). Success for individual procedures was 40 of 49 (82%) for simple repair, 24 of 25 (96%) for vault suspension and 6 of 7 (86%) for sacrospinous fixation. In all cases vault suspension or sacrospinous fixation was able to restore vaginal depth and axis with minimal or no vaginal shortening.