Posthysterectomy vaginal cuff fistula: diagnosis and management of an unusual cause of "incontinence"

OBJECTIVES

Connection between the vaginal cuff and the peritoneal cavity after hysterectomy is a rare event that can mimic urinary incontinence. The appropriate evaluation and treatment of these patients is discussed.

METHODS

Five patients underwent excision of the vaginal cuff during a 12-month period. All of these patients had a negative workup for urinary incontinence, except for 1 patient who also had stress incontinence and required a vaginal wall sling at the time of cuff excision.

RESULTS

All 5 patients are presently free of excess vaginal drainage or significantly improved, with a mean follow-up of 6 months. One patient developed stress incontinence after cuff excision and later required a vaginal wall sling. There have been no perioperative complications and no evidence of recurrent fistula.

CONCLUSIONS

Fistula of the vaginal cuff is a diagnosis of exclusion after urinary incontinence has been ruled out. A high index of suspicion is often required to make the diagnosis because these patients often present with symptoms highly suggestive of urinary leakage. Fistula of the vaginal cuff is successfully treated with excision of the vaginal cuff and the fistulous tract (if identified), with minimal morbidity.

The effects of perinatal hypoxic risk on developmental outcome in early and middle childhood: a twin study

The goal of this study of 66 twins was to determine whether motor and cognitive functions assessed in early and middle childhood are vulnerable to perinatal hypoxic risk. In an earlier study of 76 infant and toddler twins (S. Raz, F. Shah, & C. Sander, 1996), the authors found that intrapair discrepancy on the Mental Developmental Index, but not on the Psychomotor Developmental Index, of the Bayley Scales of Infant Development was associated with discordance for perinatal hypoxic risk. The twins at lower risk outperformed their higher risk co-twins. In the present study the authors sought to establish in a new sample of preschool and school-age twins whether gaps in performance persist into early and middle childhood. Although the disparity in hypoxic risk between the co-twins was typically moderate, significant intrapair differences were observed on the measure of motor performance. Among the motor abilities examined, skills involving visually guided ballistic arm movements appeared to be the most vulnerable to perinatal risk.

Vaginal evisceration

Vaginal evisceration is a rare complication of an enterocele. We report a patient who presented with spontaneous evisceration per vagina secondary to erosion through an attenuated vaginal wall. This resulted in a strangulated hernia requiring bowel resection and enterocele repair. This patient is discussed as are the risk factors and management options for patients with vaginal evisceration.

The UCLA surgical approach to sphincteric incontinence in women

Stress urinary incontinence (SUI) in the female may be treated by a variety of non-surgical and surgical therapies. However, once the patient has chosen to undergo operative repair the ideal procedure is based on three considerations: the degree of anterior vaginal wall prolapse, the degree of incontinence and associated anatomic abnormalities requiring surgical repair. In the vast majority of cases vaginal wall sling is our procedure of choice for the surgical treatment of SUI in the female. Vaginal wall sling is based on sound anatomic principles, may be performed as an outpatient procedure and is equally efficacious for the treatment of SUI due to anatomic incontinence (urethral hypermobility) and intrinsic sphincter deficiency. Since vaginal wall sling is performed through a transvaginal approach, other associated manifestations of pelvic floor prolapse such as rectocele can be addressed and repaired simultaneously. When necessary the vaginal wall sling can be easily modified to repair large grade cystoceles.

A method for intraoperative adjustment of sling tension: prevention of outlet obstruction during vaginal wall sling

OBJECTIVES

To describe a simple, yet effective method of adjusting intraoperative tension on the suspending sutures of a vaginal wall sling placed for treatment of stress urinary incontinence (SUI) in the female patient.

METHODS

A cystoscope sheath is placed per urethra and inclined to approximately 20 degrees to 30 degrees relative to horizontal. The suspension sutures are tied down directly onto the rectus fascia but do not indent it. The sheath should easily rotate in the vertical plane within the urethral lumen, maintaining elastic mobility as the sutures are tied.

RESULTS

On review of the first 160 patients who have undergone vaginal wall sling using this technique of tension adjustment, no patient has had unexpected permanent urinary retention. Preoperative urgency incontinence has remained in 10 patients (less than 7%) postoperatively; 11 patients (6.8%) have had recurrent SUI during follow-up.

CONCLUSIONS

Proper adjustment of suture tension during performance of a sling procedure for SUI is critical in preventing urethral obstruction. The technique described is simple, objective, reproducible, and highly effective.

Anterior flap extraperitoneal cystoplasty

PURPOSE

We report on our initial experience with the anterior flap extraperitoneal cystoplasty for refractory voiding symptoms secondary to detrusor hyperactivity.

MATERIALS AND METHODS

A total of 27 patients underwent anterior flap extraperitoneal cystoplasty, the principles of which include a Pfannenstiel skin incision, a small peritoneotomy with minimal manipulation of the bowel, extraperitoneal bowel resection with ileovesical anastomosis and creation of an anterior bladder wall flap.

RESULTS

Convalescence was uneventful in 25 patients (92%). Oral intake resumed on postoperative day 3 or 4, and the patient was discharged home on postoperative day 5 or 6. Voiding symptoms resolved or improved significantly in 92% of patients, who were dry or used 1 or no pads a day. Two complications required prolonged hospitalization.

CONCLUSIONS

Anterior flap extraperitoneal cystoplasty is a safe and effective treatment that has the potential to decrease postoperative complications and recovery time.

Diagnosis of stress urinary incontinence. An overview

This article represents an overview of the evaluation and diagnosis of stress urinary incontinence. Lower urinary tract anatomy in women is reviewed with particular attention to the salient features contributing to stress incontinence. Also discussed is the relevance of the distinction between anatomic incontinence and intrinsic sphincter deficiency in the classification of stress urinary incontinence. Various diagnostic techniques are described with emphasis on the importance of urodynamic evaluation in complex cases.

Vaginal wall sling for anatomical incontinence and intrinsic sphincter dysfunction: efficacy and outcome analysis

PURPOSE

A prospective cohort study was done to determine the efficacy and clinical outcome of a new technique for anterior vaginal wall sling construction to treat urinary incontinence due to intrinsic sphincter dysfunction or anatomical incontinence.

MATERIALS AND METHODS

Preoperative evaluation included lateral cystography, video urodynamics, cystoscopy and incontinence staging. Postoperative subjective and objective staging outcome measures were prospectively assigned at predetermined regular intervals by a third party.

RESULTS

Of the patients 95 had intrinsic sphincter dysfunction and 65 had anatomical incontinence. The repair failed in 7% of the 160 patients who had recurrent incontinence during followup and 9% had de novo urgency incontinence. Time to failure comparing patients with intrinsic sphincter dysfunction and anatomical incontinence was modeled using Kaplan-Meier survival curves, and the log rank test showed no significant difference between the groups (p > 0.05). Logistic regression covariates revealed no significant predictive factors for postoperative failures. Preoperative patient age was the only predictive factor for de novo instability (logistic regression model p < 0.05).

CONCLUSIONS

Our initial results indicate that the 2 groups are indistinguishable to date based on current clinical and experimental statistics except for time to full recovery of postoperative voiding and incidence of postoperative instability (regression model p < 0.05).

Transvaginal correction of pelvic prolapse

Pelvic prolapse has a myriad of clinical manifestations ranging from urethral incontinence to total vault prolapse. The evaluation and treatment of these conditions is facilitated by dividing them into three anatomic regions. Anterior vaginal wall prolapse is the most common type and includes simple urethral hypermobility as well as severe cystocele. Surgical treatment includes the modified anterior vaginal wall sling, six-corner bladder neck suspension, and formal cystocele repair. Posterior vaginal wall prolapse, manifested by rectocele and perineal relaxation, is corrected by plication of the prerectal and pararectal fascia, reconstruction of the levator hiatus, and repair of the perineal body. Vault prolapse includes enterocele, uterine prolapse, and generalized vault prolapse. The choice of treatment depends on the presence of anterior vaginal wall prolapse, the degree of vault prolapse, and the patient's desire to remain sexually active. It is important to remember that urethral incontinence is only one manifestation of pelvic prolapse, and must be treated in conjunction with other prolapse to avoid recurrence or poor results.

Vaginal reconstructive surgery for female incontinence and anterior vaginal-wall prolapse

The surgical procedure of choice to correct stress urinary incontinence using a vaginal approach depends not only on the anatomic origin of the incontinence (hypermobility or intrinsic sphincter dysfunction) but also on the degree of coexistent anterior vaginal wall prolapse. The grade of coexistent cystocele and the finding of a central or lateral defect are important observations that help the surgeon plan the optimum surgical approach. Grade 4 cystocele with central and lateral defects represents the most severe form of anterior vaginal wall prolapse. In this case, the surgical goals are to correct both central and lateral defects, as well as hypermobility related to the mid-urethra and bladder neck.

Surgery for female stress urinary incontinence

With the advent of magnetic resonance imaging, the treatment of female incontinence has undergone a renaissance. This change has primarily been due to superior understanding of anatomy and function of the supports of the urethra, bladder neck and bladder base in the female pelvis.

Obstruction following anti-incontinence procedures: diagnosis and treatment with transvaginal urethrolysis

We reviewed the charts of 41 patients who underwent transvaginal urethrolysis and resuspension of the bladder neck by the Raz technique for urethral obstruction with or without stress urinary incontinence following anti-incontinence surgery. We sought to evaluate the effectiveness of the procedure as well as to determine any factors that had an effect on the outcome of surgery. Patients were evaluated for obstruction and stress urinary incontinence by history, physical examination, video urodynamics (or multichannel urodynamics plus cystogram and voiding cystourethrography) and cystoscopy. All patients reported normal emptying before the procedure that caused obstruction. Several variables were evaluated for individual predictive values for outcome, including type of surgery causing obstruction, number of previous anti-incontinence procedures, urodynamic evidence of obstruction (high pressure, low flow), instability, concomitant stress urinary incontinence and total urinary retention, which were evaluated by the Fisher exact test, and the amount of post-void residual, bladder capacity, maximum detrusor pressure, maximum urinary flow and interval since surgery causing obstruction, which were evaluated by logistic regression analysis. Mean patient age was 59 years (range 26 to 86 years) and mean followup was 21 months. A total of 19 patients (46%) suffered from concurrent stress urinary incontinence, 23 (56%) had urodynamic evidence of obstruction (high pressure/low flow) and 6 (15%) had only radiographic or endoscopic evidence with a deviated or kinked urethra. Postoperatively, 29 patients (71%) voided normally without significant residuals. Eight patients (20%) remain on self-catheterization and 1 has persistent stress urinary incontinence. When individual variables were evaluated to determine the predictive values with respect to outcome of urethrolysis, only the preoperative post-void residual was statistically significant (the greater the post-void residual, the more likely was failure, p = 0.021). The presence or strength of the detrusor contraction preoperatively and pressure-flow analysis did not predict outcome. Of the patients with stress urinary incontinence 15 (79%) were cured and 3 (16%) were significantly improved with rare stress urinary incontinence not requiring protection. Overall, 33 patients (80%) had some benefit from surgery. Patients who emptied normally before and anti-incontinence procedure that causes obstruction or impaired emptying should not be excluded from urethrolysis based on low detrusor pressures or pressure-flow analysis alone. Simultaneous radiographic imaging and endoscopy may help to select certain patients with obstruction.

Gross brain morphology in schizophrenia: a regional analysis of traditional diagnostic subtypes

Fifty-six patients with chronic schizophrenia were categorized into 2 groups based on traditional diagnostic subtypology. They were then compared on indices of cortical and subcortical cerebrospinal fluid (CSF) volume to explore whether the more virulent nonparanoid disorder was linked to cortical or subcortical morphological brain abnormalities. They were examined also to determine whether abnormalities in a specific cerebral region were related to greater chronicity or severity of schizophrenia. The two groups differed significantly only in subcortical but not cortical CSF volume. The regional changes, however, did not appear to characterize exclusively the virulent subtypes. The results and their implications for future studies on the neuroanatomical correlates of schizophrenia subtypes are discussed.

Genitourinary problems in the elderly patient

Dramatic advances across several fronts have provided a marked improvement in the quality of life for the elderly urologic patient. Radical surgery for cancer is much safer than in the past, and our focus is on preservation of function or complete functional reconstruction. In other areas we strive to continue to deliver excellent treatment while minimizing patient morbidity. This is seen most dramatically in the treatment of urinary stone disease. Ongoing work in patients with BPH promises to provide similar benefits to this population in the coming years. At the same time, we must remember that our abundance of therapeutic options imposes a responsibility to individualize treatment so as to best serve each patient.

Physiological changes induced in cardiac myocytes by cytotoxic lymphocytes: an autoimmune model

BACKGROUND

cytotoxic lymphocytes are important in the pathogenesis of several disease states, yet, the pathophysiology of lymphocyte-myocyte interaction is not well known.

METHODS AND RESULTS

We have developed a model for the in vitro evaluation of autoimmune cytotoxic myocardial damage. Cardiac myocytes were repeatedly injected to adult autologous rats. Following 3 months, histological evidence of myocarditis was seen in 20% of the hearts. Cultured myocytes obtained from newborn rats were exposed to lymphocytes isolated from the immunized animals. Cytotoxic activity was measured using crystal violet staining test. The percentage of killing was increased as the ratio of lymphocytes/myocytes was increased. Verapamil did not block this cytotoxic effect. No killing was seen when myocytes were exposed to non-sensitized lymphocytes. Physiological changes induced in myocytes by cytotoxic lymphocytes were studied. Cell wall motion was measured by an optical method and action potentials with intracellular microelectrodes. Physiological changes observed in myocytes following exposure to cytotoxic lymphocytes included: Impaired relaxation with prolonged contractions, oscillations and prolongation of the plateau of the action potential. Cellular contraction was prolonged up to 4 s before total arrest of spontaneous activity. Verapamil but not tetrodotoxin restored action potentials and contractions to normal. Supernatant collected from cultures of myocytes and lymphocytes had the same effect on myocytes contractility as observed following exposure of myocytes to cytotoxic lymphocytes.

CONCLUSIONS

This supports our hypothesis that these physiological alterations observed in myocytes are mediated by a soluble factor secreted by cytotoxic lymphocytes.

Structural cerebral pathology in schizophrenia: regional or diffuse?

Is brain pathology in schizophrenia topographically distinct? If so, are the putative regional changes unique to the disorder? To address these questions, 56 chronic schizophrenic Ss were compared with 16 psychiatric control Ss with mood disorders and with 31 healthy volunteers on multiple-volume measures of regional cerebral atrophy obtained with computed tomography. Generalized cortical and subcortical enlargement of spaces filled with cerebrospinal fluid sparing only the occipitoparietal cortex was found in the schizophrenic Ss compared with normal control Ss. Statistically significant differences in the extent of perisylvian atrophy were noted between schizophrenic Ss and patients with mood disorders: Schizophrenic Ss evidenced greater dilation of perisylvian fissures and sulci. The implications of the results for future research and for recent theories on the etiology of schizophrenia are discussed.