[Innovative prolapse surgery without mesh implants]

BACKGROUND

In many countries, such as France, England, USA, Canada, Australia, and New Zealand, alloplastic material in prolapse surgery has been paused due to the US Food and Drug Administration (FDA) warning, and restricted in other countries like the Netherlands and Sweden. For Europe and thus Germany, the SCENIHR report allows alloplastic material to be used for prolapse repair after recurrence and in other special situations.

QUESTION

Which established and innovative prolapse surgeries without alloplastic material are currently available?

METHODS

A literature search was carried out on established, guideline-compliant pelvic floor surgeries without alloplastic material as well as innovative new approaches.

RESULTS

An established procedure for a defect in the anterior compartment is anterior colporrhaphy, which is associated with a high recurrence rate. The double-layered anterior colporrhaphy is a new approach and so far is associated with an improved 19-month outcome. Apical pelvic organ prolapse can be corrected by sacrouterine ligament fixation and vaginal sacrospinous fixation. New innovative techniques include laparoscopic unilateral pectineal suspension and the use of the semitendinosus tendon autograft to perform pectopexy or sacropexy. However, long-term data are still pending. In case of a posterior vaginal wall prolapse, posterior colporrhaphy is the therapy of choice and is associated with good success rates.

CONCLUSION

Well-known surgical procedures with native tissue are experiencing a renaissance and new, innovative surgical approaches with good postoperative results are being developed. However, long-term studies are still necessary.

Double-layered anterior colporrhaphy (DAC)-video and mid-term follow-up of 60 patients

INTRODUCTION AND HYPOTHESIS

Anterior colporrhaphy (AC) exhibits high recurrence rates, and this issue is not appropriately addressed by alloplastic material, which often necessitates reoperation. Aiming to improve the anatomical cure rate, we implemented double-layered anterior colporrhaphy (DAC). With a retrospective investigation, precise description and video of the surgical technique, we want to contribute to the development of native tissue anterior repair.

METHODS

Women treated by DAC and vaginal hysterectomy were included. Primary outcome was anatomic cure defined as prolapse < stage 2. Secondary outcomes were complication rate, resolution of postvoid residual urine, reoperation for prolapse and patient satisfaction. Follow-up encompassed a clinical gynecologic examination, the German Pelvic Floor Questionnaire and a response scale for postoperative quality of life (QoL). The key difference between DAC and AC is the continuous suture followed by the traditional interrupted sutures.

RESULTS

One hundred one patients were eligible, and 60 patients attended follow-up. Cure was achieved in 49 cases (81.7%) of cystocele with a median follow-up of 19.3 months. Fifty-five patients (91.7%) indicated an improvement in QoL.

CONCLUSIONS

We observed high anatomic cure rate and satisfaction after DAC. With description and video of the technique, it is reproducible and comparable to other methods. Randomized controlled trials should follow.

Clinical relevance of neurological evaluation in patients suffering urinary retention in the absence of subvesical obstruction

PURPOSE

Clinical relevance of neurological evaluation in patients suffered urinary retention in the absence of subvesical obstruction. Determining whether (1) women complaining residual bladder volume without prolapse and obstruction always suffer pudendal nerve damage; (2) neurogenic damage can be linked to patients history/clinical examination; (3) therapy alters regarding to neurological findings; and (4) electromyography (EMG) of musculus sphincter ani externus (MSAE) can be omitted with electronically stimulated pudendal nerve latency (ESPL) as the standard investigation.

METHODS

Women with urinary retention without ≥stage 2 prolapse or obstruction have neurological investigation including vaginally and anally pudendal terminal nerve latency (PTNL) (>2.4 ms considered abnormal) and EMG seen 7/2005-04/2010.

RESULTS

(1) 148/180 (82.2%) suffered at least moderate neurogenic damage and (2) severe neurogenic damage occurs with urge odds ratio (OR) = 3.1 or age (OR = 3.2). Correlations: spasticity with therapy changes (OR = 11.1), latencies. (a) Anally: (i) right and peripheral neuropathy (PNP) (OR = 2.5), chemotherapy (OR = 5.0); (ii) left and PNP (OR = 3.9), chemotherapy (OR = 4.8); (iii) left or right with PNP (OR = 3.9), chemotherapy (OR = 6.8); and (iv) left and right with chemotherapy (OR = 5.0). (b) Vaginally: (i) right with age >60 (OR = 3.2), radical operation (OR = 10.6); (ii) left with diabetes mellitus (OR = 2.5); and (iii) left or right with age (OR = 3.3), radical operation (OR = 8.7). (3) 19.6% therapy changes (36 patients). (4) Neither EMG nor ESPL can be replaced one by another (p = 0.12 anal, p = 0.05 vaginal).

CONCLUSION

Red flags are neurogenic damage, age >60, chemotherapy, PNP, radical operation or diabetes. In unclear situations, EMG and ESPL need to be performed to gain relevant information.

Diagnosis and Therapy of Female Pelvic Organ Prolapse. Guideline of the DGGG, SGGG and OEGGG (S2e-Level, AWMF Registry Number 015/006, April 2016)

Aims: The aim was to establish an official interdisciplinary guideline, published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). The guideline was developed for use in German-speaking countries. In addition to the Germany Society of Gynecology and Obstetrics, the guideline has also been approved by the Swiss Society of Gynecology and Obstetrics (SGGG) and the Austrian Society of Gynecology and Obstetrics (OEGGG). This is a guideline published and coordinated by the DGGG. The aim is to provide evidence-based recommendations obtained by evaluating the relevant literature for the diagnostic, conservative and surgical treatment of women with female pelvic organ prolapse with or without stress incontinence. Methods: We conducted a systematic review together with a synthesis of data and meta-analyses, where feasible. MEDLINE, Embase, Cinahl, Pedro and the Cochrane Register were searched for relevant articles. Reference lists were hand-searched, as were the abstracts of the Annual Meetings of the International Continence Society and the International Urogynecological Association. We included only abstracts of randomized controlled trials that were presented and discussed in podium sessions. We assessed original data on surgical procedures published since 2008 with a minimum follow-up time of at least 12 months. If the studies included descriptions of perioperative complications, this minimum follow-up period did not apply. Recommendations: The guideline encompasses recommendations for the diagnosis and treatment of female pelvic organ prolapse. Recommendations for anterior, posterior and apical pelvic organ prolapse with or without concomitant stress urinary incontinence, uterine preservation options, and the pros and cons of mesh placements during surgery for pelvic organ prolapse are presented. The recommendations are based on an extensive and systematic review and evaluation of the current literature and include the experiences and specific conditions in Germany, Austria and Switzerland.

Vaginal Revision of a Haematoma after Placement of Retropubic Tapes in Two Cases

Formation of a haematoma after placement of retropubic tapes for stress incontinence is a rare but typical complication potentially requiring a subsequent operation. Under certain circumstances, haematoma removal by a vaginal approach represents a milder alternative to the subperitoneal laparotomy approach under general anaesthesia. We present two cases of vaginal haematoma revision after placement of retropubic tapes. By means of this gentle alternative to the standard laparotomy approach we could avoid general anaesthesia in one case and perform the operation under analgosedative local anaesthesia. In the second case, use of the vaginal approach enabled us to avoid a laparotomy in this obese patient with a superinfected haematoma that could have led to a possible secondary wound healing problem.

Ca(2+) signals, NAADP and two-pore channels: role in cellular differentiation

Ca(2+) signals regulate a wide range of physiological processes. Intracellular Ca(2+) stores can be mobilized in response to extracellular stimuli via a range of signal transduction mechanisms, often involving recruitment of diffusible second messenger molecules. The Ca(2+) -mobilizing messengers InsP3 and cADPR release Ca(2+) from the endoplasmic reticulum via the InsP3 and ryanodine receptors, respectively, while a third messenger, NAADP, releases Ca(2+) from acidic endosomes and lysosomes. Bidirectional communication between the endoplasmic reticulum (ER) and acidic organelles may have functional relevance for endolysosomal function as well as for the generation of Ca(2+) signals. The two-pore channels (TPCs) are currently strong candidates for being key components of NAADP-regulated Ca(2+) channels. Ca(2+) signals have been shown to play important roles in differentiation; however, much remains to be established about the exact signalling mechanisms involved. The investigation of the role of NAADP and TPCs in differentiation is still at an early stage, but recent studies have suggested that they are important mediators of differentiation of neurones, skeletal muscle cells and osteoclasts. NAADP signals and TPCs have also been implicated in autophagy, an important process in differentiation. Further studies will be required to identify the precise mechanism of TPC action and their link with NAADP signalling, as well as relating this to their roles in differentiation and other key processes in the cell and organism.

Impact of Retropubic vs. Transobturator Slings for Urinary Incontinence on Myofascial Structures of the Pelvic Floor, Adductor and Abdominal Muscles

Suburethral tension-free slings (tapes or bands) are an essential component in the operative treatment of urinary incontinence. In the present contribution the influence of the type of suburethral sling (retropubic vs. transobturator) on the myofascial structures of the abdominal, adductor and pelvic floor muscles is examined. For this purpose, 70 patients were prospectively observed clinically and physiotherapeutically. Significant differences were seen in the improvement of the pelvic floor musculature (strength, endurance, speed) after placement of a suburethral sling, irrespective of whether it was of the retropubic or the transobturator type. Thus, after surgical treatment patients should be encouraged to undertake further pelvic floor exercising or this should be prescribed for them. There were no significant changes in the abdominal and adductor muscles but there were slight increases with regard to pain level, pain on palpation, and trigger points after placement of both types of sling; thus this is not a criterion in the decision as to which type of sling to use.

Normal Pressure Hydrocephalus as Cause of Urinary Incontinence - A Shunt for Incontinence

Normal pressure hydrocephalus is a frequently missed clinical entity with the typical symptom triad of gait disturbance, urinary incontinence and dementia (Hakim's triad) and occurs mostly from the 6th decade of life onwards. Early therapy can lead to a complete reversal of the symptoms. The present case report is intended to draw attention to the clinical entity normal pressure hydrocephalus (NPH) since the afflicted patients often primarily consult a gynaecologist on account of the urinary bladder disorders.

Vaginal Vault Suspension at Hysterectomy for Prolapse - Myths and Facts, Anatomical Requirements, Fixation Techniques, Documentation and Cost Accounting

Vaginal vault suspension during hysterectomy for prolapse is both a therapy for apical insufficiency and helps prevent recurrence. Numerous techniques exist, with different anatomical results and differing complications. The description of the different approaches together with a description of the vaginal vault suspension technique used at the Department for Urogynaecology at St. Hedwig Hospital could serve as a basis for reassessment and for recommendations by scientific associations regarding general standards.

Obstetric levator ani muscle injuries: current status

Levator ani muscle (LAM) injuries occur in 13-36% of women who have a vaginal delivery. Although these injuries were first described using magnetic resonance imaging, three-dimensional transperineal and endovaginal ultrasound has emerged as a more readily available and economic alternative to identify LAM morphology. Injury to the LAM is attributed to vaginal delivery resulting in reduced pelvic floor muscle strength, enlargement of the vaginal hiatus and pelvic organ prolapse. There is inconclusive evidence to support an association between LAM injuries and stress urinary incontinence and there seems to be a trend towards the development of fecal incontinence. Longitudinal studies with long-term follow-up assessing the LAM before and after childbirth are lacking. Furthermore, the consequence of LAM injuries on quality of life due to prolapse and/or urinary and fecal incontinence have not been evaluated using validated questionnaires. Direct comparative studies using the above-mentioned imaging modalities are needed to determine the true gold standard for the diagnosis of LAM injuries. This would enable consistency in definition and classification of LAM injuries. Only then could high-risk groups be identified and preventive strategies implemented in obstetric practice.

Electromotive drug administration for treatment of therapy-refractory overactive bladder

PURPOSE

Evaluate the benefits of electromotive drug administration (EMDA) as an alternative technique in patients with chronic overactive bladder in terms of improvement of symptoms, quality of life, and sexuality.

MATERIAL AND METHODS

A total of 72 patients with therapy-refractory overactive bladder according to the ICS (International Continence Society) definition, were treated by EMDA. The regimen consisted of three treatment cycles, each with 3 instillations at 2-week intervals. The solution instilled consisted of 100 mL 4% lidocaine, 100 mL distilled water, 40 mg dexamethasone, and 2 mL epinephrine. Peri-interventionally, a urine test and close circulatory monitoring were performed. All women underwent urodynamic testing and cystoscopy and kept a voiding diary. A comprehensive history was obtained, a quality of life questionnaire administered, and a gynecologic examination performed before initiation of therapy. The women underwent follow-up at 12 months after the end of therapy.

RESULTS

The patients had a mean age of 63 (+/- 11.2) years. Bladder capacity improved significantly by 109 mL (+/- 55 mL) in 51 (71%) patients (p = 0.021). The number of micturitions/day decreased significantly to 7 (+/- 2) (p = 0.013). Quality of life was improved in 54 patients (75%); p = 0.024) and sexuality in 39 (54%); p = 0.020).

CONCLUSIONS

The results suggest that EMDA can improve both quality of life and sexuality in patients with therapy-refractory chronic overactive bladder.

[External anal sphincter repair using the overlapping technique in patients with anal incontinence and concomitant pudendal nerve damage]

BACKGROUND

No single surgical technique has so far emerged as the optimal approach to treat defects of the anal sphincter in patients with postpartum fecal incontinence. Our approach is to repair the external sphincter using the overlapping technique to optimize morphological and clinical outcome. The results were correlated with preoperatively determined pudendal nerve function.

METHODS

Thirty-five patients were followed up for three years after repair of the external anal sphincter. The patients had grade 2 (n = 29) or grade 3 (n = 6) fecal incontinence. Nineteen (54 %) patients had a concomitant defect of the internal anal sphincter and 28 (80 %) had abnormal pelvic floor EMG findings. Before surgery, all patients underwent conservative treatment with biofeedback and electrostimulation. The muscle ends were overlapped with Vicryl 4-0 sutures. A standardized protocol was used for the perioperative management in all patients.

RESULTS

Of the 35 patients who underwent overlapping repair of the external anal sphincter, 32 (91 %) had a satisfactory result at 3-year follow-up based on sonomorphological criteria. These 32 patients were continent for solid and liquid stools. Six of the 35 patients (17 %) continued to have flatus incontinence. Two (6 %) patients were improved and one patient (3 %) had unchanged incontinence. Pudendal nerve damage had no effect on the outcome of surgery.

CONCLUSIONS

Our findings at 3-year follow-up show good results for the overlapping repair of the external anal sphincter in terms of morphology and clinical symptoms. This outcome depends on an adequate preoperative pelvic floor conditioning, optimal perioperative management, and use of a standardized operative technique. Surgical repair of the morphological defect is recommended even in patients with pudendal nerve damage.

Sonomorphological evaluation of polypropylene mesh implants after vaginal mesh repair in women with cystocele or rectocele

OBJECTIVE

To investigate whether the sonographically measured size of the mesh implant in women who had undergone vaginal polypropylene mesh repair 6 weeks previously correlates with the original size of the mesh and whether the mesh ensures complete support of the anterior or posterior compartment.

METHODS

Forty postmenopausal women with anterior or posterior vaginal wall prolapse and sonographically proven cystocele (n = 20) or rectocele (n = 20) were evaluated preoperatively and 6 weeks after vaginal mesh repair. Introital ultrasound was performed to identify the polypropylene mesh and measure its distal to proximal length and configuration as well as its thickness. The initial mesh length was compared with that measured by ultrasound 6 weeks postoperatively. Vaginal length was measured pre- and postoperatively.

RESULTS

The mean +/- SD age of the women was 68 +/- 7 years. The 20 women with cystocele underwent repair by means of anterior transobturator mesh implantation; the initial mesh length was 6.8 +/- 1.1 cm versus 2.9 +/- 0.6 cm postoperatively. The 20 women with rectocele underwent repair by posterior transischioanal mesh implantation; the initial mesh length was 9.9 +/- 0.8 cm versus 3.3 +/- 0.5 cm postoperatively. The mesh supported 43.4% of the length of the anterior vaginal wall and this value was 53.7% for the posterior wall (P = 0.016).

CONCLUSION

Sonography is recommended for postoperative evaluation of the anterior and posterior mesh positions after prolapse surgery. There is a considerable discrepancy between the implanted mesh size and the length measured 6 weeks later by postoperative ultrasound. Published by John Wiley & Sons, Ltd.

Changes in the MRI morphology of the stress continence control system after TVT (tension-free vaginal tape) insertion

OBJECTIVE

Magnetic resonance imaging (MRI) was used to investigate whether tension-free vaginal tape (TVT) insertion (according to Ulmsten) leads to morphologic changes of the stress continence control system.

METHODS

Twenty women (mean age 53.4 years) with clinically and urodynamically proven stress urinary incontinence without prolapse were examined by MRI before and 13 months after TVT insertion.

RESULTS

Postoperative MRI showed a signal intensity loss of the suburethral portion of the endopelvic fascia in the area of the anterior vaginal wall in 9/20 women with additional signal loss of the paraurethral portion of the fascia in 3/20 women. No morphologic changes of the levator ani muscle and the urethra were seen postoperatively.

CONCLUSIONS

TVT insertion does not damage the structures of the stress continence control system or impact on their topographic relationships. MRI identified no excessive scar formation resulting from integration of the TVT.

Follow-up after polypropylene mesh repair of anterior and posterior compartments in patients with recurrent prolapse

To retrospectively analyze the outcome of surgery in women followed up for 1 year after vaginal repair with the Apogee (support of posterior vaginal wall) or Perigee (support of anterior vaginal wall) system. A total of 120 patients with recurrent cystocele and/or rectocele or with combined vaginal vault prolapse were treated by either posterior or anterior mesh interposition depending on the defect. Follow-up after 1 year (+/-31 days) comprised a vaginal examination with prolapse grading using the POP-Q system, measurement of vaginal length, evaluation of the vaginal mucosa, and exploration for mesh erosions. Postoperatively, 112 (93%) women were free of vaginal prolapse, whereas 8 (7%) had level 2 defects. Erosions occurred significantly more often (p = 0.042) in patients treated with the Perigee system. Our results suggest that the Apogee and Perigee repair systems (monofilament polypropylene mesh) yield excellent short-term results after 1 year.

Der Einsatz von Natrium-Chondroitinsulfat bei der Behandlung der „Überaktiven Blase”

OBJECTIVE

It is not always possible to clearly differentiate the symptoms of overactive bladder and interstitial cystitis. A prospective randomized study was performed to determine whether instillation of sodium chondroitin sulphate for treatment of interstitial cystitis is also effective in treating overactive bladder. The expected benefit of this therapeutic approach in overactive bladder is based on the assumption that the glycosaminoglycan layer may be damaged in overactive bladder as well.

MATERIAL AND METHODS

Patients with chronic overactive bladder were randomized to one of two study groups each including 41 patients. Group A was treated with an anticholinergic agent (tolterodine), group B with sodium chondroitin sulphate (Uropol S). The diagnosis was established on the basis of a gynecologic examination and history, urodynamic testing, introital ultrasound, and cystoscopy. Patients were treated for 12 months.

RESULTS

An improvement of symptoms was reported by 15/35 (43 %) of the patients in group A (p = 0.000) as compared with 23/32 (72 %) of the patients in group B. The subjective outcome was corroborated by means of urodynamic testing, number of pads used, voiding frequency, and nycturia (voiding diary). Quality of life increased significantly in both groups in the course of treatment but there was no significant difference between both groups.

CONCLUSION

The results of the study presented here suggest that restoring the glycosaminoglycan layer also improves or cures the symptoms in patients with overactive bladder. Patients clearly benefit from instillation of sodium chondroitin sulphate. These results must be confirmed in larger studies before a wider use of this therapeutic option can be recommended.

[Paraurethral abscess developing after mid-urethral Zuidex-injection in women with stress urinary incontinence -- management of complications and retrospective comparison with bladder neck located injection technique]

PURPOSE

To evaluate the cause and management of paraurethral abscess developing after injection of a mixture of hyaluronic acid and dextranomer (Zuidex) for treating stress urinary incontinence.

PATIENTS AND METHOD

A total of 127 women having undergone midurethral Zuidex injection and 34 women after endoscopically guided Deflux injection into the tissue around the bladder neck were followed up 1 to 24 months after the intervention. At follow-up, the paraurethral tissue was evaluated clinically by gynecologic examination and by introital ultrasound.

RESULTS

Thirteen of 127 women (10 %) having undergone midurethral Zuidex injection had a sterile paraurethral abscess that was treated by transvaginal puncture (1 to 3 punctures with removal of 10-60 ml of fluid per patient). No case of postoperative paraurethral abscess formation was demonstrated in the control group treated by Deflux injection into the area around the bladder neck.

CONCLUSIONS

Paraurethral abscess must be excluded in the postinterventional follow-up of patients after Zuidex injection. Patients in whom an abscess is demonstrated can be treated by transvaginal puncture. Abscess formation can be avoided by injecting dextranomer/hyaluronic acid into the area around the bladder neck.

Visibility of the polypropylene tape after tension-free vaginal tape (TVT) procedure in women with stress urinary incontinence: comparison of introital ultrasound and magnetic resonance imaging in vitro and in vivo

OBJECTIVE

To determine whether introital sonography and magnetic resonance imaging (MRI) after TVT (tension-free vaginal tape) insertion can depict the polypropylene tape, and thus be used for patient follow-up.

METHODS

The study comprised an experimental part, which investigated in-vitro visualization of the polypropylene tape in a model (phantom), and a clinical part, in which 20 women (mean age, 53.4 years) with clinically and urodynamically proven stress urinary incontinence without prolapse were investigated by introital ultrasound and MRI before and 13 months after the TVT procedure.

RESULTS

In the phantom, the polypropylene tape was depicted with a low signal intensity by MRI and as a highly echogenic structure by ultrasound. In the clinical study, introital ultrasound in a mediosagittal orientation depicted the vaginal tape in all patients: it was located under either the midurethra (n = 16) or the lower urethra (n = 4), and in either the muscular coat of the urethra (n = 8) or in the urethrovaginal space (n = 12), the tape was either flat (n = 6) or curled up (n = 14), and there was no retropubic visualization of the tape. Overall, depiction by MRI was limited, and was poorer in comparison with ultrasound, especially when the tape had a sub- or paraurethral location. Retropubically, however, MRI identified the tape near the periosteum of the pubic bone (55% of cases), in the retropubic space (37.5% of cases), or near the bladder wall (7.5% of cases).

CONCLUSION

Sonography is recommended for evaluation of the suburethral and paraurethral tape portions, while MRI is suitable for retropubic evaluation after the TVT procedure.

Management bei postoperativ diagnostizierter intravesikaler TVT-Bandlage anhand zweier Kasuistiken

Recurrent urinary tract infections and symptoms of a hyperactive bladder in women having undergone a TVT (tension-free vaginal tape) procedure may be due to intravesical position of the tape. Urogenital ultrasound can provide early preliminary diagnostic evidence, which can then be confirmed by subsequent urethrocystoscopy. Minimally invasive revision can be achieved by transurethral resection of the intravesical TVT portions. Tape portions near the wall can be removed after stretching of the tape with grasping forceps inserted through a suprapubically placed trocar. This simple procedure can spare the patient a more extensive repeat operation for removal of the intravesical TVT that may even require a combined abdominovaginal approach.

Vaginale Revision bei Irritation des N. obturatorius nach Burch-Kolposuspension

Irritation of the obturator-nerve within colposuspension is a possible complication because of topographic proximity between obturator-nerve and operating-field. The main symptoms are weakness of the adductor muscles, sensory disturbance of thigh till paralysis and pain in the operating- field early after surgery. Too lateral fixing of the sutures in the pectineal ligament above the obturator-channel can cause compression of the obturator-nerve. Precocious intervention is a precondition for complete remission of symptoms, retropubic revise of surgery is evident. The method outlined here describes vaginal access for re-surgery with lateral colpotomy and dissection of the proximal colposuspension s suture. In this way a recurrent laparotomy with additional trauma of the operating-field can be avoided. In the case described here, this method led to the patients complete remission.

Pathogenesis of urethral funneling in women with stress urinary incontinence assessed by introital ultrasound

OBJECTIVE

The incidence of urethral funneling (UF) seen in women with stress urinary incontinence (SUI) during straining is reported to range from 18.6% to 97.4%. Its morphologic basis is unknown. The aim of the present study was to determine whether SUI patients with and without UF differ in terms of history, urodynamic results and magnetic resonance imaging (MRI) findings.

PATIENTS AND METHODS

Fifty-four women (mean age 52 +/- 11 years) with a history of SUI confirmed by clinical and urodynamic findings were included in the study. UF was demonstrated by introital ultrasound performed at a bladder filling volume of 300 mL during maximal straining. MRI for assessment of the urethra, levator ani muscle and endopelvic fascia was performed using axial proton-density-weighted sequences.

RESULTS

UF was demonstrated by introital ultrasound in 59% of the patients with SUI (Group 1) and was absent in 41% (Group 2). There were no differences between the two groups in mean age (P = 0.208), the incidence of mild prolapse of the anterior vaginal wall (Aa, Ba; stage I; P = 0.741), and urodynamic parameters (urethral closure pressure at rest; P = 0.507). The percentages of nulliparous and parous women were 22% and 78% in Group 1 and 54% and 46% in Group 2 (P = 0.013). The two groups did not differ in the MRI demonstration of morphologic defects of the urethra, levator ani muscle and endopelvic fascia or of combined defects.

CONCLUSIONS

The results of the present study did not elucidate the pathogenesis of UF. The demonstration of UF crucially depends on the examination technique employed.

Morphology of the suburethral pubocervical fascia in women with stress urinary incontinence: a comparison of histologic and MRI findings

To correlate MRI with histologic findings of the suburethral pubocervical fascia in women with urodynamic stress incontinence. Thirty-one women with urodynamically proven stress urinary incontinence without relevant prolapse underwent preoperative MRI. Tissue specimens obtained from the pubocervical fascia were examined immunohistochemically (types I and III collagen, smooth muscle actin) and the results compared with the MRI findings. MRI demonstrated an intact pubocervical fascia in 61.3% of the cases and a fascial defect in 38.7%. A fascial defect demonstrated by MRI was associated with a decrease in actin (P<0.09) and an increase in collagen III (P<0.01) compared to an intact fascia. In women with stress urinary incontinence, smooth muscle actin in the pubocervical fascia is decreased, changed in structure, and replaced by type III collagen. MRI allows evaluation of the pubocervical fascia and its morphologic changes.

Harn- und Analinkontinenz im Alter

Three to four million women suffer from urinary incontinence (UI) in Germany. This number will rise further as life expectancy increases, and there is an annual incidence of newly occurring UI of about 1%. Two thirds of all women with UI suffer additional symptoms of fecal incontinence. The type of incontinence present is diagnosed on the basis of patients history, clinical findings, and functional testing. The findings should be interpreted in an age-adjusted manner to avoid over-rating (e.g. urethral closure pressure at rest=100-age in cm H(2)O). The management of elderly patients focuses on conservative approaches with bladder and intestinal training as well as dietary measures serving to counteract the age-related loss of intellectual abilities. Local estrogen application has a positive effect on all forms of incontinence. Surgical approaches aim at improving symptoms since forced restoration of incontinence in elderly patients frequently induces voiding disorders.

[Current state of uterine artery embolization for treating symptomatic leiomyomas of the uterus]

A number of new approaches in treating symptomatic leiomyomas of the Uterus have been introduced in recent years. Only little scientific data is available an percutaneous or laparoscopic myolysis using focussed ultrasound, laser, or coagulation guided by magnetic resonance imaging or an laparoscopic ligation of the uterine vessels by means of bipolar coagulation or clipping. Established therapeutic options are limited by a number of disadvantages, except for total laparoscopic hysterectomy with morcellation. The latter is a minimally invasive procedure that spares important pelvic structures and thereby reduces the risk of prolapse and is associated with rapid recovery of the patients. Another minimally invasive therapeutic approach with preservation of the uterus is transarterial catheter embolization of uterine leiomyomas in which the vessels supplying the leiomyomas, in particular the branches of the uterine artery, are partly occluded by injection of synthetic (polyvinyl) beads. Uterine artery embolization has since developed into a good alternative to other therapeutic options. Studies report cure rates ranging from 77-93 %.

Updated recommendations on ultrasonography in urogynecology

Ultrasound is a supplementary, indispensable diagnostic procedure in urogynecology; perineal, introital, and endoanal ultrasound are the most recommended techniques. The position and mobility of the bladder neck can be demonstrated. In patients undergoing diagnostic work-up for urge symptoms, ultrasound occasionally demonstrates urethral diverticula, leiomyomas, and cysts in the vaginal wall. These findings will lead to further diagnostic assessment. The same applies to the demonstration of bladder diverticula, foreign bodies in the bladder, and bullous edema. With endoanal ultrasound, different parts of the sphincter ani muscle can be evaluated. Recommendations for the standardized use of urogenital ultrasound are given.

[End-to-end anastomosis in the primary repair of anal sphincter laceration occurring during delivery]

PURPOSE

To assess the quality of end-to-end anastomosis in the primary repair of anal sphincter laceration occurring during delivery.

METHODS

Forty-nine women with third degree perineal laceration (PL III) and 42 controls were included in a 3-year postpartal follow-up study.

RESULTS

Ultrasound showed end-to-end anastomosis to be inadequate in 22 (48.1 %) women. Thirty-one (63.2 %) women developed grade I-III anal incontinence.

DISCUSSION

There was no correlation between ultrasound findings and the presence of anal incontinence. The unsatisfactory sonomorphometric outcome after 6 weeks results from inadequate repair with retraction of the sphincter ends. Defects newly demonstrated after 36 months indicate dedifferentiating atrophy with damage to peripheral motor nerves.

[Introital and perineal sonography in diagnosing stress urinary incontinence - possible clinical applications]

Urogynecological ultrasound as a part of the diagnostic work-up of stress urinary incontinence enables the morphologic and dynamic assessment of the lower urinary tract and has replaced radiography in the primary diagnostic work-up of stress urinary incontinence. It is possible to classify the sonographically identified changes of the endopelvic fascia, whereby any dynamic changes must be interpreted in context with the clinical findings. Stress urinary incontinence, besides voiding dysfunction, recurrent urinary tract infections and dyspareunia, may be associated with urethral diverticula, which can be detected by ultrasound. Postoperative voiding problems, de novo urgency or recurrent urinary tract infections can be assessed by demonstrating possible causes, such as haematomas, overcorrection with postvoid residual, misplacement of the tape at the level of the bladder neck or intravesical displacement of suture or tape material. Introital and perineal ultrasound might also be used for monitoring the proper placement of sutures to reduce postoperative complications.

Ultrasound diagnosis of intra-urethral tension-free vaginal tape (TVT) position as a cause of postoperative voiding dysfunction and retropubic pain

Intra-urethral Prolene tape erosion is a rare postoperative complication of tension-free vaginal tape (TVT) plasty. In cases reported in the literature, intra-urethral tape positioning has been diagnosed by urethroscopy as late as 3-12 months after the procedure. Introital ultrasound using a vaginal sector scanner allows for the non-invasive assessment of the position of the Prolene tape in relation to the urethra. Postoperative introital ultrasound might shorten the interval between surgery and the time of diagnosis of an intra-urethrally placed tape and thus significantly shorten the duration of symptoms. We present a patient with urethral pain syndrome and dysuria following TVT plasty. In this case, introital ultrasound was not performed until 8 months after surgery, when it demonstrated intra-urethral Prolene tape positioning as the cause of the patient's complaints. All symptoms disappeared after surgical removal of the intra-urethrally placed parts of the tape. The patient is continent, suggesting that the remaining para-urethral portions of the Prolene tape depicted sonographically ensured adequate stabilization of the mid-urethra in this case. The case report emphasizes the role of introital ultrasound in assessing Prolene tape position relative to the urethra on sagittal and transverse angulated views in the postoperative diagnostic evaluation of functional disturbances occurring after TVT plasty.

Transvaginaler Verschluss einer nach Re-Sectio caesarea aufgetretenen vesico-uterinen Fistel Typ I (Jozwik)

The development of a vesico-uterine fistula is a problem which occurs with an increasing number of caesarean sections. The main symptoms are permanent urinary incontinence, cyclic hematuria ("menouria") and amenorrhoea. In only 5 % of cases, spontaneous closure with bladder catheterization over weeks and hormonal management is possible, most of the time a surgical procedure is the definitive treatment. Until now, the resection of this kind of fistula was performed using a transabdominal approach most of the time. Our procedure describes a surgical repair using a transvaginal approach by exciding the fistula out of the bladder and uterus with primary closure. In this way, a recurrent laparotomy with all known associated risks could be avoided. However, after definitive treatment of the fistula, a new pregnancy should be delivered by performing a caesarean section. In this way, a rupture of the uterus during delivery could be prevented.

Introital and transvaginal ultrasound as the main tool in the assessment of urogenital and pelvic floor dysfunction: an imaging panel and practical approach

This article reviews the different applications of ultrasound in benign urogynecological diseases. The findings presented here were obtained by introital and transvaginal ultrasound, both of which can be performed with the same equipment (5-7-MHz sector transducer, emission angle of at least 90 degrees; for introital sonography, the transducer is placed over the external urethral orifice with the transducer axis corresponding to the body axis). Female voiding dysfunction, including urge symptoms, recurrent urinary tract infections and urinary incontinence, may occur secondary to morphological and topographical changes of the urogenital organs. Findings such as urethral diverticula, periurethral masses, funneling of the urethra and distension cystoceles are identified by introital ultrasound. Transvaginal ultrasound enables the detection of pathologies of the bladder and uterus including its appendages. Ultrasound as part of the diagnostic work-up of stress urinary incontinence and genitourinary prolapse allows for the morphological and dynamic assessment of the lower urinary tract. It is possible, for example, to classify sonographically identified changes of the endopelvic fascia as lateral (distraction cystocele, funneling of the urethra) and central (pulsation cystocele) defects as well as to determine the reactivity of the pelvic floor muscles. Ultrasound has replaced radiography in yielding information on the abnormal morphology of the urogenital organs, which should be taken into account in planning the treatment of urogynecological conditions.