Trans-obturator cystocele repair of level 2 paravaginal defect

INTRODUCTION AND HYPOTHESIS

It is reported that almost one in five women will need some form of pelvic organ prolapse surgery in their lifetime, with anterior wall repair accounting for nearly half of these. Cystoceles occur secondary to defect(s) in one or more of the vaginal wall support mechanisms, including its lateral paravaginal attachments. Paravaginal defects are very common in women presenting with cystocele, thus highlighting the importance of paravaginal defect repair for optimal cystocele correction in the majority of cases. Although there are several paravaginal defect repair procedures, some entail complex techniques, whereas others rely on the use of transvaginal mesh, which is currently not permitted in many countries.

METHODS

In this video article we present a novel trans-obturator native tissue paravaginal defect repair for the management of cystocele.

RESULTS

This procedure has the advantages of avoiding complex transabdominal paravaginal defect repair, the controversial use of transvaginal mesh, or a single-point fixation to an arcus tendineus fasciae pelvis that might be difficult to identify.

CONCLUSION

We believe that the trans-obturator cystocele repair procedure offers several advantages over existing paravaginal defect repair alternatives.

Long-term efficacy follow-up of tension-free vaginal tape obturator in patients with stress urinary incontinence with or without cystocele

OBJECTIVE

To assess the long-term outcomes of tension-free vaginal tape obturator (inside-out) (TVTO) with or without anterior colporrhaphy.

METHODS

The present prospective follow-up observational study included patients attending the 2nd Department of Obstetrics and Gynecology, Aretaieio Hospital, University of Athens, Greece, between April 3 and December 20, 2017, for follow-up care after treatment for urodynamic stress urinary incontinence (USUI) with or without cystocele. Patients without cystocele had been treated with TVTO only; those with cystocele underwent TVTO with anterior colporrhaphy. The primary outcome was the objective cure rate assessed by the cough stress test during filling cystometry.

RESULTS

Follow-up data were available for 70 patients who underwent TVTO only and 38 who underwent TVTO and anterior colporrhaphy. The mean follow-up period was 13 years. Objective cure was achieved for 57 (81%) patients in the TVTO-only group and 32 (84%) patients in the TVTO and anterior colporrhaphy group. Regarding cystocele management, objective cure was recorded for 35 (92%) patients.

CONCLUSION

At 13-year follow-up, anterior colporrhaphy demonstrated a cure rate of 92% in the management of cystocele, and 84% in the management of cystocele and USUI when combined with TVTO. TVTO alone for the management of USUI had an objective cure rate of 81%.

Transobturator Bypass Utilizing Fluoroscopic Guidance

Introduction

Transobturator bypass is an older and less frequently performed revascularization of the lower extremity that is useful in the setting of multiple failed lower extremity bypasses usually due to groin sepsis and infection(s). It can be a technically challenging operation due to anatomic constraints.

Report

We describe a successful transobturator bypass utilizing fluoroscopy for passage of bypass tunneler and graft through the obturator foramen.

Discussion

Live fluoroscopy is a versatile technique and in conjunction with our described surgical technique of lower extremity bypass should help increase the technical success rates of this procedure.

Is there a difference?

Objectives

To determine whether there are any significant differences in complications and success rate between adjustable transobturator tape (TOA) and ordinary transobturator tape (TOT) in the treatment of female stress urinary incontinence (fSUI), as the TOA was recently introduced for the treatment of female SUI, its advantage being the ability to adjust the tape after surgery to address over- or under-correction.

Patients and methods

In all, 96 women with SUI (mean age 53 years, SD 10) were included in the study. Patients were randomised into two equal groups (group 1, TOA, vs. group 2, TOT). The operative duration, blood loss, intra- and post-operative complications, and the success rate, were compared between the groups.

Results

There was no statistically significant difference between the groups in cure rates (83% vs. 80%, groups 1 and 2, respectively) or in postoperative stay. The mean operative duration in group 2 was significantly shorter than in group 1. No intraoperative bleeding requiring a blood transfusion was recorded, and there were no bladder injuries. Postoperative adjustment of the tape was only required in three patients in group 1.

Conclusions

The TOA is a safe and accurate method for treating fSUI, but with experienced surgeons there was no difference in the cure rate and postoperative outcome between TOA and TOT.

The Trial of Mid-Urethral Slings (TOMUS): Design and Methodology

OBJECTIVE

Mid-urethral slings (MUS) are increasingly common surgical procedures for the treatment of stress urinary incontinence (SUI) in women. There are currently no adequately powered trials with sufficient length of follow-up comparing the efficacy or safety of the transobturator and retropubic MUS. As a result, no selection criteria are available to guide surgeons or patients. This article describes the methodology and rationale for the Trial Of Mid-Urethral Slings (TOMUS).

PATIENTS AND METHODS

The primary aims of this randomized controlled trial is to compare subjective and objective success rates for urinary incontinence (UI) at 12 and 24 months following retropubic and transobturator MUS procedures. Secondary aims are to compare the resolution of overall and stress-specific UI, morbidity, the time to adequate voiding, satisfaction, and quality of life in the two groups. TOMUS will also assess the clinical utility of pre-operative urodynamics in women undergoing MUS procedures. The primary outcome will be obtained at 12 months and 24 months. The definition of treatment success is two-fold. Objective treatment success is defined by a negative stress test, a negative 24-hour pad test and no retreatment for SUI. Subjective treatment success is defined by no self-reported leakage on 3-day diary and no self-reported SUI symptoms. Enrollment began April 2006 and is expected to be complete in 2 years.

CONCLUSIONS

The TOMUS trial is designed to provide outcome and safety information to pelvic surgeons and their patients on the two most commonly performed MUS techniques.