Faculty Bibliography

Our purpose was to evaluate the outcome of a subset of patients that had a tension-free vaginal tape-obturator (TVT-O) placed following a previous anti-incontinence procedure. We performed a retrospective analysis of 27 consecutive women who had a TVT-O placed from January 2004 to December 2007. Patients were given the Patient Global Impression of Improvement (PGI-I) questionnaire starting at the 3-month follow-up. Of 174 women who had a TVT-O placed, 27 (15.5%) had a prior failed anti-incontinence procedure or surgery performed. The mean age was 63.8 years (range 43-87). Mean follow-up was 25.7 months (range 12-47 months). Based on the PGI-I, the overall success rate was 80% (20/25). In the properly selected patients with prior intervention for stress urinary incontinence (SUI), the success rate for TVT-O of 80% appears to be comparable to that of patients who never had a previous surgical or minimally invasive treatment for SUI

PURPOSE: We evaluated the protocol that we use to determine whether a mid urethral synthetic sling will be placed at transvaginal pelvic organ prolapse repair. MATERIALS AND METHODS: A total of 140 patients underwent transvaginal repair for stage 2 to 4 pelvic organ prolapse, of whom 105 were treated according to the protocol and had a minimum 3 months of followup or required earlier intervention. Urodynamics were performed without prolapse reduction. When stress urinary incontinence was not identified, a pessary was placed and the study was repeated. Patients were designated as having urodynamic, occult or no stress urinary incontinence. Patients with urodynamic or occult stress urinary incontinence underwent a simultaneous mid urethral synthetic sling procedure, while those without urodynamic or occult stress urinary incontinence did not. Charts were reviewed to determine whether further intervention was required for stress urinary incontinence or obstruction. RESULTS: The risk of intervention due to obstruction after receiving a mid urethral synthetic sling was 8.5%. The risk of intervention for stress urinary incontinence in patients with no clinical, urodynamic or occult stress urinary incontinence and no mid urethral synthetic sling was 8.3%. The risk of intervention for stress urinary incontinence in patients with clinical stress urinary incontinence but no urodynamic or occult stress urinary incontinence and no mid urethral sling was 30%. CONCLUSIONS: Using our urodynamic protocol to manage the urethra at transvaginal pelvic organ prolapse repair the risk of intervention due to obstruction is essentially equal to the risk of intervention due to stress urinary incontinence when no clinical, urodynamic or occult stress urinary incontinence was present and no mid urethral synthetic sling was placed. In patients who report clinical stress urinary incontinence preoperatively despite no urodynamic or occult stress urinary incontinence there is a much higher rate of further intervention for stress urinary incontinence

INTRODUCTION: We sought to identify our indications for a pubovaginal sling (PVS) in the midurethral synthetic sling era. METHODS: Between June 2002 and July 2008, 369 consecutive, nonrandomized women underwent treatment for stress urinary incontinence with a sling surgery. Forty underwent PVS, while 329 midurethral slings were placed. This effort was focused on the reasons why PVS was chosen over a MUSS. RESULTS: Mean patient age was 54.9 years (range, 21-86). Clinically, 69% presented with stress urinary incontinence and 31% with mixed urinary incontinence. The majority of the patients opted for a PVS for multiple previously failed incontinence surgeries 52.5%, followed by a fixed urethra 50%, concomitant surgeries involving urethral reconstruction 22.5%, compromised anatomy 18.7%, and abdominal surgery for a separate indication 5%. Forty-four percent (15/34) were cured, 17.6% (6/34) improved, 26.4% (9/34) failed, 6% (2/34) obstructed, and 6% (2/34) lost to follow-up. CONCLUSION: In the midurethral synthetic sling era, the PVS maintains its relevance in patients presenting with complex incontinent issues

The negative impact of overactive bladder (OAB) on daily quality of life drives the large market of pharmacotherapy targeted at symptoms of urinary frequency and urgency, with or without urinary urge incontinence. Currently, the primary pharmacologic treatment modality is aimed at modulation of the efferent muscarinic receptors (M2 and M3) predominant in detrusor smooth muscle and responsible for involuntary or unwanted bladder contractions. However, due to drug effects in the muscarinic receptors of the salivary glands and intestinal smooth muscle, as well as extensive first-pass metabolism in the liver and intestinal tract yielding parent drug metabolites, adverse side effects are common and can be quite bothersome. These issues, encountered with many of the oral antimuscarinic formulations, limit their tolerability and affect long-term patient compliance and satisfaction. Thus, the benefit of pharmacotherapy for OAB must be a balance between efficacy and tolerability, also known as therapeutic index. This article reviews the current pharmacologic delivery systems available for the treatment of OAB, patient compliance, and reasons for discontinuation of medication

OBJECTIVE: The objective of our study was to retrospectively compare the degree of pelvic organ prolapse shown on dynamic true fast imaging with steady-state precession (FISP) versus HASTE sequences in symptomatic patients. MATERIALS AND METHODS: Fifty-nine women (mean age, 57 years) with suspected pelvic floor dysfunction underwent MRI using both a sagittal true FISP sequence, acquired continuously during rest alternating with the Valsalva maneuver, and a sagittal HASTE sequence, acquired sequentially at rest and at maximal strain. Data sets were evaluated in random order by two radiologists in consensus using the pubococcygeal line (PCL) as a reference. Measurement of prolapse was based on a numeric grading system indicating severity as follows: no prolapse, 0; mild, 1; moderate, 2; or severe, 3. A comparison between sequences on a per-patient basis was performed using a Wilcoxon's analysis with p < 0.05 considered significant. RESULTS: Overall, 66.1% (39/59) of patients had more severe prolapse (>or= 1 degrees ) based on dynamic true FISP images, with 28.8% (17/59) of the cases of prolapse seen exclusively on true FISP images. Only 20.3% (12/59) of patients had greater degrees of prolapse on HASTE images than on true FISP images, with 10.2% (6/59) of the cases seen exclusively on HASTE images. A statistically significant increase in the severity of cystoceles (p < 0.01) and urethral hypermobility (p < 0.01)-with a trend toward more severe urethroceles (p < 0.07), vaginal prolapse (p < 0.09), and rectal descent (p < 0.06)-was shown on true FISP images. CONCLUSION: Overall, greater degrees of organ prolapse in all three compartments were found with a dynamic true FISP sequence compared with a sequential HASTE sequence. Near real-time continuous imaging with a dynamic true FISP sequence should be included in MR protocols to evaluate pelvic floor dysfunction in addition to dynamic multiplanar HASTE sequences

OBJECTIVES: To describe the patient characteristics, physical examination and magnetic resonance imaging findings, and method of surgical repair of perineocele. A perineocele is a rare condition of an isolated central defect and herniation of the posterior perineum in patients without diffuse vaginal prolapse. METHODS: The evaluation consisted of history and physical examination and magnetic resonance imaging. With the patient in the dorsal lithotomy position, an inverted Y incision was made from the posterior vagina to the posterior rectum. The transverse perineal musculature, superficial perineal membrane, and external anal sphincter were approximated. The perineal distance from the posterior fourchette to the anus was measured preoperatively and postoperatively. Symptom and anatomic assessments were done at each postoperative visit. RESULTS: A total of 6 patients were treated, with a mean follow-up of 9.5 months. The symptoms at presentation consisted of perineal pressure, severe constipation, and the need for manual perineal reduction for defecation. The physical findings included a lack of vaginal prolapse, convexity of the perineum, and an increase in the distance from the posterior fourchette to the rectum. Dynamic magnetic resonance imaging showed no anomaly of the vaginal wall. Preoperatively, the average perineal distance was 11.2 cm and postoperatively it was 4 cm. The perineocele was successfully repaired in all patients. All but 1 patient had significant relief of constipation. CONCLUSIONS: Posterior levator defects can result in perineal hernia with perineal body attenuation, separation of the transverse perineal and anal sphincter musculature, and development of a perineocele. The relief of symptoms and correction of the anatomic defect can be achieved by reapproximation of these structures.

The objective was to determine urodynamic findings in young, premenopausal, nulliparous women with bothersome lower urinary tract symptoms and assess whether or not symptoms are predictive of specific urodynamic abnormalities. The records of 57 women were reviewed. Those with neurological disease or a primary complaint of stress incontinence were excluded. All completed the American Urological Association Symptom Index (AUASI) and underwent videourodynamics. Symptoms were compared in patients with and without bladder dysfunction and/or voiding phase dysfunction. Bladder dysfunction was diagnosed in 86% of patients with urge incontinence vs. 17% of those without (p<0.0001). Patients with voiding phase dysfunction had higher total and voiding AUASI scores. Occult neurological disease was later diagnosed in 4 women (24%) with urge incontinence and bladder dysfunction. Urge incontinence and voiding symptoms are frequently associated with urodynamically demonstrable abnormalities. Urge incontinence and bladder dysfunction may be a sign of occult neurological disease in this population. The presenting symptoms are useful in determining the utility of urodynamics in this population