Urethral diverticulum in pregnancy

AbstractUrethral diverticulum is rare in pregnancy. There is no clear guideline on the management of urethral diverticulum in pregnancy, but most cases were managed conservatively. We report a case of urethral diverticulum in a primigravida woman, who presented with anterior vaginal swelling at 14 weeks of gestation. She was managed conservatively and the cyst (approximately 8 cm × 13 cm) was aspirated during the early stage of labor. However her labor did not progress during the second stage, which resulted in an emergency cesarean section. She underwent diverticulectomy at 1 month postpartum because of the recurrence of the swelling and persistent discomfort. We believe that her dystocia may have been caused by factors other than the diverticulum. As previously described in literature, we concluded that, even in pregnant women with a large urethral diverticulum, vaginal delivery can still be considered with prior aspiration during the early stage of labor

Objective and subjective outcome 3 years after synthetic transobturator nonabsorbable anterior mesh use in symptomatic advanced pelvic organ prolapse surgery

Background: The management of using a mesh graft in the anterior compartment is reported to lead to a higher rate of recurrent prolapse after anterior colporrhaphy than after mesh repair. Several randomized controlled trials (RCTs) have shown no significantly superior subjective cure rates or reoperation rates, despite better anatomical cure rates with synthetic mesh compared with traditional anterior colporrhaphy for anterior compartment defects, however, the follow-up period in most RTCs was only 1 year. Objective: To evaluate the objective and subjective outcome in women with symptomatic advanced pelvic organ prolapse (POP) who underwent sacrospinous fixation (SSF) with anterior vaginal mesh (AVM). We postulated that in the hands of well-trained surgeons, AVM plus SSF yields better long-term success rates with a low rate of mesh-related complications. We studied the long-term postoperative outcomes of SSF with AVM. Study design: This was a retrospective study of 114 patients who underwent surgery for POP between January 2006 and March 2010. Patient assessment at baseline and 3-year postoperative follow-up was analyzed. SSF plus AVM was performed for apical and anterior compartment repair. Primary outcome was objective cure (POP Quantification Stage ≤ 1) and subjective cure defined as a negative response to Questions 2 and 3 on the POP Distress Inventory 6. Secondary outcomes were complications, symptoms severity, and quality of life as measured using validated questionnaires. Results: Postoperative data for 114 patients were analyzed. Median follow up was 59.6 months. All patients completed a minimum of 3 years follow up. The objective cure rate was 100% for anterior and apical compartments and 90.4% for posterior compartment. Regarding the individual compartment, the cure rate was significantly high (p < 0.001 for all compartments). There were four cases (3.5%) of mesh exposure in which all patients were treated under local anesthetic with excision of the exposed mesh without additional suturing of vaginal tissue at the outpatient office. Topical estrogen therapy was prescribed to facilitate re-epithelialization of vaginal wounds. There were no cases of mesh erosion into the bladder or other organs, and no patient needed mesh removal due to chronic pain or infection. There was no recurrence in the anterior and apical compartment. Eleven patients (9.6%) had recurrence of the posterior compartment during postoperative follow up. There was a significant improvements in all questionnaires with p < 0.001 for POP Distress Inventory 6, Urogenital Distress Inventory, and Incontinence Impact Questionnaire, and p = 0.001 for Prolapse/Urinary Incontinence Sexual Function Questionnaire. There was no significant difference for preoperative and 1-year postoperative urodynamic diagnosis. There were seven cases of occult urodynamic stress incontinence. Conclusion: The Perigee System gave a favorable result in both anatomical and subjective success rates with a low rate of mesh-related morbidities. The strength of the study reported here is its long-term follow up of a relatively large number of patients and the use of validated questionnaires. Limitations are that it is not a RCT; hence, selection and indication bias is unavoidable. The favorable outcome and low morbidities resulting from mesh use is from a single surgeon's perspective and may not be generalized to others

Spontaneous pregnancy after pessary placement in a patient with infertility and advanced pelvic organ prolapse

To highlight possible association of advanced pelvic organ prolapse with infertility and its successful outcome following conservative management. We report herein a 38-year-old para 1, non-overweight woman who presented with secondary infertility without any factors for infertility except for an advanced POP. She had intrauterine insemination (IUI) performed twice at a local clinic and in vitro fertilization-embryo transfer (IVF-ET) program twice in our institute unsuccessfully. She conceived spontaneously after vaginal pessary placement and delivered, vaginally, a healthy female baby weighing 3,365 g at the 38th week of gestation. Advanced POP appears to be an important risk factor for infertility. After completing an infertility workup, pessary application can be the first-line treatment modality for women with unexplained infertility due to advanced POP

Clinical outcomes of mesh exposure/extrusion: Presentation, timing and management

Background: The Food and Drug Administration has recently highlighted an increase in reported complications associated with the use of transvaginal mesh. Aims: To describe the clinical outcomes, presentation, timing and management of mesh exposure/extrusion Materials and Methods: Retrospective study from December 2006 to March 2012. A total of 40 women had vaginal mesh exposure/extrusion secondary to prior transvaginal mesh (TVM) surgery. Descriptive statistics were used for demographics and pre-operative data. Paired-samples t-test was applied for comparison of pre- and postoperation. A P value of \u3c0.05 was considered statistically significant. Results: The mesh exposure/extrusion rate was noted to be 2.64% (17/642). Vaginal bleeding in 29 of 40 (72.5%) and hispareunia in 12 of 13 (92.3%) were identified as the most common symptoms for mesh exposure/extrusion. The onset of complications occurred in two peaks: between 3 and 4 months and after 1-year of follow-up. Initial conservative treatment was given for 12.5% (5/40) of women, while 87.5% (35/40) had undergone repair for mesh exposure/extrusion (21 outpatient and 14 inpatient cases). Among those who had conservative treatment, 80% (4/5) had persistent mesh exposure. Conclusion: Persistent or new-onset abnormal vaginal bleeding and hispareunia after TVM surgery should be considered as \u27red flag\u27 symptoms for mesh exposure/extrusion. Frequent follow-up from the first 3-4 months up to 1 year postoperative may identify complications. Utilisation of mesh excision or trimming as the initial means of treatment may yield a better outcome

Anterior-apical single-incision mesh surgery (SIMS): Surgical and functional outcomes at 1 year

Study Objectives: To study the surgical and functional outcomes of single-incision mesh surgery for treatment of advanced pelvic organ prolapse (POP). Design: Case series (Canadian Task Force classification II-3). Setting: University hospital. Patients: Sixty-five patients who underwent surgery to treat symptomatic POP greater than stage II according to the Pelvic Organ Prolapse Quantification System (POP-Q). Intervention: All patients underwent anterior-apical single-incision mesh surgery using the Elevate Anterior and Apical Prolapse Repair System. Measurements and Main Results: The primary objectives were anatomical correction of anterior and apical prolapse of POP stage I or greater and absence of voiding dysfunction reported via multi-channel urodynamic study at 6months after surgery. Subjective outcome was measured via patient feedback using questions 2 and 3 of the Pelvic Organ Prolapse Distress Inventory 6 (POPDI-6). The secondary outcome was quality of life using the following: Urogenital Distress Inventory 6 (UDI-6), Incontinence Impact Questionnaire 7 (IIQ-7), POPDI-6, and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). Two-dimensional introital ultrasonography was performed in the first and third months after surgery and at 1-year follow-up. Descriptive statistics were used for demographic and perioperative data. The paired-samples t test was used for comparison of preoperative and postoperative continuous data. For all comparisons, a value of p \u3c .05 was considered statistically significant. All statistical methods were performed using commercially available software (SPSS version 17). Postoperative data were available for 64 patients. The objective outcome was 96.9%, and the subjective outcome was 93.8%. All patients demonstrated significant improvement in anatomical outcomes after prolapse surgery (p \u3c .05), and none experienced recurrence requiring further surgery. There was concomitant significant improvement in POPDI-6, UDI-6, IIQ-7, and PISQ-12 scores after surgery. A subanalysis of POP quantification measurements immediately after surgery and at 1-year postoperative follow-up demonstrated deepening of the C point and total vaginal length. Ultrasound evaluation demonstrated a significant increase in the length and thickness of mesh at 1-year follow-up. There has been no documented mesh extrusion to date. However, the number of patients with stress urinary incontinence has increased. Four patients received treatment, whereas in the remaining patients the condition was not severe enough to require surgical intervention. Conclusions: Single-incision mesh surgery for treatment of advanced POP results in improvement in anatomical and quality-of-life outcomes. No mesh exposure was recorded in the first year after surgery; however, new onset of stress urinary incontinence may occur. Ultrasound evaluation demonstrated an increase in mesh length and thickness over time, with concurrent calculated lengthening of the C point and total vaginal length

Ultrasonography and clinical outcomes following surgical anti-incontinence procedures (Monarc vs Miniarc)

Objective To evaluate the ultrasound morphology and its clinical outcome among women who had undergone Miniarc™ vs Monarc™ in the treatment of stress urinary incontinence (SUI). Study design This was a prospective study on 140 patients with USI and undergone either Miniarc or Monarc surgery. From March 2010 to December 2011, patients with clinically SUI and urodynamic stress incontinence (USI) were included in the study. Objective cure of SUI was defined as no urinary leakage on provocative filling cystometry and 1-h pad test of \u3c2 g. Subjective cure of SUI was the negative response to UDI-6. Introital ultrasound at one-year explored the sling and bladder neck\u27s position, mobility, sling tension, percentile of urethra where the sling was located and urethral kinking. Results Postoperative data was available from 130 women. The ultrasound objective data for successful treatment post-operative follow-up was available from 119 women (46 Monarc, 73 Miniarc), the rest failed to follow-up. A bladder perforation was diagnosed in the Monarc group and 15 cases (7.1% of Monarc and 16.3% of Miniarc, p = 0.082) of urinary retention was reported due to over-tensioning of the sling, majority of cases came from the Miniarc group. At rest and during Valsalva, analogous distances of the bladder neck and sling as well as the center of the urethral core were similar for both procedures. In both groups, shortest (Us) and longest diameters (Ul) of the urethral core were comparable at Valsalva which was significantly shorter and longer, respectively, compared to the values at rest. Sling position and percentage of urethral kinking were similar. Statistical analysis failed to detect any significant difference between the two groups with regards to the objective and subjective cure (p \u3e 0.05). Conclusions In conclusion, a Miniarc and Monarc exhibit similar mechanism of action with comparable subjective and objective clinical outcomes. Majority of urethral impingement was noted in the Miniarc group. A higher maximum urethral closure pressure (MUCP), longer resting Ul, and shorter resting Us suggested these observations. Postoperative ultrasonographic evaluation may give a promising future perspective for the evaluation of sling tension

Influence of anterior vaginal mesh with concomitant mid-urethral sling surgery on stress urinary incontinence: Clinical and sonographic outcome

Introduction To clinically and sonographically evaluate the influence of anterior vaginal mesh (AVM) surgery with concomitant mid-urethral sling surgery (MUS) for stress urinary incontinence (SUI). Materials and Methods Women with severe symptomatic pelvic organ prolapse (POP) stage III or IV with concomitant SUI were divided into two groups: Group I had transobturator tape (TOT) and AVM surgery and Group II underwent TOT without AVM surgery. Clinical outcome was assessed pre-operatively and 1 year post-operatively, while ultrasound evaluations were performed after one year. Objective cure was defined as no urinary leakage demonstrable on provocative filling cystometry. Subjective SUI cure was a negative response to Urogenital Distress Inventory Six (UDI-6) (question 3). Results A total of 97 women were recruited, 57 in Group I and 40 in Group II. Three women had symptomatic prolapse in Group I and 5 in Group II. There were no differences in the ultrasound and clinical outcomes between women who had mid-urethral slings with and without AVM. Successful SUI outcome was reported in 85 women. Urethral kinking was demonstrable in 50% of successful cases, but none with failed outcomes. Subanalysis among those with successful SUI outcome (n = 85) and failure (n = 12) revealed the tape, bladder neck and mesh mobility was significantly higher (P \u3c 0.001) among those with SUI success. Conclusions Among women who had MUS, there were no differences in the ultrasound and clinical outcome between those who had AVM or otherwise

Assessment of collagen versus non collagen coated anterior vaginal mesh in pelvic reconstructive surgery: Prospective study

Objective To evaluate the sonologic and clinical outcome of collagen coated (CC) versus non-collagen coated (NC) anterior vaginal mesh (AVM) for pelvic organ prolapse (POP) surgery. Study design The study is a prospective observational study which included 122 patients who had symptomatic POP stage III and IV. AvaultaPlus™ (collagen coated, CC group) was compared to Perigee™ (non collagen coated, NC group). Introital ultrasound morphology, measure of neovascularization by color Doppler and clinical outcomes were assessed. Student t test was used for comparison of pre- and post-operation continuous data (p value of \u3c0.05). Results A total of 110 (CC group = 50, NC group = 60) women completed the study. A woman in the CC group developed ureteral injury. Both groups had comparable morphologic and clinical outcomes however, the onset of changes in mesh thickness and neovascularization occurred earlier in the NC group (1 month) compared to the CC group (6 months to 1 year). Conclusion CC group was comparable to the NC group in terms of erosion rate, ultrasound and clinical assessment. Collagen coating may induce delayed inflammatory response however may also delay tissue integration. The onset of changes in mesh thickness and neovascularization may give us an insight toward utilization of collagen coated mesh for host-tissue integration

Clinical outcomes of single-incision sling procedure (MiniArc)

Objective: To evaluate the clinical outcome among women who had undergone Miniarc™ in the treatment of stress urinary incontinence (SUI). Study design: In this retrospective study from March 2010 to December 2011 patients with clinically confirmed SUI and urodynamic stress incontinence (USI) underwent Single Incision Sling Procedure (SIS). Objective cure of SUI was defined as no urinary leakage on provocative filling cystometry and 1-hour pad test of <2 g. Subjective cure of SUI was the negative response to UDI-6. Assessment was done at baseline and after 1 year follow-up. Results: Postoperative data was available for 85 women. Five women were not able to participate in the follow-up schedule and post-op questionnaire. The objective data for post-operative follow-up was available from 80 women. The average period of follow-up was 1.4 years (range 1.0 to 2.1). A total of 14 women had immediate post-operative urine retention at the first 24 hours and 6 cases were due to over-tensioning of the sling after ultrasound assessment. No case of bladder or bowel injury was recorded and no other major complications noted. Pre and post clinical findings revealed a significant improvement after 1 year follow-up based on the response to UDI-6, IIQ-7 ( 0.05). Conclusions: In conclusion, Miniarc™ was noted to have improvement in both subjective and objective clinical outcomes. Urethral indentation was noted and resolved by tape release on immediate post-operative voiding dysfunction

Single incision anterior apical mesh and sacrospinous ligament fixation in pelvic prolapse surgery at 36 months follow-up

Objective: To compare the clinical efficacy, recurrence, complications and quality of life changes 3 years after Elevate-A/single incision mesh surgery anterior apical (SIM A) and sacrospinous ligament fixation (SSF) in the management of pelvic organ prolapse (POP). Materials and methods: A prospective cohort study, 139 women, underwent transvaginal surgery for anterior and/or apical POP > stage 2, 69 patients had SIM A and 70 patients had SSF. The objective cure was defined as POP ≤ stage 1 anterior, apical according to POP-Q. Subjective cure is patient's negative feedback to question 2 and 3 of pelvic organ prolapse distress inventory 6 (POPDI-6). Patient's satisfaction was reported using validated quality of life questionnaires. Multi-channel urodynamic study was used to report any voiding problems related to the prolapse surgery 6 months after surgery. Results: 119 patients completed a minimum of 3 years follow-up. 89.8% is the overall prolapse correction success rate for SIM A and 73.3% for SSF group (p = 0.020), and 96.6% versus 73.4% at the anterior vaginal compartment respectively (p ≤ 0.001). Statistically significant difference was noticed in apical compartment with 98.3% with SIM A and 85.0% with SSF (p = 0.009). The subjective success rate, 86.4% in the SIM A and 70.0% in the SSF arm (p = 0.030) was significantly noted. Only, Pelvic Organ Prolapse Distress Inventory-6 (POPDI-6) showed significant improvement. Operation time and intra-operative blood loss tend to be more with SIM A. Conclusion: SIM A has better 3 years objective and subjective cure rate than SSF in the anterior and/or apical compartment prolapse