Clinical and quality-of-life (QoL) outcomes in women treated by tension free vaginal tape (TVT)

Objectives: To assess subjective success rates, complications and impact on quality of life (QoL) in women treated by Tension Free Vaginal Tape for urinary incontinence. Methods: A retrospective cohort analysis was made on 30 consecutive women undergoing TVT procedure alone or as concomitant to other pelvic surgical procedures, from June 2004 to October 2007. All the Patients were evaluated by history, clinical examination with POP-Q (pelvic organ prolapse-quantification) scoring for uterovaginal prolapse and urodynamic testing. Improvement of health-related QoL (quality of life) was assessed by incontinence impact questionnaire-short form (IIQ-7) and urogenital distress inventory-short form (UDI-6). The success of surgery was evaluated by asking whether the incontinence was cured, improved or had no change after the operation. Data was computed and analyzed by using SPSS version 13. Results: Concomitant surgery was performed in 14 (46.6%) cases. Median age was 47 years and duration of follow up was 14 months (range 4-37 months). Eight (26.6%) women had mixed Urinary Incontinence with Detrusor Overactivity. Previous pelvic surgery like MMK (Marshall-Marchetti-Krantz along with TAH (total abdominal hysterectomy) was found in 5 (16.6%) cases. Complications were listed as per-operative, short-term and long-term. Among the short-term complications Bladder perforation was seen in 2 cases (6.7%) and overt urinary retention in 2 cases (6.7%). Long-term complications as voiding dysfunction occurred in only 1(3.3%) case. Symptoms were labeled as completely cured in 27 (90%) patients, significantly improved in 2(6.6%) and one with mixed incontinence regarded as having worsening of urge symptoms and dysuria. Conclusion: A median follow up of 14 months showed that our surgical results of TVT alone or with concomitant surgery were similar to internationally published results and TVT can be safely performed with concomitant procedures

Assessment of experimental animal model for training obstetric anal sphincter injury techniques

The Multiparous Goat Pelvic Model was used to train obstetricians and residents for perineal and anal sphincter anatomy and techniques of repair of Obstetric Anal Sphincter Injuries (OASIs). The purpose of this study was to assess the similarity of this model with human anatomy and the usefulness of goat model for training obstetricians for perineal tears. Six workshops were conducted between June 2009 and December 2010. A total of 90 participants, including 64(70.3%) residents and 26(28.5%) consultants in Obstetrics and Gynaecology, attended hands-on training workshops using experimental goat pelvic model for the repair of perineal tears. Among the consultants, 23 (88.5%), and 60 (93.7%) residents could easily identify the goat anal sphincter. With reference to the similarity to human vaginal dimensions, 20 (76.9%) consultants and 43(67.1%) residents found it to be similar with human anatomy. Evaluating the anal canal anatomy, 22 (84.6%) consultants and 34(53.1%) residents reported it to be similar to the human anal canal. The perineal body anatomy was reported as very different by both consultants and residents (80% and 67.9% respectively). All the consultants and 49(76.5%) of the residents strongly recommended the use of this model for future hands-on workshops

Practices regarding diagnosis and management of third and fourth degree perineal tears

Objective: To review our practice of diagnosing and managing third and fourth degree perineal tears. Method: Retrospective case series conducted by reviewing medical records of all women having singleton, full term vaginal delivery at Aga Khan University Hospital, Karachi from November 1990 to October 2005. Results: The frequency of obstetric anal sphincter injury (OASI) in our department was 0.5% (135) out of a total of 26,844 vaginal deliveries. Seventy five percent were nulliparous (102). Forceps delivery was performed in 86 patients out of 135 (63.7%). In only 28 patients (20.7%), the diagnostic criterion for classification of third degree tears was used. For the repair of third degree tear end-to-end method was performed on 97 (71.9%) patients. Twenty nine women had subsequent uncomplicated vaginal deliveries. None of these patients were subjected to endo-anal ultrasonography and/or anal manometry. The documented evidence regarding planning of future delivery was found in only 4 cases. Conclusion: The frequency of distribution of third and fourth degree perineal tear in our study was 0.5% which is significantly lower than clinically suspected or recognized. Our study shows that 75.5% patients were nulliparous and the use of forceps for delivery was 63.7% among more than 50% of these patients. This indicates that forceps delivery if possible should be avoided or substituted with vacuum delivery which has a lower incidence of OASI. Most of the management was according to international accepted standards except that 72.3% were stitched under local analgesia

Animal Models of Double Incontinence: “Fecal and Urinary”

Throughout the world, animal models are being used as simulators of human anatomy and pathophysiology with most of the investigations and treatments first tested on them. Double incontinence (DI) includes both urinary and anal incontinence. This chapter is focused on the use of animals as models to understand pathogenesis, diagnosis and management of double incontinence (DI). DI is a complex disease with variant prevalence around the world which has a severe impact on quality of life (Qol). Many studies are designed to employ rodent and rabbit models to understand the pathogenesis of urinary and fecal incontinence. Urodynamic studies including leak point pressure (LPP) and urethral pressure profilometry (UPP) are used in establishing diagnosis of stress urinary incontinence. Rats have also been used to study fecal incontinence using neurophysiological and sacral nerve stimulation tests. The surgical treatment of double incontinence involves use of mesh, which was initially tested on animals. Animal models have also been used to train surgeons for perineal tear repair surgery. We conclude that the use of animal models provides best approach to learn these specialized surgical skills for medical practitioners and researchers

Repair of vesicouterine fistula by not using traditional O\u27 connor method

A 25-year-old female patient visited our clinic with complaint of cyclic haematuria. She had previous two Caesarean Sections at a secondary care hospital. Her complete urinalysis showed abundant red blood cells. Through computed tomography a fistula tract between the posterior wall of the bladder and the anterior wall of the lower uterine segment was diagnosed. The Cystoscopy revealed a fistulous opening with a diameter of nearly 1.5 cm localized between the bladder and uterine cavity. Fistulae was repaired by abdominal approach without transection of bladder. Surgery was performed by mobilization of bladder and wide anterior uterine dissection. A 2cm defect in the lower uterine segment was identified and was closed with 0 polyglycolic acid suture. Bladder defect was repaired in two layers and omental tissue flap was placed between the two surfaces. At 6 months follow the up patient was asymptomatic

Recurrent urinary tract infections in females

Uncomplicated Urinary tract infections are common in adult women across the entire age spectrum, with mean annual incidence of 15% and 10% in those aged 15-39 and 40-79 years, respectively. Urinary tract infection (UTI), with its diverse clinical syndromes and affected host groups, remains one of the most common but widejly misunderstood and challenging infectious diseases encountered in clinical practice. Recurrent urinary tract infections (UTIs) present a significant problem for women and a challenge for the doctors who care for them. The diagnosis of uncomplicated UTI can be achieved best by a thorough assessment of patient symptoms with or without the addition of a urine dipstick test. Treatment should be based on the most recent guidelines, taking into account resistance patterns in the local community. The patient who suffers from recurrent UTIs can be treated safely and effectively with continuous antibiotic prophylaxis, post-coital therapy, or self-initiated treatment. This review article covers the latest trends in the management of recurrent UTI among women. Further research is needed regarding rapid diagnosis of UTI, accurate presumptive identification of patients with resistant pathogens, and development of new antimicrobials for drug-resistant UTI

Graft and mesh use in vaginal surgery

Pelvic organ prolapse and urinary incontinence are among the most common chronic disorders in women. These are common problems whose pathogenesis remains unclear. As life expectancy increases, significantly greater number of women now present with pelvic organ prolapse and urinary incontinence requiring surgical intervention. Currently, the lifetime risk of undergoing prolapse or continence surgery is one in 11, and up to 30% of patients will require repeat reconstructive surgery and repeat surgery for incontinence in 10%. In an attempt to improve surgical outcomes and to preserve vaginal capacity and coital function, a number of synthetic and biological prostheses have been developed. This review aims to look at the role of graft and mesh in vaginal surgery. We conducted a search for English-language articles published during 1997 to 2016, using MEDLINE, PubMed and United States\u27 National Library of Medicine databases. We reviewed around 50 papers but referenced only 30 for this article. The literature review provided us a new insight regarding safety of mesh. Polypropylene mesh is safe for vaginal surgery if used by experienced surgeons. The safety of mesh becomes compromised in the hands of commercial surgical kit providers. All the new mesh tailored kits should undergo evidence-based trials and then can be safely used worldwide

A rare case: rupture of internal pudendal and uterine artery in a vaginal delivery

The management of puerperal hematomas after normal delivery has always been challenging for obstetricians. Vulvar, vulvovaginal, or paravaginal hematomas are common. On the other hand, retroperitoneal hematomas are uncommon and can be life-threatening. The diagnosis of vascular injury is rarely made preoperatively as atonic or traumatic postpartum hemorrhage (PPH), uterine rupture and amniotic fluid embolism are more common differential diagnoses. Injury to internal pudendal and uterine vessels is extremely rare in cases of vaginal delivery and, therefore, the literature on this topic is very scarce. We present a rare case of both internal pudendal and uterine artery rupture in a normal vaginal delivery, which led to massive postpartum hemorrhage. The diagnosis was made on Magnetic Resonance imaging (MRI) and arterial embolization was performed. This case stresses on the need for careful post-delivery monitoring for revealed postpartum hemorrhage. Vascular injury is a rare life-threatening cause of obstetric shock, and active; and timely operative intervention can prevent morbidity and mortality

The practice of Burch colposuspension versus mid urethral slings for the treatment of stress urinary incontinence in developing country

Objectives: To compare the effectiveness and complications of Burch colposuspension and Mid Urethral Slings (MUS) for the treatment of Stress Urinary Incontinence (SUI).Methods: We conducted a cross-sectional study of 162 patients who underwent surgery for SUI with Burch colposuspension (n=40), tension free vaginal tape (TVT) (n= 59) or transobturator tape (TOT) (n=63), from 2006 to 2014 at the Aga Khan University Hospital- Karachi. All three groups were assessed in terms of demographics, cure rates, intraoperative and postoperative complications at one and five years using incontinence impact questionnaire-short form-7 (IIQ-7) and urogenital distress inventory -short form-6 (UDI-6).Results: Mean age of the participants in Burch, TVT and TOT group was 44.1 ± 7.4, 48.3 ± 8.9, 53.0 ± 9.4 respectively. Majority of patients in TVT group were premenopausal (59.3%) and postmenopausal in TOT group (53.9%). Most abdominal hysterectomies were done in Burch group (40) while vaginal hysterectomies and anterior and posterior colporrhaphy in TOT group (55). All the procedures had both subjective and objective cure rate of more than 82% at one year, with TVT having the highest success rate of 96.61%. The objective cure rate in Burch, TVT and TOT group at five years was 74.19%, 90.30% and 81.25% respectively. Intraoperative complications included hemorrhage in one patient during Burch procedure and bladder perforation in two cases of TVT, with no significant difference in short or long-term complications with either procedure.Conclusions: All the three procedures have equal efficacy and complication rates. Even though TVT is the new gold standard but in view of current debate regarding mesh related complications, there is a need to readdress Burch colposuspension for treatment of SUI

The association of symptoms of overactive bladder with pelvic organ prolapse and its improvement after pelvic reconstructive surgery

Objectives: This study asseses the association of overactive bladder symptoms and pelvic organ prolapse severity and evaluates the effect of pelvic reconstructive surgery on overactive bladder (OAB) symptoms in women with pelvic organ prolapse (POP). It also looks into any pre and post-operative factors responsible for persistent postoperative OAB symptoms.Methods: This was a retrospective cross-sectional study conducted at the Aga Khan University Hospital, Karachi between 1st January 2014 and 31st December 2018. In this study women presenting with POP and concommitent OAB who underwent surgery for site specific defects, measured using Pelvic Organ Prolapse Quantification (POP-Q) staging system. OAB was defined as presence of urinary frequency, urinary urgency incontinence (UUI) and an affirmative response to item #15 and/or item #16 of the Pelvic Floor Distress Inventory (PFDI), which was used both pre and postoperatively. Primary outcome of the study was to find complete resolution or improvement of urinary frequency and UUI on the PFDI, 24 months after surgery. The secondary outcome was to see persistent OAB postoperatively and the factors associated with it.Results: Overactive bladder (OAB) symptoms improved significantly regardless of the severity of prolapse at 24 months postoperative period. Body mass index (BMI) and postoperative constipation were the only statistically significant variables associated with persistent OAB symptoms postoperatively.Conclusions: Surgical correction of POP results in significant improvement in symptoms of OAB, in all stages of POP and co-existing OAB. However women with high BMI and post-operative constipation may be prone to persistent frequency and/or UUI