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

Recurrent vaginal vault prolapse after vaginal hysterectomy with anterior-posterior mesh augmentation: a case report

Recurrent pelvic organ prolapse (POP) after transvaginal hysterectomy with mesh interposition and reinforcement has increased due to the widespread use of polypropylene mesh. We report a case of recurrent POP 3 years after a transvaginal mesh repair. A 74-year-old multiparous woman with a body mass index of 29.6 kg/m2 presented with recurrent symptomatic of POP associated with urinary incontinence following polypropylene mesh augmentation. A thorough examination revealed mesh displacement and enterocele. Surgical correction included repositioning of the anterior and posterior mesh, McCall culdoplasty, unilateral sacrospinous ligament fixation and excision of the exposed mesh. This patient had an excellent short-term outcome; however, long-term follow up is required. In summary, the management of recurrent POP following transvaginal mesh is challenging and should be individualized

Diagnosis and conservative management of female stress urinary incontinence

Urinary incontinence affects 17–45% of women worldwide and stress urinary incontinence is responsible for 48% of all cases. Detailed history, physical examination and investigations are crucial to identify the diagnosis underlying the incontinence symptoms to select effective therapy. Although mid-urethral sling procedures are considered to be ‘gold standard’ treatment of SUI, conservative treatment with pelvic floor muscle training and lifestyle modification is still the first line of management. This article discusses the diagnosis and conservative management of female SUI

Intravesical midurethral sling mesh erosion secondary to transvaginal mesh reconstructive surgery

Objective: We sought to evaluate the feasibility and the outcomes of correcting the intravesical mesh erosion after secondary mesh augmented pelvic reconstructive surgery pervaginally. Methods: We evaluated a case of mesh erosion following midurethral sling that occurred 4 years after secondary mesh surgery. Prior to second surgery, ultrasound and cystoscopy examination were performed to exclude mesh complication. Serial examinations during follow-up after the operation were uneventful until the patient presented 4 years after the second surgery with a history of dysuria and hematuria. Cystoscopy examination discovered intravesical mesh erosion 4 years after the secondary surgery. Removal of the midurethral sling mesh erosion and bladder repaired were done vaginally. Results: The patient was still symptom free and continent 1 year following tape excision. Urodynamic evaluation 6 months post-tape excision was also normal. Conclusion: Repeated vaginal reconstructive surgery may jeopardize a primary mesh or sling, and pose a high risk of mesh erosion, which may be delayed for several years. Removal of the mesh erosion and bladder repair are feasible pervaginally with good outcome

The diagnosis and management of ureteric injury after laparoscopy

The number of ureteric injury cases has increased in gynecological surgery. We reviewed the literature concerning the incidence of ureteric injury and the recognition and management of the ureteric injury with the controversy of delayed management of ureteric injury. To reduce the morbidity of ureteric injury, gynecologists should be aware of and familiar with the pelvic wall anatomy, the site that is most susceptible to injury. They should also have knowledge about the prevention and management of ureteric injury

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

Review on midurethral sling procedures for stress urinary incontinence

Minimally invasive suburethral slings, namely the retropubic suburethral sling or the tension-free vaginal tape (TVT), has become the mainstay for surgical management of moderate to severe stress urinary incontinence (SUI) taking over the place of Burch's colposuspension after its introduction in the 1990s. Following the introduction of retropubic sling procedures are the transobturator (TVT-O) procedures and the mini-sling procedures. This review attempts to summarize the current trend of midurethral sling (MUS) procedures in the management of SUI