Treating anterior vaginal wall prolapse with polypropylene mesh via the transoburator route minimizing the complications with the use of preventing measures. A prospective study with 2-year follow-up

AIM

Our objectives were to evaluate the efficacy of the Perigee™ transoburator (TOT) mesh kit (American Medical Systems [AMS]-Minnetonka, MN, USA) in the treatment of ≥ stage 2 symptomatic AVP following a 2-year follow-up and to discuss the role of the pre-, peri- and postoperative measures taken to prevent complications

METHODS

A total of 50 patients were eligible and were subjected to AVP surgical treatment with the use of the Perigee™ system. All patients were followed-up at 4 weeks, 2, 6, 12 and 24 months. Our primary objective was treatment success and efficacy after anatomical examination of the patient at the 24-month follow-up. Efficacy was defined as ≤ stage I AVP. All patients completed the 24-month follow-up. Our secondary objective was to examine the complication rates in relation to the use of preventative measures.

RESULTS

The proportion of patients with II to III stage significantly decreased postoperatively (P<0.001). A significantly improvement was found in all POP-Q measures (P<0.05) while mean vaginal length was similar to the preoperative values. At 24-month follow-up, 45 women were defined as ≤ stage I, indicating a 90% objective success rate (95% CI: 81.4-98.6%). Two patients had vaginal mesh extrusion (4.0%) both treated with conservative measures. No erosions occurred at any point postoperatively. De novo dyspareunia was reported in two of the 17 cases (11.8%) who reported being sexually active at follow-up. One of the two had also mesh extrusion and with appliance of the vaginal estrogen and the office excision of the exposed mesh the symptoms were resolved, while the other was treated with vaginal estrogen. Two cases (4.0%) reported de novo incontinence and both were treated with a TOT sling (monarc AMS) procedure three months after the cystocele repair. Three cases (6.0%) reported pain vaginal pain postoperatively and again our treatment of choice was vaginal estrogen cream for 4 weeks with the addition of antinflammatories for 10 days and their symptoms resolved.

CONCLUSIONS

The treatment of AVP with the use of Perigee™ TOT system can be both effective and safe. The goal is the improvement of the quality of life of the patients and is important to avoid or to keep as minimum as possible the complications. Main complications that the surgeon should bear in mind are the vaginal erosion, vaginal mesh extrusion, de novo dyspareunia, de novo incontinence and vaginal pain. Proper patient selection, the appliance vaginal estrogen cream pre- and postoperatively and following strict surgical principles are the mainstay of the success of the TOT operation. It is crucial for POP procedures to be performed by high-volume surgeons in this field, with extensive knowledge of the pelvic floor anatomy and the mesh's characteristics. Of course this is a small study and further clinical studies with larger number of patients are needed in order to further scientific evaluate the TOT operation.

Double-blind ureteral duplication: a rare urologic anomaly

We present an extremely infrequent urologic entity of asymptomatic double-blind ureteral duplication in an 8-year-old girl. Contemporary imaging modalities provided major assistance in the diagnosis. Surgical management is advocated because of the potential for future complications, such as lithiasis, obstruction of the collecting system, and renal failure.

Comparison of prolonged warm and cold ischemia on the solitary kidney during partial nephrectomy in a rabbit model

The aim of this study was to investigate the patterns of renal function recovery during partial nephrectomy (PN) on an experimental solitary kidney rabbit model and establish the upper tolerable time limits of applied ischemia. Forty-eight New Zealand rabbits underwent an open right nephrectomy and after 30 days, the animals were clustered into five groups (A, B, C, D, E). The first four groups received an open left PN, under different types of ischemia. Groups A (n = 8) and B (n = 10) were subjected to 90 and 60 min of warm ischemia (WI), respectively, while groups C (n = 10) and D (n = 10) received 90 and 120 min of cold ischemia (CI) with ice-slush cooling. Group E (n = 10) served as sham group. Serum determinations of creatinine (SCr) and BUN were recorded preoperatively and on postoperative days (POD) 1, 3, 6 and 15. The animals were euthanized and the remaining kidneys were harvested and evaluated microscopically. The type and duration of ischemia were statistically significant parameters (P < 0.001). Groups B, C and D exhibited a similar pattern of recovery from trial initiation to the 15th POD (P = 0.788 and P = 0.068, respectively). Group A was extremely differentiated, with 100% mortality caused by uremia. The microscopic findings were consistent to the serum biochemistry. In our solitary kidney rabbit model, the upper limits of tolerable WI seem to be set on 60 min. CI can safely preserve the model's renal function--even up to 120 min.