Electromotive drug administration for treatment of therapy-refractory overactive bladder

PURPOSE

Evaluate the benefits of electromotive drug administration (EMDA) as an alternative technique in patients with chronic overactive bladder in terms of improvement of symptoms, quality of life, and sexuality.

MATERIAL AND METHODS

A total of 72 patients with therapy-refractory overactive bladder according to the ICS (International Continence Society) definition, were treated by EMDA. The regimen consisted of three treatment cycles, each with 3 instillations at 2-week intervals. The solution instilled consisted of 100 mL 4% lidocaine, 100 mL distilled water, 40 mg dexamethasone, and 2 mL epinephrine. Peri-interventionally, a urine test and close circulatory monitoring were performed. All women underwent urodynamic testing and cystoscopy and kept a voiding diary. A comprehensive history was obtained, a quality of life questionnaire administered, and a gynecologic examination performed before initiation of therapy. The women underwent follow-up at 12 months after the end of therapy.

RESULTS

The patients had a mean age of 63 (+/- 11.2) years. Bladder capacity improved significantly by 109 mL (+/- 55 mL) in 51 (71%) patients (p = 0.021). The number of micturitions/day decreased significantly to 7 (+/- 2) (p = 0.013). Quality of life was improved in 54 patients (75%); p = 0.024) and sexuality in 39 (54%); p = 0.020).

CONCLUSIONS

The results suggest that EMDA can improve both quality of life and sexuality in patients with therapy-refractory chronic overactive bladder.

[Follow-up at 24 months after treatment of overactive bladder with 0.2 % sodium chondroitin sulfate]

AIM

A retrospective study was performed to investigate whether the improvement of symptoms achieved with 0.2 % sodium chondroitin sulfate in treating overactive bladder (OAB) persists after 24 months.

MATERIALS AND METHODS

Two years ago, a total of 82 patients with chronic OAB were randomly assigned to receive either anticholinergic treatment (Tolterodin; group A, n = 41) or 0.2 % sodium chondroitin sulfate (Gepan instill; group B, n = 41). Diagnostic assessment included a gynecological examination and history, urodynamic test-ing, introital ultrasound, and cystoscopy. Duration of treatment was 12 months. The patients underwent repeat follow-up after 24 months and the findings were compared with the results at 12 months.

RESULTS

In group A, 15 / 35 (43 %) women reported an improvement of symptoms after 12 months as opposed to only 5 / 35 (14 %) after 24 months. In group B, there was an improvement in 23 / 32 (72 %) at 12 months and in 18 / 32 (56 %) after 24 months (p = 0.001). The subjective results were corroborated by means of urodynamic test-ing, pad counts, voiding frequency and nycturia (voiding diary).

CONCLUSION

Our findings suggest that instillation treatment with 0.2 % sodium chondroitin sulfate results in a more sustained improvement or cure of the symptoms of overactive bladder due to development of a glycosaminoglycan layer. Long-term results are needed for confirmation.

[Management of female stress urinary incontinence. Endoscopic extraperitoneal artificial urinary sphincter--early experience]

Implantation of an artificial urinary sphincter (AUS) is an established surgical option for treating female stress urinary incontinence due to internal sphincter deficiency (ISD). However, this operation is often performed as an open surgical procedure. Here, we introduce an endoscopic extraperitoneal approach for implanting an artificial urinary sphincter. Two women (ages 22 and 79 years) underwent endoscopic extraperitoneal implantation of the AMS 800 artificial sphincter. In both cases, neurogenic bladder disease was the underlying cause of ISD. The endoscopic extraperitoneal approach allowed excellent preparation and mobilisation of the bladder neck and implantation of the AUS. The overall operating time was <120 min. Both patients were mobilised on the same day and could be discharged from the hospital after 5-6 days. The AUS were activated after 6-9 weeks. However, after an average of 6 months, total continence was achieved in both patients. Laparoscopic extraperitoneal implantation of AUS in women with moderate to severe stress urinary incontinence is safe and might be less traumatic to neighbouring organs than the open operation. However, more implantations are needed to evaluate the long-term feasibility of this method.

[External anal sphincter repair using the overlapping technique in patients with anal incontinence and concomitant pudendal nerve damage]

BACKGROUND

No single surgical technique has so far emerged as the optimal approach to treat defects of the anal sphincter in patients with postpartum fecal incontinence. Our approach is to repair the external sphincter using the overlapping technique to optimize morphological and clinical outcome. The results were correlated with preoperatively determined pudendal nerve function.

METHODS

Thirty-five patients were followed up for three years after repair of the external anal sphincter. The patients had grade 2 (n = 29) or grade 3 (n = 6) fecal incontinence. Nineteen (54 %) patients had a concomitant defect of the internal anal sphincter and 28 (80 %) had abnormal pelvic floor EMG findings. Before surgery, all patients underwent conservative treatment with biofeedback and electrostimulation. The muscle ends were overlapped with Vicryl 4-0 sutures. A standardized protocol was used for the perioperative management in all patients.

RESULTS

Of the 35 patients who underwent overlapping repair of the external anal sphincter, 32 (91 %) had a satisfactory result at 3-year follow-up based on sonomorphological criteria. These 32 patients were continent for solid and liquid stools. Six of the 35 patients (17 %) continued to have flatus incontinence. Two (6 %) patients were improved and one patient (3 %) had unchanged incontinence. Pudendal nerve damage had no effect on the outcome of surgery.

CONCLUSIONS

Our findings at 3-year follow-up show good results for the overlapping repair of the external anal sphincter in terms of morphology and clinical symptoms. This outcome depends on an adequate preoperative pelvic floor conditioning, optimal perioperative management, and use of a standardized operative technique. Surgical repair of the morphological defect is recommended even in patients with pudendal nerve damage.

Sonomorphological evaluation of polypropylene mesh implants after vaginal mesh repair in women with cystocele or rectocele

OBJECTIVE

To investigate whether the sonographically measured size of the mesh implant in women who had undergone vaginal polypropylene mesh repair 6 weeks previously correlates with the original size of the mesh and whether the mesh ensures complete support of the anterior or posterior compartment.

METHODS

Forty postmenopausal women with anterior or posterior vaginal wall prolapse and sonographically proven cystocele (n = 20) or rectocele (n = 20) were evaluated preoperatively and 6 weeks after vaginal mesh repair. Introital ultrasound was performed to identify the polypropylene mesh and measure its distal to proximal length and configuration as well as its thickness. The initial mesh length was compared with that measured by ultrasound 6 weeks postoperatively. Vaginal length was measured pre- and postoperatively.

RESULTS

The mean +/- SD age of the women was 68 +/- 7 years. The 20 women with cystocele underwent repair by means of anterior transobturator mesh implantation; the initial mesh length was 6.8 +/- 1.1 cm versus 2.9 +/- 0.6 cm postoperatively. The 20 women with rectocele underwent repair by posterior transischioanal mesh implantation; the initial mesh length was 9.9 +/- 0.8 cm versus 3.3 +/- 0.5 cm postoperatively. The mesh supported 43.4% of the length of the anterior vaginal wall and this value was 53.7% for the posterior wall (P = 0.016).

CONCLUSION

Sonography is recommended for postoperative evaluation of the anterior and posterior mesh positions after prolapse surgery. There is a considerable discrepancy between the implanted mesh size and the length measured 6 weeks later by postoperative ultrasound. Published by John Wiley & Sons, Ltd.

Changes in the MRI morphology of the stress continence control system after TVT (tension-free vaginal tape) insertion

OBJECTIVE

Magnetic resonance imaging (MRI) was used to investigate whether tension-free vaginal tape (TVT) insertion (according to Ulmsten) leads to morphologic changes of the stress continence control system.

METHODS

Twenty women (mean age 53.4 years) with clinically and urodynamically proven stress urinary incontinence without prolapse were examined by MRI before and 13 months after TVT insertion.

RESULTS

Postoperative MRI showed a signal intensity loss of the suburethral portion of the endopelvic fascia in the area of the anterior vaginal wall in 9/20 women with additional signal loss of the paraurethral portion of the fascia in 3/20 women. No morphologic changes of the levator ani muscle and the urethra were seen postoperatively.

CONCLUSIONS

TVT insertion does not damage the structures of the stress continence control system or impact on their topographic relationships. MRI identified no excessive scar formation resulting from integration of the TVT.

Follow-up after polypropylene mesh repair of anterior and posterior compartments in patients with recurrent prolapse

To retrospectively analyze the outcome of surgery in women followed up for 1 year after vaginal repair with the Apogee (support of posterior vaginal wall) or Perigee (support of anterior vaginal wall) system. A total of 120 patients with recurrent cystocele and/or rectocele or with combined vaginal vault prolapse were treated by either posterior or anterior mesh interposition depending on the defect. Follow-up after 1 year (+/-31 days) comprised a vaginal examination with prolapse grading using the POP-Q system, measurement of vaginal length, evaluation of the vaginal mucosa, and exploration for mesh erosions. Postoperatively, 112 (93%) women were free of vaginal prolapse, whereas 8 (7%) had level 2 defects. Erosions occurred significantly more often (p = 0.042) in patients treated with the Perigee system. Our results suggest that the Apogee and Perigee repair systems (monofilament polypropylene mesh) yield excellent short-term results after 1 year.

Der Einsatz von Natrium-Chondroitinsulfat bei der Behandlung der „Überaktiven Blase”

OBJECTIVE

It is not always possible to clearly differentiate the symptoms of overactive bladder and interstitial cystitis. A prospective randomized study was performed to determine whether instillation of sodium chondroitin sulphate for treatment of interstitial cystitis is also effective in treating overactive bladder. The expected benefit of this therapeutic approach in overactive bladder is based on the assumption that the glycosaminoglycan layer may be damaged in overactive bladder as well.

MATERIAL AND METHODS

Patients with chronic overactive bladder were randomized to one of two study groups each including 41 patients. Group A was treated with an anticholinergic agent (tolterodine), group B with sodium chondroitin sulphate (Uropol S). The diagnosis was established on the basis of a gynecologic examination and history, urodynamic testing, introital ultrasound, and cystoscopy. Patients were treated for 12 months.

RESULTS

An improvement of symptoms was reported by 15/35 (43 %) of the patients in group A (p = 0.000) as compared with 23/32 (72 %) of the patients in group B. The subjective outcome was corroborated by means of urodynamic testing, number of pads used, voiding frequency, and nycturia (voiding diary). Quality of life increased significantly in both groups in the course of treatment but there was no significant difference between both groups.

CONCLUSION

The results of the study presented here suggest that restoring the glycosaminoglycan layer also improves or cures the symptoms in patients with overactive bladder. Patients clearly benefit from instillation of sodium chondroitin sulphate. These results must be confirmed in larger studies before a wider use of this therapeutic option can be recommended.

[Paraurethral abscess developing after mid-urethral Zuidex-injection in women with stress urinary incontinence -- management of complications and retrospective comparison with bladder neck located injection technique]

PURPOSE

To evaluate the cause and management of paraurethral abscess developing after injection of a mixture of hyaluronic acid and dextranomer (Zuidex) for treating stress urinary incontinence.

PATIENTS AND METHOD

A total of 127 women having undergone midurethral Zuidex injection and 34 women after endoscopically guided Deflux injection into the tissue around the bladder neck were followed up 1 to 24 months after the intervention. At follow-up, the paraurethral tissue was evaluated clinically by gynecologic examination and by introital ultrasound.

RESULTS

Thirteen of 127 women (10 %) having undergone midurethral Zuidex injection had a sterile paraurethral abscess that was treated by transvaginal puncture (1 to 3 punctures with removal of 10-60 ml of fluid per patient). No case of postoperative paraurethral abscess formation was demonstrated in the control group treated by Deflux injection into the area around the bladder neck.

CONCLUSIONS

Paraurethral abscess must be excluded in the postinterventional follow-up of patients after Zuidex injection. Patients in whom an abscess is demonstrated can be treated by transvaginal puncture. Abscess formation can be avoided by injecting dextranomer/hyaluronic acid into the area around the bladder neck.

Uterine artery embolization for symptomatic fibroids: short-term versus mid-term changes in disease-specific symptoms, quality of life and magnetic resonance imaging results

BACKGROUND

Prospective study to evaluate changes in symptom severity, health-related quality of life (HRQOL) and uterine and leiomyoma volume after uterine artery embolization (UAE).

METHODS

Eighty-two women completed a validated uterine fibroid symptom and quality of life (UFS-QOL) questionnaire and underwent magnetic resonance imaging (MRI) before and 3-20 months after UAE. Primary outcome measures were changes in symptom severity and QOL at short-term follow-up [median 5 (range 3-7) months] and mid-term follow-up [median 14 (8-20) months]. Secondary outcome measures included the frequency of additional procedures to control persistent symptoms and changes in dominant fibroid volume (DFV) and uterine volume (UV).

RESULTS

Of 82 patients, 71 (86.6%) patients completed follow-up, 7 (8.5%) patients had a second procedure and 4 (4.9%) were lost to follow-up. Symptom severity scores decreased from a median of 43.75 to 21.88 (P < 0.001) in the short-term follow-up group and from a median of 43.75 to 9.38 (P < 0.001) in the mid-term follow-up group. QOL scores increased from a median of 56.90 to 87.93 (P < 0.001) and 66.81 to 96.12 (P < 0.001), respectively. During short-term follow-up, median UV decreased by 27% (95% CI 20.25-33.81, P < 0.001) and median DFV by 62% (95% CI 47.81-71.55, P < 0.001), whereas UV decreased by 36% (95% CI 23.34-55.02, P < 0.001) and DFV by 66% (95% CI 54.28-71.92, P < 0.001) for the mid-term follow-up group. A decrease in UV correlated with change in symptom severity (P < 0.005).

CONCLUSIONS

Women report significant improvements in fibroid-specific symptoms and QOL at short- and mid-term follow-ups after UAE.

Visibility of the polypropylene tape after tension-free vaginal tape (TVT) procedure in women with stress urinary incontinence: comparison of introital ultrasound and magnetic resonance imaging in vitro and in vivo

OBJECTIVE

To determine whether introital sonography and magnetic resonance imaging (MRI) after TVT (tension-free vaginal tape) insertion can depict the polypropylene tape, and thus be used for patient follow-up.

METHODS

The study comprised an experimental part, which investigated in-vitro visualization of the polypropylene tape in a model (phantom), and a clinical part, in which 20 women (mean age, 53.4 years) with clinically and urodynamically proven stress urinary incontinence without prolapse were investigated by introital ultrasound and MRI before and 13 months after the TVT procedure.

RESULTS

In the phantom, the polypropylene tape was depicted with a low signal intensity by MRI and as a highly echogenic structure by ultrasound. In the clinical study, introital ultrasound in a mediosagittal orientation depicted the vaginal tape in all patients: it was located under either the midurethra (n = 16) or the lower urethra (n = 4), and in either the muscular coat of the urethra (n = 8) or in the urethrovaginal space (n = 12), the tape was either flat (n = 6) or curled up (n = 14), and there was no retropubic visualization of the tape. Overall, depiction by MRI was limited, and was poorer in comparison with ultrasound, especially when the tape had a sub- or paraurethral location. Retropubically, however, MRI identified the tape near the periosteum of the pubic bone (55% of cases), in the retropubic space (37.5% of cases), or near the bladder wall (7.5% of cases).

CONCLUSION

Sonography is recommended for evaluation of the suburethral and paraurethral tape portions, while MRI is suitable for retropubic evaluation after the TVT procedure.

Management bei postoperativ diagnostizierter intravesikaler TVT-Bandlage anhand zweier Kasuistiken

Recurrent urinary tract infections and symptoms of a hyperactive bladder in women having undergone a TVT (tension-free vaginal tape) procedure may be due to intravesical position of the tape. Urogenital ultrasound can provide early preliminary diagnostic evidence, which can then be confirmed by subsequent urethrocystoscopy. Minimally invasive revision can be achieved by transurethral resection of the intravesical TVT portions. Tape portions near the wall can be removed after stretching of the tape with grasping forceps inserted through a suprapubically placed trocar. This simple procedure can spare the patient a more extensive repeat operation for removal of the intravesical TVT that may even require a combined abdominovaginal approach.

Vaginale Revision bei Irritation des N. obturatorius nach Burch-Kolposuspension

Irritation of the obturator-nerve within colposuspension is a possible complication because of topographic proximity between obturator-nerve and operating-field. The main symptoms are weakness of the adductor muscles, sensory disturbance of thigh till paralysis and pain in the operating- field early after surgery. Too lateral fixing of the sutures in the pectineal ligament above the obturator-channel can cause compression of the obturator-nerve. Precocious intervention is a precondition for complete remission of symptoms, retropubic revise of surgery is evident. The method outlined here describes vaginal access for re-surgery with lateral colpotomy and dissection of the proximal colposuspension s suture. In this way a recurrent laparotomy with additional trauma of the operating-field can be avoided. In the case described here, this method led to the patients complete remission.

Pathogenesis of urethral funneling in women with stress urinary incontinence assessed by introital ultrasound

OBJECTIVE

The incidence of urethral funneling (UF) seen in women with stress urinary incontinence (SUI) during straining is reported to range from 18.6% to 97.4%. Its morphologic basis is unknown. The aim of the present study was to determine whether SUI patients with and without UF differ in terms of history, urodynamic results and magnetic resonance imaging (MRI) findings.

PATIENTS AND METHODS

Fifty-four women (mean age 52 +/- 11 years) with a history of SUI confirmed by clinical and urodynamic findings were included in the study. UF was demonstrated by introital ultrasound performed at a bladder filling volume of 300 mL during maximal straining. MRI for assessment of the urethra, levator ani muscle and endopelvic fascia was performed using axial proton-density-weighted sequences.

RESULTS

UF was demonstrated by introital ultrasound in 59% of the patients with SUI (Group 1) and was absent in 41% (Group 2). There were no differences between the two groups in mean age (P = 0.208), the incidence of mild prolapse of the anterior vaginal wall (Aa, Ba; stage I; P = 0.741), and urodynamic parameters (urethral closure pressure at rest; P = 0.507). The percentages of nulliparous and parous women were 22% and 78% in Group 1 and 54% and 46% in Group 2 (P = 0.013). The two groups did not differ in the MRI demonstration of morphologic defects of the urethra, levator ani muscle and endopelvic fascia or of combined defects.

CONCLUSIONS

The results of the present study did not elucidate the pathogenesis of UF. The demonstration of UF crucially depends on the examination technique employed.

Morphology of the suburethral pubocervical fascia in women with stress urinary incontinence: a comparison of histologic and MRI findings

To correlate MRI with histologic findings of the suburethral pubocervical fascia in women with urodynamic stress incontinence. Thirty-one women with urodynamically proven stress urinary incontinence without relevant prolapse underwent preoperative MRI. Tissue specimens obtained from the pubocervical fascia were examined immunohistochemically (types I and III collagen, smooth muscle actin) and the results compared with the MRI findings. MRI demonstrated an intact pubocervical fascia in 61.3% of the cases and a fascial defect in 38.7%. A fascial defect demonstrated by MRI was associated with a decrease in actin (P<0.09) and an increase in collagen III (P<0.01) compared to an intact fascia. In women with stress urinary incontinence, smooth muscle actin in the pubocervical fascia is decreased, changed in structure, and replaced by type III collagen. MRI allows evaluation of the pubocervical fascia and its morphologic changes.

Harn- und Analinkontinenz im Alter

Three to four million women suffer from urinary incontinence (UI) in Germany. This number will rise further as life expectancy increases, and there is an annual incidence of newly occurring UI of about 1%. Two thirds of all women with UI suffer additional symptoms of fecal incontinence. The type of incontinence present is diagnosed on the basis of patients history, clinical findings, and functional testing. The findings should be interpreted in an age-adjusted manner to avoid over-rating (e.g. urethral closure pressure at rest=100-age in cm H(2)O). The management of elderly patients focuses on conservative approaches with bladder and intestinal training as well as dietary measures serving to counteract the age-related loss of intellectual abilities. Local estrogen application has a positive effect on all forms of incontinence. Surgical approaches aim at improving symptoms since forced restoration of incontinence in elderly patients frequently induces voiding disorders.

[Current state of uterine artery embolization for treating symptomatic leiomyomas of the uterus]

A number of new approaches in treating symptomatic leiomyomas of the Uterus have been introduced in recent years. Only little scientific data is available an percutaneous or laparoscopic myolysis using focussed ultrasound, laser, or coagulation guided by magnetic resonance imaging or an laparoscopic ligation of the uterine vessels by means of bipolar coagulation or clipping. Established therapeutic options are limited by a number of disadvantages, except for total laparoscopic hysterectomy with morcellation. The latter is a minimally invasive procedure that spares important pelvic structures and thereby reduces the risk of prolapse and is associated with rapid recovery of the patients. Another minimally invasive therapeutic approach with preservation of the uterus is transarterial catheter embolization of uterine leiomyomas in which the vessels supplying the leiomyomas, in particular the branches of the uterine artery, are partly occluded by injection of synthetic (polyvinyl) beads. Uterine artery embolization has since developed into a good alternative to other therapeutic options. Studies report cure rates ranging from 77-93 %.

Transarterielle Embolisation bei Uterus myomatosus: klinische Erfolgsrate und kernspintomographische Ergebnisse

PURPOSE

To analyze the clinical success rate and the findings of magnetic resonance imaging (MRI) after uterine artery embolization of symptomatic leiomyomas (fibroids) of the uterus.

MATERIALS AND METHODS

This is a prospective single-center case study of 80 consecutively treated patients, followed for 3 - 6 months (group I), 7 - 12 months, (group II), and 13 - 25 months (group III). MRI was used to determine the uterine volume and size of the dominant leiomyoma. Symptoms and causes requiring repeat interventions were analyzed.

RESULTS

Significant (p < 0.01) volume reduction of the uterus (median: 34.95 % confidence interval [CI]: 30.41 - 41.76 %) and dominant leiomyoma (median: 52.07 %, CI: 47.71 - 61.57 %) was found. The decrease in uterine volume (I-III: 22.68 %, 33.56 %, 47.93 %) and dominant leiomyoma volume (I-III: 41.86 %, 62.16 %, 73.96 %) progressed with the follow-up time. Bleeding resolved significantly (p < 0.0001) in all three follow-up groups (groups I-III: 92.86 %, 95.23 %, 96.67 %). Furthermore, urinary frequency (groups I-III: 70 %, 75 %, 82.35 %) and sensation of pelvic pressure (groups I-III: 42.86 %, 60 %, 93.75 %) improved, which was statistically significant in group III (p < 0.01). The number of leiomyomas correlated (p < 0.05) with improvement of the bleeding and the pelvic pressure. Repeat therapy was necessary for complications in four patients (5 %) and for therapeutic failure in three patients (3.8 %). Permanent amenorrhea was observed in four patients (5 %) of age 45 years or older.

CONCLUSION

Uterine artery embolization of uterine leiomyomas has a high clinical success rate with an acceptable incidence of complications and repeat interventions.

[End-to-end anastomosis in the primary repair of anal sphincter laceration occurring during delivery]

PURPOSE

To assess the quality of end-to-end anastomosis in the primary repair of anal sphincter laceration occurring during delivery.

METHODS

Forty-nine women with third degree perineal laceration (PL III) and 42 controls were included in a 3-year postpartal follow-up study.

RESULTS

Ultrasound showed end-to-end anastomosis to be inadequate in 22 (48.1 %) women. Thirty-one (63.2 %) women developed grade I-III anal incontinence.

DISCUSSION

There was no correlation between ultrasound findings and the presence of anal incontinence. The unsatisfactory sonomorphometric outcome after 6 weeks results from inadequate repair with retraction of the sphincter ends. Defects newly demonstrated after 36 months indicate dedifferentiating atrophy with damage to peripheral motor nerves.

Determination of bladder neck position by intraoperative introital ultrasound in colposuspension: outcome at 6-month follow-up

OBJECTIVE

To determine whether open colposuspension modified by intraoperative ultrasound to prevent overcorrection is a safe and effective procedure.

METHODS

Ninety women operated on for urodynamically proven genuine stress urinary incontinence underwent intraoperative introital ultrasound in a prospective observational clinical study. The positions of the bladder neck and proximal urethra were assessed by determining the parameters height (H), distance (D) and the urethrovesical angle (beta) perioperatively and for up to 6 months postoperatively. Colposuspension of the bladder neck was performed with a vertical height correction, DeltaH (resting H(intraop) - resting H(preop)) of 1 to 10 mm. Bladder neck positions were determined on an individual basis by introital ultrasound before, during and after surgery.

RESULTS

Surgical elevation of the bladder neck (median height correction, DeltaH 4 mm) resulted in a median intraoperative elevation of 9 mm (6 months: 8 mm). All postoperative measurements showed a significant reduction of the median linear movement of the bladder neck during straining (P < 0.0001). Anti-incontinence surgery resulted in a significant reduction of funneling and hypermobility 6 months after surgery (P < 0.0001). At 6-month follow-up, 94% (85/90) of the women were continent. Evaluation immediately after surgery showed voiding difficulties and urge symptoms in 9% (8/90) of the patients each and de novo urge incontinence in 1% (1/90).

CONCLUSIONS

Intraoperative introital ultrasound can help to optimize the colposuspension procedure. Ultrasonographic measurement of height H allows for objectively assessing the surgical procedure and can reduce postoperative complications by preventing excessive correction.

Technische Erfolgsrate, peri-interventionelle Komplikationen und Strahlenexposition der transarteriellen Embolisation bei Uterus myomatosus

PURPOSE

To analyze the technical success rate, incidence and type of peri-interventional complications, and radiation exposure of uterine artery embolization (UAE) in symptomatic leiomyomas of the uterus.

MATERIALS AND METHODS

This prospective study includes 75 patients consecutively treated with UAE from October 2000 through August 2002, with all interventions performed by the same radiologist. Technical success rate, interventional material, and incidence and type of peri-interventional complications (length of hospitalization) were recorded and categorized according to the definitions of the Society of Interventional Radiology (SIR). Fluoroscopy time (FT), dose-area product (DAP), and effective dose (ED) were determined for each intervention and the influence of the radiologist's experience on the radiation exposure analyzed.

RESULTS

UAE was technically successful in 97.3 % of the cases. Peri-interventional complications occurred in 14.7 %. Four complications (5.3 %) were classified as major class C according to the SIR (post-embolization syndrome requiring prolonged drug treatment and hospitalization [n = 3] perforation of the uterine artery [n = 1]). None of the complications led to discontinuation of the intervention, subsequent surgical intervention, or permanent sequelae. FT decreased significantly (p < 0.05) until the 35th intervention. The median FT decreased from 18.8 min (13.4 - 28 min [25th to 75th percentile]) to 11.8 min (9.7 - 13.3 min [25th to 75th percentile]). The DAP decreased by 25.3 % to a median of 8.547 (6.527 - 11.590 cGy*cm (2) [25th to 75th percentile]). The median ED was 31.5 mSv from the 36th intervention onward.

CONCLUSION

UAE has a high technical success rate with a low rate of peri-interventional complications. The study showed a statistically significant learning effect with a decrease in radiation exposure for the first 35 interventions. The effective dose of UAE is comparable to that of 1 to 2 small bowel enema.

Ultrasound diagnosis of intra-urethral tension-free vaginal tape (TVT) position as a cause of postoperative voiding dysfunction and retropubic pain

Intra-urethral Prolene tape erosion is a rare postoperative complication of tension-free vaginal tape (TVT) plasty. In cases reported in the literature, intra-urethral tape positioning has been diagnosed by urethroscopy as late as 3-12 months after the procedure. Introital ultrasound using a vaginal sector scanner allows for the non-invasive assessment of the position of the Prolene tape in relation to the urethra. Postoperative introital ultrasound might shorten the interval between surgery and the time of diagnosis of an intra-urethrally placed tape and thus significantly shorten the duration of symptoms. We present a patient with urethral pain syndrome and dysuria following TVT plasty. In this case, introital ultrasound was not performed until 8 months after surgery, when it demonstrated intra-urethral Prolene tape positioning as the cause of the patient's complaints. All symptoms disappeared after surgical removal of the intra-urethrally placed parts of the tape. The patient is continent, suggesting that the remaining para-urethral portions of the Prolene tape depicted sonographically ensured adequate stabilization of the mid-urethra in this case. The case report emphasizes the role of introital ultrasound in assessing Prolene tape position relative to the urethra on sagittal and transverse angulated views in the postoperative diagnostic evaluation of functional disturbances occurring after TVT plasty.

Introital ultrasound of the lower genital tract before and after colposuspension: a 4-year objective follow-up

OBJECTIVE

To assess the topography of the bladder neck by introital ultrasound before and after open colposuspension.

METHODS

Three hundred and ten women with urodynamically proven stress urinary incontinence were included in this long-term study to investigate the position and function of the bladder neck at rest and during straining. Height (H), distance (D), and urethrovesical angle of the bladder neck (beta) were measured by means of preoperative and postoperative introital ultrasound. Women were followed up; 152 of them (49%) completed 48 months of follow-up.

RESULTS

At the 6-month follow-up examination, 90.0% of the women were continent (279/310), 3.5% (11/310) showed voiding difficulties, 3.5% (11/310) had urgency, and 1.6% (5/310) had developed de novo urge incontinence. At the 48-month follow-up, 76.8% of the patients were still continent. All postoperative measurements yielded significantly lower values for angle beta at rest and during straining compared with the preoperative results (P < 0.0001). The median linear movement of the bladder neck during straining decreased from 18.0 mm before surgery to 6.4 mm at the 48-month follow-up (P < 0.0001). The median level of ventrocranial elevation of the vesicourethral junction was 14.3 mm immediately after surgery, 9.9 mm after 6 months and 6.6 mm after 48 months. The degree of surgical bladder-neck elevation was associated with postoperative urgency/de novo urge incontinence (P < 0.0001) and voiding difficulty (P < 0.0001).

CONCLUSIONS

The colposuspension procedure reduces angle beta at rest and during straining, restricts linear movement with straining, and elevates the bladder neck. Perioperative introital ultrasound improves understanding of this surgical procedure and might help to prevent postoperative complications.

Transvaginaler Verschluss einer nach Re-Sectio caesarea aufgetretenen vesico-uterinen Fistel Typ I (Jozwik)

The development of a vesico-uterine fistula is a problem which occurs with an increasing number of caesarean sections. The main symptoms are permanent urinary incontinence, cyclic hematuria ("menouria") and amenorrhoea. In only 5 % of cases, spontaneous closure with bladder catheterization over weeks and hormonal management is possible, most of the time a surgical procedure is the definitive treatment. Until now, the resection of this kind of fistula was performed using a transabdominal approach most of the time. Our procedure describes a surgical repair using a transvaginal approach by exciding the fistula out of the bladder and uterus with primary closure. In this way, a recurrent laparotomy with all known associated risks could be avoided. However, after definitive treatment of the fistula, a new pregnancy should be delivered by performing a caesarean section. In this way, a rupture of the uterus during delivery could be prevented.

[Uterine fibroid embolization - a new therapeutic option for symptomatic leiomyomata of the uterus]

Uterine fibroid embolization (UFE) is a new minimal-invasive therapy for the treatment of symptomatic leiomyomata of the uterus and a uterine-sparing alternative to surgical procedures. Short-term and mid-term results indicate a high clinical success rate with improvement of fibroid-related bleeding symptoms in 80 - 100 % of cases, improvement of bulk symptoms in 60 - 100 % of cases and reduction in fibroid volume at an average of about 36 - 78 % combined with a low rate of complications and side effects. This review discusses indications and contraindications, technique and pathophysiology, choice of material, results and complications of UFE on the basis of the current literature and our own results.