[Show abstract][Hide abstract] ABSTRACT: The objective of this review is to discuss the main goals of pelvic organ prolapse repair. Pelvic organ prolapse symptoms are variable, and prolapse degree does not necessarily correlate with perceived symptoms or other associated conditions including urinary, defecatory, and sexual dysfunction. Treatment for pelvic organ prolapse is based upon symptom bother and patient expectations. There are various surgical approaches to treat pelvic organ prolapse; however, there is no standardized definition of cure or success. Physician goals of pelvic surgery to correct prolapse include restoration of anatomy, resolution of patient symptoms, avoidance of complications and attainment of patient goals. However, patient's expectations may differ, and discussing preoperative goals and setting realistic expectations prior to treatment may guide surgical therapy and improve patient satisfaction.
Current Urology Reports 02/2014; 15(2):385. DOI:10.1007/s11934-013-0385-y · 1.51 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background and Purpose: The aim of this study was to describe the surgical technique and report the safety and feasibility of robotic-assisted laparoscopic sacrohysteropexy, a uterine sparing procedure to correct pelvic organ prolapse. Hysterectomy at the time of pelvic organ prolapse surgery has yet to be proven to improve the durability of repair. Nevertheless, the leading indication for hysterectomy in postmenopausal women is pelvic organ prolapse. Patients and Methods: We reviewed the medical records of a consecutive case series of uterine sparing prolapse repair procedures from 2005 through 2011. 15 women were identified. Procedures utilized a type I polypropylene mesh securing the posterior uterocervical junction to the sacral promontory. This was later modified to utilize a Y-shaped strip that was inserted through the broad ligaments to include the anterior uterocervical junction. Results: Objective success was defined as Baden Walker grade 0 uterine prolapse and subjective success was defined as no complaint of vaginal bulge or pressure. The mean age of women was 51.8 years (28-64). No intra-operative complications were noted. Mean operating time was 159.4 minutes (130-201) and mean estimated blood loss was 35 ml (0-100). The mean length of stay was 1.6 days (1-4) and mean length of follow-up was 10.8 months. Uterine prolapse improved in all 15 patients. Objective success was 93% (14/15) and subjective success was 80% (12/15). Conclusions: Robotic-assisted laparoscopic sacrohysteropexy was found to be a safe and feasible surgical treatment option for pelvic organ prolapse patients who desire uterine preservation.
Journal of endourology / Endourological Society 05/2013; 27(9). DOI:10.1089/end.2013.0171 · 2.10 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: PURPOSE: To determine the utility of urodynamics (UDS) in patients with obstruction secondary to anti-incontinence surgery (AIS). MATERIAL AND METHODS: We retrospectively reviewed all procedures to relieve obstruction due to AIS from 01/01-06/11. Patients were excluded if they had prior procedures to relieve obstruction, if follow-up data was missing, or if a neurologic disorder was present. Patients were grouped into the following categories prior to intervention: UDS diagnostic of obstruction vs. non-diagnostic UDS vs. no UDS testing. In addition we separated patients with predominantly storage symptoms vs. patients with incomplete emptying. RESULTS: A total of 71 women were included in the analysis; 54 women presented with an elevated PVR, 33 (61%) were diagnosed with obstruction on UDS, 4 (7.4%) had non- diagnostic UDS and 17 (32%) did not undergo preoperative UDS. All 18 patients with predominantly storage symptoms underwent UDS. In patients with incomplete emptying there was no difference between groups with respect to improvement in storage or voiding symptoms, overall cure or success according to whether they had diagnostic UDS or not. In patients who had storage symptoms and underwent UDS, those without evidence of detrusor overactivity (DO) had significantly greater improvement of their storage symptoms when compared to those with DO (85.7% vs. 53.8%, p=0.02). CONCLUSIONS: If voiding symptoms or urinary retention are the primary indication for intervention following AIS, UDS findings are not predictive of outcomes after intervention to relieve obstruction. If storage symptoms are the main indication for intervention, UDS may be valuable for patient counseling.
The Journal of urology 04/2013; 190(2). DOI:10.1016/j.juro.2013.03.113 · 3.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To characterize the symptoms and urodynamic findings of anatomical bladder outlet obstruction (AO) and functional bladder outlet obstruction (FO) in women and to determine if future endeavors at defining bladder outlet obstruction in women can group these entities together.
Retrospective review of all videourodynamic studies was performed on women from March 2003 to July 2009. Women with diagnosis of obstruction were categorized based on the cause of obstruction into 2 groups: AO and FO. Demographic data, symptoms, and urodynamic findings were compared between the 2 groups.
One hundred fifty-seven women were identified of which 86 (54.8%) were classified as having AO and 71 (45.2%) were classified as having FO. There were no differences in symptoms between the 2 groups. There was no difference (P=0.5789) in the mean detrusor pressure at maximum flow rate Qmax between AO (38.9 cm H20) and FO (41.0 cm H20). There was a difference in the Qmax between AO and FO (10.6 [0-41.7] and 7.4 [0-35.7] mL/s, respectively; P=0.0044), but there was considerable overlap between the values in these 2 groups.
Anatomical bladder outlet obstruction and FO have similar urodynamic voiding pressure findings, but Qmax was statistically significantly lower in AO. However, there is a large overlap in the Qmax values between the 2 groups. Therefore, future studies that attempt to characterize bladder outlet obstruction in women need not exclude either group.
Journal of Pelvic Medicine and Surgery 01/2013; 19(1):46-50. DOI:10.1097/SPV.0b013e31827d87cc
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVES: To define the urodynamic study findings among women with insensible urinary incontinence. METHODS: Women complaining of insensible incontinence who underwent urodynamics at our center were identified. Coexisting symptoms of stress incontinence, urgency incontinence and/or mixed incontinence were recorded. The primary outcome was the urodynamic study finding. Urodynamic stress incontinence, detrusor overactivity incontinence, combination of both or neither (no incontinence) were the possible diagnoses. RESULTS: A total of 58% of patients had insensible incontinence alone and 42% had insensible incontinence combined with other urinary incontinence symptoms. Of the patients with insensible incontinence alone, 37% had no incontinence on urodynamics, whereas urodynamic stress incontinence was diagnosed in 52%. Isolated urodynamic stress incontinence was found in 73% of patients with insensible and stress incontinence symptoms. In patients with insensible plus urgency incontinence, isolated detrusor overactivity incontinence and detrusor overactivity incontinence with urodynamic stress incontinence were found in the same percentage of women (40% each). In patients with symptoms including stress urinary incontinence, stress incontinence was the predominant urodynamic finding. CONCLUSIONS: In patients who have incontinence symptoms in addition to insensible incontinence, these symptoms are highly predictive of urodynamic findings. In particular, women with insensible incontinence, concomitant stress incontinence symptoms are most predictive of urodynamic findings (i.e. urodynamic stress urinary incontinence). In contrast, where insensible incontinence represents the only symptom, urodynamic findings vary widely, with a significant proportion having non-diagnostic studies.
International Journal of Urology 09/2012; 20(4). DOI:10.1111/j.1442-2042.2012.03146.x · 1.80 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To determine the clinical and urodynamic differences in the presentation and the value of simultaneous fluoroscopy in dysfunctional voiding (DV) and primary bladder neck obstruction (PBNO); the 2 most common causes of non-neurogenic "functional" bladder outlet obstruction in women.
A review of our urodynamic study database (March 2003 to August 2009) was conducted. DV was diagnosed when increased external sphincter activity was found during voluntary voiding on electromyography (EMG) or fluoroscopy. PBNO was diagnosed when a failure of bladder neck opening was noted on fluoroscopy during voiding. The demographics, symptoms, and urodynamic study parameters were collected. Comparisons were done using chi-square and 2-tailed t-tests.
DV was diagnosed in 34 women and PBNO in 16. The patients with DV were younger than those with PBNO (40.9 vs 59.2 years, P < .001). Women with DV showed a clinical trend toward having more storage symptoms than those with PBNO and fewer voiding symptoms. Patients with DV had a greater mean maximal flow rate (12 vs 7 mL/s, P = .027) and lower mean postvoid residual urine volume (125 vs 400 mL, P = .012). No significant differences were found in maximal detrusor pressure, detrusor pressure at maximal flow rate, or detrusor overactivity. EMG showed increased activity during voiding in 79.4% of those with DV and 14.3% of those with PBNO (P < .001).
Clinically, women with DV and PBNO had similar presentations, although those with PBNO had poorer emptying. The flow rates and patterns seemed to differ between those with DV and PBNO, although the voiding pressures were similar. EMG alone would have given the wrong diagnosis in 20.6% of those with DV (false negative) and 14.3% of those with PBNO (false positive). When fluoroscopy is used to define these entities, the accuracy of EMG to differentiate them is questionable.
[Show abstract][Hide abstract] ABSTRACT: Pelvic reconstructive surgeons in the fields of urology, gynecology and urogynecology have continually adapted new techniques in pelvic organ prolapse (POP) repair in order to improve both anatomic and subjective outcomes. In the last 5 years, robotic surgery has gained a strong foothold in urologic oncology, gynecologic oncology, cardiothoracic surgery and now in female pelvic medicine. Robotic surgery has made its way into the armamentarium of POP treatment and has allowed pelvic surgeons to adapt the 'gold standard' technique of abdominal sacrocolpopexy to a minimally invasive approach with improved intraoperative morbidity and decreased convalescence. This review article aims to discuss the techniques of robotic prolapse repair as well as morbidity, cost and clinical outcomes.
The adaptation of minimally invasive approaches to the treatment of POP initially began with laparoscopy, something only those surgeons with extensive and advanced laparoscopic skills are able to accomplish. Access to robotic technology makes conversion from open or laparoscopic to robotic surgery much more feasible for most pelvic floor surgeons. There are currently no published randomized, controlled trials comparing robotic with open or laparoscopic sacrocolpopexy, however, there are several publications reporting both retrospective and prospective series of women undergoing robotic-assisted sacrocolpopexy.
Robotic-assisted pelvic floor surgery has become an important component of the pelvic surgeon's armamentarium in the treatment of symptomatic POP. Those pelvic surgeons without significant expertise in laparoscopy required for sacral dissection and intracorporeal suturing can readily learn the necessary techniques required for robotic surgery.
Current opinion in urology 05/2012; 22(4):292-6. DOI:10.1097/MOU.0b013e328354809c · 2.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We report our experience with surgical excision for treatment of Skene's gland abscess/infection after conservative measures have failed.
A retrospective review of patients that underwent surgical excision of Skene's gland abscess/infection by a single surgeon from 06/1995 to 09/2008 was performed. Patients were separated into groups based on indication for procedure. Recurrence rate and success rate were calculated.
The final study group included 34 patients. After initial excision, 88.2% (30/34) of patients had resolution of symptoms. Recurrence of signs and symptoms that prompted further treatment occurred in 30% (9/30). In those that recurred, 88.8% (8/9) of patients had resolution of symptoms after further therapy. Overall success rate in complete resolution of symptoms after all treatment was 85.3%. Only patients to fail were in the urethral pain and recurrent UTI groups.
Surgical excision is a safe and effective therapy for the treatment of Skene's gland abscess/infection after conservative measures have failed.
International Urogynecology Journal 07/2011; 23(2):159-64. DOI:10.1007/s00192-011-1488-y · 2.16 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A basic understanding of female urethral anatomy is necessary to approach urethral reconstruction from an anatomic standpoint. This article reviews the techniques of female urethral reconstruction based on these anatomic divisions: proximal and bladder neck, midurethra, and distal urethra.
Urologic Clinics of North America 02/2011; 38(1):55-64, vi. DOI:10.1016/j.ucl.2010.12.008 · 1.35 Impact Factor