Correction of erosion after suburethral sling insertion for stress incontinence: results and related sexual function

BACKGROUND: Suburethral slings are commonly used for the surgical treatment of female stress incontinence; occasionally they can cause erosion and dyspareunia. OBJECTIVES: The primary aim of this study is to determine the outcome after reclosure of the vaginal epithelium for suburethral sling erosion. Sexual function was assessed before and after intervention using the Female Sexual Function Index (FSFI) questionnaire. DESIGN, SETTING, AND PARTICIPANTS: This was a prospective case-controlled study in which, between December 2005 and December 2007, we included patients who were referred to the Department of Urogynaecology because of vaginal erosion after suburethral sling insertion for urinary stress incontinence. For evaluation of sexual function, all patients filled in an FSFI questionnaire before intervention and at follow-up. All patients underwent gynaecological examination including colposcopy, and the site and size of the defect were noted. INTERVENTION: The edge of the vaginal epithelium was trimmed, mobilized, and closed with interrupted vertical Vicryl mattress sutures in a single layer. MEASUREMENTS: FSFI questionnaire and clinical findings. RESULTS AND LIMITATIONS: Twenty-one patients were included in the study. Eighteen patients with larger defects were operated on, and three defects healed after topical application of estrogen cream. In 16 patients, the defect had healed at follow-up; two patients with persisting defects were brought back to surgery and the procedure was repeated, paying particular attention to tension-free adaptation of vaginal tissue. In one patient, partial sling removal was performed after the second failed intervention. The domains of desire (p<0.0001), arousal (p<0.0003), lubrication (p<0.0001), satisfaction (p<0.0130), and pain (p<0.0001) improved significantly. Orgasm remained unchanged (p=0.4130; all two-tailed t-test). CONCLUSION: Suburethral erosion can be treated effectively by resuturing. Sexual function is improved in regard to desire, arousal, lubrication, satisfaction, and pain, but not orgasm. In septic patients and patients with a history of radiation, grossly infected tissue, or severe pain, excision of the mesh needs to be considered.

[Urinary incontinence]

Incontinence is a common age-dependent and increasing problem in women that may mainly present as stress incontinence, overactive bladder, mixed incontinence or other forms. A thorough history, gynaecological and neurological examination and urinalysis as initial step will lead to the diagnosis and treatment. If midstream urine is difficult to receive, a catheter urine will be easy to obtain. Further investigations as urodynamics, cystoscopy and ultrasound may be required. As initial step, stress incontinence should be treated with physiotherapy and pelvic floor exercises, if not successful with operations as suburethral slings. Slings have good long-term success rates of approximately 85 % with a low morbidity and can even be inserted under local anaesthetic. The treatment of idiopathic overactive bladder consists of bladder training, a behavioural therapy, and mainly anticholinergics. Anticholinergics may cause side effects particularly in the elderly who are under several medications that may add anticholinergic effects as antidepressants, antibiotics or antihistaminics.

Bulking agents: an analysis of 500 cases and review of the literature

Stress urinary incontinence (SUI) is common, impacts women's quality of life, and generates high costs. Physiotherapy is the first-line therapy, and if it fails, suburethral slings are the gold standard in SUI surgery. Bulking agents injected periurethrally might be a beneficial alternative, but there is a paucity of data on bulking therapy. The aim of this study was to prospectively analyze the efficacy and safety of bulking agents in the setting of a tertiary referral center.

Sexual function after suburethral sling removal for dyspareunia

INTRODUCTION: Impact on sexual function has received little attention in the medical literature for a long time. Because of the site of insertion of permanent tension free vaginal tape (TVT) the G spot might be affected or the tape might interfere with arousal and sensory stimulation. Recent studies have reported varying degrees of sexual impairment after TVT insertion ranging from 0% to 15% including dyspareunia. AIM: The aim of this study was to evaluate sexual function before and after suburethral sling removal due to postoperative female de novo dyspareunia. As a secondary outcome, general patients' satisfaction with their overall continence situation was assessed. PATIENTS AND METHODS: Between December 2005 and December 2007, we included 18 female patients who complained of de novo dyspareunia after suburethral sling insertion for urinary stress incontinence. All patients filled in an FSFI questionnaire prior to sling removal and at 3 months postoperatively. Additionally, all women were asked to estimate their general satisfaction regarding their continence situation using a Visual Analogue Scale (VAS) from 0 to 10, with 0 being the least satisfying situation and 10 being the most satisfying situation. All patients underwent gynaecological examination including ICS-pelvic organ prolapse staging (ICS-POP score). RESULTS: Of the 18 slings, ten were transobturator tapes (6 x TVT-O, 2 x Monarch, 2 x unknown) and eight were retropubic tapes (7 x TVT, 1 x SPARC). Desire, arousal, lubrication, satisfaction, and pain improved statistically significant. Orgasm scores were low with median scoring of 1.5 scores before and 1.0 scores after sling removal, and they did not change significantly after sling removal. The satisfaction rate deteriorated from a median of 7 (95% confidence interval [CI] 6.3-7.7) to a median of 4 (95% CI 3.7-5.1; p=0.99) but not statistically significant. CONCLUSIONS: Sexual function in patients with de novo dyspareunia is likely to improve after sling removal but not in all domains. Bladder function may deteriorate.

An adjustable sling in the management of recurrent urodynamic stress incontinence after previous failed midurethral tape

The aim of this prospective study was to evaluate the feasibility and outcome of an adjustable sling system AMI in patients with recurrent urinary stress incontinence after failed suburethral sling insertion.

Painful love-"hispareunia" after sling erosion of the female partner

Sling erosion/extrusion is a complication after suburethral sling insertion for female stress urinary incontinence that occurs in approximately 6% of patients. Symptoms may include vaginal discharge, infections, postcoital bleeding, and alterations of the sexual function. Little is known about the effect of sling erosion on the sexual function of the male partner.

Dissection of the Appendix with Ultrasound-Activated Scalpel: An Experimental Study in Pediatric Laparoscopic Appendectomy

Abstract Background: The aim of this study was to examine mechanical, microbiologic, and morphologic changes of the appendicle rim to assess if it is appropriate to dissect the appendix with the ultrasound-activated scalpel (UAS) during laparoscopic appendectomy. Materials and Methods: After laparoscopic resection of the appendix, using conventional Roeder slings, we investigated 50 appendicle rims with an in vitro procedure. The overall time of dissection of the mesoappendix with UAS was noted. Following removal, the appendix was dissected in vitro with the UAS one cme from the resection rim. Seal-burst pressures were recorded. Bacterial cultures of the UAS-resected rim were compared with those of the scissors resected rim. Tissue changes were quantified histologically with hematoxylin and eosin (HE) stains. Results: The average time to dissect the mesoappendix was 228 seconds (25-900). Bacterial culture growths were less in the UAS-resected probes (7 versus 36 positive probes; (p > 0.01). HE-stained tissues revealed mean histologic changes in the lamina propria muscularis externa of 2 mm depth. The seal-burst pressure levels of the appendicle lumen had a mean of 420 mbar. Seal-burst pressures and depths of histologic changes were not dependent on the different stages of appendicitis investigated, gender, or age groups. Seal-burst pressure levels were not related to different depths of tissue changes (P = 0.64). Conclusions: The UAS is a rapid instrument for laparoscopic appendectomy and appears to be safe with respect to stability, sterility and tissue changes. It avoids complex time consuming instrument change manoeuvres and current transmission, which may induce intra- and postoperative complications. Our results suggest that keeping a safety margin of at least 5 mm from the bowel would be sufficient to avoid thermal damage.