Dr Jonathan Ball

• Consultant in Intensive Care
• General Intensive Care Unit
• St George? Hospital
• London

Surgeons must be aware of the factors that contribute to mesh complications and obtain proper informed consent before mesh placement for any indication blood pressure control cheap enalapril 10 mg line. Urologic surgeons must feel confident in their repair techniques and be prepared to offer cost-effective blood pressure normal low pulse rate generic enalapril 5 mg without a prescription, reliable treatments with acceptable long-term outcomes blood pressure chart blank discount 10 mg enalapril. Urologic surgeons must feel comfortable in regard to the outcomes of mesh repair techniques and their ability to identify and address meshrelated complications blood pressure 40 year old male purchase cheap enalapril online. In women who often also experience pelvic organ prolapse blood pressure ranges enalapril 10 mg buy with amex, risk factors include age, parity, obesity, menopause, genetic predisposition, and chronic pelvic strain. In general, tissue damage from mechanical trauma and hormone effects combined with genetic predisposition and lifelong behavioral patterns culminate in the pattern of symptoms that brings patients to physician offices. Urinary incontinence treatment is recommended for symptomatic patients (Dmochowski et al, 2010). Over the past three decades, the most commonly performed surgery for stress urinary incontinence has shifted from needle suspensions to mid-urethral slings, which are recommended by the American Urological Association as the most durable treatment option for stress incontinence. Prolapse repair is offered to symptomatic patients who have failed conservative management. Symptoms range from vaginal bulge to obstructive urination or defecation to dyspareunia. Experts also recommend treatment for patients with end-organ damage from prolapse such as hydronephrosis, vaginal ulcerations, urinary retention, or cystoscopic findings of urinary obstruction. For the treatment of prolapse of the pelvic organs, the current standard of surgical repair is a mesh suspension of the prolapse to the sacral promontory (sacrocolpopexy). Mesh also can be placed vaginally to repair isolated or multiple compartment prolapse. Historically, native tissue prolapse repair was reported to have a 30% failure rate; however, more recent reviews highlight much higher subjective success rates (Lee et al, 2012). Mesh was adopted to augment native tissue repair to improve objective outcomes as measured using the Pelvic Organ Prolapse Quantification or Baden-Walker systems. Perfect support is defined as stage 0; however, 75% of asymptomatic women have greater than stage 1 findings. As a result, many patients who were satisfied with their surgical outcomes were categorized as failures if their objective measures did not meet criteria for success. This demonstrates the discrepancy between objective prolapse and subjective symptoms, which is of utmost importance when considering surgical intervention to improve quality of life. Pelvic reconstructive surgeons correct anatomy to restore function and improve quality of life. Surgical outcome should be evaluated not only by anatomic improvement but also by symptomatic improvement and demonstrable impact on overall quality of life. For surgeons, expertise with traditional and mesh-augmented pelvic reconstructive surgery is recommended. Surgeons should counsel patients on the risks and benefits of all options, while providing recommendations and obtaining informed consent. Counseling should include the risk of late-onset complications that are difficult to predict. Factors affecting complications that may present years after placement include vaginal atrophy, low-grade infection, tissue aging, or a dynamic host-graft response not completely understood. The fact that many of these risk factors are nonmodifiable makes prevention of these complications challenging. Materials Synthetic mesh is one of many materials used in pelvic reconstructive surgery and was introduced into prolapse repair to improve long-term durability compared with repairs using native tissue, fascia autografts, allografts, or xenografts. More than two decades after the widespread incorporation of polypropylene mesh into pelvic reconstructive procedures, new data suggest 10% of patients experience serious complications, including some that cannot be completely reversed (Committee on Gynecologic Practice, 2011). Some complications are minimally morbid and can be managed conservatively in outpatient settings (Niro et al, 2010). This includes vaginal mesh exposure, a finding that resulted in the discontinuation of much research that may have revealed the more serious long-term complications had the trials continued. Additional complications include bleeding, infection, fistula, pain, dyspareunia, organ perforation, obstruction, and dysfunction. Although the exact etiology of many complications is unknown, we discuss existing opinion regarding the factors contributing to mesh complications. Nerve damage from trocar passage or implant placement may manifest immediately as sharp, focused pain. Women may report decreased or lack of sensation to the labia, clitoris, or perineum. Mild complications such as voiding dysfunction or discomfort often resolve spontaneously with minimal intervention, and careful monitoring of these patients is recommended. When complications persist past the perioperative period or do not resolve with conservative management, they may require medication or intervention. Such complications include prolonged voiding dysfunction, urinary obstruction, vaginal pain or dyspareunia, erosion into an organ or exposure through the vaginal wall, and defecatory dysfunction. AnatomyofComplications Complications may be related to neurologic, musculoskeletal, or organ injury. Understanding of the innervation and organs surrounding the area of mesh placement is recommended for all surgeons who place mesh for reconstruction. This knowledge is essential for proper mesh placement and thorough evaluation of complications postoperatively. EtiologyofComplications Complications of mesh insertion occur secondary to modifiable and nonmodifiable factors. For example, when mesh is placed superficially, patients may experience bleeding, pain, dyspareunia, or infections from local ulceration and necrosis. Surrounding tissue may be predisposed to such reaction in cases of extensive local dissection, previous surgery, radiation, immunosuppression, or other local trauma. Sutures also must be selected and placed with care because wound separation would undoubtedly lead to mesh exposure. Anemia may contribute to poor tissue healing, and hematomas may become infected, place pressure on suture lines, and contribute to wound separation. Large hematomas, which may cause pain, cause urinary obstruction, or require drainage if they do not spontaneously resolve, are seen less often. Mesh is subject to bacterial contamination that may not be entirely prevented by sterile surgical technique (Culligan et al, 2003). This process is not unique to urologic surgery as demonstrated in examinations of implants used in other types of surgery (Gristina et al, 1985). Strategies to decrease contamination including hair removal, preoperative antiseptic washes, and antibiotics have been hypothesized to decrease implant contamination (Darouiche et al, 2010). Some products have protective sheaths for placement to avoid direct contact with the skin edge because this is likely a source of bacteria even after standard surgical preparation. In microscopic examinations of explanted mesh, bacterial contamination is followed by biofilm formation manifesting clinically as drainage or with nonspecific symptoms such as fatigue, fever, and chills. This process of low-grade infection may continue for a long time or escalate into cellulitis, wound separation, pain, bleeding, discharge, and erosion or organ infection. Metabolism initiates foreign body degradation, and neovascularization assists in tissue incorporation. Sensitivity of the urethra and vagina to local estrogen effects suggests that postmenopausal women may be more subject to bleeding, infection, or poor wound healing. As a result, some surgeons chose to administer preoperative estrogen, which has been demonstrated to alter vaginal cytology in women with atrophic vaginitis (Vaccaro et al, 2013). Location of fixation and trocar placement largely contribute to pain complications of mesh in urologic surgery and may vary significantly (Hinoul et al, 2007). Retropubic sling arms can incorporate urethra, bladder muscularis, levator musculature, and obturator muscle when a trocar is passed close to the pubic bone, rectus muscle, or lumbar nerve branches in their trajectory. Trans- Genitourinary Tract and Surrounding Structures Complications of mesh placed for support of the bladder or urethra range in severity. Lower urinary tract symptoms are the most commonly reported, and pain may occur at any point in bladder filling or emptying. Spasmlike pain, pain with position change, or activity-related pain may indicate involvement of the levator ani, obturator muscles, or fascia. Implanted mesh in the bladder wall is often associated with urgency and urge incontinence, whereas urethral damage may cause dysuria and urethral pain. Mesh can penetrate partially or completely through the bladder wall and can be found penetrating the mucosa, under the mucosa, or in the muscularis. Mucosal involvement is associated with complications of exposure such as hematuria and stone formation, whereas mesh in the muscularis rarely causes such complications. Complete obstruction from mesh placement typically manifests with urgency, frequency, inadequate emptying, or elevated postvoid residuals. Vaginal intercourse can be painful when mesh is placed in the vaginal muscularis superficially. Mesh penetration into the urethra or bladder typically manifests with hematuria, urinary tract infections, or pain. Retropubic sling arms may damage the ilioinguinal nerve (L1) and the genital branches of the genitofemoral nerve causing sharp localized pain, whereas obturator arms may damage the posterior branches of the femorocutaneous, posterior cutaneous (L2-S3), pudendal, perineal, inferior anal, or obturator nerves (L5-S1) (Fisher and Lotze, 2011). Mesh also may become fixated to the bony pelvis causing osteomyelitis or pain from traction as mesh shrinkage occurs between tensioned arms. Mild periosteal damage or inflammation is selflimited; however, severe localized pain may warrant diagnostic imaging (Grimes et al, 2012). Tenderness to palpation of the pelvis may be seen during this process or when implants adhere to the inferior pubic rami. Trauma to the anterior rectus muscle following retropubic sling is often positional, is relieved with rest, and resolves with time. Trocar-guided transobturator mesh may be associated with myositis, hip and thigh pain from muscles innervated by the obturator (L2-L4) and sciatic (L4-S3) nerves. Such pain occurs with abduction, adduction, lateral thigh rotation, walking, and prolonged sitting. Vagina and Pelvic Floor Musculoskeletal complications of mesh placed vaginally for prolapse are similar to complications described for the bladder and urethra. Mesh placed for apical prolapse correction may additionally affect the coccygeus muscle overlying the sacrospinous ligament or nearby piriformis muscle, innervated by the piriformis nerve (L5S2). In such cases, patients report pelvic floor spasms, dyspareunia, and prolonged pelvic pain. Pain may radiate from the gluteus, innervated by inferior gluteal nerve (S1), to the vagina. Spasms may cause incontinence or obstruction of urination or defecation, which can be particularly troubling for patients. Mesh placed for sacral suspension also has been associated with complications including sacral pain, osteomyelitis, and nerve root entrapment and disk damage. Such rare complications occur when the sutures are placed below the sacral promontory at the S1, S2, or S3 foramina. When the uterus or cervix is left in situ, mesh erosion into these organs may manifest as bleeding, cramping, drainage, or pain. Damage to lateral vasculature including obturator, uterine, and vaginal arteries also has been reported. Nerve injury to the lumbosacral plexus may occur during dissection and mesh fixation. Gastrointestinal Tract and Surrounding Structures Mesh placed for repair of rectocele may cause muscular pain. Sharp focal pain results from injury to the sciatic or pudendal nerves and typically manifests immediately after insertion. Concomitant procedures, planned procedures that were aborted, or intraoperative consultations by specialists warrant special attention. Next, a timeline of presenting symptoms should be obtained in relation to time since surgery. Lastly, details of each symptom should be described, including quality, severity, and relieving and exacerbating factors. The absence of significant findings on initial examination does not reliably rule out future complications, and patients should be counseled regarding the possible need for repeat evaluations and longterm complications. Obstruction of urination or defecation after surgery may manifest as complete or incomplete obstruction. Symptoms include urgency, frequency, and need to strain or change positions while emptying. Patients with urinary obstruction may have high or normal postvoid residuals and the presence or absence of inadequate emptying symptoms because they may have adopted compensatory strategies to achieve bladder emptying. The overall incidence of urinary obstruction requiring intervention in patients after mid-urethral sling procedures is approximately 8% (Dmochowski et al, 2010). Etiologies include penetration of sling material into the bladder or urethra, complete urethral fixation, sling excessively tight, periurethral fibrosis, or secondary bladder prolapse. In patients who present with pain, noting the severity, timing of onset, and relieving and exacerbating factors provides necessary information in determining the etiology. Routine postoperative pain is self-limited and resolves with medical management and within the perioperative period, although the exact duration is variable. The concurrent processes of tissue healing and mesh shrinkage also may contribute to pain, which is typically described as constant, dull, and worsened with activity or increases in intraabdominal pressure. Close follow-up and repeat examinations are recommended to monitor for improvement. A history of prolonged pain and bleeding of the bladder or rectum suggests mesh penetration and should be evaluated further. Some patients may report pain out of proportion to examination findings or experience pain despite local and systemic treatments. These patients warrant further evaluation as detailed subsequently because pain in susceptible patients may trigger the development of symptoms similar to those seen in patients with chronic pelvic pain. Obtaining a history of patient experience after prior surgeries; episodes of prolonged or severe pain; or pain syndromes such as interstitial cystitis/painful bladder syndrome, fibromyalgia, or chronic pelvic pain may help greatly in the management of these patients. Evaluation for complications should occur at each office visit, even in patients without a history of mesh-related complications. Some complications, such as mesh exposure and dyspareunia, may manifest 8 to 10 years after insertion because they are increased with vaginal atrophy.

Will hysterectomy at the time of sacrocolpopexy increase the rate of polypropylene mesh erosion Repair of vaginal vault prolapse by suspension of the vagina to the iliococcygeus (prespinous) fascia blood pressure medication make you cold buy enalapril 5 mg with visa. Colporrhaphy compared with mesh or graft-reinforced vaginal paravaginal repair for anterior vaginal wall prolapse: a randomized controlled trial blood pressure terms purchase enalapril 10 mg on-line. Results of abdominal sacral colpopexy using polyester mesh in the treatment of posthysterectomy vaginal vault prolapse and enterocele blood pressure 0 0 order generic enalapril canada. Porcine skin collagen implants to prevent anterior vaginal wall prolapsed recurrence: a multicenter hypertension quality of life purchase 5 mg enalapril, randomized study blood pressure 90 over 60 discount enalapril online visa. Functional and anatomical outcome of anterior and posterior vaginal prolapse repair with Prolene mesh. Prospective randomized trial of polyglactin 910 mesh to prevent recurrence of cystoceles and rectoceles. Transvaginal sacrospinous ligament fixation for the treatment of vaginal prolapse. Serious complications associated with transvaginal placement of surgical mesh in repair of pelvic organ prolapse and stress urinary incontinence, < Pyometra after Le Fort colpocleisis resolved with interventional radiology drainage. A transvaginal approach to repair of apical and other associated sites of pelvic organ prolapse with uterosacral ligaments. Surgical management of prolapse of the anterior vaginal segment: an analysis of support defects, operative morbidity, and anatomic outcome. Preoperative and postoperative analysis of site-specific pelvic support defects in 81 women treated with sacrospinous ligament suspension and pelvic reconstruction. Bilateral attachment of the vaginal cuff to iliococcygeus fascia: an effective method of cuff suspension. Health-related quality of life measures for women with urinary incontinence: the incontinence impact questionnaire and the urogenital distress inventory. Relationship of the uterosacral ligament to the sacral plexus and to the pudendal nerve. Vaginal paravaginal repair with porcine dermal reinforcement: correction of advanced anterior vaginal prolapse. Evaluation of the fascial technique for surgical repair of isolated posterior vaginal wall prolapse. A randomized comparison of polypropylene mesh surgery with site-specific surgery in the treatment of cystocoele. Abdominal-retroperitoneal sacral colpopexy for the correction of vaginal prolapse. The tensile properties of tension-free vaginal tape and cadaveric fascia lata in an in vivo rat model. Elevate anterior/apical: 12-month data showing safety and efficacy in surgical treatment of pelvic organ prolapse. Clinical and urodynamic effects of anterior colporrhaphy and vaginal hysterectomy for prolapse with and without incontinence. Laparoscopic compared with robotic sacrocolpopexy for vaginal prolapse: a randomized controlled trial. Should sacrospinous ligament fixation for the management of pelvic support defects be part of a residency program procedure Robot-assisted sacrocolpopexy for pelvic organ prolapse: surgical technique and outcomes at a single high-volume institution. The expression and function of the endothelin system in contractile properties in vaginal myofibroblasts of women with uterovaginal prolapse. Anterior vaginal wall hammock with fascia lata for the correction of stage 2 or greater anterior vaginal compartment relaxation. Prospective study of the Perigee system for treatment of cystocele-our five-year experience. Comprehensive evaluation of anterior elevate system for the treatment of anterior and apical pelvic floor descent: 2-year followup. The rectovaginal septum revisited: its relationship to rectocele and its importance in rectocele repair. Long-term results following fixation of the vagina on the sacrospinal ligament by the vaginal route (vaginae fixatio sacrospinalis vaginalis). Transvaginal paravaginal repair of high-grade cystocele central and lateral defects with concomitant suburethral sling: report of early results, outcomes, and patient satisfaction with a new technique. Posterior vaginal wall prolapse: transvaginal repair of pelvic floor relaxation, rectocele and perineal laxity. Laparoscopic sacral colpopexy approach for genito-urinary prolapse: experience with 363 cases. Treatment of anterior vaginal wall prolapse with porcine skin collagen implant by the transobturator route: preliminary results. Transperineal repair of symptomatic rectocele with Marlex mesh: a clinical, physiological and radiologic assessment of treatment. Outcomes of vaginal vault prolapse repair with a high uterosacral suspension procedure utilizing bilateral single sutures. Outcomes with porcine graft placement in the anterior vaginal compartment in patients who undergo high vaginal uterosacral suspension and cystocele repair. Uterosacral ligament suspension sutures: anatomic relationships in unembalmed female cadavers. Does trocar-guided tension-free vaginal mesh (Prolift) repair provoke prolapse of the unaffected compartments Mesh erosion in abdominal sacral colpopexy with and without concomitant hysterectomy. Cystocele repair by a synthetic vaginal mesh secured anteriorly through the obturator foramen. Uterosacral ligament vaginal vault suspension: anatomy, outcome and surgical considerations. Porcine subintestinal submucosal graft augmentation for rectocele repair: a randomized controlled trial. Thumbtack use for control of presacral bleeding, with description of an instrument for thumbtack application. Suture erosion rates and long-term surgical outcomes in patients undergoing sacrospinous ligament suspension with braided polyester suture. Urogynecologic surgical mesh: update on the safety and effectiveness of transvaginal placement for pelvic organ prolapse, <. The incidence of low-pressure urethra as a function of prolapse-reducing technique in patients with massive pelvic organ prolapsed (maximum descent at all vaginal sites). Primary surgical repair of anterior vaginal prolapse: a randomised trial comparing anatomical and functional outcome between anterior colporrhaphy and trocar-guided transobturator anterior mesh. Total colpocleisis with high levator plication for the treatment of advanced pelvic organ prolapse. Changes in tensile strength of cadaveric human fascia lata after implantation in a rabbit vagina model. A variety of materials (autologous, allograft, xenograft, and synthetic) and techniques have been pursued for sling placement. Von Giordano (1907) as a gracilis muscle graft wrapping around the urethra (Aldridge, 1942). Later, German surgeons used slings fashioned from muscle and fascia in children with incontinence (Goebell, 1910). Aldridge left the sling attached to the rectus fascia in the midline because he theorized that this would allow the sling to compress the urethra when the abdominal muscles responded to increases in intra-abdominal pressure. Aldridge stated that he came up with this "fundamental principle" by reading a case report of a surgery performed by Phillip Price in 1933, who used a fascia lata sling passed around the urethra and attached to the rectus muscle to cure the incontinence of a woman with congenital absence of the sacrum and coccyx (Price, 1933). Anecdotally, this is proven by the fact that cutting these securing sutures in a patient with an obstructive sling months after surgery will not release tension. In 1994, DeLancey published a revised model that made a significant contribution to the current understanding of the continence mechanism. These researchers noted that the pubococcygeal muscles insert at the level of the midurethra just outside the vaginal epithelial wall and play a vital role in the midurethral continence mechanism. They further propounded that this anatomic finding is important when considering methods to correct urinary incontinence. According to that report, synthetic mesh is termed a prosthesis and a biologic implant is termed a graft. Mesh located in the lower urinary tract is termed a perforation, and extrusion of mesh through the skin or vagina is termed exposure. This topic is of great importance to pelvic surgeons and their patients and will be discussed in further detail later in this chapter. Based on the aforementioned theories and other published experiments, in 1990 Petros and Ulmsten proposed a unifying concept called the integral theory. They stated that the most important factors to preserve continence were adequate function of the pubourethral ligaments, the suburethral vaginal hammock, and the pubococcygeus muscle. They postulated that injury to any of these three components from surgery, parturition, aging, or hormonal deprivation could lead to impaired midurethral function and subsequently urinary incontinence. Ulmsten and colleagues published one of numerous studies used as the basis for the integral theory in 1987. In that paper, the researchers performed biopsy of the skin and round ligament of eight continent women and seven incontinent women and found that the tissues of incontinent women contained 40% less collagen. From this information, the authors concluded that weakness of the connective tissue supporting the urethra secondary to the loss of collagen might contribute to incontinence. In this initial paper, Ulmsten and Petros reported that they completely cured incontinence in 39 of 50 (78%) women who underwent the intravaginal slingplasty and that there were no complications. In terms of complications, 2 patients developed transient urinary retention, 2 patients developed hematomas, 1 patient developed persistent urinary retention that required "a small adjustment" via a vaginal incision, 1 patient experienced mesh perforation of the bladder that was recognized at the time of surgery (mesh was replaced), and, although it is unclear if there was vaginal mesh exposure, 1 patient developed a wound infection that required a minor surgical procedure and vaginal estrogen. In that study, 39 of 40 patients were cured of their incontinence and only 1 patient experienced a complication. Data are less robust for the single-incision slings (mini-slings) and this will be discussed later in the chapter. Similar to transobturator slings, the risk of bladder or bowel injury is low with single-incision slings; however, cystoscopy is recommended in general to rule out bladder or urethral injury. The evaluation of urinary incontinence begins with a thorough history focused on the onset, frequency, character, and severity of the incontinence and other voiding symptoms. Some clinicians may find that a validated questionnaire and a voiding diary best accomplish this step. The rest of the history should be dedicated to evaluation of other factors that can affect bladder and urethral function such as neurologic diseases, medications, and prior surgeries. Also, it is important to query the patient about problems related to fecal incontinence or defecation. Knowledge of prior radiation is also useful because radiation may compromise the quality of a rectus fascial graft. A focused neurourologic examination and pelvic examination should be performed on any patient with complaints of urinary incontinence. The pelvic examination should be performed to evaluate for any correctable anatomic abnormalities that can contribute to incontinence such as a vesicovaginal fistula and any abnormalities that are the result of urinary incontinence such as vaginal epithelial irritation. During the examination, the patient should also be asked to perform Chapter84 Slings:Autologous,Biologic,Synthetic,andMidurethral 1989 Valsalva maneuvers to reveal pelvic organ prolapse, urethral hypermobility, and stress incontinence. Although the usefulness of this test is controversial, a Q-tip test can also be performed to assess abnormal mobility of the urethra. With this test a patient is considered to have urethral hypermobility if a Q-tip inserted into the urethra moves more than 30 degrees during abdominal straining (Bergman and Bhatia, 1987). Lastly, if a supine stress test with a full bladder does not demonstrate urinary incontinence, then a standing stress test is imperative. However, in some patients abnormal findings in the history, physical examination, or urinalysis may warrant this type of further evaluation. Obviously this step of evaluation is dependent on the willingness of the patient to undergo the studies and the impact that further evaluation will have on treatment options. Of note, urodynamic testing should be performed with and without a pessary if significant prolapse is present. In the incontinent patient, the goal of urodynamics is to evaluate urethral and bladder function. In addition to the evaluation of the urethra during urodynamic studies, assessment of bladder pressure during filling and emptying yields valuable prognostic information about bladder function. Abnormally small bladder capacity and decreased compliance may also negatively affect the outcomes of sling surgery, and these factors should also be considered. Initial conservative therapy includes patient self-awareness and education, dietary modification, fluid restriction, weight loss, and pelvic floor muscle training (Dallosso et al, 2003). There is significant evidence in the literature to support these methods of treatment (Osborn et al, 2013). A 2009 study by Subak and colleagues of 338 obese women randomized to one of two different weight loss programs highlighted the importance of weight loss. Another conservative treatment option is pelvic floor muscle training (Kegel exercises). The recent discontinuation of bovine-derived cross-linked collagen by its manufacturer has led to the increased use of several newer synthetic agents. However, both a Cochrane review (Kirchin et al, 2012) and a review by the Fourth International Consultation on Urinary Incontinence (Abrams et al, 2010) of periurethral bulking agents concluded that there was limited evidence for the benefit of these agents. Nevertheless, because of the low risk of side effects, periurethral bulking agents are still a good option for many patients who are not ready to undergo a more invasive surgical procedure. The ideal material provides longlasting suburethral support with minimal complications. Ideally, implanted materials should be incorporated into the host with minimal tissue reaction. In reality, most materials promote organized fibrosis and reinforce the sphincteric mechanism through improved suburethral support. Theoretically, a greater degree of fibrosis leads to better clinical results (Bidmead and Cardozo, 2000; Woodruff et al, 2008). Yet, inflammatory infiltration can lead to rapid sling material degradation and possible tissue destruction with erosion (Bidmead and Cardozo, 2000).

For small areas of mesh perforation blood pressure medication help lose weight purchase enalapril overnight, the literature supports endoscopic excision with scissors or ablation with the holmium laser as an appropriate initial step blood pressure chart omron cheap enalapril 10 mg buy line. Oh and Ryu (2009) evaluated the efficacy of transurethral resection in 14 patients with intravesical mesh prehypertension nosebleed enalapril 5 mg with mastercard. In a case report blood pressure chart according to age and weight buy 10 mg enalapril overnight delivery, Jorion (2002) excised the mesh endoscopically using an offset nephroscope transurethrally and a 5-mm laparoscopic trocar placed suprapubically arrhythmia when sleeping buy enalapril 5 mg overnight delivery. Laparoscopic grasping forceps were used to grasp the mesh, and endoscopic shears excised the mesh flush with the bladder mucosa, allowing the mesh to be easily removed. Cystoscopy at 1 month revealed healed mucosa, and the patient was continent and symptom free. In another report by Tsivian and coworkers (2004), the mesh was initially cut endoscopically, but because of an adherent calculus, the mesh could not be extracted endoscopically. Therefore a suprapubic approach was required to remove the stone and intravesical mesh. Patients often have bladder stones that have formed on the intravesical portions of the sling. For this problem, Irer and colleagues (2005) and Mahmoud and Wadie (2007) described successful endoscopic laser lithotripsy of the calculi and transurethral resection of the sling material. We reserve endoscopic (holmium laser) management of intravesical mesh perforation for very small areas of perforation in select patients. After endoscopic excision fails or as an initial treatment, mesh perforated into the bladder can be removed from a transvaginal or retropubic approach. For slings that perforate into the bladder at or below the trigone, we prefer an inverted-U incision similar to the aforementioned management of urethral perforation because this allows for exposure of the proximal urethra, bladder neck, and endopelvic fascia as well as providing a vaginal epithelial flap that avoids overlapping suture lines, theoretically decreasing the risk of a fistula. Similar to the management of urethral perforations, we do not excise the entire sling as long as it is no longer under tension and is far from the bladder. For slings that perforate the bladder dome or other areas of the bladder not accessible from a transvaginal approach, we remove the mesh transabdominally. The sling can usually easily be seen entering the bladder in the retropubic space. Although not always necessary, opening the bladder in the midline usually aids with closure and identification of the exact area of bladder perforation. In general, reconstruction should involve nonoverlapping suture lines and interposition of tissue such as a labial fat pad, greater omentum, or autologous fascial sling. In a report by Negoro and colleagues (2005), a retropubic approach was used to resect the intravesical portion of the mesh. The bladder was closed with absorbable suture, and catheter drainage was maintained postoperatively. Volkmer and colleagues (2003), Sweat and colleagues (2002), and Huang and colleagues (2005) used a combined transvaginal and abdominal approach to remove the sling in its entirety. One patient had residual urgency and frequency treated with anticholinergics; the other patients had resolution of symptoms but recurrent stress incontinence managed with collagen in one and pelvic floor muscle training and estrogen in the remaining two. There are several reported cases of successful laparoscopic removal of intravesical mesh after retropubic sling placement. One of these cases used a three-port intraperitoneal approach (Siow et al, 2005), and the other two used a three-port extraperitoneal approach (Rehman et al, 2008). Thigh and groin pain appear to be more commonly associated with the transobturator approach. A randomized controlled study from Finland (Laurikainen et al, 2007) revealed that 16% of women in the transobturator (in-to-out) group had groin pain compared with only 1. Includes one patient who had an I-Stop out-to-in transobturator midurethral sling. They also noted it to be transient and responding to nonsteroidal antiinflammatories in all but one case. They hypothesized that the cause of the pain was either subclinical hematoma or a transient neuropathic phenomenon. Roth (2007) found that in three women with persistent groin pain 3 months postoperatively, steroids and local anesthetic were effective for pain relief and had no side effects. Wound-related complications include minor superficial cutaneous infections and pelvic abscesses. In 2004, a case of necrotizing fasciitis was reported in an obese, diabetic patient (Connolly, 2004). It is interesting to note that a review of necrotizing fasciitis in gynecologic surgery found that obesity (88%), hypertension (65%), and diabetes (47%) were all factors associated with the development of fasciitis after surgery (Gallup et al, 2002). In 2006, Mahajan and colleague reported one case of failed sling and vaginal exposure that was associated with severe groin pain, fever, and chills 10 days postoperatively. The sling was easily removed through a vaginal incision, and mesh cultures were positive for Bacteroides fragilis. Abscesses and adductor myositis have also been reported, manifesting as leg pain, difficulty ambulating, and cellulitis (Goldman, 2006; DeSouza et al, 2007; Karsenty et al, 2007; Leanza et al, 2008; Zumbé et al, 2008). In 2004, Gamé and colleagues (2004) reported an infected obturator hematoma after placement of an ObTape sling that required exploration and drainage. In general, severe infectious complications appear to be more common with the older, non­loosely woven polypropylene slings (Babalola et al, 2005). Four patients with persistent or severe pain were given a combination of steroid and local anesthetic injections. Two women developed recurrent pain and had the sling excised, with significant pain relief. Of importance, with conservative treatment the incidence of persistent groin pain 12 months after surgery was only 3. In instances of chronic mesh pain and severe infection when nonoperative therapy has failed, it may be necessary to attempt a complete mesh excision from both sides of the bone. In the case of retropubic mesh this involves an abdominal and vaginal incision, and in the case of transobturator mesh this involves a medial thigh and vaginal incision. For the complete excision of transobturator mesh we typically consult an orthopedic surgeon to aid with lateral dissection of the sling. Five of the eight patients were cured of their pain after a median 8 months of follow-up. These voiding symptoms are typically the result of obstruction from the sling as a consequence of the sling being placed too tightly or in the wrong location (too proximally) or associated with pelvic organ prolapse (unrecognized preoperatively or de novo); however, some patients may have voiding dysfunction without evidence of obstruction. Based on anecdotal experience removing hundreds of chronically obstructing slings, we have found that obstructive slings are most likely to be found close to the bladder neck. In addition, we have found that progression of anterior and apical prolapse can cause a nonobstructive sling to become obstructive 10 years or more after placement of the sling. If the diagnosis of sling obstruction is in doubt, urodynamics can be performed to provide confirmation (Volkmer et al, 2003; Levin et al, 2004). The most common symptoms of obstruction are an inability to void (urinary retention), incomplete emptying, and de novo urgency and frequency. Over several weeks to a month, the irritative voiding symptoms (urgency, frequency, and pain) become more prevalent as the bladder attempts to adjust to the obstruction. The optimal evaluation for patients with postoperative voiding dysfunction is poorly defined in the literature. However, it appears that the temporal relationship correlating symptoms with an antecedent surgical procedure should be the primary criterion in selecting patients for urethrolysis and sling release procedures. Cystoscopy is useful to rule out bladder pathology, urethral mesh perforation, and a hypersuspended bladder neck. Urinary retention, defined as the need to catheterize for 72 hours or longer after surgery, was identified in 32 patients. Twenty-eight patients resumed normal voiding within 3 months, and 4 patients required a transvaginal sling release procedure. Tsivian and colleagues (2009) assessed the effect of concomitant vaginal surgery on the outcomes of transobturator sling placement. The group without concurrent vaginal surgery had no voiding dysfunction postoperatively, whereas seven (11%) in the group of patients who had undergone additional pelvic surgery experienced voiding dysfunction. Previous history of incontinence surgery was the only independent variable predictive of urinary retention. In most cases, postoperative voiding dysfunction can be successfully treated conservatively. In the Kuuva and Nilsson analysis of the Finnish database (2002), 20 of 34 patients with urinary retention resumed a normal voiding pattern after only 1 day to 2 weeks of conservative management. Only 1 of the 34 patients required midline sling lysis, and normal voiding resumed. Also, in that study there were 111 patients with voiding dysfunction but no retention. Thirteen of these patients had voiding dysfunction that lasted up to 4 months, and 2 patients required surgical transection of the sling to achieve a normal voiding pattern (Kuuva and Nilsson, 2002, 2003). Several reports have shown some benefit of urethral dilation or loosening the sling under anesthesia (Hong et al, 2003; Ozel et al, 2004; Mishra et al, 2005). In this series, the postoperative retention rate was significantly higher (23%) than in other published data. There are concerns about the potentially traumatic nature of dilation, which could induce scarring of the urethra or lead to mesh perforation. In our opinion, after 3 months the sling is fixed along its entire course, and midline sling incision may not achieve enough sling relaxation to resolve voiding dysfunction. In these cases, we perform a more formal sling excision and urethrolysis similar to that described earlier for sling excision after perforation. Reassuringly, studies by Laurikainen and Killholma (2006), Gamé and colleagues (2006), Clifton and colleagues (2014), and Klutke and colleagues (2001) found that 50%, 70%, 79%, and 94% of patients, respectively, remained continent after sling lysis. The sling was identified and either released with downward traction for 1 cm or cut in the midline. Symptoms resolved in all patients after sling release, all patients voided to completion, and 16 patients remained continent. In that study, approximately 50% of the 48 patients who required sling lysis were cured of their voiding dysfunction and remained continent. Lastly, Gamé and colleagues (2006) presented results of 30 women who required sling lysis with a lateral sling incision over a 4-year period. They cut the sling in the midline with a transvaginal approach and sutured the edges of the sling to a polypropylene mesh, thus lengthening the sling. The exact timing of sling incision in the literature is variable; however, most authors recommend waiting at least 2 weeks (Long et al, 2004; Glavind and Glavind, 2007) before sling incision in cases of sling obstruction. Even though Kuuva and Nilsson (2002) reported return to normal voiding after 6 weeks of conservative management, the majority of studies do not support waiting more than 4 weeks. In our opinion, in cases of significant obstruction or retention, the sling should be incised within 4 weeks of surgery. Also, in our experience, even though some patients may return to "normal voiding" with conservative management, they often have persistent urgency and frequency. Kuhn and colleagues (2009a) reviewed the impact of sling removal on postoperative female de novo dyspareunia and found that the pain improved significantly. There is also evidence that treatment of urinary incontinence can improve sexual function after surgery. In the randomized controlled trial by Ward and Hilton (2008), the rate of dyspareunia actually decreased from 34% preoperatively to 13% 5 years after sling surgery. The authors mostly attributed the improved sexual function to a significant decrease in coital incontinence. This complication is usually variably and subjectively reported in the literature. A review of the literature reveals that severe bleeding or hematoma occurs in approximately 2% to 3% of patients and can usually be managed with observation or local compression (see Table 84-13 on the Expert Consult website). Marszalek and colleagues (2007) performed a cross-sectional analysis and noted that a 14. Of interest, this study revealed that a postoperative hematoma may be a relatively common asymptomatic event after trocar passage. Serious complications such as vascular perforation, intestinal perforation, or even death remain extremely rare. The major complications included 39 vascular injuries, 38 bowel injuries, and 10 deaths. However, while the use of mesh during pelvic organ prolapse repairs has increased, so too have complications related to its use. In June 2010, a settlement was reached to halt the first class-action lawsuit against the manufacturer of ObTape (Mentor-Porgés) (Chapple et al, 2013). Bard and Ethicon have already discontinued their mesh products, and as litigation increases, other manufacturers may decide to follow suit. Currently, most litigation is directed at device manufacturers; however, this could change. It is important for pelvic surgeons to continue to thoroughly counsel their patients about the permanent nature of mesh products and the potentially serious complications related to their use. A prospective randomized trial comparing tension-free vaginal tape and transobturator suburethral tape for surgical treatment of stress urinary incontinence. Five-year outcomes of the tension-free vaginal tape procedure for treatment of female stress urinary incontinence. A nationwide analysis of transvaginal tape release for urinary retention after tension-free vaginal tape procedure. Tension-free vaginal tape versus transobturator tape as surgery for stress urinary incontinence: results of a multicentre randomised trial. Tension-free vaginal tape versus colposuspension for primary urodynamic stress incontinence: 5-year follow-up. Normal postoperative urodynamic testing does not predict voiding dysfunction after Burch colposuspension versus pubovaginal sling. Concomitant vaginal surgery did not affect outcome of the tension-free vaginal tape operation during a prospective 3-year follow-up study.

PosteriorCompartmentRepair Symptoms attributable to posterior compartment prolapse can be divided conceptually as herniation symptoms blood pressure guidelines 2015 purchase online enalapril, defecatory dysfunction blood pressure 8660 buy generic enalapril line, and sexual dysfunction (Cundiff et al blood pressure good average purchase discount enalapril on-line, 2004) heart attack 90 percent blockage buy 10 mg enalapril mastercard. Herniation symptoms include vaginal bulging and bleeding of the epithelium from excoriation hypertension vision 10 mg enalapril buy mastercard. Defecatory dysfunction includes stool trapping requiring vaginal splinting or manual digitations, defecatory urgency, and constipation. It is important to differentiate among outlet obstruction (including defects in the support of the posterior compartment, perineum, and rectum), motility disorders, and anismus (Cundiff et al, 2004). Motility disorders, which usually involve impaired transit of the rectum and anus, are treated with dietary modifications and medication. Anismus responds to biofeedback, and pelvic floor support defects are treated surgically. In combined disorders, it is recommended that nonsurgical treatment for anismus or slow-transit constipation (the most common disorder of motility) be treated before embarking on surgical intervention. Sexual dysfunction is thought to be secondary to dyspareunia, although decreased desire and anorgasmia may also be contributing factors (Handa et al, 2004). Several authors have sought to identify patient factors that would predict who might benefit most from rectocele repair (Murthy et al, 1996; Watson, 1996) these include sensation of vaginal mass or bulge, need for digitalization (splinting) to complete rectal evacuation, nonemptying or partial emptying on defecography, and presence of a large rectocele. Sensation of incomplete emptying and constipation are not specific to rectoceles and may be associated with other disorders including irritable rectum and slow-transit constipation. Patients should be counseled that surgical repair of the posterior compartment may likely reduce vaginal protrusion symptoms and decrease or eliminate the need for vaginal splinting. However, some patients may have persistence of constipation, because motility disorders and anismus can independently coexist with prolapse and persist after a seemingly successful repair. Nieminen and colleagues randomized 30 patients to rectovaginal fascia plication or transanal repair (Nieminen et al, 2004). Both approaches resulted in a high rate of symptom resolution (93% for the vaginal approach vs. The traditional posterior colporrhaphy was devised in the 19th century to treat perineal tears, Abdominal Hysteropexy Early reports of abdominal hysteropexy described suturing of the uterus directly to the sacral promontory (anterior longitudinal ligament) or attaching a strip of autologous fascia between the cervix and the promontory. Additional techniques have used a variety of grafts to harness support, commonly the use of polypropylene mesh secured posteriorly to the cervix and posterior vaginal wall with an anterior segment that is passed through the broad ligament to support the anterior cervix and anterior vaginal wall. Metaanalysis of the available data suggests a 63% to 100% (mean 91%) anatomic success rate and a 1. Uterosacral hysteropexy is performed by plicating the uterosacral ligaments and anchoring the cervix with or without the addition of a culdoplasty. Minimal high-quality data exist comparing this technique with the others mentioned earlier or with hysterectomy. Meta-analysis of 176 laparoscopic uterosacral hysteropexy reports an 83% success rate (Wei et al, 2012). The original description involved plicating the pubococcygeus muscles and the posterior vaginal wall and reconstruction of the perineal body, which was termed posterior colpoperineorrhaphy (Cundiff et al, 2004). This resulted in a rigid inferior shelf, which reduced the herniation of the posterior wall and prevented descensus of the vaginal vault or uterus. In 1961, Francis and Jeffcoate reported a high incidence of dyspareunia after colporrhaphy with levator plication (Francis et al, 1961). In addition, there is evidence to suggest that the traditional posterior colporrhaphy with levator plication may worsen defecatory symptoms. Khan and Stanton reported increased symptoms of fecal incontinence, constipation, incomplete evacuation, and dyspareunia postoperatively (Khan and Stanton, 1997). Because of the increase in dyspareunia postoperatively, plication of the levator ani muscles has largely been abandoned. Sitespecific repairs and midline fascial plication without levator ani plication have emerged as the predominant surgical treatments of rectocele. It is important to remember that level 1 and 2 evidence supports the superior objective outcomes of midline posterior plication without levatorplasty compared with site-specific repairs. If a patient requires an anterior or middle compartment repair, it is performed first (Rovner and Ginsberg, 2001). The anterior wall can be retracted with a Heaney retractor to improve visualization. The rectovaginal fascia (muscularis) is separated from the vaginal epithelium with Metzenbaum scissors. The tips of the scissors should be pointed toward the vaginal epithelium to avoid rectal injury. The dissection proceeds laterally until the pararectal attachments to the pelvic sidewall are visualized. In cases of large posterior defects, a purse-string suture of 2-0 or 3-0 absorbable suture may be placed at the base of the rectal herniation to reduce it; however, care should be taken to avoid foreshortening the posterior wall cephalad to caudad. In addition, this acts to bring the attenuated rectovaginal tissue together to aid in its reapproximation. The rectovaginal tissue is then plicated in the midline with either interrupted or continuous 2-0 absorbable suture. Care is taken to avoid excessively lateral placement or wide spacing of these sutures, which could result in painful ridges along the posterior vaginal wall. Suture placement is continued distally and incorporated into a perineal body reapproximation. The excess vaginal epithelium is trimmed and closed with an absorbable 2-0 suture. To minimize complications associated with posterior colporrhaphy, a site-specific defect repair was described. Richardson described discrete defects in the rectovaginal fascia found in both patients undergoing posterior colporrhaphy and cadaveric dissections (Richardson, 1993). He found that the most common defect was the transverse configuration, separating the vaginal septum from the perineal body. This essentially results in a separation of the rectovaginal tissues from the perineal body. The goal of the site-specific repair is to restore the anatomy by closing these discrete defects. For a high rectocele the incision may be as high as the vaginal apex; for smaller rectoceles the incision is started at the most caudal position. The rectovaginal fascia (muscularis) is separated through a virtually bloodless plane from the vaginal epithelium. The index finger of the nondominant hand is then inserted into the rectum to facilitate identification of the fascial defect. The excess vaginal epithelium is trimmed and the vaginal epithelium is closed with interrupted sutures. A triangular incision at the mucocutaneous junction is made (Rovner and Ginsberg, 2001). The triangular island of posterior vaginal wall is sharply removed from the prerectal levator fascia. Horizontal mattress sutures are used to approximate the attenuated perineal body fibromuscular tissue. Once these are brought together, the muscles of the urogenital diaphragm are reconstituted and support is restored to the central tendon. It is important that a smooth contour be created along the suture line, because ridges may cause dyspareunia. A vaginal packing moistened with saline, antibiotic solution, cream, or gel is then placed. Kahn and Lopez reported on the anatomic and functional results of posterior repair using levator plication. Both reported anatomic success; however, many patients complained of bowel symptoms and dyspareunia postoperatively (Khan and Stanton, 1997). Because of these adverse events associated with levator plication, this technique has been largely abandoned. They found that posterior colporrhaphy and site-specific rectocele repair had similar functional and anatomic outcomes. In a follow-up study of these same patients specifically looking at bowel symptoms, Gustilo-Ashby found that anatomic cure was associated with a reduced risk of postoperative straining and sensation of incomplete bowel evacuation, but not with other bowel symptoms (Gustilo-Ashby et al, 2007). They found that bowel symptoms, including feeling of incomplete emptying, straining to defecate, splinting to defecate, and fecal incontinence, improved significantly after rectocele repair. Abramov and colleagues retrospectively studied patients with advanced posterior vaginal prolapse and compared patients who underwent posterior repair with those who underwent site-specific repair (Abramov et al, 2005). They found that the recurrence of posterior defects was higher in the site-specific group compared with the midline plication of the rectovaginal fascia: 33% versus 14% for second degree, and 11% versus 4% for third degree. In addition, recurrence of symptomatic rectocele was greater in the site-specific group (11% vs. Rates of de novo dyspareunia and postoperative bowel symptoms were the same in both groups. Maher and colleagues prospectively studied the efficacy of posterior repair with plication of the rectovaginal fascia (Maher et al, 2004). They found that improved anatomic outcome correlated with improved functional outcomes. Eighty-seven percent no longer experienced obstructive defecation postoperatively. Significant improvements were seen in awareness of prolapse, obstructive defecation, straining to defecate, hard stools, dyspareunia, and digitations. Singh and colleagues reported on a prospective study of 42 women evaluated for bowel, sexual, urinary, and prolapse symptoms as well as anatomic outcomes after fascial plication technique (Singh et al, 2003). Sixty-five percent had improvement of the defecatory symptoms, and 38% had improvement of sexual discomfort. In contrast to the generalized repair of midline plication of the rectovaginal fascia, several authors have reported their experience with site-specific repair. Glavind and Madsen prospectively studied 67 patients who underwent a discrete repair (Glavind and Madsen, 2000). Of the 67 patients, 64 were found to have a discrete defect, which was repaired, and in 3 there was an attenuation of the tissue. At 3-month follow-up, 85% of those who reported bowel symptoms preoperatively reported resolution of symptoms. Porter and colleagues examined anatomic, functional, and QoL aspects of posterior colporrhaphy in a retrospective study (Porter et al, 1999). Improvement or cure was noted for pain or pressure, vaginal mass, splinting, and difficulty with defecation. Preoperative dyspareunia improved in 73% of patients, worsened in 19%, and occurred de novo in 3 patients. Emotional health also improved, specifically thoughts of embarrassment and frustration. Statistically significant symptom relief was noted in the realms of protrusion, manual evacuation, difficult defecation, and dyspareunia. At 1 year, 7 of 11 patients who had used manual evacuation preoperatively returned to doing so. The authors commented that this might have been the result of a functional decompensation of the rectum, which is not corrected surgically. Finally, Cundiff reported on the anatomic and functional aspects of discrete fascial defect repair of the posterior compartment (Cundiff et al, 1998). Splinting was eliminated in 63% of patients who reported this symptom preoperatively. The mean improvement did not correlate to the anatomic correction but did correlate with alleviation of defecatory symptoms, stressing the importance of symptom relief being of priority to the patient over anatomic correction. Interposition Graft Repairs of the Posterior Compartment Both synthetic mesh and biologic grafts have been used in posterior repairs, though data are lacking regarding routine use. Also, several authors caution against the use of synthetic materials in the posterior compartment owing to the potential for dyspareunia and visceral erosion, favoring the use of biologic grafts (Chen el at, 2007). Kohli and Miklos reported anatomic outcomes in 43 patients who underwent a site-specific repair with cadaveric dermis; 30 were available for evaluation at an average of 12. The graft was fixed proximally to the vaginal apex, laterally to the levator ani muscles, and distally to the perineal body. Ninety percent of those examined had a grade 0 rectocele by the Baden-Walker classification (Kobashi et al, 2005). Contrary to these encouraging results, Altman reported on 29 patients using collagen mesh for symptomatic rectocele (Altman et al, 2005). Twenty-three were available at 3-year follow-up; 41% had recurrence of stage 2 or greater, and 12 of 23 patients reported incomplete rectal evacuation. The researchers advocated further study before recommending the routine use of graft-augmented tissue repair. Fifty patients underwent posterior repair, 17 of whom had both anterior and posterior repair. In this descriptive study, 90 patients underwent loose placement of an interposition graft in the posterior compartment with no primary repair. Five patients with recurrence of the rectocele did not have prolapse in other compartments (Lim et al, 2005). When deciding on treatment options for the posterior compartment, both the surgeon and the patient should be aware that graft extrusion rates of 1. The proposed advantages of kits are a "less invasive" procedure, standardization of technique, standardization of mesh, and the ability to repair multiple compartments through a vaginal approach. The presence of the mesh at the level of the vaginal apex with fixation is in contrast to the traditional colporrhaphy and may provide correction to multiple compartments, thus making comparisons with traditional prolapse repairs challenging. Implanting surgeons must realize that these procedures are using a significantly higher volume of mesh than conventional mid-urethral slings, and some procedures involve placing trocars into the deep pelvic musculature.

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