Characteristics of circumferential vesico-vaginal fistulas: A cross-sectional and multicentric study

The objective of the study was to determine the risk factors for development of circumferential fistula. We carried out a crosssectional, multicentric and analytical study over 7 years period, from 1st January, 2010 to 31 December, 2016. We compared circumferential and non- circumferential fistula patients in order to determine the risk factors for circumferential fistula development. Circumferential fistula accounted for 20% (91/456) of all vesico-vaginal fistulas. The mean age of the 456 patients was 35.9 years±12.15 (min 15 years; max 72 years). On univariate analysis, factors associated with the risk of circumferential fistula were: residence (P=0.039; OR=1.7), parity (P=0.04; OR=0.47), marital status before fistula (P=0.002; 4.3), duration of labor (P=0.041; OR=2.7) and fistula aetiology (P=0.038; OR=2.54). In a logistic regression model, two factors remained significant: marital status before fistula (P=0.029; OR=0.13) and duration of labor (P=0.017; OR=0.26). Circumferential fistula occurs in urban, primiparous, unmarried women who have been in labor for more than 41 hours.

Giant leiomyoma of the urinary bladder: A case report

Urinary bladder leiomyoma is a rare tumour accounting for less than 0.5% of all urinary bladder tumours. Till now, less than 250 cases were documented with variable sizes, most of them were less than 10 cm in maximum diameter. Here we present a 68- year-old female patient with urinary bladder giant leiomyoma measuring about 13 cm. She presented with right loin pain. Postcontrast computed tomography of the abdomen and pelvis revealed a large posterolateral right-sided urinary bladder mass with moderate right hydroureteronephrosis. It was managed by partial cystectomy. The patient had an uneventful postoperative course. Postoperative pathological examination of the specimen confirmed giant leiomyoma of the urinary bladder.

Autologous mid-urethral fascial sling for stress urinary incontinence: Long term outcomes

There has been an increasing interest in mesh-free surgical options for Stress Urinary Incontinence (SUI). Traditionally rectus fascia autologous slings were placed at the bladder neck but more recently they are positioned at the mid-urethra (aMUS). The long-term outcomes for these patients are described. A retrospective analysis of aMUS patients between 2009-2014 by a single surgeon for primary SUI was performed. All patients were evaluated preoperatively with urodynamics. Patient reported outcomes were collected via postal questionnaire using the ICIQ-UI short-form questionnaire, 7-point Global Impression of Improvement score, questions on pad usage, self-catheterisation, overactive bladder treatment and re-operation rates. Results included 31 patients (response rate 63.8%). The median age was 49 years and median BMI was 27. Twenty-seven per cent (27%) of patients had stress predominant mixed urinary incontinence pre-operatively. Median length of follow up was 8 years (5- 11); 60% of patients were dry and pad-free. Seventy-seven per cent (77%) found the surgery led to “much improvement” or “very much improvement” in quality of life. Thirteen per cent (13%) of patients reported a deterioration in quality of life. The median ICIQ-UI short form score was 5.5. 16.7% were taking medication and 1 patient received botulinum toxin therapy for overactive bladder symptoms. All these patients had mixed urinary incontinence on preoperative urodynamics. The re-operation rate was 13.3%. One patient was selfcatheterising. Three out of 31 (10%) had experienced pelvic pain, with 2 out of 31 (6%) experiencing dyspareunia. AMUS shows good long-term continence outcomes and is associated with low rates of de-novo overactive bladder symptoms and voiding dysfunction.

Is hyacinth exercise better than pelvic floor exercise alone for urinary incontinence: A randomized trial

Urinary Incontinence (UI) negatively impact women’s physical, psychological and health-related quality of life. Pelvic strengthening exercise is the first line management in UI. We hypothesized that Hyacinth exercise is better than Pelvic Floor Exercise (PFE) in strengthening pelvic floor muscles, thus reducing female urinary incontinence. This randomized controlled trial involved 180 women with UI. Participants were taught on either Hyacinth exercise or PFE alone. Improvement in urinary symptoms and pelvic muscle strength were evaluated using a validated female pelvic floor questionnaire and objectively measured at 2 months and 6 months. Significant improvement in urinary symptoms and pelvic muscle strength post treatment at 2 months and 6 months was seen in both groups with p≤0.001. Although earlier improvement seen in Hyacinth group, it did not reach level of significant when compared, between the two exercises. Mean bladder score (PFE vs Hyacinth arm) 9.13±6.54 vs. 8.74±5.21, p=0.93 (2 months) and 5.80±4.15 vs. 5.79±4.22, p=0.92 (6 months). Although there was no statistical difference between the two groups for our primary and secondary outcomes, Hyacinth group demonstrated earlier improvement in urinary symptoms at 2 months.

Oral D mannose in the prevention and treatment of recurrent urinary tract infections: A review

The results of several studies reveal that antibiotics may promote treatment resistance by causing alterations in the intestinal flora. The development of a gut reservoir of resistant bacteria promotes the development of UTIs through autoinfection. This review aims to address clinical reliability, efficacy and safety of long-term treatment with oral D mannose for the prevention of Recurrent Urinary Tract Infections (RUTI) in females. A comprehensive MEDLINE, Embase, Scopus and Cochrane search was performed for English language reports published before December 2018 using the term “recurrent urinary tract infections and D mannose” was carried out. We searched Medline, Embase, Scopus and the Cochrane Register of Controlled Trials from January 2010 to December 2018. Eligible studies did not include non-oral therapy, local (vaginal) treatment in women with recurrent UTIs. We identified eligible original articles. A few limitations of the review are the heterogeneity of the available studies, their different rational and aim, the assumption of D mannose for prophylaxis or treatment of recurrent UTIs. Oral D mannose performs well in the prevention of UTIs recurrences, significant improvement of urinary symptoms was observed, the disease- free time was longer in the groups of patients under prophylaxis with D mannose in comparison with control groups (no treatment, antibiotic prophylaxis, prophylaxis with Proanthocyanidin (PAC) etc. The review has limitations, as the studies are heterogeneous, the meta-analysis requires classifications that can also be arbitrary. Furthermore, single-arm studies are not included. Some of the authors found this evidence inconclusive, which results as a limitation of the study. D mannose prolonged the recurrence-free interval of recurrent UTIs, thus reducing the prolonged or cyclical use of antibiotics, improving clinical symptoms, with a significant difference between treatment and control groups (no treatment, antibiotic prophylaxis, prophylaxis with Proanthocyanidin). However, most clinical trials used an association of different substances commingled with D mannose, dosages and regimens of D mannose were different. For this reason, the evidence of the efficacy of D mannose remains low.

Correlation of levator ani muscle strength measurement between Modified Oxford Grading Scale and perineometer on pelvic organ prolapse patient

Pelvic Organ Prolapse (POP) is a debilitating condition affecting about half of all women aged of more than 60 years globally. Reduced levator ani muscle strength in POP is associated with worse symptoms and prognosis. Measurement of levator ani muscle strength can be done with several tools such as perineometer and digital palpation. However, there is currently no study regarding conformity between tests. The aim of this study is to determine the correlation between tests in POP patients. An analytic observational study using cross sectional design was done to determine conformity between perineometer and digital examination using Modified Oxford Grading Scale (MOS) in Dr Cipto Mangunkusumo National General Hospital, Indonesia during the period of July, 2018 to June, 2020. Correlation between tests was determined using Spearman test. Cut-off of perineometer reading for each MOS score was also determined. A total of 110 subjects examined with both perineometer and digital palpation were recruited to the study. Positive correlation was observed between perineometer reading and Modified Oxford Grading Scale (r = 0.790, p < 0.001). According to the result, values between 0.01 – 9.64 cmH2O correspond to very weak pressure (MOS 1); 9.65 – 22.49 cmH2O represent weak pressure (MOS 2); 22.5 – 35.24 cmH2O represent moderate pressure (MOS 3); ≥ 35.25 cmH2O represent good pressure (MOS 4). There was a strong correlation between MOS and perineometer result for measuring levator ani strength in POP patients.

Urinary symptoms and urodynamic findings before and after vaginal surgery for pelvic organ prolapse

To ascertain the difference in urodynamic findings, specifically bladder sensation, and urinary symptoms after vaginal surgery for Pelvic Organ Prolapse (POP). Retrospective data analysis of 126 women who underwent vaginal surgery for POP without simultaneous anti-incontinence procedure from January 2013 to April 2019 at Siriraj Hospital, Thailand. Baseline characteristics, intraoperative details and pre and post-operative urinary symptoms and urodynamic findings were recorded. There was no significant difference in the pre and post-operative first desire to void, at 158±53 mL and 162±64 mL, respectively (p=0.518). Incidence of increased bladder sensation was also unchanged, from 46.0% to 46.8% (p=1.00). Post-operative urodynamic stress incontinence was significantly increased, from 15.9% to 31.0% (p=0.003), as was the incidence of weak bladder contractility index (<100), from 47.3% to 61.8% (p=0.005). Significant improvements in post-operative urge urinary incontinence, urgency and voiding dysfunction were noted, from 50.8% to 31.7% (p=0.001), 63.5% to 38.9% (p<0.001) and 42.9% to 5.6% (p<0.001), respectively. No significant difference in bladder sensation after vaginal surgery for POP repair was noted. However, urinary symptoms significantly improved after surgery.

A retrospective evaluation after insertion of the MicroGYNious single incision sling in cases of stress urinary incontinence

In the literature the rate of stress incontinence is reported between 29-75%. Compared to the established tension free vaginal tapes, the question arises, whether stabilization of the urethra can also be achieved by minimally invasive single incision slings. The aim of this retrospective analysis is to evaluate the cure rate after insertion of MicroGYNious sling. The study was carried out on 115 patients, who received a MicroGYNious sling. It was used both as a single operation for stress urinary incontinence and as a combined procedure. The degree of incontinence preoperatively and continence rate postoperatively with follow-ups (6 weeks, 6 months, one year, two years and three years) were recorded. Due to a high number of lost to follow-up after one year, only the data up to one year postoperative were included in the analysis. Preoperatively, grade I incontinence was found in 6.1%, grade II 35.7%, grade III 58.3% of the operated women. The continence rate was 96.7% postoperatively, 90 % after 6 weeks, 87.2 % after 6 months, 86.7% after one year. In terms of continence rates, the MicroGYNious sling shows similar results compared to the established procedures. Therefore, this sling provides a good treatment option for the stress urinary incontinence. These good results must be confirmed in prospective randomized trials.

Transvaginal subfascial synthetic mesh sling in female stress urinary incontinence: A Novel technique

The object of this paper is to assess the treatment outcome and overall efficacy of a novel technique of transvaginal subfascial synthetic mesh for female stress urinary incontinence. The study included 53 patients of female stress urinary incontinence managed at our institution between March 2005 and December 2015. Preoperative evaluation included a detailed history, base-line investigations and cystoscopic examination including stress test, uroflometry with residual urine was done in all cases. Lower urinary tract imaging and urodynamic evaluation was done in selected cases . patients with concomitant pelvic organ prolapse and severe BMI were excluded from the study. All patients underwent a transvaginal subfascial sling procedure under regional anesthesia. Urethral catheter was removed the day after procedure. Post procedure results were assessed in terms of improvement in stress urinary incontinence, procedure related complications, and overall satisfaction of the patient. Mean age of the patients was 43.5 years (25-63 years). All patients were multiparous. Complete resolution of symptoms in 49 patients (92.4%) while in 4 patients (7.5%) had some degree of SUI. Urinary retention in 3 (5.6%), increased frequency in 5 (9.4%) patients and urge incontinence in 2 (3.7%) One (1.8%) had mesh erosion at 3 months after the procedure. None of the patient had any sexual dysfunction on follow up. Overall success rate of the procedure was around 93%.However patients with preoperatively urge incontinence needs anticholinergics in post operative period for 1-2 months. Operative time was 30-45 minutes. Three patients (5.6%) who experience transient postoperative retention had no symptoms of SUI on follow up. Transvaginal subfascial sling is a modification of the original mid urethral sling procedure with an advantage of being less invasive, simpler to learn and achieve similar results compared to other sling procedures.

Vesico-vaginal fistula: A clinical study

In a retrospective study, the records of 34 women with a mean ± SD age of the patients was 36.62 ± 9.02 years were assessed; 32.35% of the vesico-vaginal Fistula (VVF) occurred after abdominal hysterectomy, 11.77% after Caesarean section, 32.35% after difficult vaginal delivery and 23.53% after instrumental delivery. Six women (17.64%) had a previous failed repair. The duration (mean ± SD) of the VVF was 5.68 ± 1.59 months. Of the 34 VVF patients, 20 (58.82%) were Mid-Vaginal VVF, 8 (23.53%) were Circumferential VVF, 3 (8.82%) were Juxta cervical VVF and 3 (8.82%) were Juxta Urethral VVF. An abdominal approach was used in 21 cases (61.76%), vaginal repair was contemplated in 8 (23.53%) cases and Laparoscopic in 5 (14.71%). At a mean duration of follow-up was 33.06 ± 1.72 months and the VVF was cured in 28 (82.4%) patients. Only previous intervention and timing of surgery (P=0.004) and surgical approach (P=0.02) maintained significance in our study. An abdominal/ Laparoscopic approach seems to give superior results. Previous failed repair had a significant negative effect on success. A late repair (≥6 months) is associated with higher success rates.