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Dyspareunia associated with paraurethral banding in the transobturator sling
Letters to the Editors 2. Nick AM, Bruner JP, Moses R, Yang EY, Scott TA. Second-trimester intraabdominal bowel dilation in fetuses with gastroschisis predicts neonatal bowel atresia. Ultrasound Obstet Gynecol 2006;28:821-5. 3. Parulekar SG. Sonography of normal fetal bowel. J Ultrasound Med 1991;10:211-20. © 2010 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2010.06.074
REPLY We appreciate the comments by Salomon et al regarding our analysis of the association of prenatal intraabdominal bowel dilation (IBD) with postnatal bowel complications. It is agreed that prenatal IBD may prove to be a useful prognostic factor of outcomes for which its utility as a diagnostic marker has not yet been characterized fully. Our conclusions in our analysis highlight IBD—in particular, multiple loops of IBD—as a potential important diagnostic marker that should be investigated in future, prospective, larger cohort studies. Our analysis suggests an association between these variables but does not imply a pathophysiologic relationship nor infer a causational relationship between IBD and bowel complications. In our large, retrospective study of consecutive fetuses with gastroschisis, our analysis suggests that IBD is associated with postnatal gastrointestinal complications in fetuses with gastroschisis. One of the points that Salomon et al raises is that IBD was detected in both the second or third trimester. Because this was a retrospective review, time-dependent and actuarial data after the progression or resolution of IBD could not be evaluated in a retrospective manner. Hence, we analyzed all fetuses that demonstrated any IBD at any time point and reported on their clinical outcomes.
www.AJOG.org Our analysis highlights IBD as an important prognostic factor that needs further investigation in prospective, large cohort studies. Retrospective analysis identifies important variables that can be studied in blinded prospective studies. Because of the rare nature of gastroschisis, a metaanalysis may be required to aggregate the statistical power to make critical insights to this disease. The most important finding in our analysis was the potential association of multiple loops of IBD with postnatal complications. In our analysis, which compared fetuses with multiple loops of IBD with a single loop, multiple loops of IBD were associated significantly with an increased rate of complications. This potential prognostic factor of multiple IBD loops has not been investigated previously in a large, consecutive series of fetuses, such as we investigated in our study. Last, we agree with Salomon et al that IBD, as suggested in our analysis, may be associated with worse outcomes and may require that fetuses be observed in a closer manner, with possible intensive care, and that these interventions with these findings may ultimately improve care for fetuses with IBD and gastroschisis. We thank our colleagues for their comment and hope that our contribution highlights in this retrospective, consecutive, large cohort study an association of IBD with bowel complications and demonstrates the further need to evaluate IBD and gastroschisis in prospective, large cohort studies. f Nancy G. Huh, MD University of California San Francisco Radiology 505 Parnassus Ave. San Francisco, CA 94143 © 2010 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2010.06.075
Dyspareunia associated with paraurethral banding in the transobturator sling TO THE EDITORS: We read with interest the recent work by Cholhan et al.1 They introduced a phenomenon they call paraurethral banding, which are palpable bands in the urethral folds. This is an interesting observation that might be helpful in understanding dyspareunia after sling operations.2 The results showed that postoperatively 4 of the 25 patients in the transobturator group complained of de novo dyspareunia, compared with no dyspareunia complaints in the retropubic group (P ⫽ .04). Furthermore, paraurethral banding was observed only in the transobturator procedure (P ⬍ .001). This is an important message. However, the complaints of dyspareunia should be compared only within sexually active patients (24% vs 0%). The 4 women with de novo dyspareunia not only underwent the transobturator procedure alone but also 3 of them had undergone concurrent surgery. These concurrent surgeries may have contributed to the de novo complaints of dyspareunia and therefore should have been listed for both groups in their Table 1. e10
American Journal of Obstetrics & Gynecology DECEMBER 2010
The female sexual function index (FSFI) was used to assess sexual function and was performed only after the operation. The FSFI of the transobturator vs retropubic group showed no significant difference postoperatively, although 3 of the patients in the transobturator group had a FSFI pain score of 0. The writers described the inadequate power as a reason. If we look carefully at the data in their Table 3, the transobturator evaluation was performed in 25 patients after the operation; however, in their Table 3, 17 patients were described as sexually active. In the retropubic group, 16 patients were preoperatively sexually active, and 5 patients became sexually active postoperatively. The best evaluation is to compare the pre- and postoperative FSFI pain score of both groups. It is possible that the pre-FSFI pain score of the transobturator group was initially higher than the retropubic group. Then, the difference in preand postoperative FSFI scores between both groups is probably significant.
Letters to the Editors
www.AJOG.org Another important matter that was not discussed in the article is incontinence during intercourse; coital incontinence is a prognostic factor for improvement of sexual function after incontinence surgery.3 Without the important information of coital incontinence and a preoperative FSFI, we think that the postoperative evaluation with the FSFI has no value and leads only to discussion. Future research should be performed to further determine what exactly paraurethral banding is, if it is caused by the transobturator procedure, and if it is correlated with the patients complaints of dyspareunia. We look forward to the results of f this future research. Henk Willem Elzevier, MD, PhD Milou Dieuwertje Bekker, MD Department of Urology Leiden University Medical Center PO Box 9600 2300 RC, Leiden, the Netherlands [email protected] REFERENCES 1. Cholhan HJ, Hutchings TB, Rooney KE. Dyspareunia associated with paraurethral banding in the transobturator sling. Am J Obstet Gynecol 2010;202:481-5. 2. Elzevier HW, Putter H, Delaere KP, Venema PL, Nijeholt AA, Pelger RC. Female sexual function after surgery for stress urinary incontinence: transobturator suburethral tape vs tension-free vaginal tape obturator. J Sex Med 2008;5:400-6. 3. Bekker M, Beck J, Putter H, et al. Sexual function improvement following surgery for stress incontinence: the relevance of coital incontinence. J Sex Med 2009;6:3208-13. © 2010 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2010.07.006
REPLY We appreciate the interest in our article by Drs Elzevier and Bekker. As we stated in our article, this project was brought about by observing paraurethral banding in some of our patients with a transobturator sling.1 The commentators bring up the point that the de novo dyspareunia that 3 of our 4 patients with a transobturator sling reported could have been caused by the concurrent prolapse surgery. We did list the concurrent prolapse surgeries, none of which were specifically on the anterior compartment and none of which could have caused the paraurethral banding that we observed. Additionally, we objectively identified the source of the dyspareunia as the paraurethral bands. Furthermore, comprehensive physical examination demonstrated no other areas of discomfort in these patients. There was no difference between the 2 groups in the number or types of concurrent sur-
geries. De novo dyspareunia was reported in only 4 patients, all of whom displayed paraurethral banding. Coital incontinence is certainly an important issue that relates to satisfaction after surgery for stress urinary incontinence.2 However, the aim of our study was not to look for satisfaction or overall sexual function but to report specifically the paraurethral banding caused by the transobturator sling and to determine whether dyspareunia was experienced because of these bands. We agree that, with the addition of preoperative female sexual function index scores, we may have been able to show statistical differences in the pain scores between the 2 groups. However, this is not possible, given the retrospective nature of this study. Like many of the studies on sexual function that have been published, which include works by the commentator, this study lacks preoperative information on sexual function.3 However, we certainly do not believe that this article or other similar articles are of “no value.” The discussion that has been generated, the questions that have been formulated, and the future research that will be developed, not to mention the findings and conclusions from the article itself, certainly speak to the value of this kind of work. As Drs Elzevier and Bekker noted, the message that paraurethral banding was found only in patients that received transobturator slings is important. We found in our study that these bands contributed to a substantial (24%) dyspareunia rate. We recommend a careful inspection of the anterior vaginal wall and consideration of the likelihood of the development of paraurethral bands in preoperative management. We also look forward to additional research in this area to add to the underf standing of this potentially troublesome complication. Timothy B. Hutchings, DO Hilary J. Cholhan, MD Kristin E. Rooney, MD Women’s Continence Center of Greater Rochester 500 Helendale Ave., Ste. 265 Rochester, NY 14609 [email protected] REFERENCES 1. Cholhan HJ, Hutchings, TB, Rooney KE. Dyspareunia associated with paraurethral banding in transobturator sling. Am J Obstet Gynecol 2010;202:481-5. 2. Bekker M, Beck J, Putter H, et al. Sexual function improvement following surgery for stress incontinence: the relevance of coital incontinence. J Sex Med 2009;6:3208-13. 3. Elzevier HW, Putter H, Delaere K, Venema PL, Nijeholt L, Pelger RCM. Female sexual function after surgery for stress urinary incontinence: transobturator suburethral tape vs tension-free vaginal tape obturator. J Sex Med 2008;5:400-6. © 2010 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2010.07.005
DECEMBER 2010 American Journal of Obstetrics & Gynecology
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REPLY We appreciate the comments by Salomon et al regarding our analysis of the association of prenatal intraabdominal bowel dilation (IBD) with postnatal bowel complications. It is agreed that prenatal IBD may prove to be a useful prognostic factor of outcomes for which its utility as a diagnostic marker has not yet been characterized fully. Our conclusions in our analysis highlight IBD—in particular, multiple loops of IBD—as a potential important diagnostic marker that should be investigated in future, prospective, larger cohort studies. Our analysis suggests an association between these variables but does not imply a pathophysiologic relationship nor infer a causational relationship between IBD and bowel complications. In our large, retrospective study of consecutive fetuses with gastroschisis, our analysis suggests that IBD is associated with postnatal gastrointestinal complications in fetuses with gastroschisis. One of the points that Salomon et al raises is that IBD was detected in both the second or third trimester. Because this was a retrospective review, time-dependent and actuarial data after the progression or resolution of IBD could not be evaluated in a retrospective manner. Hence, we analyzed all fetuses that demonstrated any IBD at any time point and reported on their clinical outcomes.
www.AJOG.org Our analysis highlights IBD as an important prognostic factor that needs further investigation in prospective, large cohort studies. Retrospective analysis identifies important variables that can be studied in blinded prospective studies. Because of the rare nature of gastroschisis, a metaanalysis may be required to aggregate the statistical power to make critical insights to this disease. The most important finding in our analysis was the potential association of multiple loops of IBD with postnatal complications. In our analysis, which compared fetuses with multiple loops of IBD with a single loop, multiple loops of IBD were associated significantly with an increased rate of complications. This potential prognostic factor of multiple IBD loops has not been investigated previously in a large, consecutive series of fetuses, such as we investigated in our study. Last, we agree with Salomon et al that IBD, as suggested in our analysis, may be associated with worse outcomes and may require that fetuses be observed in a closer manner, with possible intensive care, and that these interventions with these findings may ultimately improve care for fetuses with IBD and gastroschisis. We thank our colleagues for their comment and hope that our contribution highlights in this retrospective, consecutive, large cohort study an association of IBD with bowel complications and demonstrates the further need to evaluate IBD and gastroschisis in prospective, large cohort studies. f Nancy G. Huh, MD University of California San Francisco Radiology 505 Parnassus Ave. San Francisco, CA 94143 © 2010 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2010.06.075
Dyspareunia associated with paraurethral banding in the transobturator sling TO THE EDITORS: We read with interest the recent work by Cholhan et al.1 They introduced a phenomenon they call paraurethral banding, which are palpable bands in the urethral folds. This is an interesting observation that might be helpful in understanding dyspareunia after sling operations.2 The results showed that postoperatively 4 of the 25 patients in the transobturator group complained of de novo dyspareunia, compared with no dyspareunia complaints in the retropubic group (P ⫽ .04). Furthermore, paraurethral banding was observed only in the transobturator procedure (P ⬍ .001). This is an important message. However, the complaints of dyspareunia should be compared only within sexually active patients (24% vs 0%). The 4 women with de novo dyspareunia not only underwent the transobturator procedure alone but also 3 of them had undergone concurrent surgery. These concurrent surgeries may have contributed to the de novo complaints of dyspareunia and therefore should have been listed for both groups in their Table 1. e10
American Journal of Obstetrics & Gynecology DECEMBER 2010
The female sexual function index (FSFI) was used to assess sexual function and was performed only after the operation. The FSFI of the transobturator vs retropubic group showed no significant difference postoperatively, although 3 of the patients in the transobturator group had a FSFI pain score of 0. The writers described the inadequate power as a reason. If we look carefully at the data in their Table 3, the transobturator evaluation was performed in 25 patients after the operation; however, in their Table 3, 17 patients were described as sexually active. In the retropubic group, 16 patients were preoperatively sexually active, and 5 patients became sexually active postoperatively. The best evaluation is to compare the pre- and postoperative FSFI pain score of both groups. It is possible that the pre-FSFI pain score of the transobturator group was initially higher than the retropubic group. Then, the difference in preand postoperative FSFI scores between both groups is probably significant.
Letters to the Editors
www.AJOG.org Another important matter that was not discussed in the article is incontinence during intercourse; coital incontinence is a prognostic factor for improvement of sexual function after incontinence surgery.3 Without the important information of coital incontinence and a preoperative FSFI, we think that the postoperative evaluation with the FSFI has no value and leads only to discussion. Future research should be performed to further determine what exactly paraurethral banding is, if it is caused by the transobturator procedure, and if it is correlated with the patients complaints of dyspareunia. We look forward to the results of f this future research. Henk Willem Elzevier, MD, PhD Milou Dieuwertje Bekker, MD Department of Urology Leiden University Medical Center PO Box 9600 2300 RC, Leiden, the Netherlands [email protected] REFERENCES 1. Cholhan HJ, Hutchings TB, Rooney KE. Dyspareunia associated with paraurethral banding in the transobturator sling. Am J Obstet Gynecol 2010;202:481-5. 2. Elzevier HW, Putter H, Delaere KP, Venema PL, Nijeholt AA, Pelger RC. Female sexual function after surgery for stress urinary incontinence: transobturator suburethral tape vs tension-free vaginal tape obturator. J Sex Med 2008;5:400-6. 3. Bekker M, Beck J, Putter H, et al. Sexual function improvement following surgery for stress incontinence: the relevance of coital incontinence. J Sex Med 2009;6:3208-13. © 2010 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2010.07.006
REPLY We appreciate the interest in our article by Drs Elzevier and Bekker. As we stated in our article, this project was brought about by observing paraurethral banding in some of our patients with a transobturator sling.1 The commentators bring up the point that the de novo dyspareunia that 3 of our 4 patients with a transobturator sling reported could have been caused by the concurrent prolapse surgery. We did list the concurrent prolapse surgeries, none of which were specifically on the anterior compartment and none of which could have caused the paraurethral banding that we observed. Additionally, we objectively identified the source of the dyspareunia as the paraurethral bands. Furthermore, comprehensive physical examination demonstrated no other areas of discomfort in these patients. There was no difference between the 2 groups in the number or types of concurrent sur-
geries. De novo dyspareunia was reported in only 4 patients, all of whom displayed paraurethral banding. Coital incontinence is certainly an important issue that relates to satisfaction after surgery for stress urinary incontinence.2 However, the aim of our study was not to look for satisfaction or overall sexual function but to report specifically the paraurethral banding caused by the transobturator sling and to determine whether dyspareunia was experienced because of these bands. We agree that, with the addition of preoperative female sexual function index scores, we may have been able to show statistical differences in the pain scores between the 2 groups. However, this is not possible, given the retrospective nature of this study. Like many of the studies on sexual function that have been published, which include works by the commentator, this study lacks preoperative information on sexual function.3 However, we certainly do not believe that this article or other similar articles are of “no value.” The discussion that has been generated, the questions that have been formulated, and the future research that will be developed, not to mention the findings and conclusions from the article itself, certainly speak to the value of this kind of work. As Drs Elzevier and Bekker noted, the message that paraurethral banding was found only in patients that received transobturator slings is important. We found in our study that these bands contributed to a substantial (24%) dyspareunia rate. We recommend a careful inspection of the anterior vaginal wall and consideration of the likelihood of the development of paraurethral bands in preoperative management. We also look forward to additional research in this area to add to the underf standing of this potentially troublesome complication. Timothy B. Hutchings, DO Hilary J. Cholhan, MD Kristin E. Rooney, MD Women’s Continence Center of Greater Rochester 500 Helendale Ave., Ste. 265 Rochester, NY 14609 [email protected] REFERENCES 1. Cholhan HJ, Hutchings, TB, Rooney KE. Dyspareunia associated with paraurethral banding in transobturator sling. Am J Obstet Gynecol 2010;202:481-5. 2. Bekker M, Beck J, Putter H, et al. Sexual function improvement following surgery for stress incontinence: the relevance of coital incontinence. J Sex Med 2009;6:3208-13. 3. Elzevier HW, Putter H, Delaere K, Venema PL, Nijeholt L, Pelger RCM. Female sexual function after surgery for stress urinary incontinence: transobturator suburethral tape vs tension-free vaginal tape obturator. J Sex Med 2008;5:400-6. © 2010 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2010.07.005
DECEMBER 2010 American Journal of Obstetrics & Gynecology
e11