- Email: [email protected]
Pregenzer–schwartz procedure for cystourethrocele
questions missed. As physicians and health care providers, patients can only be treated when their needs are understood.
Histologic Results of a New Treatment for Stress Urinary Incontinence without Implantable Materials Donald L. Galen, MD Reproductive Science Center of the Bay Area, San Ramon, CA Objective: Collagen in tissue such as endopelvic fascia shrinks when heated. A new method to treat stress urinary incontinence using collagen shrinkage to lift the urethra and bladder neck without the use of implantable materials has shown promising efficacy. This study reports histologic findings from animal and IDE clinical trials after thermal treatment. Methods: Tests on animal that the fascia were conducted using a probe to deliver radiofrequency energy. Animal samples were histologically evaluated to determine strength at 0, 7, 21, and 42 days posttreatment. Also, tissue samples from two patients who had thermal urethroplasty were analyzed 6 months posttreatment. Results: Animal tests showed fascia shrinks upon thermal treatment and does not restretch during the healing time of 42 days. Tissue strength followed previously published healing curves for electrocautery treatments. Systematic treatment methodology showed tissue shrinkage ranged from 25% to 50%. Histologic samples at 6-month patient follow-up showed normal tissue had regenerated. No adhesions were observed. Conclusions: Shrinkage of endopelvic fascia using radiofrequency energy results in normal collagen formation and healing very similar to published data. This treatment holds promise for the successful treatment of stress urinary incontinence without implantable materials.
Foley Catheterization in the Postoperative Patient Terry S. Dunn, MD Denver Health Medical Center, Denver, CO
Dave Forshner, MD, and Carol Stamm, MD Objective: Foley catheters are used routinely in gynecologic surgery. We wanted to address the issue of whether this was necessary and affected patient outcome. The question asked in this study is, “Does early removal of the Foley catheter after pelvic surgery affect recatheterization, febrile morbidity, symptomatic urinary tract infections, and patient comfort?” Methods: This is a prospective randomized clinical trial conducted at a university teaching hospital on all patients undergoing hysterectomy or cesarean delivery, not requiring
30S Monday Posters
bladder suspension or strict fluid management. The Foley catheter was either removed immediately, postoperatively, or on the first postoperative day. The variables studied were recatheterization, febrile morbidity, symptomatic urinary tract infections, and pain. Results: Seventy-eight patients were included in this trial. Twenty-nine patients underwent a cesarean delivery, 38 patients underwent a vaginal hysterectomy, and 11 patients underwent abdominal hysterectomy. The outcome for these patients are as follows: in all cases only five patients had a fever, P value was nonsignificant, two patients had urinary tract infections with a P value that is nonsignificant, and recatheterization occurred in five patients (P value of 0.17). The level of pain was measured using a standardized pain scale, described as mild, moderate, or severe. Evaluating all cases, n ⫽ 78 (P ⫽ 0.001), patients had significantly less pain with early removal of the Foley catheter. The same was true when done for all cesarean hysterectomies; the pain was significantly less (0.001) in the early removal group. There were no patients with severe pain in the early removal group. Conclusions: Patients who had the Foley catheter removed immediately following surgery had no increase in fever, urinary tract infections, or incidence of recatheterization. There was also significantly less pain in the early removal group. In some patients, the Foley catheter is not required in the postoperative period and patients report less discomfort.
Pregenzer–Schwartz Procedure for Cystourethrocele Gerard J. Pregenzer, MD Somerset Hospital, Warren, NJ Objective: Modification of the Schwartz-Pregenzer urethropexy in the presence of genuine stress incontinence and concomitant cystole utilizing polyprolene mesh graft and a laparoscopic stapler. Methods: Of the 80 women who underwent a Schwartz– Pregenzer urethropexy for a hypermobile urethra and stress incontinence, 15 also had significant paravaginal lateral wall defect. To correct this defect, the usual 1 ⫻ 3 cm mesh was cut in the shape of an L, measuring 3 ⫻ 4 cm. The long part of the polyprolene mesh was placed adjacent to the urethra. A laparoscopic stapler was used to staple the mesh about 1 cm from the urethra on the vaginal fascia. The mesh was then elevated and stapled to the arcus tendinus. We then proceeded with the Schwartz–Pregenzer urethropexy and the procedure was completed. Results: All of the 15 patients (aged 31–79 years) who underwent this modification of the Schwartz–Pregenzer urethropexy have had excellent results. There has been excellent elevation of the anterior vaginal wall with full resolution of cystourethrocele. Average operative time was 30 minutes (range 17– 45 min). Blood loss was less than 25 mL. Our follow-up is currently up to 12 months with the Pregenzer– Schwartz procedure. All are very satisfied with the results.
Obstetrics & Gynecology
Conclusions: Because cystocele in the presence of bladder neck hypermobility requires correction for long-term success in treating genuine stress incontinence, our modification and use of mesh and stapler avoids the pitfalls of suturing and the invasiveness of vaginal repair while retaining the benefits of low morbidity, same day surgery, and rapid recovery with a cure for genuine stress incontinence and cystourethrocele.
Schwartz–Pregenzer Urethropexy Marlan Schwartz, MD Somerset Hospital, Warren, NJ Objective: To report the results of our laparoscopic urethropexy using polypropylene mesh graft and laparoscopic stapler. Methods: Women with hypermobile proximal urethra and genuine stress incontinence underwent direct video laparoscopic extraabdominal bladder neck suspension. A 1 ⫻ 3 cm piece of polypropylene mesh was placed in the space of Retzius and stapled to the bladder neck using about 5– 6 staples over a wide area to ensure appropriate elevation and then stapled to the ipsilateral Cooper’s ligament. Results: Eighty women (aged 31–79 years) underwent the Schwartz–Pregenzer urethropexy over a 4-year period. The average blood loss was less than 25 mL (range 20 –100 mL) and the average operative time 25 minutes (range 13– 45 min). Most patients are discharged 4 – 6 hours after surgery. Success was defined as a negative cotton swab test result and remaining continent. Over an average follow-up of 36 months, the procedure has resulted in satisfactory urethrovesical support in 78 women with an overall success of greater than 98%. Conclusions: The Schwartz–Pregenzer urethropexy offers a rapid, cost-effective, efficient, and effective cure for genuine stress incontinence. It also has very low morbidity and shorter hospitalization and recovery time when compared with open and other laparoscopic techniques.
Laparoscopically Assisted Vaginal Hysterectomy with Morcellation of the Large Uterus Marlan Schwartz, MD Somerset Hospital, Warren, NJ Objective: Laparoscopic removal of large uteri (200⫹ g) can be performed safely utilizing 2 or 3 cannula sites without exceeding 10 mm. Methods: Laparoscopic hysterectomies and laparoscopically assisted vaginal hysterectomies were performed on 65 women ages 35–55 years. The surgical specimens’ weight range was 220 –910 g. An electric morcellator was used to facilitate removal in 60 patients. Thirty-seven cases were performed
VOL. 95, NO. 4 (SUPPLEMENT), APRIL 2000
using a 2 trocar technique, whereas 28 cases used two 5 mm trocars and one 10 mm for morcellation. Bipolar cautery was used in all cases. Results: Over a 5-year period, 65 patients underwent laparoscopic removal of a large uterus. Most of the time a morcellator was used to remove the specimen. Operative times ranged from 90 minutes to 4 hours. Blood loss was typically less than 100 mL. Sixty patients were discharged the next day, whereas five were discharged on the second postoperative day. Postoperative pain was minimal. Conclusions: Laparoscopic removal of large uteri with the aid of the electric morcellator is a safe and cosmetic method of performing hysterectomy with low morbidity, shorter recovery times, and a more rapid return to daily activity when compared with other approaches.
A Comparison of Two Saline Infusion Sonography Catheters Jill T. Snyder, DO St. Luke’s Hospital, Bethlehem, PA
James Anasti, MD Objective: To compare a low-cost, nonballoon tip catheter to a more expensive balloon tip catheter in the performance of saline infusion sonography (SIS). Saline infusion sonography has been the focus of several studies in the field of gynecology. The majority of these utilized various balloon tip catheters. A successful SIS depends on a reliable infusion catheter. Although many types of catheters are used, no comparisons on the effectiveness of different catheters have been reported. Methods: Women between the ages of 18 – 80 years who presented to a community hospital clinic with dysfunctional uterine bleeding were eligible for the study. Premenopausal women underwent saline infusion sonography if they failed traditional medical therapy. Postmenopausal women had the procedure as part of their initial workup. All women had the procedure performed by one investigator using the nonballoon tip catheter first. If the images were inadequate, the balloon tip catheter was then used. Adequacy was determined by complete visualization of the endometrial cavity. Results: Twenty-three patients were eligible. The mean age was 45.2, parity 2.6, endometrial cavity size 7.4. Five patients failed both catheters (2 with cervical stenosis and 3 with intolerance to either catheter). Of the remaining 18 patients, 13 (72%) had an adequate study utilizing the nonballoon catheter. Of the 5 nonballoon tip failures, all had successful studies utilizing the balloon tip catheter. Of note, these 5 patients had significantly more discomfort with the balloon tip catheter. Conclusions: The nonballoon tip catheter is a low-cost comparable alternative to the balloon tip catheter in the performance of saline infusion sonography. Our preliminary results suggest a higher patient tolerance for the nonballoon catheter.
Monday Posters 31S
Histologic Results of a New Treatment for Stress Urinary Incontinence without Implantable Materials Donald L. Galen, MD Reproductive Science Center of the Bay Area, San Ramon, CA Objective: Collagen in tissue such as endopelvic fascia shrinks when heated. A new method to treat stress urinary incontinence using collagen shrinkage to lift the urethra and bladder neck without the use of implantable materials has shown promising efficacy. This study reports histologic findings from animal and IDE clinical trials after thermal treatment. Methods: Tests on animal that the fascia were conducted using a probe to deliver radiofrequency energy. Animal samples were histologically evaluated to determine strength at 0, 7, 21, and 42 days posttreatment. Also, tissue samples from two patients who had thermal urethroplasty were analyzed 6 months posttreatment. Results: Animal tests showed fascia shrinks upon thermal treatment and does not restretch during the healing time of 42 days. Tissue strength followed previously published healing curves for electrocautery treatments. Systematic treatment methodology showed tissue shrinkage ranged from 25% to 50%. Histologic samples at 6-month patient follow-up showed normal tissue had regenerated. No adhesions were observed. Conclusions: Shrinkage of endopelvic fascia using radiofrequency energy results in normal collagen formation and healing very similar to published data. This treatment holds promise for the successful treatment of stress urinary incontinence without implantable materials.
Foley Catheterization in the Postoperative Patient Terry S. Dunn, MD Denver Health Medical Center, Denver, CO
Dave Forshner, MD, and Carol Stamm, MD Objective: Foley catheters are used routinely in gynecologic surgery. We wanted to address the issue of whether this was necessary and affected patient outcome. The question asked in this study is, “Does early removal of the Foley catheter after pelvic surgery affect recatheterization, febrile morbidity, symptomatic urinary tract infections, and patient comfort?” Methods: This is a prospective randomized clinical trial conducted at a university teaching hospital on all patients undergoing hysterectomy or cesarean delivery, not requiring
30S Monday Posters
bladder suspension or strict fluid management. The Foley catheter was either removed immediately, postoperatively, or on the first postoperative day. The variables studied were recatheterization, febrile morbidity, symptomatic urinary tract infections, and pain. Results: Seventy-eight patients were included in this trial. Twenty-nine patients underwent a cesarean delivery, 38 patients underwent a vaginal hysterectomy, and 11 patients underwent abdominal hysterectomy. The outcome for these patients are as follows: in all cases only five patients had a fever, P value was nonsignificant, two patients had urinary tract infections with a P value that is nonsignificant, and recatheterization occurred in five patients (P value of 0.17). The level of pain was measured using a standardized pain scale, described as mild, moderate, or severe. Evaluating all cases, n ⫽ 78 (P ⫽ 0.001), patients had significantly less pain with early removal of the Foley catheter. The same was true when done for all cesarean hysterectomies; the pain was significantly less (0.001) in the early removal group. There were no patients with severe pain in the early removal group. Conclusions: Patients who had the Foley catheter removed immediately following surgery had no increase in fever, urinary tract infections, or incidence of recatheterization. There was also significantly less pain in the early removal group. In some patients, the Foley catheter is not required in the postoperative period and patients report less discomfort.
Pregenzer–Schwartz Procedure for Cystourethrocele Gerard J. Pregenzer, MD Somerset Hospital, Warren, NJ Objective: Modification of the Schwartz-Pregenzer urethropexy in the presence of genuine stress incontinence and concomitant cystole utilizing polyprolene mesh graft and a laparoscopic stapler. Methods: Of the 80 women who underwent a Schwartz– Pregenzer urethropexy for a hypermobile urethra and stress incontinence, 15 also had significant paravaginal lateral wall defect. To correct this defect, the usual 1 ⫻ 3 cm mesh was cut in the shape of an L, measuring 3 ⫻ 4 cm. The long part of the polyprolene mesh was placed adjacent to the urethra. A laparoscopic stapler was used to staple the mesh about 1 cm from the urethra on the vaginal fascia. The mesh was then elevated and stapled to the arcus tendinus. We then proceeded with the Schwartz–Pregenzer urethropexy and the procedure was completed. Results: All of the 15 patients (aged 31–79 years) who underwent this modification of the Schwartz–Pregenzer urethropexy have had excellent results. There has been excellent elevation of the anterior vaginal wall with full resolution of cystourethrocele. Average operative time was 30 minutes (range 17– 45 min). Blood loss was less than 25 mL. Our follow-up is currently up to 12 months with the Pregenzer– Schwartz procedure. All are very satisfied with the results.
Obstetrics & Gynecology
Conclusions: Because cystocele in the presence of bladder neck hypermobility requires correction for long-term success in treating genuine stress incontinence, our modification and use of mesh and stapler avoids the pitfalls of suturing and the invasiveness of vaginal repair while retaining the benefits of low morbidity, same day surgery, and rapid recovery with a cure for genuine stress incontinence and cystourethrocele.
Schwartz–Pregenzer Urethropexy Marlan Schwartz, MD Somerset Hospital, Warren, NJ Objective: To report the results of our laparoscopic urethropexy using polypropylene mesh graft and laparoscopic stapler. Methods: Women with hypermobile proximal urethra and genuine stress incontinence underwent direct video laparoscopic extraabdominal bladder neck suspension. A 1 ⫻ 3 cm piece of polypropylene mesh was placed in the space of Retzius and stapled to the bladder neck using about 5– 6 staples over a wide area to ensure appropriate elevation and then stapled to the ipsilateral Cooper’s ligament. Results: Eighty women (aged 31–79 years) underwent the Schwartz–Pregenzer urethropexy over a 4-year period. The average blood loss was less than 25 mL (range 20 –100 mL) and the average operative time 25 minutes (range 13– 45 min). Most patients are discharged 4 – 6 hours after surgery. Success was defined as a negative cotton swab test result and remaining continent. Over an average follow-up of 36 months, the procedure has resulted in satisfactory urethrovesical support in 78 women with an overall success of greater than 98%. Conclusions: The Schwartz–Pregenzer urethropexy offers a rapid, cost-effective, efficient, and effective cure for genuine stress incontinence. It also has very low morbidity and shorter hospitalization and recovery time when compared with open and other laparoscopic techniques.
Laparoscopically Assisted Vaginal Hysterectomy with Morcellation of the Large Uterus Marlan Schwartz, MD Somerset Hospital, Warren, NJ Objective: Laparoscopic removal of large uteri (200⫹ g) can be performed safely utilizing 2 or 3 cannula sites without exceeding 10 mm. Methods: Laparoscopic hysterectomies and laparoscopically assisted vaginal hysterectomies were performed on 65 women ages 35–55 years. The surgical specimens’ weight range was 220 –910 g. An electric morcellator was used to facilitate removal in 60 patients. Thirty-seven cases were performed
VOL. 95, NO. 4 (SUPPLEMENT), APRIL 2000
using a 2 trocar technique, whereas 28 cases used two 5 mm trocars and one 10 mm for morcellation. Bipolar cautery was used in all cases. Results: Over a 5-year period, 65 patients underwent laparoscopic removal of a large uterus. Most of the time a morcellator was used to remove the specimen. Operative times ranged from 90 minutes to 4 hours. Blood loss was typically less than 100 mL. Sixty patients were discharged the next day, whereas five were discharged on the second postoperative day. Postoperative pain was minimal. Conclusions: Laparoscopic removal of large uteri with the aid of the electric morcellator is a safe and cosmetic method of performing hysterectomy with low morbidity, shorter recovery times, and a more rapid return to daily activity when compared with other approaches.
A Comparison of Two Saline Infusion Sonography Catheters Jill T. Snyder, DO St. Luke’s Hospital, Bethlehem, PA
James Anasti, MD Objective: To compare a low-cost, nonballoon tip catheter to a more expensive balloon tip catheter in the performance of saline infusion sonography (SIS). Saline infusion sonography has been the focus of several studies in the field of gynecology. The majority of these utilized various balloon tip catheters. A successful SIS depends on a reliable infusion catheter. Although many types of catheters are used, no comparisons on the effectiveness of different catheters have been reported. Methods: Women between the ages of 18 – 80 years who presented to a community hospital clinic with dysfunctional uterine bleeding were eligible for the study. Premenopausal women underwent saline infusion sonography if they failed traditional medical therapy. Postmenopausal women had the procedure as part of their initial workup. All women had the procedure performed by one investigator using the nonballoon tip catheter first. If the images were inadequate, the balloon tip catheter was then used. Adequacy was determined by complete visualization of the endometrial cavity. Results: Twenty-three patients were eligible. The mean age was 45.2, parity 2.6, endometrial cavity size 7.4. Five patients failed both catheters (2 with cervical stenosis and 3 with intolerance to either catheter). Of the remaining 18 patients, 13 (72%) had an adequate study utilizing the nonballoon catheter. Of the 5 nonballoon tip failures, all had successful studies utilizing the balloon tip catheter. Of note, these 5 patients had significantly more discomfort with the balloon tip catheter. Conclusions: The nonballoon tip catheter is a low-cost comparable alternative to the balloon tip catheter in the performance of saline infusion sonography. Our preliminary results suggest a higher patient tolerance for the nonballoon catheter.
Monday Posters 31S