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Pelvic Floor: General

Role of hormones in the pathophysiology of pelvic floor disorders in women.
Bhatia NN, Ho MH
Curr Opin Obstet Gynecol. 2006 Oct;18(5):525-7.

31st Annual IUGA Meeting, Athens, Greece, 6-9 September 2006.
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Sep;17 Suppl 8

The clinical significance of postpartum transperineal ultrasound of the anal sphincter.
Maslovitz S, Jaffa A, Levin I, Almog B, Lessing JB, Wolman I
Eur J Obstet Gynecol Reprod Biol. 2006 Aug 14;.

BACKGROUND AND OBJECTIVE: To evaluate the clinical significance of postpartum anal sphincter damage by transperineal ultrasonography (TPUS) performed on the day of delivery. METHODS: Continence questionnaires were handed out and TPUS was performed on 154 consecutive primiparous women 6-24h after vaginal delivery. At 2 and 6 months later, complaints and sphincteric sonographic appearance were reassessed. The puerperal women's clinical status and sonographic findings in the immediate and late postpartum period were evaluated. RESULTS: Thirty-five (23%) women complained of anal incontinence on the first postpartum day and anal sphincter damage was demonstrated by TPUS in 31 (89%) of them. Four women with anorectal complaints had an intact anal sphincter by TPUS. Follow-up questionnaires, 2 months later, revealed 30 symptomatic women: all of them had sonographically recognized tears on the initial TPUS and 27 of them had positive findings on the TPUS performed 2 months after birth. Six months after delivery, 27 women reported symptoms and all of them had sphincteric disruption evidenced on TPUS performed on the day of delivery. All the women with intact sphincter on the initial TPUS were asymptomatic 6 months later. CONCLUSION: TPUS findings on the day of delivery are related to long-term anorectal complaints, supporting a potential role for TPUS as a screening aid for anal sphincter tears

[Blunt pelvic injury.]
Holanda M, Culemann U, Burkhardt M, Pohlemann T
Chirurg. 2006 Aug 4;.

Life-threatening complex pelvic fractures are commonly associated with vast peripelvine soft-tissue injuries and hemorrhage. Correct assessment and classification of the existing pelvic trauma and additional severe injuries present is required for accurate diagnosis and effective therapy. Treatment of the usually multiply injured patient is time-sensitive. The circulatory situation is the benchmark for diagnostic and therapeutic actions. Emergency stabilization of an initially unstable pelvic ring should be done first, followed by an extraperitoneal tamponade, if needed to control bleeding. The positive results of these actions can be measured by hemodynamic parameters. Delayed definitive internal stabilization of the anterior and/or posterior pelvic ring is then performed according to the fracture classification.

[Pelvic and perineal trauma : Diagnosis and interventional radiology.]
Galanski M
Chirurg. 2006 Aug 9;.

The integration of multislice CT (MSCT) in the imaging of emergency trauma has led to a paradigm shift in trauma management. In case of hemodynamically instable patients, initial imaging is limited to a small set of standardized radiographs. Computed tomography is the imaging modality of choice for further diagnostic work-up. Consequently it should be used at an early stage and in a less restricted manner for complete assessment of the pelvic injury and to determine therapeutic management. The MSCT allows full assessment of bone, parenchymal, and vascular injuries in a single examination in the shortest time possible. High-resolution 3D imaging provides additional options. There is increasing support for primary use of MSCT in critically ill patients due to the comprehensive imaging it allows while maintaining a fast scan time. The potential and limitations of diagnostic imaging in pelvic ring fracture and associated injuries are explained. Indications for vascular interventions in arterial bleeding are discussed.


Urogynecology: The Importance of Long-Term Follow-up.
Nygaard I
Obstet Gynecol. 2006 Aug;108(2):244-5.

Urogynecology and the underserved.
Wilkinson J
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Oct;17(5):429. Epub 2006 Jul 8.

The Ulf Ulmsten Lecture presented at the opening ceremonies of the 30th Annual Congress of the International Urogynecologic Association-August 10, 2005, Copenhagen, Denmark.
Shull B, Foster R
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Oct;17(5):430-5. Epub 2006 Jul 11.

Histologic evaluation of human cadaveric fascia lata in a rabbit vagina model.
Walter AJ, Morse AN, Leslie KO, Hentz JG, Cornella JL
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Feb;17(2):136-42. Epub 2005 Jun 23.

The purpose of this study was to evaluate the histologic response of human cadaveric fascia lata after vaginal implantation. Freeze-dried, gamma-irradiated cadaveric fascia lata from three lots was implanted between the rectovaginal membrane and vaginal epithelium in New Zealand white rabbits. Rabbits were killed at 2, 4, 8, and 12 weeks after implantation. At necropsy, gross findings were described and specimens for routine cultures were taken. Histologic evaluation determined graft integrity, neovascularization, inflammatory response, and host tissue incorporation. Nine rabbits were available for histologic analysis and 14 for gross and microbiologic analysis. Vaginal erosions occurred with three grafts. The remainder were adherent to the surrounding tissues. Erosion was associated with bacterial colonization of the graft. Autolysis of one graft occurred at 4 weeks. Over time, the inflammatory response decreased and neovascularization increased; by 12 weeks, the graft collagen was replaced by host collagen. Cadaveric fascia lata serves as scaffolding for host tissue incorporation with replacement by host collagen.

[Development and validation of a model of training at home to the laparoscopy]
Robert G, Calvet C, Lapouge O, Vallee V, Emeriau D, Ballanger P
Prog Urol. 2006 Jun;16(3):352-5.

INTRODUCTION AND OBJECTIVES: Practice on a Pelvitrainer training is an essential part of the training of surgeons in laparoscopy. Most university departments are equipped with this type of model, but this equipment is expensive, cumbersome and often poorly accessible. The authors propose a new laparoscopy home training model and compare its performances with those of the reference training model. MATERIAL AND METHOD: The laparoscopy home training model is composed of a laptop computer; a Web Cam and a translucent plastic box. Ten operators with various levels of training were timed during 4 simple exercises performed on the home training model and were then timed when performing 6 interrupted sutures with this model and with a Pelvitrainer RESULTS: All operators successfully performed the proposed exercises. The mean operating time was correlated with the level of training (35 minutes versus 15 minutes for the 3 most experienced operators). The suture time was comparable with the home trainer (14 minutes) and the Pelvitrainer (13 minutes). The home training model is less expensive (75 euros), more accessible and easier to install (3 minutes) than the Pelvitrainer and can be used outside of medicalized structures. CONCLUSION: Trainee operators can practice laparoscopy at home. The manufacture of a Home-trainer requires simple material. The training capacities of this model are similar to those of a Pelvitrainer, but it is less cumbersome, less expensive and more readily available. This type of model could be used by each operator at home to improve his/her performances and to accelerate training.

[Vaginal prolapse and stress urinary incontinence: combined treatment by a single prosthesis]
Sergent F, Resch B, Diguet A, Verspyck E, Marpeau L
Prog Urol. 2006 Jun;16(3):361-7.

OBJECTIVES: To evaluate the efficacy and possible short-term and medium-term complications of vaginal prosthetic surgery with transobturator fixation to treat prolapse and stress urinary incontinence (SUI) that are often associated in a single operation. MATERIAL AND METHOD: From February 2002 to August 2004, 45 patients with a mean age of 66 +/- 11 years presenting essentially stage 3 or 4 cystocele associated with SUI (documented for 40 cases and revealed by reduction of the prolapse for the other five) were operated according to the transobturator infracoccygeal sling technique. RESULTS: With a mean follow-up of 31 +/- 9 months, the success rate of the technique was estimated to be 98% anatomically (only one failure) and 91% in terms of urinary symptoms (73% of patients were cured, 18% were improved and 9% failed). No cases of urinary retention were observed, except for one patient with a secondarily infected pelvic haematoma requiring evacuation and the partial removal of the prosthesis. The mean residual urine on discharge was 83 ml. Two patients developed de novo overactive bladder The prostheses exposure rate was 18%. CONCLUSION: Combined treatment of vaginal prolapse and associated urinary incontinence is possible by the use of a single transvaginal prosthesis. The medium-term anatomical results are very good. The results on continence are good and a subsequent specific procedure is always possible in the case of failure or insufficient improvement. The prostheses exposure rate is similar to that observed with synthetic transvaginal prostheses.

Re: Biocompatible properties of surgical mesh using an animal model.
Papadimitriou J, Petros PE
Aust N Z J Obstet Gynaecol. 2006 Aug;46(4):368.

Hyaluronic Acid/Carboxymethylcellulose Membrane Barrier versus Taurolidine for the Prevention of Adhesions to Polypropylene Mesh.
Erpek H, Tuncyurek P, Soyder A, Boylu S
Eur Surg Res. 2006 Jul 26;38(4):414-417.

Background: A hyaluronic acid/carboxymethylcellulose (HA/CMC) membrane is an effective measure to prevent polypropylene mesh induced adhesions. We hypothesized that taurolidine 2% solution might be a cost-effective alternative to decrease adhesion formation. Materials and Methods: Twenty-four rats were randomized into three groups: mesh alone (group 1), mesh + taurolidine 2% (group 2), and mesh + HA/CMC (group 3). Polypropylene mesh (4 cm(2)) was used to repair surgically induced anterior abdominal wall defects. Taurolidine 2%or a HA/CMC membrane was used as an antiadhesive measure. The animals were sacrificed 6 weeks after the operation, and adhesions to the prosthetic material were evaluated with digital image analysis. Results: Group 1 (mesh alone) had the highest adhesion ratio (58.5 +/- 4.8%) compared with groups 2 and 3 (p < 0.05). The differences between groups 2 (mesh + taurolidine 2%; adhesion ratio 42.9 +/- 1.6%) and 3 (mesh + HA/CMC; adhesion ratio 40.3 +/- 3.0%) were not significant (p > 0.05). Conclusions: The animals of both treatment groups (2 and 3) had lower adhesion ratios compared with the controls (group 1). In particular, the HA/CMC membrane did not present with a superior antiadhesive effect compared with taurolidine. Therefore, taurolidine is a cost-effective alternative to HA/CMC membranes when a polypropylene mesh is used in direct contact with the abdominal viscera. Copyright (c) 2006 S. Karger AG, Basel.

Prevention of adhesion to prosthetic mesh in incisional ventral hernias: comparison of different barriers in an experimental model.
Dilege E, Coskun H, Gunduz B, Sakiz D, Mihmanli M
Eur Surg Res. 2006;38(3):358-64. Epub 2006 Jul 4.

Background: The purpose of this study was to compare the intra-abdominal adhesion formation following ventral hernia repair by using oxidized regenerated cellulose (ORC) as a barrier underneath polypropylene mesh (PPM), and sodium hyaluronate/carboxymethylcellulose (HA/CMC)-coated PPM. Methods: A ventral abdominal defect was created in each of 30 male rats which were divided into three groups. In group 1 (control) the defect was repaired with PPM; in group 2 ORC was laid over the viscera and the defect was repaired with PPM, and in group 3 HA/CMC-coated PPM was used for the repairing procedure. On the 28th postoperative day all the rats were sacrificed and adhesions were evaluated by laparoscopic exploration followed by histopathological examination. Results: Animals treated with ORC and PPM, and HA/CMC-coated PPM showed significantly less adhesions than the control group (p = 0.026) and the intra-abdominal adhesions of the rats in these two groups were significantly easier to release than in the control group (p = 0.001). There was no significant difference between the ORC and HA/CMC groups. Conclusions: ORC used together with PPM is as effective as HA/CMC-coated PPM and ORC can be used as an adhesion barrier in intra-abdominal hernia repair. Copyright (c) 2006 S. Karger AG, Basel.


Response to: Compartment syndrome following pelvic surgery in the lithotomy position.
O'Leary D
Ann R Coll Surg Engl. 2004 Nov;86(6):490.


Normative pelvic floor parameters in children assessed by transabdominal ultrasound.
Bower WF, Chase JW, Stillman BC
J Urol. 2006 Jul;176(1):337-41.

PURPOSE: Successful management of dysfunctional voiding in children hinges on retraining inappropriate pelvic floor muscle recruitment. Recently dynamic pelvic floor muscle activity was visualized in adults using transabdominal ultrasound. We evaluated transabdominal ultrasound for visualizing and measuring pelvic floor muscle activity in normative children. MATERIALS AND METHODS: A total of 21 volunteers, including 10 boys and 11 girls 7 to 16 years old (mean age 11.6) who were free of bladder disorders consented to participate in the study. Subjects were screened and demonstrated normative bladder emptying before being imaged while supine and standing using a sagittal curved linear array 2 to 5 MHz transducer over the suprapubic region. After pelvic floor muscle contraction was explained 4 parameters were measured 3 times each, including the direction of movement/displacement from freeze-frame ultrasound images, and endurance and coordination from ultrasound movie loops. The methodology for digitizing movie data were developed, tested and found to be reliable. New variables of endurance as a percent of maximum coordination amplitude and coordination as the amplitude between maximum and minimum effort were created. RESULTS: Overall 66% and 71% of subjects demonstrated anterior displacement of the pelvic floor during voluntary contraction while lying and standing, respectively, with no significant difference in lying vs standing. However, coordination displacement was greater while lying than standing. During 20-second contractions pelvic floor muscle activity attained peak amplitude at 5.5 seconds, followed by a marked decay with 1 or more cycles of muscular re-recruitment. It was observed that fatigue led to repeat recruitment of the rectus and oblique abdominal muscles. CONCLUSIONS: In children free of voiding dysfunction pelvic floor displacement and coordination are highly variable. Noninvasive ultrasound of the pelvic floor provided visual assessment of muscular activity, a biofeedback component for the patient and measurement potential for the therapist.

Stimulating aspects of sacral nerve stimulation.
Staskin DR
J Urol. 2006 Jun;175(6):1991-2.


The effects of the exaggerated lithotomy position for radical perineal prostatectomy on respiratory mechanics.
Choi SJ, Gwak MS, Ko JS, Lee H, Yang M, Lee SM, Kim GS, Kim MH
Anaesthesia. 2006 May;61(5):439-43.

Summary The exaggerated lithotomy position is used during radical perineal prostatectomy to increase perineal exposure. The aim of this study was to evaluate the effects of the exaggerated lithotomy position on respiratory mechanics and arterial blood gases. In the exaggerated lithotomy position, dynamic compliance and static compliance were found to be significantly decreased by 27.4% and 34.8%, respectively, whilst peak, plateau, and mean airway pressures increased significantly by 34.0%, 45.8% and 31.7%, respectively. The physiological dead space/tidal volume ratio and total inspiratory work of breathing increased significantly by 11.1% and 33.7%, respectively. Arterial oxygen tension was significantly decreased by 26.9%; however, no significant differences were seen in end-tidal or arterial carbon dioxide tension. These results indicate that the exaggerated lithotomy position under general anaesthesia can cause significant effects on respiratory system mechanics and arterial oxygenation and highlights the need for careful monitoring of patients placed in this position for surgery.

An initial evaluation of pelvic floor function and quality of life of bladder exstrophy patients after ureterosigmoidostomy.
Miles-Thomas J, Gearhart JP, Gearhart SL
J Gastrointest Surg. 2006 Apr;10(4):473-7.

Classic bladder exstrophy is characterized by displaced pelvic floor musculature and significant skeletal and genitourinary defects. A paucity of data exist evaluating long-term pelvic floor function in exstrophy patients after ureterosigmoidostomy. This study is an initial attempt to evaluate the prevalence of urofecal incontinence, pelvic organ prolapse, and overall quality of life in patients who have had ureterosigmoidostomies. Fifty-two individuals who underwent ureterosigmoidostomy between 1937 and 1990 were identified through the Ureterosigmoidostomy Association and the Johns Hopkins bladder exstrophy database and mailed questionnaires approved by the Institutional Review Board (Johns Hopkins). Data were analyzed with SigmaStat 3.0 (SPSS, Inc., Chicago, IL). Eighty-three percent of the subjects responded, with a mean age of 44.4 years (range, 14-73 years) and mean of 40.9 years (range, 14-65 years) after ureterosigmoidostomy. Prevalence of daily urinary and fecal incontinence was 48% (n = 20) and 26% (n = 11), respectively, whereas the prevalence of weekly combined urofecal incontinence was 63% (n = 27). The incidence of pelvic organ prolapse in this cohort was 48% (n = 20). In these patients, a significant risk of urofecal incontinence and pelvic organ prolapse exists. Long-term follow-up studies are needed to understand the role of pelvic floor musculature in this complex birth defect.

Inflammatory response to bovine pericardium: reply to letter by Davila.
Lazarou G, Powers K, Pena C, Bruck L, Mikhail MS
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Apr 13;.

Surgipro mesh: not all multifilaments are the same.
Rodeheaver GT
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Apr 26;.

Introduction to the 2005 IUGA Grafts Roundtable.
Davila GW
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Apr 25;.

InteXen tissue processing and laboratory study.
Winters JC
Int Urogynecol J Pelvic Floor Dysfunct. 2006 May 6;.

The goal of this manuscript is to discuss the utilization of InteXen graft material, which is a natural, biocompatible matrix. There is unfortunately little data concerning this material; so, many of the concepts introduced in this manuscript are theoretical. We will discuss the rationale behind using InteXen as the biologic material of choice.

Clinical implications of the biology of grafts: conclusions of the 2005 IUGA Grafts Roundtable.
Davila GW, Drutz H, Deprest J
Int Urogynecol J Pelvic Floor Dysfunct. 2006 May 6;.

With few exceptions, the current expansion of graft utilization in pelvic reconstructive surgery is not a product of evidence-based medicine. Abdominal sacrocolpopexy and suburethral sling procedures are two situations under which synthetic graft utilization is indicated, based on randomized prospective trials and reported clinical outcomes. Otherwise, indications and contraindications for graft utilization are unclear. Current published data on the biology of synthetic and biologic grafts are limited and overall not very helpful to the reconstructive surgeon who is faced with the selection of a graft for use during a reconstructive procedure. This Roundtable presented the opportunity for a series of basic science researchers to present their data to a group of reconstructive surgeons and provide publishable background information on the various currently available grafts. The occurrence of healing abnormalities after graft implantation is becoming increasingly recognized as a potentially serious problem. To date, definitions and a classification system for healing abnormalities do not exist. Based on the input from basic scientists and experienced surgeons, a simple classification is suggested based on the site of healing abnormality, timing relative to graft implantation, presence of inflammatory changes, and the viscera into which the graft is exposed. Many opportunities for clinical and basic science research exist. As the use of grafts in reconstructive surgery is expanded, surgeons are encouraged to familiarize themselves with currently published data, and determine whether a graft should, or should not be, utilized during a reconstructive procedure, and if so, the type of graft best indicated in each specific clinical situation.

Tissue engineering a clinically useful extracellular matrix biomaterial.
Hiles M, Hodde J
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Apr 27;.

Implantable biomaterials are one of the most useful tools in the surgeon's armamentarium, yet there is much room for improvement. Chronic pain, tissue erosion, and late infections are just a few of the serious complications that can occur with conventional, inert materials. In contrast, tissue-inductive materials exist today. Combinations of biologically important molecules for directing cell growth and providing structural stability can be found in naturally occuring extracellular matrices. These "soft-tissue skeletons" of Mother Nature can be harvested, processed, and provided in a medically safe and biologically active form for repairing many different tissues in the human body. The future of surgical practice may well be determined by how well these new implant materials recreate the tissues they replace.


Childbirth and pelvic floor dysfunction: An epidemiologic approach to the assessment of prevention opportunities at delivery.
Patel DA, Xu X, Thomason AD, Ransom SB, Ivy JS, Delancey JO
Am J Obstet Gynecol. 2006 Mar 28;.

Female pelvic floor dysfunction is integral to the woman's role in the reproductive process, largely because of the unique anatomic features that facilitate vaginal birth and also because of the trauma that can occur during that event. Interventions such as primary elective cesarean delivery have been discussed for the primary prevention of pelvic floor dysfunction; however, existing data about potentially causal factors limit our ability to evaluate such strategies critically. Here we consider the conceptual principles of epidemiologic function and the availability of data that are necessary to make informed recommendations about prevention opportunities for pelvic floor dysfunction at delivery. Available epidemiologic data on pelvic floor dysfunction suggest that there may be substantial opportunities for the primary prevention of pelvic organ prolapse at delivery. Although definitive recommendations await further epidemiologic studies of the potential risk and benefits of obstetric practice change, it is hoped that this discussion will provide a novel, quantitative framework for the assessment of pelvic floor dysfunction prevention opportunities.

Highlights from the combined society of urodynamics and female urology and international society of pelvic neuromodulation annual meeting.
Lemack GE, Siegel S, Comiter C, Damaser M, Kobashi K, Payne C, Rodriguez L, Wright EJ
J Urol. 2006 May;175(5):1852-6.

Safety of MRI at 1.5Tesla in Patients with Implanted Sacral Nerve Neurostimulator.
Elkelini MS, Hassouna MM
Eur Urol. 2006 Mar 3;.

OBJECTIVES: Sacral neuromodulation has become an established method to treat voiding dysfunction. Currently the use of implanted sacral nerve stimulators is becoming more popular worldwide. Magnetic resonance imaging (MRI) is an important diagnostic tool for many medical and neurological disorders. Many radiology centers do not perform MRI examinations on patients with implanted sacral nerve stimulator. The basis for this policy is that potential hazards such as motion, dislocation or torquing of the implanted pulse generator (IPG), heating of the leads, and damage to the IPG may occur, resulting in painful stimulation. In contrast, many studies conducted on MRI at 1.5Tesla in patients with implantable devices have found the examination to be safe if the area to be imaged is out of the isocenter of the MRI scanner and other precautions are taken. METHODS: Eight MRI examinations at 1.5Tesla were conducted in areas outside the pelvis on six patients with implanted sacral nerve stimulator (InterStim((R)) neurostimulator; Medtronic, Inc, Minneapolis, MN, USA). Implanted pulse generators were examined before and after MRI procedures. All patients had their parameters recorded; then the IPGs were put to "nominal" status. Patients were monitored continuously during and after the procedure. After the MRI session, the site of the implanted device was examined and changes were reported. Devices were then re-programmed to their previous setup with the use of a programmer (model 7432; Medtronic, Inc). Voiding diaries were collected after MRI procedures and compared with previous records. RESULTS AND CONCLUSION: During the MRI session, no patient showed symptoms that required stopping the examination. There was no change in perception of the stimulation after re-programming of the implanted sacral nerve stimulator, according to patients' feedback. Devices were functioning properly, and no change in bladder functions was reported after MRI examinations. Finally, we hope that presenting these cases will encourage performance of more comprehensive studies on implanted sacral nerve stimulators on a larger patient population in the near future.

Spontaneous extrusion of sacral nerve implant secondary to massive weight loss.
Nold CJ, McLennan MT
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Apr 11;.

Sacral neuromodulation (Interstim, Medtronic, Minneapolis, Minnesota) is a recognized treatment for refractory urgency, frequency, and urge incontinence. Revision rates range from 10-33% mainly for pain over the implantable pulse generator site (IPG) or lead migration [Hassouna et al. J Urol 163:1849-1854, 2000; Schmidt et al. J Urol 162:352-357, 1999; Spinelli et al. J Urol 166:541-545, 2001; Swinn et al. Eur Urol 38:439-443, 2000; Weil et al. Eur Urol 37:161-171, 2000; Evaraert et al. Int Urogynecol J Pelvic Floor Dysfunct 11:231-236, 2000]. We report a case of spontaneous extrusion of the IPG through the subcutaneous fat and skin secondary to marked weight loss after gastric bypass surgery. Continued weight loss resulted in multiple surgical interventions and eventual removal of the device.

Wound infections in patients with interstim sacral nerve stimulators.
Dinsmore R Jr, Washington B, Hines B
Obstet Gynecol. 2006 Apr;107(4 Suppl):45S.

Current status of robotics in female urology and gynecology.
Elliott DS, Chow GK, Gettman M
World J Urol. 2006 Mar 24;.

Currently, there has been limited reporting and research in the female urology and gynecological literature concerning the use of robotics. To date, robotics have been utilized only for the treatment of three benign gynecologic conditions: benign hysterectomy; repair of vesicovaginal fistula; and sacrocolpopexy which is a treatment for posthysterectomy vaginal vault prolapse. We describe a novel minimally invasive technique of vaginal vault prolapse repair and present our initial experience. The surgical technique involves placement of five laparoscopic ports: three for the daVinci(R) robot and two for the assistant. A polypropylene mesh is then attached to the sacral promontory and to the vaginal apex using Gortex sutures. Thirty-one patients underwent a robotic-assisted laparoscopic sacrocolpopexy at our institution in the past 24 months for severe symptomatic vaginal vault prolapse. Complications were limited to mild port site infections in two patients, which resolved with oral antibiotic therapy. While our early experience utilizing robotic repairs in female urology and gynecology is encouraging, long-term data are needed to confirm these findings and establish longevity of the repair.

Female pelvic floor dysfunction in the Middle East: a tale of three factors-culture, religion, and socialization of health role stereotypes.
Rizk DE, El-Safty MM
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Apr 11;

Patients' knowledge of potential pelvic floor changes associated with pregnancy and delivery.
McLennan MT, Melick CF, Alten B, Young J, Hoehn MR
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Jan;17(1):22-6. Epub 2005 Jul 8.

Physicians cite pelvic floor injury as a major reason for Cesarean section as their personal preferred delivery mode. This study was undertaken to determine whether patients receive information about possible pelvic floor complications of pregnancy/delivery. Day 1 post-partum women completed a 52-item questionnaire assessing information given during routine antenatal care. Pelvic floor and general questions were intermixed. Of the 232 patients, the mean age was 26.9 years, with 59.5% white, 32.8% African-American and 7.7% other. Most (84.5%) had at least grade 12 education. The following percentage of patients reported receiving no information about: Kegel exercises 46.1%; episiotomy 51.3%; urinary incontinence 46.6%; fecal incontinence 80.6%; change in vaginal caliber 72.8%; neuropathy 84.9%. Counseling on all of these issues occurred significantly less frequently than education on general pregnancy topics. Our results suggest that knowledge and instruction of pelvic floor risks is very much lacking and provide us with an impetus to develop educational tools.

Pelvic echinococcosis in differential diagnosis of pelvic masses.

Aydogdu T, Gungor T, Tug M, Cavkaytar S
Eur J Obstet Gynecol Reprod Biol. 2006 Mar 10;.


Evaluation and management of malfunctioning sacral neuromodulator.
Gaynor-Krupnick DM, Dwyer NT, Rittenmeyer H, Kreder KJ
Urology. 2006 Feb;67(2):246-9.

OBJECTIVES: To describe a strategy for revising the malfunctioning InterStim device and to provide an algorithm for evaluation and management. METHODS: We retrospectively reviewed 82 patients who had undergone InterStim placement. Ten patients (eight women and two men) experienced complications and subsequently underwent revision of their device between October 2001 and October 2003. Five patients had originally received a permanent implant after a successful percutaneous test stimulation trial, and five had undergone a test stimulation using the tined lead. Indications for revision included gradual onset of recurrent voiding dysfunction (n = 2), lead migration (n = 5), generator malfunction (n = 1), generator site pain and infection (n = 1), and genital/rectal pain with stimulation (sensory discomfort; n = 1). RESULTS: Of the 10 patients who underwent revision, 7 experienced complete resolution of their problem. Eight patients had lead site changes and two had generator replacements. No intraoperative or postoperative complications occurred in the revision cases. CONCLUSIONS: In our experience, 70% of patients who undergo revision of the malfunctioning InterStim can expect success. In this study, no difference in success appeared to be related to the original cause of malfunction. In the management of malfunctioning sacral neuromodulators, we recommend an attempt at revision before permanent explantation.

Introducing patient cards in clinical routine: evaluation of two research projects.
Birkmann C, Demski H, Engelbrecht R
Methods Inf Med. 2006;45(1):73-8.

OBJECTIVE: Two research projects were analyzed in order to identify key factors of success and/or failure in introducing patient card-based systems in clinical routine. METHODS: In DIABCARD an evaluation study focussing on user friendliness and user acceptance was conducted. In ByMedCard-HCPP the project's system was validated and the timeliness of the project's work analyzed. RESULTS: User friendliness and user acceptance of the DIABCARD system were fairly high. The ByMedCard-HCPP system was complete in its major components and functionalities; introducing the ByMedCard-HCPP system in clinical routine delayed the project. CONCLUSIONS: A multitude of key factors of success such as utilized technologies, user involvement, and commitment of partners seems to contribute to the success and/or failure of introducing patient card-based systems in healthcare.

Lest formalisms impede insight and success: evaluation in health informatics--a case study.
Moehr JR, Anglin C, Schaafsma J, Pantazi S, Grimm N
Methods Inf Med. 2006;45(1):67-72.

OBJECTIVES: To illustrate the advantages of an open-ended formative evaluation approach using a project-specific selection of methods over the controlled trial approach in the evaluation of health information systems. To illustrate factors leading to success and others impeding it in a telehealth project. METHODS: The methods and results of an evaluation of the BC Telehealth Program are summarized. RESULTS: The evaluation gave a comprehensive picture of the project, including assessment of the effects of an array of telehealth applications, and their economic impact. Factors leading to success and others preventing it are identified from the level of overall program management to the project specifics. The results include unanticipated effects and explanations for their reasons of occurrence. Neither the comprehensiveness of information nor the timeliness was achieved in a related project using a controlled trial approach. CONCLUSIONS: Not all types of health information system projects can be evaluated using the controlled trial approach. This approach may impede important insights. It is also usually much less efficient. Funding agencies and journal editors have to take this into account when selecting projects for funding and submissions for publication.

Evaluation of health information applications--challenges ahead of us.
Brender J
Methods Inf Med. 2006;45(1):62-6.

OBJECTIVES: The aim of the paper is to review the challenges for evaluation in the light of characteristics of the healthcare sector, present as well as future. METHODS: The approach is a synthesis based on highlights from the literature. RESULTS: The review addresses the following issues: 1) the role of evaluation activities within a systems development or implementation context; 2) suggestions on the nature of success and failure characteristics; and 3) evaluation aspects viewed in the perspective of different types of systems. Constructive evaluation, evaluation being the act of bringing about a decision-making basis, is perceived as the means to minimize failure and maximize success from the very beginning of the development or implementation. Based on these discussions, the challenges that evaluation and evaluators are facing are debated. CONCLUSION: The ultimate challenge ahead is first to fill the gap of presently needed evaluation methods. This need is in particular related to evaluation of cognitive and work process-oriented aspects of IT-based solutions. Finally, the challenge is to provide constructive evaluation methods and methodologies for dealing with the full complexity and dynamics of the target domain, for application within the entire lifecycle of the IT-based systems and solutions.


Optimizing pelvic surgery outcomes.
Davila GW
Cleve Clin J Med. 2005 Dec;72 Suppl 4:S28-32.

Most perioperative complications related to graft use can be prevented by appropriate preoperative and postoperative tissue management. Intraoperative cystoscopy should be a routine part of most pelvic reconstructive procedures. A rectal examination should be performed at the end of each surgical procedure to document rectal integrity. Under most circumstances, graft erosions can be managed without the need to remove the entire graft or jeopardizing the surgical repair.

Textbook recommendations for preventing and treating perineal injury at vaginal delivery.
Stepp KJ, Siddiqui NY, Emery SP, Barber MD
Obstet Gynecol. 2006 Feb;107(2):361-6.

OBJECTIVE: To assess general obstetrics textbooks regarding the quality and quantity of information about perineal injury at vaginal delivery. METHODS: An obstetrics and gynecology resident, a perinatologist, and a urogynecologist evaluated 7 obstetrics textbooks by using a standardized abstraction form that delineated descriptions of anatomy and physiology, episiotomy use, and perineal trauma prevention and repair. RESULTS: Two textbooks briefly described anal sphincter anatomy, but none provided a detailed discussion of the relative contribution of anatomic components to continence. Four textbooks discussed the evidence for and against midline or mediolateral episiotomy, and 6 advised against routine episiotomy. Six textbooks described grading lacerations, but only one described detailed repair techniques for all grades. Two textbooks discussed techniques to reduce perineal trauma at the time of delivery. Only one textbook discussed the need to reapproximate the normal anal sphincter anatomy during perineal repair. CONCLUSION: Although most textbooks accurately reflect current literature regarding routine episiotomy, there is limited discussion of advantages and disadvantages of various types of episiotomy and little offered regarding prevention and repair of perineal trauma at delivery. LEVEL OF EVIDENCE: III.

Risk of bladder injury during vaginal hysterectomy in women with a previous cesarean section.
Agostini A, Vejux N, Colette E, Bretelle F, Cravello L, Blanc B
J Reprod Med. 2005 Dec;50(12):940-2.

OBJECTIVE: To determine the risk of bladder injury during vaginal hysterectomy in women with a previous cesarean section. STUDY DESIGN: Analysis of selected studies found through a MEDLINE search from 1980 to 2003. RESULTS: Four comparative studies (women with or without a previous cesarean section) were selected and analyzed. Risk of bladder injury was significantly increased in only 1 study. Analysis of cumulative data did not find a significant difference (8 of 430 [1.86%] vs. 11 of 1,227 [0.89%], p = 0.12). CONCLUSION: The risk of bladder injury during vaginal hysterectomy does not seem to be increased in women with a previous cesarean section.

Combined bladder, urethral and uterine rupture after a normal, spontaneous vaginal delivery at home: a case report.
Zeteroglu S, Bayrakli H, Yilmaz Y, Sahin HG
J Reprod Med. 2005 Nov;50(11):874-6.

BACKGROUND: Uterine rupture and associated injury to the maternal bladder and urethra have been rarely reported. All those cases were associated with a scarred uterus or augmentation of labor. We report a case of simultaneous bladder, urethral and uterine rupture in an unscarred uterus following delivery at home. CASE: A 22-year-old woman was referred from a peripheral hospital to the emergency unit of the Medical Faculty, Yuzuncu Yil University, after delivering at home. On vaginal examination, the bladder neck and proximal one third of the urethra were ruptured. Intraoperatively it appeared that the posterior wall of the bladder and bladder base had ruptured and separated from the level of the interureteric ridge. An extensive rupture of the lower uterine segment to the left sidewall of the uterus was seen. CONCLUSION: To prevent these complications, uneducated, traditional birth attendants should be replaced by at least midwives, and the rate of unsupervised home delivery should be reduced.