Search PubMed⌕ Search

Biomedical subjects

Hans Peter Dietz

Publications and source records attributed to Hans Peter Dietz.

15 recordsLinked to original sources
PubMed2006

TVT vs Monarc: a comparative study.

Following the success of the tension-free vaginal tape (TVT), there has been considerable interest in technique modifications such as the transobturator approach for implant placement. We attempted to elucidate possible anatomical and clinical differences between the two methods in a retrospective cohort study. One hundred and fourteen women who had undergone TVT or Monarc implantation were assessed by or under the supervision of the senior author, with identical tensioning technique. They were followed up by an interview, uroflowmetry, and translabial 3D ultrasound. There were significant differences for patient satisfaction (P=0.013), subjective overall cure/improvement (P=0.0018), and the symptom of poor stream (P=0.03), all favoring the Monarc group. On imaging Monarc tapes appeared more proximal at rest (P=0.006) and Valsalva (P=0.002) and remained further from the symphysis pubis on Valsalva (P=0.01). At 9 months follow-up, there was no significant difference as regards to cure rates for stress incontinence between the two suburethral slings. Monarc tapes are located more proximally and may be less obstructive, judging from a lower incidence of symptoms of voiding dysfunction. Patient satisfaction and overall subjective cure/improvement were higher after Monarc. In summary, the Monarc is an effective TVT alternative, achieving cure of stress incontinence by similar means. It may be less obstructive, resulting in improved patient satisfaction.

Female↗
PubMed2006

Pelvic floor trauma following vaginal delivery.

PURPOSE OF REVIEW: Recent years have seen a steady increase in the information available regarding pelvic floor trauma in childbirth. A review of this information is timely in view of the ongoing discussion concerning elective caesarean section. RECENT FINDINGS: In addition to older evidence regarding pudendal nerve injury, it has recently been shown that inferior aspects of the levator ani and fascial pelvic organ supports such as the rectovaginal septum can be disrupted in childbirth. Such trauma is associated with pelvic organ prolapse, bowel dysfunction, and urinary incontinence. Elective caesarean section seems to have a limited protective effect that appears to weaken with time. Older age at first delivery may be associated with a higher likelihood of trauma and subsequent symptoms. SUMMARY: Pelvic floor trauma is a reality, not a myth. It is currently not possible, however, to advise patients as to whether avoidance of potential intrapartum pelvic floor trauma is worth the risk, cost, and effort of elective caesarean section. In some women this may well be the case. The identification of women at high risk for delivery-related pelvic floor trauma should be a priority for future research in this field.

Age Factors↗
PubMed2006

Ultrasound of the post-partum uterus.

AIMS: To assess the appearance of the post-partum uterus on transabdominal ultrasound, and to correlate these findings with maternal morbidity. METHODS: In a prospective observational study, 94 women were seen within 24 h of their delivery and assessed by transabdominal ultrasound. Volumetric data were calculated from measurements of intrauterine echogenic areas. All women were contacted for a telephone interview 1-4 months following their delivery to assess whether they had experienced morbidity associated with their delivery such as post-partum haemorrhage, pyrexia, prolonged hospital stay, follow-up investigations or surgical intervention. RESULTS: Two areas of echogenic material were identified in the upper and lower segment of the post-partum uterus. These were assessed independently for dimensions and volumes. The upper segment area had an average thickness of 13.8 mm and an average volume of 35.6 cm(3) The lower segment/cervical area held considerably more material with an average volume of 54.8 cm(3). The mean duration of post-partum bleeding was 4.2 weeks. None of the recruited women required a blood transfusion. The average hospital stay was 4 days. Twenty-two (23%) of the participants experienced a febrile illness following delivery, and 19 (20%) were commenced on antibiotics. None of these parameters of post-partum morbidity were associated with the ultrasound findings. CONCLUSIONS: In this study ultrasound evaluation in the immediate post-partum period revealed unexpectedly large volumes of echogenic material in the uterine cavity. However, such volumes of echogenic material were not associated with postnatal morbidity, and can probably be accepted as normal.

Adult↗
PubMed2005

Levator trauma after vaginal delivery.

OBJECTIVE: To date, the evidence on pelvic floor injury in labor remains sketchy due to a lack of prospective studies comparing pelvic floor imaging before and after childbirth. We intended to define the incidence of major trauma to the pubovisceral muscle. METHODS: A total of 61 nulliparous women were seen at 36-40 weeks of gestation in a prospective observational study. The assessment included an interview and 3-dimensional translabial ultrasound and was repeated 2-6 months postpartum. RESULTS: Fifty women (82%) were seen postpartum. Of the 39 women delivered vaginally, levator avulsion was diagnosed in 14 (36%, 95% confidence interval 21-51%). Among those delivered vaginally, there were associations with higher maternal age (P = .10), vaginal operative delivery (P = .07), and worsened stress incontinence postpartum (P = .02). CONCLUSIONS: Avulsion of the inferomedial aspects of the levator ani from the pelvic sidewall occurred in approximately one third of all women delivered vaginally and was associated with stress incontinence 3 months after childbirth.

Adult↗
PubMed2005

Paravaginal defects: a comparison of clinical examination and 2D/3D ultrasound imaging.

BACKGROUND: Paravaginal defects are often assumed to be the underlying anatomical abnormality in anterior compartment descent. Neither clinical examination nor ultrasound assessment are generally accepted diagnostic modalities. AIMS: To compare clinical examination and translabial 3D ultrasound in the detection of such defects. METHODS: Fifty-nine women without previous prolapse or incontinence surgery were seen prospectively. Clinical and ultrasound assessments were carried out in blinded fashion. 3D translabial ultrasound was undertaken after voiding and supine. Volumes were acquired at rest, on Valsalva and on levator contraction. Loss of paravaginal support ('tenting') in the axial plane was taken to signify paravaginal defects. RESULTS: Paravaginal defects were reported clinically in 14 cases on the left (24%), 19 times on the right (32%). Two 3D ultrasound examinations did not yield satisfactory volumes, leaving 57 for analysis. Neither midsagittal nor coronal views yielded data that correlated with clinical assessments. In the axial plane there was absence of tenting at rest in 32/57 (57%) patients, but this did not correlate with clinical findings. Loss of tenting on Valsalva was observed less often (21/57, 37%) and was weakly associated with clinically observed lateral defects (P = 0.036). CONCLUSIONS: Pelvic floor ultrasound in midsagittal, axial or coronal planes does not correlate well with clinical assessment for paravaginal defects. This could be due to poor clinical assessment technique or limitations of the ultrasound method. On the other hand, paravaginal defects may be uncommon or clinically irrelevant. On present knowledge, the paravaginal defect has to be regarded as an unproven concept.

Adult↗
PubMed2005

Which bowel symptoms are most strongly associated with a true rectocele?

BACKGROUND: Posterior vaginal wall prolapse is common in parous women and may be due to rectocele, enterocele or perineal hypermobility. Translabial ultrasound can be used to detect defects of the rectovaginal septum, that is, a 'true rectocele', potentially avoiding the need for defecation proctography. However, it is currently unknown whether specific sonographic appearances are associated with bowel symptoms. AIMS: To correlate symptoms of bowel dysfunction and sonographic findings. METHODS: In a prospective observational study, 505 women were seen during attendance at tertiary urogynaecological clinics and underwent a standardised interview, which included a set of questions regarding bowel function. They were assessed clinically and by translabial ultrasound, supine and after voiding. The presence of a rectocele was determined on maximal Valsalva. RESULTS: Clinically, 314 women (64%) were found to have a rectocele. There were associations between clinical staging and ampullary descent on ultrasound (P < 0.001), the presence of a true rectocele (P < 0.001) and the depth of a defect (P < 0.001). Defects of the rectovaginal septum ('true rectocele') were identified in 54%. They were associated with symptoms of incomplete bowel emptying (P < 0.001) and digitation (P = 0.002), and less so with dyschezia (P = 0.01), faecal incontinence (P = 0.02) and chronic constipation (P = 0.04). CONCLUSIONS: True rectoceles are found in more than half of women presenting with pelvic floor disorders. This finding correlates strongly with clinical prolapse grading--large clinical rectoceles are more likely to be caused by a fascial defect. Incomplete bowel emptying and digitation are significantly associated with such defects detected on ultrasound.

Adolescent↗
PubMed2004

How important is TVT location?

BACKGROUND: The tension-free vaginal tape (TVT) is claimed to be a midurethral procedure, but data on sling placement are scarce to date. The aim of this study was to investigate tape position and mobility and correlate this with postoperative symptoms of bladder dysfunction. METHODS: One hundred and forty-one women 5 weeks to 2.1 years (mean 0.66 years) after TVT placement took part in a prospective clinical observational study. Appointments consisted of standardized symptom questionnaire, clinical stress test flowmetry and translabial ultrasound. The main outcome measures were patient symptoms, subjective satisfaction and cure/improvement. Paired t-test and anova statistics were employed for continuous, normally distributed parameters. RESULTS: Tape position varied from 30 mm above to 12.7 mm below the symphysis at rest and between 15 mm above to 18.7 mm below the symphysis on Valsalva. The horizontal distance of the tape from the symphysis pubis was weakly associated with recurrent stress incontinence (p = 0.048). More cranial tapes were weakly associated with urge incontinence (p = 0.03), frequency (p = 0.048) and symptoms of voiding dysfunction (p = 0.029). There was no association between tape placement and patient satisfaction or subjective cure/improvement. CONCLUSIONS: Position and mobility of the TVT vary markedly. This may be explained by varying degrees of dissection, localization of incisions and the preoperative degree of anterior vaginal wall prolapse. However, variations in placement seem to have relatively little effect on symptoms.

Adult↗
PubMed2004

Levator function before and after childbirth.

BACKGROUND: Vaginal childbirth is assumed to affect pelvic floor muscle function as a result of direct trauma and/or neuropathy. AIMS: To assess levator function by ultrasound prior to and after delivery and correlate changes with delivery data. METHODS: A total of 200 nulliparous women were seen at 6-18 and 32-37 weeks' gestation as well as 2-5 months post-partum. Appointments consisted of an interview, paper towel test, flowmetry and translabial ultrasound (supine and after voiding). The most effective of at least three contractions was used for evaluation according to a previously published method quantifying cranioventral displacement of the bladder neck. Labour and delivery details were collected through data collection sheets and the institutional database. RESULTS: A total of 173 women were seen in late pregnancy; 169 returned on average 93 days post-partum. At the last visit, a reduction of cranioventral lift from 11.2 mm (SD 4.5) to 8.8 mm (SD 4.2) was noted (P <0.001) which correlated weakly with active second stage (Spearman's r=-0.196, P=0.013), passive second stage (r=-0.15, P=0.059) and total second stage of labour (r=-0.225, P=0.004). Good antenatal levator function was not protective of changes in levator function or pelvic organ support. CONCLUSIONS: Childbirth reduces bladder neck displacement on levator contraction. The main obstetric determinant affecting levator function seems to be the length of the second stage. A Caesarean section in the second stage appears to exert no protective effect. It seems to be full engagement of the fetal head, not childbirth itself, that impairs levator function.

Cohort Studies↗
PubMed2004

Voiding function after tension-free vaginal tape: a longitudinal study.

BACKGROUND: The tension-free vaginal tape (TVT) has become popular for the surgical treatment of urodynamic stress incontinence. It seems to function via an intermittent obstructive effect that is easily demonstrated on imaging, although there is no agreement regarding its effect on voiding. AIMS: The present study was designed to longitudinally evaluate flowmetry indices and voiding symptoms after TVT placement. METHODS: A total of 145 consecutive patients were seen at yearly intervals after TVT placement, and 108 have now attended at least twice. A standardised questionnaire was filled in and a clinical stress test performed. The patients were asked to void for flowmetry; ultrasound was performed translabially for residual urine, tape position and mobility. RESULTS: After TVT placement, maximum flow rate (MFR) centiles dropped from 49.66 (SD 32.45) to 22.86 (SD 23.56), P < 0.001. However, when first and last postoperative visits were compared, there was a significant increase in MFR centiles (20.07 (SD 20.83) to 24.92 (SD 23.94), P = 0.021). This effect appeared to be almost linear over time when analysed on anova. The residuals decreased highly significantly (P < 0.001). This was accompanied by a reduction in symptoms of voiding dysfunction such as 'poor stream' (P = 0.024), 'straining to void' (P = 0.038) and 'incomplete emptying' (P = 0.019). CONCLUSIONS: The tension-free vaginal tape reduces MFR and flow rate centiles. It can have an obstructive effect on voiding, although this does not appear to be a major clinical problem. Voiding seems to improve over time, and this is accompanied by a reduction in the prevalence of symptoms of voiding dysfunction.

Female↗
PubMed2004

Will there ever be an end to the Caesarean section rate debate?

Caesarean section rates continue to rise. To date, no serious attempt has been made to address this issue. There are no scientific grounds for identifying an 'appropriate' level for Caesarean section rates. A 'Term Cephalic Trial' may provide such information, but poses major logistic and ethical challenges. The authors propose that a combination of known and newly developed predictors of emergency operative delivery may allow an antenatal risk assessment that could make intervention trials both ethically sound and logistically feasible.

Australia↗
PubMed2004

Does pregnancy affect pelvic organ mobility?

BACKGROUND: It is generally accepted that parity is a strong predictor of pelvic organ prolapse and incontinence. However, controversy persists as to whether this effect is due to pregnancy itself or parturition. AIMS: To define the contribution of early and late pregnancy to bladder mobility. METHODS: Case control series, using 88 non-pregnant control subjects recruited for a heritability study on urinary incontinence and prolapse, matched for age and ethnicity with 28 pregnant women seen at 10-17 weeks and again at 32-39 weeks' gestation. Main outcome parameters were ultrasound measures of anterior, central and posterior compartment descent as well as joint mobility measurements. RESULTS: Patients in early pregnancy showed higher values for bladder mobility in comparison with non-pregnant controls, although this did not reach significance for all parameters. However, when late pregnancy data were tested against non-pregnant controls, this difference reached significance for all tested parameters. Uterine and rectal descent did not show any significant differences between groups. Results for joint mobility were inconsistent. CONCLUSIONS: This study supports the hypothesis that bladder and urethral mobility increase in pregnancy. This effect is already noticeable at 6-18 weeks. As similar changes are also seen in elbow hyperextension, a generalised effect on connective tissue biomechanics, likely hormonal, can be hypothesised.

Adolescent↗
PubMed2004

Genetic covariation of pelvic organ and elbow mobility in twins and their sisters.

A range of environmental risk factors, with childbirth the most notable, have been associated with the development of pelvic organ prolapse and urinary incontinence. However, indications of genetic influence (positive family histories, ethnic differences) have prompted research into the heritability of measures of pelvic organ descent and joint mobility, which have also been associated with prolapse and incontinence. Genes appear to influence about half of the variation in these measures and, furthermore, the pelvic organ measures are associated with elbow hyperextension at a phenotypic level (r approximately .2). We examined these measures in young, nulligravid women to determine if their association is due to a common genetic source. Data were collected from 178 Caucasian female co-twins and non-twin sisters, 50 of whom returned to be retested, which allowed reliability to be estimated and unreliable variance to be isolated in the multivariate analyses. Structural equation modeling was used to estimate genetic associations between latent elbow and bladder mobility factors for which heritabilities were estimated to be 0.80 and 0.64 respectively. The association between these factors appeared to be mediated by common genes (genetic r = .48, non-shared environmental r = -.06), with genes influencing latent elbow mobility accounting for 14% of the variation in latent bladder mobility. We speculate that genes influencing connective tissue structure may underlie this association.

Adolescent↗
PubMed2003

Which women are most affected by delivery-related changes in pelvic organ mobility?

OBJECTIVE: Vaginal childbirth is a risk factor for female pelvic organ prolapse and stress incontinence. Imaging studies have suggested that vaginal delivery leads to increased anterior vaginal wall mobility. The authors intended to define the relationship between antepartum pelvic organ mobility and delivery-related changes in these parameters. STUDY DESIGN: Prospective observational clinical study conducted on 200 nulliparous women recruited from antenatal clinic. Patients were assessed by translabial ultrasound in late pregnancy and 2-5 months postpartum. RESULTS: Vaginal childbirth resulted in highly significant changes to all parameters used to describe pelvic organ mobility. These alterations were more marked in those women with limited pelvic organ mobility prior to childbirth, and these negative correlations were highly significant (anterior compartment r=-0.519, P<0.0001, central compartment r=-0.539, P<0.0001, posterior compartment r=-0.604, P<0.0001). CONCLUSIONS: Women with little pelvic organ mobility before childbirth appear to be those that show most marked delivery-related changes.

Cervix Uteri↗
PubMed2003

Does the tension-free vaginal tape stay where you put it?

OBJECTIVE: The tension-free vaginal tape (TVT) is a widely used procedure for the surgical treatment of urodynamic stress incontinence. Long-term follow-up data remain scarce. It has been speculated that scar formation leads to tape shortening and stiffening. This study was designed to longitudinally investigate tape position and mobility. STUDY DESIGN: An observational clinical study was performed using ultrasound parameters of tape position and mobility on Valsalva maneuver as main outcome parameters. RESULTS: Of 92 women eligible for a minimum of two postoperative assessments, 72 (78%) attended at least twice after TVT placement, at a median interval of 1.6 years. Sixty-eight data sets remained after exclusion of 4 patients who had undergone tape division. At the last visit, the tape was found to be more caudal, at rest (P <.001) and on Valsalva maneuver (P =.002). Tape mobility on Valsalva maneuver remained virtually unchanged. CONCLUSION: The TVT does not seem to contract or shorten over a median observation period of 1.6 years. On the contrary, it appears to slowly migrate caudally.

Adult↗