Biomedical subjects
Publications and source records attributed to J Christian Winters.
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.
PURPOSE: The incidence of site specific pelvic organ prolapse defects following sacral colpopexy is not clearly reported. We evaluated site specific pelvic organ defects after colpopexy and determined its impact on patient satisfaction. MATERIALS AND METHODS: A total of 40 women with vault prolapse underwent abdominal sacral colpopexy, culdeplasty and paravaginal repair. Followup consisted of pelvic examination and satisfaction assessment every 6 months. The Baden-Walker classification was used and prolapse halfway to the introitus (grade II) or greater was considered significant prolapse. Surgical failure was identified as grade III prolapse or greater. Satisfaction was assessed on a scale of 1 to 3 with 3 being highly satisfied and according to whether patients perceived a successful outcome. RESULTS: A total of 40 patients with an average age of 66.5 years (range 48 to 81) had an average followup of 25.5 months (range 18 to 42). Of the 40 patients 22 (55%) did not have significant prolapse, including 14 with no prolapse, and 8 with grade I cystocele and/or rectocele. Of the 40 patients 18 (45%) had recurrent significant prolapse, including cystocele in 8 (grades II and III in 4 each), rectocele in 6 (grades II and III in 2 and 4, respectively), and grade II cystocele and rectocele in 3. There was 1 case of recurrent vault prolapse. Eight of 40 cases (20%) were considered surgical failures. Patients without prolapse were highly satisfied (average score 2.95) and 100% considered surgery to have been successful. The recurrent prolapse group was less satisfied (mean score 2.5) and 66.7% considered the surgery successful. CONCLUSIONS: Recurrent pelvic organ prolapse is not an uncommon finding after colpopexy and it may adversely affect patient satisfaction.
PURPOSE OF REVIEW: The success in the use of the tension-free midurethral sling procedures (tension-free vaginal tape, suprapubic arch, transobturator tape) has dramatically altered the approach to the surgical management of stress urinary incontinence in women and marked a resurgence in the use of mesh. We will analyze the characteristics of synthetic meshes and explain the rationale for using monofilament materials with larger pore sizes. Thus, the purpose of this review is to introduce the surgeon to a variety of commercially available mesh materials and the characteristics that make mesh suitable for use as sling grafts. RECENT FINDINGS: Type I macroporous mesh materials appear most suitable for transvaginal implantation. Utilization of these materials in a minimally invasive retropubic or transobturator approach, promising early and intermediate follow-up data has been achieved. The outcome of these procedures in women with urethral hypermobility and genuine stress incontinence seems clear. No controlled data, however, exist to define the role of these procedures in difficult cases of stress incontinence. Newer generations of minimally invasive slings may offer treatment alternatives in these difficult cases. SUMMARY: Minimally invasive slings using Type I mesh materials are safe and effective. 'Hybrid' type slings may offer alternatives in difficult cases of stress urinary incontinence.
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Perhaps the most significant advance in the modern-day surgical management of stress urinary incontinence is the introduction of the tension-free midurethral sling procedures. Based on a theory of anatomy and function, which emphasizes the importance of the midurethra in maintaining continence during stress, these minimally invasive procedures are being used widely in the surgical treatment of stress urinary incontinence. As surgeons continue to experience excellent early results, a major concern is defining the role of the traditional pubovaginal sling placed at the bladder neck. In addition to the obvious indications to consider a more traditional sling procedure (markedly atrophic vaginal wall or situations that may promote sling erosion), are there other clinical scenarios in which there still is a role for the traditional pubovaginal sling? Several clinical conditions that warrant consideration of a traditional sling procedure are presented in this review. Based on the mechanism of action and clinical data demonstrating decreased efficacy of midurethral sling procedures, we propose that a traditional pubovaginal sling be considered in the following clinical conditions: lack of urethral mobility, mixed urinary incontinence, concomitant urethral reconstruction, and after a failed sling procedure. In the absence of randomized control trials, we present evidence that makes a case for consideration of the traditional sling procedure in these complex clinical conditions.
AIM: To assess outcome and patient satisfaction utilizing Duraderm allograft as sling material. METHODS: Twenty five patients undergoing the Duraderm sling procedure were evaluated by pelvic examination, post-void residual urine, and multi-channel urodynamics. Follow-up included repeat examination, stress test, and chart review. Patient satisfaction was assessed by phone interview with an independent examiner. Outcome was defined as dry (no leaking at all and patient perception of satisfaction), improved (minimal leak requiring < or =1 pad daily and patient perception of satisfaction), or failure. RESULTS: Average age was 62.0 years (30-83); average daily preoperative pad usage was 3.5 (2-8). Duraderm allograft measuring 2 x 12 cm was used. Mean postoperative catheter time was 7.7 days (3-37 days). At 6 months, 17/25 (68%) were dry, 6 (24%) improved, and 2 (8%) failed. Mean intermediate follow-up at 14.8 months (8-23 months) revealed 8/25 (32%) patients were dry, 9 (36%) were improved, and 8 (32%) failed Duraderm sling. Mean pad use after surgery was 1.4 (0-6). Of the 25, 19 (76%) were satisfied with the surgical outcome, 17 (68%) noted they would have surgery again, and 17 (68%) would recommend the procedure. CONCLUSIONS: Initial results of pubovaginal sling using Duraderm graft are satisfactory; however, longer term follow-up is disappointing. Graft degeneration previously described after utilization of cadaveric fascia lata may be possible following implantation of cadaveric dermis.
The role of urodynamics in the routine preoperative evaluation of women with stress urinary incontinence is controversial. The introduction of tension-free mid-urethral sling procedures has created a new paradigm in surgical management. The capability of performing these procedures on an ambulatory basis has created more uncertainty about the use of urodynamic testing. The long-term results of these procedures in patients with intrinsic sphincteric deficiency, mixed incontinence, and voiding dysfunction are not clearly known. This article reviews the mechanism of action and results of tension-free slings and proposes a rational role for urodynamic testing in patients considered for these procedures.
AIMS: To report outcome and urodynamic follow-up of incontinent ileovesicostomy in quadriplegic patients with neurogenic bladder. METHODS: Seven patients (five male, two female; mean age, 33.7 yr) with neurogenic bladder underwent ileovesicostomy for management of leakage or complications of chronic catheter drainage. Five had chronic indwelling catheters: three suprapubic and two urethral. Preoperatively, all had upper tract evaluation and videourodynamics. All seven patients had detrusor hyperreflexia. Preoperative detrusor leak point pressures averaged 42.7 cm H(2)O. Two females had intrinsic sphincteric deficiency from prolonged Foley catheter drainage. Ileovesicostomy involves isolation of a 15-20-cm segment of terminal ileum. The proximal 6-8 cm of this segment is opened on the antimesenteric border. The dome of the bladder is opened widely in a transverse manner and the proximal portion of the bowel is sutured onto the bladder. The distal portion of the ileum remains tubularized and becomes the stoma. RESULTS: There were no intraoperative complications. Operative time averaged 159 minutes. Associated procedures included removal of bladder calculus (n = 1), pubovaginal sling (n = 2), and Marshall Marchetti Krantz suspension (n = 1). Mean blood loss was <200 cc in six patients. Mean hospital stay was 8 days. Complications in two patients included: fascial stenosis requiring stoma revision (n = 1), wound infection (n = 1), and postoperative ileus (n = 1). Mean follow-up was 37.4 months. Postoperatively, mean detrusor leak point pressures were 16.7 cm H(2)O (P = 0.0061). Patient satisfaction is high with only one complaint of occasional difficulty fitting the appliance. CONCLUSIONS: Ileovesicostomy is an effective method of urinary drainage in quadriplegic patients. Detrusor leak point pressures were lowered, and upper tracts were preserved. No long-term complications were encountered.