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Biomedical subjects

R D Cespedes

Publications and source records attributed to R D Cespedes.

At least 19 recordsLinked to original sources
PubMed2001

Occult stress urinary incontinence and the effect of vaginal vault prolapse on abdominal leak point pressures.

OBJECTIVES: To compare the difference in abdominal leak point pressures (ALPPs) between patients with large cystoceles and severe vaginal vault prolapse and to assess the frequency of occult stress urinary incontinence (SUI) in these groups. METHODS: A total of 24 adult female patients with pelvic prolapse underwent prospective fluorourodynamic testing to determine the change in ALPP with and without reduction of the pelvic prolapse. Twelve patients had grade III-IV vaginal vault prolapse and 12 had large cystoceles without vault prolapse. ALPP testing was performed with the prolapse unreduced and then reduced using gauze packing and a vaginal speculum. RESULTS: In patients with vault prolapse, the frequency of occult SUI was 50% (6 of 12) and the mean decrease in ALPP was 59 cm H(2)O after prolapse reduction. In the patients with cystocele, all patients had overt SUI, and the mean change in ALPP was 11 cm H(2)O after prolapse reduction. A component of intrinsic sphincter deficiency was identified in 9 (75%) of 12 women with vault prolapse after reduction, and 8 (66%) of 12 women with no vault prolapse had a component of intrinsic sphincter deficiency before reduction, with an additional 2 (17%) of 12 patients after reduction. CONCLUSIONS: There is a high incidence of occult SUI in patients with vault prolapse and the ALPP after reduction is decreased to a much greater degree in patients with vaginal vault prolapse than in patients with cystocele alone. By reducing the pelvic prolapse during urodynamic testing, an accurate ALPP can be obtained, allowing the appropriate incontinence procedure to be performed.

Female↗
PubMed2001

Acute urinary retention and urinary incontinence.

AUR is a commonly seen genitourinary emergency. It has many etiologies, including obstructive, neurogenic, pharmacologic, and extraurinary causes. Treatment is immediate bladder decompression by transurethral catheterization and treatment of the provoking etiology. Urinary incontinence is less commonly seen as a presenting complaint in the ED. For the emergency physician, the key lies in recognizing its underlying cause. Neurologic and pharmacologic causes need to be considered in all patients. Urinary incontinence that is not caused by a neurologic emergency can be referred for further outpatient evaluation.

Acute Disease↗
PubMed2001

Pelvic organ prolapse.

The separate disease entities that are included in the general term of pelvic organ prolapse have been discussed in detail in this chapter. The focus of discussion centered on the pathophysiology and clinical presentation of these conditions. At this point, the emergency physician should be able to properly recognize, assess, initiate treatment, and obtain appropriate referral in cases of pelvic organ prolapse. Postoperative complications commonly seen after these entities are repaired have also been reviewed to help the emergency medicine physician recognize and mange common postoperative complications.

Emergency Service, Hospital↗
PubMed2001

Treatment options for outlet obstruction following anti-incontinence surgery in females.

Urethral obstruction following surgical treatment of stress incontinence can result in a wide spectrum of symptoms ranging from mild urgency to complete retention at its most extreme. Management of these symptoms can be challenging and requires a careful history, pelvic examination, and urodynamics in some instances. In patients refractory to medications or conservative measures, urethrolysis is commonly used to treat the underlying outlet obstruction. The selection of which urethrolysis technique to use can be difficult, as many different methods have been described. In many cases, the choice of technique can be tailored to the original procedure(s) that caused the obstruction. Multiple urethrolysis procedures using a transvaginal approach have been described. One type involves perforation of the endopelvic fascia through a lateral approach. This urethrolysis usually is successful in treating obstruction after needle suspensions and pubovaginal slings, whereas retropubic procedures such as a Marshall-Marchetti-Krantz (MMK) or Burch procedure may require an anterior urethrolysis using a suprameatal approach. In cases where a Burch or MMK was performed and a sling subsequently placed, a combined lateral and anterior approach may be needed to treat the obstruction. In certain cases, a suprapubic approach may be required when the vaginal anatomy was drastically altered or a prior transvaginal urethrolysis failed. Using a urethrolysis technique tailored to the procedure that caused the obstruction, most cases of iatrogenic urethral obstruction should be treatable and result in resumption of normal voiding without producing stress urinary incontinence.

Female↗
PubMed2001

Transabdominal approach to repair of vaginal vault prolapse.

PURPOSE: To review the preoperative evaluation of women with vaginal vault prolapse and describe the surgical methods of treatment using a transabdominal approach. METHODS: Abdominal sacral colpopexy is the most widely performed method of transabdominal correction of vaginal vault prolapse. The procedure is completed by securing the apex to the vagina to the periosteum of the sacrum with mesh. This procedure is demonstrated in great detail. Successful repair can be achieved by other transabdominal approaches and by laparoscopic approaches. RESULTS: Twenty women (mean age 67.9 years) were evaluated for complex pelvic floor prolapse. Six (30.0%) patients had failed transvaginal sacrospinus ligament fixation. Abdominal sacrocolpopexy utilizing Marlex mesh, Halban culdeplasty, and paravaginal repair was performed on all patients. Five posterior repairs and one anterior repair was done. The average operating time for the colpopexy and enterocele repair alone is approximately 90 minutes. The average blood loss was 284 cc. The average hospital stay was 3.7 days. The mean follow-up is 11.3 months (6-27 months). The vaginal vault is well supported in all patients with no recurrent enterocele or vault prolapse. Three patients have asymptomatic grade II cystoceles, and three patients have asymptomatic grade II rectoceles. There were few complications. No mesh complications have been encountered. CONCLUSIONS: Vaginal vault prolapse can be a difficult problem to diagnose and treat. Successful treatment requires thorough knowledge of the anatomy, methods of diagnosis, and treatment options. The abdominal sacrocolpopexy achieves excellent correction of vaginal vault prolapse with minimal morbidity.

Abdomen↗
PubMed2001

Colpocleisis for the treatment of vaginal vault prolapse.

Most females with total vault prolapse undergo reconstructive procedures to restore normal anatomy and function; however, elderly patients who no longer desire sexual intercourse or are medically unstable can be treated effectively with a vaginal closure or colpocleisis. The traditional approach to colpocleisis has been to simply invert the vagina using pursestring sutures after removing the vaginal mucosa. Although simple to perform, after repairing referred treatment failures who used this approach, we began to use a different approach that emphasizes the strength of an anterior repair and extensive posterior repair that then is sutured together. This vaginal closure is reinforced with a strong perineorrhaphy. This multicompartment colpocleisis was performed in 38 elderly females (mean age 77, range 68 to 88) with total vault prolapse. No treatment failures were noted with a mean follow-up of 24 months (range 3 to 52 months), and all patients were satisfied with the results of the procedure. No significant complications occurred, and no patient has regretted the loss of sexual function. The aim of this article is to discuss the indications, procedural aspects, and results of performing a multicompartment colpocleisis and partial colpocleisis for total vault prolapse in elderly females.

Aged↗
PubMed2001

Male slings for postprostatectomy incontinence.

PURPOSE: Over the past few years, there has been increasing interest in using male slings for postprostatectomy incontinence (PPI). Currently, three different forms of the male sling has been described: one using synthetic materials and two using human fascia or dermis. This article will give a historical perspective on the male sling and describe the surgical techniques and early results using two different types of male slings using fascia or dermis. MATERIALS AND METHODS: From 1997 to 1999, nine patients with PPI underwent a bladder neck sling procedure using a combined perineal and abdominal approach. All patients had a suprapubic incision to expose the rectus muscle and to place a suprapubic tube. Since 1999, we have used a wide cadaveric fascial or dermal sling placed at the proximal bulbar urethra. Using an entirely perineal approach, the sling ends are fixated to the inferior pubic rami using bone anchors. RESULTS: Of 9 patients with bladder neck slings, 6 are dry, 1 is significantly improved, and 2 have failed, at a mean follow-up of 13 months. For the perineal male sling, 26 (45%) of 58 patients were completely dry, and overall 47 (81%) of 58 were significantly improved or were dry at a mean 6 months postoperatively. Neither group had significant complications. CONCLUSIONS: Both male slings appear to be safe and effective procedures for treating PPI; however, longer follow-up and additional experience are needed to determine their true role in the treatment of PPI.

Dermis↗
PubMed2000

Abdominal sacral colpopexy and abdominal enterocele repair in the management of vaginal vault prolapse.

Vaginal vault prolapse and enterocele represent challenging forms of female pelvic organ relaxation. These conditions are most commonly associated with other pelvic organ defects. Proper diagnosis and management is essential to achieve long-term successful outcomes. Physical examination should be carried out in the lithotomy and standing positions (if necessary) in order to detect a loss of vaginal vault support. With proper identification of the vaginal cuff, one should assess the degree of mobility of the vaginal cuff with a Valsalva maneuver. If there is significant descent of the vaginal cuff, vaginal vault prolapse is present, and correction should be considered. The abdominal sacral colpopexy is an excellent means to provide vaginal vault suspension. This procedure entails suspension of the vaginal cuff to the sacrum with fascia or synthetic mesh. This procedure should always be accompanied by an abdominal enterocele repair and cul-de-sac obliteration. In addition, many patients require surgical procedures to correct stress urinary incontinence, which is either symptomatic or latent (occurs postoperatively after prolapse correction). Complications include: mesh infection, mesh erosion, bowel obstruction, ileus, and bleeding from the presacral venous complex. If the procedure is carried out using meticulous technique, few complications occur and excellent long-term reduction of vaginal vault prolapse and enterocele are achieved. The purpose of this article is to review the preoperative evaluation of women with pelvic organ prolapse, and provide a detailed description of the surgical technique of an abdominal sacral colpopexy.

Aged↗
PubMed2000

Anterior approach bilateral sacrospinous ligament fixation for vaginal vault prolapse.

The sacrospinous ligament fixation (SSLF) was first described as a unilateral fixation; however, bilateral fixation, when possible, allows a symmetrical vaginal reconstruction and provides additional vaginal vault support. We evaluated the outcome of treating total vault prolapse using a bilateral SSLF through an anterior vaginal approach. From July 1996 to July 1999, 28 patients (mean age 67) underwent bilateral SSLF procedures through an anterior vaginal approach. All patients had either grade 3 or 4 vault prolapse, and all patients had associated enteroceles, cystoceles, and rectoceles. All patients underwent fluorourodynamic evaluation including an abdominal leak point pressure (ALPP) with reduction of the vaginal prolapse. A pubovaginal sling was performed in 25 patients and all 28 patients underwent an anterior colporrhaphy, rectocele, and enterocele repair. A vaginal paravaginal repair was performed in 22 cases. At a mean follow-up of 17 months (range 5 to 35), 27 of 28 patients were cured, 1 patient had an asymptomatic unilateral grade 1 vault prolapse, 2 patients had developed small asymptomatic cystoceles and there had been no recurrence of rectoceles or enteroceles. Stress incontinence had been cured in all patients; however, 2 patients continued to have mild urge incontinence requiring <1 pad per day. Two patients complained of transient gluteal pain. We believe the anterior approach bilateral SSLF is a safe procedure with excellent medium term results in women with grade 3 to 4 vaginal prolapse.

Aged↗
PubMed1999

Retroperitoneal recurrences after retroperitoneal lymph node dissection for low-stage nonseminomatous germ cell tumors.

OBJECTIVES: To evaluate the incidence and sites of retroperitoneal recurrence after modified retroperitoneal lymph node dissection (RPLND) for low-stage nonseminomatous germ cell tumors (NSGCTs). METHODS: A retrospective review of 88 patients who underwent RPLND for Stage I or II NSGCTs between 1971 and 1991 was performed to determine the incidence and site of any retroperitoneal recurrence. RESULTS: Six retroperitoneal recurrences (four isolated and two in conjunction with failures at other sites) were found with a minimum follow-up of 5 years. All 6 patients had left-sided primary tumors, with three recurrences near the left renal hilum and two near the right renal hilum. All recurrences were at or outside the boundaries of the surgical dissection. Only one retroperitoneal recurrence may have been prevented by performing a bilateral dissection. CONCLUSIONS: Although uncommon, local recurrences can occur after RPLND. The right and especially the left renal hilum appear to be at higher risk of failure, possibly because of incomplete dissection in these areas. A more complete dissection in these areas may further decrease the local recurrence rate. Overall, the data presented and the studies reviewed suggest that modified RPLND reliably removes metastatic tumor with a low failure rate. If failures do occur, they are usually outside of the template and would not necessarily be prevented with a complete bilateral infrahilar dissection.

Follow-Up Studies↗
PubMed1998

A followup on transurethral collagen injection therapy for urinary incontinence.

PURPOSE: Transurethral collagen injection therapy has been used successfully in treating stress urinary incontinence due to intrinsic sphincter deficiency since United States Food and Drug Administration approval in October 1993. MATERIALS AND METHODS: Telephone interview and chart review were performed on 139 women with intrinsic sphincter deficiency documented using video urodynamics, of whom 73% had grade 3 incontinence (leakage without effort). Median followup was 18 months (range 6 to 36). Median patient age was 72 years. RESULTS: A total of 103 patients (74%) was substantially improved after collagen therapy, 29 (20%) were improved and 7 had no improvement. Of the substantially improved group 72% obtained continence after 2 or fewer injections. Of the patients 11% required a "booster" injection more than 6 months after initial treatment. Complications, such as hematuria, urinary tract infections or transient urinary retention, were rare. CONCLUSIONS: Our results confirm the safety and efficacy of transurethral collagen. Once continence is achieved further collagen therapy is rarely necessary.

Aged↗
PubMed1998

Our experience with pubovaginal slings in patients with stress urinary incontinence.

PURPOSE: Pubovaginal slings successfully treat stress urinary incontinence in women with intrinsic sphincter deficiency. Because of its durability, it has been an attractive procedure in select patients with urethral hypermobility. We examine our experience with pubovaginal sling. MATERIALS AND METHODS: A total of 150 patients were evaluated for pelvic prolapse and urinary incontinence. An abdominal leak point pressure was determined in all patients. Of patients with type II stress urinary incontinence, 36 patients (80%) underwent additional gynecological procedures at the time of the pubovaginal sling, compared to 29% with intrinsic sphincter deficiency and 33% with coexisting urethral hypermobility and intrinsic sphincter deficiency. RESULTS: The overall cure rate was 93% with a mean followup of 22 months. At 1 week postoperatively spontaneous voiding was accomplished by 56% of the patients with urethral hypermobility and 57% with intrinsic sphincter deficiency. Only 2.8% of patients required surgical therapy for prolonged urinary retention. De novo urgency/urge incontinence occurred in 19% of women with a 3% incidence of persistent urge incontinence. CONCLUSIONS: Pubovaginal slings are effective and durable. Voiding dysfunction is uncommon and is temporary in most patients.

Adult↗
PubMed1998

Transvaginal urethrolysis for urethral obstruction after anti-incontinence surgery.

PURPOSE: Urethral obstruction following a stress incontinence procedure occurs in 5 to 20% of patients. We examine the success of transvaginal urethrolysis in resolving voiding dysfunction. MATERIALS AND METHODS: A retrospective chart review was performed on 39 patients who had undergone transvaginal urethrolysis for urethral obstruction following an anti-incontinence procedure. Preoperatively, a history was taken, and pelvic examination and either video urodynamics or cystoscopy were done. RESULTS: All 39 patients complained of urge incontinence, 13% had urinary retention, 51% had incomplete bladder emptying and 36% voided to completion but had irritative voiding symptoms. Previous surgery included retropubic urethropexy in 41% of the cases, pubovaginal sling in 38% and bladder neck suspension in 21%. Mean length of followup after urethrolysis was 16 months. Of the 39 patients 33 (85%) had resolution of urge incontinence but 5 still required occasional intermittent catheterization. The remaining 6 patients had continued urge incontinence. An augmentation procedure was performed in 4 patients with improvement of symptoms. CONCLUSIONS: Our data support transvaginal urethrolysis for the treatment of iatrogenic urethral obstruction. It is a rapid, effective and minimally invasive technique that should be considered if voiding dysfunction does not resolve spontaneously.

Adult↗
PubMed1998

Pelvic prolapse: diagnosing and treating cystoceles, rectoceles, and enteroceles.

The current generation of women is maintaining a healthier and more active lifestyle into an older age. Treatable conditions such as stress urinary incontinence and pelvic prolapse detract from this active lifestyle. In many cases, an improved quality of life can be maintained by treating pelvic prolapse conditions with relatively minor surgical procedures. Optimal treatment requires a knowledge of pelvic floor anatomy, an understanding of the various pelvic floor defects, and experience in selecting the appropriate procedure. The unequivocal diagnosis of pelvic prolapse conditions can only be made on physical examination. Each section of the vagina -- anterior, posterior, lateral, and apex -- must be inspected and evaluated separately to define the true nature and degree of prolapse. The examination should be performed with a moderate amount of urine in the bladder, and the patient must strain forcefully during the procedure. In some cases, this requires that the patient stand or sit upright during part of the examination to allow all areas of prolapse to become manifest. When the proper procedures are performed, excellent long-term results can be anticipated. The successful treatment of cystoceles requires an evaluation for both lateral and central defects, as inadequate treatment of either defect will lead to recurrences. The treatment of rectoceles is more controversial: Most clinicians would repair symptomatic rectoceles, but many choose not to treat asymptomatic rectoceles because there is little documented benefit to justify the risk of postoperative dyspareunia. Small asymptomatic enteroceles may be treated with a pessary; however, large symptomatic enteroceles usually require surgery.

Female↗
PubMed1998

Pelvic prolapse: diagnosing and treating uterine and vaginal vault prolapse.

Uterine prolapse is often associated with a concomitant rectocele, cystocele, and/or an enterocele. Moderate degrees of prolapse are often associated with a feeling of pelvic heaviness or fullness or low back pain. The symptoms usually worsen with exertion and ease with bed rest. In severe prolapse, the cervix may descend outside the vaginal introitus, and patients may complain that a "mass" is protruding from the vagina. Bleeding from mucosal ulcerations or from the cervical os may occur due to rubbing of the prolapsed tissue against the patient's clothing. The commonly associated problems of cystoceles and rectoceles may lead the patient to complain of difficulty voiding, recurrent urinary infections, and/or "splinting" to defecate. Mild cases of uterine prolapse do not require therapy unless the patient is symptomatic; in most cases of second- or third-degree prolapse, however, patients may be quite uncomfortable and desire therapy. Nonsurgical options, such as a pessary, are usually tried first if the patient desires conservative therapy. Operative repair for uterine prolapse is usually approached vaginally if the uterus is small. An abdominal approach may be preferred if the uterus is large or if the woman has had multiple previous pelvic procedures or has extensive endometriosis or other processes that may obliterate the cul-de-sac. In either approach, the uterosacral and cardinal ligaments must be carefully ligated and tied together, and the cul-de-sac must be obliterated to reduce the risk of subsequent enterocele and to properly suspend the vaginal vault.

Female↗