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Biomedical subjects

W A Addison

Publications and source records attributed to W A Addison.

At least 19 recordsLinked to original sources
PubMed2001

Vaginal mesh erosion after abdominal sacral colpopexy.

OBJECTIVE: Our goal was to compare the prevalence of vaginal mesh erosion between abdominal sacral colpopexy and various sacral colpoperineopexy procedures. STUDY DESIGN: We undertook a retrospective analysis of all sacral colpopexies and colpoperineopexies performed between March 1, 1992, and February 28, 1999. The patients were divided into the following 4 groups: abdominal sacral colpopexy, abdominal sacral colpoperineopexy, and 2 combined vaginal and abdominal colpoperineopexy groups, one with vaginal suture passage and the other with vaginal mesh placement. Survival analysis and Cox proportional hazards models were developed to examine erosion rates and time to erosion between groups. RESULTS: A total of 273 abdominal sacral vault suspensions were performed with the use of permanent synthetic mesh. There were 155 abdominal sacral colpopexies and 88 abdominal sacral colpoperineopexies. Among the 30 combined abdominal-vaginal procedures, 25 had sutures attached to the perineal body and brought into the abdominal field and 5 had mesh placed vaginally and brought into the abdominal field. Overall, mesh erosion was observed in 5.5% (15/273). The prevalence of mesh erosion was 3.2% (5/155) in the abdominal sacral colpopexy group and 4.5% (5/88) in the abdominal sacral colpoperineopexy group (P not significant). The rates of erosion when sutures or mesh was placed vaginally were 16% (4/25) and 40% (2/5), respectively, and were significantly increased in comparison with the rates for abdominal sacral colpopexy (hazard ratio, 5.4; 95% confidence interval, 1.6-18.0; P = .005; vs hazard ratio, 19.7; 95% confidence interval, 3.8-101.5; P < .001). These variables retained their significance after we controlled for other independent variables, including age, concomitant hysterectomy, concomitant posterior repair, and estrogen status. The median time to mesh erosion was 15.6 months for abdominal sacral colpopexy, 12.4 months for abdominal sacral colpoperineopexy, 9.0 months in the suture-only group (P < .005), and 4.1 months in the vaginal mesh group (P < .0001). CONCLUSIONS: The rate of mesh erosion is higher and the time to mesh erosion is shorter with combined vaginal-abdominal sacral colpoperineopexy with vaginal suture and vaginal mesh placement in comparison with abdominal sacral colpopexy.

Adult↗
PubMed2000

A survey of pessary use by members of the American urogynecologic society.

OBJECTIVE: To describe trends in pessary use for pelvic organ prolapse. METHODS: An anonymous survey administered to the membership of the American Urogynecologic Society covered indications, management, and choice of pessary for specific support defects. RESULTS: The response rate was 48% (359 of 748). Two hundred fifty surveys were received at the scientific meeting and 109 were returned by mail. Seventy-seven percent used pessaries as first-line therapy for prolapse, while 12% reserved pessaries for women who were not surgical candidates. With respect to specific support defects, 89% used a pessary for anterior defects, 60% for posterior defects, 74% for apical defects, and 76% for complete procidentia. Twenty-two percent used the same pessary, usually a ring pessary, for all support defects. In the 78% who tailored the pessary to the defect, support pessaries were more common for anterior (ring) and apical defects (ring), while space-filling pessaries were more common for posterior defects (donut) and complete procidentia (Gellhorn). Less than half considered a prior hysterectomy or sexual activity contraindications for a pessary, while 64% considered hypoestrogenism a contraindication. Forty-four percent used a different pessary for women with a prior hysterectomy and 59% for women with a weak pelvic diaphragm. Ninety-two percent of physicians believed that pessaries relieve symptoms associated with pelvic organ prolapse, while 48% felt that pessaries also had therapeutic benefit in addition to relieving symptoms. CONCLUSION: While there are identifiable trends in pessary use, there is no clear consensus regarding the indications for support pessaries compared with space-filling pessaries, or the use of a single pessary for all support defects compared with tailoring the pessary to the specific defect. Randomized clinical trials are needed to define optimal pessary use.

Adult↗
PubMed1999

Understanding lower urinary tract function in women soon after bladder neck surgery. Continence Program for Women Research Group.

The aim of this work was to correlate anatomic and urodynamic measures with function following bladder neck surgery. Eighty-seven women who underwent bladder neck surgery at two tertiary academic medical centers in the southeastern U.S. were studied in this prospective outcomes analysis. Preoperative and 6-week and 6-month postoperative status was assessed with urodynamic testing, physical examination, and condition-specific quality of life instruments. Correlations of dynamic urethral obstruction (quantified by pressure transmission ratio, PTR, determinations) and urethral support (quantified by urethral axis measurements) with functional status were determined. At 6 weeks, 50% of the subjects with inadequate dynamic obstruction (PTR < 90%) had genuine stress incontinence (GSI) compared to 5% of those with PTR >/= 90% (P = .00002). Of those with excessive obstruction (PTR > 110%), 32% had detrusor instability (DI) and 47% had emptying phase dysfunction (EPD) compared to 6% and 24%, respectively, of those with PTR </= 110% (P = .006 and P = .04). At 6 months, subjects with excessive obstruction were more likely to have EPD than other subjects (75% vs. 27%, P = .001). Those with optimal dynamic obstruction (PTR >/= 90% but </= 110%) were more likely to have normal function (no GSI, no DI, and no EPD) than those with higher or lower PTRs (59% vs. 34%, P = .04). Urethral axis measurements did not correlate with functional status at either follow-up session. The magnitude of dynamic urethral obstruction is related to function after bladder neck surgery. Excessive obstruction is associated with DI and EPD, inadequate obstruction with GSI, and optimal obstruction with normal function. Neurourol. Urodynam. 18:629-637, 1999.

Adult↗
PubMed1999

Accuracy of clinical assessment of paravaginal defects in women with anterior vaginal wall prolapse.

OBJECTIVE: The objective of this study was to determine the accuracy of clinical assessment of paravaginal defects in women with anterior vaginal wall prolapse. STUDY DESIGN: A retrospective chart review of all women undergoing surgery for anterior vaginal wall prolapse during the years of 1994 to 1996 identified operative notes that described the surgical assessment of paravaginal support. These surgical findings were compared with the preoperative clinical assessment. Clinical parameters that predicted poor correlation were identified. Statistical analysis used the chi(2) test. RESULTS: One hundred seventeen patients had surgery for anterior vaginal prolapse. Seventy had documentation of an intraoperative paravaginal support evaluation. Of these, 44 patients had vaginal procedures, and 26 had abdominal procedures. All patients had at least stage 2 prolapse before surgery, and all were noted to have excellent pelvic support 4 to 6 weeks after surgery. The prevalence of paravaginal defects at surgery was 47% on the right and 41% on the left. The sensitivity and negative predictive value for the clinical assessment for paravaginal defects were good on both the right and left sides, whereas the specificity and positive predictive values were poor. Stage of prolapse, previous hysterectomy, or previous anterior colporrhaphy did not significantly affect the accuracy of the clinical examination in predicting fascial defects. However, previous retropubic urethropexy did significantly decrease the accuracy of the clinical examination in predicting right paravaginal defects (P <.01) but not left. CONCLUSION: Although preoperative clinical assessment for paravaginal defects is useful, it does not substitute for careful intraoperative evaluation for endopelvic fascial defects.

Adult↗
PubMed1998

An anatomic and functional assessment of the discrete defect rectocele repair.

OBJECTIVE: The aim of this study was to describe the anatomic and functional results of the discrete fascial defect rectocele repair. STUDY DESIGN: Sixty-nine women underwent rectocele repair at Duke University Medical Center during a 3-year period beginning January 1, 1994. Repair was limited to reapproximation of discrete defects in the rectovaginal fascia, without levator plication or perineorrhaphy. Outcome measures included Pelvic Organ Prolapse Quantitation measurements, prolapse stage, and a symptom questionnaire. Univariate and nonparametric tests were used as appropriate. RESULTS: Before the operation 46% patients (32/69) reported constipation, 39% (27/69) reported splinting, 32% (22/69) reported tenesmus, and 13% (9/69) reported fecal incontinence. The median preoperative posterior Pelvic Organ Prolapse Quantitation stage was 2 (1-4). Pelvic Organ Prolapse Quantitation stage had improved for all but 2 women at 6 weeks. Eighteen percent (8/43) had recurrent rectoceles at 12 months. Mean values for the points describing the posterior vaginal wall improved >2 cm (P <.0001). Although perineorrhaphy was not performed, the genital hiatus decreased by 2. 3 cm (P <.0001), with no significant change in the length of the perineal body. Functional results mirrored anatomic results, with statistically significant improvements for all symptoms. CONCLUSIONS: The discrete defect rectocele repair provides anatomic correction of rectoceles with alleviation of associated symptoms for most women.

Adult↗
PubMed1998

Urethral prolapse after collagen injection.

A woman who was treated for intrinsic urethral sphincteric deficiency with periurethral injection of glutaraldehyde cross-linked collagen had prolapse of the urethral mucosa and recurrence of incontinence. She subsequently required surgical resection and a fascia lata sling. This is the first known occurrence of this postinjection complication.

Aged↗
PubMed1998

Management of pelvic organ prolapse.

The wide variety of available pessaries permits rather precise choice of pessary to meet a given patient's needs. Different approaches are reviewed. A paradigm for choosing a surgical repair based on the fascial and muscular support defects, as well as the functional demands and limitations of the patient is presented.

Exercise Therapy↗
PubMed1998

Reliability and correlation of measurements during and after bladder neck surgery. The Continence Program for Women Research Group.

OBJECTIVES: To assess the reliability of seven intraoperative measurements of the effects of bladder neck suspension and correlate these measurements with postoperative dynamic urethral obstruction, quantified as the cough-pressure transmission ratio. PATIENTS AND METHODS: Sixty women undergoing surgery for bladder neck hypermobility had seven measurements performed in duplicate: (i) the endoscopic appearance of the bladder neck: (ii) the bladder neck-retropubic surface distance (BN-RP distance); (iii) urethral axis; (iv) slow urethral pressure profilometry (UPP); (v) fast UPP; (vi) straining UPP; and (vii) dynamic UPP. Reliabilities were assessed by computing the intraclass correlation coefficient (R) for continuous data or Kappa statistic (K) for ordinal data. Pearson correlation coefficients were used to assess the relationships between the intra-operative measures and postoperative pressure transmission. RESULTS: The intra-operative reliabilities for maximum pressure, length and area from the three UPP techniques were high (R=0.88-0.98) as were those for urethral axis measurements (R=0.98). In contrast, reliabilities were poor for pressure transmission ratios (R=0.15-0.33), BN-RP distance (R=0.55), and endoscopic appearance (K=0.10). There were significant correlations of the pressures from the UPPs and intra-operative pressure transmission ratios with postoperative pressure transmission ratios; however, the poor intra-operative reliability of intra-operative pressure transmission limits their usefulness. None of the other measures correlated significantly with postoperative pressure transmission ratios. CONCLUSIONS: Of the measures studied, only intra-operative UPPs had both high reliability and good postoperative correlations.

Aged↗
PubMed1997

Abdominal sacral colpoperineopexy: a new approach for correction of posterior compartment defects and perineal descent associated with vaginal vault prolapse.

OBJECTIVE: Our purpose was to assess a modification of abdominal sacral colpopexy in 19 patients. STUDY DESIGN: The rectovaginal space was dissected to the superior aspect of the posterior vaginal fascia still contiguous with the perineal body. Mersilene (Ethicon, Somerville, N.J.) mesh was sutured to this fascia and along the entire posterior vaginal wall. Patients with vault prolapse, perineal descent, and associated rectoceles or enteroceles are reported. Outcome measures included bowel symptoms and pelvic organ prolapse staging. Defecography was performed in three patients. Wilcoxon signed rank analysis was used for comparison of prolapse measures. RESULTS: Mean follow-up was 11 weeks. Bowel symptoms improved in 8 of 11 women. No subjects had greater than stage II prolapse postoperatively and median improvement in stage was 3 (range 2 to 4). The mean decrease in the genital hiatus measurement was 3.13 +/- 1.25 (range 2 to 6) cm. Postoperative defecography documented correction of rectoceles and enteroceles and improvement in perineal descent with straining. CONCLUSIONS: Abdominal sacral colpoperineopexy is effective surgery for vaginal vault prolapse associated with perineal descent and posterior vaginal defects.

Adult↗
PubMed1997

The value of intraoperative cystoscopy in urogynecologic and reconstructive pelvic surgery.

OBJECTIVE: Our goal was to evaluate the role of intraoperative cystoscopy during surgery for pelvic organ prolapse and urinary incontinence. STUDY DESIGN: Charts of 224 consecutive patients who had intraoperative cystoscopy performed after urogynecologic surgery were reviewed. RESULTS: Nine injuries occurred that were unsuspected before cystoscopy, for an incidence of 4%. Six ureteral ligations occurred, four after Burch cystourethropexy and two after vaginal culdoplasty. Intravesical sutures were noted after two Burch procedures, and another injury occurred with passage of fascia lata through the bladder during a pubovaginal sling procedure. Eight injuries were managed by removal and replacement of the suture or sling with only one requiring ureteroneocystotomy. When patients with injuries were compared with those without, there were no statistical differences in demographic or surgical parameters. CONCLUSIONS: The potential for damage to the lower urinary tract is significant with complex urogynecologic surgery. Because of the increased and delayed morbidity associated with unrecognized injury, intraoperative surveillance cystoscopy should be considered a part of all such procedures.

Adult↗
PubMed1997

Sacral osteomyelitis: an unusual complication of abdominal sacral colpopexy.

BACKGROUND: Abdominal sacral colpopexy using permanent mesh is an established technique for repair of vaginal vault prolapse. Infection is not a frequent complication. We report two cases of lumbosacral osteomyelitis treated with intravenous antibiotics without mesh removal. CASES: The first patient had known advanced degenerative arthritis. Unremitting severe low back pain 5 years after abdominal sacral colpopexy prompted magnetic resonance imaging (MRI), revealing osteomyelitis and diskitis. The second patient developed symptoms 2 months postoperatively, and MRI indicated osteomyelitis with epidural abscess. Both patients received intravenous antibiotics, and neither required surgical debridement or mesh removal. CONCLUSION: Osteomyelitis can present remote from the operation and can be difficult to diagnose. Protracted parenteral antibiotic therapy can be definitive treatment without mesh removal.

Aged↗
PubMed1996

Randomized prospective comparison of needle colposuspension versus endopelvic fascia plication for potential stress incontinence prophylaxis in women undergoing vaginal reconstruction for stage III or IV pelvic organ prolapse. The Continence Program for Women Research Group.

OBJECTIVE: Severe prolapse may mask potential genuine stress urinary incontinence in women. Some have suggested that a suspending urethropexy be performed in women who have potential genuine stress incontinence demonstrated by barrier reduction of the prolapse preoperatively. Our aim was to compare outcomes after prolapse surgery that included a formal bladder neck suspension with those operations that did not. STUDY DESIGN: This prospective randomized clinical trial assigned 32 women with bladder neck hypermobility and stage III or IV pelvic organ prolapse to receive either a needle colposuspension or bladder neck endopelvic fascia plication as part of the vaginal reconstructive surgery. Twenty-nine subjects underwent detailed clinical, anatomic, urodynamic, and quality-of-life evaluations before and 6 weeks and 6 months after surgery; 23 completed urinary diary and quality-of-life evaluations after a mean of 2.9 years. RESULTS: Needle colposuspension increased short-term complications without providing additional protection from de novo stress incontinence. Barrier testing before surgery predicted urethral sphincteric resistance after surgery; however, such testing neither predicted a patient's function after surgery nor indicated the need for a suspending urethropexy. The combination of a needle colposuspension with a sacrospinous ligament suspension predisposed to the early development of support defects of the upper anterior vaginal segment and to failure of bladder neck support. CONCLUSIONS: Preoperative barrier testing in women with severe prolapse is not useful in identifying individuals who require a suspending urethropexy. Needle colposuspension increases short-term complications, lacks durability, and may predispose to early and severe recurrent anterior prolapse when performed with a sacrospinous ligament vault suspension.

Aged↗
PubMed1996

Voiding function following prolapse surgery. Impact of estrogen replacement.

OBJECTIVE: To identify factors that would predict postoperative bladder function in postmenopausal women undergoing pelvic reconstructive surgery for pelvic organ prolapse. STUDY DESIGN: Demographic variables and urodynamic measures were analyzed in respect to the length of postoperative bladder catheterization. RESULTS: Patient age, the presence of abnormal preoperative voiding patterns or elevated postvoid residuals, the route of surgical approach and the performance of urethropexy did not correlate significantly with the length of postoperative catheterization; only hormonal status did. Postmenopausal women using estrogen replacement therapy required significantly fewer days of catheterization than those who were not receiving estrogen replacement therapy. CONCLUSION: The use of preoperative estrogen replacement therapy is associated with a reduction in the length of postoperative bladder catheterization in women undergoing pelvic reconstructive surgery for pelvic organ prolapse.

Aged↗
PubMed1995

Comparison of oral estrogens and estrogens plus androgen on bone mineral density, menopausal symptoms, and lipid-lipoprotein profiles in surgical menopause.

OBJECTIVE: To compare an oral estrogen-androgen combination with estrogens alone on bone, menopausal symptoms, and lipoprotein profiles in postmenopausal women. METHODS: Surgically menopausal women received oral esterified estrogens (1.25 mg), or esterified estrogens (1.25 mg) and methyltestosterone (2.5 mg) daily, for 2 years. Bone mineral density of the lumbar spine and hip, menopausal symptoms, lipoprotein profiles, and biochemical and hematologic indices were evaluated. RESULTS: Sixty-six patients were enrolled in the study. Both treatment regimens prevented bone loss at the spine and hip; combined estrogen-androgen therapy was associated with a significant increase in spinal bone mineral density compared with baseline (n = 24; mean score +/- standard error 3.4 +/- 1.2%, P < .01). In the estrogen group, high-density lipoprotein (HDL) cholesterol increased significantly and low-density lipoprotein cholesterol decreased significantly. Cholesterol, HDL cholesterol, and triglycerides decreased significantly in the estrogen-androgen group. Menopausal symptoms of somatic origin (hot flashes, vaginal dryness, and insomnia) were improved significantly by both treatments. Neither adverse hepatic effects nor significant safety or tolerance problems were reported in either group. CONCLUSION: Oral estrogen-androgen increased vertebral bone mineral density compared with pre-treatment values and relieved somatic symptoms. Safety indices, including lipoprotein levels, indicated that the combination was well tolerated over the 2 years of treatment.

Administration, Oral↗
PubMed1993

Pelvic relaxation involving the middle compartment.

Loss of pelvic support involving the 'middle compartment' is manifested by herniation through the central pelvic floor in proximity to the intersection of an imaginary line from the public symphysis to the coccyx with another from one ischial spine to opposite ischial spine. Loss of middle compartment support may exist in association with 'anterior compartment' defects, 'posterior compartment' defects, or both. The severity of middle compartment relaxation ranges from mild uterine descensus to total uterovaginal prolapse when the uterus is present. When the uterus has been removed, it may range from vaginal vault descent to total vaginal eversion and includes all grades of enterocele. Middle compartment defects are usually not isolated. The recent literature relevant to middle compartment defects consists primarily of additional reports on surgical management, including continued modification and evolution of surgical techniques. Larger surgical series with longer follow-up periods have been reported. Cadaveric and histologic studies have appeared which have added to the understanding of normal anatomy and the disruptions thereof, which can cause middle compartment defects. Sophisticated diagnostic imaging techniques have generated preliminary reports which are of interest.

Female↗
PubMed1992

Pelvic inflammatory disease: findings during inpatient treatment of clinically severe, laparoscopy-documented disease.

OBJECTIVES: We evaluated the relationship between clinically severe pelvic inflammatory disease and laparoscopic diagnosis and grading, comparative treatment with clindamycin plus cefamandole or doxycycline, and a management protocol for inpatient pelvic inflammatory disease treatment. STUDY DESIGN: Thirty-three patients who met our clinical criteria for severe pelvic inflammatory disease underwent diagnostic laparoscopy. Pelvic inflammatory disease patients were randomized to double-blind treatment with clindamycin plus cefamandole or doxycycline within our management protocol; postdischarge oral antibiotics were omitted. RESULTS: Laparoscopy confirmed pelvic inflammatory disease in 23 (70%) patients; 10 (44%) had mild pelvic inflammatory disease by laparoscopic grading. Laparoscopic grade alone predicted necessary duration of therapy to response: mild pelvic inflammatory disease, 2.3 +/- 0.5 days; moderate pelvic inflammatory disease, 2.7 +/- 1.5 days; and severe pelvic inflammatory disease, 3.9 +/- 1.5 days (p less than 0.05). Using the management plan presented, response rates for both antibiotic regimens were 100%. CONCLUSIONS: Clinical diagnosis and grading of severe pelvic inflammatory disease has poor specificity. Laparoscopic grading of severity of pelvic inflammatory disease seems accurate. Both clindamycin plus cefamandole and clindamycin plus doxycycline are equally effective regimens for treatment of pelvic inflammatory disease and did not require supplementation after discharge. Our management plan is objective and practical; daily bimanual examination is the most sensitive indicator of persistent disease.

Adult↗