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The 13th

National Congress of
Urogynecology

UROGYN 2016

Editors Assoc.
Prof. Dr Elvira Bratila

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INDEX

Foreword 10

Incidence and influence of urinary incontinence on institutionalized women life quality 11


ANASTASIU-POPOV Diana Maria, TOTH GA, HINOVEANU Denisa Adriana,
ANASTASIU D., GLUHOVSCHI A.

Variability of renal markers in preeclampsia 16


TOTH GA., CRAINA M., ANASTASIU POPOV Diana Maria, ANASTASIU D.,
GLUHOESCHI A.

Ultrasound landmarks in diagnosis of pelvic floor disorders.


A comprehensive overview 20
BERCEANU Costin, CÎRSTOIU Monica, MEHEDINŢU Claudia, BRĂTILĂ Petre,
BERCEANU Sabina, BOHÎLŢEA Roxana, BRĂTILĂ Elvira

Hormone deficiency and its impact on the lower urinary tract 29


BERCEANU Costin, CÎRSTOIU Monica, MEHEDINŢU Claudia, BRĂTILĂ Petre,
BERCEANU Sabina, VLĂDĂREANU Simona, BOHÎLŢEA Roxana, BRĂTILĂ Elvira

Intrapartum and postpartum bladder management 39


BODEAN Oana, MUNTEANU Octavian, VOICU Diana, VASILESCU Sorin,
BOHILTEA Roxana, CIRSTOIU Monica

Pelvic floor ultrasound - review 46


Bohîlțea Roxana Elena, Cîrstoiu Monica Mihaela, Turcan Natalia,
Munteanu Octavian, Bodean Oana, Voicu Diana, Baroș Alexandru,
Brătilă Elvira

Mechanism and Risk Factors for Pelvic Organ Prolapse - Review 50


Bohîlțea Roxana Elena, Cîrstoiu Monica Mihaela, Turcan Natalia,
Bohîlțea Laurențiu Camil, Munteanu Octavian, Bodean Oana, Voicu Diana,
Baroș Alexandru, Brătilă Elvira

Stress urinary incontinence (sui) due to causes other than parturition 56


BOȚ Mihaela, VLĂDĂREANU Radu, VLĂDĂREANU Simona, ZVÂNCĂ Mona,
PETCA Aida

Delayed Recognition of a Sigmoid Colon Iatrogenic Lesion Following Total Abdominal


Hysterectomy in a Patient with a Previous Episode of Acute Diverticulitis 63
Socea Bogdan, Alexandru Carâp, Smaranda Alexandru,
Moculescu Cezar, Bobic Simona, Dimitriu Mihai, Socea Laura,
Vlad Denis Constantin
Index
Iatrogenic Ureteral Injuries During Gynecological Procedures 66
Vlad Denis Constantin, Alexandru Carâp, Anca Nica, Moculescu Cezar,
Bobic Simona, Socea Bogdan

The benefits of laparoscopically assisted vaginal hysterectomy 69


Cristurean V-C., Nour C., Cardon I.

Assessing the severity of acute pelvic inflammatory disease 73


CERNETCHI Olga, CAUS Catalin, CAUS Natalia,
RAILEAN Ludmila, ILIADI TULBURE Corina

Approach to complications caused by prosthetic materials used


in pelvic reconstructive surgery 77
CIORTEA Răzvan, RADA Maria Patricia,
BERCEANU Costin, MĂLUŢAN Andrei Mihai, MOCAN Radu, IUHAS Cristian,
BUCURI Carmen Elena, CÂMPIAN Eugen Cristian, DICULESCU Doru, MIHU Dan

Lower urinary tract symptomatology in deep infiltrating


and bladder endometriosis 83
COROLEUCĂ Ciprian-Andrei, BRĂTILĂ Elvira, BRĂTILĂ Petre, HUDIȚĂ Decebal,
STĂNCULESCU Ruxandra, COMANDAȘU Diana, COROLEUCĂ Cătălin-Bogdan

Vaginal hysterectomy - an economic and less invasive type of approach 87


Stuparu-Cretu Mariana, Caraman Liliana,
Calin Alina Mihaela

Laparoscopic cerclage in pregnant and non pregnant women 93


DORU CIPRIAN Crisan

Cure of stress urinary incontinence with canal transobturator tape 99


DORU CIPRIAN Crisan, RATIU Adrian

Comparative study of surgical care of stress incontinence using tension-free


vaginale tape and transobturator tape 105
DICULESCU Doru, MIHU Dan, CIORTEA Răzvan, CIUCHINĂ Septimiu,
MĂLUȚAN Andrei, IUHAS Cristian, GROZA Daria, CAPOLNA Miorița,
CĂLĂTAN C.

The results of the treatment of stress urinary incontinence by


“Bega-I Munteanu” procedure 110
Gluhovschi Adrian, Anastasiu Doru Mihai,
Anastasiu Popov Diana Mria

Study on the level of knowledge about contraception of high school students 117
HINOVEANU Adriana Denisa, ANASTASIU Popou Diana Maria,
CARAIVAN Magdalena, ANASTASIU Entertainment, GLUHOVSCHI Adrian

5
Index
Uterine Fibroids and Urinary Symptoms 121
HORHOIANU Irina-Adriana, HORHOIANU Vasile-Valerica,
GRIGORIU Corina, CIRSTOIU Monica

Lower Urinary Tract Disfunction and Oncologic Pelvic Surgery 128


HORHOIANU Irina-Adriana, DUMITRACHE Mihai,
DRAGOI Vlad, CIRSTOIU Monica

Challenges of the surgical resection in pelvic masses involving


uro-genital organs in women - our experience 135
DAVITOIU Dragos, DIMA Ana Laura, BALEANU Vlad, MANDA Ana Laura

Corrective Procedures for Apical Defects Associated with 2nd and 3rd Degree
Anterior Vaginal Wall Prolapse 142
MANTA Anca, BRATILA Petre Corrnel, COMANDASU Diana, BERCEANU Costin,
MEHEDINTU Claudia, CIRSTOIU Monica, BOHILTEA Roxana,
CONSTANTIN Vlad Denis, BRATILA Elvira

Bladder Evacuation Disorders Following Radical Surgery for Cervical Cancer 148
MANTA Anca, BRATILA Petre Cornel, COMANDASU Diana,
BERCEANU Costin, MEHEDINTU Claudia, CIRSTOIU Monica,
BOHILTEA Roxana, STANCULESCU Ruxandra,
CONSTANTIN Vlad Denis, BRATILA Elvira

The Effect of Estrogen Deficiency Related to Aggressive Chemotherapy


on Female Urogenital Tract 155
PLOTOGEA Mihaela Nicoleta, TANASE Alina Daniela,
SECUREANU Adrian Florin, IONESCU Sorin, BRATILA Elvira,
BERCEANU Costin, CIRSTOIU Monica Mihaela, MEHEDINTU Claudia

Laparoscopic Ureterolysis in the Management of Deep and Infiltrative


Pelvic Endometriosis - Case report 164
MEHEDINTU Claudia, DIACONU Victor, SECUREANU Adrian Florin,
IONESCU Sorin, BRATILA Elvira, BERCEANU Costin,
CIRSTOIU Monica Mihaela, ANTONOVICI Marina Rodica,
PLOTOGEA Mihaela Nicoleta, IONESCU Oana Maria

Modified Aburel Procedure for the Treatment of Uterine Prolapse with


Stress Urinary Incontinence - Personal Experience 170
MITRAN Mihai, PANA Doru, POPESCU Alina,
VELICU Octavia, COMANDASU Diana-Elena, BRATILA Elvira

Reconstructive options in managing the neurogenic


bladder disfunction in children 177
MUNTEANU Alexandra, FILIPOIU Florin, IONESCU Sebastian,
CIRSTOIU Monica, RADULESCU Luiza, STAVARACHE Irina,
MUNTEANU Octavian

6
Index
Reconstructive options after iatrogenic ureteral lesions 183
MUNTEANU Octavian, MUNTEANU Alexandra,
VOICU Diana, BODEAN Oana, BOHALTEA Roxana,
BRATILA Elvira, CIRSTOIU Monica

Treating genital prolaps revolutionary concept, 4 years from applying


“Process Saba Nahedd” - 90 cases 188
SABA Nahedd

The Management of Grade II/III Hydronephrosis During Pregnancy 195


NASTAS Ana, STANCULESCU Ruxandra, MEHEDINTU Claudia,
BERCEANU Costin, COMANDASU Diana-Elena, CIRSTOIU Monica,
BOHILTEA Roxana, VLADAREANU Simona, PATRASCOIU Sorin,
NASTAS Alexandru, BRATILA Elvira

Treatment of Interstitial Cystitis in Menopausal Women 200


NASTAS Ana, MEHEDINTU Claudia, BERCEANU Costin, CIRSTOIU Monica,
BOHILTEA Roxana, COMANDASU Diana-Elena, PATRASCOIU Sorin,
NASTAS Alexandru, BRATILA Elvira

Female sexual dysfunction and pelvic floor surgery 205


NENCIU Cătălin George, AFLOAREA Adina Elena, ALBU Ruxandra Andreea,
VOICU Diana, MUNTEANU Octavian, VASILESCU Sorin, ȘANDRU Florica,
DUMITRAȘCU Mihai Cristian

Modern Treatment In Pelvic Perineal Statics Dysfunctions 211


SIMONA Niculescu, MIHAI Burniche, DAN Niculescu

Assessing etiological prognostic factors associated with preterm birth by


a questionnaire-based risk score 217
OANCEA Alexandru, FRANDES Mirela, LUNGEANU Diana, ANASTASIU Doru,
STANESCU Casiana, ANASTASIU-POPOV Diana Maria

Associations between the risk of preterm birth, gestational age at which


the birth occurred and birth weight of newborns 223
OANCEA A, ANASTASIU D, TOTH AG, FRANDEȘ Mirela,
STĂNESCU Casiana, GLUHOVSCHI A, ANASTASIU-OPOV Diana Maria

Repairing the vesicovaginal fistula by transvesical (extraperitoneal) approach 229


PATRASCOIU Sorin, BRATILA Elvira, BRATILA Petre, STROESCU Cezar,
HANNA Adrian, ZAMFIR Radu, MISCHIE Oana Gabriela, POPA Laura,
CONSTANTIN Carmen, GILCA Iulian, PUSCASU Ana, BIRCEANU Adelina,
GURAU Claudia, COPCA Narcis

7
Index
Suburethral endometriosic cyst and stress urinary incontinence 234
PATRASCOIU Sorin, GILCA Iulian, BRATILA Elvira, COPCA Narcis,
PIVNICERU Catalin, STROESCU Cezar, CONSTANTINICA Victor,
ZAMFIR Radu, ROSULESCU Corneliu, PRIE Ioan, MISCHIE Oana Gabriela,
BIRCEANU Adelina, GURAU Claudia

Management of vesicovaginal fistula by combined transperitoneal


and tansvesical approach 240
PATRASCOIU Sorin, BRATILA Elvira, BRATILA Petre, COPCA Narcis,
ZAMFIR Radu, MISCHIE Oana Gabriela, PRIE Ioan, GURAU Claudia,
ROSULESCU Corneliu, CONSTANTINICA Victor, GILCA Iulian

Laparoscopic pectopexy: a new technique for the treatment


of vaginal apical prolapse 247
PIRTEA Laurentiu, SECOSAN Cristina, ILINA Razvan, SAS Ioan,
PIRTEA Marilena, HORHAT Florin, JIANU Adelina, GRIGORAS Dorin

Transperineal Ultrasound Role for Pelvic Floor Dysfunction Evaluation 252


PLES Liana, SIMA Romina-Marina, STANESCU Anca Daniela,
POENARU Mircea Octavian, MOGA Marius

Comparison Between Classical and Protetic Surgical Intervention


for Pelvic Floor Dysfunctions and Urinary Stress Incontinence 258
POENARU Mircea Octavian, SIMA Romina-Marina,
DAN Diana, STANESCU Anca Daniela, PLES Liana

Pregnancy complications in women with Abruptio Placentae 262


SAGAIDAC Irina, FRIPTU Valentin

Up-date Concerning Medical Drugs Useful To Treat Urinary Incontinence 267


STANCULESCU Ruxandra, COMANDASU Diana-Elena,
BAUSIC Vasilica, BRATILA Elvira

Robotic Assisted Sacrocolpopexy: operative technique and post-operative


outcomes for a single center experience in a series of 158 patients 271
STANIMIR Marius, BENIJTS Jan, TWAHIRWA Michael, CHIUȚU Luminița,
NEMEȘ Răducu, MITROI George, ASSENMACHER Christophe

Quality of life outcomes after Robotic Assisted Sacrocolpopexy:


a single center experience in a series of 50 patients 279
STANIMIR Marius, BENIJTS Jan, TWAHIRWA Michael, CHIUȚU Luminița,
NEMEȘ Răducu, MITROI George, ASSENMACHER Christophe

The Role of Urodynamics in Evaluation of Women with Urinary Incontinence 286


TÎRNOVANU Mihaela Camelia, PASAT Sebastian, COZOREANU Ana Maria,
CARA Andreea Raluca, TÎRNOVANU Ştefan Dragoş, HOLICOV Monica,
ONOFRIESCU Mircea

8
Index
Pelvic organ prolapse in women: Our experience at
Bucharest Emergency University Hospital 292
VOICU Diana, Oana BODEAN, Octavian MUNTEANU,
VASILESCU Sorin, Roxana BOHILTEA, Vlad BALEANU,
Claudia MEHEDINTU, Costin BERCEANU, CIRSTOIU Monica

9
Foreword

FOREWORD

We have the pleasure to present to you the proceedings volume of The XIIIth National
Congress of Urogynecology held in Brasov between 29 September – 1 October 2016. The
Romanian Society of Urogynecology is knowing a very large development and admiration by
the other societies of urogynecology in Europe.

This year the meeting was larger than ever, bringing together about 200 attendants. A
main attraction was the pre-congress course “Hysterectomy minimally invasive by vaginal and
laparoscopic approaches”.

A selection of the papers accepted to the congress is now published in this proceedings
volume with the commitment of the publisher. In this volume the readers will find beside
updated information in most fields of urogynecology, a cross-sectional profile of our scientific
research. Of course, the responsibility of the content belongs to the contributors.

We are confident that the readers will find this book useful and welcome.

Conf. Dr. Elvira Bratila


Editor
President of the Congress

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© Filodiritto Editore - Proceedings

Incidence and influence of urinary incontinence on


institutionalized women life quality
ANASTASIU-POPOV Diana Maria1, TOTH GA1,2,
HINOVEANU Denisa Adriana2, ANASTASIU D.1,3,
GLUHOVSCHI A.1
1
Department XII Obstetrics, Gynecology and Neonatology, “Victor Babes” University of Medicine and
Pharmacy, Timisoara (ROMANIA)
2
Obstetrics and Gynecology, “Bega” Maternity Clinic, Timisoara (ROMANIA)
3
Department of Functional Sciences/Medical Informatics and biostatistics, “Victor Babes” University
of Medicine and Pharmacy, Timisoara (ROMANIA)
E-mail: doru_anastasiu@yahoo.com

Introduction

Urinary incontinence is a hard to define clinical entity. There is no unanimous definition


accepted, some authors considering it a symptom, others describing it as a disease [9, 10].
Urinary incontinence is still an actual problem due to the increase in life expectance of
women witch leads to a higher incidence for these disease, this affection being a concern for
women over 60 years.
It’s still an actual problem due to the fact that it has an influence on the quality of life for
women, being a personal problem as well as a problem for the family. In the same time it is an
issue for prophylaxis as well for the choice of treatment being it surgical or therapeutic.
Choosing an surgical treatment is another issue because there are 200 surgery’s available
for urinary incontinence in this moment [1, 2].
There are problems as well with the differential diagnosis as well with the investigations
that need to be made.
Incidence for urinary incontinence is variable in the data found is the medical literature
depending on: studied population, age and profession.
In the same time we need to keep in mind that this pathology is underdiagnosed due to
the fact that women don’t show up for medical examination for this disease because they are
embarrassed by it.
In the United States there are around 11 million women witch are affected by urinary
incontinence from witch 1.5milion are institutionalized [4, 5, 25]. In Europe around 55% of
the women population suffers from a form of urinary incontinence from witch 5-6% needs a
surgical treatment. In Austria 250.000 women are diagnosed with urinary incontinence.
Statistically speaking the incidence is between 5 – 25% a value witch is lower in reality due
to the taboo character of this disease.
Monthly statistics in UK show that 46% of the women witch come for clinical prime care
assistance suffer for a type of urinary incontinence being it mixt or the urge to urinate.
On a study population of 22.000 Thomas finds in England an incidence for urinary
incontinence of 5% in the age group of 5 and 34 years, 19% in 35 – 74 years and 16% for the
group over 74 years.
Brocklehurst [6] finds on study population of 4000 people an incidence of 9% for urinary

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© Filodiritto Editore - Proceedings
incontinent and 57% on the group with the age between 45 and 69 years.
In England on a study population of women over 65 witch are institutionalized Harrison [7]
found a incidence for urinary incontinence in 1/3 of the women and Stots et. all. Found that ¾
of women in a geriatric department suffer from urinary incontinence.
There are few studies in Romania for the incidence of urinary incontinence. In Bucharest,
Poiana, Nahed and Saba found an incidence of 20%, appreciating that 50% of the women that
come for a gynecologic examination suffer form urinary incontinence in preclimax.
The Center for urinary incontinence appreciates that 25% of the women over 65 have
symptoms for urinary incontinence for witch 50% are stress urinary incontinence, 25% urge
incontinence and 25% are mixed urinary incontinence.
On a study population of 327 women Bumbu in Oradea found an incidence of 23% and
Marta Arsoly in Targul Mures [5] through a screening found an incidence of 21,9% in women
with the age of 70-75 years, every second women suffering from urinary incontinence.
In Timisoara, Anastasiu found on a group of 1329 women an incidence of 17% for urinary
incontinence of various degrees and on a group of 1100 of exanimated women through directed
talks about the existence or not of a urinary incontinence an incidence of 10,75% [2, 11].
In this conditions we can appreciate that the prevalence of urinary incontinence in women
in Romania is between 18-20%. A study made by Dioknot showed that 50% of institutionalized
women suffer from urinary incontinence, 59% of these not telling they’re doctor of this
problem. The social impact of urinary incontinence on women points out that regardless of the
type of urinary incontinence in the first phase it leads to a state of discomfort along the way as
shown by Joyles [14] and Brocklehurst (6.13) cause a feeling of embarrassment and anxiety
that may progress to depression, going through this with progressing stages of shame and
anger because of perceived an odor that may occur especially in the elderly with poor hygiene.
At this stage they hide they’re affection for they’re husband and friends [6].
Evolution of urinary incontinence may lead to a restriction of social and sexual life (trips,
theater, sports). Harris (7) showed that in this phase 2% of women lose they’re friends. The
worse the symptoms become women stop their activity, 4% of the women staying in the
comfort of their home close to a toilet. It is noteworthy that 40% of women report that urinary
incontinence significantly affects their life and lifestyle. This is due to the fact that women
are forced to have better care for their personal hygiene (special underwear for incontinence,
medicated pad, toilet nearby).
In severe forms of urinary incontinence, the condition does not allow women to leave their
home thus considering themselves infirm, many using catheters and other devices, probes
bladder, artificial sphincters that increase the risk of urinary infections. Unfortunately many of
these women do not seek medical advice, although they are concerned about their affection,
researching it on the internet, reading literature about their disease and practicing from their
own initiatives exercises to strengthen the pelvic floor muscles or using self-medication.

Material and Methods

We have a group of 92 institutionalized women with the age between 50 and 91 in 2 houses
for elderly people in the county of Timis. One is in the urban area and one is the countryside.
We did a complete medical history with a directed talk to point out the presents of urinary
incontinence, a complete medical checkup with gynecologic examination to investigate the
urinary incontinence, inclusive provocation test and driptest for the type of urinary incontinence.

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Table 1. Study group according to age
Age Nr. Cases Percent
51-60 6 6,52
61-65 9 9,78
66-70 15 16,30
71-75 24 26,08
76-80 12 13,04
81-85 16 17,39
>85 10 10,86
Total 92 99,97

The study highlighted several body changes in menopausal women insisting on those who
might have influence on the occurrence of urinary incontinence.
Thus it was found that 47.2% of cases of anorexia with muscle hypotrophy especially in
women over 70 years as well as obesity in 52.17% of cases with a body mass index greater
than 25, 18.75% of them were with 1st degree of obesity, 56.25% with 2nd degree and 25% with
3rd degree of obesity.
We mention that 84,78% of them were under treatment for HTA with hypotensive
medication and B-blocants and 13,04% with Diabetes Mellitus type II and 17.39% had various
degrees of atherosclerosis.
Of the women who strongly denied the existence of a urinary incontinent 16 (53.33%) did
not accept the challenge test for urinary incontinence, we are convinced that at least half of
them could be symptoms of urinary incontinence relying on the results of the driptest which
showed that 9.78% of with bladder instability, 29.34% in a mixed-type incontinence and in
60.86% of cases are with stress urinary incontinence.
In conclusion we can say that the incidence of urinary incontinence in the study group
was 90.2%. These women are not disturbed by those symptoms due the fact that they are
institutionalized and gave up on social life. No women in the study group acted any type
treatment for urinary incontinence offered by the doctor this suggesting the pessimistic view
on menopause and the consolation in the approach on the so called “old age” although the
urinary incontinence has a negative effect on their life quality.

Conclusion

1. The morphofunctional changes in a women’s body at menopause are significant and


obvious in institutionalized women due to the lack of estrogens.
2. The incidence of urinary incontinence in this category of women is 90,2% from witch
60,86% suffer from stress urinary incontinence.
3. Urinary incontinence has a negative effect on the quality of life in institutionalized women
but it does not bother them due to the fact that they are in isolated and they refused any
treatment type offered by they’re doctor.

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contemporane; vol A IV Conf DKMT Timisoara, 2007 pag 19 – 20.
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24. Tahtinen RM, Auvinen A, Cartwright R – Smoking and blader symptons in women.
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Variability of renal markers in preeclampsia


TOTH GA.1,2, CRAINA M.1,3, ANASTASIU POPOV Diana Maria2,
ANASTASIU D.1,3, GLUHOESCHI A.1
1
Department XII Obstetrics, Gynecology and Neonatology, “Victor Babes” University of Medicine and
Pharmacy, Timisoara (ROMANIA)
2
Obstetrics and Gynecology, “Bega” Maternity Clinic, Timisoara (ROMANIA)
3
Department of Functional Sciences/Medical Informatics and biostatistics, “Victor Babes” University
of Medicine and Pharmacy, Timisoara (ROMANIA)
E-mail: doru_anastasiu@yahoo.com

Introduction

Gestational hypertensions remains one of the main concerns of contemporary obstetrics


due to complications that may appear to pregnant woman and the fetus, having paramount
importance on fetal mortality, induction of premature birth and eclampsia being the third
leading cause of maternal mortality.
All these complications occur despite efforts in research directed towards this area in the last
100 years. Minor forms reveal a high incidence of gestational hypertension of 8-15% (16,30) at
the same time representing an incidence of 5-10% of all pregnant women (1,2,6,22,40). During
pregnancy the maternal body goes through a lot of adaptability changes to being pregnant, the
most significant changes being for the urogenital and cardiovascular systems.
Morphological and functional changes in the kidney during a state of gestation are very
significant and important for the pregnancy.
Proteinuria is common during preganancy and has it’s limits between 200-500mg/24h
(41.42). The mechanisms for the development of proteinuria include increased glomerular
filtration rate (GFR) inability to absorb filtered proteins and renal hemodynamics disorders
induced by accentuated lordosis and compression of the uterus on the renal vein (40,41,46,47).
Uric acid is an end product of purine metabolism filtered at the glomerulus. The bulk of
filtered uric acid excretion is reabsorbed. It seems that the regulatory mechanism for uric acid
secretion works due to a balanced active secretory reabsorption. During pregnancy there is
an increase clearance for uric acid, its values normally exceeding 3-4mg%. A uremia 4mg%
higher than in a pregnant pregnant can suggest a higher the risk of preeclampsia (25,45,47).
In literature we find that hyperuricemia is a very serious maternal and fetal prognostic
factor, especially when it’s associated with arterial hypertension and proteinuria. The
Nephrology School from Timisoara showed that the renal secretion of uric acid is proportional
with it’s plasmatic concentration and that the uric acid resorption is the first that gets affected,
hyperuricema being an element for renal impairment in gestational hypertension, being an
expression of hypovolemia.
The serum creatinine in pregnant women with preeclampsia is sometimes lower then in
nonpregnant women due to the glomerular filtration rate. In preeclampsia the kidney is so
bad injured that the creatinine serum is 2 to 3 times lower then the normal values, especially
in those cases that go with acute renal failure (28,29,32,39,40). All these elements indicated
a major involvement in the etiopathology of gestational hypertension, theyre variability
depending on gestation age and the presents of preeclampsia symtoms. The urea levels are

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usualy not modified during pregnancy, thou it can have a slightly lower values due to the high
glomerular filtration rate.

Methodology

We analyzed in our study a group of 300 pregnant women witch had all exams made when
they came to the 1st prenatal examination and done again at 28 weeks of gestation. In this
group for all pregnant women, blood pressure, weight, checked for edemas, urine examination
for proteinuria and micro albuminuria. The presents and increase of those in the 2nd trimester
of pregnancy is an indication of preeclampsia in 80% of cases. At 28 weeks of pregnancy for
all women in the group we calculated the index Theodoru-Pascu and did the roll-over test
(17,20,34).
From all laboratory test that we did during the whole pregnancy we insisted on renal
markers, the kidney being the most affected organ in gestational hypertension. We used and
Architech CI 8220 and Disfunction to evaluated those markers.
From a total of 300 pregnant women 267 (89%) had a normal out come, 33 (11%) had
gestational hypertensions. From those 20 (60,6%) had mild symptoms with an gestosis index
of 4 and the other 13 (39,4%) had preeclampsia and an gestosis index between 5 and 12 the
maximal value being 16.
The cases with an gestosis index under 5 had mild symptoms for gestational hypertension,
edema or albuminuria, the sever form of gestational hypertension and preeclampsia had an
gestosis index higher then 5 and needed hospitalization for observation and investigation.
We analyzed the values of the laboratory examinations for the cases with gestational
hypertension and we found that in 15 (45,45%) of the cases we found pathological values
as follows: hyperuricemina in 4 cases (12,12%), presents of urea in 3 cases, and proteinuria
>0.3mg% in 8 (29,26%) of cases.
The serum creatinine wasn’t modified in pregnant women with gestational hypertension
nor in the ones with preeclampsia. In all cases of gestational hypertension and preeclampsia
there were renal injury’s present, indicated by the renal markers. From 33 pregnant women 22
(66,6%) underwent C-section and 11(33,3%) vaginal birth. In this group we had no fetal death
and no maternal mortality.

Conclusions

The incidence of preeclampsia in the study group was 11% of which 60.6% were mild or
moderate form and in the remaining 39.4% being with preeclampsia.
During the analyses of the renal makers we showed that proteinuria and uric acid had the
highest variability, those rising to high values in sever cases. All cases with preeclampsia
underwent C-section. Our conduct of choosing to terminate early a pregnancy is sustained by
the absents of fetal and maternal mortality. The association of hyperuricemia and proteinuria
are makers for a bad meterno-fetal outcome and indicated the presents of preeclampsia.

REFERENCES

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3. Chiovschi S, Vasile C, Vasile M – Immunologic implication in preclampisa in:

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Munteanu I, rippman E, Hrubaru N. – Maternal-Fetal Risk in gestosis Roma, Cic Editioni
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factor of extreme ages in: Maternal Fetal Risk in Gestos, CicEditini Internationali, 1996,
pag 133 – 135.
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arteriala, Timisoara , Ed. Helicon, 1995, pag 279 – 308.
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Appleton – County – Crofst, 1980, 4, 30, pag 94 – 95.
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pag 5.
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hypertension in pregnancy; a prospective study – Ciln. Exp. hypertens Bg, 1990, 2, pag
125 – 134.
10. Jenkins DM – Immunology of gestots in: Perinata perspectives – Carring for the high risk
fetus and mother – Alber Szent Gyorky Medical university szeged, 1990 pag 30 – 40.
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Clin.Obstet-Gynecol 1977, 4, pag 665 – 669.
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17 pag 144.
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histology. Gynecol, 1969, 167, pag 214 – 220.
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patologie, diagnostic, tratament – Rev.Obstet.Ginec, 1993, 41, pag 1 – 4, 5 – 8.
16. Munteanu I., Rippman FT., Hrubaru N. – Maternal-fetal risk in gestos, Roma Cic Editioni
Internationali, 1996.
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ameninta de disgravidia tardiva in Bolile cardiovasculare la femeia gravia, Bucurest –
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18. Need JA – preeclampsia in pregnancy by different fathers – immunological studies,
Br.Med.J, 1975, 1, pag 548 – 549.
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Risk in Gestos, Roma, CIC Editoni Internationli, 1996 pag 444 – 448.
21. Pascu H, Teodoru G – Scorul disgravidiei in: Asistenta mamei si copilului, Ed. Med. Buc,
1974 pag 25 – 52.
22. Parapakkham S – An epidemiologic study o eclampsia, ObstetGynecol, 1979, 54 pag
26 – 31.
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de termen in hipertensiune arterila severa in timpul graviditatii, Rev.Obst.Ginec, 1985, 3,
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Litech Craiova, 1996, pag 65 – 71.
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Enciclopedica, Bucuresti; 1989.
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32. Sibai BM – Prevention of preelcmpsai: Is it possible?; J. Maternal Fetal invest.; 1992, 2,
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findings. Obstet-Ginecol, 1982, 52,2, pag 153 – 157.
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Ginecol, Timisoara, 1993, pag 299 – 300.
36. Virtej P, Bodea C, Dorobantu M, albu A – Evaluarea efectelor hipertensiunii arterial
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38. Yabes, De Suane M: Increasingly safe and successful pregnancies. Ed. Elsevier, 1996.
39. Wallenbug HCS, Visser W – Maternal hemodynamics in sever hypertensive disorders
in pregnancy in “Perinatal perspective” proceeding of the 22nd international congress of
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pag 111 – 118.
41. Romosan I, Coraba A, Tuculeanu D – Aportul renourinar si arcina in: Imunteau – Tratat
de obstetrica ed a II-a, Buc. Ed. Academiei Romane vol II; pag 260 – 282.
42. Romosan I – Rinichiul – Ghid diagnostic si terapeutic , Ed. Medicala , 1999.
43. Romosan I: Rinichiul morfologie clinica. Ed. Helion , Timisoara, 1993.
44. Pritchard J., Cunningham O., Pritchard S. - The Parkland Memorial Hospital protocol for
treatment of eclampsia: evaluation of 245 cases.1984, 148; pag 951-983.
45. Lind T., Godfrey KA, Otnn H – Changes in serum uric acid concetrations during normal
pregnancy, Br. J. Obstet, 1984 pag 91 – 128.
46. Zosin C, Chiovschi ST, Dragan P, Golea O, Romosan I, Zosin Ioana – Rinichiul si sarcina,
Ed. Facla, Timisoara; 1985.
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Munteanu I – Tratat de obstetrica Ed. II Buc. Editura Academia Romana, 2006, pag 928
- 959.

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Ultrasound landmarks in diagnosis of pelvic floor


disorders. A comprehensive overview
BERCEANU Costin1, CÎRSTOIU Monica2, MEHEDINŢU
Claudia2, BRĂTILĂ Petre2, BERCEANU Sabina1,
BOHÎLŢEA Roxana2, BRĂTILĂ Elvira2
1
Department of Obstetrics and Gynecology, University of Medicine and Pharmacy Craiova
(ROMANIA)
2
Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy,
Bucharest (ROMANIA)
E-mails: dr_berceanu@yahoo.com, dr_cirstoiumonica@yahoo.com, claudiamehedintu@yahoo.com,
pbratila49@yahoo.com, dr.berceanu@gmail.com, r.bohiltea@yahoo.com, elvirabarbulea@gmail.com

Abstract

Ultrasonography (US) can provide useful information in diagnosing the stress urinary
incontinence (SUI) by morphologically assessing the bladder, as well as the status and mobility
of the urethral-bladder mobility. Morphologically, the prolapsed uterus and vaginal walls are
the messengers of anatomical defects. The clinical examination assesses the hernia defect and
the prolapsing degree. The content of the hernial sac and the mechanism of prolapse occurrence
are important for an accurate treatment. US can provide data on the content of the hernial sac,
can explain the symptoms – difficulties of bladder, rectal evacuation, SUI – and directs on
the anatomical defects. The US diagnosis solutions in uterovaginal prolapse are represented
by the transperineal (translabial) ultrasound – TPUS, transvaginal ultrasound – TVUS or
endoanal ultrasound – EAUS. The US assessment of the anterior pelvic compartment aims to:
measure the residual urine volume, thickness of the detrusor, dynamics of the bladder neck,
the presence of the cystocele, the integrity of the urethra, tumours or diverticula. The introital
US (5MHz probe) can diagnose the elongation of the cervix or the colpocele – the retroverted
uterus occupying the posterior hernial sac. EAUS and 2D/3D TPUS are complementary in
assessing the posterior compartment. The US landmarks of the posterior compartment are: the
central tendon of perineum – triangular shape, slightly hyperechoic, located anteriorly the anal
sphincter; the rectovaginal septum – hyperechoic appearance between the (hypoechogenic)
vaginal wall and rectal muscles and anorectal angle – between the longitudinal axis of the anal
canal and the posterior rectal wall.
Conclusions: US is non-invasive versus the cystourethrogram/defecography, cost-efficient
compared to the dynamic MRI, enables the real-time evaluation of the pelvic floor, providing
functional anatomy data or the assessment of the position and dynamics of the polypropylene
meshes. US is useful in the preoperative assessment by the possibility to evaluate the contents
of the hernia sac and correlation of anatomic defect – symptoms. US contributes to assessing the
post-therapeutic results, the position of the synthetic meshes and to checking their functional
effect.

Keywords: morphologic evaluation, anatomic defect, dynamic assessment

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General Aspects

The topographic and morphological changes in urogenital organs that generate stress
urinary incontinence can be assessed by ultrasound techniques. [1]
The ultrasound examination (US) of urogenital organs provides the following techniques:
transperineal/translabial ultrasound (TPUS), transvaginal ultrasound (TVUS) or endoanal
ultrasound (EAUS). [1, 2]
The surgical management of the pelvic floor disorders depends on the overall understanding
of its structural and functional integrity. [3]
Pregnancy and childbirth are unanimously acknowledged risk factors for the development
of anatomic and functional disorders of the pelvic floor – prolapse of the pelvic organs and
urinary incontinence. [3, 4]
Falkert A et al. Suggest that the changes of the hormonal status characteristic to the
pregnancy condition and anatomic and functional particularities of the pregnant uterus lead
to connective tissue remodelling and subsequent occurrence of morphological and functional
disturbances in the pelvic floor. [5]
Currently, the diagnostic assessment involves the clinical, ultrasound examination,
urodynamic and anorectal tests, video-cystourethrogram or dynamic cystourethrogram. [2-5]
The usefulness of dynamic magnetic resonance imaging is controversial in terms of high
costs and limited access. [3, 6-9]
The prevalence of urinary incontinence among women in Western countries has been
estimated to range between 12 and 38% and increases with age. [5, 10]
US has many advantages compared to other imaging techniques, through the minimum
discomfort, relative easiness of use, a reasonable learning curve, absence of ionizing radiations,
relatively low examination, favourable cost-effectiveness ratio, as well as the wide availability.
[3, 11]
The genital prolapse is a relatively common problem, and Falkert A et al. Estimate that in
general, women have 12% lifetime risk to be undergo a surgical treatment for this pathology
that also constantly includes urinary inconsistence. [5, 10-13]
Morphologically, the prolapsed uterus and vaginal walls are the messengers of anatomical
defects. The clinical examination assesses the hernia defect and the prolapsing degree. The
content of the hernial sac and the mechanism of prolapse occurrence are important for an
accurate treatment. [14]

Transperineal Ultrasound

US can provide data on the content of the hernial sac, can explain the symptoms – difficulties
of bladder, rectal evacuation, stress urinary incontinence and directs on the anatomical defects.
The transducer is placed in the vulvar area and is slightly rotated 5-10 degrees until an
image of the urethra and bladder is obtained. The next step is to slowly and progressively
rotate until the flat rectum and perineal plate appear in the image, continuing to keep the
urethra and bladder in the image. The descent of pelvic organs is assessed. [3, 10, 11, 14]
Santoro GA et al. recommend that the TPUS for the assessment of stress urinary
incontinence to be done with a patient placed in the dorsal lithotomy position, with the hips
flexed and abducted, and a convex transducer positioned on the perineum between the mons
pubis and the anal margin. [3]
The TPUS of the pelvic floor uses conventional convex transducers (with frequencies of
3-6MHz and field of view of at least 70 degrees). [3, 7, 14]
The TPUS assessment of the anterior compartment aims at the following parameters: the
residual urine volume (Fig. 1 A), thickness of the detrusor, dynamics of the bladder neck, the

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presence of the cystocele, the integrity of the urethra, diagnosis of tumours or diverticula.
(Table 1)

Table 1. Ultrasound assessment of urogenital organs in diagnosis of the stress urinary


incontinence
Compartment Ultrasound landmarks

Anterior Residual urine volume


Thickness of the detrusor
Dynamics of the bladder neck
Presence of the cystocele
Integrity of the urethra
Diagnosis of tumours and diverticula
Middle Translabial ultrasound - no diagnosis data
Introital ultrasound (5MHz probe) – can diagnose the
elongation of the cervix.
Colpocele – the retroverted uterus occupying the posterior
hernial sac
Posterior Central tendon of perineum
Rectovaginal septum
Anorectal angle
Investigation of the anal sphincter

The dynamics of the bladder neck can be assessed by using this technique; under normal
conditions, it remains closed under stress. The opening of the bladder neck – the normal
posterior urethtral-bladder between 900-1100 changes from 900 to over 1800 during the Valsalva
manoeuvre (Fig. 1 B). The descent of the bladder neck on the lower edge of the symphysis
implies a difference of rest –Valsalva > 25mm. [3-5, 15, 16]
Cystocele diagnosis (Fig. 2) by assessing the lowering degree of the bladder base below
the bladder neck, by more than 4 cm under the lower edge of the pubic symphysis. [14, 17, 18]

Fig. 1 A. Measurement of bladder residue (A x B x 5.6 mm). B. 3D TPUS Measurement of


the posterior urethral-bladder angle

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Fig. 2 Cystocele diagnosis

The two-dimensional transperineal US also assesses the medium compartment (Fig. 3). In
the mid-sagittal secion, the cervix placed unusually low is isoechoic and frequently generates
acoustic shadowing. [3-5]
The body of the uterus can be assessed in the same section. The introital ultrasound using
the 5MHz transducer can diagnose the elongation of the cervix. [1, 3-5, 7, 14]
The assessment of the posterior compartment involves the 2D/3D translabial/ transperineal
US, endoanal ultrasound after the clinical examination. The video-defecography and magnetic
resonance imaging can be used.

Fig. 3. Introital ultrasound – can diagnose the elongation of the cervix. Colpocele – the
retroverted uterus occupying the posterior hernial sac

The evaluable structures in the posterior compartment are the central tendon of the perineum
of triangular shape, slightly hyperechoic, located anteriorly the anal sphincter, the rectovaginal
septum having a hyperechoic appearance between the (hypoechogenic) vaginal wall and rectal
muscles and anorectal angle arranged between the longitudinal axis of the anal canal and the
posterior rectal wall. [3-5, 17, 18] (Table 1)
The dynamic evaluation of the anterior compartment is done in the mid-sagittal plane,
having the advantage of the landmark exactly on the lower edge of pubic symphysis. [3-5]
The ultrasound investigation may reveal anatomical defects hiding behind the posterior
vaginal wall prolapse: rectocele, perineal (rectal) hypermobility – change in the central tendon
of the perineum, enterocele, rectal intussusceptions and investigation of the anal sphincter. [3,

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4, 19]
The measurable landmarks in the posterior compartment for evaluating the retrocele are
represented by the maximum depth of the protrusion of the rectal wall in the posterior vaginal
wall, the rectal descent related to the line intersecting the lower edge of the pubis, the maximum
protrusion being measured on the line perpendicular to the contour of the anterior rectal wall.
The rectocele may be diagnosed when the protrusion exceeds 10mm (Fig. 4). [3, 17-19]

Fig. 4 Rectocele – defect of the retrovaginal septum (R - rectocele)

Perineal hypermobility when the rectovaginal septum is intact, although there is rectal
descent, the protrusion of the rectal wall in the posterior vaginal wall is not observed – a
protrusion that sets the rectocele diagnosis. [3-5, 17-21]
Rectal intussusception or rectal invagination – this term practically defines an enterocele
containing the ptosis sigmoid, omentum or thin intestinal loops protruding in the rectal walls,
not in the vaginal wall. Under stress, the rectal wall pushed by the enterocele protrudes in the
lumen of the anal canal (Fig. 5). It is associated with biometric abnormalities of the urogenital
hiatus and pubic-rectal muscle avulsion. [3-5, 17-21]

Fig. 5 Rectal intussusception. A. Gel applied intravaginally (arrow). B. Protrusion of the


rectal wall. The plication appearance of the intraluminal rectal wall
(Ac - anal canal, R - rectum, S - sigmoid)

The internal anal sphincter can also be located by ultrasound, most preferably with a 5
MHz transducer, from the perineum. The transducer is placed on the central tendon of the
perineum and is turned towards the rear. Thus, the thickness of the anterior and posterior
portions of the internal anal sphincter can be measured. This procedure is less unpleasant

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compared to endoanal ultrasound. [3-5, 21]

Transvaginal Ultrasound

The TVUS is performed with the patient placed in the same position as that used for the
TPUS. [3]It is important to maintain the transducer inserted into the vagina in neutral position
and avoid exercising an excessive pressure on the neighbouring structures, not to distort the
anatomy. The TVUS is usually carried out having the patient at rest, during the maximum
Valsalva manoeuvre. [3, 22]

Endoanal Ultrasound

Santoro GA et al. describe this technique with a high multifrequency, 360 degrees rotational
mechanical probe or a radial electronic probe, as described above for TVS. [3]
The patient may be placed in a dorsal lithotomy, left lateral or prone position. [3, 22]
The anatomic evaluation of the anal canal involves assessing the upper portion (the anal-
rectal junction) – the pubic-rectal muscle anchoring the sphincter complex to the pubic ramus,
internal anal sphincter – hypoechogenic circular fibres, it does not have a constant thickness
over the entire length of the anal canal, the external anal sphincter with hyperechoic appearance
– the longitudinal muscle of the anus – located in the intersphincteric groove and the junction
with the levator ani muscle. [3, 4, 10]
The US assessment of the synthetic meshes is of significant importance, because synthetic
implants cannot be investigated by X-ray or computed tomography exploration. In terms
of ultrasound, they are intensely hyperechoic, and the US can be assess either the incorrect
location of them, or the failure in achieving the support for the compartment wherein they have
been placed (Fig. 6). [2, 10, 24]

Fig. 6 Volumetric assessment of synthetic meshes. Multi slice view - MSV

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The assessment of suburethral bandelets is done with a full bladder, at rest and stress. The
proper placement of the bandelet involves 3-5 mm of the urethral wall and more than 1 cm of
the pubic symphysis. The bandelet is properly placed on the limit between the distal urethra
and medium urethra, and under stress, the bandelet is placed in the medium urethra. [3, 24-29]

Conclusions

The US is non-invasive versus the cystourethrography/defecography, cost-efficient


compared to the dynamic MRI, enables the real-time evaluation of the pelvic floor, providing
functional anatomy data or the assessment of the position and dynamics of the polypropylene
meshes. US is useful in the preoperative assessment by the possibility to evaluate the contents
of the hernia sac and correlation of anatomic defect – symptoms. US contributes to assessing the
post-therapeutic results, the position of the synthetic meshes and to checking their functional
effect. US becomes an important element both in the SUI, enabling the morphological and
dynamic assessment of the lower urinary tract, as well as in the preoperative assessment for
establishing the surgical conduct.

REFERENCES

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11. Dietz H. (2007). Quantification of major morphological abnormalities of the levator ani.
Ultrasound Obstet Gynecol 29, pp. 329–334.
12. Rortveit G, Brown JS, Thom DH, Van Den Eeden SK, Creasman JM, Subak LL. (2007).
Symptomatic pelvic organ prolapse: prevalence and risk factors in a population-based,
racially diverse cohort. Obstet Gynecol 109, pp. 1396–1403.
13. Fialkow MF, Newton KM, Lentz GM, Weiss NS. (2008). Lifetime risk of surgical
management for pelvic organ prolapse or urinary incontinence. Int Urogynecol J Pelvic
Floor Dysfunct 19, pp. 437–440.
14. Brătilă E, Vlădăreanu S, Berceanu C, Cîrstoiu M, Mehedințu C, Comandașu D, Mitran
M. (2015). Rolul sarcinii și al nașterii în apariţia tulburărilor de statică pelvică. Revista
Ginecologia.ro 10, (4/2015), pp. 28-33.
15. Khullar V, Cardozo LD, Salvatore S, Hill S. (1996). Ultrasound: a noninvasive screening
test for detrusor instability. Br J Obstet Gynaecol 103, pp. 904–908.
16. Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B, Lee J,Monga A, Petri E,
Rizk DE, Sand PK, Schaer GN. (2010). An International Urogynecological Association
(IUGA)/International Continence Society (ICS) joint report on the terminology for female
pelvic floor dysfunction. Int Urogynecol J 21, pp. 5–26.
17. Lee SJ, Park JW. (2000). Follow-up evaluation of the effect of vaginal delivery on the
pelvic floor. Dis Colon Rectum 43, pp. 1550–1555.
18. Bratila E, Bratila CP, Comandasu DE. (2015). Recurrent rectovaginal fistula treated by
acellular interposition graft. A case report. Paripex – Indian Journal of Research 4(3/2015),
pp. 28-30.
19. Valsky DV, Messing B, Petkova R, Savchev S, Rosenak D, Hochner-Celnikier D, Yagel
S. (2007). Postpartum evaluation of the anal sphincter by transperineal three-dimensional
ultrasound inprimiparous women after vaginal delivery and following surgical repair of
third-degree tears by the overlapping technique.Ultrasound Obstet Gynecol 29, pp. 195–
204.
20. Dietz H, Shek K. (2008). Levator avulsion and grading of pelvic floor muscle strength. Int
Urogynecol J 19, pp. 633–636.
21. Thyer I, Shek C, Dietz HP. (2008). New imaging method for assessing pelvic floor
biomechanics. Ultrasound Obstet Gynecol 31, pp. 201–205.
22. Santoro GA, Wieczorek AP, Stankiewicz A, Wozniak MM, Bogusiewicz M, Rechbereger
T. (2009). High-resolution threedimensional endovaginal ultrasonography in the
assessment of pelvic floor anatomy: a preliminary study. Int Urogynecol J 20, pp. 1213–
1222.
23. Santoro GA, Fortling B. (2007). The advantages of volume rendering in three-dimensional
endosonography of the anorectum. Dis Colon Rectum 50, pp. 359–368.
24. Bratila E, Bratila CP, Coroleuca CB, Cirstoiu MM, Berceanu C. (2015). The impact of
biomaterials in the reconstructive gynecologic surgery. Gineco.eu 42 (4/2015), pp. 172-
175.
25. Svabik K, Martan A, Masata J, El Haddad R. (2009). Vaginal mesh shrinking – ultrasound
assessment and quantification. Int Urogynecol J 20, pp. S166.
26. Meyer SM, Salchli F, Achtari C, Hohlfeld P, De Grandi P. (2005). Monitoring the pelvic
floor: is it possible? Preliminary results with a new microsystem device. Int Urogynecol J
Pelvic Floor Dysfunct 16, pp. S77.
27. Tunn R, Picot A, Marschke J, Gauruder-Burmester A. ( 2007). Sonomorphological
evaluation of polypropylene mesh implants after vaginal mesh repair in women with
cystocele or rectocele. Ultrasound Obstet Gynecol 29, pp 449–452.

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28. Devreese A, Staes F, De Weerdt W, Feys H, Van Assche A, Penninckx F, Vereecken
R. (2004). Clinical evaluation of pelvic floor muscle function in continent and
incontinentwomen. Neurourol Urodyn 23, pp. 190–197.
29. Shek KL, Rane A, Goh J, Dietz HP. (2009). Stress urinary incontinence after transobturator
mesh for cystocele repair. Int Urogynecol J 20, pp. 421–425.

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Hormone deficiency and its impact on the lower


urinary tract
BERCEANU Costin1, CÎRSTOIU Monica2, MEHEDINŢU
Claudia2, BRĂTILĂ Petre2, BERCEANU Sabina1,
VLĂDĂREANU Simona2, BOHÎLŢEA Roxana2,
BRĂTILĂ Elvira2
1
Department of Obstetrics and Gynaecology, University of Medicine and Pharmacy Craiova
(ROMANIA)
2
Department of Obstetrics - Gynaecology and Neonatology, “Carol Davila” University of Medicine
and Pharmacy, Bucharest (ROMANIA)
E-mails: dr_berceanu@yahoo.com, dr_cirstoiumonica@yahoo.com, claudiamehedintu@yahoo.com,
pbratila49@yahoo.com, dr.berceanu@gmail.com, simconst69@gmail.com, r.bohiltea@yahoo.com,
elvirabarbulea@gmail.com

Abstract

The horomonal receptors are present in supporting structures of pelvic organs, especially
in pubocervical muscle and pubocervical fascia involved in the continence mechanisms. Due
to the low production of estrogens in late menopause, genitourinary atrophy can lead to a
variety of symptoms with significant impacts on the quality of life. The development of any
incontinence was associated with a higher baseline BMI, weight gain, and an increase in
anxiety symptoms. Estrogen levels can be normal, low or even high depending on the stage
of the transition to menopause. Only in menopause the estrogen levels are extremely low
or undetectable. The main postmenopausal changes are hormonal deficiency and ageing and
these are overlapping effects. The effects of ageing and the postmenopausal bladder changes
include capacity decreasement, compliance decreasement, post void residual increasement,
glycosaminoglycan layer thinning and the ability to initiate or suppress detrusor contractility
is impaired. Age-related postmenopausal urethral changes include epithelium thinning, blood
flow and vascular pulsations decreasement and total collagen reduction. Alpha adrenergic
receptors are also decreasing, as well as a slowing of nerve conduction time is noticed. The
central element of the aging process in the lower urinary tract is the urethral support impaired
by degenerative changes in elastic connective tissue. The vaginal route for administration of
estrogens has some advantages as avoiding enterohepatic circulation, the lowest possible dose,
no endometrial stimulation, cyclical progestogens unnecessary, no systemic side effects, exerts
mainly local effect and acceptable following breast cancer. The role of oestrogens remains
important in the management of women with urogenital symptoms. Traditional knowledge has
been challenged by large epidemiological studies and may not be representative of our patient
populations. Current evidence would favour the use of vaginal oestrogens.

Keywords: hormonal receptors, lower urinary tract, incontinence, estrogens

Overview of the menopause transition


The menopause is a physiologically state in which a woman spend 30% of her entire life.

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[1, 2]
The future will reserve us a spectacular demographic phenomenon: the ageing of world
population from 530 mil. in 2010 to 1.3 billion in 2040. 8% of world population have urogenital
symptoms. [1-3]
Since the ‘80 years the studies have shown that the estrogen deficiency is the leading factor
in the aetiology of lower urinary tract symptoms and 70% of women relate the onset of the
stress urinary incontinence to their final menstrual period. [3, 4]
In the lower urinary tract we can find estrogen, progesterone and androgen receptors. [5]
Vagina and bladder base have the same pattern including all type of hormone receptors. [3, 5]
The hormonal receptors are present in supporting structures of pelvic organs, especially in
pubocervical muscle and pubocervical fascia involved in the continence mechanisms. [5, 6]
Due to the low production of estrogens in late menopause, genitourinary atrophy can lead
to a variety of symptoms with significant impacts on the quality of life. [3]
The urethral mucosa and urinary bladder thinning leads to the occurrence of the urinary
symptoms including dysuria, frequent urination, sensation of impending urination, urinary
incontinence or recurring infections of the urinary tract. [3, 7, 8]
On the one hand, the urethral shortening and atrophic changes on the other hand may lead
to stress or strain urinary incontinence. [3,7-9]
In a recent study, Waetjen et al. have evaluated the women in transition to menopause and
observed a slight increase in the incidence of stress urinary incontinence and strong sensation
of needing to urinate [10]
The development of any incontinence was associated with a higher baseline BMI, weight
gain, and an increase in anxiety symptoms. [10]
A biological basis may explain the association between menopausal stage and the reporting
of new onset incontinence. Some women report that their incontinence is affected by menstrual
cycle phase, with most women reporting increases in incontinence in the luteal phase when
both estradiol and progesterone levels are elevated. [11]
Also, It is possible that for women in the peri-menopause, the increased frequency of
anovulatory cycles and the associated relatively prolonged elevated levels or peaks of estrogen
in a subset of women increases the likelihood of developing infrequent incontinence, while the
lower or declining estrogen levels of postmenopause decreases that risk. [10-12]
Estrogen levels can be normal, low or even high depending on the stage of the transition
to menopause. Only in menopause the estrogen levels are extremely low or undetectable. [3]

Postmenopausal lower urinary tract changes

The main postmenopausal changes are hormonal deficiency and ageing and these are
overlapping effects. The prevalence of one or another factor may show individual variances
related to several factors such as genetic, geoethinic or behavioural particularities. [13, 14]

The effect of hypoestrogenism

It has been demonstrated that collagen metabolism does not change in menopause and
the effect of hypoestrogenism consists in a decrease in sensory treshold wich could generate
overactive bladder and decrease of urethral venous plexus creating a favourable conditions for
stress urinary incontinence. [3, 15-18]
The effects of ageing and the postmenopausal bladder changes include capacity
decreasement, compliance decreasement, post void residual increasement, glycosaminoglycan
layer thinning and the ability to initiate or suppress detrusor contractility is impaired. [15-18]
The symptoms of lower the urinary tract are frequent causes for which patients seek

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specialised check-up. [15, 16]
The change in the urinary system functions is systematised in Table 1, adapted from Wall
L.L., 1999. [16]

Table 1. Classification of urinary symptoms in women (Wall LL, 1999, adapted) [16]

Abnormal Abnormal Abnormal


Abnormal evacuation
accumulation sensation bladder content
- Incontinence - Delay in starting the urine - Urgent sensation - Abnormal colour
- Strain incontinence flow of micturition - Abnormal odour
- Stimulation - Effort to urinate - Dysuria - Haematuria
incontinence - Low urine flow - Bladder pain - Pneumaturia
- Mixed incontinence - Intermittent urine flow - Pain in the flank - Gallstones
- Unconscious - Full evacuation - Pressure - Foreign bodies
incontinence - Post-micturition dribble - Loss of bladder
- Urinations at short - Acute urinary retention sensation
time intervals
- Nocturia
- Nocturnal enuresis

Urinary incontinence involves the involuntary loss of urine, representing both a social
issue and one related to hygiene, being a symptom, and not a diagnosis. [3, 8, 15, 16, 19]
The estrogenic deficit related to menopause determines the occurrence of urogenital
manifestations by epithelial atrophy, reduction of the connective tissue and alteration of tissue
perfusion. [20]
Estrogens increase the sensitivity of alpha-adrenergic receptors in the urethral smooth
muscle and in the bladder neck, increasing the muscle tone and contractility and maintaining
the urinary continence. Estrogen hormones also improve the urethral tissue perfusion, being
demonstrated that the vascular bed has a critical role in maintaining the intraurethral pressure.
[20-23]
The genital tract and the urinary one are intimately associated anatomically and
embryologically, the common embryonic origin in the urogenital sinus, lower genital tract,
vulva and lower third of the vagina, as well as the urethra and bladder trigon explain the
density of estrogen receptors at this level and the tissue suffering under the conditions of
estrogen deficiency (Table 2). [16, 20-23]

Table. 2 Hormonal receptors in LUT and in the pelvic support [5, 23]
Anatomic ER PR AR
structures
Hormonal Pubocervical
receptors in + - -
muscle
pelvic support Levator ani muscle ?(+/_) - -
Cardinal ligament + + -
Sacrouterine
+(a,b) + -
ligament
Pubocervical fascia + (a,b) - -

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Hormonal Urethra + +
receptors in
LUT Urethral
+
Sphyncter
Periurethral veins +
Vagina + + +
Bladder base + + +
LUT - lower urinary tract, ER - estrogen receptors, PR - progesterone receptors, AR -
androgen receptor
For this table, data from the following sources have been used:
Fu X, Rezapour M, Wu X, Li L, Sjögren C, Ulmsten U. (2003). Expression of estrogen receptor - alpha
and - beta in anterior vaginal walls of genuine stress incontinent women. Int Urogynecol J Pelvic
Floor Dysfunct 14(4), pp. 276-81.
Goeshen K, Petros P, Funogea A, Brătilă E, Brătilă P, Cîrstoiu M. (2016). Planşeul pelvic la femeie.
Anatomia funcţională, diagnostic şi tratament-în acord cu teoria integrative, Editura Universitara
Carol Davila Bucharest, Bucharest.

The striated muscles and pelvic floor fascia act on the entire pelvis in order to prevent
the displacement of pelvic organs, to maintain the continence and control the activities of
excretion. [16, 23]
The prolapsed of pelvic organs, vaginal relaxation with cystocele, rectocele or uterine
prolapsed are not a direct consequence of the lack of estrogens, the etiology being multifactorial
and progressive over time. Old age is obviously an important factor. [3, 24-26]

The effect of ageing

Age-related postmenopausal urethral changes include epithelium thinning, blood flow and
vascular pulsations decreasement and total collagen reduction. Alpha adrenergic receptors are
also decreasing, as well as a slowing of nerve conduction time is noticed. [3, 7, 16, 27-29]
The central element of the aging process in the lower urinary tract is the urethral support
impaired by degenerative changes in elastic connective tissue. [3, 7, 27]
The main ageing effect for stress urinary incontinence is the degenerative changes in elastic
connective tissue of urethral support. Plenty of other anatomical and functional modifications
are to be found. [3,7,27-29]
The mucosa of the urethra is thining and loses the ability of coaptation. The atrophy of vaginal
mucosa induces major changes in vaginal ecosystem. In the absence of lactobacilar flora the
vagina is colonized by mixed germs inducing pH modification (Table 3). [3, 16, 20, 23]

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Table 3. The effects of urogenital ageing [3,20]
Lower urinary - Stress/ strain urinary incontinence
tract - Recurring urinary infections
- Dysuria
- Nocturia
- Frequent urination
- Urgent sensation of urination
Genital - Vaginal stenosis
- Genital prolapse
- ↓ of libido
- Dyspareunia
- Vaginal dryness
- Itchiness
- Postcoital bleeding
- Genital infections
This table is designed as a synopsis of the effects of urogenital ageing and data
from the following sources have been used:
Schorge JO, Schaffer JI, Halvorson LM, Hoffman BL, Bradshaw KD, Cunningham
FG. (2008). Menopausal Transition. In: Williams Gynecology, McGraw Hill, New
York, pp. 468-491.
Vârtej P, Vârtej I, Poiană C. (2014). Ginecologie endocrinologică, Ediţia a IV-a,
Editura All, Bucharest, pp. 156-222.

The support of pelvic organs is maintained by complex interactions between the muscles
of the pelvic floor, its connective tissues and vaginal wall. This morpho-functional complex
provides the support and physiological functioning of the vagina, urinary bladder urethra and
rectum. [3, 30-33]
Arcus tendineus fascia pelvis is a complex of parietal fascia covering the median area of
the internal obturator and levator ani muscles. Recent studies prove that a major factor for the
occurrence of genital prolapsed is the loss of the connective tissue support on the vaginal apex,
leading to the rupture or elongation of the arcus tendineus fascia pelvis. [3, 16, 23]
The complex of fascia and connective tissues of the pelvic floor can lose their bearing
capacity through the aging process, which also contributes to the reduction of the neuroendocrine
signals in the pelvic structures. [3, 23, 34, 35]

Controversies and certitudes in using oestrogens for incontinence

Oestrogen treatment for urinary incontinence has been tested using oral, transdermal
and vaginal routes of administration. Available evidence suggests on one hand that vaginal
oestrogen treatment with oestradiol and oestriol is not associated with the increased risk of
thromboembolism, endometrial hypertrophy, and breast cancer as observed with systemic
administration, and on the other hand the fat that vaginal (local) treatment is primarily used to
treat symptoms of vaginal atrophy in postmenopausal women. [36-39]
The main problem related to estrogen effect on stress urinary incontinence is the route of
administration. As a matter of this fact there are two main questions arising: In women with

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urinary incontinence, does oral (systemic) oestrogen cure or improve urinary incontinence
compared to no treatment? and In women with urinary incontinence, does vaginal (local)
oestrogen cure or improve urinary incontinence compared to no treatment or other active
treatment?
A study on 28 randomised trials shows a statistically significant improvement of stress
urinary incontinence and urinary incontinence after estrogen treatment over placebo, but we
have too few data to asses dose and route of administration.
Another meta-analysis shows that local estrogens may improve incontinence but no date
regarding types of estrogen and mode of delivery. (Table 4)

Table 4. Cochrane Incontinence Group Meta-analysis


Maher C et al., 2004 [40] Cochrane 28 randomised trials
Incontinence 2926 women
Group Meta- Overall, a statistically higher cure and improvement
analysis rate for oestrogen over placebo (RR: 1.61; CI: 1.04-
2.49)
Stress Incontinence (43% Vs 27%)
Urge Incontinence (57% Vs 28%)
No serious adverse events
Too few data to assess type, dose and route of
administration

Cody JD et al., 2012 [41] Cochrane 33 randomised trials


Incontinence 19313 women
Group Meta- 1262 women involved in trials of local oestrogens
analysis Systemic oral oestrogens worsen incontinence
Oestrogen alone (RR: 1.32; 95%; CI: 1.17-1.48)
Oestrogen and Progestogen (RR 1.11; 95%; CI: 1.04-
1.18)
Local oestrogens may improve incontinence (RR 1.11;
95%; CI: 1.04-1.18)
Not enough data regarding types of oestrogen and
mode of delivery
The focused study on hormone replacement therapy included a large cohort of women but
their goal was not to prove the results on urinary incontinence. These studies were designed for
prevention of ischemic heart disease, osteoporosis and evaluation of thromboembolism risk.
The incontinence data simply represent a sub-group post hoc analysis. Two of the studies used
conjugated equine oestrogens rather than synthetic oestradiol, which is more commonly used
in Europe. Many of the patients had significant co-morbidities and were older than 60.
In women with stress urinary incontinence the use of oral conjugated equine estrogens,
estradiol, or estrone showed no improvement. [42-44]
Two placebo-controlled trials using sub-cutaneous estradiol or oral estriol showed no
benefit for improvement of urinary incontinence. [45]
The oral and subcutaneous use of conjugated equine estrogens, estradiol and or estrone
showed no benefit for improvement of stress urinary incontinence.
The vaginal route for administration of estrogens has some advantages as avoiding
enterohepatic circulation, the lowest possible dose, no endometrial stimulation, cyclical
progestogens unnecessary, no systemic side effects, exerts mainly local effect and acceptable
following breast cancer. [15, 23, 29, 45]

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Vaginal oestrogens have also direct action to the urogenital cells. Hormone therapy reduces
autonomic and sensory vaginal innervation density, which may, in part, contribute to relief
from vaginal discomfort. Topical therapy causes more dramatic reductions in innervation than
systemic HRT, which explains the greater improvement reported with local oestrogens. [46]
Cardozo et al., in 11 randomized placebo controlled trials including 430 women, shows
that estrogens are superior to placebo in terms of urge incontinence, frequency, nocturia, first
sensation, bladder capacity and urgency. [47]
Tseng et al showed significantly improvement of quality of life when Tolterodine treatment
was associated with Premarin cream twice weekly. [48]
On the contrary the study of Serrati et al shoved no difference in terms of efficacy between
adding vaginal estriol and treatment with Tolterodine alone. [49]
The recent study of Nappi and Davis in 2012 demonstrate the role of use of vaginal
estrogens only for UUI and OAB without evidence for stress urinary incontinence. [50]

Conclusions

Vaginal oestrogen therapy can be given as conjugated equine oestrogen, oestriol or oestradiol
in vaginal pessaries, vaginal rings or creams. Current data do not allow differentiation among
the various types of oestrogens or delivery methods. The ideal treatment duration and the
long-term effects are uncertain. The role of oestrogens remains important in the management
of women with urogenital symptoms. Traditional knowledge has been challenged by large
epidemiological studies and may not be representative of our patient populations. Current
evidence would favour the use of vaginal oestrogens. More evidence is needed in order to
rationalise type, dose and route of administration. Precise role of exogenous oestrogen therapy
remains unclear.

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34. Dieter AA, Wilkins MF, Wu JM. (2015). Epidemiological trends and future care needs for
pelvic floor disorders. Curr Opin Obstet Gynecol 27(5), pp. 380-4.
35. Rodríguez-Mias NL, Martínez-Franco E, Aguado J, Sánchez E, Amat-Tardiu L. (2015).
Pelvic organ prolapse and stress urinary incontinence, do they share the same risk factors?
Eur J Obstet Gynecol Reprod Biol 190, pp. 52-7.
36. Cody JD, Jacobs ML, Richardson K, Moehrer B, Hextall A. (2012). Oestrogen therapy
for urinary incontinence in post-menopausal women. Cochrane Database Syst Rev 10,
CD001405.
37. Lyytinen H, Pukkala E, Ylikorkala O. (2006). Breast cancer risk in postmenopausal
women using estrogen-only therapy. Obstet Gynecol 108(6), pp. 1354-60.
38. Kelley C. (2007). Estrogen and its effect on vaginal atrophy in post-menopausal women.
Urol Nurs 27(1), pp. 40-5.
39. Castelo-Branco C, Cancelo MJ, Villero J, Nohales F, Juliá MD. (2005). Management of
post-menopausal vaginal atrophy and atrophic vaginitis. Maturitas 52(Suppl 1), pp. S46-
52.
40. Maher C, Baessler K, Glazener CM, Adams EJ, Hagen S. (2004). Surgical management of
pelvic organ prolapse in women. Cochrane Database Syst Rev (4), CD004014.
41. Cody JD, Jacobs ML, Richardson K, Moehrer B, Hextall A. (2012). Oestrogen therapy
for urinary incontinence in post-menopausal women. Cochrane Database Syst Rev 10,
CD001405.
42. Jackson S. (1999). Lower urinary tract symptoms and nocturia in men and women:
prevalence, aetiology and diagnosis. BJU 84(Suppl 1), pp. 5-8.
43. Wilson PD, Al Samarrai T, Deakin M, Kolbe E, Brown AD. (1978). An objective
assessment of physiotherapy for female genuine stress incontinence. Br J Obstet Gynaecol
94(6), pp. 575-82.
44. Tseng LH, Liang CC, Tsay PK, Wang AC, Lo TS, Lin YH. (2008). Factors affecting
voiding function in urogynecology patients. Taiwan J Obstet Gynecol 47(4), pp. 417-21.
45. Cardozo L, Rekers H, Tapp A, Barnick C, Shepherd A, Schussler B, Kerr-Wilson R,
Van Geelan J, Barlebo H, Walter S. (1993). Oestriol in the treatment of postmenopausal
urgency: a multicentre study. Maturitas 18(1), pp. 47-53.
46. Griebling TL, Liao Z, Smith PG. (2012). Systemic and topical hormone therapies reduce
vaginal innervation density in postmenopausal women. Menopause 19(6), pp. 630-5.
47. Cardozo L, Lose G, McClish D, Versi E. (2004). A systematic review of the effects of

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estrogens for symptoms suggestive of overactive bladder. Acta Obstet Gynecol Scand
83(10), pp. 892-7.
48. Tseng LH, Wang AC, Chang YL, Soong YK, Lloyd LK, Ko YJ. (2009). Randomized
comparison of tolterodine with vaginal estrogen cream versus tolterodine alone for the
treatment of postmenopausal women with overactive bladder syndrome. Neurourol
Urodyn 28(1), pp. 47-51.
49. Serati M, Salvatore S, Uccella S, Cardozo L, Bolis P. (2009). Is there a synergistic
effect of topical oestrogens when administered with antimuscarinics in the treatment of
symptomatic detrusor overactivity? Eur Urol 55(3), pp 713-9.
50. Nappi RE, Davis SR. (2012). The use of hormone therapy for the maintenance of
urogynecological and sexual health post WHI. Climacteric 15(3), pp. 267-74.

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Intrapartum and postpartum bladder management

BODEAN Oana1, MUNTEANU Octavian1, VOICU Diana2,


VASILESCU Sorin2, BOHILTEA Roxana1, CIRSTOIU MONICA1
1
“Carol Davila” University of Medicine and Pharmacy, Bucharest (ROMANIA)
2
Emergency University Hospital Bucharest (ROMANIA)
Corresponding author: Munteanu Octavian, e-mail: octav_munteanu@yahoo.com

Abstract

During labour and in the postpartum period the urinary bladder is usually at risk for possible
injuries and dysfunction. In the postpartum, the bladder has a tendency of being underactive,
therefore is vulnerable to retention. Also, the bladder sensation may be affected and most
women are not aware of a fully distended bladder and the voiding necessity. A prolonged
over distension can permanently affect the detrusor muscle causing severe or permanent
dysfunction such as: acute urinary retention, incontinence, recurrent urinary tract infections.
Any woman can develop postpartum voiding dysfunction regardless of mode of delivery
and some patients may have permanent complications later in life. We present our experience
with a number of cases who developed bladder dysfunction in the postpartum.

Keywords: urinary incontinence, bladder dysfunction, postpartum

Background

Bladder care is a very important aspect of management in the postpartum period. Voiding
dysfunction can occur in any patient and if left undetected, it can produce permanent damage
to the detrusor muscle. There is no universal protocol for postpartum bladder care and many
cases can be easily missed. [1]
Definitions
Urinary retention is defined as the inability to urinate despite sustained effort. [2] Acute
urinary retention is defined by the International Continence Society as a painful or palpable
bladder with the patient unable to pass any urine when the bladder is full. [3] Some patients
pass a small amount of urine due to bladder over distention (overflow incontinence). Pain
may also not be present in the postpartum following epidural analgesia. Most frequently,
postpartum urinary retention is described as the absence of spontaneous micturition within 6
hours of delivery. There are two types of urinary retention described in the literature: acute
(overt) and chronic (covert). [4] Acute retention is the sudden onset of the inability to void,
leaving a significant residual urine in the bladder. Chronic retention refers to a non-painful
bladder with a post-void residual volume of over 150 ml. [5]
Incidence
The reported incidence of postpartum bladder dysfunction varies due to inconsistencies

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in the definitions and methods of diagnosis. It is estimated that 10-15% of women have some
degree of voiding dysfunction after delivery. [6] Part of these patients may have significant
and long term dysfunction leading to urinary incontinence. [7]
There is a series of possible risk factors which need to be recognised by the patient and the
medical team involved in patient care in order to prevent complications. It cannot be predicted
which patient will develop postpartum urinary retention [8] or other voiding dysfunction,
therefore every case has its own peculiarity. Aim of this study is to highlight the necessity of
proper recognition of postpartum voiding problems.

Cases
Case 1
- 27 years old, G1P1
- Spontaneous vaginal delivery at 39 weeks
- epidural analgesia
- Delivered 3700g new born baby
- At 8 hours post-partum patient describes: mild abdominal pain and impossible spontaneous
micturition
- Palpable bladder
- Abdominal ultrasound: distended bladder
- Foley catheter inserted: voids 3200 ml urine
- Foley is maintained for 12 hours
- The patient is encouraged to drink more fluids and to urinate by herself after the catheter
is removed
- Abdominal ultrasound at 2 hrs after catheter removal (Fig. 1)
- Resumption of spontaneous urination
Case 2
- 34 years old, G3P2
- Caesarean section (CS) at 37 weeks for fetal distress
- Spinal anaesthesia
- 2900 g new born baby
- Foley catheter inserted prior to intervention
- At 6 hrs post CS: diuresis=2500 ml normochromic urine, then mild haematuria.
- Removal of Foley catheter: patient is unable to pass any urine. No visible urethral injury
at inspection
- Replace Foley: catheter is inserted with difficulty (urethral obstacle)
- Urology specialist is consulted. Cystoscopy.
- Conclusion: urethral oedema, possibly due to malposition or traction of catheter.
- Foley is maintained for 48 hours
- Resumption of spontaneous urination with normochromic urine
Case 3
- 32 years old G2P1
- spontaneous vaginal delivery at 40 weeks
- 3650g new born baby
- epidural anaesthesia
- long labour
- Foley in for 2nd stage of labour
- 2nd stage>3 hours

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- perineal injury
- At 2 hours post-partum: urinary incontinence
- No visible urethral injury at inspection
- Incontinence persists 6 weeks postpartum
- Conclusion: Foley catheter in maintained during expulsion of fetal head. Urethral
distension
Case 4
- 36 years old G7P5
- heavy smoker
- spontaneous vaginal delivery at 39 weeks of a 3800 g baby
- other large babies (3750 g, 3900 g, 4200 g) delivered vaginally
- reported cystocele and urinary incontinence after 3rd baby
- recurrent urinary tract infections prior to current pregnancy
- recurrent urinary tract infections and long term urinary incontinence
- patient returned for surgical cure of urinary incontinence (Fig. 2, Fig.3, Fig. 4)

Figure 1. Ultrasound image of bladder Figure 2. Ultrasound image of vaginal


after remission of urinary retention in prolapse in multiparous woman
patient with vaginal delivery

Figure 3. Cystocele, urinary Figure 4. Surgical treatment of urinary


incontinence on a multiparous woman incontinence with TOT mesh. Cure of
cystocele and rectocele

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Discussion

Risk factors

Although one cannot predict which patient will develop postpartum voiding dysfunction,
there are a few suggested risk factors [9] (Table 1):

Table 1: Suggested risk factors for post-partum voiding dysfunction


Risk factor:
Nulliparous women
Prolonged labour or long 2nd stage of labour
Instrumental delivery (forceps)
Perineal injury
Caesarean section
Regional analgesia
Immobility
History of previous voiding problems

Pathophysiology

The pathophysiology of post-partum urinary retention is multifactorial and it can be


explained by:
- hormonal changes during pregnancy (the post-partum bladder is hypotonic due to elevated
progesterone levels) [10]
- local trauma during delivery (trauma to the pelvic floor muscles and nerves, trauma to the
bladder)
- pudendal nerve damage by pelvic floor tissue stretching or injury (instrumental delivery,
prolonged labour) [11]
- tissue oedema of the urogenital area (large baby, compression of the presenting part onto
the birth canal, instrumental delivery, perineal lacerations)
- physiological factors (fear of pain, lack of privacy) [12]

Diagnosis

Symptoms of acute urinary retention are the most obvious: inability to urinate and painful
palpable bladder. However, pain may be absent in women who had an epidural or it can be
mistaken by caesarean wound pain. Some patients have overflow incontinence due to over-
distended bladder and some patients are asymptomatic. [13]
Chronic urinary retention with incomplete voiding of bladder in the postpartum present
with [14]:
- difficult initiation of voiding after birth
- the sensation of bladder fullness after voiding
- frequent urination with small volumes
- dribbling urine after voiding

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- nocturia

Bladder distention can be felt by abdominal palpation, but volumes smaller than 300 ml
are difficult to detect. Catheterisation is the best method to measure residual volumes in the
postpartum, but it can be uncomfortable for the patient and it increases the risk of urinary
tract infection. Bladder ultrasound is useful and non-invasive, but once a significant residual
volume is detected, it should be confirmed by catheterisation. [15]

Bladder care management for vaginal delivery

Intrapartum bladder care is very important, as it is the first step to prevent urinary
dysfunction. There are no universally accepted standard protocols described in the literature,
but most practitioners encourage bladder emptying every 4 hours in the first stage of labour. At
the beginning of the active phase of the second stage, the bladder must be emptied. If a Foley
catheter is used, the balloon must be deflated when the woman starts pushing. [16] Otherwise,
urethral trauma may occur, as it did in case 3. Urethral tear may occur, with a visible balloon
at inspection and urinary incontinence in the first hour post-delivery. Prior to any instrumental
delivery, the bladder must be emptied either by an in and out catheter or with a Foley catheter.
All catheters must be removed prior to operative delivery. Each void should be measured
and recorded, as well as volume intake.
Postpartum bladder care includes a key moment: timing of first void after delivery.
This moment should be documented by the medical practitioner (nurse and doctor). After
spontaneous vaginal delivery, the first void should occur in the first 4-6 hours after delivery.
[17]
The patient is encouraged to drink at least 1500 ml of fluids in 24 hours and to mobilise
as soon as possible. For women who had an epidural or an operative delivery an indwelling
catheter is recommended for at least 6 hours postpartum. In case of severe genital trauma some
authors recommend an indwelling catheter for 24 hours following delivery. [18, 19]

Bladder care management for caesarean section

In our hospital the Foley catheter is usually removed at 12 hours after caesarean section,
unless the nurse is instructed by the surgeon to leave it in for a longer time. After catheter
removal, the patient is encouraged to increase fluid intake, to move and urinate in the next 2-4
hours.

Management of suspected/confirmed postpartum urinary retention

According to the WHO Technical Consultation on Postpartum and Postnatal Care, “every
post-delivery woman should void within 6 hours; if not, catheterisation should be performed”.
[20-22]
Therefore, in our hospital, if the patient did not urinate within 6 hours she is asked to
drink more fluids and she is provided more privacy and proper analgesia in order to obtain
spontaneous micturition. Vulvar oedema must also be excluded. If voiding is not possible within
6 hours, despite proper hydration, an abdominal ultrasound scan followed by catheterisation is
performed. A Foley catheter can be inserted for at least 24 hours if there is a residual volume >

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150ml. If acute urinary retention is detected, a Foley catheter is immediately inserted in order
to empty the bladder and it can be kept in place for 5 days. The patient is also checked for
urinary tract infection. [23]

Postpartum urinary incontinence

Urinary incontinence that occurs in the first hours or days after birth may be a sign of fistula
or pelvic floor muscle or nerve injury. A Foley catheter should be inserted and fistula should
be ruled out. [24] A urology specialist should be consulted. Incontinence can be present for a
long time and it can impair the woman’s life. Multiparous women or those who had operative
vaginal deliveries, or large babies are especially prone to developing pelvic floor muscle
rupture, anal and vaginal fistulae cystocele, rectocele, vaginal prolapse, anal incontinence.
[25] Therefore, we recommend surgical treatment of such pathology.

Conclusion

Urinary dysfunction in the postpartum period can occur in any patient despite suggested
risk factors. Intrapartum bladder care and prevention of postpartum urinary retention are very
important in order to prevent acute bladder distention and to avoid permanent bladder and
urinary tract damage. The lack of protocols can lead to a poor management of cases. Therefore,
we consider useful a better standardization of procedures in order to being able to recognise
the problems and to provide proper treatment.

REFERENCES

1. Carley, M. E., Carley, J. M., Vasdev, G., Lesnick, T. G., Webb, M. J., Ramin, K. D., &
Lee, R. A. (2002). Factors that are associated with clinically overt postpartum urinary
retention after vaginal delivery. American journal of obstetrics and gynecology, 187(2),
430-433.
2. Yip, S. K., Sahota, D., Pang, M. W., & Chang, A. (2004). Postpartum urinary retention.
Acta obstetricia et gynecologica Scandinavica, 83(10), 881-891.
3. Rizvi, R. M., Z. S. Khan, and Z. Khan. «Diagnosis and management of postpartum urinary
retention.» International Journal of Gynecology & Obstetrics 91.1 (2005): 71-72.
4. Haylen, Bernard T., et al. «An International Urogynecological Association (IUGA)/
International Continence Society (ICS) joint report on the terminology for female pelvic
floor dysfunction». International urogynecology journal 21.1 (2010): 5-26.
5. Lim, Jeanette L. «Post partum voiding dysfunction and urinary retention”. Australian and
New Zealand Journal of Obstetrics and Gynaecology 50.6 (2010): 502-505.
6. WHO - Postpartum care of the mother and newborn: a practical guide. Maternal and
newborn health.
7. Brătilă E., Vlădăreanu S, Berceanu C, Cîrstoiu M. et al., “Rolul sarcinii și al nașterii în
apariţia tulburărilor de statică pelvică”. Revista Ginecologia.ro Anul III, Nr.10, (4/2015),
pg. 28-33, ISSN 2344 – 2301, ISSN – L 2344 – 2301.
8. Brătilă E., Vlădăreanu S, Berceanu C, Cîrstoiu M.-The anatomy of urinary continence in
women Revista Ginecologia.ro Anul III, Nr. 10, (4/2015), pg. 45-51, ISSN 2344 – 2301,
ISSN – L 2344 – 2301.

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9. Saultz, John W., William L. Toffler, and Janette Y. Shackles. “Postpartum urinary
retention”. The Journal of the American Board of Family Practice 4.5 (1991): 341-344.
10. Teo, Roderick, et al. “Clinically overt postpartum urinary retention after vaginal delivery:
a retrospective case-control study”. International Urogynecology Journal 18.5 (2007):
521-524.
11. Bollard, Ruth C., et al. “Anal Sphincter Injury, Fecal and Urinary Incontinence”. Diseases
of the colon & rectum 46.8 (2003): 1083-1088.
12. Tan, Jo-Lynn, Tracy Ruane, and Margaret Sherburn. “The role of physiotherapy after
obstetric anal sphincter injury: An overview of current clinical practice”. Australian and
New Zealand Continence Journal, The 19.1 (2013): 6.
13. Liang, C. C., et al. “Postpartum urinary retention after cesarean delivery”. International
Journal of Gynecology & Obstetrics 99.3 (2007): 229-232.
14. Kekre, Aruna N., et al. “Postpartum urinary retention after vaginal delivery”. International
Journal of Gynecology & Obstetrics 112.2 (2011): 112-115.
15. Persson, Jan, Pål Wølner-Hanssen, and Hakan Rydhstroem. “Obstetric Risk Factors for
Stress Urinary Incontinence: A Population Based Study”. Obstetrics & Gynecology 96.3
(2000): 440-445.
16. Mulder, F. E. M., et al. “Postpartum urinary retention: a systematic review of adverse
effects and management”. International urogynecology journal 25.12 (2014): 1605-1612.
17. Rortveit, Guri, et al. “Urinary incontinence after vaginal delivery or cesarean section”.
New England Journal of Medicine 348.10 (2003): 900-907.
18. Østergaard, Jeanett, Jens Langhoff-Roos, and L. M. Møller. «[Postpartum urinary
retention]». Ugeskrift for laeger 172.7 (2010): 528-533.
19. Basson, Jennifer, C. L. E. Van der Walt, and Chris F. Heyns. «Urinary retention in
women». Continuing Medical Education 31.5 (2012): 182-184.
20. MacLean, Allan B., Linda Cardozo, and Allan B. MacLean, eds. Incontinence in women.
RCOG Press, 2002.
21. National Collaborating Centre for Primary Care (UK. «Postnatal care: routine postnatal
care of women and their babies». (2006).
22. World Health Organization. «WHO technical consultation on postpartum and postnatal
care». (2010).
23. Groutz, Asnat, et al. «Persistent postpartum urinary retention in contemporary obstetric
practice. Definition, prevalence and clinical implications». The Journal of reproductive
medicine 46.1 (2001): 44-48.
24. Ching Chung, Liang, et al. “Postpartum urinary retention: assessment of contributing
factors and long term clinical impact”. Australian and New Zealand journal of obstetrics
and gynaecology 42.4 (2002): 367-370.
25. Bratila, E., et al. “Recurrent Obstetric Rectovaginal Fistula Treated By Surgisis Graft-
Case Report”. Dan L. Dumitrascu, Piero Portincasa (2015): 59.

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Pelvic floor ultrasound – review


Bohîlțea Roxana Elena1,2, Cîrstoiu Monica Mihaela1,2,
Turcan Natalia2, Munteanu Octavian1,2, Bodean Oana2,
Voicu Diana2, Baroș Alexandru1,2, Brătilă Elvira1,3
1
“Carol Davila” University of Medicine and Pharmacy, Bucharest
2
Bucharest University Emergency Hospital
3
“St. Pantelimon” Clinic Emergency Hospital, Bucharest
Correspondent author: Roxana Bohîlțea
E-mail: r.bohiltea@yahoo.com

Abstract

It is possible that for the physician, clinical evaluation alone of women with pelvic organ
prolapse complicated with urinary and fecal incontinence or defecation disorders to be
insufficient for an appropriate assessment. The role of ultrasonography is currently limited
around the investigation of pelvic floor disorders. Besides that, the sonography presents the
advantage of a low cost, non-invasively, accessible and very much represents a part of general
practice in obstetrics and gynecology spread universally. Insensible urine loss, persistent
dysuria, symptoms of prolapse, obstructed defecation or fecal incontinence are just a few
of indications for pelvic floor incontinence. Trough transrectal, transvaginal, transperineal/
translabial ultrasonography, functional and structural abnormalities like residual urine,
detrusor wall thickness, bladder neck mobility, urethral integrity anterior, central and posterior
compartment prolapse can be evaluated. By means of 2-dimensional pelvic floor ultrasound
or, if its possible 3-/4-dimensional, the delivery related levator trauma can be easily diagnosed,
this being the most important known etiologic factor for pelvic organ prolapse. Definitely,
diagnosis by imaging is more reproducible that a clinical based one.

Keywords: ultrasound, transperineal, pelvic prolapse

Introduction

Ultrasound imaging represents one of the greatest revolution in medicine; it is used


for medical purposes for several decades, having the advantage of safety when properly
performed (1). One of the disadvantages is the operator-dependent status technology, a correct
examination requiring an experience of a large variety of normal and abnormal examination. In
gynecology, ultrasonography is used by routine, some of the main indication being evaluation
of the menstrual cycle and abnormal uterine bleeding (endometrium, follicles), examination
of the position of intrauterine device, assessment of a pelvic mass, confirmation if a suspected
hydrosalpinx or adnexal abscess, evaluation of congenital uterine anomalies and screening
for malignancy (2). Transvaginal sonography is preferential in gynecology being safe with no
radiation, simple, cheap, easily accessible and provides high spatial and temporal resolutions.

Translabial or transperineal ultrasound have and increasing tendency of use for the evaluation

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of the pelvic floor in course of diagnosis and for deciding an appropriate management of
women with pelvic organ prolapse and urinary or fecal incontinence (3). Despite is mentioned
clinical purposes, ultrasound is valuable also in research purposes. The role of ultrasonography
is currently limited around the investigation of pelvic floor disorders of patients with
previously surgical procedures who can be completed examined by ultrasound that help to see
and understand pelvic modifications. Additional maneuvers (Valsalva, squeezing) performed
during ultrasound examination helps to see the organs of the pelvis that are changing their
normal position and also the grade of this abnormal condition (4). As respects the sonographic
pelvic floor examination after a reconstructive surgery, the use is the correlation of various
methods of reconstruction with the prevalence of reintervention.

The etiology of pelvic flor disorders is not completely understood, however, delivery-
related levator ani injury remains to be the main etiological factor for pelvic organ prolapse
and recurrence after pelvic reconstructive surgery; an appropriate evaluation of levator ani
anatomy and function can be provided only by pelvic ultrasonography (5).

Recalling other uses of pelvic floor ultrasound, we mention the possibility of determining
residual urine (pre and post-operatory); detrusor wall thickness; bladder neck mobility; urethral
integrity, Also, diverse abnormal condition can be visualized and evaluated such as urethral
diverticula, rectal intussusception, mesh dislodgment, and avulsion of the puborectalis muscle
(5) (Fig 1, 2).

Fig. 1, 2 Recurrent central compartment pelvic organ prolapse, transperineal ultrasound

Indication for pelvic ultrasound

In multiple cases, diagnosis by imaging is more reproducible than diagnosis by palpation;


for example palpation of levator ani trauma requires considerable skills and teaching (6),
ultrasound on the other part being simpler and easier to teach. Dietz HP, in his published
review on pelvic floor ultrasound (4) suggests a series of 12 indication for performing pelvic
floor imaging (4):
1. Recurrent urinary tract infections
2. Urgency, frequency, nocturia, and orurge urinary incontinence
3. Stress urinary incontinence
4. Insensible urine loss
5. Bladder-related pain
6. Persistent dysuria
7. Symptoms of voiding dysfunction

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8. Symptoms of prolapse, ie, sensation oflump or dragging sensation
9. Symptoms of obstructed defecation, eg,straining at stool, chronic constipation,vaginal or
perineal digitation, andsensation of incomplete bowel emptying
10. Fecal incontinence
11. Pelvic or vaginal pain afterantiincontinence or prolapse surgery
12. Vaginal discharge or bleeding afterantiincontinence or prolapse surgery

Examination technique

Basic 2-dimensional translabial pelvic floor ultrasound requires a 3.5- to 6-MHz curved
array transducer and a monochrome video printer. The position should be dorsal, with hips
flexed and slightly abducted, imaging in standing position is also possible. Prior voiding is
preferred, as an empty rectum. Visibility can be reduced by the poor hydration of tissues and
by vaginal scars; obesity does not represent an inconvenient. The transducer should be placed
in perfect contact with the labia without exerting pressure. A midsagittal view will include
anteriorly the symphysis, the urethra and bladder neck, the vagina, cervix, rectum, and anal
canal (4).
Anterior compartment prolapse includes usually a cystocele. In this cases ultrasound is
helpful in determining the bladder neck mobility and funneling of the internal urethral meatus,
the impact of both this situation being urinary incontinence. Valsalva maneuver is used to
evaluate the patients with urinary stress incontinence and also asymptomatic women; during
the maneuver funneling of the internal urethral meatus may be observed (7). In other line,
translabial ultrasound can detect foreign bodies or bladder tumors (8).
Central compartment includes uterine prolapse, and usually is obvious clinical diagnosis;
ultrasound for this compartment is used to assess the impact of an enlarged retroverse uterus
with an implicit anteriorized cervix, explaining this way the symptoms of voiding dysfunctions.
Pelvic floor ultrasound is beneficial in the assessment of the posterior compartment prolapse,
respectively rectocele. Colorectal surgeons use this technique as an initial investigation of
women with defecatory symptoms; studies show that ultrasound is much better tolerated than
defecation proctography (9, 10). A defect of the rectovaginal septum can be observed on
ultrasound exam; these patients are the candidates for a defect-specific rectocele repair as first
introduced by Cullen Richardson (11).

Clinical impact

With the help of pelvic floor ultrasound, clinical data and studies results were objectified,
confirming that vaginal delivery is reflected in major morphologic abnormalities of levator
structure and function (12). Levator defects are associated with cystocele recurrence after
anterior repair, hysterectomy and anti-incontinence and prolapse surgery according to Dietz
HP et al (13) and Model A. et al (14). Palpation of these defects is possible but difficult, hard
interpretable and requires an intense special training, ultrasound being more reproducible,
accessible and easily learned in these areas (15). Hiatal distention on Valsalva > 25 cm2 is
defined as “ballooning” associated with prolapse recurrence after rectocele repair (16); it can
be measured in axial plane, the degree of distention being strongly associated with prolapse and
symptoms of prolapse (17). Another important fact resulted from the use of ultrasonography
in pelvic floor disorders diagnosis is the possibility of comparing pre and post-operative
data in patients with recurrent prolapse, helping to understand the impact of certain surgical
procedures, influencing the future management strategies (4).

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REFERENCES

1. Phillips RA, Stratmeyer ME, Harris GR. Safety and U.S. Regulatory considerations in
the nonclinical use of medical ultrasound devices. Ultrasound Med Biol 2010; 36:1224.
2. AIUM Practice Guideline for the Performance of Pelvic Ultrasound Examinations.
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10. Perniola G, Shek K, Chong C, Chew S,Cartmill J, Dietz H. Defecation proctographyand
translabial ultrasound in the investigation ofdefecatory disorders. Ultrasound Obstet Gy-
necol 2008; 31: 567-71.
11. Richardson AC. The rectovaginal septumrevisited: its relationship to rectocele and its im-
portance in rectocele repair. Clinical Ob Gyn 1993; 36:976-83.
12. Gainey HL. Post-partum observation of pel-vic tissue damage. Am J Obstet Gynecol
1943; 46: 457-66.
13. Dietz HP, Chantarasorn V, Shek KL. Avul-sion of the puborectalis muscle is a risk factorfor
recurrence after anterior repair. Int Urogy-necol J Pelvic Floor Dysfunct 2009;20(suppl
2): S172-3.
14. Model A, Shek KL, Dietz HP. Do levator de-fects increase the risk of prolapse
recurrenceafter pelvic floor surgery? Neurourol Urodyn2009;28(suppl 1): 888-9.
15. Weinstein MM, Pretorius D, Nager CW, Mit-tal R. Inter-rater reliability of pelvic floor
muscleimaging abnormalities with 3D ultrasound. Ul-trasound Obstet Gynecol 2007; 30:
538.
16. Barry C, Dietz H, Lim Y, Rane A. A short-term independent audit of mesh repair for
thetreatment of rectocele in women, using 3-di-mensional volume ultrasound: a pilot
study.Aust N Z Continence J 2006;12:94-9.
17. De Leon J, Steensma AB, Shek C, DietzHP. Ballooning: how to define abnormal disten-
sibility of the levator hiatus. Ultrasound ObstetGynecol 2007; 30: 447.

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Mechanism and Risk Factors for Pelvic Organ


Prolapse - Review

Bohîlțea Roxana Elena1,2, Cîrstoiu Monica Mihaela1,2,


Turcan Natalia2, Bohîlțea Laurențiu Camil1,
Munteanu Octavian1,2, Bodean Oana2, Voicu Diana2,
Baroș Alexandru1,2, Brătilă Elvira1,3
1
“Carol Davila” University of Medicine and Pharmacy, Bucharest
2
Bucharest University Emergency Hospital
3
“St. Pantelimon” Clinic Emergency Hospital, Bucharest
Correspondent author: Roxana Bohîlțea
E-mail: r.bohiltea@yahoo.com

Abstract

Female pelvic organ prolapse refers to a loss of fibromuscular support of the pelvic viscera
resulting the protrusion of the pelvic organs into the vaginal canal. These are worldwide
problems that affect the quality of life of millions of women. The mortality due to this
condition is rare, but symptomatic form is common, 11% of all women requiring at least
one corrective surgical procedure. Thanks to standardized evaluation method, pelvic organ
prolapse quantification system, the distribution of the severity of this condition among general
population is highly studied. Through this article we intend to review the latest specialized
literature discussing the clinical presentation, pathophysiology, evaluation and management of
pelvic organ prolapse. Also, we proposed to summarize the risk factors leading to pelvic organ
prolapse such as age, vaginal childbirth and obesity, diabetes, connective tissue disorders,
neurological diseases and genetic predisposition to the development of pelvic organ prolapse.

Keywords: pelvic prolapse, risk factors, connective tissue disorder

Introduction

Pelvic organ prolapse refers to the herniation of the pelvic organs into the vaginal canal and
represents a global health problem (1). As the proportion of elderly women in the population
increases, the prevalence of pelvic organ prolapses increases exponentially, and this injury
continues to be commonly encountered by the gynecologist. Usually this pathology presents
together with urinary incontinence and/or fecal incontinence, the association of these three
conditions being summarized as pelvic floor disorders. Being a common condition, affecting
millions of women, the patients experience various symptoms that impact significantly the
life quality (2). Pelvic Floor Lifespan Model elaborated by DeLancey et al. (3) comprises the
description of the functionality of the female pelvic floor across a woman’s lifespan. During life
time, three functionality phases of a woman’s pelvic floor are described; phase 1 characterized
by the period predisposing factors and the maximum potential of the pelvic floor muscle; phase
2, characterized by the “inciting factors” added secondary to vaginal birth related injuries and
also the ability of the woman’s recovery; phase 3 or “intervening factors”, refers to the natural

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course of the pelvic floor muscle atrophy that accompanies physiological aging. Reported data
affirm that about 50% of parous women develop symptoms related to pelvic organ prolapse
(4) and the risk of the necessity of surgical correction is 11% (5). The reflection of the high
prevalence of the pelvic organ prolapse is represented by the important annual costs used in this
direction. The surgical repair of prolapse was the most common surgical procedure performed
in women older than 70 years over several years (6). In course of time reconstructive surgery
of pelvic organ prolapse was improved, but the basic principle remains the re-suspension of
the vaginal apex and anterior and posterior vaginal wall. Despite important health technology
evolution, the failure rate of the reconstructive surgery is high, estimated incidence of women
that require re-intervention is estimated to be about 30%, according to Olsen AL et al. (7).

Prevalence

Due to the fact that pelvic organ prolapse may present symptomatic and in equal proportion
asymptomatic and also it is impossible to determine how many women with pelvic organ
prolapse do not presents himself to a gynecologist, the real prevalence of this condition
remains difficult to specify. National Health and Nutrition Examination Survey (NHANES) of
the United States conducted a cross-sectional study including 1961 women aged 20 to 80. The
used method was just subjective, with the purpose to determine the prevalence of symptomatic
pelvic organ prolapse by an interview, without using clinical examination. Reported prevalence
was 2.9% (8), afterwards, this incidence was underreported, with the notice that the study was
able to identify only women with advanced prolapse. An incidence of 50% for symptomatic
pelvic organ prolapse, among parous women was worldwide approved (9).
An indirect value for the prevalence of the pelvic organ prolapse is suggested by the number
of women who undergo surgical prolapse repair, noticing here that annually approximatively
200.000 reconstructive surgical procedures are performed only in the USA (10). Citing data of
other studies, we mention a number of 200.000 of correction procedures performed annually
for this pathology (11), with the maximum incidence at the age 80 to 85. The percentage of
re-intervention for this injury is reported to be 30% (12).

Risk factors

Risk factors leading to pelvic organ prolapse comply with the same factors that lead to the
development of anterior and posterior vaginal wall prolapse. The etiology is multifactorial;
forwards the main risk factors are enumerated considering their incidence.
1. Number of vaginal deliveries (13) and related pelvic floor trauma. The causal role of
parity is sustained by the fact that the incidence of pelvic floor disorders increase directly
proportional with the number of vaginal delivery, it has been estimated that 75% of pelvic
organ prolapses can have the main risk factor the pregnancy and childbirth (14). Table 1
comprise the most representative studies for illustrate de impact of parity and age among
nulliparous and parous women.
Study Nulliparous women Parous women
National survey of United Pelvic organ prolapse 0.6% Pelvic organ prolapse: one
States nonpregnant women birth (2.5%); two births
(3.7%; and three or more
births (3.8%).
Norwegian Study on urinary incontinence 14% urinary incontinence 22 to
premenopausal women 34%

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Oxford Family Planning study the risk of hospital


admission for pelvic
organ prolapse surgery
increased markedly for the
first (fourfold) and second
(eightfold) birth, and then
increased less rapidly for
subsequent births (third:
ninefold; fourth: 10-fold)
Table 1. Studies regarding the impact of parity on pelvic floor diseases (15, 16, 17)

2. Previous hysterectomy, objectified by a case control-stud, which included 160.000


women with a previous hysterectomy that were more predisposed to require a subsequent
pelvic floor repair intervention comparing to the control cases (14).
3. Obesity was correlated with the pelvic floor injuries, based on the increased abdominal
pressure that leads to structural damage and neurological dysfunctions predisposing to pelvic
organ prolapse (18). According to Prolapse Quantification system (POP-Q) BMI is not
correlated with pelvic organ prolapse severity (19), data regarding this hypothesis show no
significant difference in the stage of pelvic organ prolapse between obese and women with a
normal BMI (20).
4. Ageing. The impact of advancing age on the prevalence of pelvic organ prolapse was
objectified by the study of Swift S et al on 1000 women presenting for an annual gynecological
exam, the results showed that every 10 years of age conferred an increased risk of prolapse of
40% (21).
5. Levator ani avulsion. The levator ani complex has an incontestable important role as
pelvic support and also as keeping proper orientation of the female pelvic organs. This function
requires an intact qualitative and functional nervous innervation. Parturition may include the
injury of the described complex and implicitly an inappropriate functionality of it.

Anatomy and mechanism of the pelvic organ prolapse

The anatomy of the female pelvic floor favors the downward of the pelvic organs if the
presented risk factors are present. The etiology is most commonly related to connective tissue,
neural, and/or neural defects in the normal structural support (21). Normal anterior wall support
includes levator ani muscles (pubococcygeus, puborectalis, and iliococcygeus) and also a layer
of dense fibrous musculoconnective tissue (22). Uterosacral and cardinal ligaments are formed
by the condensation of the endopelvic fascia, and have an important role in the stabilization
of the pelvic organ in the correct position (23). On the other side, the bladder does not have
an original support; the only anatomic resistance structure is the vagina, on which the bladder
overlies. There are three levels of vaginal support that are connected by the endopelvic fascia.
The first level is represented by the uterosacral/cardinal ligament complex and is the first
line support of the uterus and upper vagina, the loss of this level is reflected trough the prolapse
of the uterus and/or the vagina. Second level, represented by paravaginal attachments, the
length of the vagina to the superior fascia of the levator ani muscle and the arcus tendineus
fascia pelvis; the injury of this levels contributes to anterior vaginal wall prolapse. Level three
is constitute by perineal body, perineal membrane, and superficial and deep perineal muscles,
which injury can result in a posterior prolapse (rectocele) (24).

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Clinical manifestations

Usually the symptoms are related specifically to the prolapsed structures, main affected
functions are urinary, defecatory or sexual (25). Symptoms are related to the position and,
interesting not correlated to the stage of the prolapse (26). An important percentage of women
with pelvic organ prolapse present asymptomatic, and no treatment in these cases is required.
The symptoms that often accompany this condition are vaginal or pelvic pressure, the
sensation of a vaginal bulge or a structure that falls out of the vagina (Fig 1, 2). There are
cases when the patient describes the structure that is seen beyond the introitus; ulceration and
bleeding may result in this situation. Stage I or II prolapse includes frequently the affection
of the bladder with the incontestable appearance of the urinary incontinence (27). In the case
of advanced anterior prolapse, an increased difficulty voiding may be developed; the patient
could relate the necessity of changing the position or manually reduce the prolapse to urinate.
Other urinary symptoms related to pelvic organ prolapse are enuresis, incontinence with
sexual intercourse, dysuria (28).

Fig. 1, 2 Pelvic organs prolapse grade 4

Defecatory symptoms appear if any posterior compartment is affected: rectocele, enterocele,


sigmoidocele, perineocele, internal rectal prolapse (intussusception), or full mucosal rectal
prolapse.
On sexual function, prolapse of pelvic organ associates adverse effects on orgasm or sexual
satisfaction (29).
The diagnosis of pelvic organ prolapse is clinically next to a detailed anamnesis. The staging
is accorded to the Society of Gynecologic Surgeons, American Urogynecologic Society, and
International Continence Society, the Pelvic Organ Prolapse Quantitation (POPQ) system.

Management

The treatment is indicated for patient with urinary, defecation and sexual dysfunction, or
symptoms of prolapse. Expectant management is preferred in asymptomatic cases or the patient
tolerates their symptoms and chose to avoid the treatment (30). Conservative management has
the advantage of avoiding the surgical complication that may appear and the disadvantage of
the necessity of ongoing maintenance. Vaginal pessary is a silicone device which supports
the pelvic organs; they must be removed and cleaned regularly. Randomized trials reported
improved pelvic organ prolapse symptoms after pelvic floor muscle training and lifestyle

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advice program (31). Estrogen therapy was evaluated by only three trails whit the unanimous
result that the estrogenic therapy focuses mostly on vaginal atrophy and less on the prolapse
itself (32).
For all symptomatic women with pelvic organ prolapse, surgical treatment is recommended.
The approach may be abdominal or vaginal and could or not include graft materials.
As mentioned above, the reoperation rate is high, evaluated on up to 30%; the prognosis
depending on the severity of symptoms, extent of the prolapse, physician experience, and
patient expectations (33).

REFERENCES

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3. DeLancey JOL, Kane Low L, Miller JM, et al. Graphic integration of causal factors of
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4. Subak LL, Waetjen LE, van den Eeden S, Thom DH, Vittinghoff E, Brown JS (2001) Cost
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8. Nygaard I, Barber MD, Burgio KL, et al. Prevalence of symptomatic pelvic floor disorders
in US women. JAMA 2008; 300:1311.
9. LL Subak, LE Waetjen, S van den Eeden, DH Thom, E Vittinghoff, JS Brown. Cost of
pelvic organ prolapse surgery in the United States. Obstet Gynecol 2001; 98: 646–65.
10. Jones KA, Shepherd JP, Oliphant SS, et al. Trends in inpatient prolapse procedures in the
United States, 1979-2006. Am J Obstet Gynecol 2010; 202: 501.e1.
11. Boyles SH, Weber AM, Meyn L. Procedures for pelvic organ prolapse in the United
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organ prolapse and urinary incontinence. Obstet Gynecol 1997; 89:501.
13. Blandon RE, Bharucha AE, Melton LJ 3rd, et al. Incidence of pelvic floor repair after
hysterectomy: A population-based cohort study. Am J Obstet Gynecol 2007; 197: 664.e1.
14. Elvira Brătilă, Simona Vlădăreanu, Costin Berceanu, Monica Cîrstoiu, Claudia Mehedințu,
Diana Comandașu, Mihai Mitran. Rolul sarcinii și al nașterii în apariţia tulburărilor de
statică pelvică. Revista Ginecologia.ro; 2015 10(4): 28-33
15. Mant J, Painter R, Vessey M. Epidemiology of genital prolapse: observations from the
Oxford Family Planning Association Study. Br J Obstet Gynaecol 1997; 104:579.
16. Rortveit G, Hannestad YS, Daltveit AK, Hunskaar S. Age- and type-dependent effects of
parity on urinary incontinence: the Norwegian EPINCONT study. Obstet Gynecol 2001;

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98:1004.
17. Nygaard I, Barber MD, Burgio KL, et al. Prevalence of symptomatic pelvic floor disorders
in US women. JAMA 2008; 300:1311.
18. Altman D, Falconer C, Cnattingius S, Granath F. Pelvic organ prolapse surgery following
hysterectomy on benign indications. Am J Obstet Gynecol 2008; 198: 572. e1.
19. Kesharvarz H, Hillis SD, Kieke BA, Marchbanks PA. Hysterectomy surveillance—United
States 1994–1999. MMWR Surveill Summ 2002, 51 (SS05): 1–8.
20. RC Bump, PA Norton. Epidemiology and natural history of pelvic floor dysfunction.
Obstet Gynecol Clin North Am 1998, 25: 723–746.
21. Klauss Goeshen, Peter Petros, Andrei Funogea, Elvira Brătilă, Petre Brătilă, Monica
Cîrstoiu. Planșeul pelvic la femeie. Anatomia funcțională, diagnostic și tratament - în
acord cu teoria integrativa. Editura Universitara «Carol Davila Bucuresti», Bucuresti,
2016, ISBN 978-973- 708-894-9.
22. Mant J, Painter R, Vessey M. Epidemiology of genital prolapse: observations from the
Oxford family planning association study, BJOG 1997, 104: 579–585.
23. Swift S, Woodman P, O’Boyle A, et al. Pelvic Organ Support Study (POSST): the
distribution, clinical definition, and epidemiologic condition of pelvic organ support
defects. Am J Obstet Gynecol 2005; 192:795.
24. Boyles SH, Edwards SR. Repair of the anterior vaginal compartment. Clin Obstet Gynecol
2005; 48:682.
25. Stepp KJ, Walters MD. Anatomy of the lower urinary tract, rectum and pelvic floor. In:
Urogynecology and Reconstructive Surgery, 3, Walters M, Karram M (Eds), Mosby,
Philadelphia 2007: 24.
26. Percy JP, Neill ME, Swash M, Parks AG. Electrophysiological study of motor nerve
supply of pelvic floor. Lancet 1981; 1:16.
27. Jelovsek JE, Maher C, Barber MD. Pelvic organ prolapse. Lancet 2007; 369:1027.
28. Kahn MA, Breitkopf CR, Valley MT, et al. Pelvic Organ Support Study (POSST) and
bowel symptoms: straining at stool is associated with perineal and anterior vaginal descent
in a general gynecologic population. Am J Obstet Gynecol 2005; 192:1516.
29. Elvira Brătilă. Complicații uroginecologice în chirurgia vaginală. Editura Universitara
«Carol Davila Bucuresti», Bucuresti, 2016, ISBN 978-973- 708-902-1.
30. Tok EC, Yasa O, Ertunc D, et al. The effect of pelvic organ prolapse on sexual function in
a general cohort of women. J Sex Med 2010; 7:3957.
31. Braekken IH, Majida M, Engh ME, Bø K. Can pelvic floor muscle training reverse
pelvic organ prolapse and reduce prolapse symptoms? An assessor-blinded, randomized,
controlled trial. Am J Obstet Gynecol 2010; 203:170.e1.
32. Weber MA, Kleijn MH, Langendam M, et al. Local Oestrogen for Pelvic Floor Disorders:
A Systematic Review. PLoS One 2015; 10:e0136265.
33. Lavelle RS, Christie AL, Alhalabi F, Zimmern PE. Risk of Prolapse Recurrence after
Native Tissue Anterior Vaginal Suspension Procedure with Intermediate to Long-Term
Followup. J Urol 2016; 195:1014.

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Stress urinary incontinence (sui) due to causes other


than parturition
BOȚ Mihaela1, VLĂDĂREANU Radu1, VLĂDĂREANU Simona1,
ZVÂNCĂ Mona1, PETCA Aida1
1
ROMANIA, Obstetrics - Gynaecology and Neonatology Department, Elias University Emergency
Hospital, Bucharest, University of Medicine and Pharmacy Carol Davila
E-mails: mihaelabot@yahoo.com, vladareanu@gmail.com, simconst69@gmail.com, aidapetca@
gmail.com

Abstract

Stress urinary incontinence represents involuntary loss or leakage of urine from the urethra
during the increase in intra-abdominal pressure, thus significantly affecting the patient’s well-
being on a social, psychological and physical level. With population ageing, the incidence
of this condition will grow and will have a bigger and bigger impact on the deterioration of
quality of life. The prevalence of this condition is largely different depending on the study,
ranging from 20% to 50%. The prevalence of the condition increases with age, starting from
6,5% in 20/25 year-old women, until 35-50% in 80 year-old women, thus menopausal women,
even nulliparous ones, manifest SUI. Although nulliparous patients or the ones who had a C
section are not included in the SUI risk group, a series of women show this condition as a result
of the alteration of the pelvic floor statics during pregnancy. An excessive body weight, with
a high body mass index (BMI), is one of the important risk factors in urinary incontinence.
The bigger BMI is, the more frequent urinary incontinence symptoms are. Female patients
with professions which involve intense physical effort or athletes may be affected by this
pathology, too. The most frequent activities which can cause involuntary loss of urine have
been reported in women who are involved in high impact sports such as jumps and running
(athletic sports).

Introduction

In women, urinary incontinence represents involuntary loss or leakage of urine from the
urethra during the increase in the intra-abdominal pressure, after coughing, sneezing, laughing
or heavy lifting and which is not accompanied by the sensation of urinary urge [1]. Usually,
involuntary loss of urine is not accompanied by any other symptoms, such as a painful urge,
pain, a burning sensation in the urethra or polyuria [1, 2].
Stress urinary incontinence largely affects the patient’s well-being on a social, psychological
and physical level and has a negative impact on family life and health care services [3]. We
see female patients with a low self-esteem, depression and sexual dysfunctions [4]. With
population ageing, the incidence of this condition will grow to have a bigger and bigger effect
on the deterioration of quality of life [1].

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Menopause

The 20th century brought about a longer life span and, as a consequence, a decrease of the
quality of life of the elderly. The age of menopause is, without any change, assessed to be
approximately 50, therefore, considering the fact that women live more nowadays, they spend
one third of their life during postmenopausal period [5].
Ageing symptoms of urogenital system occur in approximately 50% of women.
The prevalence of the condition increases with age, starting from 6,5% in 20-25 year-old
women [5] to 35-50% [5, 7] in women older than 80. A higher incidence in white women and
the fact that nulliparous females show this condition too are elements which plead in favour of
involving the constitutional factor, along with the well-known theories trying to explain stress
urinary incontinence as a multi-parity, estrogenic deficiency through its atrophying effect upon
venous plexuses.
The exact prevalence of urinary incontinence in women is difficult to assess, considering
that a vast part of the affected population does not report the condition out of socio-cultural
reasons. Thus, it largely fluctuates depending on each study, ranging from 20% to 50%.
The incidence of urinary incontinence in these female patients is double in the 50 - 54
age group as opposed to the one of females younger than 40 years old because the urogenital
atrophy caused by estrogenic deficiency is an established component of urinary incontinence
pathogeny, although randomised studies failed to prove any association.
Stress urinary incontinence can worsen during the week before the menstrual period. In
that moment, the reduced level of estrogen may cause a decreased pressure of the periurethral
muscular layer, increasing the chances of involuntary loss of urine. Similarly, due to the
decreased level of estrogen, the same mechanism is involved in the post-menopausal period
[8] too. The relationship between the urinary continence/incontinence and level of hormones
is confirmed by the fact that cyclical hormonal changes happening during menstrual cycle
determine changes in the parameters of the urodynamic test [2]. Estrogens affect the mechanism
of urinary continence by increasing the urethral resistance, increasing the sensory threshold
of the urinary bladder, as well as increasing the sensitivity of alpha receptors in the urethral
smooth muscle [2, 5]. Probably, estrogen receptors are to some extent responsible even for the
central control of micturition [2]. The decrease of the serum estrogen level produces changes
on all these levels.
It is presumed that the functioning of the structures involved in the control of micturition
in SUI may become less efficient with advancing age and might become the groundwork for
estrogen therapy [1, 5, 9] whenever there are no clear contraindications.
The integrity of levator ani muscle is unanimously accepted as being very important in the
urinary continence [10, 11] and, as it is basically a striated muscle is subject to change with
ageing and time, e.g. the loss of its mass, known as sarcopenia [12].

Nulliparous women and patients after Caesarean sections

Although nulliparous patients or the ones who underwent a C-section are not included in
the risk group, a series of women are affected by this condition. SUI incidence is by 5,7%
higher after giving birth by C-section compared to nulliparous women and by 8,4% higher
after vaginal deliveries compared to deliveries by C-section [13]. According to EPINCONT
Study [13], there is no significant difference in the incontinence prevalence rate in women who

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underwent an elective C-section and the ones who had an emergency C-section.
Vaginal delivery is an established risk factor for urinary incontinence among young and
middle-aged women. It has been suggested that vaginal delivery is the main contributing
factor because of the deterioration of the muscle tissue or the nervous endings in the pelvic
floor. Nevertheless, pregnancy itself may cause mechanic or/and hormonal changes, which
determine urinary incontinence [14, 15]. Therefore, stress urinary incontinence in women who
gave birth by C-section is a result of the alteration of the pelvic floor statics during pregnancy.
Even if these results are relevant for advising patients to choose C-sections, the results
should not be used as an argument for the increased use of Caesarean delivery.
Stress urinary incontinence in nulliparous patients can also be seen in patients with an
increased intra-abdominal pressure as a result of obesity, chronic obstructive pulmonary
diseases or asthma, which involve repeated and long coughing episodes or chronic constipation
[6].

Overweight

An excessive body weight, with a high body mass index (BMI), is one of the important risk
factors of urinary incontinence. The higher the BMI, the more frequent urinary incontinence
symptoms are. Asymmetric obesity (BMI > 30 kg/m2) with an excess of adipose tissue on the
abdominal level determines involuntary urine loss 4-5 times more frequently than in women
with a normal body weight [16]. The increase in the intra-abdominal pressure, which coincides
with a high BMI, leads to a proportionally higher intravesical pressure, which overcomes the
urethral closure pressure and determines urinary incontinence. Obesity, which is an important
etiologic factor in SUI, nevertheless does not influence the urodynamic parameters [17].
Although the role of obesity in the complex etiopathogenesis of urinary incontinence
has not been fully acknowledged or studied, there is no doubt that weight loss often leads
to alleviation of symptoms, an improvement of micturition control, and an improvement of
quality of life, too [18]. This fact is best evidenced during weight loss obtained through a diet
programme or bariatric surgery, when stress urinary symptoms are alleviated [19].

Intense physical activity

Patients with professions which involve intense physical effort or athletes may be
affected too by this pathology, but incontinence is many times underreported [20]. In high
performance athletes, stress incontinence can occur during playing any sport which involves
effort, sudden and repeated increase and decrease of intraabdominal pressure, straining the
resistance of perineal floor [8]. Urinary incontinence prevalence ranges from 28% to 80%
among sportswomen. The most frequent activities susceptible of provoking involuntary loss
of urine are being reported in women involved in high impact sports 20 such as jumps and
running (athletic sports).
In these women, involuntary urine loss can occur outside the training or the competing
programme too, during daily or recreational activities [20].
92,5% of the female athletes who admit having SUI state that the involuntary urine loss
occurs rather during training opposed to 51, 2 during competition (probably due to increased
catecholamine levels, which determine the urethral alpha-receptors to maintain its closure)
[21].

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The thickness of the ani levator and ouborectalis muscles was measured by means of
nuclear magnetic resonance imaging [22], while pubovesical muscle was measured by means
of translabial ultrasound in female athletes and the bladder neck descent was observed, along
with the hypertrophy of the ani levator muscle, with a larger hiatus [23]. Intensive trainings
led to the mentioned morphological changes, but also to compensatory hyper-distensibility
functional changes in female athletes. These changes corroborated with a decrease of collagen
production in their skin and periurethral tissue and a decreased ratio of type I/type III collagen
24, 25 in some women explain the stress urinary incontinence.
Outside high performance sports activities, 8,5% young women between 16 and 20 years
old have reported involuntary urine loss during physical education classes [26].
Also, female smokers or the ones that use caffeine-based preparations or medicines show
an increased incidence of this condition [3].

Treatment

Urinary incontinence treatment should start with treating determinant or contributing


factors such as: eating disorders, genital atrophy, smoking, obesity and a decreasing intake of
caffeine. Athletes should avoid excessive fluid intake before trainings and competitions, but at
the same time they should avoid dehydration [27].
Physical training for strengthening the pelvic floor muscle is an important component
in preventing and treating urinary incontinence, having no known side effects. Therefore, it
should be chosen as the first therapeutic approach, especially in nulliparous women [28].
Cochrane established after a review of 17 studies that for the women unable to do physical
exercises, the use of vaginal cones or local electrostimulation is equally efficient [29].
Along with anticholinergic medication30, which is used in treating SUI, other substances
such as imipramine can improve quality of life of women who suffer from urinary incontinence,
but they have not been tested for athletes [31]. Adrenergic agonists such as Pseudoephedrine
hydrochloride are efficient, but they may have usually rare and minor side effects, but also
serious ones, such as arterial hypertension and cardiac arrhythmia. Moreover, they are
forbidden to elite athletes [32]. Duloxetine, a serotonin-norepinephrine reuptake inhibitor, can
significantly improve the quality of life for stress urinary incontinence patients. Duloxetine is
frequently associated with nausea, which may cause non-compliance with this treatment [33].
Indication for surgical treatment is considered when the involuntary urine loss is very
upsetting for patients, the incontinence has been under a gynaecologist observation during
clinical examination, its causes have been properly assessed and the conservative therapy failed
[31]. Surgical treatments include pubovaginal or transobturator midurethral sling procedures,
retropubic suspension or periurethral injection therapy. Surgical treatment is not indicated for
young women, including elite athletes who are continent during regular, daily activities and
have incontinence only during physical trainings [34].
Stem-cell therapy could be the next step in treating urinary incontinence. In years to come,
it will enable a broadening of indications for SUI women with associated comorbidities,
who cannot undergo surgical treatment. Being administered in the periurethral region, stem
cells contribute to increasing the urethral occlusion pressure, thus restoring normal urinary
continence [35].

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Conclusions

Stothers and colab [36] show that age has the most important effect in the occurrence
of urinary incontinence. Obesity significantly contributes to an increased prevalence of this
condition, while weight loss is highly important in alleviating SUI symptoms.
The objective of this article was to present this difficult clinical problem and to assess the
occurrence frequency of stress urinary incontinence, with consideration of the most frequent
risk factor of this condition in the group of nulliparous, perimenopausal women with SUI after
C-section delivery, or athletes without morphological pelvi-genital statics disorders.

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i społeczny. (Stress urinary incontinence as a clinical therapeutic and social problem)
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2. Ahn KH, Kim T, Hur JY, Kim SH, Lee KW, Kim YT. Relationship between serum
estradiol and follicle-stimulating hormone levels and urodynamic results in women with
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3. Nicolae Crisan, Dimitrie Nanu - Ginecologie – Ed. Știința și Tehnică 1995, ISBN 973-
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4. Coyne KS, Sexton CC, Irwin DE, et al. The impact of overactive bladder, incontinence
and other lower urinary tract symptoms on quality of life, work productivity, sexuality
and emotional well-being in men and women: results from the EPIC study. BJU Int 2008;
101:1388–95.
5. Contreras Ortiz O. Stress urinary incontinence in the gynecological practice. Int J
Gynaecol Obstet. 2004; 86 Suppl 1: S6-16.
6. Nygaard I, Barber MD, Burgio KL, et al. Prevalence of symptomatic pelvic floor disorders
in US women. JAMA 2008; 300:1311-6.
7. Sub redacția Irinel Popescu, Constantin Ciuce - Tratat de chirurgie, ediția a 2-a, 2014,
ISBN 978-973-27-2185-8
8. Crepin G, Biserte J, Cosson M, Duchene F (October 2006). “[The female urogenital
system and high level sports]”. Bull. Acad. Natl. Med. (in French). 190 (7): 1479–91;
discussion 1491–3. 17450681.
9. Rechberger T. Nowości w diagnostyce i leczeniu zabiegowym nietrzymania moczu u
kobiet. (Developments in diagnostics and treatment of urinary incontinence in women)
Przew Lek. 2007; 2: 94-100 (in Polish).
10. Norton P, Brubaker L. Urinary incontinence in women. Lancet 2006; 367:57-67. 442
11. DeLancey JOL, Kearney R, Chou Q, Speights S, Binno S. The appearance of levator
ani muscle abnormalities in magnetic resonance images after vaginal delivery. Obstet
Gynecol 2003; 101:46-53.
12. Mitchell WK, Williams J, Atherton P, Larvin M, Lund J, Narici M. Sarcopenia, dynapenia,
and the impact of advancing age on human skeletal muscle size and strength; a quantitative
review. Front Physiol 2012; 3, nr260,1-18.
13. Guri Rortveit, M.D., Anne Kjersti Daltveit, Ph.D., Yngvild S. Hannestad, M.D., and Steinar
Hunskaar, M.D., Ph.D., for the Norwegian EPINCONT Study - Urinary Incontinence
after Vaginal Delivery or Cesarean Section- N Engl J Med 2003; 348:900-907March 6,

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2003DOI: 10.1056/NEJMoa021788
14. Rortveit G, Hannestad YS, Daltveit AK, Hunskaar S. Age- and type-dependent effects of
parity on urinary incontinence: the Norwegian EPINCONT study. Obstet Gynecol 2001;
98:1004-1010
CrossRef|Web of Science|Medline
15. Thom DH, Brown JS. Reproductive and hormonal risk factors for urinary incontinence
in later life: a review of the clinical and epidemiologic literature. J Am Geriatr Soc 1998;
46:1411-1417
Web of Science|Medline
16. Hannestad YS, Rortveit G, Daltveit AK, Hunskaar S. Are smoking and other lifestyle
factors associated with female urinary incontinence? The Norwegian EPINCONT Study.
BJOG. 2003; 110(3): 247-54.
17. Bai SW, Kang JY, Rha KH, Lee MS, Kim JY, Park KH. Relationship of urodynamic
parameters and obesity in women with stress urinary incontinence. J Reprod Med. 2002;
47(7): 559-63.
18. Whitcomb EL, Horgan S, Donohue MC, Lukacz ES. Impact of surgically induced weight
loss on pelvic floor disorders. Int Urogynecol J. 2012 Apr 12. [Epub ahead of print].
19. Bart S, Ciangura C, Thibault F, Cardot V, Richard F, Basdevant A, Chartier-Kastler E.
Stress urinary incontinence and obesity. Prog Urol. 2008; 18(8): 493-8.
20. Orly Goldstick and Naama Constantini - Urinary incontinence in physically active women
and female athletes - Br J Sports Med 2014 48: 296-298 originally published online May
18, 2013 doi: 10.1136/bjsports-2012-091880.
21. Thyssen HH, Clevin L, Olesen S, et al. Urinary incontinence in elite female athletes and
dancers. Int Urogynecol J 2002; 13:15–17.
22. Kruger JA, Murphy BA, Heap SW. Alterations in levator ani morphology in elite
nulliparous athletes: a pilot study. Aust NZ J Obstet Gynecol 2005; 45:42–7.
23. Kruger JA, Dietz HP, Murphy BA. Pelvic floor function in elite nulliparous athletes.
Ultrasound Obstet Gynecol 2007; 30:81–5.
24. Keane DP, Sims TJ, Abrams P, et al. Analysis of collagen status in premenopausal
nulliparous women with genuine stress incontinence. Br J Obstet Gynecol 1997; 104:994–
8.
25. Ulmsten U, Ekman G, Giertz G, et al. Different biochemical composition of connective
tissue in continent and stress incontinent women. Acta Obstet Gynecol Scand 1987;
66:455–7.
26. Nygaard IE1, Thompson FL, Svengalis SL, Albright JP.- Urinary incontinence in elite
nulliparous athletes- Obstet Gynecol. 1994 Aug;84(2):183-7.
27. Greydanus DE, Patel DR. The female athlete before and beyond puberty. Pediatr Clin N
Am 2002;49:553–80.
28. Hay-Smith J, Mørkved S, Fairbrother KA, et al. Pelvic floor muscle training for prevention
and treatment of urinary and faecal incontinence in antenatal and postnatal women.
Cochrane Database Syst Rev 2008;(4):CD007471.
29. Herbison GP, Dean N. Weighted vaginal cones for urinary incontinence. Cochrane
Database Syst Rev 2002;(1):CD002114.
30. Greydanus DE, Patel DR. The female athlete before and beyond puberty. Pediatr Clin N
Am 2002; 49:553–80.
31. Corcos J, Gajewski J, Heritz D, et al. Canadian Urological Association guidelines on
urinary incontinence. Can J Urol 2006; 13:3127–38.

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32. Alhasso A, Glazener CMA, Pickard R, et al. Adrenergic drugs for urinary incontinence in
adults. Cochrane Database Syst Rev 2005;(3): CD001842.
33. Mariappan P, Alhasso AA, Grant A, et al. Serotonin and noradrenaline reuptake
inhibitors (SNRI) for stress urinary incontinence in adults. Cochrane Database Syst Rev
2005;(3):CD004742.
34. ø K. Pelvic floor physical therapy in elite athletes. In: Bø K, Berghmans B, Mørkved S,
et al, eds. Evidence-based physical therapy for the pelvic floor. Oxford, UK: Butterworth-
Heinmann Elsevier, 2007:369–78.
35. Stangel-Wójcikiewicz K, Majka M, Basta A, Stec M, Pabian W, Piwowar M, Chancellor
M. Adult stem cells therapy for urine incontinence in women. Ginekol Pol. 2010; 81:
378-381.
36. Stothers L, Friedman B. Risk factors for the development of stress urinary incontinence in
women. Curr Urol Rep. 2011; 12(5): 363-9.

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Delayed Recognition of a Sigmoid Colon Iatrogenic


Lesion Following Total Abdominal Hysterectomy in a
Patient with a Previous Episode of Acute Diverticulitis

Socea Bogdan1,2, Alexandru Carâp1,2, Smaranda


Alexandru1, Moculescu Cezar1, Bobic Simona1,2,
Dimitriu Mihai2,3, Socea Laura4, Vlad Denis Constantin1,2
1
General Surgery Department, “St. Pantelimon” Emergency Clinical Hospital, Bucharest
(Romania)
2
Surgery Department, “Carol Davila” University of Medicine and Pharmacy, Bucharest (Romania)
3
Obstetrics and Gynecology Department, “St. Pantelimon” Emergency Clinical Hospital, Bucharest
(Romania)
4
Organic Chemistry Department, “Carol Davila” University of Medicine and Pharmacy, Bucharest
(Romania)
E-mail: alexandru_carap@hotmail.com

Abstract

Gastrointestinal injuries can occur during gynaecological procedures. The range of


gastrointestinal lesions is very wide and encompasses the small and large intestines, the rectum
and less frequently the gastric region. We present the case of a 47 year old woman that had a
medical history significant for acute diverticulitis and that sustained an iatrogenic colon lesion
during an abdominal hysterectomy for leiomyoma. The lesion was not diagnosed at the time
of surgery and required reoperation and Hartmann’s procedure. Iatrogenic gastrointestinal
lesions during gynaecological procedures are an overlooked entity in the medical literature.
While their incidence is not extremely high, their potential complications can lead to
serious disability, as evidenced by the case we present, and even mortality. All gynaecologists
should be trained in simple enteral and colorectal resections and when doubtful situations
appear a digestive surgeon should be a part of the management team. We recommend that
in cases with previous diverticular disease a digestive surgeon should assist during surgery
in order to help with difficult dissections and to evaluate the health of the sigmoid colon and
decide its eventual resection.

Keywords: gynaecology, iatrogenic large bowel lesion, acute diverticulitis

Introduction

Gastrointestinal injuries can occur during gynaecological procedures. The range of


gastrointestinal lesions is very wide and encompasses the small and large intestines, the rectum
and less frequently the gastric region. Small intestine injuries and large bowel injuries can
take place during dilatation and curettage, total abdominal hysterectomy and hysteroscopic
and laparoscopic procedures [1]. Mild injuries of the intestines are amenable to simple suture

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repair but extensive lesions may require resections [2]. Lesion can occur during opening of
the abdomen and adhesiolysis in the previously operated patients and during the surgical
steps required to perform the specific gynaecological procedure. Colon injuries can appear
in patients that have surgery for left adnexal masses and patients with a history of pelvic
inflammatory disease and diverticulitis [3]. The aim of this case report is to emphasize the
importance of a high index of suspicion for colonic lesions during gynaecological procedures
in women who have a history of diverticulitis. We would also like to state that the presence of
a general surgeon or of a colorectal surgeon during procedures for these patients is advisable.

Case report

We present the case of a 47 year old woman that was scheduled for a total abdominal
hysterectomy for a voluminous, bleeding, uterine fibroma. Her medical history is significant
for arterial hypertension and an episode of acute diverticulitis one year prior to the current
presentation. She was diagnosed and treated for Hynchey class III acute diverticulitis with
laparoscopic lavage and drainage. The episode resolved successfully following surgical
treatment and the patient presented no new symptoms pertaining to diverticulitis. Repeated
episodes of bleeding have resulted in a gynaecological consult, ultrasound and bioptic curettage
one month prior to presentation that resulted in the previously mentioned diagnosis, an 8/8
cm uterine leiomyoma. The patient was scheduled for total abdominal hysterectomy. During
the procedure extensive adhesions were found and lysed in the pelvis. After adhesiolysis,
the operation continued uneventfully. Hysterectomy was performed and a drainage tube was
placed in the pelvis through a separate stab wound. In the postoperative period the patient’s
condition progressively worsened, she was febrile and had no bowel movements and on the
third postoperative day the abdomen was distended, painful and presented guarding especially
in the lower abdomen. Drainage was minimal and serous. Plain abdominal x-rays identified
distended bowel loops with multiple air-fluid levels suggesting an intestinal obstruction.
Abdominal ultrasound identified free fluid in the abdomen and an exploratory laparotomy
was performed. Intraoperative exploration revealed distended bowel loops and free feculent
fluid in the peritoneal cavity. After the aspiration and lavage of the peritoneal cavity a partial
section of the sigmoid colon was identified and a Hartmann’s procedure was performed. The
patient recovered well and she was discharged on the 6th postoperative day. She is scheduled
for Hartmann reversal at six months.

Discussion

Iatrogenic gastrointestinal lesions during gynaecological procedures are an overlooked


entity in the medical literature. While their incidence is not extremely high, their potential
complications can lead to serious disability, as evidenced by the case we present, and even
mortality. Classification of these lesions by the procedure performed shows a correlation
between procedures and the site of the injury at the level of the bowel. Total abdominal
hysterectomy has a correlation with cecal lesions, dilatation and curettage associates with
small bowel injuries while gastric lesions associate seldom with laparoscopic surgery and
trocar placement [4, 5]. Other studies find a high rate of small bowel lesion that occur during
adhesiolysis, 61-75% [6, 7]. Although these rates may differ between case series one aspect is
very clear, and that is that a high rate of intestinal iatrogenic lesions appear in patients that had

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previous abdominal surgery and extensive adhesions, with rates as high as 44-64% [6]. Early
and intraoperative diagnosis is the rule for gastrointestinal iatrogenic lesions, the exteriorization
of feculent biliary fluid leading, most commonly, to a straightforward diagnosis. Missed bowel
lesions due to thermal injury are more frequently associated with laparoscopic procedures
[8]. Adhesions are a common complication of acute diverticulitis whatever the treatment
modality is. It is not yet clear whether treatment with lavage and drainage without resection for
Hinchey class III disease will lead to more adherences compared to other treatment strategies
[9]. Reports are scarce about diverticulitis and gynaecological procedures and their risk for
iatrogenic gastrointestinal injuries. However we believe that in our case the adhesions were
the reason for the sigmoid injury. Early recognition of the lesion is of paramount importance.
Intraoperative diagnosis can most often be resolved by primary suture repair (approximately
50% of cases). However if the lesion occurs on a diseased sigmoid colon with a previous
episode of acute diverticulitis, resection is probably the safer option. The extensiveness of
the injury can be the difference between simple suture repair and resections followed by
anastomosis or stoma formation. Unrecognised lesions can lead to sepsis and septic shock
and their delayed repair is most commonly done by resection of the affected segment and
anastomosis and/or stoma formation. All gynaecologists should be trained in simple enteral
and colorectal resections and when doubtful situations appear a digestive surgeon should be a
part of the management team. We recommend that in cases with previous diverticular disease
a digestive surgeon should assist during surgery in order to help with difficult dissections and
to evaluate the health of the sigmoid colon and decide its eventual resection. As laparoscopic
techniques become ever more prevalent, special attention should be paid in the training of
basic digestive techniques in order to avoid occult lesions of bowel.

REFERENCES

1. Richter R. Prophylaxis and therapy of intestinal complications in surgical gynecology.


Ther Umsch. 1981;38(6):516-23.
2. Davis JD. Management of injuries to the urinary and gastrointes- tinal tract during
cesarean section. Obstet Gynecol Clin North Am. 1999;26(3):469-80.
3. Paloyan D, Tommaso F, William W. Clinical Reproductive: Medicine and Surgery. In:
Paloyan D, Tommaso F, William W, editors. Intestinal Problems in Gynecologic Surgery.
GLOWM; 2008.
4. Mesdaghinia, E., Abedzadeh-kalahroudi, M., & Hedayati, M. (2013). Iatrogenic
Gastrointestinal Injuries During Obstetrical and Gynecological Operation Moussavi-
Bioki, 2(2), 81–84.
5. Rock JA, Jones HW. TeLinde’s Operative Gynecology. 2011.
6. Bhattee GA, Rahman J, Rahman MS. Bowel injury in gynecologic operations: analysis of
110 cases. Int Surg. 2006;91(6):336-40.
7. Krebs HB. Intestinal injury in gynecologic surgery: a ten-year ex- perience. Am J Obstet
Gynecol. 1986;155(3):509-14.
8. Baggish MS. Lessons in timely recognition of laparoscopy-relat- ed bowel injury.
JFPonlinecom. 2008;20(7):55-60.
9. Fingerhut A, Veyrie N. Complicated diverticular disease: the changing paradigm for
treatment. (2012), 39(4), 322–327.

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Iatrogenic Ureteral Injuries During Gynecological


Procedures

Vlad Denis Constantin1,2, Alexandru Carâp1,2, Anca Nica1,


Moculescu Cezar1, Bobic Simona1,2, Socea Bogdan1,2
1
General Surgery Department, “St. Pantelimon” Emergency Clinical Hospital, Bucharest (Romania)
2
Surgery Department, “Carol Davila” University of Medicine and Pharmacy, Bucharest (Romania)
E-mail: alexandru_carap@hotmail.com

Abstract

Traumatic injuries to the ureter are rare occurrences whether from external trauma or
iatrogenic trauma. They make up about 1-2% of all urinary tract injuries. The most common
causes of iatrogenic ureteral injuries are complications of pelvic procedures most often
gynecological, endourological, urological, vascular and colorectal. The aim of this paper is
to present our experience with ureteral iatrogenic injuries that occurred during gynecological
procedures and their diagnosis and management. For this we used data recorded in the patient’s
chart, operative descriptions and imaging studies. We analyzed these variables retrospectively.
We analyzed six cases of ureteral injury following gynecological procedures that occurred
in our department in the period January 2014 – April 2016. Four cases had an intraoperative
diagnosis and primary repair while the remaining two were diagnosed postoperatively. All six
cases had a favorable outcome after reconstructive surgery. Gynecological procedures have the
highest rate of ureteral injuries among surgical specialties. Rapid diagnosis is the cornerstone
of management and allows for a timely reconstruction and minimal morbidity.
Delayed diagnosis can have serious consequences including nephrectomy. It is therefore
essential that a high index of suspicion should be maintained during procedures that present a
risk of ureteral injuries.

Keywords: iatrogenic ureteral injury, gynecology

Introduction

Traumatic injuries to the ureter are rare occurrences whether from external trauma or
iatrogenic trauma. They make up about 1-2% of all urinary tract injuries [1]. Reasons for this
low number of injuries include their retroperitoneal anatomical position, and their mobility
and flexibility. Blunt trauma that results in ureteral injury is very rare and most traumatic
lesions of the ureter are a consequence of penetrating injuries, most often gunshot wounds [2].
The most common causes of iatrogenic ureteral injuries are complications of pelvic
procedures most often gynaecological, endourological, urological, vascular and colorectal.
These types of lesions can appear in open or laparoscopic approaches [3]. The mechanisms
by which injuries occur are partial or complete clamping, incomplete or complete transection,
suture ligation, angulations with secondary obstruction and ischemic lesions resulting from

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denudation. Conditions that are frequently associated with ureteral injuries are reoperations,
inflammation, extensive tumors, ureteral duplications and renal ectopia, and external irradiation
[4].

Methods

The aim of this paper is to present our experience with ureteral iatrogenic injuries that
occurred during gynaecological procedures and their diagnosis and management. For this we
used data recorded in the patient’s chart, operative descriptions and imaging studies.
We analysed these variables retrospectively. The lesions were characterized by the affected
ureteral segment, the mechanism of iatrogenic injury and the procedure that led to the injury.
In the period January 2014 – April 2016 six cases of iatrogenic ureteral injury were
identified, all female patients subjected to gynaecological procedures.

Results

All six injuries were located in the pelvic portion of the ureter. The procedures that led to
the injuries were total hysterectomy for bleeding voluminous uterine fibromas in four cases
and two Wertheim procedures for cervical cancer. The mechanism of injury was: incomplete
transection in three cases, complete transection, suture ligation and ischemic injury in one case
respectively. Surgical procedures were used for repair in all cases. Depending on the time of
diagnosis the repair was performed during the same surgical procedure in four cases, or in a
delayed fashion in two cases.
The four cases that were diagnosed intraoperatively with complete and incomplete
transections underwent primary repair. The three cases with compete transection required
uretero-ureteral anastomosis. In the case with incomplete transection simple suture was
possible. Postoperative recovery was uneventful in these four cases showcasing the
importance of intraoperative recognition of iatrogenic ureteral lesions. In the remaining two
cases, one suture-ligation and one ischemic injury to the ureter the diagnosis was delayed and
occurred after the development of pain and the use of abdominal ultrasound and iv urography
that showed hydronephrosis and the obstruction in the pelvic ureter. Direct ureterovesical
anastomosis was performed in these cases and the postoperative course was generally good
but the cases required a longer hospital stay (mean 17 days compared to mean 5 days in the
intraoperative diagnosis group) and required a second surgical procedure.

Discussions

It is estimated that, while uncommon, the greatest number of iatrogenic ureteral injuries
occur after gynaecological procedures, 52 to 82% of iatrogenic ureteral injuries in reports by
Lee et al., Dowling et al and Stoller [5, 6, 7]. The rate is higher for abdominal hysterectomy
compared with vaginal hysterectomy although a selection bias is suspected as large tumors,
infected pathologies that pose more technical difficulties are often approached abdominally.
Clinical factors that predispose to ureteral injuries are a large uterus, endometriosis, pelvic
organ prolapse and prior pelvic surgery [8]. Prevention of ureteral injuries is of great interest
as iatrogenic lesions can sometimes lead to catastrophic events. A proposition for prevention
is the routine catheterization of the ureter preoperatively. A recent randomized study however

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found no statistical difference when comparing a group with and a group without preoperative
catheterization [9]. The diagnosis of ureteral injuries depends on many factors like the extent
and the type of injury. While ischemic lesions can only be assumed intraoperatively complete,
partial transections and suture-ligations should be diagnosed intraoperatively. Early diagnosis
is preferable and can avoid serious complications including nephrectomy in the setting of
delayed recognition and therapeutic intervention. Unfortunately only 10-15% of all lesions
are recognized intraoperatively [10]. Urinary extravasation is the most obvious sign that can
lead to recognition. If the exact site cannot be determined intravenous indigo carmine can be
useful together with intraoperative excretory urography. In the case of ligation, after liberating
the ureter from the ligature its viability should be assessed. Partial transections are amenable
by simple suture. Uretero-ureteral anastomosis over a double J stent is the procedure of choice
for early repair considering that it retains the physiologic antireflux mechanism and keeps an
intact bladder. Ureterocystoneostomy procedures are safe and applicable especially in the case
of delayed diagnosis for the distal ureter. Gynaecological procedures have the highest rate of
ureteral injuries among surgical specialties. Rapid diagnosis is the cornerstone of management
and allows for a timely reconstruction and minimal morbidity. Delayed diagnosis can have
serious consequences including nephrectomy. It is therefore essential that a high index of
suspicion should be maintained during procedures that present a risk of ureteral injuries.

REFERENCES

1. Summerton DJ, Djakovic N, Kitrey ND, Kuehhas FE, Lumen N, Serafetinidis E, et


al. Guidelines on urological trauma. In: EAU Guidelines. Arnhem (The Netherlands):
European Association of Urology (EAU); 2014. p.30-33.
2. Elliot SP, Mc Anninch JW. Ureteral injuries from external violence: the 25-year experience
at San Francisco General Hospital. J Urol. 2003; 170(4 Pt 1):1213-6.
3. Selzman AA, Spirnak JP. Iatrogenic ureteral injuries: a 20-year experience in treating 165
injuries. J Urol. 1996; 155(3):878-81.
4. Pfitzenmaier J, Gilfrich C, Haferkamp A, Hohenfellner M. Trauma of the ureter. In:
Hohenfellner RAS, editor. Emergencies in Urology. New York, NY: Springer; 2007.
p.233-45.
5. Dowling, R., Corriere, J., Jr and Sandler, C. (1986) Iatrogenic ureteral injury. J Urol 135:
912–915.
6. Lee, R., Symmonds, R. and Williams, T. (1988) Current status of genitourinary fistula.
Obstet Gynecol 72: 313–319.
7. Stoller, M. and Wolf, J. (1996) Endoscopic ureteral injuries. In: McAninch, J. (ed.),
Traumatic and Reconstructive Urology. Philadelphia, PA: Saunders.
8. Vakili, B., Chesson, R., Kyle, B., Shobeiri, S., Echols, K., Gist, R. et al. (2005) The
incidence of urinary tract injury during hysterectomy: a prospective analysis based on
universal cystoscopy. Am J Obstet Gynecol 192: 1599–1604.
9. Chou, M., Wang, C. and Lien, R. (2009) Prophylactic ureteral catheterization in
gynecologic surgery: a 12-year randomized trial in a community hospital. Int Urogynecol
J 20: 689–693.
10. Dobrowolski Z, Kusionowicz J, Drewniak T, Habrat W, Lipczyñski W, Jakubik P, et
al. Renal and ureteric trauma: diagnosis and management in Poland. BJU Int. 2002;
89(7):748-51.

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The benefits of laparoscopically assisted vaginal


hysterectomy

Cristurean V-C.1, Nour C.2, Cardon I.2


1
Department of Obstetrics and Gynecology, Ovidius University of Medicine, Constanta(Romania)
2
Department of Obstetrics and Gynecology, “Sfântul Apostol Andrei” Emergency Clinical County
Hospital, Constanta (Romania)
E-mails: cristurean.constantin@gmail.com1 dr.cardoniuliana@gmail.com2

Abstract

The aim of our study was to compare in terms of uterine volume and surgical proceedures
associated with 30 cases of uterine pathology but with unprolapsed uterus or a minimal degree
of prolapse such as 1st or 2nd degree of prolapse. Laparoscopically assisted vaginal hysterectomy
offers a technique to overcoming clasic contraindications of vaginal hysterectomy approach
meaning uterine wheight and adhesions prior surgycal proceedures, increasing complexity
of the proceedures being a pathway to allow adnexectomies, ovarian cystectomies, McCall
culdoplasty (by approach of uterosacral ligament in posterior and medium third also better
interception of the ureter). It appears particularly useful for increased safety and convenience
for operators by better approaching on difficult vaginal hysterectomy also we think about it
to be favoring operators with a lower level of surgical performance and surgical experience,
increase operator confidence and optimism in addressing vaginal hysterectomy with a high
degree of difficulty all these for the most important conclusion about this approach which is
inceasing the safety of the patients.

Keywords: Difficult vaginal hysterectomy, Laparoscopically assisted vaginal hysterectomy, safety of


patients, uterine prolapse, uterine wheight

Background

Hysterectomy can be performed vaginally, abdominally, laparoscopically, or with


robotic assistance, the route depending on physician choice however patient option should
be taken into account. Choosing route for hysterectomy should be on closely related factors
like safety of patient, cost-effectiveness, and medical needs of the patient, indications and
contraindications well known by physicians. A laparoscopic-assisted vaginal hysterectomy
(LAVH), a precursor to the TLH (total laparoscopic hysterectomy) is a technique to secure
the ovarian via laparoscopy, the remainder of procedure is completed vaginally mentioning
the laparoscope is often reinserted after closure of the vaginal cuff with the purpose to inspect
the abdominal cavity and vaginal cuff for proper haemostasis at the end of the procedure [1].
Kovac et al has been conducted an algoritm, which comes to help the clinicians in choosing
the route by which hysterectomy will be performed [2].

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Objective

The aim of our study was to compare in terms of uterine volume and surgical proceedures
associated with 30 cases of uterine pathology but with unprolapsed uterus or a minimal degree
of prolapse such as 1st or 2nd degree of prolapse (Graph 1).

Results

The 30 cases of hysterectomies were divided into two groups by approach of hysterectomy
namely group of VH (vaginal hysterectomy) with 13 cases and group of LAVH (laparoscopically
assisted vaginal hysterectomy) with 17 cases, according to main indications on both approach
vaginal hysterectomy and laparoscopically assisted vaginal hysterectomy such as cervix
pathology, endometrial pathology and severe uterine bleedings unresponsive to treatment,
uterine leiomyomas, ovarian pathology associated to uterine pathology (Table 1). Approach
by laparoscopically assisted vaginal hysterectomies allowed us to addressing to heavier uterine
weights such as 500g (n=1) and 600g (n=1) also average uterine weight in group of LAVH
was 207g, compared to average uterine weight in group of VH with 172g (Table 2). The
incidence of hysterectomy performed for uterine leiomyomas had close percentages in both
groups (group of VH- 61,33% and group of LAVH- 70,58%) also had close percentages
for severe uterine bleedings unresponsive to treatment (group of VH- 15,40% and group of
LAVH- 11,77%). In approaching of ovarian pathology associated to uterine pathology of the
30 cases of hysterectomies all of them were performed by laparoscopically assisted vaginal
hysterectomy (11,77% in group of LAVH and 0% in group of HV) whereas cervix pathology
like cervical dysplasia had higher incidence in group of VH (23,07%) than in group of LAVH
(5,88%). Approach through laparoscopically assisted vaginal hysterectomies allowed us to
increasing complexity of surgery due to the possibility that it offers, namely to make the
optimum adnexectomies (64,70% in group of LAVH compared to 7,69% in group of VH),
ovarian cystectomy (11,76% in group of LAVH and 0% in group of VH), salpingectomies
(17,64% in group of LAVH and 0% in group of VH), adheziolysis (52,945 in group of LAVH
and 0% in group of VH) and McCall culdoplasty (by approach of uterosacral ligament in
posterior and medium third, 53,84% in group of LAVH and 23,52% in group of VH) (Table 3).

Discussion

The aim of the study wasn’t being in contradictions with the expert studies carried out today
furthermore we were guided by it knowing that for the gynecologic surgeons, the laparoscope
has been considered a tool to evaluate possible contraindications to vaginal hysterectomy
with the primary goal being to assist in oophorectomy [4, 5] and leading us to conclusions
mentioned below.

Conclusions

Laparoscopically assisted vaginal hysterectomy offers a technique to overcoming clasic


contraindications of vaginal hysterectomy approach meaning uterine wheight and adhesions
prior surgycal proceedures, increasing complexity of the proceedures being a pathway to
allow adnexectomies, ovarian cystectomies, McCall culdoplasty (by approach of uterosacral

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ligament in posterior and medium third also better interception of the ureter). It appears
particularly useful for increased safety and convenience for operators by learning the difficult
vaginal hysterectomy also we think about it to be favoring operators with a lower level of
surgical performance and surgical experience, increase operator confidence and optimism
in addressing vaginal hysterectomy with a high degree of difficulty all these for the most
important conclusion about this approach which is inceasing the safety of the patients.

Graph 1. Uterine prolapse degrees repatition on study


Laparoscopic assisted
Vaginal Hysterectomies
Indication of the approach vaginal hysterectomies
(number of cases)
(number of cases)
Cervix pathology 3 1
Endometrial pathology and
severe uterine bleedings 2 2
unresponsive to treatment
Uterin leiomyoma 8 11
Ovarian pathology associated
0 2
to uterine pathology
Table 1. Repartition on number of cases by indication of approach on study
Laparoscopic assisted
Uterine weights Vaginal hysterectomies
vaginal hysterectomies
Under 280g* 12 (cases) 13 (cases)
Above 280g* 1 (case) 4 (cases)
Greutate medie 172g 207g
*
Benchmark acording
to Petre Brătilă.
Histerectomia
vaginală. Editura
Dobrogea, Constanța,
2006[3]

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Table 2. Uterine weights in both approach on study, vaginal hysterctomies and
laparoscopically assisted vaginal hystrectomies
Laparoscopically assisted
Surgycal proceedures Vaginal hysterectomies
vaginal hysterectomies
associated to approach of
vaginal hysterectomies (13 cases)
(17 cases)
Unilateral and bilateral
1 11
adnexectomies
Ovarian cystectomy 0 2
Bilateral salpingectomies 0 3
Adhesiolysis (adhesions
prior surgycal 0 9
proceedures)
McCall culdoplasty 7 4
Table 3. Surgycal proceedures associated to approach of vaginal hysterectomies on study

REFERENCES

1. ACOG Committee Opinion No. 444: choosing the route of hysterectomy for benign
disease. Obstet Gynecol. 2009 Nov. 114(5):1156-8.
2. Kovac SR. Clinical opinion: guidelines for hysterectomy. Am J Obstet Gynecol. 2004
Aug. 191(2):635-40.
3. Petre Brătilă. Histerectomia vaginală. Editura Dobrogea, Constanța, 2006 SR, Guidelines
to determine the role of laparoscopically assisted vaginal hysterectomy. Am J Obstet
Gynecol. 1998; 178(6):1257-63.
4. Kovac SR, the Divisions of Pelvic Reconstructive Surgery and Urogynecology and
General Obstetrics and Gynecologic Surgery, Am J Obstet Gynecol. 1998; 178:1257-
1263.

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Assessing the severity of acute pelvic inflammatory


disease

CERNETCHI Olga1, CAUS Catalin1, CAUS Natalia1,


RAILEAN Ludmila1, ILIADI TULBURE Corina1
1
Republic of Moldova, State University of Medicine and Pharmacy “Nicolae Testemitanu”
E-mails: ocernetchi@yahoo.com, catalincaus@yahoo.fr, natic05@yahoo.com, liuda_flv@yahoo.com,
corina.iliadi@usmf.md

Abstract

Assessing the severity of acute pelvic inflammatory disease (APID) represents a dilemma
for the contemporary researchers that is still to be solved. Evaluating the patients using the
MIL score (clinical manifestations + imaging data + laboratory data) is aimed at determining
the severity of the acute pelvic inflammatory disease (APID) and at optimizing the medical
and surgical conduct as well. This mathematical score sums up three parameters: clinical
manifestations, imaging data and laboratory data, which then establishes the degree of severity
(mild, moderate and severe).

Keywords: APID, PID, MIL score, disease severity

Introduction

Acute pelvic inflammatory disease (APID) is a medical and social problem of an increasing
resonance, being the most common gynecologic condition observed in women of reproductive
age. The latest study regarding the gynecologic morbidity in the Republic of Moldova has
established that out of 106142 surveyed female patients, 88.71% had suffered previously
of APID. This disease represents the third reason of hospitalization in the gynecologic in-
patient unit in the Republic of Moldova. The main etiological factor for the development of
an ectopic pregnancy is a flare of APID, which precedes the ectopic pregnancy [1]. Women’s
health remains a priority of the state, which is responsible of maintaining the welfare and the
reproductive health of the nation. The quality of care is influenced by the correctness rate of
the early diagnosis of APID and by the prescribing of an effective and safe treatment.
The presence of difficulties in establishing the early and complete diagnosis can lead to
severe forms of APID. One of the most pressing issues in the early diagnosis of APID and
therefore related to the issue of reducing the amount of time before the surgical treatment are:
establishing the duration of the conservative treatment, determining the optimal period for
surgery and evaluating the effects after employing the chosen medical conduct. Currently, in
the scientific literature, there is a lack of special instruments (scores) developed for assessing
the severity degree of the inflammatory processes in APID that are to be used during patient

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hospitalization at the in-patient unit.

Materials and methods

The present work (focused on the issue of APID), is a simple randomized blinded study
focused on diagnostics. The sample of 234 female patients that were hospitalized with acute
pelvic inflammatory disease was selected according to the CDC criteria [2]. There has been
developed a mathematical score, with values ranging from 0 to 3 that corresponds to the data
from clinical, paraclinic and laboratory examinations. The usefulness of the MIL score (table
1) is based on the possibility of evaluating the female patient and guiding the medical conduct,
namely in the initiation of either an exclusively pharmacological treatment or by facilitating the
process of preparing the female patient for surgery during the early hours after hospitalization.

Results

Table 1. MIL score for assessment of the severity degree of acute pelvic inflammatory
disease (APID)
Score
0 1 2 3
Clinical Manifestations
General status satisfactory altered +nausea +vomiting
Fever 37 38 39 40
Leukorrhoea absent slight abundant purulent
Abdominal pain non-significant unilateral bilateral diffuse
tenderness at
pain at the tenderness of
the projected
Vaginal exam painless mobilization of both uterine
areas of uterine
the cervix appendages
appendages
Imagistic data
Uterus ordinary
inhomogeneous thickened +liquid
(endometrium) appearance
lateral uterine
Fallopian tubes non-visible unilateral bilateral
formation
ordinary affected
Ovary unilateral bilateral
appearance appendage
Presence of non-significant
Douglas pelvis subhepatic
liquid fluid amount
Laboratory data
Leukocytes <9,000 >10,000 11,000-20,000 >21,000
C-reactive
<6 >6 10-50 >51
protein

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Vaginal pH (3,8-4,5) (5,0-5,5) (6,0-7,2) (>7,2)


Semi-
quantitative <0,5 >0,5 >2 >10
Procalcitonin
Urine test strip negative leukocytes +erythrocytes +nitrates etc.
Syphilis (rapid
negative positive - -
test)
Gonorrhea
negative positive - -
(rapid test)
Chlamydia
negative positive - -
(rapid test)

A MIL score (table1) value of up to 15 indicates a mild form of APID; values between
16 to 28 point to moderate clinical form of APID and a score greater than 29 indicates the
presence of a serious form of APID. According to our research, after evaluating the MIL score
of the female patients included in the study, we have observed that 41.88% of the patients
have a mild form of APID, 32.47% - moderate severity of APID and 25.64% have the severe
form of APID. Laparoscopy is considered the gold standard for assessing the severity and the
anatomic and clinical form of APID. In this study, there has been given a priority to perform
laparoscopy. In the first 48 hours, laparoscopy has been performed for 73.01% of patients,
where it was observed that the moderate form was present in 30.76% of cases, the generalized
form was observed in 23.07% of cases; and the remaining 46.15% patients had mild forms
of APID. After analyzing the data, we can conclude that the MIL score has shown a high
diagnostic value and can be used to assess the severity of APID.

Discussion

There should be conducted an evaluation of long-term usage of the MIL score and there
should be performed an assessment of its diagnostic value concerning using it in order to
determine the severity degree of APID. The first steps have been made in this research, but
we encourage and hope that subsequently there will be developed other scores that will aid
physicians in the process of determining the clinical form and the evolution of acute pelvic
inflammatory disease.

Conclusions

1. The MIL score was of a great value to this study, allowing the initiation of early surgical
treatment and was found out to be useful in assessing the degree of severity of acute pelvic
inflammatory disease and in preventing complications.
2. There should be conducted comparative studies regarding the severity score assessment
for acute pelvic inflammatory disease.
3. The concept of summing up clinical data with imaging and laboratory data can be used
also for other pathological conditions and by other medical specialties with the aim of
assessing the severity of the process.

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REFERENCES

1. Tihon-Pascal L. (2015). Aspectele clinice şi medico-sociale ale stărilor de urgenţă


ginecologică în Republica Moldova. Autoreferatul tezei de doctor în ştiinţe medicale.
Chişinău. 30p.
2. Center for Disease Control and Prevention. (2002). Sexually transmitted diseases treatment
guidelines 2002, MMWR, Recommendation, vol. 51, pp. 01-78.

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Approach to complications caused by prosthetic


materials used in pelvic reconstructive surgery

CIORTEA Răzvan¹, RADA Maria Patricia¹,


BERCEANU Costin², MĂLUŢAN Andrei Mihai¹, MOCAN Radu¹,
IUHAS Cristian¹, BUCURI Carmen Elena¹,
CÂMPIAN Eugen Cristian³, DICULESCU Doru1, MIHU Dan¹

¹ Universitatea de Medicină și Farmacie “Iuliu Hațieganu” Cluj-Napoca, Disciplina Obstetrică –


Ginecologie II (Romania)
2
Universitatea de Medicină și Farmacie Craiova, Departamentul Obstetrică-Ginecologie (Romania)
³ Saint Louis University, Division of Urogynecology, Female Pelvic Medicine & Reconstructive
Surgery (USA)
E-mails: r_ciortea@yahoo.com, mpr1388@gmail.com, dr_berceanu@yahoo.com,
malutan.andrei@gmail.com, radumocan@yahoo.com, iuhascristianioan@yahoo.co.uk,
cbucurie@yahoo.com, campianec@slu.edu, dan.mihu@yahoo.com

Abstract

Increased recurrence of pelvic organ prolapse (POP) following reconstructive pelvic surgery
entails a careful surgical technique, corroborated with the possibility of using biological or
synthetic prostheses to ensure adequate support.
Simultaneous correction of pelvic floor disorders and urinary incontinence can be
performed using prosthetic material that facilitates the consolidation of local tissue and have
supportive role. Attention should be paid to potential complications arising from the use of
these materials: erosions, pain, infections, dyspareunia, perforation of adjacent organs, urinary
and/or neuromuscular disorders and relapses.
Selecting suitable patients in whom prosthetic materials might be used for pelvic floor
diseases is a key element that contributes to the success of an intervention. Risk factors such
as diabetes, advanced age, smoking predict unfavorable prognostic.
Use of prosthetic materials should be adapted to the anatomo-clinical particularities and
differentiated for primary, secondary or relapses corrections and the benefits of surgical
prosthesis usage should exceed the risk of complications as well.
One of the current concerns is represented by mesh erosions, the most common complication
following vaginal surgery involving prosthetic materials. The frequency of this complication
varies depending on surgical approach and the used materials.
In order to minimize the occurrence of complications caused by surgical pelvic reconstruction
techniques and predict a favorable outcome, extensive experience of the operator, high quality
of prosthetic materials and patient selection should be all present.

Keywords: pelvic organ prolapse, vaginal mesh, complications

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Introduction

POP is a disorder in which one or more of the pelvic organs drop from their normal position.
In patients with severe symptomatic POP that disrupts life and in whom nonsurgical treatment
options have not helped, surgery may be considered. Reconstructive surgery has the goal of
restoring the organs to their original position.
Even though different terms like exposure, extrusion or perforation were proposed by the
International Urogynecological Association (IUGA) and International Continence Society
(ICS), the generic term erosion appears to best describe the protruding prosthetic material
into the vaginal wall [1]. The incidence of mesh erosions is dependent on the type and size
of the mesh but no mesh material is nonsusceptible to erosions. Monofilament, macroporous
polypropylene mesh with large pore size seems to entail a reduced infection risk, but a
significantly more intense aggregation of macrophages in the area may indicate a stronger
inflammatory response of the vaginal wall. This fact may be the trigger for the erosion.
Dyspareunia, another complication that may appear after vaginal reconstructive surgery
is caused by mesh erosion, mesh infection or extensive fibrosis [2]. Vaginal surgery alone,
without the use of prosthetic materials, may also cause dyspareunia, but there is one subjective
element that can suggest mesh generated dyspareunia, namely male dyspareunia (hispareunia)
[3]. Chronic pelvic pain is a challenging aspect after pelvic floor reconstruction. Transobturator
approach for placing slings is susceptible for generating pelvic pain due to anatomical reasons.
Symptoms of the complications vary depending on the organ involved. Vaginal erosion
may present with vaginal bleeding, abnormal discharge, dyspareunia or vaginal pain. Mesh
erosion into the bladder/urethra include painful voiding, urinary frequency, urgency, hematuria,
recurrent urinary tract infection, urinary calculi and urinary fistula [4].
Mesh infection may or may not be associated with vaginal mesh exposure. Non-specific
pelvic pain, persistent vaginal discharge or bleeding, dyspareunia, and urinary or fecal
incontinence are the most common manifestations of vaginal mesh-related infection. Clinical
examination may reveal induration of the vaginal incision, vaginal granulation tissue, draining
sinus tracts and prosthesis erosion or rejection [5].

Methodology

This article was written based on the authors’ clinical experience in pelvic reconstructive
surgery and taking into account current concepts regarding this subject. Scientific support was
found in PubMed, ScienceDirect and Cochrane resources; studies regarding complications
arising from synthetic mesh use in POP and urinary incontinence were mainly of interest.
Different surgical procedures are used nowdays for the repair of POP. Concerning vaginal
procedures, an increased interest has been shown in the use of synthetic meshes. Especially
in patients with tissues of poor quality, prostetic repair seems to be a reliable therapeutic
option. Materials should be inert, nonresorbable and resistant to infection. Based on published
experimental and clinical experience, polypropylene is assumed to be the most appropriate
material for POP vaginal repair procedures. The following characteristics of polypropylene
meshes should be present: resistance to degradation by tissue enzymes, indefinite strength
in clinical use, elastic property that allows adaptation to various stresses, possibility to be
trimmed without unraveling.
Prosthetic materials that are necessary in pelvic organ reconstruction were categorized
two decades ago [6]. Type I monofilament, macroporous polypropylene mesh with large pore
size (> 75 μm) is currently preffered. Type II monofilament microporous (< 10 μm) mesh use
may result in a higher risk of infection. T ype III multifilament mesh have interstices that are
<10 μm and bacteria can easily replicate within these spaces [6]. Preference for one type of

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material or another is generated by the potential complications.
Monofilament meshes are preferred over multifilament ones because of reduced infection
risk. Upon insertion of a mesh there is an immediate competition between bacteria and host
immune protective cells at the surface of the mesh. Bacteria are protected from phagocytosis
in small pores since immune protective cells like leucocytes cannot readily enter these spaces
of multifilament materials which supports bacterial colonization and may result in prolonged
infection [6].
Pore size should also be considered when choosing a mesh. Greater pore size promote
better vascularization and ensures increased tensile strength and more deposition of mature
collagen while smaller pores prevent vascularization [7].
Conservative management of mesh erosions should always be initially attempted.
Abstention from intercourse [8] should be initiated and use of topical estrogens may facilitate
growing of vaginal mucosa over the mesh [9]. Partial or complete removal of the mesh should
sometimes be performed depending on the eroded situs, always trying to spare as much of the
vaginal mucosa as possible.
Recommended management of intravesical or intraurethral mesh erosion is the removal
of the mesh from the bladder or urethra through vaginal or abdominal approach. Mechanical
injury by mesh alone may rarely cause erosion in bowel and fistulas with or without local
abcess [10].
Management of mesh infection requires removal of the entire prosthetic material, along
with drainage of abscess cavities and administration of intravenous or oral antibiotics,
accordingly to microbiological studies [11]. It is important to ensure a gentle tissue dissection
and continuous follow-up after the surgery.
Concerning dyspareunia and pelvic pain related to mesh insertion, if initial conservative
management with anti-inflammatory medications does not relieve pain, removal of mesh with
its attendant risk of recurrence of pelvic floor defect, might be needed [12].

Discussions

Native tissue reconstruction procedures for pelvic floor disfunctions are associated with a
high recurrence rate [13] that may be attributable to the technique or poor quality of the tissue.
To overcome the disadvantages of native tissue, non-autologous biodegradable material
was proposed as a supportive alternative. Their use is limited because of the unpredictability
of tissue, high costs, and bacterial adherence [14].
Over the last years, synthetic materials had rapidly increasing popularity due to increased
efficacy as compared with autologous materials and decreased operating time [15] Their use is
especially justified in stress urinary incontinence, but they are also used in POP management.
Patient-related risk factors include advanced age, estrogen deficiency, prior surgical
scarring, diabetes, steroid use, smoking. On the other hand, younger age and sexual activity
was found to be a risk factor for mesh erosions [16]. Mesh-related risk factors are dependent
on the mesh type. Techique-related risk factors include concomitant surgery (especially
hysterectomy) but this fact is controversial [17].
US Food and Drug Administration (FDA) reported erosion of mesh through the vagina
as the most common and consistently reported mesh-related complication from transvaginal
surgeries using mesh. In a recent meta-analysis, that included 110 articles (11,785 patients)
noted that the mean incidence of graft erosion was 10.3% [18]. Lower erosion rate was
associated with commercial kits as compared with surgeon-tailored mesh (1.4% vs. 23.6%)
[19].
Rectal mesh erosion is a very rare complication of POP repair with synthetic mesh, a
few cases being reported [20]. In women who have had previous POP repair and present
rectal symptoms as bleeding, rectal mesh erosion should be considered. It should be initially

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managed by trimming of the mesh, most of the cases requiring re-intervention [21]. Depending
on the extension of the defect, a temporary colostomy may be considered for protection.
More common than bowel injury after POP repair is bladder or uretral injury. In case of
mesh erosions of this organs, after the removal of the material, and correction of the defect, a
urinary catheter has to be maintained longer and associated with antibiotic therapy. A recent
review reported that urinary catheter left in place for a median of 14 days (range, 6 to 21 days)
lead to favorable outcome [22].
Concerning the surgery, the most important procedure to reduce mesh complications is to
minimize the length of the incision and tension-free closure of the incision [23]. Anchoring
the mesh may also reduce the erosion rate by preventing excessive movement and extrusion
through vaginal incision. Among notable complications that may arise from malpositioning of
the mesh we note persistance of urinary incontinence. This fact may suggest as well urgency
component of mixed urinary incontinance, not related to mesh insertion. On the opposite side,
too much tensioning of the mesh may lead to voiding dysfunction [24].
Mesh infection may appear and it was proven to be related to mesh type. Its incidence ranges
from 0–8% [2]. Dyspareunia may be caused by mesh erosion, mesh infection, mesh shrinkage
or fibrosis. A recent meta-analysis reported an overall incidence of 9.1% in 70 studies analyzed
[26]. A reported fact was that there was no difference in the rates of dyspareunia while using
absorbable and non-absorbable mesh at one year [26].
Another challenging aspect after use of synthetic mesh for pelvic floor reconstruction is
chronic pelvic pain [27], inside-to-outside transobturator approach generating less pain [28].
When a supportive mesh needs to be repositioned after surgery, it is questiobable whether
patients should have a new one implanted or the old one should be adjusted. If the mesh is
placed for stress urinary incontinence, the question that arises is if the first corrective procedure
was suspension through transobturator tape (TOT), should the repositioning procedure be the
same or transvaginal tape (TVT) should be used? A comparative study concerning midurethral
placement of tension-free vaginal tapes has shown that bladder perforations are reported more
in TVT but incidence of vaginal erosions and groin pain are exceedingly more in TOT groups.
TVT has been found to be superior to TOT and preferable in demanding conditions such
as prior anti-incontinence operation failures, obese women and scarred tisssues [29]. Also, in
case of mesh rejection, it is debatable whether the same procedure or another one should be
performed in order to correct the defect, after the process of removal of the mesh. It can take
more than one surgery to remove it completely and reach healthy sourrounding tissue that will
cover the defect.
Mixed urinary incontinence is also subject of controversy. Different types of urinary
incontinence require different surgical approaches. Most options for urinary incontinence
surgery treat stress incontinence. If both stress incontinence and urge incontinence are present,
beside surgically adressing the problem, non-surgical management should be initiated for urge
incontinence in order to obtain remission of symptoms. In patients in whom the history and
physical examination alone may not provide sufficient and accurate information on which to
base surgical therapy, urodynamic studies might be used.

Conclusions

Surgical procedures using synthetic meshes are designed as gold standard method for the
management of stress urinary incontinence. Beside this, their use is on an increasing trend in
the management of pelvic floor prolapse. Complications may appear associated with these
reparative procedures and confront gynecologists and urologists in their daily practice. It is
imperative to raise awareness of these complications in order to proper counsel the patient.
There is no solid evidence based algorithm regarding the best approach and surgical
procedure in case of complications. However, vaginal mesh excision techniques were

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demonstrated to be safe and successful.

REFERENCES

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recurrent thigh abscesses for five years after a transobturator tape implantation for stress
urinary incontinence. Korean J Urol. 2010; 51(9):657-9.
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the repair of abdominal defects: experimental study in dogs. Hernia. 2001; 5:59–64.
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Urol. 2003; 169(6):2242-3.
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complications with slings for managing female stress urinary incontinence. BJU Int. 2008
Aug; 102(3):333-6.
10. Nicolson A, Adeyemo D. Colovaginal fistula: a rare long-term complication of
polypropylene mesh sacrocolpopexy. J Obstet Gynaecol. 2009 Jul; 29(5):444-5.
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Outcomes after anterior vaginal wall repair with mesh: a randomized, controlled trial with
a 3 year follow-up. Am J Obstet Gynecol. 2010; 203(3):235.
13. Karlovsky ME, Kushner L, Badlani GH. Synthetic biomaterials for pelvic floor
reconstruction. Curr Urol Rep. 2005; 6(5):376-84.
14. Rehman H, Bezerra CC, Bruschini H, Cody JD. Traditional suburethral sling operations
for urinary incontinence in women. (Cochrane Database Syst Rev. 2011; (1):CD001754.
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17. Abed H, Rahn DD, Lowenstein L, Balk EM, Clemons JL, Rogers RG. Incidence and
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Pelvic Floor Dysfunct. 2009; 20(8):919-25.
23. Çelik H, Harmanlı O. Evaluation and management of voiding dysfunction after midurethral
sling procedures. J Turk Ger Gynecol Assoc. 2012; 13(2): 123–7.
24. Latthe PM, Singh P, Foon R, Toozs-Hobson P. Two routes of transobturator tape procedures
in stress urinary incontinence: a meta-analysis with direct and indirect comparison of
randomized trials. Arch Gynecol Obstet. 2011; 284(6):1461-6.
25. Foon R, Smith P. The effectiveness and complications of graft materials used in vaginal
prolapse surgery. Curr Opin Obstet Gynecol. 2009; 21(5):424-7.
26. Chen X, Tong X, Jiang M, Li H, Qiu J, Shao L, Yang X. A modified inexpensive
transobturator vaginal tape inside-out procedure versus tension-free vaginal tape for
the treatment of SUI: a prospective comparative study. Arch Gynecol Obstet. 2011;
284(6):1461-6.
27. Latthe PM, Singh P, Foon R, Toozs-Hobson P. Two routes of transobturator tape procedures
in stress urinary incontinence: a meta-analysis with direct and indirect comparison of
randomized trials. Arch Gynecol Obstet. 2011; 284(6):1461-6.
28. Chawla A. Transobturator tapes are preferable over transvaginal tapes for the management
of female stress urinary incontinence. Indian J Urol. 2009; 25(4): 554–7.

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Lower urinary tract symptomatology in deep


infiltrating and bladder endometriosis

COROLEUCĂ Ciprian-Andrei1, BRĂTILĂ Elvira1, BRĂTILĂ


Petre2, HUDIȚĂ Decebal3, STĂNCULESCU Ruxandra1,
COMANDAȘU Diana1, COROLEUCĂ Cătălin-Bogdan1
1
“Carol Davila” University of Medicine and Pharmacy, Bucharest, Department of Obstetrics and
Gynecology - “Sf. Pantelimon” Clinical Emergency Hospital, Bucharest (ROMANIA)
2
“Carol Davila” University of Medicine and Pharmacy, Bucharest; Minimally Invasive Surgery
Hospital Euroclinic “Regina Maria” Bucharest (ROMANIA)
3
“Carol Davila” University of Medicine and Pharmacy, Bucharest, Department of Obstetrics and
Gynecology (ROMANIA)
E-mails: cip_coroleuca@yahoo.com, elvirabarbulea@gmail.com, pbratila49@yahoo.com, decebal.
hudita@yahoo.com, ruxandra_v_stanculescu@yahoo.com, diana.comandasu@yahoo.com,
ccoroleuca@yahoo.com

Abstract

The incidence of lower urinary tract endometriosis is underestimated due to nonspecific


clinical picture. The aim of our study was to assess urinary symptoms in patients with deep
infiltrating and bladder endometriosis.We conducted a retrospective analysis that included
21 patients with bladder endometriosis diagnosed from January 2011 to January 2016. All
patients were investigated preoperatively by transvaginal ultrasound and cystoscopy. All
endometriosis cases were confirmed histologically after laparoscopic surgery or cystoscopic
biopsy. Patients mean age was 34.2 years. Bladder endometriosis prevalence was 10.71%
in a group of 196 patients with endometriosis (21/196). The most frequent symptoms were
dysuria, urinary frequency, urinary infections and repeated hematuria. Bladder endometriosis
is the most common localization of urinary tract endometriosis. Diagnosis is often delayed
because patients are asymptomatic or have nonspecific symptoms. Patients thorough medical
history combined with imagistic and endoscopic examination are essential for early diagnosis
of bladder endometriosis.

Keywords: endometriosis, bladder endometriosis, urinary tract endometriosis, lower urinary tract,
deep infiltrative endometriosis

Introduction

Endometriosis is a benign condition defined by the presence of the endometrial tissue outside
the uterine cavity. Endometriosis generally affects women of reproductive age, with a peak
incidence between 35 and 50 years. Even though literature figures vary widely, endometriosis
prevalence is estimated around 10% in premenopausal women [1]. Endometriosis affects the
quality of life through two major manifestations: infertility and chronic pelvic pain of variable

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intensity.
Considering the extent of the lesions, endometriosis is classified into three categories:
superficial endometriosis (peritoneal or ovarian), ovarian endometriomas and deep infiltrative
endometriosis (DIE). Ovaries and pelvic peritoneum are the most common locations of the
superficial endometriosis implants. In more advanced stages of the disease deep implantation
sites of endometriosis are described, defined by deep subperitoneal tissue penetration by
endometriosis lesions over a distance > 5 mm [2]. In descending order of frequency, deep
endometriosis locations are utero-sacral ligaments (USL), the pouch of Douglas, rectum,
sigmoid, vagina and urinary bladder [3, 4].
Urinary tract endometriosis (UTE) is an uncommon condition. The incidence of urinary
tract endometriosis ranges from 0.3 up to 12% of all women affected by endometriosis [5, 6].
Bladder endometriosis (BE) is the most common location of UTE, representing 85% of
these cases [7].
BE usually affects women in the reproductive age with a mean age of 35 years [8]. Although
possible, postmenopausal BE is extremely rare because endometriotic tissue is estrogen
dependent and generally undergoes remission after menopause [8]. Depending on the time of
onset, BE is classified as “primary BE” – spontaneously occurring disease (11% of all patients
with DIE) and “secondary BE” – iatrogenic lesion occurring after pelvic surgery (cesarean,
hysterectomy) [9]. Similarly with endometriosis, the pathogenesis of BE is still unclear and
four etiologic hypotheses are widely supported: the embryonal theory, the migratory theory,
the transplantation theory and the iatrogenic theory. Around 50% of all patients with BE have
a history of pelvic surgery [8]. BE lesions usually evolves from the bladder serosa toward
mucosa and is often multifocal; the most frequent BE sites are the trigone and the dome [10].
Patients with BE often reports nonspecific symptoms and the diagnosis is incidental during
a check-up procedure for a known DIE or for infertility. The aim of our study was to assess
urinary symptoms in patients with deep infiltrating and bladder endometriosis.

Material and methods

We conducted a retrospective study between January 2011 until January 2016, in the
Obstetrics and Gynecology Clinic of “St. Pantelimon” Clinical Emergency Hospital, Bucharest.
The analysis included 21 patients with BE out of 196 patients with endometriosis (prevalence
10.71%). All endometriosis cases were confirmed histologically after laparoscopic surgery
or cystoscopic biopsy. All patients had a complete evaluation, including history, physical
examination (bimanual vaginal examination), urine examination (general urine analysis
and urine culture), transvaginal ultrasound (TVUS) with a 7.5 MHz transvaginal probe and
cystoscopy.

Results

The patient mean age was 34.2 years. Five patients (23.81%) were nulliparous; of the
remaining 16 patients, 10 women had a cesarean section (47.61% of the series) – “secondary
BE”. 42.85% of the patients (9/21) had a history of endometriosis in some other location, while
in 12 cases (57.14%) the urinary tract was the first diagnosis of endometriosis.
In 5 cases (23.81%) a palpable nodule was identified by clinical examination on the
posterior wall of the urinary bladder.

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Urine examination showed macroscopic hematuria in 7 cases (33.33%) and microscopic
hematuria in 9 cases (42.85%). Urine cultures were positive for E. Coli in 4 cases (19.1%).
In 15 cases (71.42%) TVUS identified the presence of hypoechoic nodular structures with
regular or irregular contour or linear hypoechoic thickenings in the walls of bladder or in
vesicouterine space, which were confirmed histologically as endometriosis.
Cystoscopy was performed in all cases and in 7 patients (33.33%) were identified 7 lesions
(1 lesion per patient) that involved the full thickness of the bladder wall including the mucosal
lining; in the other 14 patients (66.66%) cystoscopy showed bluish irregular submucosal
lesions. Regarding the location of the lesions, 10 lesions (47.61%) were located on the bladder
fundus, 5 lesions (23.81%) on the posterior wall and 6 lesions (28.57%) in the retrotrigone
area.
Six patients (28.57%) were asymptomatic. In the remaining 15 symptomatic patients
(71.42%), symptomatology consisted in: dysuria in 12 cases (57.14%), pollakiuria in 8
patients (38.1%), urinary tract infection in 4 cases (19.1%), hematuria in 7 cases (33.33%)
and menouria (hematuria coinciding with menstruation) in 7 cases (33.33%). Regarding the
relation with the menstrual period, 10 patients (47.61%) reported symptoms that occur in a
cyclic pattern, usually during the premenstrual period.

Discussion

Bladder endometriosis symptomatology vary considerably depending on the location and


site of the lesion [7]. Although can be asymptomatic, 70% of women with BE have lower
urinary tract symptoms [7]. Specific symptoms are present infrequently and BE is frequently
underdiagnosed.
Usually patients report nonspecific symptoms such as dysmenorrhea, dyspareunia,
infertility and chronic pelvic pain. Patients with BE complain also about dysuria, hematuria,
pollakiuria, urinary tract infections, burning sensation and suprapubic discomfort and pain,
as part of an acute urethral syndrome [6, 7, 11]. Hematuria is described only in 20-35% of
patients, due to the fact that endometrial lesion infiltrates the bladder from the pericystium
toward the mucosa (from outside to inside) and for this reason BE rarely infiltrates the mucosal
layer of the hollow viscera [7, 12]; our study showed similar results. Menouria appears in
20-25% of cases, only when mucosa is affected [13]; our results (33.33%) are higher, but in
accordance with the lesions that infiltrated the mucosal layer of the bladder.

Conclusions

Bladder endometriosis is the most common localization of urinary tract endometriosis.


Diagnosis is often delayed because patients are asymptomatic or have nonspecific symptoms.
The most frequently reported symptoms are dysuria, pollakiuria, hematuria, menouria
and urinary tract infections. Patients thorough medical history combined with imagistic and
endoscopic examination are essential for early diagnosis of bladder endometriosis.

REFERENCES

1. Vigano P, Parazzini F, Somigliana E, Vercellini P. Endometriosis: epidemiology and

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aetiological factors. Best Pract Res Clin Obstet Gynaecol 2004; 18:177–200.
2. Koninckx PR, Meuleman C, Demeyere S, Lesaffre E, Cornillie FJ. Suggestive evidence
that pelvic endometriosis is a progressive disease, whereas deeply infiltrating endometriosis
is associated with pelvic pain. Fertil Steril 1991; 55:759–765.
3. Jenkins S, Olive DL, Haney AF. Endometriosis: pathogenetic implications of the anatomic
distribution. Obstet Gynecol 1986; 67: 335–338.
4. Cornillie FJ, Oosterlynck D, Lauweryns JM, Koninckx PR. Deeply infiltrating pelvic
endometriosis: histology and clinical significance. Fertil Steril 1990; 53: 978–983.
5. Chapron C, Fauconnier A, Vieira M, Barakat H, Dousset B, Pansini V, Vacher-Lavenu
MC, Dubuisson JB: Anatomical distribution of deeply infiltrating endometriosis: surgical
implications and proposition for a classification. Hum Reprod 2003; 18: 157–161.
6. Collinet P, Marcelli F, Villers A, Regis C, Lucot JP, Cosson M, Vinatier D: Management
of endometriosis of the urinary tract. Gynecol Obstet Fertil 2006; 34: 347–352.
7. Donnez J, Spada F, Squifflet J, Nisolle M: Bladder endometriosis must be considered as
bladder adenomyosis. Fertil Steril 2000; 74: 1175–1181.
8. Comiter CV: Endometriosis of the urinary tract. Urol Clin North Am 2002; 29: 625– 635.
9. Vercellini P, Frontino G, Pisacreta A, De Giorgi O, Cattaneo M, Crosignani PG: The
pathogenesis of bladder detrusor endometriosis. Am J Obstet Gynecol 2002; 187: 538–
542.
10. Somigliana E, Vercellini P, Gattei U, Chopin N, Chiodo I, Chapron C: Bladder
endometriosis: getting closer and closer to the unifying metastatic hypothesis. Fertil Steril
2007; 87: 1287–1290.
11. Villa G, Mabrouk M, Guerrini M, Mignemi G, Montanari G, Fabbri E, Venturoli S,
Seracchioli R: Relationship between site and size of bladder endometriotic nodules and
severity of dysuria. J Minim Invasive Gynecol 2007; 14: 628–632.
12. Abrao MS, Dias JA Jr, Bellelis P, Podgaec S, Bautzer CR, Gromatsky C: Endometriosis
of the ureter and bladder are not associated diseases. Fertil Steril 2009; 91: 1662–1667.
13. Westney OL, Amundsen CL, McGuire EJ: Bladder endometriosis: conservative
management. J Urol 2000; 163: 1814–1817.

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Vaginal hysterectomy - an economic and less invasive


type of approach

Stuparu-Cretu Mariana¹,², Caraman Liliana¹,²,


Calin Alina Mihaela¹,³
1
Faculty of Medicine and Pharmacy, University “Dunarea de Jos” Galati (ROMANIA)
2
Obstetrics and Gynecology Hospital “Bunavestire” Galați (ROMANIA)
3
Clinical Hospital “Sf. Apostol Andrei” Galați (ROMANIA)
E-mails: marianascretu@yahoo.com, lilicaraman2009@yahoo.com

Abstract

Introduction
As caesarean section in the obstetrics, the hysterectomy kept its place on the podium of the
most common surgeries in gynecology. The way still oscillates between the transabdominal
approach and vaginal approach and/or laparoscopic. Although the frequency of vaginal
hysterectomy has increased, the indications regarding the type of approach covers both
the pathology and age and parity, leaving the orientation to the surgeon’s sole discretion,
depending on his professional experience.

Materials and methods


The therapeutic indication, route of approach, complications and costs regarding the
non-gynecological cases hysterectomised in the Gynecology Departments of Galati Clinical
Hospitals “Bunavestire” and “Sf. Andrei” in the last eight years were analyzed in retrospect.

Results
The main indications for which abdominal hysterectomy has been carried out were the
excessive bleeding (24.7%) and uterine fibroids (59.1%), while the vaginal approach has been
practiced for uterine prolapse in 60.8% of cases, for women aged over 60 years or general
pathologies associated. Recovery of patients was faster in cases with vaginal approach, and
the average length of hospital stay, the costs of investigations, and the medication were lower
in the same cases.

Conclusion
Although the vaginal way of approach represented a percentage below 20% of the casuistry,
the study demonstrated the benefits for the patients regarding the range of ages, development
of complications, and recovery and the benefits of efficiency and unit costs.

Keywords: hysterectomy, surgical approach, vaginal hysterectomy

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Introduction

After cesarean section, the gynecological practice kept hysterectomy on the podium of the
most common surgeries performed around the globe, indicated for benign causes in over 90%
of cases. As the etymology suggests (hystera-uterus + ektomé –cutting out), hysterectomy
refers mainly to the removal of the uterus. The decision to keep or not the cervix and annexes
described the types of hysterectomy (subtotal, total or radical).
Originally mentioned in ancient Greece, the medical history notes the first vaginal
hysterectomy (VH) in Italy at the beginning of the XVI century, followed by impaired sexual
life. Later, in the XVIII century, most doctors forecast a low probability of survival after
hysterectomy due to a mortality rate of ~90% due to massive bleeding or infections [1], [2].
The XIX century brought the benefits of antisepsis and anesthesia and thus the success of
hysterectomy, the first successful VH being mentioned in Germany in 1813. The laparoscopic
procedure has been used since 1940, and the first laparoscopic-assisted VH was practiced in
1989 [1], [2].
Studies in recent years estimate that over one third of women in the United States have had
a hysterectomy by age 60, and yearly costs amount to ~$ 50 million [3], [4]. Hysterectomy has
been the subject of many studies and today is considered a routine surgery. The medical aspect
of the indications and possible complications as well as the efficiency of medical acts in terms of
costs and postoperative recovery of patients have been analyzed. Dilemmas which have arisen
over the years referred to the need for intervention, psychological impact, complications, and
limitations versus conservative alternative therapies. [5]. Most often, the collation between the
pathology of patient, other personal data, and the preferences of the surgeon based on personal
experience, decided both the indication for surgery and the approach way (abdominal, vaginal
or laparoscopic).

Methodology

The retrospective study comprises data concerning the age and environment of patients,
therapeutic indication and the approach route of hysterectomies performed during the period
2008-2015 in the Obstetrics and Gynecology Hospital “Bunavestire” and the Obstetrics and
Gynecology Department of Clinical Hospital “Sf. Apostol Andrei” Galati, Romania. For the
same type of pathology, the existence of complications, recovery and hospitalization costs
were compared between the types of interventions.
Data were obtained from the statistics of the county, identified by codes comprised in
the International Classification of Diseases, WHO’s 10th Revision and the medical records
of health facilities. The main diagnoses for which a hysterectomy was carried out have been
identified by age group. The cases were grouped by type of abdominal and vaginal approach
and those with the same diagnosis code have been compared. Hospitalization costs relating to
the average number of hospitalization days, investigations, medication and medical supplies,
the occurrence of complications have been noted. Data were processed for statistical purposes
with Microsoft Excel 2010 program, Data Analysis ToolPak.

Results

The 90 beds of the gynecology departments are serving the female population of Galati

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County, represented by 246,275 people aged over 19 years, from the total of 632,452
inhabitants at the end of 2015 [6]. A rate of 5.6% of patients are from neighboring counties.
The study identified 1182 women hysterectomised during the period 2008-2015, so the
intervention was practiced on 24.2/100,000 inhabitants in 2008 and 30.8/100,000 inhabitants
in 2015, far below the country average reported [6]. Basically, 187 from 1,000 women in
Galati County aged over 19 years have had a hysterectomy in the past eight years. If in the
USA 217 hysterectomies have been performed per 100,000 inhabitants, when referring to
Europe, the Eurostat statistics show that in 2015, the highest number of hysterectomies
was estimated in Germany (153.4/100,000 inhabitants) and Switzerland, and the fewest in
Denmark (20/100,000 inhabitants). Laparoscopic surgical approach to hysterectomy prevails
in Switzerland, Poland, Finland (over half of cases), while Romania is the penultimate country
on the Eurostat list (2.3 of a total of 106.6/100,000 inhabitants), followed by Macedonia [7].
The studied cases were divided into two groups, depending on the type of approach: 232
women have undergone an intervention by vaginal route (19.6%) and the remaining 944 cases
were solved by abdominal route (80.4%) - Table1. We note that the number of VH declined
progressively due to the change of surgical teams, young professionals who replaced the
retired doctors, preferred the abdominal approach - however, the percentage is similar to other
previous studies [8]. In case of VH, most doctors comply to excise the uterus (80%), compared
to 37.6% for abdominal hysterectomy (AH). In more than half of AH, a bilateral anexectomy
was practiced, compared to 17.4% for VH and a small percentage of unilateral anexectomy.
The results are comparable with data from the French College of Obstetrics and Gynecology,
which recommends the preservation of the ovaries for premenopausal women. [9].
The age of patients was comprised between 27 and 84 years, with a higher percentage of
AH for the groups of 25-59 years, compared to VH which prevailed at ages over 60 years-
Table 1. From the point of view of surgical indication, AH was preferentially practiced in case
of excessive bleeding (1/4 of cases) and symptomatic uterine fibroids (over 1/2 of cases), the
vaginal hysterectomy in case of uterine prolapse being preferred to ~ 2/3 of cases, for women
aged 60 years or associated general pathologies - Table 1.

Table 1: The correlation for the main frequency features in cases with VH and AH
Frequency % VH AH p-value*
Type of approach 19,6 80,4 -
Age (range 27-84 years)
25-39 years 2,1 14,9
40-59 years 26,3 72
60-79 years 67,7 12,1 <0,001
80 years and more 3,9 0,3
(0,00044)
Type
The uterus ablation only 80 37,6
H+ unilateral anexectomy 2,6 8,4
H+ bilateral anexectomy 17,4 54 <0,001
The main diagnosis

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Abnormal uterine bleeding 13 24,7


Symptomatic uterine leiomyomas 17 59,1
Prolapse 60,8 0,7
Endometrial hyperplasia 3,2 2,9
<0,001
Other causes 5,5 9,6
The percentage of experienced 32,6 72,7 <0,001
physicians (in 2015)
Complications
No 95,3 95,6 >0,05
Yes 4,7 4,4
Source: Author ’s analysis
p-value is calculated using the t-student test, ANOVA
VH=vaginal hysterectomy; AH=abdominal hysterectomy
*
significant for p<0,05
By comparison, an american study made in 2007 estimated that the frequency of abdominal
surgical approach was 66%, 21.8% for vaginal approach and 11.8% for laparoscopy [8]. In
2008, other specialists appreciated that the frequency of hysterectomies would decrease from
5.4‰ to 5.1 ‰ in four years. For this period, the main benign diseases requiring surgical
interventions were: symptomatic uterine fibroids, endometriosis, uterine prolapse, endometrial
hyperplasia, cervical dysplasia and excessive uterine bleeding, requiring in the US the
execution of approx. 600,000 hysterectomies per year [10].
A small percentage of studied cases suffered complications in both hysterectomy types:
4.7% (n=11) of cases with VH (9 urinary tract infections and 2 local hematoma) and 4.4%
(n=42) of cases with AH (34 moderate urinary infections, 6% wound infections and 2 local
hematoma). Prevalence established is low compared to other studies [11]. On the other hand, if
we analyze the time and costs to solve them, then AH surpassed the HV by the total costs (by a
greater average admission to hospital) and broken down by categories (medicines and medical
supplies, laboratory tests), and the statistical difference being of significant importance. -
Table 2.
Table 2: Comparison of hospitalization costs by type of hysterectomy
Normal evolution Whith complication
p-value*
VH AH VH AH
Admission days 6,6±1,1 8,4±0,9 7,7±1,6 9,2±1,7 0,027
numbers
Costs per day (RON)
Medication 28,9±4,5 42,8±9,8 41,9±5,3 65,3±7,8 <0,001

Laboratory tests 16,2±1,4 20,1±2,4 17,5±2,4 20,5±2,4 0,012

Sanitary materials 36,6±9,1 45,2±5,2 44,7±8,8 51,3±11,3 0,003


Total 93,8±19,1 117,7±7,3 132,6±7,1 205,1±8,7 <0,001

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Source: Author,s analysis


VH=vaginal hysterectomy; AH=abdominal hysterectomy
*
significant of p<0,05
Regard to the patient’s data in the decision for the surgical approach, the genital and general
pathology of the patient, the size of the uterus, parity and safety and anesthetic risks are taken
into consideration by the medical studies [12], [13]. The ideal procedure for the practitioner
would be to choose the best option in terms of indication, adapted to the patient and at a
reasonable cost of the medical services. The conclusions groups of researchers that analyzed
the types of approach for hysterectomy in all aspects, recommend the vaginal route as gold-
standard for benign disorders, supplemented (if necessary) by laparoscopy [3], [12], [13]. The
advantages of vaginal hysterectomy are highlighted over the years as they overcome the initial
practical contraindications [14], [15]. From this point of view, the future gynecologists are
recommended to acquire the appropriate surgical techniques, so as to be able to choose the
most appropriate to each patient [16]

Conclusions

Although the vaginal way of approach represented a percentage below 20% of the casuistry,
the study demonstrated the benefits for the patients regarding the range of ages, development
of complications, and recovery and the benefits of efficiency and unit costs. Recovery of
patients was more rapid in cases with vaginal approach, the average number of hospitalization
days was lower by ~30%, and the costs of investigations, as the medication, were lower in the
same cases (with or without complications).
This supports the conclusions of other expert studies [17], [18], [19] although for our zone
the prevalence of AH was demonstrated. Preference for the type of approach in the studied
cases was linked to both genital pathology, and the experience of surgeons. As also stated in
other studies, practical courses for young professionals would be useful to obtain the ability
necessary for all types of gynecological surgery [20].

REFERENCES

1. Sutton,C. (1997). Hysterectomy: A historical perspective. Baillière s Clinical Obstetrics


and Gynaecology 11(1),pp.1-22.
2. Kovac, SR. (2004). Clinical opinion: guidelines for hysterectomy. Am J Obstet Gynecol.
191(2), pp.635-40.
3. ACOG.(2009). Choosing the route of hysterectomy for benign disease. ACOG Committee
Opinion No. 444. Obstet Gynecol, 114, pp.1156-8.
4. Wright,JD. Herzog,TJ. Tsui,J. Ananth,CV. Lewin, SN. Lu, Y-S. et al. (2013). Nationwide
trends in the performance of inpatient hysterectomy in the United States. Obstet Gynecol,
122(2 Pt 1), pp.233-41.
5. Ridgeway,BM.(2015).Does prolapse equal hysterectomy?The role of uterine conservation
in women with uterovaginal prolapse. Am J Obstet Gynecol.213(6), pp.802-9.
6. Național Roumanian Institute of Statistique (2015). www.insse.ro/cms/files/.
7. EUROSTAT(2015).http://ec.europa.eu/eurostat/statistics-explained/index.php/ Surgical_
operations_ and_procedures_statistics.

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8. Wu,JM. Wechter, ME. Geller,EJ. Nguyen,TV. Visco, AG. (2007). Hysterectomy rates in
the United States, 2003. Obstet Gynecol, 110(5), pp.1091-5.
9. Deffieux,X. Rochambeau,B. Chene,G. Gauthier,T. Huet,S. Lamblin,G. Agostini,A.
Marcelli,M. Golfier,F.(2016). Hysterectomy for benign disease: clinical practice
guidelines from the French College of Obstetrics and Gynecology.EJOG,202,pp.83-91
10. Whiteman,MK. Hillis,SD. Jamieson,DJ. Morrow,B., Podgornik,MN. Brett, KM.
Marchbanks, PA. (2008). Inpatient hysterectomy surveillance in the United States, 2000-
2004. Am J Obstet Gynecol,198(1), pp.34.e1-7.
11. Clarke-Pearson, DL. Geller, EJ.(2013). Complications of hysterectomy. Obstet Gynecol,
121(3), pp.654-73.
12. A Cochrane Review of 34 RCTs (2009): vaginal hysterectomy has the best outcomes over
laparoscopic and abdominal hysterectomy. Obstet Gynecol, 114, pp.1156–8.
13. Datta, S. Bruce, D.(2012). Surgical approaches to hysterectomy for benign gynaecological
disease : RHL commentary, The WHO Reproductive Health Library; Geneva: World
Health Organization, apps.who.int/entity/rhl/archives/.../index.html.
14. Moen, MD, Richter, HE.(2014). Vaginal hysterectomy: past, present, and future, Internat
Urogynecol J, 25(9), pp 1161–5.
15. Chen B., Ren DP., Li JX., Li CD. (2014). Comparison of vaginal and abdominal
hysterectomy: A prospective non-randomized trial. Pak J Med Sci, 30(4), pp.875-9.
16. Olah, K. (2005). Vaginal hysterectomy in the absence of prolapse, The Obstetrician &
Gynaecologist, 7(4), pp 233-240.
17. Landeen, LB. Bell, MC. Hubert, HB. Bennis, LY. Knutsen-Larson, SS. Seshadri-Kreaden,
U.(2011). Clinical and cost comparisons for hysterectomy via abdominal, standard
laparoscopic, vaginal and robot-assisted approaches. S D Med. 64(6),pp.197-9, 201, 203.
18. Gupta, J.(2015). Vaginal hysterectomy is the best minimal access method for hysterectomy.
Evid Based Med, doi:10.1136/ebmed-2015-110300.
19. AAGL Advancing Minimally Invasive Gynecology Worldwide.AAGL position
statement(2011): route of hysterectomy to treat benign uterine disease. J Minim Invasive
Gynecol, 18(1), pp.1–3.
20. Asoğlu,MR. Achjian,T. Akbilgiç,O. Borahay,MA. Kılıç,GS.(2016). The impact of a
simulation-based training lab on outcomes of hysterectomy. J Turk Ger Gynecol Assoc,
17, pp. 60-4.

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Laparoscopic cerclage in pregnant and non pregnant


women

DORU CIPRIAN Crisan1


1
Clinical Municipal Hospital Timisoara
E-mail: crisandc@yahoo.com

Abstract

Background
The classical surgical treatment for cervical insufficiency is vaginal placement of a cervical
cerclage. There are cases in which the vaginal approach is not possible, such as congenital
shortened cervix, cervical amputation, cervical scars obstructing the vaginal approach,
the failure of a previous cervical cerclage, cervical-vaginal fistulas. In such conditions, a
transabdominal approach for cerclage is an option, allowing the correct placement of the tape
at the level of internal cervical ostium. Laparoscopic cervical cerclage is associated with good
pregnancy outcomes but comes at the cost of a higher risk of serious surgical complications.
The aim of this study was to evaluate intraoperative and long-term pregnancy outcomes
after laparoscopic cervical cerclage, performed preconceptive or during first trimester of
pregnancy.

Method
Strictly respecting the inclusion criteria cited above, we performed laparoscopic cervical
cerclage for cervical insufficiency between January 2014 until April 2016 using a polyester
tape. Our cohort consists of four case of preconceptional laparoscopic cerclage and seven
laparoscopic cerclage during first trimester of pregnancy.

Results
Eleven women were included in the study. Of these, seven were pregnant at the time of
laparoscopic cervical cerclage. The cerclage in pregnant women was made after they had at
least one of the screening tests for genetic disorders and until the risk of spontaneous first
trimester abortion has passed (>12 weeks). The duration of surgery was 60±10 minutes in
pregnant patients, and 45 +/-10 minutes for non pregnant patients. No serious intraoperative or
postoperative complications occurred. The patients were discharged at 72 hours after surgery.
We had no miscarriages, only one pregnancy had a preterm delivery at 32 weeks gestation
because of the rupture of membranes, with caesarean section. The rest of the pregnancies
delivered at term (at 38 weeks of gestation), all by cesarean section, leaving the tape on place.
From the preconceptional cerclage group, only one got pregnant after cerclage and
delivered by cesarean section at 37 weeks. All babies were healthy.

Summary
Performing a laparoscopic cervical cerclage, does not increase intraoperative complications,

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especially in early pregnancy. In cases of midtrimester miscarriage caused by a very short
cervix, and inefficiency of transvaginal cerclage, the laparoscopic placement of the cerclage
is the only efficient management of cervical insufficiency. The method is an important option
to avoid infections of the cervix and premature rupture of the membranes, having a good
obstetrical outcome

Keywords: laparoscopic cerclage, polyester tape, cervical insufficiency, cervical cerclage,


transabdominal cerclage

Introduction

Cervical insufficiency (cervical incompetence) (CI) is defined by the American College


of Obstetricians and Gynecologists (ACOG) as the inability of the uterine cervix to retain a
pregnancy in the second trimester, in the absence of uterine contractions, and it represents up
to 1% of obstetrics population (1). The diagnosis of cervical insufficiency may be based on a
history of midtrimester pregnancy loss.
The classical treatment for CI is the transvaginal cervical cerclage (TVC), which has been first
practiced in 1950 by Lash and Lash. The technique was improved by Shirodkar and McDonald
(2). The first laparoscopic procedure of placement of a cervical cerclage was described by
Sciabetta in a women without pregnancy but with a history of midtrimester pregnancy loss
(3). After that, the procedure was introduced to pregnant women. Anatomic unsuitability for
transvaginal cerclage, for example short cervix after conization or amputation of the cervix in
carcinomas, cervical-vaginal fistulas and cervical tears and laceration, trachelectomiy which
prevent the access to the cervix, failure of previous (TVC), are indications for the abdominal
approach. (4), (5)
Indications for the insertion of a cerclage may be divided into prophylactic cerclage
versus therapeutic cerclage. The clinical history of shortening and dilatation of the cervix, and
abortions or preterm delivery, are indications to use the prophylactic method (6).

Material and Method

A single cohort study was made between January 2014 and August 2016, on 11 women
with a classic history of cervical insufficiency, who all experienced midtrimester abortion or
in whom prior vaginal cervical cerclage has been unsuccessful.

Iclusion Criteria

We included in the study all women with a poor obstetrical history, having a very short
or absent vaginal part of uterine cervix due to high cervical amputation. All pacients had a
history of second midtrimester miscarriage or preterm delivery (27 weeks of gestation, 1 case)
because of the cervix insufficiency and failure of transvaginal cerclage. From the 11 patients,
in seven cases the laparoscopic cerclage was placed during the first trimester of pregnancy (12
– 13 weeks gestation). In four cases we performed a preconceptional cerclage.
We have to mention one case consisted of a short and incompetent cervix after cervical high
amputation for stage 0 cervical cancer, followed by one year of negative vaginal smear, and

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an unsuccessful transvaginal cerclage. In this case we performed a preconceptional cerclage.
In another case, we performed the cerclage on an malformed incomplete septate uterus, at
12 weeks of gestation.
In all cases we used a non resorbable polyester 5 mm width tape with pointless needles
attached on both ends (Cervical set band, Braun).

Surgical Technique

All procedures were performed under general anesthesia.


In pregnant women, the gestational age was between 12 and 13 weeks of pregnancy, and
they all underwent screening for fetal genetic abnormalities (ultrasound, biochemical)
Before surgery, cervical culture was collected to exclude infections. In pregnant women
we administered progesterone intravaginal, 200 mg twice a day, for two days before surgery
and 7 days after, and antibiotic treatment (Cefrtriaxona 1g) during surgery. No other tocolysis
was made. Transvaginal uterine manipulator was used only in one non-pregnant women, but
due to an almost absent cervix, it was difficult to use in the other cases. No intraabdominal
uterine manipulator was used in pregnant patients. The surgical procedure was performed by
two operators, and with the help of an assistant that used transvaginaly either a mounted buffer
or simply the fingers to slowly mobilize the pregnant uterus or expose utero – vesical space.
Pneumoperitoneum was induced using the Veress needle technique. On subombilical
incision the 10mm optical trocar was placed, followed by three 5-mm trocars, two of them
placed laterally on right and left lower quadrant, the third one suprapubically. The surgical
steps were: inspection and visualization of the uterosacral ligaments, the incision of the
uterovesicalis peritoneal fold (Fig. 1), and gently pushing down the bladder, followed by
direct visualization of the uterine pedicle. On the left trocar, we introduced the polyester tape
with one needle on each end. We visualized the posterior face of the broad ligaments and
uterosacral ligamenst, with the help of the vaginal assistant.
We started by introducing the tape from the left uterine side, from anterior to posterior,
medially from the uterine pedicle. (Fig. 2). The exit point of the needle was above the uterine
insertion of left uterosacral ligament. The same procedure was done on the right side, but the
needle was introduced from posterior to anterior, above the right uterosacral ligament, and
exiting medial from the uterine pedicle. The bleeding was almost absent in all cases of non-
pregnant women and bellow 100 ml in pregnant cases. After correct placement of the tape at
the level of internal cervical ostium, a tight knot was made with both ends of the tape after
removing the needles, anterior at the cervico-isthmic junction (Fig. 3). The knot was then fixed
to the uterine isthmus by two non-resorbable sutures. The last stept was the peritonization (Fig.
4) that covered the knot.

Fig. 1: Surgical steps of laparoscopic abdominal cerclage: the incision of the uterovesicalis

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plica

Fig. 2: Surgical steps of laparoscopic abdominal cerclage: Introduction of the needle with the
tape through the broad ligament from posterior to anterior medial to the right uterine artery in
the avascular space

Fig. 3: Surgical steps of laparoscopic abdominal cerclage: Both ends of the polyester tape are
at the right position to make a firm knot

Fig. 4: Surgical steps of laparoscopic abdominal cerclage: peritonization.


We monitored the cervix length postoperative and during pregnancy, with transvaginal
sonography. (Fig 5)

Results

From the total of eleven women included in our study, 7 were pregnant at the time of the
(LAC) and 4 were non-pregnant women, but all of them had had history of (CI) and pregnancy
loss at second trimester. The average age of patients was 29+/-2 days.
The duration of laparoscopy was 60 ± 10 minutes in pregnant patients and 45+/-10 min
for non-pregnant patients. No serious intraoperative or postoperative complications occurred.
The bleeding during the procedure was under 100ml. The patients were discharged at 72
hours after surgery. We had no miscarriages, only one pregnancy that ended at 32 weeks
because of premature rupture of membranes, with caesarean section. The rest of the pregnancies
delivered at term (at 38 weeks of gestation with caesarean section) with good maternal and
fetal outcome.
From the 4 non-pregnant women who had had (LAC), only one got pregnant and delivered

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successfully by caesarean section at 37 weeks. In all cases, the tape was left in place.

Discussion

In our hospital, in the last 20 years, we did not performed any abdominal cerclage, but
since laparoscopy has improved the surgical benefits, we decided to practice (LAC) in all
cases of strict indication, were (TVC) is ineffective. All of the cervical cerclage were made
prophylactic, no cases of therapeutic cerclage. The pregnancy age was between 12 and 13
weeks of gestation, after performing the first trimester prenatal diagnose (genetic tests and first
trimester ultrasound). In the same time, the small gestational age allows the operator to mobilize
the uterus without intraabdominal manipulator, but with the help of a transvaginal mounted
buffer). It is very important to identify the avascular space medial from the uterine artery, in
the broad ligament, to avoid intraoperative bleeding. We can determine the level of internal
cervical ostium by examining the uterine insertion of utero-sacral ligament. Laparoscopic
approach facilitates correct placement of the tape at the internal cervical ostium. This way,
infection rate decreases significantly, as compared to vaginal cerclage. We had no cases of
pelvic infections even after the caesarean section. Complications of laparoscopic cerclage are
similar to those associated with transabdominal cerclage and they are widely reported between
0% and 25 %. They include uterine vessel bleeding, impaired surgical visibility due to morbid
obesity, perioperative pregnancy loss, infection, and thromboembolism (7). A very low rate of
chorioamniotitis was reported after transabdominal cerclage when compared with the vaginal
route. (11)
In addition, erosion of the Mersilene tape suture used in most cases through the lower
uterine segment has been reported. We did not experienced any of these complications, and
the polyester tape that we used did not create any local rejet. All pregnant patients were
administered vaginal progesterone for one week after the procedure, since progesterone
significantly reduces the risk of abortion or preterm delivery. (9)
A review made by Olga Tusheva and col. showed a very high rate of obstetrical success
of laparoscopic cerclage, ranging between 75% and 100%, and a very low complication rate
of 10%. (8)
One discussion should be made regarding the fertility outcome in the non-pregnant
group who underwent (LAC) because there is a concern regarding the decrease up to 25% of
pregnancy rate after preconceptional cerclage (Burger NB, 2011). We had only one pregnancy
obtained in these group after a high amputation for cervical stage 0 cancer, which delivered at
37 weeks. Unfortunately, tubal patency was not checked during the laparoscopic procedure in
none of the cases.
The disadvantage of the laparoscopic cerclage is that the patient will undergo two surgeries,
one for the placement of the tape and the second one is the caesarean section. Another
disadvantage appears in case of a miscarriage before 24 weeks, when removal of the cerclage
tape is required, a situation when we can use the laparoscopic route even at 19 weeks. (10).
Laparoscopic cerclage offers the benefits of a very short admission time and very fast
recovery, and considering the indications, it has a very good obstetric outcome.

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Fig. 5: transvaginal ultrasound in early pregnancy. position of the cerclage tape (arrows)

Conclusions

Laparoscopic transabdominal cerclage is a safe and effective procedure resulting in


favourabile obstetric outcomes in women with a poor obstetric history.

REFERENCES

1. Rand L, Norwitz ER. Current controversies in cervical cerclage. Semin Perinatol 2003;
27:73.
2. Lash A F, Lash S R. Habitual abortion: the incompetent internal os of the cervix. Am J
Obstet Gynecol.1950; 59:68–76. [PubMed] 85.
3. Scibetta J J, Sanko S R, Phipps W R. Laparoscopic transabdominal cervicoisthmic
cerclage. Fertil Steril.1998;69:161–163. [PubMed]
4. Benson R C, Durfee R B. Transabdominal cervicouterine cerclage during pregnancy for
the treatment of cervical incompetency. Obstet Gynecol. 1965; 25:145 – 155. [PubMed]
5. Burger N B, Einarsson J I, Brölmann H A. et al. Preconceptional laparoscopic abdominal
cerclage: a multicenter cohort study. Am J Obstet Gynecol. 2012; 207:2730 – 2.73E14.
6. D.Bolla, L.Raio, S.Imboden, M.D. Muller.Laparoscopic Cerclage as a treatment option
for cervical insufficiency obstet Gynecol.2015 august 75(8):833-838.
7. Davis G, Berghella V, Talucci M, Wapner RJ. Patients with a prior failed transvaginal
cerclage: a comparison of obstetric outcomes with either transabdominal or transvaginal
cerclage. Am J Obstet Gynecol. 2000; 183:836–839. [PubMed]
8. Olga A Tusheva, Sarah L Cohen, Thomas F McElrath, Jon I Einarsson, Laparoscopic
placement of Cervical Cerclage, Rev. Obstet. Gynecol. 2012 5 (3-4), e 158 - e165.
9. Romero R, Nicolaides K, Conde-Agudelo A, et al. Vaginal progesterone in women with
an asymptomatic sonographic short cervix in the midtrimester decreases preterm delivery
and neonatal morbidity: a systematic review and metaanalysis of individual patient data.
Am J Obstet Gynecol.2012; 206:124. e1–124.e 19. [PMC free article] [PubMed]
10. James F. Carter, Ashlyn Savage, Laparoscopic removal of abdominal cerclage at 19 weeks
gestation, JSLS,2013, Jan – Mar, 17 (1) 161-163.
11. Davis G, Berghella V, Talucci M, Wapner RJ. Pacients with a prior failed transvaginal
cerclage: a comparison of obstetric outcomes with either transabdominal or transvaginal
cerclage. Am.J Obstet Gynecol. 2000.

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Cure of stress urinary incontinence with canal


transobturator tape

DORU CIPRIAN Crisan1, RATIU Adrian1


1
Universty of Medicine and Pharmacy “V. Babes” Timisoara, (ROMANIA)
E-mails: crisandc@yahoo.com, dr.ratiu@gmail.com

Abstract

Background
Stress urinary incontinence (SUI) is the involuntary leakage of urine when intrabdominal
pressure rises. In women, SUI is the most common subtype of urinary incontinence, wich is
treated by the placement of a midurethral sling (MUS) placed either transobturator (TOT) or
retropubicaly transvaginal tension free. (1). The aim of this study was to evaluate the efficiency
of two methods for placing the MUS sling, either the modified distal urethral sling or canal
TOT versus the classical conventional way, in the treatment of stress urinary incontinence,
considering that some complication after MUS are determined by the position of the sling.

Material and Method


30 women with SUI were included in the study. The diagnose of SUI was made on
anamnesis, physical examination, Valsalva urinary leakage with patient in lithotomy position.
We identified 15 pacients (group 1) were a conventional MUS was performed, and another
15 pacients (group 2) were a canal TOT tape procedure was performed.
Midurethral transobturatory tape (TOT) technique is vaginally performed by inserting the
tape through the obturator foramen from the inside to the outside, then passed under a bridge
of dissected vaginal tissue in the urethral area, under spinal or general anesthesia.
The Incontinence Impact Questionnaire-Short Form (IIQ-7) and Urogenital Distress
Inventory Short Form (UDI-6) were used to compare the patient’s subjective satisfaction
before the procedure and after six month for both groups.

Results
The average of patients was 51,3 years in group 1 and 50,2 years in group 2, having a
similar obstetrical background. All procedures were successfully performed in average time
of 20 minutes for group 1 and 35 minutes for group2, with a minimum blood loss. Continence
was obtained and maintained after 6 month in 86,6% in the first group and 100 percent in
group 2.
Each qustionare revealed significant improvement of SUI cure after canal TOT tape and
longer term benefits as compared to conventional single incision MUS.

Conclusion
The insertion of midurethral transobturatory tapes (TOT) via paraurethral incision, is

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currently considered to be the preferred treatment for the stress urinary incontinence. This
article is describing our experience using a canal transobturator tape, with better results in
maintaining continence as compared to the conventional MUS procedure.

Keywords: stress urinary incontinence, canal transobturator tape, suburethral sling

Introduction

Female stress urinary incontinence (SUI) is a common condition, with prevalence rates
ranging from 12.8 to 46.0%.
Several procedures have been demonstrated for the surgical treatment of SUI and/or POP.
Tension-free vaginal tape (TVT) and transobturator tape (TOT) represent the most effective
and popular techniques.
The aim of our study was to compare canal TOT technique and conventional MUS in term of
efficiency and rate of complications. Our supsition was that the most important complications
after conventional MUS (persistent SUI, difficulties to urinate and high vesical residuu) are
caused by improper placement of the sling, to close to the proximal urethra and bladder neck.

Material and Method

We performed a prospective study on 30 patients diagnosed with stress urinary incontinence


without anterior vaginal wall prolapse who underwent two different TOT procedure techniques.
We selected only patients without previous incontinence surgery.
A trained one surgeon performed all operations under spinal anesthesia.
The patients were divided into two groups according to two different incision techniques.
In the single-incision technique group (group 1), the incision was started from 1.5 cm below
the external meatus and extended vertically 1.5 cm on the anterior vaginal wall. Tape was
inserted via outside-in transobturator route.
In the double-incision technique group (group 2), Canal TOT was then performed by using
the technique previously described in the literature (3, 4) but instead of doing two 1.5 cm
oblique lateral incisions we made two longitudinal incisions in the anterior vaginal wall 1.5 cm
below the external urethral meatus and parallel to the urethra. (Fig. 1)
After, a suburethral canal is created bluntly between the lateral incisions. The canal is
located in the layer between the periurethral fascia and the urethra. The tape is transferred
beneath the suburethral canal (Fig. 2). Bilateral paraurethral dissection of the vagina is
performed in the direction of the ischiopubic ramus through the dissected lateral incision. The
tunneler is passed through the obturator membrane. Its tip is palpated with the index finger
on the medial side of the obturator membrane by paraurethral dissection and the rest of the
procedure was similar to that of group 1.
Because the mesh is placed in a the suburethral canal, displacement of the mesh does not
often occur after surgery. (Fig. 3)
Incisions of the anterior vaginal wall were sutured with absorbable suture material (Fig. 3).
Finally, vaginal packing with povidone-iodine-saturated gauzes was applied.
The Foley catheter inserted during the procedure was removed the day after when all patients
were discharged. The patient’s medical histories and results of the physical examination,
urinalysis, urine culture were evaluated as part of the preoperative preparation.

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The Incontinence Impact Questionnaire-Short Form (IIQ-7) and Urogenital Distress
Inventory Short Form (UDI-6) were used to compare the patient’s subjective satisfaction
before the procedure and after six month for both groups. (6, 7)
All vaginal incisions were close with absorbabile sutures, and betadine solution was use to
wash the vagina.

Fig. 1 preoperative view

Fig. 2 (suburethral canal)

Fig. 3 (suburethral mesh) Fig. 4 (suture of the vagina)

Results

The average age of the patients in group 1 was 51.3 years (range, 34 to 65 years) and in
group 2 was 50.2 years (range, 36 to 63 years). The average number of vaginal births was
similar in both groups, 2.56 (range 1-3) and 2.10 (range 1-4). (Table1) A total of 30 patients
had the TOT operation, group 1 (15 cases) single incision TOT and group 2 (15 cases) double
incision TOT (canal-TOT). The average operation time was 20 minutes (range, 15-30 min) in
the single incision group and 35 minutes (range 25-40 min) in the double incision group.
Hospitalization time was the same in both groups since we had no surgery complications
and the average quantities of blood lose was similar between groups 86ml (range, 70-120ml)

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in group 1 and 95ml (range70-130) in group 2. There were no postoperative complications
such as bladder, bowel, or vascular injury There were no urination-related complications
except for four cases of transient, de novo urgency, three in group 1 and one case in group 2.
(Table 2). They were maged by another operation, and a canal TOT tape with good results,
after removing the initial tape.
Continence was maintained after six month in 13 cases (86.6%) of group 1 and all 15 cases
after canal TOT (100%) Each questionnaire revealed statistically significant improvement after
canal TOT. The IIQ-7 score was decreased significantly in group 2 (0.37±0.27) as compared to
group 1 (0.63±0.38), p<0.005 and UDI-6 score as well, 4.18±2.9 in group 1 and 3.57±2.60 in
group 2, p<0.005 suggesting that canal-TOT has more long time benefits than single incision
TOT. (Table 3)

Discussions

According to the “hammock hypothesis”, continence is preserved when urethral closing


pressure increases following an increase in abdominal pressure owing to compression of the
urethra by its hammock-like supportive layer. (8)

Table 1. Preoperative patient characteristics


Characteristic Group 1 Group 2
Age (yr.) mean(range) 51.3 (34-65) 50.2 (36-63)
No. of vaginal deliveries mean(range) 2.56 (1-3) 2.10 (1-4)
Previous incontinence surgery (nr) 0 0
Incontinence 15 15
Pure stress (nr) 10 11
Mixed type (nr) 5 4

Table 2. Operative data


Variable Group 1(TOT) Group 2(canal TOT)
Operation time (min) 20 (15-30) 35 (25-40)
Blood loss (ml) 86 (70-120) 95 (70-130)
Hospital stay (day) 2 2
Intraoperative and short term complications
Bladder perforation 0 0
De novo urgency 3 1
Weak stream 0 0
Hematoma in Retzius space 0 0
Difficult emptying 0 0
Long-term complications
Urinary obstruction 0 0
Inguinal pain 0 0
Mesh erosion 0 0

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Dyspareunia 0 0

Table 3. IIQ-7 and UDI-6 preoperative and postoperative after six month
Preoperative Postoperative (six month)

Group 1 Group 2 Group 1 Group 2


IIQ-7 mean±SD 1.24 (±0.55) 1.27 (±0.50) 0.63 (±0.38) 0.37 (±0.27) p<0.005

UDI-6 7.35 (±4.1) 7.23 (±4.4) 4.18 (±2.9) 3.57 (±2.60) p<0.005

mean±SD

The very large use of MUS procedure has started after Ulmsten first introduced TVT in
1995, on the basis of integral theory (9). It is a simple but highly efficient method, and the
complications after surgery include infections of urinary tract and vagina, bladder and urethral
perforation, vessel and nerve injury, persistent or recurrent SUI or difficulties in micturition.
It is known that 5% to 23% of all patients have persistent or recurrent SUI after a midurethral
sling procedure (6). These might be caused by a too loosely placed tape, erosion, or because of
inadequate placement of the sling at the midurethral level. A lot of reports present the fact that
if the sling is placed at the base of the bladder, it will worsen the incontinence (11). Bladder
neck funneling was also considered a cause for persistent SUI (13).
If the suburethral tape is placed between 50th and 80th percentile of cervical length, the cure
rate was exceeding 90% (12), while if it is placed under the proximal urethra it increases the
failure risk by 6 times (13). In order to prevent the sling migration, some authors described
their technique of using two point fixation of the sling at the midurethral level, obtaining a cure
rate of 95% versus 89% with no fixation. (14).
Our small cohort study compared the use of a modified surgical MUS, a canal TOT tape
that has been reported to have a high success rate and a low number of complications (3, 4). The
suburethral canal does not allow the tape to migrate from its initial placement at midurethral
level. Also the use of a Foley catheter is mandatory, because it presents exactly were the
midurethral part is, and it allows the operator to put any level of tension that he desires on the
tape, with no complication on micturition.
The canal TOT had no erosion, no dyspareunia, and an excellent cure rate of SUI after 6
month surveillance.

Conclusions

We can conclude that the treatment of stress urinary incontinence by using the canal TOT
technique is 100% efficient in comparison to the conventional SUI, that had 95% efficiency.
The main advantage of canal TOT is the correct placement of the sling at midurethral level
and preventing the migration of the sling to the proximal urethra and bladder neck.

REFERENCES

1. Botlero R, Urquhart DM, Davis SR, Bl RJ (2008) Prevalence and incidence of urinary
incontinence in women: review of the literature and investigation of methodological

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issues. Int.Urol 15:230–234).
2. Serati M, Salvatore S, Uccella S, Artibani W, Novara G, Cardozo L, Bolis P (2009)
Surgical treatment for female stress urinary incontinence: what is the gold standard
procedure? Int Urogynecol J Pelvic Floor Dysfunct 20:619–621.
3. Lee SH, Kim TB, Kim KH, Jung H, Lee MS, Yoon SJ. Preliminary report on a modified
surgical technique using canal transobturator tape for the treatment of female stress
urinary incontinence. Korean J Urol 2008; 49:1119-24.
4. Lee JH, Yoon HJ, Lee SJ, Kim KH, Choi JS, Lee KW. Modified transobturator tape
(canal transobturator tape) surgery for female stress urinary incontinence. J Urol 2009;
181:2616-21.
5. Chang Hee Kim, Tae Beom Kim, Jin Kyu Oh, Sang Jin Yoon, Khae Hawn Kim, Kwang
Taek KimModified Distal Urethral Polypropylene Sling (Canal Transobturator Tape)
Procedure: Efficacy for Persistent Stress Urinary Incontinence After a Conventional
Midurethral Sling Procedure, Int Neurourol J 2013; 17:18-23.
6. Ogah J, Cody DJ, Rogerson L. Minimally invasive synthetic suburethral sling operations
for stress urinary incontinence in women: a short version Cochrane review. Neurourol
Urodyn 2011; 30:284-91.
7. Daneshgari F, Kong W, Swartz M. Complications of mid urethral slings: important
outcomes for future clinical trials. J Urol 2008; 180:1890-7.
8. DeLancey JO. Structural support of the urethra as it relates to stress urinary incontinence:
the hammock hypothesis. Am J Obstet Gynecol 1994; 170:1713-20.
9. Ulmsten U, Henriksson L, Johnson P, Varhos G. An ambulatory surgical procedure under
local anesthesia for treatment of female urinary incontinence. Int Urogynecol J Pelvic
Floor Dysfunct 1996; 7:81-5.
10. (Ogah J, Cody DJ, Rogerson L. Minimally invasive synthetic suburethral sling operations
for stress urinary incontinence in women: a short version Cochrane review. Neurourol
Urodyn 2011; 30:284-91.
11. Poon C, Zimmern P. When the sling is too proximal: a specific mechanism of persistent
stress incontinence after pubovaginal sling placement. Urology 2004; 64:287-91.
12. Kociszewski J, Rautenberg O, Perucchini D, Eberhard J, Geissbuhler V, Hilgers R, et al.
Tape functionality: sonographic tape characteristics and outcome after TVT incontinence
surgery. Neurourol Urodyn 2008; 27:485-90.
13. Yang JM, Yang SH, Yang SY, Yang E, Huang WC, Tzeng CR. Clinical and
pathophysiological correlates of the symptom severity of stress urinary incontinence. Int
Urogynecol J 2010; 21:637-43.
14. Rechberger T, Futyma K, Jankiewicz K, Adamiak A, Bogusiewicz M, Bartuzi A, et al.
Tape fixation: an important surgical step to improve success rate of anti-incontinence
surgery. J Urol 2011;186: 180-4.

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Comparative study of surgical care of stress


incontinence using tension-free vaginale tape and
transobturator tape

DICULESCU Doru1, MIHU Dan1, CIORTEA Răzvan1,


CIUCHINĂ Septimiu1, MĂLUȚAN Andrei1, IUHAS Cristian1,
GROZA Daria1, CAPOLNA Miorița1, CĂLĂTAN C.2
1
UMF “Iuliu Hatieganu”, Clinica “D. Stanca” Cluj-Napoca (ROMANIA)
2
GHRSA Mulhouse, Service de Gynecologie et Obstetrique (FRANCE)
E-mails: ddiculescu@yahoo.com, gccalatan@yahoo.fr

Abstract

Introduction
Tension free vaginale tape (TVT) and transobturator tape techniques (TOT) are frequently
used for the treatment of stress incontinence.

Objectives
The purpose of this study is a comparative evaluation of the eficacy and postoperative
complications of the two methods used for the treatment of stress incontinence. The study
is also trying to establish the superiority of one method regarding both indications and
postoperative results.

Method
This was a unicentric rethrospective study wich included all the patients admited in the
Obstertrics and Gynecology section of Mulhouse Hospital (France), who underwent surgery
using TVT and TOT technique, in a period of 10 years. From the patients admited in the study
76 were treated by using TVT technique and 176 by TOT technique. The postoperative follow-
up was between 7 and 12 months.

Discutions
The average age of two groups was not significantly different (58.4 years TVT and 57.09
years TOT). Most of the patients who underwent surgery presented with stress incontinence,
28.9% of TVT group presented with mixed incontinence compared with 17% of the TOT
group and a very small number of patients belonging to both groups presented with urge
incontinency.
Postoperative, 76.6% of the TOT group patients were found to have post- void residual
urine, greater than 58.2% in the TVT group. 18.2% of TVT patients developed imediate
postoperative complications, almost twofold compared to 8.5% in the TOT group. This was
shown by all comparative studies performed until now. 31.6% from TVT group presented with
late postoperative complications compared with only 18.8% from the TOT group.

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Conclusions
Both TOT and TVT techniques are efficient in treating stres incontinence in women, with
differences like increased post-void residue in TOT, but with a lower rate of imediate and
late postoperative complications for the same technique. Both surgical techinqes can induce
dysuria, but mixed or urged rezidual incontinence where more frequent in the patients who
underwent surgery using TVT technique.

Keywords: stress incontinence, TVT, TOT

Introduction

Tension free vaginale tape (TVT) and transobturator tape techniques (TOT) are frequently
used for the treatment of stress incontinence.

Objectives

The purpose of this study is a comparative evaluation of the eficacy and postoperative
complications of the two methods used for the treatment of stress incontinence. The study
is also trying to establish the superiority of one method regarding both indications and
postoperative results.

Method

This was a unicentric rethrospective study wich included all the patients admited in the
Obstertrics and Gynecology section of Mulhouse Hospital (France), who underwent surgery
using TVT and TOT technique, in a period of 10 years. From the patients admited in the study
76 were treated by TVT technique and 176 by TOT technique. The postoperative follow-up
was between 7 and 12 months.

Results

Most of the operated patients in this study presented with urinary stress incontinence in
both groups, 28,9% of those who TVT group and 17% of TOT group had mixed urinary
incontinence and a small number suffered from urge incontinence.
Patients in the TOT group presented urinary incontinence in an early stage, comparing to
those from TVT group. In the third stage where 17.6% of TOT and 32.9% of TVT.

Imediate postoperative evaluation

The distribution of the urinay catheterisation was significantly diferent depending the type
of surgery. 98.7% of the TVT group needed catheterisation, comparing to 86.9% of the TOT
group. There was alaso a diference regarding the amount of time needed for the catheters to be
left in place: 33.4 hours for the TOT group to 48.5 hours for the TVT group.
The distribution of the post-void residual urine after the catheter removal was significantly
different depending the technique: 76.6% from the TOT group against 58.2% of the TVT
group. There was no significant difference regarding the post- void urinary volume.
The distribution of complications varied also: 18.4% of the patients who underwent TVT

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surgery developed postoperative complication compared to 8.5 of those with TOT.
There was no significant differences between the two groups regarding postoperative
complications such as: urinary retention (>150ml or 1/3 of the evacuated volume), the
amount of time the retention persisted (days), infections (urinary or pelvic). All infectious
complications where represented by urinary tract infections in both groups.

Late postoperative evaluation

The distribution of postoperative late complications was significantly different depending


on the surgical technique: 31.6% of the TVT group developed late postoperative complications
comparing to 18.8% of the TOT group.
No significant difference regarding the distribution of urinary retention, late postoperative
infectious complications or of the affected area (urinary, pelvic) was shown between the two
groups.
Depending the type of the surgical technique there was a significantly different distribution
of the residual urinary incontinence between the two groups: 23.7% in TVT group and 10.8%
in TOT group.
Another significantly different distribution was shown in the effort-mixed residual
incontinence: 6.6% of the patients from TVT group had urinary incontinence and 8% of the
TOT group.

Discutions

No considerable difference of the measured or registered preoperative parameters was found,


except for type of urinary incontinence. There were different types of urinary incontinence
with a different distribution: most patients presented with stress urinary incontinence, but
28.9% of the patients who underwent TVT surgery had mixed urinary incontinence beside
17% of the patients who underwent TOT surgery.
In the TOT group the stage of the stress urinary incontinence was less advanced compared
to the TVT group.
During surgery, there was no difference regarding the measured parameters between the
two groups, except for urinary catheterization. 98.7% of the patients belonging to the TVT
group needed catheterization compared to only 86.9% of the patients from TOT.
In postoperative follow-up there was a significant difference between the two groups
regarding the presence of post-void: 76.6% of patients from the TOT group, greater than
58.2% of patients from the TVT group.
From the patients who underwent TVT surgery 18.4% developed immediate postoperative
complications, almost two fold compared to only 8.5% of the patients who underwent TOT
surgery. This fact was found by every study made until present [5, 6, 8, 10].
At late postoperative evaluation of the two groups there were differences regarding late
postoperative complications: 31.6% in TVT group compared to 18.8% TOT group. The most
frequent complications in this study were urinary retention, de novo dysuria, urinary tract
infections among the patients who underwent TVT and urinary tract infection, externalization
of the prosthetic material among patients who underwent TOT surgery. The externalization
of the prosthetic material is not a complication due to surgical technique [1, 9, 13]. All the
prosthetic tapes were made from the same material and had the sub urethral part made of
silicone. This type of trans-obturator tape was withdrawn from the market.
Among the TVT patients 6.6% presented with post-void urinary incontinence compared

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to 8% among the TOT patients. An increased number of patients belonging to TVT group
experienced mixed or urge urinary incontinence. This can be explained by the high percentage
of preoperative mixed urinary incontinence in this group of patients, but also trough the
enhanced potential of TVT technique to induce de novo dysuria compared with TOT technique
[2, 3, 4, 7, 11].
In terms of quality of life, the majority of patients complaint about physical effort related
postoperative life quality decrease followed by global life quality decrease due to urinary tract
disorders. Patients who regained normal bladder function after surgery showed a subjective
improvement of life quality. Subjective recovery is superior to objective recovery probably
due to the fact that even a urinary symptomatology amelioration could be interpreted as a
recovery [12]. The occurrence of new symptoms like de novo dysuria led to the decrease of
patients satisfaction. By answering to image related questions, most of patients reported an
improved self-image and an improved sexual life.

Conclusions

The presence of postoperative post void urinary volume, in the TVT group, depended
on the type of preoperative incontinence, most of the patients presenting with mixed urinary
incontinence.
Patients who underwent TOT surgery had a higher post-void urinary volume than patients
who underwent TVT surgery.
Patients belonging to TVT group developed a higher number of early and late postoperative
complications than patients belonging to TOT group.
The occurrence of small intra- and postoperative incidents and accidents had no influence
on postoperative outcomes
Both surgical techniques can induce de novo dysuria, but there was a high number of
patients in TVT group presenting with postoperative variable volume of post-void urine and
mixed or urge urinary incontinence.

REFERENCES

1. Cervigni M, Natale F. The use of synthetics in the treatment of pelvic organ prolapse. Curr
Opin Urol, 2001;11(4):429-435.
2. Delorme E. La bandelette transobturatrice: un procede mini-invasif pour traiter
l’incontinence urinaire d’effort de la femme. Prog Urol, 2001;11:1306-1313.
3. Deval B, Haab F, Pigne A, Rayr Ch. L’incontinence urinaire feminine: Actualites 2008.
Gynecol Obstet Fertil, 2008;36:1-7.
4. Dursun P, Bildaci TB, Zeynoglu HB, et al. Transobturator tape operation is more effective
in premenopausal women than in postmenopausal women with stress incontinence.
Korean J Urol, 2011;52(9):612-615.
5. Dyrkorn OA, Kulseng-Hanssen S, Sandvik L. TVT compared with TVT-O and
TOT: results from the Norwegian National Incontinence Registry. Int Urogynecol J
2010;21(11):1321-1326.
6. Jeon MJ, Jung HJ, Chung SM, et al. Comparison of the treatment outcome of pubovaginal
sling, tension-free vaginal tape and transobturator tape for stress urinary incontinence
with intrinsec sphincter deficiency. Am J Obstet Gynecol, 2008;199:1-4.
7. McGuire EJ, Lytton B, et al. The value of urodynamic testing in stress urinary incontinence.

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J Urol, 1980;124(2):256-258.
8. Novara G, Artibani W, Barber MD, et al. Updated systematic review and meta-analysis
of the comparative data on colposuspensions, pubovaginal slings, and midurethral tapes
in the surgical treatment of female stress urinary incontinence. Eur Urol, 2010;58(2):218-
238.
9. Rechberger T, et al. A randomised comparison between monofilament and multifilament
tapes for stress incontinence surgery. Int Urogynecol J Pelvic Floor Dysfunct, 2003;
14(6):432-436.
10. Schierlitz L, Dwyer PL, Rosamilia A, et al. Effectiveness of tension-free vaginal tape
compared with transobturator tape in women with stress urinary incontinence and intrinsec
sphincter deficiency: a randomized controlled trial. Obstet Gynecol, 2008;112:1253-1261.
11. Sergent F, Gay-Crosier G, Marpeau L. Bandelettes sous-uretrales et incontinence urinaire
d’effort. Gynecol Obstet Fertil, 2009;37:353-357.
12. Villet R, Salet-Lizee D, Cortesse A, et al. L’incontinence urinaire de la femme.
Paris:Masson, 2005;83-120.
13. Von Theobald P, Labbe E. The triple perineal operation with prothesis. First 100 cases
results. Rev Med Univ Navarra, 2004;48(4):70-74.

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The results of the treatment of stress urinary


incontinence by “Bega-I Munteanu” procedure

Gluhovschi Adrian1, Anastasiu Doru Mihai1,


Anastasiu Popov Diana Mria1
1
University of Medicine and Pharmacy Victor Babes Timisoara
Department of Obstetrics and Gynecology Neonatal and Child XII
University Clinic of Obstetrics and Gynecology “Bega” Timisoara, (ROMANIA)

Static pelvic changes or genital prolapse occupies, through local and general disturbances
which they generate, an important place in the gynecological pathology, still raising today
serious problems regarding treatment.
A female genital prolapse with an urinary incontinence and a number of other disorders
makes it an invalid person whose physical impairments influence her mental state, constituting
a burden to familial and social environment.
Meanwhile, as Huguier shows, there can exist an urinary incontinence which is masked
by the existence of a “prolapsed-pessary”, which resting on the distal end of the urethra, may
prevent externalization of urinary incontinence that can become manifest after solving the
prolapse.
Supportive elements are the genital-perineal pelvic floocomposed out of the levator ani
muscle, perineal muscles and tendon center of the perineum and which among other things
make the connection between the genital soft channel and the bone one. These elements must
be considered when you are in front of a vaginal approach of a genital prolapse associated
with urinary incontinence. Usually in these cases urinary incontinence is a stress incontinence,
which occurs by equalization of bladder and urethra pressure, having an anatomical component
manifested by changing the urethro-posterior bladder angle and the fall of urethra and vesical
junction.
This form of urinary incontinence receives surgical treatment through techniques that allow
a correct junction ascension. Clinical manifestation of this form of incontinence is usually
associated with genital prolapse predominantly Grade II or a voluminous cystocele.
The condition is the prerogative of older women with a history of multiple births, these
women usually featuring old and perineal tears and even rectocele or voluminous elitrocel.

After specifying the true anatomical form of urinary incontinence by investigations the
surgical treatment is required and in general must respect two principles (Alessandrescu):

1. The intervention must be simple and effective considering the fact that its benign pathology
without a vital prognosis.
2. The surgical procedure should provide the best anatomical and functional correction
because recurrences and reintervention increase the number of complications.

Associated with a variable degree of genital prolapse, surgical option determine resorting
to plastic and reconstructive surgery techniques aiming to restore both form and function
especially.

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From the vaginal surgical aproach the oldest and common tehniques the Kelly, Marion
and Ingelman-Sundeberg are practiced extensively. These interventions aim to strengthen the
muscles of the urethra and bladder neck, to restore their tone.
A deficiency of these processes is a limited possibility of lifting the junction which reduces
the percentage of successes, deficiencies remedied through interventions with TOT TVT strip
sling.
The alternative tehnique to these interventions proposed by us and which we have
named “Bega procedure” consists in modifying original tehnique by Kelly that raises some
accomplishments by achieving a percentage of anatomical and functional corrections of
urethro-bladder junction.

The actual technique of intervention are summarized in eight surgical steps:

Step 1:
The insertion of the vaginal valves and cleaning the area. Clamping the cervix with the
Museaus forceps.

Step 2:
Fixing the vaginal mucosa with the help of one or two Koher forceps up until 1-1,5 cm
from the ureteral meatus.

Step 3:
Semicircular incision Crossen at 1,5 cm from from the external orifice of the cervix.

Step 4:
The separation of the vaginal mucosa from the bladder by identifying the cleavage area and
the longitudinal sectioning on the median line of the vaginal mucosa up until 1,5 cm from the
external orifice of the urethra.

Step 5:
The dissection of the lateral vaginal walls while identifying (if at all possible) the Halban
fascia. It is preferred that this dissection to be as wide as possible. The dissection procedure is
different from patient to patient due to the case particularities.

Step 6:
The separation of the bladder from the uterus by sectioning the pillars. The hemostasis is
performed by cauterizing of ligaturing the sectioned blood vessels. It is highly recommended

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that this sectioning should be avoided as much as possible.

Step 7:
The reduction of the cystocele during the classical procedure Kelly-Marion is performed
by the placement of threads in “X” and in “U” to obtain a pouch around the internal orifice of
the urethra. In our procedure we are using the surget with vicryl threads to obtain the pouch in
which we insert the bladder diverticulum. For security reasons we apply three nonabsorbable
threads in the Kelly spots, at a great distance in the lateral dissected vaginal area, grabbing
the Halban fascia of the fibrosis fascia, resulting in a sub urethral folding. The usage of
nonresorbable threads assures the maintenance of the fold, and due to the fibrosis scar tissue
that will form, the bladder will have a higher stability in its position and will not slide down
even in stressful situation.

Step 8:
Excess vaginal mucosa was excised as necessary in each case, after which we sutured the
vaginal mucosa with reversed threads. Using reverse threads offers a good hemostasis.
Besides this, performing this fold creates a mass of scar tissue in contact with nonabsorbable
reinforcing threads suspended over the wound sustaining the anterior vaginal wall and the
bladder.
In reducing cystocele, we practice a higher muscle excision resulting in diminished vaginal
elasticity essential in the bladder neck in “critical elasticity area” that has a well defined role
in the phenomenon of continence (Petros, Ulmsten). This allows the sub coccyges muscle
(anterior portion) and floor lifter (posterior portion) to attend the locking mechanisms of the
urethra and bladder neck.

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During step 2 of the surgical procedure the posterior colpoperineoplasty is usually


performed In order to achieve an appropriate support of the anterior vaginal wall and rectocele
correction when necessary.

The intervention is standard, using a surgical trick to strengthen the tendinous center of the
peritoneum.

The time in which we close the vaginal incision consists in the remake of the vaginal
mucosa by applying a thread in “X” at the proximal angle of the excision and the folding of
the vaginal mucosa that extends with the median raphe of the peritoneum, being perpendicular
on its own tendinous center.

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The scar made this way and the fold leads to an increase resistance of the tendinous center
of the peritoneum.
The suturing of the vaginal mucosa is realized with inverted threads, the inverted folding of
the mucosa creates a median raphe across the incision, which, together with the median raphe
of the peritoneum creates a solid scar that consolidates the vaginal mucosa. The vaginal suture
is thus created until the carunculilor mirtiformi, the last thread is kept in the forceps until the
suturing of the levator anal muscles.
The suture of the levator anal muscles is performed by pushing with the index of the left
hand on the inferior angle of the incision above the anal sphincter and with the right hand we
pass three consecutive resorbable threads that are being kept in a Pean forceps until the suture
of the vagina.

We continue with the suture of the posterior vaginal wall until the vulvas posterior
commissure, after which we tie the threads from the levator anal muscles and continue with a
reverse suture.

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Evaluating the results of this procedure.


In analyzing this procedure we looked at 320 patients, representing 61,18% of a lot of 523
that underwent this procedure in our clinic. We observed a progressive usage of this procedure,
since it led to favorable results.
For a fair evaluation, we did a retrospective study by asking former patients to come to
be reexamined and to fill out a questionnaire. For the patients that did not want to come back,
we asked that they only fill out the form. The questions were regarding personal information,
medical history, type of procedure underwent, how they felt after the operation, if they had
any problems afterward and in what interval, troubles in their sex life due to their condition,
other inconveniences.
From our surgical lot that underwent this procedure, that being 320 patients, 170 came
back for a reexamination, representing 53,12%.

From this 170 patients:

• 26 15,29% were operated 7 years ago


• 28 16,48% 6 years ago
• 34 20% 5 years ago
• 39 22,94% 4 years ago
• 21 12,35% 3 years ago
• 14 8,24% 2 years ago
• 8 4,70% 1 year ago

From the interviewed patients, 15 – 8,82% did not solicit any gynecological examination
after the initial surgical intervention. We noticed the great percentage of 92,82% (168 cases)
of patients that didn’t have any recurrence symptomatology of urinary incontinence after the
procedure and only 2 cases (1,12%) that developed some urinary incontinence after 2 to 3
months, most of them (7 – 4,11%) developed the symptoms after more than 3 years after the
operation.
From the reexamined and interviewed patients, 30,39% admitted that they did not take the
medical advices seriously.
Also we noticed that from the reexamined lot 79 cases (46,47%) had a healthy and normal
sex life.
In the rest of the cases, the answers we got were mostly negative, due to advanced age and

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the interruption of their sex life.
The examination revealed a good pelvic stasis, without any evidence of any vaginal walls
prolapse, even in stressful conditions and the existence of some smooth scars that show no
signs of strangulation or stenosis of the vagina.
Trough genital exam we realized a comparison between the patients condition now and
before the operation.
Take note that from 170 patients, only 54 (31,76%) were operated under 2 years ago,
the rest were between 3 and 5 years ago, this giving the healing percentage an uncontestable
validity.
The statistics show that 75% had a relapse over 3 years from the initial intervention.
Regarding the relapse, 3,25% of the cases for urinary incontinence were fixed trough indirect
urethrocistopexia, Marshall-Marchetti-Krantz type interventions, Burch type intervention and
direct urethrocistopexia, Pereira and Dan Alessandrescu type operations or Sling type ones.

Discussions

1. The different elements of classical methods that we use refers to the suspension urethro-
bladder junction by applying two layers of which one with nonabsorbable thread that performs
at the first wireless application from a plicaturare sub urethral vaginal fascia.
2. Reversed suture of vaginal mucosa should be performed at a greater distance from the
edge of the incision makes a plication that gives a scar along the midline which in contact with
applied suspended non-absorbable wires realize a good quality and adherent scar tissue, which
does not allow urethro-bladder junction slipping under stress condition.
3. The large number of patients operated by this technique, 320, and the number of fallow-
ups 170 with good results, emphasizes the value of the process. The high percentage of healing
(94.71%) have a statistic value and long term results are olso satisfying.
4. Using this procedure as “first intention” to correct a urinary incontinence enables
approach without difficulty to any other classic procedure of correcting urinary incontinence,
either by abdominal or vaginal approach in case of relapse.
5. Vaginal approach enables efficient correction of the degree of descent junction urethro-
bladder by palpation and pushing up the clogged junction in time. At the same time it allows
an effective correction of genital prolapse and is associated in varying degrees in 80% of cases
by allowing exact assessment for excision of excess vaginal mucosa.
6. Wide excision of excess vaginal mucosa has the effect of reducing essential elasticity
(in the area of critical elasiticitate), contributing to correcting mechanisms of the urethra and
bladder neck closure.
7. That the resumption of normal sexual activity is possible in these women operated and
that were not reported strangulation or stenosis in women examined several years after surgery
is an argument in sustaining the type and the suture material used in the method applied by us.

REFERENCES

1. Einstein, A. (1916). General Theory of Relativity. Annalen der Physik 49(7), pp. 769

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Study on the level of knowledge about contraception of


high school students
HINOVEANU Adriana Denisa1,2,3,
ANASTASIU Popou Diana Maria1,2,3, CARAIVAN Magdalena,
ANASTASIU Entertainment1,2,3,*, GLUHOVSCHI Adrian1,2,3
1
Faculty of Medicine and Pharmacy “Victor Babes”, Timisoara (ROMANIA)
2
Department XII - Obstetrics - Gynecology – Neonatology – Child Care, Timisoara (ROMANIA)
3
University Clinic of Obstetrics - Gynecology “Bega” Timisoara (ROMANIA)
*
Correspondence author
E-mails: adrianahinoveanu@yahoo.com, doru_anastasiu@yahoo.com*

Introduction

The level of general culture and health culture is a product of health education and which
is shaping up by definition as a factor actively involved in personal and community health
determinism. It has a direct link in achieving health through prevention of diseases, which is
more important in human evolution than treating them.
According the definition, the status of human health involves physical health -mental,
sexual and social. The sexual component is closely related to the reproductive component that
represents a separate chapter in the life of women.
Contraceptive means discovered so far all constitute means of prevention and family
planning, the appearance of “successor” being planned by the couple when they wish and when
they consider that they can ensure a smooth and healthy development of the child. Occurrence of
unwanted pregnancies particularly at young girls (students) can have significant consequences
of the most damaging to the health of women through recourse to abortion, through empirical
methods that can lead to the appearance of septic abortions with all the complications that they
can generate. Also, the use of such problem solving through an abortion upon request may
cause a Syndrome of Depressive Self-blaming with long-term effects or to the impossibility to
remain pregnant, a fact also capable of generating an Anxious or Depressive Syndrome. Last
but not least, the abandonment of a newborn, immediately after birth can generate a mental
disorder with unforeseen consequences throughout life. All this can be avoided by practicing
contraception to prevent pregnancy.
The beginning of sexual life at 12-14 years old and lack of knowledge on the matter can
result in the occurrence of pregnancy of minors which are then likely to develop specific
pathology at these ages.
For these reasons we realized this study on the knowledge about contraception from an
earliest age, respectively high school students, concerned to see the degree of risk to which are
exposed young girls.
Family planning services have an important role in the stability of the family, contributing
to the creation of an informational system and to ensuring health education based on up-to-date
scientific information mass disseminated.

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Material and method

We proceeded to investigate a group of 248 high school students, mainly in class 11th
and 12th in order to test the level of knowledge regarding contraception and to identify the
percentage beginners of sexual life as well as how are information channels used to obtain
information about sex life and notions of contraception.
For this purpose we used questionnaires specially designed by us having as examples
forms of the International Society of Sexology and the European Society of Contraception.
For appreciation of truthfulness of answers we requested the anonymity of forms
completion.
The first part of the form relates to general data concerning the age, living standards, origin
environment, nationality, hobbies.
The second aspect relates to the age of first sexual contact, alcohol consumption, smoking,
the amount of money available on a monthly basis, the relationship with parents regarding
their knowledge of the beginning of sexual life.
The third aspect of the questionnaire includes questions regarding the level of knowledge
about contraception (methods, use techniques, safety).
A last aspect of the questionnaire includes questions that pertain to the interruption of
pregnancy rate by uterine curettage, induced abortion risks, and the abandonment of newborn
in maternity after birth.
After completing the form we held discussions regarding contraception and risks on
induced abortion, they sparked the curiosity of the students, from discussions it concluded
their ability to obtain information in this matter.

Results obtained

We had a study group consisting of 248 students in high school classes between the ages
of 14-19 year old in which 240 (96,77%) aged 15-18 years and 4 (1,61%) aged 14 respectively
21 years of age, the average age of the group being 16 years and 6 months. Surprisingly a
percentage of 1.61% are married, the rest of 244 (98,39%) being unmarried.
Considering that the environment of origin can have an influence on the level of general
culture, health culture,we noted the sexual emancipation of 220 (88,70%) who originated in
the urban area and only 28 (11%) in rural areas. Urbanization brings with it an increased
abundance of studies on the smallest areas of feelings, leading to an accelerated maturation
and early puberty installation. It can be appreciated that there is an acceleration of puberty
development in particular to urban girls who come from a better social environment. Girls
from rural areas or those from low economic social environment, the evolving phenomenon of
acceleration occurs later or accidentally.
Nationality structure shows that 238 (95.97%) are of Romanian nationality 4 (1.61%)
Hungarian, 1 (0.40%) German and 5 (2.02%) other nationalities.
Conducting a sporting activity influences the physical, intellectual, mental developement
as wel as the emprovement of skills, leading to an harmonious buildup of body and installing
early maturation of the cortex. Unfortunately only 62 (25%) of the entire lot practice phisical
exercice, 186 (75%) do not even participate in physical education classes.
The 21st century vices commonly spread among young people (smoking, alcohol
consumption, drug use) we found a fairly significant percentage of 27.42% smokers and

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20.56% consuming alcohol. No case was declared as drug users.
When asked about how many times the urgent tablet may be taken within two months,
a rate of 49.6% said they did not know, 43,95 replied that once, 5.24% answered that when
needed and 1.20% replied 4-5 times. This proves that half the group did not have correct
information on emergency contraception pill.
Referring to preventing pregnancy by reliable protection, 15.32% have no notion on this
protection, 71.37% trust Condon, 15.72% in intrauterine devices (IUD), 22.17% take the Pill,
6.85% in the method of “Double Dutch”; but the test shows that 68.55% did not know what
this means, only 0.81% being properly informed.
Analysis of the questionnaires revealed that 28.22% of the group have no concept on
induced abortion, and the remaining 71.78% of the group have much erroneous notions about
this topic. To be noted that 27.2% of the entire group does not consider abortion a sin, 72.98%
considering it a sin. This comes in conjunction with the fact that 70.57% would not have
an abortion in case of accidental pregnancy unlike 27.42% who would resort to an abortion
or even abortion inducing. The problem of underage motherhood is increasingly attracting
attention because the number of adolescent mothers increases. The fact is that individual and
professional development of a young mother is at least jeopardized by early motherhood. This
is also consistent with the increase of abandonement at birth of the newborn by young mothers,
phenomenon which unfortunately is growing. Most full-term pregnancy is often due to late
presentation for uterine curettage.
Regarding the question of whether abortion on demand should be banned, 62.91% say NO,
and 37.9% say YES, because it is in discrepancy with the curettage schoolgirls might have for
unwanted pregnancy.
Medical practice has shown that it is much better to prevent the occurrence of unwanted
pregnancy than, once pregnant, woman to result in termination of pregnancy by a method
of uterine curettage or induced abortion with all the negative consequences, sometimes
unavoidable results of these maneuvers.
There are not still vivid in memory the tragedies of toxic septic abortions from periods of
banned abortions that took tens of lives, young women, sometimes mothers who paid these
mistakes with their lives.
The teenager must have on hand a value system that would facilitate and mediate her
gradual integration into adulthood.

Conclusion

1. The level of knowledge on contraception of high school female students is average,


although there is a broadening in the age of sexual initiation increasingly younger; 35.8%
in our study.
2. Among high school female students who started sexual life 66.67% practice contraception.
3. Over 10% of high school schoolgirls have no idea about contraception.
4. Notions about contraception of high school female students came in lowest percentage
from doctor and parents, and the highest percentage from different sources and from
friends.
5. Over 30% of the study group have no notion about emergency contraception.
6. Over 20% of students have no idea regarding the risks of induced abortion.
7. It is noted the discrepancy between the fact that 70% of high school schoolgirls consider

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abortion a sin they would not assume and they would give birth, and that 62.91% do not
consider that abortion on demand should be banned.
8. We consider as very necessary the intensification sexual education made by doctors, by
family planning centers and NGOs.

REFERENCES

1. Berlescu ME, Cosmovici N – The evaluation of family well – being, East European
Medical Journal, 2, 35 – 38, 1993.
2. Dorobanţu I – Health Education, Medical Publishing House Bucharest, 1985; 184-189.
3. Darolle R – La contraception c`est aussi l`affaire des home. Presses de la cite, Paris,
1974.
4. Geraud R – Gynecologie psychosomatique, Mason, Paris, 1983.
5. Heinz Grassel – Youth Sexuality Education, Didactic and Pedagogic Publishing, Bucharest,
1971.
6. IPPF Medical Bulletin n. 3/June 1994 – IMAP Statement on contraceptive efficiency
7. Kleinman L.Ronald – Contraception Hormonale, IPPF, London, 1991.
8. Koo Borbala – PPA Profile: Society for Education on Contraception Romania - Planned
Parenthhood in Europe no. 11/1992.
9. Munteanu I., Copaci V. – Elements of Family Planning, Timisoara, 1992.
10. I. Munteanu – Obstetrics - Gynecology, Lito UMF, 1999 pag. 184-187.
11. R. Negrea Muresan Fl., Prisca R. Scridon R. Scurtu C. – Family Planning. Contraception,
Sincron Publisher Cluj, 1991 pag. 191-193.
12. V. Niţescu – Adolescence, Scientific and Encyclopedic Publishing, Bucharest, 1985.
13. Population Reports n. 3/1987 - Hormonal Contraception: New Long - Acting Methods.
14. Prisada Margareta, D. Pletea – Aspects of emergency hormonal contraception, Family
Medicine Magazine, Year II, No. 1, Febr. 1995 Timisoara.
15. Rudolf Neubert – Issues of gender education, Youth Publishing House Bucharest 1962.
16. Zbranca E. – Contraception, Junimea Publishing, 1990.

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Uterine Fibroids and Urinary Symptoms

HORHOIANU Irina-Adriana¹, HORHOIANU Vasile-Valerica¹,


GRIGORIU Corina¹, CIRSTOIU Monica¹
1
“Carol Davila” University of Medicine Bucharest
E-mail: irinah7@gmail.com

Abstract

Uterine fibroids are the most frequent benign uterine tumors in gynecologic pathology
often associated among others with urinary symptoms. Herein we present a prospective study
attained in the time frame august 2014 – April 2016 including a number of 47 patients who
underwent either surgical, conservatory or medical therapy for symptomatic fibroids associated
with urinary symptoms and good symptom remission among each group. Thus it has been
established that large uterine fibroids can have a negative impact on bladder function with
symptoms ranging from diurnal frequency, urgency and nocturia due to the direct pressure
exerted by the enlarged uterus to acute urinary obstruction. Not only voluminous fibroids but
also a large extremely anteverted uterus and also smaller but subserosal bladder bluging fibroids
can exert the same irritative and pressure effect. Intermittent obstruction can appear either due
to bladder traction due to extremely retroverted uteruses with fibroids and adherences but
also anterior and superior cervical deflection with bladder compression. Surgical, conservatory
and medical fibroid and uterus treatments are available and register parallel good bladder
symptoms alleviation with a tendency to perform the conservative treatemnt for selected cases
due to the fact that it is less invasive. Continous need should be exterd in order to exlcude the
confounding factors associated with bladder disfunction as treatment does not improve them.

Keywords: hysterectomy, bladder, embolization, myomectomy, gonadotrophin releasing hormone

Introduction

Uterine fibroids are the most frequent benign uterine tumors in gynecologic pathology.
In the majority of cases they appear to be asymptomatic leading to incidental pelvic or
ultrasound discovery. When symptomatic they can produce bleeding related symptoms such
as menorrhagia, metrorrhagia or both, pain related symptoms like pelviabdominal pain,
dysmenorrheea or dyspareunia and volume or pressure related symptoms for example bladder
related symptoms and digestive symptoms. While the first two classes of symptoms appear to
be more often, the last one including the bladder related symptoms is rather rare and usually
involves correct urological diagnosis in order to differentiate the uterine or fibroid cause from
the rest of urogynecological ones.

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Results

In this original article we present a prospective study attained in the time frame august
2014 – April 2016 including a number of 47 patients who underwent therapy for symptomatic
fibroids including with associated urinary symptoms. The main two therapy arms were
divided into a surgical treatment arm which included myomectomy or hysterectomy and a
conservatory treatment arm containing the patients eligible for uterine artery embolization and
medical therapy such as gonadotrophin releasing analogues etc.

The inclusion criteria were the following:

Inclusion criteria
symptomatic uterine fibroids defined by rapid growth or uncontrollable bleeding related, or
pain related symptoms
associated urinary pressure related symptoms such as polyuria, intermittent obstruction or
urinary frequency or urgency
thorough genitourinary exam excluding any other confounding genitourinary factors that
might cause the bladder related symptoms

The mean patient age was 38,77 ± 12,33 years with 5 fibroids – 11% experiencing rapid
growth, 70% (33) bleeding related symptoms, 56% (26) pain related symptoms and 34% (16)
pressure related symptoms out of which 100% were also urinary related.

Patient division into the 2 arms was done in accordance to the patients treatment indication,
local and ultrasound aspect, preexisting pathology or contraindications but also taking the
patients wishes to preserve fertility and genital function into consideration. The surgical arm
thus yielded 30 (63%) patients eligible for surgery out of which 8 underwent conservative and
the rest of 22 hysterectomy either with or without adnexal conservation. The rest of 17 (27%),
in the conservatory arm, underwent uterine artery embolization (13) and 4 had gonadotrophin
releasing analogues (gnrh) indication for a limited period of time of about 3 months in order to
prepare for conservative surgery. The mean uterine volume was of about 340, 63±217, 52 ml
(750,82-143,50 ml) with only one uterus registering fixed retroversion. One or more fibroids
were associated per uterus, the mean fibroid volume measuring 72,23±68 ml (346,5 - 0,98

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ml) and having a predominant anterior or fundal location with sometimes endometrial cavity
compression or uterus lateral deviation; 4 dominant fibroids registered subserous anterior
location leading direct bladder bulging.

urinary urinary
surgical arm conservatory arm
30 symptoms 17 symptoms
embolsation
myomectomy 8 1 13 4
procedure
hysterectomy 22 9 gnrh analogues 4 2

The total of 16 patients, present in 34% of fibroids, were divided in accordance to the
above mentioned table and presented the following symptoms: urinary frequency associated
with poliuria and nocturia in 15 patients – 94%, intermittent urinary obstruction in 1 single
case discussed below – 6% and urinary stress incontinence present in 6 patients – 37% all
non-atributed to other pelvic muscle or urinary pathologies. Following patient treatment, the
urinary symptoms, as in the other groups have subsided as follows: in the hysterectomy group
as in the uterine artery embolization group no urinary symptoms were present anymore, the
patient which underwent myomectomy expressed alleviated urinary frequency and out of the
2 patients with gnrh therapy one registered complete remission and the other alleviation of
symptoms – urinary frequency and stress incontinence.

urinary symptoms conservatory urinary symptoms


surgical arm 30 17
remission arm remission
embolsation
myomectomy 8 alleviation - 0/1 procedure 13 100% - 4/4
50% - 1/2 + 1
hysterectomy 22 100% - 9/9 gnrh analogues 4 alleviation

One patient enrolled in the study, 45 years of age, had an interesting symptom association.
She complained from urinary frequency associated with intermittent obstruction. The first time
of obstruction occurred in 2014 with presentation to the urology ward for inability to void with
pelvic pain and pressure; acute urinary retention was diagnosed and the patient underwent
24 hour bladder catheterization, antibiotics and anti-inflammatory treatment with complete
remission. In the following year the patient had recurrent voiding difficulties with one more
acute episode, thorough urological consultation yielding no cause for obstruction and with
intermittent most probably subacute urinary retentions as the patient learned from the urology
ward to move her cervix in order to urinate and in case of emergency even to do intermittent
bladder catheterisation. She also suffered from chronic pelvic pain for almost 2 years and a
slightly enlarged highly retroverted and slightly left deviated uterus with a posterior fundal
fibroid of about 3/4 cm which as it was established modified the whole bladder position
including tractioning the bladder neck and probably thus leading to intermittent obstruction.
She was a good candidate for surgery and following operation her urinary symptoms
fortunately subsided; as stated the cause for intermittent obstruction was bladder malposition
due to posterior and lateral traction and local adherence formation.

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Various transvaginal
Various transvaginal andand transabdominal
transabdominal ultrasound
ultrasound images
images of fibroid
of fibroid aspectsaspects of patients
of patients included
in the
included instudy
the study

Discussions

In accordance to [1] similar percentages for uterine and fibroid symptoms were also
registered in the general literature – 90% of patients with typical fibroid symptoms and 10%
registering only rapid growth; out of the 90%, 71% were bleeding related, 56% were pain
related and 35% were pressure related with also 35% urinary and 3% digestive tract afflictions
[1].
As in our study it was established according to [2] that large uterine fibroids can have a
negative impact on bladder function with symptoms rangin from diurnal frequency, urgency
and nocturia due to the direct pressure exerted by the enlarged uterus [2]. We would also state
the fact that not only voluminous fibroids but also a large extremely anteverted uterus and
also smaller but subserosal bladder blugind fibroids can exert the same irritative and pressure
effect.
There are also cases in literature associated with acute urinary tract retention due to large
fibroids despite the fact that it is considered a extremely rare with an incidence of 7 in 100.000
persons per year [3, 4]. As in our case the patient registered difficult bladder emptying with
need to void every 3 to 4 hours using a strong valsalva maneuver especially in standing position
with exertion of suprapubic pressure or digital cervix manipulation. She also experienced
an episode of acute urinary retention with remission upon bladder catheterisation and with
discovering a large 12 week retroverted uterus and a big posterior wall fibroid of about 5.7/4.3
cm which was compression the bladder anteriory toward the pelvic wall. The patient recovered
in full in regard to bladder function following hysterectomy. In anoter series of cases with
urinary obstruction the fibroid pushed the cervix in a superior and anterior position (aterior
cervical deflection) leading to obstrucion of the urethra in supine position [5, 6]. Our only
case of intermittent obstruction describes a highly retroverted an left deviated uterus due to a
4 cm fundal fibroma which probably associated bladder traction and adherences which were

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the cause for the obstructive mechanism instead of the literature mechanism which provides
forward pushing and compression of the badder.
Urinary symptoms appear to thoroughly correced by numerous types of treatment.
Surgical treatment – hysterectomy – is an option with complete urinary symptom remission
in the case in which the the urinary retention was due to the fibroid or uterus compression
and not other etiologies [5, 6]. Our small study reveals the same aspect, complete symptom
remission immediately after surgery. But not only surgery appears to be of help in this certain
case of obstruction; uterine fibroid embolization is known to produce immediate symptom
improvement leading to spontaneuous voiding afterwards [7]. The authors believe that uterine
artery embolization may be considered as a first line threrapy in these selected casez due to the
rapid response and the nonsurgical type of therapy [7].
According to [1] the urinary irritative symptoms such as urinary frequency and stress
incontinence and pelvic pressure also registered good remission, of about 82% (9 out of 11
patients) (95%; [48.22%, 97.71%]) after uterine artery embolization with varince between
73% and 89% [1, 11, 12, 13, 14]. Not only the bladder irritative symptoms have registered
remission due to embolization but also hydronephrosis cause by large fibroids reigsterd efficient
shirnkage with less compliciations than hysterectomy; the before mentione complications are
due to urinary tract lesions induced bu pelvic anatomy distorsion and narrowed operatory field
leading to an incidence of 0.33% of ureteral lesion durig hysterectomy [12]. Also a drop in
creatinine levels was detected with complete resolution of hydronephrosis in 7 out of 10 cases
and imporevement in 3 out of 10 cases [12, 13].
When conducting a comparison between hysterectomy and uterine artery embolization for
symptomatic uterine fibroids with urinary symptoms no differences in quality of life during a
10 year period have been noticed (patient satisfaction - 78% of the uterine artery embolization
group vs 87% in the hysterectomy group); in conclusion it was considered that most of the
hysterectomies for such pathology could be avoided (2/3)with transtion to embolization as it is
less invasive for well selected patients [8, 9]. Gnrh therapy are also helpful, leading to a drop
in uterine size of about 55% (from 728 ml to 323ml) many of the abovementioned symptoms
registerin alleviation - disappearance in diurnal frequency in11 out of 12 patiens – p<0.005,
decrease in nocturia in 8 out of 10 (p<0.02) and in urgency in 11 out of 13 (p<0.005). It is
important to know and carefully evaluate and follow up patients with gnrh treatment as in the
first period a flare up effect can occur as noted in the following case in whic h ra transient rapid
uterine enlargement was registred 7 days after gnrh therapy due to hyperestrogenism shorty
after gnrh administration. Gnrh therapy is though not meant tobe singular therapy but shoul
be associated with hystrectomy or myomectomy or even uterine artery embolization as after
medication cessation rapid uterine growth is otherwise registered [10].
There is though need to correctly evaluate the cause of urinary smptoms as urge urinary
incontinence and stress urinary incontinence as it appaears are not correlated with the uterien
volume – no alleviation of such symptoms nore in the the cystometric and urethral pressure
profile measurements after uterine volume shrinkage [2].

Conclusions

Large uterine fibroids can have a negative impact on bladder function with symptoms
ranging from diurnal frequency, urgency and nocturia due to the direct pressure exerted by
the enlarged uterus to acute urinary obstruction. Not only voluminous fibroids but also a
large extremely anteverted uterus and also smaller but subserosal bladder bluging fibroids
can exert the same irritative and pressure effect. Intermittent obstruction can appear either

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due to bladder traction due to extremely retroverted uteruses with fibroids and adherences but
also anterior and superior cervical deflection with bladder compression. Surgical, conservatory
and medical fibroid and uterus treatments are available and register parallel good bladder
symptoms alleviation with a tendency to perform the conservative treatemnt for selected cases
due to the fact that it is less invasive. Continous need should be exterd in order to exlcude the
confounding factors associated with bladder disfunction as treatment does not improve them.

References

1. Horhoianu Irina-Adriana. Doctoral thesis. 2012. Editura universitatii de Medicina si


Farmacie „Carol Davila” Bucuresti.
2. Rami Langer, Abraham Golan, Menachem Neuman, David Schneider, Ian Bukovsky,
Eliahu Caspi. The effect of large uterine fibroids on urinary bladder function and
symptoms. American Journal of Obstetrics and Gynecology. 1990. 163.4.1.1139-1141.
3. Dah-Ching Ding, Kwei-Shuai Hwang. Female acute urinary retention caused byanterior
deflection of the cervix which was augmented by an uterine myoma. Taiwan J Obstet
Gynecol. 2008.47.3.350-351.
4. Choong S, Emberton M. Acute urinary retention. BJU Int. 2000;85:186–201.
5. Yang JM, Huang WC. Sonographic findings of acute urinary retention secondary to an
impacted pelvic mass. J Ultrasound Med 2002;21:1165–9.
6. Barnacle S, Muir T. Intermittent urinary retention secondary to a uterine leiomyoma. Int
Urogynecol J Pelvic Floor Dysfunct 2007;18:339–41.
7. Ziv J. Haskal, Hector Armijo-Medina. Uterine Fibroid Embolization for Patients with Acute
Urinary Retention. Journal of Vascular and Interventional Radiology. 2008.19.10.1503-
1505.
8. De Bruijn AM, Ankum WM, Reekers JA, et al. Uterine artery embolization vs hysterectomy
in the treatment of symptomatic uterine fibroids: 10-year outcomes from the randomized
EMMY trial. Am J Obstet Gynecol 2016;volume:x.ex-x.ex.
9. J. Spies, D. Shveiky, C. Iglesia, J. Lee, M. Jones, J. Peterson, C.J. Huang. Abstract No.
168: The impact of uterine fibroid embolization (UFE) on lower urinary tract symptoms.
Journal of Vascular and Interventional Radiology. 2011. 22.3. supplement. S72-s73.
10. Friedman AJ. Acute urinary retention after gonadotropinreleasing hormone agonist
treatment for leiomyomata uteri. Fertil Steril 1993;59:677–8.
11. Juna F, Yamina L, Yushuna Z, Lijuanb W, Xingyea W, Haoa Q,Wenlib G. Effect of
selective uterinearteryembolization on symptomatic uterine fibroids. Journal of Medical
Colleges of PLA. 2009. 24. 6: 346-353.
12. Pron G, Bennett J, Common A, Wall J, Asch M, Sniderman K. The Ontario Uterine
Fibroid Embolization Trial. Part 2. Uterine fibroid reduction and symptom relief after
uterinearteryembolization for fibroids. Fertility and Sterility. 2003. 79. 1: 120-127.
13. Lupattellia T, Basileb A, Garacic FG, Simonettic G. Percutaneous uterinearteryembolization
for the treatment of symptomatic fibroids: current status. European Journal of Radiology.
2005. 54.1: 136-147.
14. Worthington-Kirsch RL, Siskin GP, Hegener P, Chesnick R. Comparison of the Efficacy
of the Embolic Agents Acrylamido Polyvinyl Alcohol Microspheres and Tris-Acryl
Gelatin Microspheres for Uterine Artery Embolization for Leiomyomas:A Prospective
Randomized Controlled Trial. Cardiovasc Intervent Radiol. 2011. 34. 3: 493-501.

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15. Mirsadree S, Tuite D, Nicholson A. Uterine artery embolization for ureteric obstruction
secondary to fibroids. Cvlr. 2008. 31. 6: 1094-1099.

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Lower Urinary Tract Disfunction and Oncologic


Pelvic Surgery

HORHOIANU Irina-Adriana¹, DUMITRACHE Mihai¹,


DRAGOI Vlad¹, CIRSTOIU Monica¹
1
“Carol Davila” University of Medicine Bucharest
E-mail: irinah7@gmail.com

Abstract

Radical pelvic procedures such as abdominal radical hysterectomy mostly with overimposed
pelvic irradiation for oncologic disease though being a lifesaving procedure can sometimes be
associated with quality of life alteration among which urinary tract dysfunction.
Herein we present 2 cases of abdominal radical hysterectomy for oncological disease with
associated pelvic radiation therapy and urinary symptoms such as initial anuria with further
nocturia, frequent micturitions and passive urine loss. After a thorough evaluation acute initial
urinary retention with further significant postvoidal residual volume presence were found in
association with urinary incontinence, detrusor disfunction and altered sphincter motility. The
before mentioned symptoms are most probably due to partial autonomic system denervation
during dissection and to the perivesical adhesions and bladder wall inflamation appeared
following surgery and radiation therapy in association with risk factors such as vaginal births,
low body mass index and a weakend pelvic floor due to denutrition. It is our belief that urinary
symptoms can persist indefinitely sometimes being mostly underevaluated and also hard to
quantify. Preexisting pelvic pathology can be a confounding factor, thus the need to thoroughly
evaluate the patient. Also special attention should be paid to assess the risk for future urinary
problems before and after surgery.

Keywords: hysterectomy, incontinence, detrusor, radiation, disease

Introduction

Radical pelvic procedures such as abdominal radical hysterectomy mostly with overimposed
pelvic irradiation for oncologic disease though being a lifesaving procedure can sometimes be
associated with quality of life alteration. Among such, the following examples can be named:
sexual dysfunction, diffuse lower body edema, urinary tract dysfunction, radiation pathology
etc. Herein we present a series of 2 cases of radical abdominal hysterectomy with and without
pelvic radiation therapy with postprocedural urinary tract alteration.

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Results

Case1 represents a 52 years old patient, with a history of 2 term vaginal births diagnosed
with a grade 2 endometrial adenocarcinoma and no known prior urinary afflictions. The
patient underwent radical hysterectomy and pelvic lymphadenectomy with successful pelvic
reintervention for postprocedural 12 hour bleeding. She then followed a 2 step internal and
external radiation therapy adding a total of 24 gray. Following surgery mild urge incontinence
appeared which did not subside in time but was associated according to the voiding diary with a
need to void every 2 hours per day with passive urine loss mostly immediately after micturition
at the change in position but also at night with the patient experiencing a constant sensation
of wetness and nocturia. This led to a constant usage of mattress covers and disposable pads
which among others resulted in a lower quality of life and constant irritation. The patient also
had numerous hospital visits for abdominal and pelvic pain, lower body edema, denutrition
(body mass index 17.5) and subocclusive states with establishment of pelvic radiation
induced disease especially ileal bowel disease with parietal thickening, stenosis and moderate
consecutive dilation. She was operated on twice for intestinal occlusion with peritonitis and
ileal pelvic blockade with severe perivisceral inflammation leading to a manual ileotransverse
shunting anastomosys. Though undergoing numerous anti-inflammatory treatments ranging
from nonsteroidal anti-inflammatory drugs to cortisone treatment the urinary and digestive
symptoms with the pelvic edema did not subside but were constant. Upon consultation the
pelvic examination did not show any vaginal prolapse and surprinsingly enough an almost
normal vaginal length without any evidence of visualisable urinary fistulas. According to her
7 days voiding diary the 24 hour total voiding volume was 2000 ml and the nocturnal urine
volume was 800 ml respectively also associated with an increased amount of water ingestion
due to a sensation of constant dehydration. Her urinalysis was negative for any pathological
aspects and no urinary tract infections were discovered on culture. The 24 hour pad test was
positive for urine and the insertion of an internal tampon for 12 hours with prior methylene
blue ingestion did not reveal any staining infirming the fistula suspicion. The ultrasound
aspects discovered a reduced maximal voiding volume of about 370 (5,5 cm x 2,1 cm x 6,3 cm
x 0,52) ml associated with a rather flattened and laterally tractioned bladder aspect probably
due to adherences and pelvic radiation disease. The calculated ultrasound post voiding residual
volume was 167 ml (3,2 cm x 1,8 cm x 5,58 cm x 0,52). Cistoscopy did not reveal any presence
of fistulas nor any other pathological outcome. The patient was directed to undergo urodynamic
analysis and further testing.

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Case 2

Represents a patient with no history of urinary disease nor any surgery except a cesarean
section at 29 years for dystocia which was at the age of 58 diagnosed with stage I cervical
carcinoma. Radical hysterectomy and pelvic lymphadenectomy was done, the patient suffering
in the immediate postoperative period from a paralytic ileus and acute urinary retention with
3 days urinary catheterization, parasympathomimetic (myostin) treatment, anti-inflammatory
treatment and 7 days selective alfa 1 adrenoreceptor blocker with slow remission afterwards.
The patient then experienced urinary incontinence with almost irritative micturition at less
than hourly intervals and passive urine loss independent of her position or effort resulting in
hydration fear in the hope of alleviating her symptoms. She also opted for mattress covers
and disposable daily pads during this period of time. Luckily the patient’s symptoms subsided
slowly in a 2 month period after surgery, without any other reoccurrence. The patient’s pelvic
examination did not reveal any suspicious elements, no prolapse was found, the vaginal cuff
was shortened due to surgery but nontender and without any fibrosis. The pelvic ultrasound
did not reveal any superimposing pathology, the prevoiding bladder volume was normal, the
residual postmicturition volume slowly subsided from 150 to under 30 ml and no free fluid was
observed intraperitoneally.

Discussions

Urinary tract dysfunctions after surgery with or without any overimposed radiotherapy can
have a negative impact on the patient’s quality of life being thus an important concern.
A thorough literature search has been done in order to correctly assess the real burden that
impacts this problem.
We have concluded that there are two types of urinary pathology in accordance to the
time of appearance after surgery and their acute status. At first, immediately after surgery,
acute urinary retention such as in the case our second patient, residual volume or haematuria
due to bladder lesions can occur. According to [1] complete urinary retention occurs in
13.7% of patients and postmicturition residual volume in 7.3% respectively, for a policy of
immediate catheter removal after surgery with predisposition for the ones undergoing vaginal
hysterectomy [1].
Following the immediate postoperative period a second type of urinary tract dysfunctions
can appear mostly represented by stress urinary incontinence but also voiding dysfunction
mostly prolonged from the immediate postoperative period, storage dysfunction, haematuria
and passive urine loss most probably suggesting urinary fistula formation, such as in both our
cases.
It is our belief that urinary symptoms are mostly underevaluated and also hard to quantify.
This is due to the fact that the success of the (oncologic) surgery mostly shadows any
other overimposing symptoms. According to [2], 78% of the patients included in the study
who turned out to have urinary symptoms did not consider them to be a problem [2]. Also,
especially stress urinary incontinence is hard to fully quantify as symptoms can occur at several
years free interval from surgery according to [3].
Despite common knowledge there is conflicting data in the general literature in regards to
post surgical urinary pathology, especially stress urinary incontinence, some being in favor
some against its correlation with surgery arguing the fact that a preexisting overimposed pelvic

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floor pathology could be the real cause [3, 4, 5, 6]. An example of lack of correlation is the twin
study in which after the concurrent pelvic floor defect surgeries were excluded from analysis, no
relationship between stress urinary incontinence and hysterectomy was found [6]. Many other
literature studies promote a strong correlation between surgery and pelvic urinary disorders
such as [3, 7]. According to [7], notable differences in the irritative and obstructive scores of
the urogenital distress inventory – (UDI6) were found between the hysterectomy group (type
III radical hysterectomy, type I simple hysterectomy) and the control group which had no
surgical intervention. Differences were also found among hysterectomy type (radical versus
simple or supracervical hysterectomy) and route (vaginal versus transabdominal hysterectomy)
in regards to urinary symptoms. Most of the studies advocate for a greater impairement in
regards to radical hysterectomy versus extrafascial abdominal hystrectomy while some find no
differece between the 2 in regards to mild (50% of subjects, 42% of controls) or moderate to
severe incontinence symptoms (34% subjects, 35%controls) – p=0.72 [3, 8].
According to [7] signficant differences were found as to the irritative and obstructive score
(UDI-6), with the radical hysterectomy group having the most severe effect in comparison
to the one for benign pathology especially in regards to urgency and obstructive symptoms,
leading also to alteration in quality of life scores (QoL) and sexual life scores (PISQ-12)
[7]. Urinary tract disfunctions have thus been found to be a common impairment following
radical hysterectomy, registering a wide variance from 8% to 80% according to [9] (medical
search conducetd between the years 1952-2012 for urinary tract disfunctions) and an overall
incidence of about 72% [9]. The high variance is thought to probably be due to different
bladder function evaluation methods [9].
Significant alterations in bladder function and control have been found in the post radical
hysterectomy patients such as: high incidence of an overactie detrusor function with low
compliance (34%), decrease in the maximal urethral closure pressure leading to alteration in
bladder capacity and compliance, impaired bladder sensation and decrease in closure pressure
transmission ratio [9, 10]. Thus, most of patients are voiding by abdominal straining after
radical hysterectomy mostly due to partial sympathetic and parasympathetic denervation
during dissection [10]. This partial interruption of the autonomic fibers, innervating the bladder
and proximal part of the vagina, occurs during the anterior, lateral and posterior parametrial
and vaginal cuff resection [11]. It is thought that the surgical damage leads to decentralisation
rather than complete denervation leading to either an unmasking of intrinsic detrusor
activity characterised by loss of betaadrenergic innervation and consequent alfa adrenergic
hyperinervation either a dominance of the remaining sympathetic innervation [11]. Translated
from an anatomic point of view one can conclude according to [11] that a shortened vaginal
lenght is omnious for patients with detrusor disfunction (storage and voidig disfunctions) - the
size of the lateral parametria did not differ among groups of urodynamic diagnosys but the
lengh of vagina varied being shorter for patients with detrusor disfunction than for these with
a normal diagnosis or genuine stress incontinence [11]. Also other anatomical contributing
factors are worth being mentioned such as perivesical adhesions and bladder wall inflamation
due to surgery and radiation therapy [12]. Judging the anatomy in accordance to our patients
we have found that cervical length plays an important role as both our symptomatic patients
experienced a reduction, the first one having also the great disadvantage of perivisceral
adhesions and diffuse inflammatory response due to the 3 reinterventions and pelvic irradiation
with following radiation disease. In accordance to the before mentioned facts, radical
hysterectomy leads to a significant decrease in detrusor instability (preop 37.5% vs. postop
15.6%, P<0.0050) while stress incontinence does not alter significantly as much (preop 9.4%

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vs postop 18.8%, P>0.005) according to [10]. According to [11] stress urinary incontinence
appeared more frequent in 53% of cases (55.1% according to [12]) while difficulty in urination
was more frequent – 69.4% – according to [12] (storage disfunctions in 47% and voiding
disfunctions in 3%); frequent urinary tract infections (30.6%) and urinary frequency and
urgency (30.6%) were also noted.
Radiation therapy appears to have a negative effect on the global bladder function in
accordance with the following urodynamic and ultrasound alterations leading to a hypertonic
bladder with reduced compliance, detrusor disfunction and internal sphincter alteration [12,
13, 14]. When comparing the cystometric capacity, according to [12] the radical hysterectomy
group registered larger volumes than the associated radiotherapy grup (331+/-139ml vs. 38+/-
111 ml; p=0.024). Our first patient has a reduced bladder volume of 370ml, in accordance to
the rest of patients that underwent radical hysterectomy but luckly not as low as in the radiation
therapy group despite of pelvic radiation disease presence leading to the conclusion that there
is a grade of detrusor alteration. The postvoidal residual volume appeared present in 42.9%-
50% of cases (>100ml) having equal incidence among groups and a long duration of time
(positive at 5-15 years post surgery) [12, 13]. Our first patient has also a significant amount of
residual volume, 167 ml. There was greater incidence of low or poorly compliant bladder in
the plus radiotherapy group (< 10 mL/cmH2O; 43.8% - 15.2%) but with equivalent bladder
disfunction (detrusor underactivity of about 85.7%, detrusor overactivity in 10.2% and normal
detrusor function in 4.1%) [12]. Urethral disfunctions were equally frequent among groups
registering internal sphyncter disfunction, non relaxing urethral sphyncter and only 14.3%
of cases with normal urethral function [12]. The urethral disfunctions apear to be a cause
of partial loss of alpha adrenergic tone in the proximal urethra, weakend pelvic floor with
deficit in bladder neck support and complete autonomic denervation with worse outcomes for
radiation therapy patients [12, 15].
According to [2, 3] there is an association with postoperative urinary incontinence and
certain risk factor such as body mass index, at least one delivery, pulmonary disease, menopausal
status and preoperative urinary incontinence [2,16]. The predictive variables according to [2]
for urinary retention were considered to be the following: cystitis, age, dysuria, previous anal
sphincter rupture, large for gestational weight neonates and preoperative urinary retention
symptoms [2]. Thus, the need to pay special attention and assess the risk for future urinary
problems in the pre and postoperaory period. Our first patient has 2 of the risk factor mentioned
above - 2 vagial births of term neonates, low body mass index but also a weakend pelvic floor
due to denutrition and persistent inflammatory reactions with perivesical adhesions.
Timing is also considered a major factor responsible for the wide range of bladder
disfuntion incidence [9]. Accordind to the literature the resume in normal micturition cand
appear according to [12] in 92% of radical hysterectomy patients in about 1 year or may persist
indefinitely according to other studies in 20-50% of cases [12, 17, 18]; our second patient
registered a 2 months interval to complete bladder recovery but the first one who experienced
radiotherapy needs speciality treatment as her symptoms persist for over 2 years.

Conclusions

Urinary tract dysfunctions after surgery with or without any overimposed radiotherapy can
have a negative impact on the patient’s quality of life being thus an important concern.
We have concluded that there are two types of urinary pathology in accordance to the time
of appearance after surgery and their acute status. At first, immediately after surgery, acute

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urinary retention, residual volume or haematuria due to bladder lesions can occur. Following
the immediate postoperative period a second type of urinary tract dysfunctions can find its
way mostly represented by stress urinary incontinence but also voiding dysfunction mostly
prolonged from the immediate postoperative period, storage dysfunction, haematuria and
passive urine loss most probably suggesting urinary fistula formation. The above presented
urinary symptoms are most probably due to partial autonomic system denervation during
dissection and to the perivesical adhesions and bladder wall inflamation appeared following
surgery and radiation therapy in association with risk factors such as vaginal births, low body
mass index and a weakend pelvic floor due to denutrition. It is our belief that urinary symptoms
can persist indefinitely sometimes being mostly underevaluated and also hard to quantify.
Preexisting pelvic pathology can be a confounding factor, thus the need to thoroughly
evaluate the patient before and after surgery. Also special attention should be paid to assess
the risk for future urinary problems before and after surgery.

REFERENCES

1. F Ghezzi, A Cromi, S Uccella, G Colombo, S Salvatore, S Tomera, P Bolis. (2007).


Immediate Foley removal after laparoscopic and vaginal hysterectomy: Determinants
of postoperative urinary retention. Journal of Minimally Invasive Gynecology.14(6).
pp.706-711.
2. S.M. Axelsen, L.K. Petersen. (2006). Urogynaecological dysfunction after radical
hysterectomy. European Journal of Surgical Oncology (EJSO). 32(4). pp. 445-449.
3. CH Hsieh, WC Chang, TY Lin, TH Su, YT Li, TC Kuo, MC Lee, MS Lee, ST Chang.
(2011). Long-term effect of hysterectomy on urinary incontinence in Taiwan. Taiwanese
Journal of Obstetrics and Gynecology. 50 (3). pp. 326-330.
4. D Altman, F Granath, S Cnattingius, C Falconer. (2007). Hysterectomy and risk of stress-
urinary-incontinence surgery: nationwide cohort study. The Lancet. 370 (9597). pp. 1494-
1499.
5. Catharina Gustafsson, Åsa Ekström, Sophia Brismar, Daniel Altman. Urinary incontinence
after hysterectomy-three-year observational study. Rology. 2006.68.4.769-774.
6. Jay-James R. Miller, Sylvia M. Botros, Jennifer L. Beaumont, Sarit O. Aschkenazi,
Tondalaya Gamble, Peter K. Sand, Roger P. Goldberg. Impact of hysterectomy on stress
urinary incontinence: an identical twin study. AJOG. 2008. 198.5.565 e1-e4.
7. Selcuk Selcuk, Cetin Cam, Mehmet Resit Asoglu, Mehmet Kucukbas, Arzu Arinkan,
Muzaffer Seyhan Cikman, Ates Karateke. Effect of simple and radical hysterectomy on
quality of life – analysis of all aspects of pelvic floor dysfunction. European Journal of
Obstetrics & Gynecology and Reproductive Biology.
8. Rebecca A. Brooks, Jason D. Wright, Matthew A. Powell, Janet S. Rader, Feng Gao,
David G. Mutch,L. Lewis Wall. Long-term assessment of bladder and bowel dysfunction
after radical hysterectomy. Gynecologic Oncology. 2009. 114.1.75:79.
9. Francesco Plotti, Roberto Angioli,Marzio Angelo Zullo, Milena Sansone, Tiziana
Altavilla, Elena Antonelli, Roberto Montera, Patrizio Damiani, Pierluigi Benedetti Panici.
Update on urodynamic bladder dysfunctions after radical hysterectomy for cervical
cancer. Critical Reviews in Oncology/Hematology. 2011. 80.2. 323-329.
10. Gin-Den Chen, Long-Yan Lin, Po-Hui Wang, Hong-Shen Lee. Urinary tract dysfunction
after radical hysterectomy for cervical cancer. Gynecologic Oncology. 2002.85.2.292:297.
11. Marzio Angelo Zullo, Natalina Manci, Roberto Angioli, Ludovico Muzii, Pierluigi

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Benedetti Panici. Vesical dysfunctions after radical hysterectomy for cervical cancer: a
critical review. Critical Reviews in Oncology/Hematology.2003. 48.3. 287-293.
12. Fei-Chi Chuang, Hann-Chorng Kuo2. Management of Lower Urinary Tract Dysfunction
After Radical Hysterectomy With or Without Radiotherapy for Uterine Cervical Cancer.
J Formos. Med. Asoc. 2009. 108.8. 619-626.
13. Fraser AC. The late effects of Wertheim’s hysterectomy on the urinary tract. J Obstet
Gynaecol Br Commonw 1966;73:1002–7.
14. Hazewinkel MH, Sprangers MA, Van der Velden J, Van der Vaart CH, Burger MP,
Roovers JP. Long-term cervical cancer survivors suffer from pelvic floor symptoms: a
cross-sectional matched cohort study. GynecoOncol.2010.117(2). 281-286.
15. Diana-Elena Comandasu, Elvira Bratila, Monica Carstoiu, O. Munteanu Titlul lucrarii:
Automonic innervation of the pelvis, Romania Journal of Functional and Clinical, Macro-
and Microscopical Anatomy and of Anthropology, Vol. XIV, Year 2, Nr. 2, 2015, ISSN
1583 – 4026, revista indexata BDI.
16. Planșeul pelvic la femeie. Anatomia funcțională, diagnostic și tratament-în acord cu teoria
integrative, Autori: Klauss Goeshen, Peter Petros, Andrei Funogea, Elvira Brătilă, Petre
Brătilă, Monica Cîrstoiu, Editura Universitara «Carol Davila Bucuresti», Bucuresti, 2016,
ISBN 978-973- 708-894-9.
17. Woodside JR, McGuire EJ. Detrusor hypertonicity as a late complication of a Wertheim
hysterectomy. J Urol. 198.;127. 1143–5.
18. Smith PH, Turnbull GA, Currie DW, et al. The urological complications of Wertheim’s
hysterectomy. Br J Urol 1969. 41. 685–8.

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Challenges of the surgical resection in pelvic masses


involving uro-genital organs in women – our
experience

DAVITOIU Dragos1, DIMA Ana Laura2, BALEANU Vlad3,


MANDA Ana Laura4
1
1st Surgery Clinic Emergency University Hospital Bucharest (Romania)
2
1st Surgery Clinic Emergency University Hospital Bucharest (Romania)
1 Surgery Clinic Emergency University Hospital Bucharest (Romania)
3 st

1 Surgery Clinic Emergency University Hospital Bucharest (Romania)


4 st

E-mails: davitoiudragos@yahoo.com, analauramanda@yahoo.com

Abstract

Involvement of the urinary and genital tract in cases of pelvic masses is not an uncommon
event. In women particularly most of the pelvic masses that grow to a certain dimension have
the tendency to invade or compress the rest of the pelvic organs, as the total volume of the
pelvis is not expandable.
We conducted a retrospective study of the surgical cases of pelvic tumours in women that
have been operated on the last two and a half years in our service and that have genital or
urinary involvement that needed a certain extra procedure to be performed in order to remove
the tumour or some other kind of palliative surgery and tried to establish if there are rules to
be drawn in this surgery.
Of the 40 patients that met the criteria to be included, 15 were diagnosed with a tumour of
digestive origin, 19 were diagnosed with a tumour of genital origin and 6 had a pelvic mass of
different origin.
Surgery consisted mainly of composite organ resections, as most of the cases were stage
IV malignancies.
The conclusions from the study were: in pelvic masses of different origins, mainly stage IV
rectal or genital malignant tumours, a composite resection can be performed in most cases with
good functional results; there is no standard surgery in such cases, the only rule is to resect as
much as possible.

Keywords: pelvic mass, ureter compression, composite resection

Introduction

Involvement of the urinary and genital tract in cases of pelvic masses is not an uncommon
event. In women particularly most of the pelvic masses that grow to a certain dimension have
the tendency to invade or compress the rest of the pelvic organs, as the total volume of the

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pelvis is not expandable [1].
The anatomic situation of the ureters posterior in the retroperitoneum makes them the least
probable to be involved in a growing pelvic mass, but as the tumour passes a certain volume at
first compression takes place and then invasion, especially in cases of malignancies.
The urinary bladder is mostly compressed or invaded by a tumour of the uterus or ovary,
as it lies immediately posterior to the feminine genital organs and is in intimate contact to
the cervix and vagina through the vesicovaginal fascia [1], [2], [3]. It is also possible for the
urinary bladder to be invaded by a rectal or rectosigmoidian tumour that grows to the anterior
pelvic space, although this is the case in large tumours that first invades and grow pass the
genital organs.
The uterus and vagina are mostly involved in tumours with rectal or rectosigmoidal origin,
as they are in close contact with those organs in the pelvis. The uterus might be also involved
in cases of ovarian tumours, malignant or not.
The surgical difficulties posed by a large tumour that had invaded or had compressed
urinary and/or genital organs in the pelvis are a challenge for the surgeon, especially in general
and oncologic surgery where such cases are mostly encountered.
We studied those cases in the last two and a half years in our service and tried to establish
by this study if there are any rules that can be applied to those cases.

Clinical study

Methodology

We conducted a retrospective study of the surgical cases of pelvic tumours in women that
have been operated on the last two and a half years in our service and that have genital or
urinary involvement that needed a certain extra procedure to be performed in order to remove
the tumour or some other kind of palliative surgery.
Inclusion criteria were:
- Pelvic tumour;
- Involvement of the urinary and/or genital organs;
- Surgery performed with extra procedure for local condition needed.

Results

From a total of 255 patients admitted into our clinic that had a diagnostic of pelvic mass 40
met the criteria listed above. From those 15 were diagnosed with a tumour of digestive origin,
19 were diagnosed with a tumour of genital origin and 6 had a pelvic mass of different origin.
We included malignancies as well as benign tumours, as benign tumours presented as well
with compression of the urinary organs that needed an extra procedure for the removal of the
pelvic mass.
In the case of the digestive tumours, most of them were of rectal origin, namely 10. They
were all malignancies staged as T4 tumours as it invaded other organs. Uterus was mostly
involved, but also urinary bladder, ovary – especially left ovary, and the left ureter. There were
4 cases of rectosigmoid tumours and one case of gastrointestinal stromal tumour located on
the sigmoid colon. The urinary and genital organs involved in those were the same as for the
rectal localization.

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The pelvic masses with genital tract origin were mostly of ovarian origin, as there were 14
such cases. From those 14 cases of ovarian tumours 8 were malignancies, staged as T4 and
stage IV, as they presented with peritoneal carcinomatosis, 4 were benign tumours that had
large volume and all of them proved to be mature teratoma of the ovary, and 2 cases presented
as ovarian mass proved to be of metastatic origin from the stomach and the transverse colon
(Krukenberg tumours). In most cases of ovarian malignancies the urinary bladder was involved
by the pelvic metastases that made up a pelvic mass involving the uterus and the ovaries (Fig.
1). In the case of benign tumours the ureter was involved by compression from the large
pelvic mass. Other tumours of genital origin that presented as a pelvic mass with urinary and
digestive involvement were 3 large uterus leiomyoma that compressed the urinary bladder and
ureters in the pelvis, and also 1 case of cervical cancer stage IV that had a large pelvic mass
that involved all the pelvic organs and 1 case of cancer of fallopian tube cancer that invaded
the urinary bladder and the sigmoid.

Figure 1. CT scan of the pelvis showing a large ovarian tumour that invades the uterus and
the bladder

The other group of 6 cases that presented as a pelvic mass was made up of two sigmoid
perforated diverticulitis, one with a sigmoid-vaginal fistula and abscess, the other with pelvic
abscess, both of them with compression of the left ureter; 2 cases of retroperitoneal mass
that compressed and invaded respectively the ureter, one of those being a retroperitoneal
large lipoma of the right retroperitoneal space and the other being a retroperitoneal sarcoma
that invaded the ileum and left ureter; in 1 case there was a left fallopian tube abscess that
compressed the left ureter and in 1 case a neurinoma located to the pelvis immediately right to
the uterus, that compressed and dislocated both ureters (Fig. 2, Fig. 3, Fig. 4).

Figure 2. CT scan of the pelvis showing a large tumour that occupies the whole pelvic cavity
(neurinoma), and compression of the ureters and the urinary bladder

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Figure 3. CT scan of the abdomen showing compression of the ureters and hydronephrosis
secondary to a pelvic neurinoma (same case)

Figure 4. CT scan of the abdomen and pelvis showing the pelvic tumour

In regard to surgery, in most cases of digestive tumours a type of resection was performed
after biopsy and radiation therapy, and the resection was in most cases a rectosigmoidectomy
with low colo-recto-anastomosis. In 5 cases amputation of the rectum was necessary as the
tumour was of low rectal origin. In all cases the left ureter was dissected from the mass and in
4 cases a partial resection of the urinary bladder was necessary. There were 7 cases in which
total hysterectomy was performed due to invasion of the uterus or vagina. There were also 4
cases in which no resection could be performed and the surgery was limited to a colostomy
and dissection of the ureter that appeared to be largely invaded, thus limiting the surgery to
palliation. Later those were remitted to the urology service for ureter stenting and to oncology
service for treatment.
In the case of ovarian malignancies as they were all were diagnosed as stage IV disease the
surgery performed was mostly debulking surgery that involved dissection of the ureter and the
urinary bladder from the peritoneal masses that compressed it and in 3 cases partial resection
of the urinary bladder. All cases of ovarian cancer were remitted to the oncology department
for treatment and most of them proceeded to second-look surgery after oncologic treatment
when the remaining peritoneal and pelvic masses were removed (Fig. 5 and Fig. 6).

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Figure 5. Intraoperative image of an ovarian tumour that invaded the uterus and the urinary
bladder

Figure 5. Intraoperative image of a second look surgery for an ovarian tumour; the right
ureter dissected from the posterior peritoneum

In the cases of ovarian teratoma and the large uterine leiomyoma the pelvic mass was
removed entirely and the ureter was dissected from the tumours that made compression on
it. In one case the bladder needed to be partially resected due to the intimate contact with the
pelvic mass.
The fallopian tube cancer required complex surgery that involved total hysterectomy,
partial resection of the bladder, sigmoidectomy and colostomy, later being referred to the
oncology department.
In the other cases of pelvic masses of miscellaneous origins, the surgical procedures were
adapted to each particular case. Thus, in the case of the pelvic abscesses of sigmoid diverticulitis
origin surgery consisted of drainage of the abscess that compressed the retroperitoneum as
well as resection of the sigmoid colon with colostomy; in the case of the sigmoid-vaginal
fistula as the patient had already had a hysterectomy, the vagina was just sutured. In both
cases the abscess had dissected to the retroperitoneum and the left ureter was as well cleared
from the abscess. The same procedure was performed as well in the case of the fallopian
abscess; in addition left anexectomy was performed. In the case of the retroperitoneal tumours,
the benign lipoma required dissection of the retroperitoneal space and dissection of the right
ureter from the tumour, as well as an incision on the anterior thigh for the lipoma had an
extension to the Scarpa triangle; in the case of the retroperitoneal sarcoma resection of the
tumour was impossible, and a digestive derivation was performed, later the patient was sent to
urology and oncology departments respectively. For the neurinoma located next to the uterus
besides resection of the tumour, total hysterectomy was performed due to the local anatomical

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conditions and also due to the fact that there were also cystic lesions of both ovaries that
proved to be benign tumours; both ureters were dissected and freed of tumour as well.

Discussions

As it was shown from the study we performed, there were no certain surgical procedures
that could be predicted for sure preoperatively in such cases of pelvic masses with urinary and
genital involvement.
In most of these cases included in the study, namely 28 of the 40 cases, the pelvic mass was
a cancer staged as T4, most of them even stage IV. The surgical conduct in such cases is based
on the principle of palliation that means a less oncologic approach to surgery and just solving
the case as best as it can be done [2], [4], [5], [6], [7].
Discussion concerning the opportunity of extensive surgery in such cases is old, since the
first pelvic exenteration was performed more than 50 years ago. The risks associated to such
surgery exist, but most studies nowadays indicate that the benefit of composite resection exists
and it improves free-disease survival as well as quality of life. That is the case proven by a
meta-analysis even in ovarian cancer [2], [5], [6], [7], [8] [9], [10], [11].
The difficulty of the surgical procedures performed in order to achieve a composite
resection of a pelvic mass may be justified by the clinical results, especially the quality of life
that is the purpose of palliative surgery [5], [6], [7], [10], [11]. In the cases that we encountered
in our study we could not define a certain standard procedure that can be applied in such cases.

Conclusions

In pelvic masses of different origins, mainly stage IV rectal or genital malignant tumours,
a composite resection can be performed in most cases with good functional results. There is no
standard surgery in such cases, the only rule is to resect as much as possible.

REFERENCES

1. Standring, S., Borley, N.R., Collins, P., Crossman, A. R., Gatzoulis, M. A., Healy, J. C.,
Johnson, D., Mahadevan, V., Newell, R. L. M., Wigley, C. (2008). Gray’s Anatomy 40th
Edition, Elsevier Ltd, pp. 1041-1055, 1083-1092, 1073-1162, 1245-1254, 1279-1304.
2. Townsend, C. M., Beuachamp, R. D., Evers, B. M., Mattox, K. L. (2012) Sabiston
Textbook Of Surgery: The Biological Basis Of Surgical Practice, 19th Edition, Elsevier
Inc, pp. 1338-1362, 2003-2023.
3. Bratila, E., Bratila, C.P., Coroleuca, C.B., Coroleuca, C.A. (2015) Collateral circulation in
the female pelvis and the extrauterine anastomosis system. Romania Journal of Functional
and Clinical, Macro- and Microscopical Anatomy and of Anthropology, Vol. 14, Year 2,
Nr. 2, 2015, ISSN 1583 – 4026.
4. Kawamura, J., Tani, M., Sumida, K. et al. The use of transureteroureterostomy during
ureteral reconstruction for advanced primary or recurrent pelvic malignancy in the era of
multimodal therapy, Int J Colorectal Dis (2016). doi:10.1007/s00384-016-2672-9.
5. Bristow, R. E., Tomacruz, R. S., Armstrong, D. K., Trimble, E.L., Montz, F. J. Survival
Effect of Maximal Cytoreductive Surgery for Advanced Ovarian Carcinoma During the
Platinum Era: A Meta-Analysis (2002). Journal of Clinical Oncology 2002 March 01 vol

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20 (5), pp: 1248-1259, doi: 10.1200/JCO.20.5.1248.
6. Temple, W. J. and Saettler, E. B. (2000), Locally recurrent rectal cancer: Role of composite
resection of extensive pelvic tumors with strategies for minimizing risk of recurrence. J.
Surg. Oncol., vol. 73, pp: 47–58. doi:10.1002/(SICI)1096-9098(200001)73:1<47: AID-
JSO12>3.0.CO;2-M.
7. Penalver, M.A., Barreau, G., Sevin, B.U., Averette, H.E. (1996). Surgery for the treatment
of locally recurrent disease. J Natl Cancer Inst Monogr. 1996; (21), pp:117-122 (ISSN:
1052-6773).
8. Strauss, D. C., Hayes, A. J., Thomas J. M. (2011) Retroperitoneal tumours: review of
management. The Annals of The Royal College of Surgeons of England 2011 93:4, pp:
275-280.
9. Woodfield, J. C., Chalmers, A. G., Phillips, N. and Sagar, P. M. (2008), Algorithms for
the surgical management of retrorectal tumours. Br J Surg, 95. pp: 214–221. doi:10.1002/
bjs.5931.
10. Koda, K., Shuto, K., Matsuo, K., Kosugi, C., Mori, M., Hirano, A., Hiroshima, Y., Tanaka,
K. (2016) Layer-oriented total pelvic exenteration for locally advanced primary colorectal
cancer. Int J Colorectal Dis. 2016; 31(1), pp:59-66 (ISSN: 1432-1262).
11. Pathiraja, P., Sandhu, H., Instone, M., Haldar, K., Kehoe, S. (2014) Should pelvic
exenteration for symptomatic relief in gynaecology malignancies be offered? Arch
Gynecol Obstet. 2014; 289(3), pp:657-662 (ISSN: 1432-0711).

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Corrective Procedures for Apical Defects Associated


with 2nd and 3rd Degree Anterior Vaginal Wall
Prolapse

MANTA Anca1, BRATILA Petre Corrnel1, COMANDASU Diana2,


BERCEANU Costin3, MEHEDINTU Claudia4,
CIRSTOIU Monica5, BOHILTEA Roxana5,
CONSTANTIN Vlad Denis6, BRATILA Elvira2
1
Euroclinic Minimally Invasive Hospital, Bucharest, Gynecology Department (ROMANIA)
2
UMF “Carol Davila” Bucharest, Obstetrics-Gynecology Department, “Sf. Pantelimon” Clinical
Emergency Hospital, Bucharest (ROMANIA)
3
UMF Craiova, Obstetrics-Gynecology Department, County Emergency Hospital Craiova(ROMANIA)
4
UMF “Carol Davila” Bucharest, Obstetrics-Gynecology Department, “Nicolae Malaxa” Clinical
Hospital (ROMANIA)
5
UMF “Carol Davila” Bucharest, Obstetrics-Gynecology Department, University Emergency Hospital
of Bucharest (ROMANIA)
6
UMF “Carol Davila” Bucharest, General Surgery Department, “Sf. Pantelimon” Clinical Emergency
Hospital, Bucharest (ROMANIA)
E-mails: anca_manta81@yahoo.com, pbratila49@yahoo.com, diana.comandasu@yahoo.com, dr_
berceanu@yahoo.com, claudiamehedintu@yahoo.com, dr_monicacirstoiu@yahoo.com, r.bohiltea@
yahoo.com, constantindenis@yahoo.com, elvirabarbulea@gmail.com

Abstract

Introduction
The pelvic organ prolapse represents one of the most frequent gynecological disorders,
with a prevalence of over 50%, and a relapse rate of over 30%.

Purpose
The analysis of the use of different types of surgical procedures in apical prolapse associated
with anterior vaginal wall prolapse.

Material and method


The multicenter retrospective study was carried out during the period 2011-2016, on a
number of 387 cases. The cases analyzed were diagnosed with apical prolapse associated with
anterior vaginal wall prolapse of 2nd and 3rd degree, who underwent a colposacrosuspension,
sacrospinous ligament suspension or techniques for the restoration of the pericervical ring.

Results
Out of the 387 cases analyzed in 5 years, the diagnostic in 90,43% of the cases was of
cystocele (350 cases), 60% (210 cases) of them being of 2nd – 3rd degree. The apical defect
associated to 2nd – 3rd degree cystocele was recorded in all 210 cases. The colposacrosuspension
was performed on 73 cases, that represented 34,76%, the sacrospinous ligament suspension

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in 21 cases (10%) as a technique for restoration of the pericervical ring, and in 116 cases
(55,28%) we used a 4-arms polypropylene mesh with transobturator passage accompanied by
McCall procedure.

Debates
The apical defects are often associated with anterior vaginal wall prolapse, combined
techniques being necessary for the correction of both anatomic defects. Although the most used
techniques are the colposacrosuspension and the sacrospinous ligaments colposuspension, we
have considered another procedure for the restoration of the pericervical ring. Each method
has its advantages and disadvantages; at present, there is no consensus with regards to the
surgical treatment of these defects.

Conclusions
The concomitant correction of both anatomic defects decreases the relapse rate as compared
to the surgical treatment of the monocompartmental defect.

Keywords։ apical defect, anterior prolapse, corrective procedures

Introduction

The pelvic organ prolapse represents one of the most frequent disorders in the gynecological
practice, with a prevalence of over 50%, and a relapse rate of over 30%. It represents a disorder
that affects the quality of living, specifying the fact that the risk of a woman to undergo a
surgical intervention for prolapse repairing over her lifetime is of 11.9%, most of the times the
diagnostic of prolapse being random and discovered on a routine examination or for another
symptomatology. [1], [2], [3]
The pelvic organ prolapse is defined by the modification of the normal anatomic condition,
consisting in the descent of one or several topographic segments – the anterior vaginal wall, the
posterior vaginal wall, the apex or the vaginal vault (according to the International Continence
Society).
A series of risk factors were described for the occurrence of the genital prolapse, such as
age, obesity, the number of vaginal deliveries, hysterectomy in antecedents, etc. [2]
In anterior-posterior sense, the pelvis is divided into three compartments – anterior,
comprising the bladder and the urethra, median, comprising the vagina and the uterus and
posterior, including the rectal wall. In practice, there are different disorder combinations in
these compartments, including the anterior, the posterior compartment or the apical segment.
[3]
From a classification point of view, our study comprises the 2nd degree prolapse cases,
when the most distal point of the prolapse is less than 1 cm or distal from the hymeneal ring
plan and the 3rd degree prolapse, when the most distal point of the prolapse is more than 1 cm
below the level of the hymeneal ring but does not come out by more than 2 cm. [1]
The existence of disorders in several compartments needs correction procedures addressed
to all those compartments. The relapse rate remains, nevertheless, very high, its causes being
yet controversial. [4]

Purpose

The analysis of the use of different types of surgical procedures in the case of apical

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prolapse associated with anterior vaginal wall prolapse.

Material and method

The multicenter retrospective study was carried out during the period 2011-2016, on
a number of 387 cases. The diagnostic evaluation was performed by the use of the Petros
questionnaire and by local clinical examinations. A primary effect was diagnosed in 68%
of the cases, and 32% were represented by cases of relapsed prolapse. Most of the patients
come from the urban environment (59%), the majority of them (66%) being post-menopause
patients. Out of the 387 cases, in 350 (90,43%) of the cases, the diagnosis was of cystocele. In
60% of the cases, the cystocele was associated to disorders in other compartments. The 2nd and
3rd degree cystocele was diagnosed in 210 cases (60%). As a physiopathological mechanism,
the sliding cystocele was diagnosed in 61 cases (29,04%), the pulsion cystocele in 124 cases
(59,04%), and the cystocele produced by both mechanisms in 25 cases (11,9%). The 2nd
and 3rd degree cystocele associated to the apical defect was diagnosed in all 210 cases. The
interventions performed consisted in colposacrosuspension in 73 cases (34,76%), in 116 cases
(55,28%) we used a 4-arms polypropylene mesh with transobturator passage accompanied
by McCall procedure and restoration of the pericervical ring respectively, by using the 4-arm
polypropylene mesh, 2 transobturator and 2 fixed on the sacrospinous ligaments in 21 cases
(10%).

Results

The study was carried out on 387 cases of genital prolapse treated surgically during a
period of 5 years. Of the total of 210 cases analyzed, we registered 4 cases of postoperative
complications following colopsacrosuspension. In one case it was represented by the
detachement of the mesh from the sacrum bone’s surface, while in the other 3 cases the
prolapsed relapsed, in one patient being a vaginal vault prolapse and in 2 patients anterior
compartment prolapse. After the insertion of the 4 arms mesh with transobturator passage
and McCall procedure, there were no relapsing prolapse cases, the follow-up period after this
intervention being of 5 years, as the study interval, while after the cervical ring restoration
using a 4 arms polyproliplene mesh, with 2 arms passed transobturator and 2 arms fixed at
the sacrospinous ligaments there were also no complications or relapses recorded, but with a
follow-up up interval of 2 years.

Debates

Although the anterior vaginal wall prolapse (cystocele or colpocele) represents the most
common type of prolapse, it is frequently associated with apical defects. [5] The mechanism
of the production of this association is the sliding of the anterior vaginal wall with the vaginal
apex because of a support disorder. Thus, the surgical treatment involves combined techniques
of repair of both anatomic disorders.
The way of approaching these defects can be vaginal, abdominal or laparoscopic.[5], [6],
[7] Irrespective from the modality of approach chosen, the purpose of the intervention is to
correct the normal pelvic anatomy, to preserve the normal position of the vagina, its length, but
also the intestinal, bladder and sexual functions.[7], [8] Although there are no certain data, the
vaginal path is the most commonly used [5], having the advantage of reduced postoperative
pain, as compared to the others, being also esthetic, without postoperative scars. Its main

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disadvantage consists in the limitation of access to certain structures.
The genital prolapse repair procedures can be performed by using the patient’s own tissues
or polypropylene meshes. The main disadvantages in using the meshes are the post-operative
pain, the risk of erosion, the immobility of the vaginal wall and dyspareunia. [6]
The most used methods for the fixation of the vaginal apex consist in the fixation to the
sacrospinous ligament, the fixation to the iliococcygeus and sacrocolpopexy fascia, while the
techniques used for the correction of the anterior compartment are represented by anterior
colporrhaphy, anterior colpoplasty with meshes, paravaginal repair and colposuspensions. We
have considered a technique for the restoration of the pericervical ring by using a 4-arms
mesh, its anterior arms being passed transobturator and the posterior arms being fixed to the
sacrospinous ligaments. This technique reestablishes the normal position of the vaginal apex
on one hand and, on the other hand, it corrects the bladder support.
The choice of the surgical procedure must be adapted to each case, the correct pre-
operative diagnostic and the confirmation of the disorders intraoperative being the top key of
the intervention’s success. The selection of an incorrect technique may lead to the occurrence
of new disorders and de novo postoperative symptoms.
The sacrocolpopexies were considered until short time ago, the gold standard of the
interventions for the apical prolapse. [6], [7], [8], [9] The procedure, that can be performed
both on abdominal and on laparoscopic way, consists in the use of a polypropylene mesh,
through which the vaginal wall is attached to the anterior longitudinal ligament of the sacrum.
The results of the intervention are very good, with a success rate of 90%. [6] The main
disadvantages of this intervention consist in the long duration of the procedure, a long interval
to professional reintegration and a high risk of bleeding. Also, there is a risk of ureter injury,
due to the anatomic position close to the sacrum. But the procedure presents also numerous
advantages, as the low degree of post-operative dyspareunia as compared to the vaginal
procedures, a lower degree of residual prolapse and a longer time to the occurrence of the
relapse. [7] The use of the laparoscopic approach, introduced by Nezhat in 1992, decreases the
risk of some of these disadvantages. [10]
For the association of the apical prolapse with the anterior vaginal wall disorder, we can
associate to this technique a vaginal procedure, such as the anterior colporrhaphy.
The sacrospinous ligaments fixation represents one of the most used techniques for the
correction of the apical prolapse. It was described by Sederl in Germany in 1958.[6] It is executed
vaginally, with all the advantages arising from it. The technique consists in the dissection of
the pararectal space, followed by the fixation of the vaginal wall to the sacrospinous ligaments.
The procedure can be executed by fixation to the sacrospinous ligament, the result being
the deviation of the vagina to the respective side, or to both sacrospinous ligaments.
There are no randomized studies proving a higher efficacy of the fixation to one sacrospinous
ligament or to both ligaments. [11] The results of this procedure are very good, with a relapse
percentage between 2,4% and 19%. When the procedure is not combined with a technique for
the correction of the anterior vaginal wall prolapse, it is followed by a higher percentage of
prolapse relapse in the anterior compartment. [6], [11]
The main disadvantage of this technique consists in a high intensity pain, present in over
50% of the patients in the first 48 hours postoperative. [6] Other potential complications consist
in vascular and nervous lesions.
Another usual procedure for the correction of the apical prolapse, on the vaginal way,
consists in the fixation of the vaginal wall to the utero-sacral ligaments. If the fixation to
the sacrospinous ligaments can be made extraperitoneally, the fixation to the utero-sacral
ligaments is executed intraperitoneally. [6] This is a technique described for the first time in
1957 by Miller. The main complication of this technique, described by the author, consists in

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the ureter injury. From the point of view of the procedure’s efficacy, there are no significant
differences proven from the point of view of the relapse percentage or the reoccurrence of the
symptomatology as compared to the fixation to the sacrospinous ligaments. [6], [12]
The suspension to the iliococcygeus fascia represents a second line procedure introduced by
Inmon in 1963 and modified by Schull in 1993. [6], [13] Its main indication is the case where
the utero-sacral ligaments cannot be correctly identified or are insufficient for the suspension
of the vaginal wall.
Although the approach path and the dissection of the pararectal space is similar to the
technique of fixation to the sacrospinous ligaments, due to the use of the iliococcygeus muscle
fascia near the ischial spine and laterally from the rectum, the risk of vascular and nervous
injury is more reduced. The main advantage consists in the maintenance of the vagina’s
natural axis, without deviation as in the case of the fixation to the sacrospinous ligaments. It
is described as a bilateral procedure and supposes a more reduced tension in the vaginal wall
than in the case of fixation to the sacrospinous ligaments. [11], [13], [15]
For the repair of both the apical defect and the anterior vaginal wall disorder, we used
combined correction procedures, including any of the procedures described above for the
repair of the apical defect and associating a procedure addressed to the anterior vaginal wall
defect. The most used procedures addressed to this compartment are the anterior colpoplasty
and the anterior colpoplasty using polypropylene meshes. [14], [15]
The anterior colporrhaphy is addressed to the anterior vaginal wall prolapse by central fascia
defect and it is very used due to the technique’s ease and the possibility of its combination with
another technique for the correction of the apical defect. It consists in the restoration of the
Halban fascia, the excision of the vaginal mucous excess and the suture of the anterior vaginal
wall. The procedure is burdened by a high relapse percentage if used in the case of anterior
vaginal wall disorder by paravaginal defect.
In the case of 2nd and 3rd degree anterior wall defects, we currently use the correction by
polypropylene meshes. These meshes are fixed to the cervix and the meshe’s arms cross the
obturator membrane.
The most used technique of cystocele correction by sliding is usig a 4-arm polypropylene
mesh, fixed to the cervix and with the arms passed through transobturator passage, the superior
ones elevating the bladder’s base, while the inferior ones raising the vaginal apex. [15]
The technique of simultaneous correction of both defects, introduced by us, consists in the
restoration of the pericervical ring. The restoration of the pericervical ring has two objectives
– the reattachment of the pubocervical fascia at the cervical level and the concomitant repair
of the specific fascia defects. We use a 4-arms polypropylene mesh, two anterior and two
posterior. Initially, we fix the two posterior arms of the mesh at the level of the sacrospinous
ligaments, tunneled from anteriorly to posteriorly and then we fix the anterior arms of the mesh
freely to the obturator membrane, by using passage instruments.

Conclusion

The anterior vaginal wall prolapse is frequently associated to apical prolapse.


There are numerous procedures designed for the correction of the disorders specific to
each vaginal compartment, the technique being chosen considering the particularities of each
patient, the particularization of the therapeutic approach being always necessary. Nevertheless,
a correct diagnostic and an adaptation of the surgical procedure for the concomitant correction
of the associated anatomic defects have been proven to reduce the relapse rate as compared to
the monocompartmental surgical approach.

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REFERENCES

1. Bratila, E. (2016). Complicatii uroginecologice in chirurgia vaginala, cap.5, pp. 53-86


2. Bratila, E., Vladareanu, S., Berceanu, C., Cirstoiu, M., Mehedintiu, C., Comandasu, D.,
Mitran, M. (2015). Rolul sarcinii si nasterii in aparitia tulburarilor de statica pelvica,
Revista Ginecologia.ro, III, 10, pg 28-33, ISSN 2344-2301, ISSN-L 2344-2301.
3. Summers, A., Winkel L.A., Hussain, H.K., DeLancey, J.O.L. (2006). The relationship
between anterior and apical compartment support. American Journal of Obstetrics and
Gynecology, volume 194, Issue 5, pp.1438-14434.
4. Rooney, K., Kenton, K., Mueller, E.R., FitzGerald, M.P., Brubaker, L. (2006). Advanced
anterior vaginal wall prolapse is highly correlated with apical prolapse. American Journal
of Obstetrics and Gynecology, volume 195, Issue 6, pp.1837-1840.
5. Barber, M.D., Maher, C. (2013). Apical prolapse. International Urogynecology Journal,
Volume 24, Issue 11, pp. 1815-1833.
6. Kong, M.K., Bai, S.W. (2016). Surgical treatment for vaginal apical prolapse. Obstetrics
and Gynecology Science, 59(4), pp. 253-260.
7. Rosati, M., Bramante, S., Bracale, U., Pignata, G., Azioni, G. (2013). Efficacy of
Laparoscopic Sacrocervicopexy for Apical Support of Pelvic Organ Prolapse. Journal of
the Society of Laparoendoscopic Surgeons, 17(2), pp. 235-244.
8. Bratila, E., Bratila, P.C., Negroiu, A.T. (2014). Vaginally-assisted laparoscopic
hysterosacropexy for advanced utero-vaginal prolapse a series of 32 cases. Ars Medica
Tomitana, volume 20, issue 2, pp. 63-70.
9. Moen, M., Gebhardt, J., Tamussino, K. (2015). Systematic reviews of apical prolapse
surgery։ are we being misled down a dangerous path?. International Urogynecology
Journal, Volume 26, Issue 7, pp. 937-939.
10. Bratila, E., Bratila, P.C. Laparoscopically assisted vaginal colophysterosacropexy.
Gineco.ro, 2010, VI(VI), 20.2/2010, pg. 118 – 122.
11. Uzoma, A., Farag, K.A. (2009). Vaginal vault prolapse. Obstetrics and Gynecology
International, Volume 2009, Article ID 275621.
12. Alas, A.N., Anger, J.T. (2015). Management of apical pelvic organ prolaps. Current
urology report. 16։33.
13. [13] Serrati, M., Braga, A., Bogani, G., Maggiore, U.L.R., Sorice, P., Ghezzi, F., Salvatore,
S. (2015). Iliococcygeus fixation for the treatment of apical vaginal prolapse: efficacy and
safety at 5 years of follow-up. International Urogynecology Journal, volume 26, issue 7,
pp.1007-1012.
14. Rudnicki, M., Laurikainen, E., Pogosean, R., Kinne, I., Jakobsson, U., Teleman, P.
(2016). A 3–year follow-up after anterior colporrhaphy compared with collagen-coated
transvaginal mesh for anterior vaginal wall prolapse: a randomised controlled trial. An
International Journal of Obstetrics and Gynaecology, Volume 123, Issue 1, pp. 136-142.
15. Groeshen, K., Petros, P., Funogea, A., Bratila, E., Bratila, P., Cirstoiu, M. (2016). Planseul
pelvic la femeie. Anatomia functionala, diagnostic si tratament- in acord cu teoria
integrativa, Editura Universitara Carol Davila Bucuresti, ISBN 978-973-708-894-9.

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Bladder Evacuation Disorders Following Radical


Surgery for Cervical Cancer

MANTA Anca1, BRATILA Petre Cornel1, COMANDASU Diana2,


BERCEANU Costin3, MEHEDINTU Claudia4, CIRSTOIU
Monica5, BOHILTEA Roxana5, STANCULESCU Ruxandra2,
CONSTANTIN Vlad Denis6, BRATILA Elvira2
1
Euroclinic Minimally Invasive Hospital, Bucharest, Gynecology Department (ROMANIA)
2
UMF “Carol Davila” Bucharest, Obstetrics-Gynecology Department, “Sf. Pantelimon” Clinical
Emergency Hospital, Bucharest (ROMANIA)
3
UMF Craiova, Obstetrics-Gynecology Department, County Emergency Hospital Craiova(ROMANIA)
4
UMF “Carol Davila” Bucharest, Obstetrics-Gynecology Department, “Nicolae Malaxa” Clinical
Hospital (ROMANIA)
5
UMF “Carol Davila” Bucharest, Obstetrics-Gynecology Department, University Emergency Hospital
of Bucharest (ROMANIA)
6
UMF “Carol Davila” Bucharest, General Surgery Department, “Sf. Pantelimon” Clinical Emergency
Hospital, Bucharest (ROMANIA)
E-mails: anca_manta81@yahoo.com, pbratila49@yahoo.com, diana.comandasu@yahoo.com, dr_
berceanu@yahoo.com, claudiamehedintu@yahoo.com, dr_monicacirstoiu@yahoo.com, r.bohiltea@
yahoo.com, constantindenis@yahoo.com, elvirabarbulea@gmail.com

Abstract

Introduction
Cervical cancer represents one of the most severe gynecological malignancies in women.
The base of the multimodal treatment is represented by radical surgery.
Purpose꞉ The analysis of the bladder evacuation disorders occurring after radical treatment
for cervical cancer.

Material and method


The multicenter retrospective study was carried out on 127 patients with different stages
of cervical cancer, during the period 2011-2016, who underwent a radical surgical treatment.
43,30% of the cases (55 cases) were practiced a radical trachelectomy (3 cases laparoscopic
radical trachelectomy and 52 cases vaginal radical trachelectomy) with laparoscopic
pelvic lymphadenectomy, while 56,70% of the cases (72 patients) were practiced a radical
hysterectomy with bilateral pelvic lymphadenectomy – abdominal (83,31%) and respectively
laparoscopic (16,68%).

Results
Vesical evacuation disorders were recorded in 3 cases. The average time for the restoration
of the physiological micturition was spontaneously recorded after a variable period of 3-7 days
after the extraction of the bladder catheter.

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Debates
The surgical radical treatment for cervical neoplasm is followed by numerous complications,
among which are included vesical evacuation disorders following nervous injuries at the
bladder level.

Conclusions
Bladder evacuation disorders following radical surgery indicated for cervical cancer occur
with a variable incidence, most of them being solved spontaneously.

Keywords։ cervical cancer, radical treatment, vesical evacuation

Introduction

Cervical neoplasm represents the second genital cancer in women after ovarian cancer and
the second cause of mortality by neoplastic affections met in countries with a reduced access
to screening and prevention programs. [1]
The base of the multimodal treatment is represented by radical surgery. Among the
procedures performed, we mention the radical hysterectomy and the radical trachelectomy,
which can be performed by abdominal, laparoscopic and vaginal route, with our without
laparoscopic assistance.
The radical hysterectomy represents the standard treatment and refers to the uterus excision
in block, together with the parameters and a third to a half portion of the vagina. [2] Most of
the gynecological surgeons add the pelvic lymphadenectomy to this intervention, while the
bilateral adnexectomy is not part of the protocol of this intervention.
In certain selected cases, in young women with incipient stages, when we desire to keep
their fertility, the procedure practiced is the radical trachelectomy. This procedure consists in
the removal of the cervix and of the surrounding tissues with the preservation of the uterine
body, and the bilateral pelvic lymphadenectomy. The surgical intervention can be performed
laparoscopically as well as vaginally.
The procedures involve a good awareness of the local anatomy, in particular of the pelvis
innervation, and a detailed dissection for the mobilization of the uterus from the bladder and
the rectum. Nevertheless, the radical treatment can be followed by numerous complications,
among which we mention the urinary ones. Due to the anatomic localization of the cervix,
during radical surgery beside the direct lesions of lower urinary tract (bladder and urethra) and
of ureters, there can also occur lesions of the pelvic nerves and vascular lesions of the lower
urinary tract or of the pelvic floor muscles. [3], [4]

Purpose

The analysis of the vesical evacuation disorders occurred after radical treatment for cervical
cancer.

Material and method

The multicenter retrospective study was carried out on 127 patients with different stages
of cervical cancer, during the period 2011-2016, who underwent a radical surgical treatment.
In 43,30% of the cases (55 cases) it was practiced radical trachelectomy (3 cases laparoscopic
radical trachelectomy and 52 cases vaginal radical trachelectomy) with laparoscopic pelvic

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lymphadenectomy, while in 56,70% of the cases (72 cases) it was performed radical
hysterectomy with bilateral pelvic lymphadenectomy – abdominal (83,31%) and laparoscopic
(16,68%).

Results

Vesical evacuation disorders were recorded in 3 cases. Detachment of the urinary catheter
was performed at 12-24 hours postoperative, when bladder evacuation dysfunctions were
noticed. After that the urinary catheter was reinstalled. The average time for the restoration of
the physiological micturition was spontaneously recorded after a variable period of 3-7 days
after the extraction of the bladder catheter.

Debates

Knowing the good anatomy of the pelvis organs, in particular the innervation of the genital
organs is the key element in the gynecological oncologic surgery. The innervation of the pelvic
organs is sensitive, sympathetic and parasympathetic.
The hypogastric nerves, right and left, arising from the upper hypogastric plexus, once
reaching the pelvis, have a cranial-caudal direction, being situated posterior and parallel with
the ureters, median from the internal iliac artery. In their course, they will be positioned in the
lateral part of the utero-sacral ligaments, to the posterior side of the paracervix.
The injury of the hypogastric nerves can occur during the resection of the paracervix in
the posterior side, near the initial part of the utero-sacral ligaments and of the recto-vaginal
dissection. [4], [5], [6]
The sympathetic innervation arises from the lower hypogastric plexus, while the
parasympathetic innervation is given by the splanchnic pelvic nerves coming from the sacral
plexus.
The inferior hypogastric nerves are situated laterally to the utero-sacral ligaments, at
approximately 2 cm from their origin in the uterus. They are responsible for the relaxation of
the vesical detrusor muscle and the contraction of the urethral sphincter. [3]
The bladder has an autonomous, sympathetic and parasympathetic innervation.
The bladder and the vessels irrigating the bladder present an innervation that comes
from the paraaortic sympathetic chains. Their stimulation due to the pressure modifications
determined by the bladder filling and the internal urethral sphincter closure will lead to the
cessation of the vesical muscles’ contractions, which will allow the bladder to fill. If there are
nervous lesions at this level, the urinary incontinence will appear by a reverse mechanism. [4],
[5]. The internal urethral smooth sphincter has an alpha-adrenergic sympathetic innervation,
while the external urethral sphincter is innervated by the pudendal nerve.
By injuring these nervous structures, there may occur bladder evacuation disorders, with
an impact over the life quality of these patients, considering the fact that the vesical evacuation
disorders represent the main complication after the radical surgery for cervical cancer. [4]
The nerve-sparing concept appeared because of this reason, aiming the reduction of the
lesions to the pelvic autonomous innervation and, therefore, the reduction of the urinary
dysfunctions due to radical surgery.
The inferior hypogastric plexus is situated at the level of the anorectal junction, on the
anterior-lateral face of the rectum. The nervous fibers coming from here mount into the upper
third of the vagina and reach the bladder by the vesical-vaginal and vesical-uterine ligaments.
The lesion of these nervous fibers can occur during the resection of the inferior part of the

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cardinal ligaments and of the utero-sacral ligaments in the distal part of the parameters. These
nervous fibers contain sympathetic fibers from the hypogastric nerves and parasympathetic
fibers from the sacral plexuses S2-S4. The role of the parasympathetic fibers is that of voluntary
micturition by the contraction of the vesical detrusor.
The accidental lesion of the parasympathetic fibers will determine the presence of a
hypocontractile bladder and evacuation disorders.
The pudendal nerve, coming from the ventral branch of the sacral nerve, is a motor nerve
having a role in the contraction of the urethra’s external ridged sphincter, of the external anal
sphincter and in the innervation of the pelvic muscles. The lesion of this structure results in
urinary incontinence and genital prolapse. [4], [5]
During the hysterectomy and radical trachelectomy, the most frequent occurrences are
the lesions at the level of the hypogastric nerves or of the inferior hypogastric plexus, which
result in the denervation of the bladder and of the urethra and the appearance of the vesical
evacuation disorders. They can occur singularly or associated with direct lesions of the vesical
wall, with urethral fibroses, vascular lesions or lymphatic stasis. [4], [6]
From a clinical point of view, the vesical evacuation disorders are manifested by the loss of
the urinary sensation, mictional imperiosity, urinary incontinence or nocturia.
The nervous lesions determining these manifestations can occur during different
operative times in radical hysterectomies. Three classifications are currently used for the
radical hysterectomies - Piver-Rutletge-Smith (PRS)-1974, Gynecologic Cancer Group of
the European Organization of Research and Treatment of Cancer (GCG-EORTC) - 2007
and Querlow and Morrow (QM)-2008, the last one being also adapted to rather conservatory
interventions as well as to different approaches of surgical interventions for cervical cancer.
[7]
The preoccupation of the oncological gynecological surgeons for the nervous plexuses has
been recorded since the beginnings of the radical hysterectomies, when in 1921 Okabayashi
published Takayama’s technique, which has as particularity the preservation of the nervous
plexuses. From the current classifications mentioned above, the QM classification is particular
as certain subtypes of radical hysterectomies follow the preservation of the autonomous nerves
and the paracervical lymphadenectomy. [7]
The PRS (1974) and GCG-EORTC classifications comprise 5 classes, while the QM
classification has only 4 types, each of the types B, C and D having 2 subtypes; Class I-
extrafascial hysterectomy by which the ureters are identified by transparency, without
dissecting or injuring them, the uterine arteries are sectioned and ligatured laterally, the utero-
sacral ligaments and the cardinal ligament are not resected and the vagina is not resected. In
the GCG-EORTC Classification, Class I is represented by the simple hysterectomy and in the
QM Classification, Class A is still the extrafascial hysterectomy with some modifications as to
the previous classification, which consist in the dissection and palpation of the ureters without
dissecting the periureteral tissue, while the uterine arteries, the utero-sacral ligaments and
the cardinal ligaments are sectioned and ligatured as close to the uterus as possible with the
resection of a small portion of the vagina, smaller than 1 cm.
Class II of the PRS Classification and Type II of the GCG-EORTC Classification consist
in a modified radical hysterectomy. Class II Wertheim – the ureters are dissected from the
paracervical region without being resected from the pubovesical ligament, the uterine arteries
are sectioned at a median level form the ureter, the utero-sacral ligaments are sectioned at
the middle of the sacral insertion, the cardinal ligaments are resected in their median half,
the upper third of the vagina is resected and pelvic lymphadenectomy. Type I presents some
modifications - the ureters are dissected up to their entry into the bladder, the uterine arteries
are sectioned and ligatured in the median half of the parameters, the proximal resection of

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the utero-sacral ligaments, with the resection of the median half of cardinal ligaments and
the resection of 1-2 cm of the superior vagina. Type B presents two subtypes։ B1- with
deperitonization of uteruses and their lateral mobilization, partial resection of utero-sacral and
vesical-uterine ligaments, section of the paracervical tissue at the level of the urethral tunnel,
removal of a vaginal portion by at least 1 cm under the level of the cervix or of the tumor,
without removing the paracervical lymphatic nodules, and B2 which adds the paracervical
lymphadenectomy.
Class III is represented by Meigs classical radical hysterectomy, with complete dissection
of the ureters into the pubovesical ligaments with the exception of a small part, where the
umbilical-vesical artery is situated at the level of their entry into the bladder, the uterine arteries
are sectioned at the origin in the hypogastric region, the utero-sacral ligaments are excised at
their sacral origin, the cardinal ligaments are sectioned near the pelvic wall, with the removal
of the superior half of the vagina and the execution of the routine pelvic lymphadenectomy.
Some modifications appear in Type III։ resection of the utero-sacral ligaments, section of
the uterine arteries at the origin, resection of parameters near the pelvic wall and resection of
the vagina only in the superior third. Type C includes two subtypes - C1 with full mobilization
of the ureters, section of utero-sacral ligaments at the level of the rectum, section of vesical-
uterine ligaments at the level of the bladder, full resection of the paracervical tissue, extension
of the resected vagina portion by 15-20 mm under the level of the cervix or of the tumor and
corresponding paracolpos, with the preservation of the autonomous innervation and C2, that
includes the same steps without the preservation of the autonomous innervation.
Class IV involves a higher degree of radicality by complete resection of the ureter in the
pubovesical ligament, section of the umbilical-vesical arteries and resection of three superior
quarters of the vagina. Type IV is different from Type III in the increase of the vagina portion
resected to three quarters and of the corresponding paravaginal tissue and Type D - D1 – with
complete resection of the paracervical tissue up to the pelvic wall together with the hypogastric
vascular pedicle and with the exposure of the sciatic nerve and with completely ambulant
ureter and D2 – with resection of the muscles and fascia of the pelvic wall.
Class V supposes the resection of the ureter portion and of the invaded bladder and the
re-implantation of the ureter into the bladder and Type V supposes supralevatorial partial
pelvectomy.
All these types and subtypes of radical hysterectomies are in accordance with the tumor
dimensions, the peritumoral invasion and the invasion of the lymphatic ganglions, the difference
consisting in that the first classification step does not represent a radical intervention and IV
and V are extensive interventions. [7] The advantages of the QM classification are numerous,
as they can be adapted for a conservatory surgery and also for different types of approaches –
abdominal, laparoscopic, laparoscopic assisted vaginal and even robotic. [7], [8], [9]
Depending on the localization, dimension and degree of aggressiveness of the tumor, the
surgeon can choose for the performance of an intervention subtype for one side and another
subtype on the other side, with the purpose of reducing as much as possible the post-operative
complications but without being into the radicality detriment. Depending on the intervention
selected, the resection extension, there can occur the above mentioned urinary complications,
from the most simple ones, with partial denervation and fast restoration of the functions to the
most complicated, with difficult correction.
With regards to the urinary complications, their severity is determined by the type and
severity of the nervous lesions. Thus, a lesion of the anastomoses between the splanchnic
nerves and the visceral branches of the sympathetic pelvis bodies will determine the loss of
the sensation of full bladder. [4], [5] The nervous lesions can present different lesion degrees,
from neurapraxia, which presents a potential spontaneous regeneration from a few hours

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to a few weeks, from a medium 48 hours to 7 days, and to a full nervous section, which
can be definitive. Also, the same severity as the nervous lesion itself can also be found in
the interruption of the vascular support of those nervous plexuses, which leads to definitive
lesions. [4], [6]
The nerve-sparing concept appeared for this reason, in the oncological surgery of the
cervical cancer, with the purpose of reducing, as much as possible, the number of urinary
or sexual complications. [7], [10], [11] This technique was mentioned for the first time by
Kobayashi in Japan. [11], [12]
The nerve-sparing radical hysterectomies are addressed to incipient stages of cervical
cancer. Nevertheless, even if there have been numerous studies performed during the last
years, there is no consensus over the standardization of this procedure, the limits of resection
varying depending on the author. [12]
The key point in this type of hysterectomy is represented by the cardinal ligaments and
the level at which they are resected. They comprise a vascular part and a neural part, which
contains the pelvic splanchnic nerves. The limit between these two portions is given by the
median rectal artery. Other authors modified this limit to the parametrial dissection. [12] The
nerve-sparing concept supposes the resection of the vascular part with the preservation of the
nervous part of the cardinal ligaments. [13]
Due to the protection of the nervous part, the life quality of these patients is significantly
improved by the reduction of the urinary complications, while the recurrence rate is not higher
than in case of classical radical hysterectomies. [4], [10], [11], [12], [13]

Conclusions

The cervical cancer surgery is one of the most complex surgical interventions due to the
localization of the cervix. The vesical evacuation disorders due to the nervous lesions represent
one of the most frequent complications of cervical cancer radical surgery. The concept of
nerve-sparing appeared thus in the radical surgery, with results similar to the classical radical
hysterectomy from the point of view of the oncologic safety, but with superior results from
the point of view of urinary complications. Yet, it remains a non-standardized technique, its
application depending on the cancer stage of the respective patient.

REFERENCES

1. Frumovitz, M. (2016). Invasive cervical cancer։ Epidemiology, risk factors, clinical


manifestation, and diagnosis, www.uptodate.com.
2. Mann, W.J. (2016). Radical hysterectomy, www.uptodate.com.
3. Volpi, E. (2011). Anatomy of the Autonomic Innervation of the Pelvic Organs Some
considerations for pelvic surgeons, obgyn.net.
4. Aoun, F., van Velthoven, R. (2015). Lower urinary tract dysfunction after nerve-sparing
radical hysterectomy, International Urogynecology Journal, Volume 26, Issue 7, pp. 947-
957.
5. Comandasu, D.E., Bratila, E., Carstoiu M., Munteanu, O. (2015). Automonic innervation
of the pelvis, Romanian Journal of Functional and Clinical, Macro- and Microscopical
Anatomy and Of Anthropology, Vol XIV, Year 2, Nr2, ISSN 1583-4026.
6. Bratila, E., Bratila C.P., Coroleuca, C.B., Coroleuca, C.A. (2015). Collateral circulation
in the female pelvis and the extrauterine anastomosis system. Romanian Journal of
Functional and Clinical, Macro- and Microscopical Anatomy and Of Anthropology, Vol

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XIV, Year 2, Nr2, ISSN 1583-4026.
7. Marin, F., Plesca, M., Bordea, C.I., Moga, M.A., Blidaru, A. (2014). Types of radical
hysterectomies- from Thoma Ionescu and Wertheim to present day. J Med Life Volume
7, Issue 2, pp. 172-176.
8. Puntambekar, S.P., Lawande, A., Desai, R., et al (2013). Nerve- sparing robotic radical
hysterectomy our technique. Journal of robotic surgery. Volume 8, Issue 1, pp. 43-47.
9. Barbulea Raducea, E., (2006) Histerectomia vaginala asistata laparoscopic. Histerectomia
vaginala-tratat sub redactia Bratila. P., pp.243-253.
10. Jarruwale, P., Huang, K.G., Benavides, D.R., Su, H., Lee, C.L. (2013). Nerve-sparing
radical hysterectomy in cervical cancer. Gynecology and Minimally Invasive Therapy,
Volume 2, Issue 2, pp. 42-47.
11. Xue, Z., Zhu, X., Teng, Y. (2016). Comparison of Nerve-Sparing Radical Hysterectomy
and Radical Hysterectomy: a Systematic Review and Meta-Analysis. Cell Physiol
Biochem, Volume 38, pp. 1841-1850.
12. Ditto, A., Martinelli, F., Mattana, F. et al. (2011). Class III Nerve-sparing Radical
Hysterectomy Versus Standard Class III Radical Hysterectomy: An Observational Study.
Ann Surg Oncol, Volume 18, pp. 3469-3478.
13. Chen, C., Li, W., Liu, P., Zhou, J., Lu, L., Su, G., Li, X., Guo, Y., Huang, L. (2012).
Classical and nerve-sparing radical hysterectomy: An evaluation of the nerve trauma in
cardinal ligament. Gynecologic Oncology, Volume 125, Issue 1, pp. 245-251.

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The Effect of Estrogen Deficiency Related to


Aggressive Chemotherapy on Female Urogenital Tract

PLOTOGEA Mihaela Nicoleta1,2, TANASE Alina Daniela3,*,


SECUREANU Adrian Florin2, IONESCU Sorin2,
BRATILA Elvira1, BERCEANU Costin4,
CIRSTOIU Monica Mihaela1, MEHEDINTU Claudia1,2
1
“Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
2
“Nicolae Malaxa” Clinical Hospital, Bucharest, Romania
3
“Fundeni” Clinical Institute, Bucharest, Romania
4
University of Medicine and Pharmacy, Craiova, Romania
E-mails: nicole_plotogea@yahoo.co.uk, alina.tanase@icfundeni.ro, a_secureanu@yahoo.com,
sorin.1960@yahoo.com, elvirabarbulea@gmail.com, dr_berceanu@yahoo.com, dr_cristoiumonica@
yahoo.com, claudiamehedintu@yahoo.com
*
corresponding author: Tanase Alina Daniela, email: alina.tanase@icfundeni.ro

Abstract

Introduction
Aggressive chemotherapy, as included in the bone marrow transplant (BMT) regimen,
is commonly used nowadays to treat and heal different types of malignant diseases. The
treatment is often associated to injury to other organs and systems beside the targeted one, and
premature menopause is a frequent non-malignant complication. The genitourinary syndrome
of menopause includes a variety of signs and symptoms, not only related to urogenital tract,
but affecting the person as a whole.

Material and methods


This research is a part of an ongoing study started in 2014 and held within the Obstetrics and
Gynecology Department of “Nicolae Malaxa” Clinical Hospital with the aid of Bone Marrow
Transplant Department of “Fundeni” Clinical Institute, Bucharest, Romania. It includes a
number of 14 young women which have undergone a BMT and are currently diagnosed with
premature menopause. Patients were examined and requested to complete a questionnaire
regarding menopausal symptoms and associated dysfunctions.

Results
The analysis of the data revealed mild to moderate vulvovaginal atrophy in all patients
included, with increased severity and associated dysfunctions in the ones not receiving local or
systemic estrogen replacement therapy (ERT). Patients reported vaginal dryness, dyspareunia,
dysuria, increased vulvovaginal and urinary infections, decreased sexual activity, emotional
distress, reduced quality of life.

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Conclusions
Estrogen deficiency, especially when brutally installed following an aggressive treatment
as bone marrow transplant regimen, is associated with deep and irreversible changes of the
urogenital tract. Persistent vaginal and urinary signs and symptoms are present despite the fact
that most of the women are receiving ERT, leading to decreased self-esteem and quality of life.

Keywords: estrogen deficiency, vulvovaginal atrophy, chemotherapy

Introduction

An increasing number of young people develop haematological malignancies as primary


disease or secondary to solid tumors, and they undergo aggressive treatment and procedures
to overcome the disease. The exact incidence of the hematological malignancies is unknown,
but it is believed that every year hundreds of young girls and women develop such disorders,
requiring prolonged and chemotherapy, followed by bone marrow transplantation (BMT)
[1]. The transplant regimen associates, in selected cases, total body irradiation to aggressive
chemotherapy and immunotherapy, and leads to injuries to other organs and systems as part of
short or long time complications. One of the most common long term consequences of BMT
is represented by premature ovarian failure and its subsequent genitourinary syndrome of
premature menopause [2]. It includes a variety of menopausal signs and symptoms, increased
risk of vaginal and urinary infections, sexual dysfunctions, secondary infertility and decreased
quality of life [3, 4, 5].

Methodology

This research is a part of an ongoing study started in 2014 and held within the Obstetrics
and Gynecology Department of “Nicolae Malaxa” Clinical Hospital with the aid of Bone
Marrow Transplant Department of “Fundeni” Clinical Institute, Bucharest, Romania. The
study included 14 young women, after signing an informed consent. They had undergone stem
cell transplantation as part of the cancer treatment and they were diagnosed subsequently with
estrogen deficiency urogenital symptoms and premature ovarian failure. The inclusion criteria
required at least one year after transplant, no GVHD or immunosuppressive treatment, no
secondary malignancies or vital organ insufficiency.
Patients were examined and requested to complete a questionnaire regarding menopausal
symptoms and associated vaginal, urinary and psychological dysfunctions.

Results

The analysis included data collected from 14 young women included in the study. It
was analysed data provided both by the questionnaire and collected during gynecological
examination.
Women were aged between 19 and 29 at the time of the transplant procedure. The indication
for BMT was hematological cancer – leukemia, lymphoma, or acute leukemia following
lymphoma. The transplant regimen was considered for each patient in particular, depending
on primary disease, stage and presence or not of the remission, age, associated illnesses. It
included Busulfan, Fludarabine, Thiotepa, ATG, Thymoglobulin (Anti-thymocyte globulin)

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and Cyclophosphamide; out of them, 4 females were exposed to total body irradiation (TBI).
All women included in the study had no previous remarkable medical history, other general
or ob-gyn history. The patients were diagnosed with genitourinary syndrome of menopause
and POF between 6 and 8 month following transplant procedure, the diagnosis being based on
urogenital dysfunctions and abnormal hormone level. It was tested all hormonal metabolism
and, as it concerns ovarian function testing, Estradiol, Progesterone and FSH showed levels
suggesting menopause [6]. It was recommended estrogen replacement, either with combined
oral contraceptives (COC) or hormone replacement therapy (HRT). In spite of medical
advice, 2 patients were not fond of hormonal therapy, so they took into consideration natural
plant-based products. 5 patients were given local estrogen substitution because of severe
vulvovaginal atrophy.
At the time of diagnosis patients reported both general and gynecological symptoms
associated to menopause and presented in Tabel 1.

Table 1. General and Gynecological menopausal symptoms


General symptoms associated to Hot flashes, Sweets, Irritability, Mood swings, Hair
(premature) menopause loss, Isolation, Dry skin and eyes, Concentration and
memory alteration, Decreased energy, Weight gain,
Impaired body image, Depression, Decreased self-
esteem, Decreased quality of life
Urogenital symptoms associated Vaginal dryness, Vulvovaginal atrophy, Decreased
to menopause libido, Dyspareunia, Dysuria, vulvovaginal infections,
Urinary infections, Breast engorgement, Subfertility/
Infertility, Decreased number of sexual intercourse

Vasomotor menopause symptomatology diminished with the administration of HRT.


There are still reported dry skin and eyes, abnormal hair growth and density, difficulties in
concentration, decreased energy, which can also be associated to both aggressive chemotherapy
regimen and graft versus host disease (GVHD).
Urogenital sign and symptoms did not respond as well as vasomotor with the administration
of hormonal therapy. Intimacy was probably the most troubled because of various degrees
of vulvovaginal disorders, but also because of short and long term consequences of
chemotherapy/irradiation and brutally installed menopause such as decreased libido and
lubrication, pain during intercourse, difficulties in achieving an orgasm, decreased number of
sexual intercourses. All women showed significant decrease in sexual and emotional related
quality of life.
As for vaginal and urinary dysfunctions, the analysis of the data revealed, as shown in
Table 2, that 12 out of 14 patients, the one taking HRT, reported mild or moderate alterations,
while the 2 patients that were not taking estrogen substitution had severe vulvovaginal
dysfunctions. It was also reported more frequently infections than prior to treatment, both
urinary and vaginal, especially when HRT was not administrated. Vaginal dryness appeared
more often that dysuria and they both correlated to the extent of damage of the genital tract.

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Table 2. Genitourinary signs and symptoms related to estrogen deficiency
  Vulvovaginal Vaginal Dysuria Vulvovaginal Urinary
atrophy dryness infections infections

P1 moderate often rarely sometimes rarely

P2 mild sometimes rarely rarely rarely

P3 moderate sometimes rarely sometimes rarely

P4 moderate often rarely rarely rarely

P5 severe permanent sometimes frequently sometimes

P6 mild sometimes rarely sometimes rarely

P7 mild sometimes rarely rarely rarely

P8 moderate sometimes sometimes frequently sometimes

P9 moderate often sometimes often sometimes

P10 mild sometimes rarely rarely rarely

P11 mild sometimes rarely rarely rarely

P12 severe permanent sometimes frequently sometimes

P13 mild sometimes rarely rarely rarely

P14 moderate often sometimes often sometimes

Regarding sexual function and activity, as can be seen in Table 3, mild alterations were
related to mild dysfunctions. Sexual activity was reported to be decreased in all cases,
commonly slightly to moderate. Dyspareunia was reported by all patients, regardless of
hormonal substitution. It was severe/always and correlated to rare or even absent sexual
activity by the two patients who were not taking HRT.
Dyspareunia was directly associated to vaginal dryness, but even in cases where the
atrophy was not found to be advanced, women reported it as being always. Better outcome
was noticed in the cases where local hormonal products were administrated suggesting that
either estrogen or dehydroepiandrosterone (DHEA) increases vaginal wellbeing and facilitates
sexual intercourse.

Table 3. Sexual functions and psychological impact related to estrogen deficiency


Dyspareunia Sexual activity Emotional Quality of life
dystress
P1 often decreased moderate Moderately decreased

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P2 sometimes Slightly decreased moderate Mildly decreased

P3 often decreased moderate Moderately decreased

P4 sometimes Slightly decreased moderate Moderately decreased

P5 always Rare sexual activity moderate Moderately decreased

P6 sometimes Slightly decreased moderate Moderately decreased

P7 sometimes Slightly decreased moderate Moderately decreased

P8 always decreased moderate Moderately decreased

P9 often Slightly decreased moderate Moderately decreased

P10 sometimes Slightly decreased moderate Moderately decreased

P11 sometimes decreased moderate Moderately decreased

P12 always Rare sexual activity moderate Moderately decreased

P13 sometimes decreased moderate Moderately decreased

P14 often decreased moderate Moderately decreased

The last aspect that was taken into consideration was the psychological impact. To
emotional wellbeing and quality of life contribute both general and gynecological factors.
The gynecological changes and the brutally induced urogenital syndrome of menopause
have a direct negative impact on female intimacy and emotional wellbeing. Women report their
intimate life issues to affect their relationships or a new one. Infertility seems to have even a
greater negative impact on women, most of them being young and childless. This concern leads
to difficulties in having/keeping a lasting relationship and decreased self-esteem. Besides the
diagnosis of menopause/premature ovarian failure and the subsequent incapability of having
a child, quality of life is also affected by fear of disease relapse, disease/treatment-related
symptoms, health care satisfaction and doctor-patient relationship, daily job difficulties, risk
of secondary malignancies, risk of breast cancer associated to estrogen replacement, absence
of POF treatment, financial issues of egg donation IVF, social difficulties in the process of
adoption in the context of a cancer-survivor parent and spiritual concerns.

Discussions

Bone marrow transplant procedure is known as a method that cures certain diseases of the
hematopoietic system with an effectiveness confirmed by an increasing number of procedures
reported worldwide. Transplantation of owns hematopoietic or hematopoietic stem cell
transplantation from a donor part of the treatment process, mainly as consolidation, and have

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their place in the algorithm of the procedures provided for the treatment of certain types of
leukemia, lymphoma and newly, less common or as clinical studies, in other disorders [1].
The methods of preparation for transplant are on a combination of medication (aggressive
chemotherapy – alkylating drugs, aneuploidy inducers, topoisomerase II inhibitors,
antimetabolites, natural or monoclonal antibodies) associated or not with total body irradiation
(TBI) in order to cause a total destruction of the recipient’s bone marrow, followed by stem
cell administration. The BTM treatment is highly active on abnormal malignant remaining
cells, it facilitates stem cell implantation and with low probability of relapse. Unfortunately,
the damage goes beyond its purpose and it could affect any organ, leading to impaired or
loss of normal function of different systems or organs [7]. Ovarian toxicity is an important
and common side effect of curative chemo/radiotherapy. Commonly, the results following
chemotherapy and radiation show reduced follicles and/or ovarian atrophy, but when it comes
to BMT regimens, the risk of developing permanent ovarian failure is very high [8, 9]. When
associated in BMT regimens, TBI is the greatest risk for permanent ovarian failure. In children
treated with stem cell transplantation, growth and sexual development are impaired and sterility
is common in adulthood. Uterine radiation can be associated with high risk of spontaneous
abortion, pre-term labor and low birth rate, very young women being more susceptible to the
uterine damage from radiation [10, 11]. The overall ovarian function recovery in women was
reported to be up to 10%, while the conception incidence is reported to be up to 3% among the
female transplant survivors [12].
The most common events associated with premature induced menopause are the
vasomotor complaints, such as hot flashes and body sweets [13]. The estrogen withdrawal
affects primarily the hypothalamus, so the extent of symptoms is associated directly to the
serum concentration of hormones following onset. When menopause is brutally installed, as it
happens after oophorectomy or as a consequence of chemotherapy, the intensity and frequency
is greater as a result of abrupt loss of ovarian products. Almost simultaneous to vasomotor
symptoms, women develop the genitourinary disease. Studies have demonstrated estrogen
sensitivity of genitourinary tract, identifying estrogen receptors both in the genitalia and
urinary tract [13,14]. This results in the abrupt onset of dyspareunia and vaginitis, consequence
of decrease vaginal secretions, lubrication and change in ph. Those are followed by more
profound changes in the anatomy and physiology of the genitourinary system, as restricted
blood flow, epithelial atrophy and loss of connective tissue elasticity [4]. The urinary tract also
changes after onset of menopause, and includes atrophic alterations that occur in the urethra
and periurethral tissue. Estrogen deficiency can lead to increased risk and frequency of vaginal
and urinary infections, and can also contribute to urge or stress incontinence [3].
As regards intimacy and sexual life, premenopausal women following chemical induced
premature ovarian failure lose libido rapidly after onset of menopause, even though libido is
considered to be a cognitive phenomenon. Studies of postmenopausal women have shown that
estrogen-reversible, atrophic genital tract changes substantially influence sexual activity but
that estrogen replacement does not alter libido [15, 16]. Even though estrogen replacement is
effective for vasomotor symptoms, when it comes to genital dysfunctions, its action is limited
and the symptomatology is not completely reduced for women with premature ovarian failure
following BMT [17]. Hormone replacement therapy is dedicated to pre, peri or postmenopausal
women with a need of hormone levels below than those of a young women. Studies have shown
that when testosterone is provided, reversal can be more substantial [6]. In these patients,
androgen administration produced an increase in sexual fantasies, sexual desire, and arousal
during intercourse but did not alter the number of orgasms or the frequency of intercourse, so

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we can suppose that androgens play a major role in postmenopausal loss of libido, knowing that
productions and concentration of androgens fall as a result of ovarian failure [4]. Concomitant
to HRT associated or not with androgens, the studies suggest that an important role of recovery
in genital dysfunctions is played by local intra vaginal administration of hormones. Drug
provided this route may contain estrogen, progesterone, testosterone and DHEA, with proven
benefits especially as regards of testosterone and DHEA [18]. Beside hormonal products,
vaginal lubricants are intended to relieve friction and dyspareunia related to vaginal dryness
during intercourse, with the ultimate goal of trapping moisture and providing long-term relief
of vaginal dryness. Although data are limited on the efficacy of these products, prospective
studies have demonstrated that vaginal moisturizers improve vaginal dryness, pH balance, and
elasticity and reduce vaginal itching, irritation, and dyspareunia [4].
Studies have reported good levels of well-being in long term survivors following BMT,
even though there are increased reports of fatigue, which can persist few years after the
transplant, lack of energy, sleep problems, sexual dissatisfaction [19]. Sexuality and intimacy
in more disturbed in women rather than man and more frequent in women with iatrogenic
premature menopause [15, 20]. In women, the loss of gonadal function, in particularly, is
significantly affecting the long-term quality of life. Regardless of the cause, loss of fertility is
an emotionally challenging experience for women, causing distress levels comparable to other
major health conditions and depression levels twice that of a normal population and quality of
life in decreased in the matter of well-being, relationships, sexuality, but for those surviving
cancer it may be connected to the physical ramifications of cancer treatment, affecting not only
the patient, but also the partner and family [21]. Cancer related infertility reflects in greater
sexual dysfunctions and lower physical quality of life comparing to non-cancer infertility. The
loss of fertility is sometimes reported as painfully as the cancer diagnosis itself, women citing
a sense of reclaiming their lives, a wish to feel normal again and the desire to achieve the
goals set prior to cancer diagnosis [22]. Women reported infertile as a result of treatment were
significantly more like to report poorer mental health and cancer-specific distress than women
who did not experience fertility issues after cancer treatment [23].

Conclusions

The genitourinary syndrome of menopause is often associated to aggressive chemotherapy


and or irradiation per se or appears as a part of the premature ovarian failure condition related
to stem cell transplant procedure. Brutally installed premature menopause induces deep
and often irreversible alterations of the urogenital tract. Persistent vaginal and urinary signs
and symptoms are present years after transplant despite the fact that most of the women are
receiving hormonal replacement. Together with urogenital dysfunctions, subsequent sexual
sexual dissatisfaction, secondary infertility and impaired body image lead to decreased self-
esteem and quality of life for the young women involved.

REFERENCES

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2. Mohty, M., Apperley, JF. (2010). Long-term physiological side effects after allogeneic
bone marrow transplantation. Hematology Am Soc Hematol Educ Program 2010:229-36.

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3. Shapiro, S. (2001). Addressing Postmenopausal Estrogen Deficiency: A Position Paper of
the American Council on Science and Health. Medscape General Medicine 3(1).
4. Karram, M., Soko,l ER., Salvatore, S. (2015). Genitourinary syndrome of menopause:
Current and emerging therapies. OBG Management 28(8).
5. Schover, LR., Van der Kaaij, M., Van Dorst, E., Creutzberg, C., Huyghe, E., Kiserud, CE.
(2014). Sexual dysfunction and infertility as late effects of cancer treatment. EJC Suppl.
12(1): 41–53.
6. Sell Lluveras, JL., Padrón Durán, RS., García Álvarez, CT., Torres Barbosa, F. (2002).
SEXUAL FUNCTION AND SEX HORMONES IN WOMEN WITH PREMATURE
MENOPAUSE. Cuban Medical Research IV(1).
7. Orio, F., Muscogiuri, G., Palomba, S., Serio, B., Sessa, M., Giudice, V., Ferrara, I.,
Tauchmanovà, L., Colao, A., Selleri, C. (2014). Endocrinopathies after Allogeneic
and Autologous Transplantation of Hematopoietic Stem Cells. ScientificWorldJournal
2014:282147.
8. Absolom, K., Eiser, C., Turner, L., Ledger, W., Ross, R., Davies, H., Coleman, R.,
Hancock, B., Snowden, J., Greenfield, D., on behalf of the Late Effects Group Sheffield.
(2008). Ovarian Failure Following Cancer Treatment: Current Management and Quality
of Life. Hum Reprod 23(11):2506-2512.
9. Liu, J., Malhotra, R., Voltarelli, J., Stracieri, AB., Oliveira, L., Simoes, BP., Ball, ED.,
Carrier, E. (2008). Ovarian recovery after stem cell transplantation. Bone Marrow
Transplantation 41, 275–278.
10. Meirow, D., Nugent, D. (2001). The effects of radiotherapy and chemotherapy on female
reproduction. Hum Reprod Update 7(6):535-43.
11. Sun, CL., Francisco, L., Kawashima, T., et al. (2010). Prevalence and predictors of chronic
health conditions after hematopoietic cell transplantation: a report from the Bone Marrow
Transplant Survivor Study. Blood 116:3129–3139.
12. Carter, A., Robison, LL., Francisco, L., Smith, D., Grant, M., Baker, KS., Gurney, JG.,
McGlave, PB., Weisdorf, DJ., Forman, SJ., Bhatia, S. (2006). Prevalence of conception
and pregnancy outcomes after hematopoietic cell transplantation: report from the Bone
Marrow Transplant Survivor Study. Bone Marrow Transplant 37(11):1023-9.
13. Portman, DJ., Gass, MLS. (2014). Genitourinary Syndrome of Menopause. Menopause
21(10):1063-1068.
14. Zagaria, MAE. (2011). Urogenital Symptoms of Menopause: Atrophic Vaginitis and
Atrophic Urethritis. US Pharm 36(9):22-26.
15. Lee, JJ. Sexual Dysfunction After Hematopoietic Stem Cell Transplantation. (2011).
Oncol Nurs Forum 38(4):409-412.
16. Thygesen, KH., I Schjødt, I., Jarden, M. (2012). The impact of hematopoietic stem
cell transplantation on sexuality: a systematic review of the literature. Bone Marrow
Transplantation 47, 716–724.
17. Zhuoyan, L., Mewawalla, P., Stratton, P., Yong, ASM., Bronwen E. Shaw, BE., Hashmi,
S., Jagasia, M., Mohty, M., Majhail, NS., Savani, BN., Rovó, A. (2015). Sexual Health in
Hematopoietic Stem Cell Transplant Recipients. Cancer 121(23): 4124–4131.
18. Archer, DF. (2015). Dehydroepiandrosterone intra vaginal administration for the
management of postmenopausal vulvovaginal atrophy. J Steroid Biochem Mol Biol
145:139-43.
19. Chiodi S1, Spinelli S, Ravera G, Petti AR, Van Lint MT, Lamparelli T, Gualandi F, Occhini
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in 244 recipients of allogeneic bone marrow transplantation. Br J Haematol 110(3):614-9.
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Baser, RE., Barakat, RR. (2010). A cross-sectional study of the psychosexual impact of
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Laparoscopic Ureterolysis in the Management of Deep


and Infiltrative Pelvic Endometriosis – Case report

MEHEDINTU Claudia1,2, DIACONU Victor2,


SECUREANU Adrian Florin2, IONESCU Sorin2,
BRATILA Elvira1, BERCEANU Costin3,
CIRSTOIU Monica Mihaela1, ANTONOVICI Marina Rodica1,2,*,
PLOTOGEA Mihaela Nicoleta1,2, IONESCU Oana Maria2
1
“Carol Davila” University of Medicine and Pharmacy, Bucharest
2
“Nicolae Malaxa” Clinical Hospital, Bucharest
3
University of Medicine and Pharmacy, Craiova
E-mails: claudiamehedintu@yahoo.com, victor_diaconu@yahoo.com, a_secureanu@yahoo.com,
sorin.1960@yahoo.com, elvirabarbulea@gmail.com, dr_berceanu@yahoo.com, dr_cristoiumonica@
yahoo.com, marina.antonovici@gmail.com, nicole_plotogea@yahoo.co.uk, ionescuoanamaria@gmail.
com
*
corresponding author: Antonovici Marina Rodica, email: marina.antonovici@gmail.com

Abstract

Introduction
Endometriosis is defined as the presence of endometrial-like tissue outside the uterine cavity.
Affecting primary the pelvic organs, those ectopic implants can cause serious complications.
Ureteral involvement is a rare condition, frequently asymptomatic and can cause kidney loss.
Here, we present the case of a 34-year-old woman with right side ovarian endometrioma and
ureteral stenosis due to fibrosis overlying the right pelvic sidewall, managed by laparoscopic
approach.

Case presentation
34-year-old infertile woman was diagnosed during routine gynaecological examination with
right side ovarian tumor. The vaginal sonography, MRI and urinary ultrasound investigations
pointed towards an 8/7 cm right ovarian endometrioma, as well as an asymptomatic right
side stage III hydroureteronephrosis with renal cortical thinning. Preoperative management
required urologic expertise in the form of ureteral stenting. Laparoscopic inspection revealed a
right side ovarian endometrioma adherent to the bowel, pelvic sidewall extensive fibrosis and
Douglas pouch obliteration. Laparoscopic cystectomy and extensive adhesiolysis including
right ureterolysis were carried out successfully. Pathologic examination of the periureteral
excised tissue yielded endometriosis.

Conclusions
Ureteral involvement in pelvic organ endometriosis can be an unfortunate but rare and
ignored pathology. Preoperative evaluation of the urinary tract impairment in patients with

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endometriosis is important. Laparoscopic surgical approach is based on extent of disease and
can be carried out successfully in the hands of a highly experienced laparoscopic surgeon.

Keywords: endometriosis, ureterolysis, laparoscopy

Introduction

Endometriosis, a debilitating disease, is defined as the presence of functional endometrial-


like tissue (endometrial glands and stroma) outside the uterine cavity [1, 2]. In some ways, this
tissue has a similar behaviour as malignancies: estrogen-dependent progressive and invasive
growth, recurrence and a tendency to metastasize [1]. This chronic condition is estimated to
affect 5% - 10% of reproductive aged women [2, 3] having considerable economic implications
both for the patient and the National Health System [4]. Affecting primary the pelvic organs
(ovaries, the fossa ovarica, the uterosacral ligaments and the posterior cul-de-sac), those
ectopic implants can cause serious complications [3]. Ureteral involvement is a rare condition
(0.1-1% of women with endometriosis) [3, 5], frequently asymptomatic and which can cause
the kidney loss [3] because of the silent obstruction of the ureter [6]. Here, we present the case
of a 34-year-old woman with right side ovarian endometrioma and ureteral stenosis due to
fibrosis overlying the right pelvic sidewall, managed by laparoscopic approach.

Case presentation

34-year-old infertile woman with chronic non-cycling right side abdominal pain was
diagnosed during routine gynaecological examination with right side ovarian tumor. Her
menstrual cycles were normal. Her medical history was unremarkable. The vaginal sonography
revealed an 8/7 cm right side ovarian cystic tumor (with the ultrasound features of an
endometrioma), while the abdominal ultrasound pointed towards an asymptomatic right side
stage III hydroureteronephrosis with renal cortical thinning. The MRI investigation sustained
the initial diagnosis of ovarian endometrioma, highlighting the intimate relationship between
this tumor and the right side ureter and bowel. In addition, urography was performed aiming
to evaluate the length of the ureteral impairment, showing a serious narrowing of the right
ureteral diameter in its pelvic pathway (approximately 3 cm in length), with a delay of the
contrast substance’s excretion on the right side, while the left kidney and ureter appeared to be
normal at this investigation.
A multidisciplinary team formed by a gynaecologist, urologist and general surgeon
evaluated the case and took into consideration that the ureteral stenosis is secondary to
extensive pelvic endometriosis. Thus, preoperative management included a double J ureteral
stenting. Laboratory test results including urine analysis, urine culture, CBC and renal serum
biochemical tests were normal.
After 2 weeks, the patient was put under general anesthesia and laparoscopic standard
technique was performed using a 10 mm 30 degrees operative laparoscope and three 5 mm
auxiliary trocars with a intraabdominal pressure of 10-12 mm Hg. Laparoscopic inspection
revealed a right side ovarian tumor with thick smooth walls intimately adherent to the
bowel, pelvic sidewall extensive fibrosis and Douglas pouch obliteration. Laparoscopic
ovarian cystectomy and extensive pelvic adhesiolysis were carried out successfully. The
surgeon aimed to completely free the ureter from its adhesions, starting at the level where

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the ureter was visible and without adhesions and progressing downwards until its insertion
into the bladder. Intraoperative frozen section confirmed the previously suspected ovarian
endometrioma etiology, while the pathologic specimen of the periureteral excised tissue
yielded endometriosis.
Our patient was discharged on the 5th postoperative day and the double J stent was removed
after six weeks. Postoperative, the patient followed a 3 months of 3.75 mg Diphereline/
monthly treatment. At the 6, 12 and 18 months postoperative follow-up sessions, the pelvic
and urinary ultrasonographies showed no evidence of ovarian or hydronephrosis recurrence,
nor a pregnancy.

Discussions

From the onset of symptoms, the average time delay to diagnose endometriosis ranges
between 6 to 10 years [2, 7, 8]. This condition represents a significant healthcare system
burden, becoming essential to consider efforts that may decrease diagnostic delays and accurate
evaluate the extent of disease, thus reducing the number of incomplete or failed surgeries [2].
Endometriosis affects approximately 5 to 10% of women of reproductive age [2, 5].
Three types of endometriosis are described according to the morphology and localization:
ovarian, superficial peritoneal and deep infiltrative endometriosis (DIE) [3].
DIE most commonly invades the rectovaginal space, uterosacral ligaments, parametrium,
bowel or urinary tract [3]. Up to 5% of women having pelvic endometriosis associate urinary
tract endometriosis [9] and the most affected urinary organ is the bladder [10]. Ureteral
endometriosis is a rare condition (up to 1%) [9], evolving usually asymptomatic and leading
to silent renal failure due to obstructive uropathy [3, 11]. It is associated in two-thirds of cases
with ipsilateral ovarian endometriomas [4]. Commonly, the left side ureter is more frequently
involved (ratio 4:1) [3, 10-13] due its distal segment neighbouring to the reproductive organs
[11, 14]. Bilateral disease has been reported in up to 20-25% of the cases [15].
Ureteral endometriosis can be subcategorized into two types: intrinsic or extrinsic [6,
13], these two types often cannot be reliably distinguished from each other before surgery
[16]. The intrinsic type is more rare and characterized by the presence of endometriotic tissue
in the ureteral wall [6], in those cases the stenosis being more frequently and more severe
and associating more often hydronephrosis [9]. On the other hand, the extrinsic ureteral
endometriosis is more frequent (80% of ureteral endometriosis) [12, 13] and represented
by the presence of endometrial stromal and glandular tissue located in the proximity of the
ureter, but not infiltrating the ureteral muscularis [9, 12], leading rarely to ureteral stenosis and
hydronephrosis [8]. We consider our case being an extrinsic like type of ureteral endometriosis,
ascribing to the ovarian endometrioma extrinsic compression and extensive pelvic adhesions
the credit for the silent hydroureteronephrosis.
Clinical features of uterer endometriosis were absent in our case, the chronic pelvic pain
in the right side being several years considered non-specific and treated with NSAID. In
generally, the clinical characteristics of ureteral endometriosis is typically marked by non-
specific symptoms, and as many as 50% of patients are often asymptomatic, leading to silent
kidney loss in 25-50% cases [10]. Because of the poverty of clinical signs and insufficient
preoperative evaluation, ureteral endometriosis is suspected before surgery in only 40%
of patients [10] and 30 % of the patients will have reduced kidney function at the time of
diagnosis [14].

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Diagnosis of ureter endometriosis relies heavily on clinical suspicion [14]. With the
potential of silent kidney’s loss function, the suspicion may require prompt preoperative
investigation in patients in which there is a high likelihood of genitourinary endometriosis (for
ex. uterosacral ligaments clinically involved or ovarian endometriomas present) [14]. Renal
function should be assessed with laboratory tests and, if available, renal scintigraphy [4, 16].
Some authors recommend the use of pelvic ultrasound, intravenous pyelography,
ureteroscopy, two-dimensional endoluminal sonographic imaging of the ureter with 3D
reconstruction, CT or MRI/MRI excretion urography to facilitate diagnosis [4, 11, 14, 16].
3T-MRI technique enables precise preoperative mapping of deeply infiltrating endometriosis
implants, being either a single diagnostic method or a method complementary to prior
diagnostic procedures [17]. However, preoperative diagnosis is difficult, and ultimately, the
final diagnosis requires confirmation of deeply infiltrative endometrial tissue on a pathology
specimen [14].
When suspected ureteral endometriosis, systematic ureteric stenting prior to surgery
is recommended in all patients [11]. After extensive surgery in the area of the ureters, it is
recommended that ureteric stents should be left in place for four to six weeks [16].
Laparoscopy is the gold standard for definitive diagnosis and surgical treatment of
endometriosis [14, 18]. High power surgical instruments, combined with excellent vision
allow that laparoscopic dissection around the ureter occur with minimal complications [18].
For extrinsic ureteric endometriosis, surgery’s primary goal is to free (ureterolysis) and
decompress the ureter [16]. Laparoscopy allows direct localization of endometrial tissue around
the ureter, while its role in patients with intrinsic endometriosis is limited [11]. Karadag et
al. published an article in 2014 in which clearly state the lack of efficiency of laparoscopic
ureterolysis in cases of intrisic ureter endometriosis due to its high rate of reccurence [3]. In
intrinsic ureteric endometriosis, the objective is partial resection of the ureter with end-to-end
anastomosis or direct ureteric neoimplantation [3, 11, 16, 19]; though technically challenging,
these procedures can be performed by a skilled surgeon. In 2011, Frick at al. and Nehzat
et al. reported separately successfully robotic-assisted laparoscopic treatment of ureteral
endometriosis, insisting that the high costs of this procedure is outweighed by the benefit to
the patient [5, 20] although it has similar outcome with standard laparoscopy [20].
The prognosis of ureteral endometriosis depends on the time of diagnosis [11]. The
prognosis it is worsened by the bilateral ureteral and renal impairment secondary to the disease
itself of to the extensive pelvic surgery [11]. The resolution of ureteral obstruction is possible
after laparoscopic ureterolysis [21]. In case of an early diagnosis, an appropriate medical or
surgical treatment may prevent renal function deterioration. However, recurrence can occur
[11].

Conclusions

Ureteral involvement in pelvic organ endometriosis can be an unfortunate but rare and
ignored pathology. Preoperative evaluation of the urinary tract impairment in patients with
endometriosis is important. Laparoscopic surgical approach is based on extent of disease and
can be carried out successfully in the hands of a highly experienced laparoscopic surgeon.

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REFERENCES

1. Mehedintu, C., Plotogea, M.N., Ionescu, S., Antonovici, M. (2014). Endometriosis still a
challenge. J Med Life 7(3), pp.349-357.
2. Fraser, M.A., Agarwal, S., Chen, I., Singh, S.S. (2015). Routine vs. expert-guided
transvaginal ultrasound in the diagnosis of endometriosis: A retrospective review. Abdom
Imaging 40, pp.587–594.
3. Karadag, M.A., Aydin, T., Karadag, O.I., Aksoy, H., Demir, A., Cecen, K., Tekdogan,
U.Y., Huseyinoglu, U., Altunrende, F. (2014). Endometriosis presenting with right side
hydroureteronephrosis only: a case report. J Med Case Rep. Dec 11(8), pp.420.
4. Rozsnyai, F., Roman, H., Resch, B., Dugardin, F., Berrocal, J., Descargues, G., Schmied,
R., Boukerrou, M., Marpeau, L.; CIRENDO Study Group. (2011). Outcomes of surgical
management of deep infiltrating endometriosis of the ureter and urinary bladder. JSLS
15(4), pp.439-447.
5. Frick, A.C., Barakat, E.E., Stein, R.J., Mora, M., Falcone, T. (2011). Robotic-assisted
laparoscopic management of ureteral endometriosis. JSLS 15(3), pp.396-399.
6. Mu, D., Li, X., Zhou, G., Guo, H. (2014). Diagnosis and treatment of ureteral endometriosis:
study of 23 cases. Urol J. 11(4), pp. 1806-1812.
7. Hadfleld, R., Mardon, H., Barlow, D., Kennedy, S. (1996). Delay in the diagnosis of
endometriosis: a survey of women from the USA and the UK. Human Reproduction 11(4)
pp.878-880.
8. Santos, T.M., Pereira, A.M., Lopes, R.G., Depes Dde, B. (2012). Lag time between onset
of symptoms and diagnosis of endometriosis. Einstein (Sao Paulo) 10(1), pp. 39-43.
9. Camanni, M., Bonino, L., Delpiano, E.M., Berchialla, P., Migliaretti, G., Revelli, A.,
Deltetto, F. (2009). Laparoscopic conservative management of ureteral endometriosis: a
survey of eighty patients submitted to ureterolysis. Reprod Biol Endocrinol 7:109, pp.1-7.
10. Wang, P., Wang, X.P., Li, Y.Y., Jin, B.Y., Xia, D., Wang, S., Pan, H. (2015).
Hydronephrosis due to ureteral endometriosis in women of reproductive age. Int J Clin
Exp Med. 15;8(1), pp.1059-1065.
11. Ponticelli, C., Graziani, G., Montanari, M. (2010). Ureteral endometriosis: a rare and
underdiagnosed cause of kidney dysfunction. Nephron Clin Pract 114, pp.89–94.
12. Mason, R.J., Alamri, A., Gusenbauer, K., Kapoor, A. (2016). Intrinsic ureteral
endometriosis as a cause of unilateral obstructive uropathy. Urol Assoc J 10(3-4), pp.
119-121.
13. Machairiotis, N., Stylianaki, A., Dryllis, G., Zarogoulidis, P., Kouroutou, P., Tsiamis,
N., Katsikogiannis, N., Sarika, E., Courcoutsakis, N., Tsiouda, T., Gschwendtner,
A., Zarogoulidis, K., Sakkas, L., Baliaka, A., Machairiotis, C. (2013). Extrapelvic
endometriosis: a rare entity or an under diagnosed condition? Diagn Pathol. Dec 2; 8:194.
14. Nezhat, C., Paka, C., Gomaa, M., Schipper, E. (2012). Silent loss of kidney seconary to
ureteral endometriosis. JSLS 16(3), pp. 451-455.
15. Kumar, S., Tiwari, P., Sharma, P., Goel, A., Singh, J.P., Vijay, M.K., Gupta, S., Bera,
M.K., Kundu, A.K. (2012). Urinary tract endometriosis: Review of 19 cases. Urol Ann.
4(1), pp.6-12.
16. Halis, G., Mechsner, S., Ebert, A.D. (2010). The diagnosis and treatment of deep
infiltrating endometriosis. Dtsch Arztebl Int. 107(25), pp.446-455.
17. Bianek-Bodzak, A., Szurowska, E., Sawicki, S., Liro, M. (2013). The importance and
perspective of magnetic resonance imaging in the evaluation of endometriosis. Biomed

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Res Int.
18. Smith, I.A.R., Cooper, M. (2010). Management of ureteric endometriosis associated with
hydronephrosis: An Australian case series of 13 patients. BMC Research Notes, 3:45.
19. Nezhat, C.H., Malik, S., Nezhat, F., Nezhat, C. (2004). Laparoscopic ureteroneocystostomy
and vesicopsoas hitch for infiltrative endometriosis. JSLS. 8(1), pp.3-7.
20. Nezhat, C., Hajhosseini, B., King, L.P. (2011). Robotic-assisted laparoscopic treatment of
bowel, bladder, and ureteral endometriosis. JSLS. 15(3), pp.387-392.
21. Nezhat, C., Nezhat, F., Nezhat, C.H., Nasserbakht, F., Rosati, M., Seidman, D.S. (1996).
Urinary tract endometriosis treated by laparoscopy. Fertil Steril. 66(6), pp. 920-924.

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Modified Aburel Procedure for the Treatment of


Uterine Prolapse with Stress Urinary Incontinence –
Personal Experience

MITRAN Mihai1,2, PANA Doru1, POPESCU Alina3,


VELICU Octavia1, COMANDASU Diana-Elena4,
BRATILA Elvira1,4
1
“Panait Sarbu” Obstetrics and Gynecology Clinical Hospital, Bucharest, (ROMANIA)
2
UMF “Carol Davila” Bucharest, Obstetrics-Gynecology Department, Bucharest (ROMANIA)
3
“Panait Sarbu” Obstetrics and Gynecology Clinical Hospital, Research Department, Bucharest,
(ROMANIA)
4
“Sf. Pantelimon” Clinical Emergency Hospital, Bucharest (ROMANIA)
E-mails: michael_digital@yahoo.om, dorupana@yahoo.com, dr.apopescu68@gmail.com , diana.
comandasu@yahoo.com, elvirabarbulea@gmail.com

Abstract

Uterine prolapse occurs when pelvic floor muscles and ligaments stretch and weaken.
Pelvic organs prolapse (POP) appears in more than 50% on women, 75% of them having
different stages of POP and accusing different symptoms at the gynecologist. We propose
to present a personal technique designed for the surgical approach of uterine prolapse,
describing the surgical steps and the postoperative results according to our experience. Our
technique is based on Proffesor’s Aburel pyramidalopexy indicated for simple hysteropexies,
in case of first and second degree uterine prolapse. We described and used the technique of
colpoistmopyramidalopexy, with indication in cases of first and second degree of POP with
stress urinary incontinence (SUI). We start by practicing a subtotal hysterectomy with bilateral
salpingectomy in case of patients younger than 45 years old, respectively adnexectomy in
patients older than 45 or presenting ovarian abnormalities. The second important difference
from the original technique is represented by the support technique by anchoring of the
second thread to the folded utero-sacral ligaments, instead of the round ligaments. The main
indication of the procedure was represented in our study by stage 1 or 2 uterine prolapse
with stress urinary incontinence associated or not with uterine leiomyomas. The inclusion
criteria were represented by negative colposcopy, normal PAP smear and negative HPV-DNA
genotyping. Exclusion criteria were the following: any type of cervical pathology, modified
PAP smear, positive HPV-DNA testing for high-risk genotypes. The study was conducted
between March 2015 and September 2016 and included a number of 10 patients. We used
a randomization algorithm, with the rigorous compliance of both inclusion and exclusion
criteria. Our procedure showed significant reduction of stress urinary incontinence quantified
both clinically and subjectively through questionnaires. All patients showed improvement
of urinary and sexual dynamics. The surgical technique described by us is relatively simple
to understand and execute. The postoperative evolution after modified Aburel procedure is
simple, associating a low risk of relapse or fistula. Compared to other surgical techniques used

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in the treatment of pelvic organ prolapsed, it has lower risks of intraoperative lesions.
Also, the procedure is inexpensive, since it does not use expensive heterologous mesh-
type materials and it does not require specialized tools. The absence of phenomena specific
to heterologous material including processes like rejection, erosion or dyspareunia represents
another advantage of the method.

Keywords։ pelvic organ prolapse, stress urinary incontinence, colpo-isthmo-pyramidalopexy, Aburel


procedure

Introduction

Uterine prolapse occurs when pelvic floor muscles and ligaments stretch and weaken. The
uterus then slips down into or protrudes out of the vagina. Uterine prolapse can happen to
women of any age, but it often affects postmenopausal women who have had one or more
vaginal deliveries. Pelvic organs prolapse (POP) appears in more than 50% on women, 75%
of them having different stages of POP and accusing different symptoms at the gynecologist.
[1] [2]
The staging of Pelvic Organ Prolapse according to Baden – Walker grade system includes:
 0 - Normal position for each respective site, no prolapse;
 1 - Descent halfway to the hymeneal ring;
 2 - Descent to the hymeneal ring;
 3 - Descent halfway past the hymeneal ring;
 4 - Maximal possible descent. [1]
Pelvic organ prolapse quantification stage system defines the following stages:
 I > 1 cm above the hymeneal ring;
 II < 1 cm proximal or distal to the plane of the hymeneal ring;
 III > 1 cm below the plane of the hymen, but protrudes no further than 2 cm less than the
total vaginal length;
 IV - Eversion of the lower genital tract is complete. [1]
There are many factors involved in uterine prolapse etiology, including vaginal delivery,
chronic increases in intra-abdominal pressure (e.g. chronic obstructive pulmonary disease),
obesity, smoking, advanced age, estrogen deficiency, diabetes mellitus, pelvic trauma (include
pelvic surgery damages). There are also risk factors that predispose a woman to POP like race,
sex, genetics (abnormalities in the anatomy, physiological features and cellular biological
features of muscular and vaginal wall). [2]
Genetic factors are linked to collagen subtypes and tissue metabolism, elastin and elastin
turnover. Also the matrix metalloproteinases are involved in tissue metabolism.
Age has an important role in uterine prolapse etiology and that seems to be a general
agreement. The rate of prolapse surgery increases with age, the peak incidence being in the
sixth decade. [3]
The role of estrogen hormones is very important (it is known that there are estrogen
receptors on the nuclei of connective tissue and smoth muscle cells of the bladder trigone,
urethra, vaginal mucosa, levator ani muscle, arcus tendinous and uterosacral ligaments). Some
studies demonstrate that there is a decrease of collagen concentration that corresponds to
estrogen decrease (menopausal state). [4]
In addition, hormone therapy used longer than five years may have a protective role in
pelvic dysfunctions appearance.

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Rizk and Fahim conclude that: «The hypothesis that estrogen deficiency after the menopause
accelerates the adverse effects of biological aging on pelvic floor support mechanisms…seems
plausible.»
Some surgeons believe that abnormalities of the connective tissue and impediments in
connective tissue repair may predispose to prolapse. Tissue denervation and devascularization,
anatomic alterations and increased degradation of collagen may all lead to a decrease in
mechanical strength and predispose the individual to prolapse. [5]
Is well known that collagen is the most common protein of the body and there are different
collagen types involved in ensuring the strength of tissues and resistance to external mechanical
forces. The age and abnormalities in collagen metabolism and pelvic prolapse are associated
with collagen changes. The most important types of collagen are: type I, type II, type III,
glycoprotein collagen (proteinglycans).
Some studies have confirmed presence of abnormal histological structures in association
with prolapse. Increased collagen destruction is associated with pelvic prolapse. [6]

Purpose

We propose to present an original technique designed for the surgical approach of


uterine prolapse, describing the surgical steps and the postoperative results according to our
experience. Our technique is based on Proffesor’s Aburel’s pyramidalopexy indicated for
simple hysteropexies, in first and second degree uterine prolapse. We described and used a
technique of colpo-isthmo-pyramidalopexy, with indication in cases of grade 1-2 of pelvic
organ prolapse with stress urinary incontinence.

Material and method

Our idea was to use autologous tissue, which can be interposed between the bladder
and the uterine isthmus, thus raising the cisto-urethral junction. We performed Aburel’s
technique, which mainly describes a histeropexy, in case of retroversoflexed uteri with first or
second degree prolapse, with some personal modifications. We start by practicing a subtotal
hysterectomy with bilateral salpingectomy in case of patients younger than 45 years old,
respectively adnexectomy in patients older than 45 or presenting ovarian abnormalities. The
second important difference is represented by the support technique, respectively by anchoring
of the second thread to the folded uterosacral ligaments, instead of the round ligaments. The
main indication of the procedure was represented in our study by fisrt and second degree
uterine prolapse with stress urinary incontinence associated or not with uterine leiomyomas.
The inclusion criteria were represented by colposcopic negative cervix, normal PAP
smear and negative HPV-DNA genotyping. Exclusion criteria were the following: any type of
cervical pathology, modified PAP smear, positive HPV-DNA testing for high-risk genotypes.
The study was conducted between March 2015 and September 2016 and included a
number of 10 patients. We used a randomization algorithm, with the rigorous compliance
of both inclusion and exclusion criteria. All the patients signed an informed consent after
thorough explanation of the procedure and study design, and the Ethics Committee of the
hospital approved our study.

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Results

From the preliminary results of our study we can affirm that our new surgical technique
for first and second degree uterine prolapse associated with stress urinary incontinence had
good postoperative results at six weeks follow-up. Thus, the modified Aburel colpo-itshmo-
pyramidalopexy procedure showed significant reduction of stress urinary incontinence
quantified both clinically and subjectively through questionnaires with visual analog scales
and at the same time reduction until disappearance of the cystocele. All 10 patients from the
group showed improvement of the urinary and sexual dynamics. As for disease relapses, there
were no cases of recurrent prolapse after this procedure. The limitations of our study were
represented by the reduced number of cases, as we could not carry out a study on a large group,
but it is a prospective, ongoing study; all selected patients were diagnosed with second degree
uterine prolapse; last but not least, the difficult access to the cervix postoperative, for cytology
and colposcopy monitoring represents another disadvantage.

Debates

The treatment of POP includes hygienic-dietary measures like weight reduction, treating
constipation or chronic coughing, avoiding heavy lifting and pelvic floor exercises (Kegel)
efficient in incipient forms of prolapse, the insertion of a removable silicone pessary into the
vagina which supports the pelvic organs or finally, if these non-surgical actions don’t have a
good therapeutic response, prolapse surgery. [7]
The surgical approach of POP includes a series of interventions described over time,
which needs to be personalized according to the type and stage of the prolapse in each case.
The surgical approach can be vaginal, laparoscopic, abdominal or a combination of them.
According to the compartment where the defect is encountered, we can describe anterior
vaginal wall prolapse, posterior vaginal wall prolapsed and apical and uterine prolapse. Surgery
addresses to each of these compartments according to the anatomy and the physiopathological
mechanism. Anterior compartment prolapse can be treated using an anterior colporrhaphy
which can be associated with an anterior bridge, indicated especially in patients showing a
central vaginal defect, by folding the pubocervical fascia and diminishing the bladder and
anterior vaginal protrusion.
In cases of large cystoceles or association with stress urinary incontinence, placement of
a polypropylene mesh with transobturator passage can be useful. [8] Paravaginal defect can
be addressed laparoscopically, abdominally or vaginally by opening the retropubic space of
Retzius and reattaching the anterolateral vaginal sulcus with the overlying endopelvic fascia to
the obturator internus and pubococcygeus muscles and fascia at the arcus tendineus fascia of
the pelvis. Posterior compartment repair involves traditionally a colpoperineoplasty with the
folding of the rectovaginal fascia in the midline and thus the reduction of the rectocele. The
use of synthetic materials in the posterior compartment is restricted, as erosion complication
incidence is higher in this area. Regarding apical vaginal prolapse and uterine prolapse the most
frequently used abdominal interventions are laparoscopic sacral colpopexy and total abdominal
hysterectomy with high uterosacral ligament suspension. That way is achieved the fixation of
the upper vagina or the uterus to the sacrum surface, by using meshes and sutures or autologous
fascia lata through the anterior sacral ligament (presacral fascia) at the level of the sacral
promontory or at S1-S2. [9] Other more rarely used procedures are Marion-Moschcowitz that

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involves a spiral suture around the rectovaginal pouch which is closed circumferentially and
Halban that involves a few sutures in the sagittal plane closing the anterior and posterior parts
of the pouch of Douglas. Vaginal approach of uterine prolapse is preferred by many surgeons
due to the shorter recovery period and shorter intraoperative time compared to abdominal
interventions. The most commonly used techniques for the suspension of the prolapsed uterus
are the sacrospinous ligament fixation, the modified McCall culdoplasty, the iliococcygeus
suspension and high uterosacral ligament suspension. All these vaginal procedures require the
use of heterologous material including mostly polypropylene macropore meshes, which carry
specific postoperative complications. Other vaginal interventions used for POP are Manchester
operation (including anterior colporrhaphy, cervix amputation and the upper vagina lifting
using transverse cervical ligament sutures) or LeFort colpocleizis as obliterative procedure in
case of patients that do not wish to preserve their sexual function. [10]
Proffesor Eugen Aburel described the surgical technique of pyramidalopexy, indicated in
his opinion for simple histeropexies in case of first and second degree uterine prolapsed. The
procedure involves a Pfannenstiel incision with the preparation of the muscular-aponeurotic
flap and its fixation with a first thread at the top of the flap and the caudal portion of the vagina,
a second thread to the vagina, folding it and at 1 cm from the pyramidal flap. The third thread
will include the round ligament, the bladder peritoneum paramedian right, the superior side
of the pyramid flap near the base, the bladder peritoneum paramedian left, the corresponding
round ligament and the anterior uterine surface at 1 cm above the flexion fold. During the entire
procedure the uterus remains in its place. The last operating step is represented by restoration
of the abdominal wall by consolidating the base of the pyramidal flap and completing its
peritonization.
Aburel modified procedure imagined by us or colpo-isthmo-pyramidalopexy is indicated
in cases of first or second degree prolapse associated with stress urinary incontinence. The
technique also involves a Pfanennstiel incision with the opening of the peritoneal cavity and
pelvic organ inspection. We then perform a subtotal hysterectomy, with the bladder peritoneum
detachment off the cervix and vagina highlighting. (Fig. 1) The vagina is then folded using an
‘eight shaped’ no. 1 polyglycoic acid thread left free on a clamp. (Fig. 2) After that a thread
is passed at 1 cm from the utero-sacral ligament insertion, folding them with it and keeping
it on a clamp. (Fig. 3) The next step is the preparation of the muscular-aponeurotic flap, in
such way that the pyramidal muscles insertion on the aponeurosis is kept. (Fig. 4) The flap is
fixed then with the top at the vaginal thread and with the median part at the utero-sacral folded
ligaments. (Fig. 5) The final step is represented by the restoration of the abdominal wall, with
the consolidation of the flap without peritonization.
The modifications we brought to the initial Aburel procedure take into account the
physiopathology of SUI and, not least, the symptomatology of the patients. We perform a
subtotal hysterectomy with bilateral tubal excision, considering the recent studies suggesting
an increased risk of endometrial cancer or tubal cancer in patients over 40 years. Most
patients also have smaller or larger uterine leiomyomas and do not want to preserve their
fertility any more. The intervention can be completed with a Crossen type classic posterior
colpoperineoplasty with perineal miorraphy or posterior bridge in case of small or moderate
rectocele. (Fig. 6, 7, 8)

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Fig. 1. Cervical stump after Fig. 2. Folded vagina Fig. 3. Folded utero-sacral
subtotal hysterectomy with an ‘eight shaped’ ligaments
thread

Fig. 4. Musculo-aponeurotic flap Fig. 5. Fixation of the flap to the vaginal and
preparation utero-sacral threads

Fig. 6. Preoperative aspect Fig. 7. Postoperative aspect Fig. 8. Aspect after


Crossen colpoperineoplasy
Conclusions

The surgical technique described by us is relatively simple to understand and execute. The
postoperative evolution after modified Aburel procedure is simple, associating a low risk of
relapse or fistula. The procedure has good urinary and sexual functional results. Compared
to other surgical techniques used in the treatment of pelvic organ prolapsed, it has lower
risks of intraoperative lesions – e.g. injuries of the bladder, rectum. Also, the procedure is
inexpensive, since it does not use expensive heterologous mesh-type materials, and it does

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not require specialized tools. The absence of phenomena specific to heterologous material
including processes like rejection, erosion or dyspareunia represents another advantage of
the method. The technique can be used including in small provincial hospitals which don’t
have the facilities and technical possibilities met in university centers. The main condition for
obtaining all the advantages of the procedure is the rigorous fulfillment of inclusion criteria.

REFERENCES

1. Uterine Prolapse Deffinition – Mayo Clinic.


2. Tinelli, A., Malvasi, A., Rahimi, S., Negro, R., Vergara, D., Martignago, R., Pellegrino,
M., Cavallotti, C. (2010) Age-related Pelvic Floor Modifications and Prolapse Risk
Factors in Postmenopausal Women.Menopause; 17(1):204-212.
3. Kuncharapu, I., Majeroni, B.A., Johnson, D.W. (2010) Pelvic Organ Prolapse. Am. Fam.
Physician; 1;81(9):1111-1117.
4. Onwude, J.L. (2007) Genital prolapse in women. Clin. Evid. (Online); http://
clinicalevidence.bmj.com/ceweb/conditions/who/0817/0817_T1.jsp.
5. Bratila, E., Bratila, P., Coroleuca, C., Argaseala, I. (2015). Complicatii uroginecologice
in chirurgia vaginala.
6. Lazarou, G., Grigorescu, B.A., Talavera, F., Karjane, F.W., Strohbehn, K., Trupin, S.R.
(2016). Pelvic Organ Prolapse Treatment & Management. http://emedicine.medscape.
com/article/276259.
7. Bratila, E., Bratila, P.C. (2010). Laparoscopically assisted vaginal colophysterosacropexy.
Gineco.ro, an VI, volume VI, nr. 20.2/2010, pg. 118 – 122.
8. Bratila, E., Bratila, P.C., Negroiu A.T. (2014). Vaginally-assisted laparoscopic
hysterosacropexy for advanced utero-vaginal prolapse: a series of 32 casesPublicatia:
Revista Ars Medica Tomitana; 2(77): 63-70, 10.2478/arsm-2014-0012, Volume 20, Issue
2 (May 2014), pg. 63-70.
9. Brătilă, E., Vlădăreanu, S., Berceanu, C., Cîrstoiu, M., Mehedințu, C., Comandașu, D.,
Mitran, M. (2015). Rolul sarcinii și al nașterii în apariţia tulburărilor de statică pelvică;
Revista Ginecologia.ro, Anul III, Nr.10, (4/2015), pg. 28-33, ISSN 2344 – 2301, ISSN – L
2344 – 2301.
10. Bratila, E., Bratila, C.P, Stanculescu, R., Comandasu, D.E. (2015). New alternative for
treatment of advanced uterovaginal prolapse in postmenopausal women; Maturitas. An
International Journal of Midlife Health and Beyond Volume 81, Issue 1 (2015), page 253.

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Reconstructive options in managing the neurogenic


bladder disfunction in children

MUNTEANU Alexandra1, FILIPOIU Florin2, IONESCU


Sebastian1, CIRSTOIU Monica3, RADULESCU Luiza4,
STAVARACHE Irina5, MUNTEANU Octavian2

1
Department of Pediatric Surgery, Emergency Clinical Hospital for Children “M.S. Curie” (ROMANIA)
2
Department of Anatomy, “Carol Davila” University of Medicine and Pharmacy Bucharest (ROMANIA)
3
Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy
Bucharest (ROMANIA)
4
Department of Neonatology, Universitary Emergency Hospital of Bucharest (ROMANIA)
5
“Carol Davila” University of Medicine and Pharmacy Bucharest (ROMANIA)
Correspondence to Octavian Munteanu E-mail: octav_munteanu@yahoo.com

Abstract

Introduction
One of the areas targeted intensively by pediatric urologists in the last years, is the
management of neurogenic incontinence in children, a condition with an important social and
psychological impact. In these patients there is an asynchrony between the urethral sphincter
and detrusor muscle tonus which causes the impossibility of urination.

Materials and methods


We performed a meta-analysis of the international specialized literature published in the
last years, in order to determine the long-term benefits of reconstructive options used in the
reconstructive treatment of neurogenic sphincter incontinence in children. Profile databases
(PubMed, ISI Web of Science, Cochrane, the US National Library of Medicine and Science
Direct) accounted for the search platform of eligible articles. In addition, each article’s
bibliography was studied in this meta-analysis for a more accurate assessment. The results of
each bladder reconstruction technique were compared using six main objectives - continence,
intermittent need of catheterization, the effects on bladder compliance, the need of bladder
augmentation, the upper urinary tract changes and other complications.

Results
Using an artificial bladder sphincter is the optimal long-term solution compared with other
techniques described. The Kropp bladder neck reconstruction technique has a high rate of
postoperative complications. The data on the sling of neck bladder, urethral lengthening or the
suspension were limited.

Conclusion
According to studies that were conducted in the last years, the first line of treatment in

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children with neurogenic incontinence is the implant of an artificial bladder sphincter and
not Kropp’s technique of bladder neck reconstruction, due to low rates of postoperative
complications.

Keywords: meta-analysis, management, neurogenic sphincter incontinence

introduction

Neurogenic bladder is a condition where there is an abnormal functioning of the bladder


caused by central or peripheral nervous system conditions or secondary to pelvic pathology.
It can be acquired or congenital [1]. In pediatric population neurogenic bladder appears
frequently as a consequence of nervous system pathologies such as spinal cord injury, cerebral
palsy, spinal dysraphism, myelomeningocele, lipomeningocle or sacral agenesis. Acquired
causes appear due to pelvic pahology such as malformations or tumors [2-4].
This disease leads to loss of bladder fullness sensation and therefore the patient can
not urinate in one large portion and at the same time urinary incontinence and urinary tract
infections appear [1].
Urinary bladder’s role is to store and eliminate urine in a coordinated, controlled way
[2, 5]. The storage and evacuation are possible with the normal function of bladder neck,
striated external sphincter and detrusor muscle [5]. When there is an asynchrony between
detrusor muscle and urinary sphincter normal urination is not possible and therefore urinary
incontinence occurs. Detrusor muscle is innervated by fibers from sacral plexus and the
sphincter and bladder are innervated by conus medullaris [3].
Neurogenic bladder sphincter dysfunction can lead to bladder-wall disruption and severe
and irreversible renal disease [6].
The management of children with neurogenic incontinence remains a challenge and some
procedures to maintain the continence can be used.
There are some children with neurogenic dysfunction that might respond to alpha-
sympathomimetics agents and intermittent catheteziation, however most of them require
surgical procedures of bladder neck to achieve continence [6, 7].

materials and methods

We performed a meta-analysis of the international specialized literature published in the


last years, in order to determine the long-term benefits of reconstructive options used in the
reconstructive treatment of neurogenic sphincter incontinence in children.
Profile databases (PubMed, ISI Web of Science, Cochrane, the US National Library of
Medicine and Science Direct) accounted for the search platform of eligible articles. In addition,
each article’s bibliography was studied in this meta-analysis for a more accurate assessment.
The results of each bladder reconstruction technique were compared using six main
objectives:

- continence;
- intermittent need of catheterization;
- the effects on bladder compliance;
- the need of bladder augmentation;

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- the upper urinary tract changes;
- other complications.
All data was interpreted using SPSS™ 9 and Microsoft Excel™

results

This pathology has an important social and psychological impact and therefore the
management of urinary sphinteric incontinence represents a challenge and there is no single
surgical technique to be cited as universally effective [8]. Moreover there is not a consensus
regarding the definition of dryness which is often confounded with the effect of simultaneous
bladder augmentation cystoplasty [9, 10].
To re-establish the urinary continence the resistance of bladder outlet has to be incresead
[10]. This increasing can be realised with major reconstructive surgical procedures such as
artificial urinary sphincter, bladder neck closure, urethral lengthening or slingplasty [10].

Artificial urinary sphincter

The gold standard treatment for urinary incontinence in males is using an artificial urinary
sphincter [11, 12]. It is a successful procedure that improves the patient’s life quality although
the risk of future surgical procedures can occur in 20-50% of men [11]. The efficacy of this
method in pediatric population is reported to be 80-92% [12].
Clark et al. demonstrated that there risk factors for complications and reoperation are:
infections, exposure to radiations, artificial urinary sphincter erosion and the surgeon’s lack of
experience [11].
Belloli, G et al. state that this procedure is used only when the patient does not respond
to conservative treatment or is unfitable for such conservative procedures [12]. It can be
used in children elder than 11 years old [12]. There are some conditions for this procedure
to be succesful. Detrusor hyperreflexia has to be excluded or pharmacologically controlled,
the bladder compliance has to be normal, the bladder’s storage ability has to be intact, the
emptying of the bladder has to be complete, without residual urine and the upper urinary tract
should not have anomalies [12].
Bar-Yosef et al. demonstrated in a study on 21 children with mielomenengocel that artifical
urinary sphincter is a trustworthy method for patients with neurogenic bladder because it
provides sustainable high rates of urinary continence with durable results [13].

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Figure 1. – Cystoscopic aspect in a patient diagnosed with neurogenic bladder disfunction

Bladder neck closure

Bladder neck closure is a procedure which blocks the normal communication between
urethra and bladder [14]. The eficaccy of this procedure varies between 80 and 100% [14,
15]. It should be used to control urinary incontinence only when the others procedures failed
because it is an irreversible surgical technique. During this procedure ejaculatory ducts,
hypogastric nerve and pelvic splanchnic plexus can be damaged [14].
Hernandez-Martin et al. demonstrated on a group of 20 patients aged between 4 and 19
years that bladder neck closure is an effective approach to incontinence when other methods
failed [15]. It achives urinary continence in most patients. The most frequent long term
complications are those related to calculi and catheterizable stoma [15].
De Troyer et al. compared open bladder neck surgery (n=40 patients) with bladder neck
closure (n=23 patients) and observed that the continence rate was higher in the group with
bladder neck closure [16]. Therefore, this procedure can be used in children with intractable
incontinence. It does not present extra morbidity and the succesful rate is high.

Slingplasty

In a 14-year observational study Snodgrass and Granberg observed that the combination
between bladder neck sling and augmentation achieved dryness in 37 to 88% [17].
Daneshmand et al. demonstrated that in selected male patients puboprostatic fascial sling
can be an effective procedure [18]. It is an easy method and it avoids the difficulties of bladder
neck surgery [18]. Slingplasty and bladder augmentation can prevent the need for prosthetics
[18].
Nguyen et al. observed in a group of 7 boys who underwent placement of a fascial sling
around neck bladder for neurogenic sphinteric incontinence due to myelodysplasia, sacral
agenesis and spinal trauma that rectus fascial sling was a succesful procedure to treat the

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incontinence [7]. Continence was achived after 3 to 6 months and remained durable in time
[7].

Kropp’s procedure

Kropp’s procedure is a technique şin which the urethra is narrowed and lenghtened while
a detrusor flap is tubularized and inplanted into the trigone, creating a flap-valve mechanism
[19]. Postoperative complication rate is high [19].
Szymanski et al. observed that Kropp’s and Salle’s procedures achieved the following
rates of dryness: 75-78% at 4-hourly intervals and 88-94% at 3-hourly intervals [20]. Difficult
catetherization is one of the most frequent complications [20].

conclusion

According to studies that were conducted in the last years, the first line of treatment in
children with neurogenic incontinence is the implant of an artificial bladder sphincter and
not Kropp’s technique of bladder neck reconstruction, due to low rates of postoperative
complications.

REFERENCES

1. Verpoorten, C., Buyse G.M. (2008). The neurogenic bladder: Medical treatment. Pediatric
Nephrology 23(5), pp. 717–725.
2. Mahajan, P.V. Subramanian, S., Danke, A., Kumar, A. (2016) Neurogenic Bladder Repair
Using Autologous Mesenchymal Stem Cells. Case Reports in Urology.
3. Golbidi, S., Laher I. (2010). Bladder dysfunction in diabetes mellitus. Frontiers in
Pharmacology. 1, pp. 136.
4. Sturm, R.M., Cheng, E.Y. (2016). The Management of the Pediatric Neurogenic Bladder.
Current Bladder Dysfunction Reports. 11(3), pp. 225-233.
5. Goeshen, K., Petros, P., Funogea, A., Brătilă, E., Brătilă, P., Cîrstoiu M., (2015). Planșeul
pelvic la femeie. Anatomia funcțională, diagnostic și tratament-în acord cu teoria
integrativa, Editura Universitara “Carol Davila”, Bucuresti.
6. Verpoorten, C., Buyse, G.M. (2008). The neurogenic bladder: medical treatment. Pediatric
Nephrology (Berlin, Germany). 23(5), pp. 717-725.
7. Nguyen, H. T., Bauer, S. B., Diamond, D. A., Retik, A. B. (2001). Rectus fascial sling for
the treatment of neurogenic sphincteric incontinence in boys: is it safe and effective?. The
Journal of urology, 166(2) pp. 658-661.
8. Churchill, B.M., Bergman, J., Kristo, B., Gore, J. L. (2010). Improved continence in
patients with neurogenic sphincteric incompetence with combination tubularized posterior
urethroplasty and fascial wrap: The lengthening, narrowing and tightening procedure. The
Journal of Urology 184(4), pp. 1763-1767.
9. Lloyd, J. C., Spano, S. M., Ross, S. S., Wiener, J. S., Routh, J. C. (2012). How dry is dry?
A review of definitions of continence in the contemporary exstrophy/epispadias literature.
The Journal of urology, 188 (5), pp. 1900-1904.
10. Alova, I., Margaryan, M., Bernuy, M., Lortat-Jacob, S., Lottmann, H. B. (2012). Long-
term effects of endoscopic injection of dextranomer/hyaluronic acid based implants for

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treatment of urinary incontinence in children with neurogenic bladder. The Journal of
urology, 188(5), pp. 1905-1909.
11. Clark, R., Winick-Ng, J., McClure, J. A., Welk, B. (2016). Corticosteroid Usage is
Associated with Increased Artificial Urinary Sphincter Reoperation.Urology.
12. Belloli, G., Bedogni, L., Musi, L. (1984). Urinary incontinence in the neuropathic
bladder in children. Treatment using an artificial urinary sphincter. La Pediatria medica e
chirurgica: Medical and surgical pediatrics, 7(5), pp. 685-690.
13. Bar-Yosef, Y., Castellan, M., Joshi, D., Labbie, A., Gosalbez, R. (2011). Total continence
reconstruction using the artificial urinary sphincter and the Malone antegrade continence
enema. The Journal of urology, 185(4), pp. 1444-1448.
14. De Troyer, B., Van Laecke, E., Groen, L. A., Everaert, K., Hoebeke, P. (2011). A
comparative study between continent diversion and bladder neck closure versus continent
diversion and bladder neck reconstruction in children.Journal of pediatric urology, 7 (2),
pp. 209-212.
15. Hernandez-Martin, S., Lopez-Pereira, P., Lopez-Fernandez, S., Ortiz, R., Marcos, M.,
Lobato, R., Jaureguizar, E. (2015). Bladder neck closure in children: long-term results and
consequences. European Journal of Pediatric Surgery, 25 (01), pp. 100-104.
16. De Troyer, B., Van Laecke, E., Groen, L. A., Everaert, K., Hoebeke, P. (2011). A
comparative study between continent diversion and bladder neck closure versus continent
diversion and bladder neck reconstruction in children.Journal of pediatric urology, 7 (2),
pp. 209-212.
17. Snodgrass, W., Granberg, C. (2016). Clinical indications for augmentation in children
with neurogenic urinary incontinence following bladder outlet procedures: Results of a
14-year observational study. Journal of pediatric urology, 12 (1), 46-e1.
18. Daneshmand, S., Ginsberg, D. A., Bennet, J. K., Foote, J., Killorin, W., Rozas, K. P.,
Green, B. G. (2003). Puboprostatic sling repair for treatment of urethral incompetence in
adult neurogenic incontinence. The Journal of urology, 169 (1), pp. 199-202.
19. Kropp, K. A., Angwafo, F. F. (1986). Urethral lengthening and reimplantation for
neurogenic incontinence in children. The Journal of urology, 135 (3) pp 533-536.
20. Szymanski, K. M., Rink, R. C., Whittam, B., Ring, J. D., Misseri, R., Kaefer, M., Cain, M.
P. (2016). Long-term outcomes of the Kropp and Salle urethral lengthening bladder neck
reconstruction procedures. Journal of Pediatric Urology.

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Reconstructive options after iatrogenic ureteral lesions

MUNTEANU Octavian1,2, MUNTEANU Alexandra3,


VOICU Diana2, BODEAN Oana2, BOHALTEA Roxana2,4,
BRATILA Elvira5, CIRSTOIU Monica2,4

1
Department of Anatomy, “Carol Davila” University of Medicine and Pharmacy Bucharest (ROMANIA)
2
Department of Obstetrics and Gynecology, Universitary Emergency Hospital of Bucharest (ROMANIA)
3
Department of Pediatric Surgery, Emergency Clinical Hospital for Children “M.S. Curie” (ROMANIA)
4
Department of Obestrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy
Bucharest (ROMANIA)
5
Department of Obstetrics and Gynecology, Universitary Emergency Hospital of Bucharest (ROMANIA)
E-mail: drzlatianualexandra@gmail.com (Munteanu Alexandra)

Abstract

Introduction
Gynecological surgeries are responsible for 50% of iatrogenic ureteral injuries. Therefore
rapid recognition and appropiate management of any type of iatrogenic ureteral lesion are
essential goals of any surgeon operating in the pelvis.

Material and Methods


In order to evaluate reconstructive options after iatrogenic ureteral trauma we performed a
meta-analisys of the international specialized literature published in the last years. Therefore
we reviewed all publications with this topic cited in the main profile databases (PubMed, ISI
Web of Science, Cochraine, the US National Library of Medicine and Science Direct). The
statistical interpretation of the data was carried out using Windows Excel 2010™ and SPSS™
programs.

Results
Most specialists use a scale of 5 degrees in classification of iatrogenic ureteral lesions. In
most publications analyzed management depends on the type of iatrogenic utereteral trauma
(angulation crushed by the improper application of forceps, ligation, sectioning (partial or
complete) resection or stripping peri-ureteral vascular plexus) and its location.

Conclusions
Studies published in the past years have shown that pelvic segment of the ureter is most
often damaged, especially during surgical gynecological interventions. The management of
these patients depends on: the location of the trauma, its dimensions, the manner in which the
ureter was affected, and the anatomic characteristics of the patient.

Keywords: meta-analysis, reconstructive options, iatrogenic ureteral injuries

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Introduction

Surgical treatment in Obstetrics and Gynecology is responsible up to 75% of urinary tract


injury, 75% for benign indication [1, 2]. Gynecological surgery injures the lower urinary tract
due to the close embryological and anatomical relationship of the genital tract and urethra,
bladder and ureters [1, 2].
Urinary tract injuries have to be rapidly recognized because they are leading to long-term
morbidity, re-interventions, fistulas, renal failure and extremely rare, death may occur [1].
The most frequently affected organ in gynecologic surgery is the urinary bladder although
the most vulnerable part of the lower urinary tract is the ureter [3, 4]. Most of the injuries occur
in the distal ureter, followed by the upper third part and middle third [1-4]. Usually, the sites
of iatrogenic injury are: pelvic brim (close to the infundibulo-pelvic ligament), pelvic sidewall
(where the uterine artery is above the ureter), at the level of uterosacral ligaments and at the
level of cardinal ligament [3, 4]. The surgical method of reconstruction depends on the site and
the type of trauma [4].
The first step to avoid ureteral iatrogenic trauma is to understand the anatomy [2, 5]. The
ureter can be injured when it is located in an abnormal position, when it is compressed by a
pelvic tumor or when it is confused with a blood vessel [4, 5].
During lymphadenectomy, oophorectomy and internal iliac artery ligation the most
susceptible part of the ureter for injury is the pelvic brim [1, 2]. During myomectomy or
hysterectomy, the susceptible site is at the level of internal cervical os within the cardinal
ligament [1]. During colposuspension or colporrhaphy the distal segment and intraparietal
may be injured, close to the bladder trigone [1].
The incidence of ureteric iatrogenic injury during abdominal or pelvic surgery varies
between 0.2-10%, while during obstetrical and gynecological surgery it reaches 50% [2, 5, 6].
The incidence of ureteric trauma during laparoscopic interventions is 1%, during Wertheim-
Meigs hysterectomy is 4% and between 1,7 and 3% after urogynecological interventions [7].
The common risk factors for ureteric iatrogenic trauma are: previous pelvic surgery,
enlarged uterus, ovarian cancer, endometriosis, abnormal pelvic anatomy and pelvic radiation
[5, 8, 9].

Material and methods

In order to evaluate reconstructive options after iatrogenic ureteral trauma we performed a


meta-analisys of the international specialized literature published in the last years. Therefore
we reviewed all publications with this topic cited in the main profile databases (PubMed, ISI
Web of Science, Cochraine, the US National Library of Medicine and Science Direct).
We were particulary interested in the clasiffication of ureteral iatrogenic trauma in order to
determine reconstructive options for each type of lesion.
The statistical interpretation of the data was carried out using Windows Excel 2010™ and
SPSS™ programs.

results

Most specialists use a scale of 5 degrees in classification of iatrogenic ureteral lesions. In


most publications analyzed management depends on the type of iatrogenic utereteral trauma

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(angulation crushed by the improper application of forceps, ligation, sectioning (partial or
complete) resection or stripping peri-ureteral vascular plexus) and its location.
The American Association for the Surgery of Trauma classifies ureteric iatrogenic lesions
into 5 grades [10]:
• grade I: contusion or haematoma without devascularization;
• grade II: transection less than 50%;
• grade III: transection more than 50%;
• grade IV: complete transection with less than 2 cm of devascularization;
• grade V: avulsion with more than 2 cm of devascularization.
The management of patients with iatrogenic ureteral trauma depends on the site and the
type of lesion (see Table 1).
Type of injury Management
Needle Follow up unless bleeding or urine leakage appears
Crushing Catheterization for 10-14 days
Ligature Ligature removing and catheterization for 10-14 days
Small opening Suture and catheterization for 10-14 days
Partial transection Stent
Complete transection without loss of ureteral segment
< 5 cm uretero-vesical Ureterocystostomy tension free with mucous tunnel to prevent
junction the reflux
> 5 cm uretero-vesical Termino-terminal ureteral anastomosis – leads to strictures
junction
Termino-lateral anastomosis – the superior end is invaginated in
the inferior end
Complete transection with loss of ureteral segment
• Ureteroneocystostomy
- psoas hitch: suspension of the bladder to the greater
psoas muscle
- boari flap: suspension of the bladder to the greater
psoas muscle with a flap around the intra-parietal
segment of the ureter
- mobilization of the ureter towards the bladder
• Trans-ureterostomy
• Ureteroileocystostomy
• Ureterocalicostomy
• Kidney auto-transplant
Table 1 – The management of patients with iatrogenic ureteral trauma depending on the site
and the type of lesion

discussions

It is compulsory to detect a ureteral iatrogenic injury as soon as possible in order to improve


the outcome of reconstructive surgery [11]. The management of these patients depends on the
injury’s nature, size, placement, the comorbidities and the time of discovery [11]. Intraoperative

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detection of the lesions and the repair are mandatory in case of iatrogenic trauma due to the
urine leakage that can appear post-surgery causing important pathologies. Ozdemir et al.
demonstrated that the most frequent cause of iatrogenic ureteral trauma is ligature [12].
Gopinath and Jha affirm that ureteric lesions that are discovered relatively late should
be managed likewise to those discovered intraoperative [1]. The difference is that surgical
repair is performed after 3 to 6 months and nephrostomy is mandatory in order to protect renal
function [1]. Complications after ureteric reconstructive procedures are: strictures, ureteric
reflux, hydronephrosis, stenosis or fistula [1].
De Cicco et al. demonstrated that when hydronephrosis is present a preoperative ureteral
stent is an efficient method to prevent ureteral iatrogenic trauma [13]. In the same study he
also postulated that the first line of management of ureteral iatrogenic injuries should be
laparoscopy [13]. However, there are specialists who recommend classic laparotomy [9].
A debatable matter is the managment of ureteral laceration. While many experts reccomend
only stenting, in another study De Cicco et al. demonstrated in another study that a suture and
stent is superior to stenting only [EB, 14].
In 2015 Odegard et al. performed a study on 305 women and observed that the majority of
ureteral iatrogenic injuries are on the left side [15]. The right ureter is located more proximately
to the midline and is also more profound than the opposite [15]. This position is important in
the management of iatrogenic injuries [15].
Wijaya et al. state that laparoscopic ureteroureterostomy should be the gold standard
method of ureter repair, and not ureterocystostomy as preffered by other experts. [11]
Ku et al. affirm that the outcome of an early reconstruction is similar to the outcome of
delayed repair and ureteral iatrogenic injuries should not be fixed immediately [16]. The
recommanded procedure is nephrostomy drainage and ureteral stent [16]. However most
specialist recommend the initiation of treatment as soon as posible in order to prevent long
term complications.

conclusions

Studies published in the past years have shown that pelvic segment of the ureter is most
often damaged, especially during surgical gynecological interventions. The management of
these patients depends on: the location of the trauma, its dimensions, the manner in which the
ureter was affected, and the anatomic characteristics of the patient.

REFERENCES

1. Gopinath, D., Jha, S. (2016). Urological complications following gynaecological surgery.


Obstetrics, Gynaecology & Reproductive Medicine,26(10), pp. 291-296.
2. Munteanu, O., Ispas, A. T., Filipoiu, F., Stroica, L., Tarta-Arsene, E., Bulescu, I. A.,
Cirstoiu, M. (2013). Anatomo-clinical aspects of the most common sites of iatrogenic
ureteral injuries in dystocic pelvises during gynecologic procedures. Romanian Journal
of Functional & Clinical, Macro-& Microscopical Anatomy & of Anthropology/Revista
Româna de Anatomie Functionala si Clinica, Macro si Microscopica si de Antropologie,
12(1).
3. Haestier, A., Sherwin, R. (2011). Urological complications following gynaecological
surgery. Obstetrics, Gynaecology & Reproductive Medicine,21(1), pp. 15-19.

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4. Mendez, L. E. (2001). Iatrogenic injuries in gynecologic cancer surgery.Surgical Clinics
of North America, 81(4), pp. 897-923.
5. Cirstoiu, M., Munteanu, O. (2012). Strategies of preventing ureteral iatrogenic injuries in
obstetrics-gynecology. Journal of medicine and life, 5(3), pp. 277.
6. Dowling, R. A., Corriere Jr, J. N., & Sandler, C. M. (1986). Iatrogenic ureteral injury. The
Journal of urology, 135(5), pp. 912-915.
7. Dandolu, V., Mathai, E., Chatwani, A., Harmanli, O., Pontari, M., Hernandez, E. (2003).
Accuracy of cystoscopy in the diagnosis of ureteral injury in benign gynecologic surgery.
International Urogynecology Journal, 14(6), pp. 427-431.
8. Daly, J. W., & Higgins, K. A. (1988). Injury to the ureter during gynecologic surgical
procedures. Surgery, gynecology & obstetrics, 167(1), pp. 19-22.
9. Bratila E. (2016) Complicații uroginecologice în chirurgia vaginală, Editura Universitara
«Carol Davila Bucuresti», Bucuresti, ISBN 978-973- 708-902-1.
10. The American Association for the Surgery of Trauma. Injury Scoring Scale. Table 20 –
Ureter injury.
11. Wijaya, T., Lo, T. S., Jaili, S. B., Wu, P. Y. (2015). The diagnosis and management of
ureteric injury after laparoscopy.Gynecology and Minimally Invasive Therapy, 4(2), pp.
29-32.
12. Ozdemir, E., Ozturk, U., Celen, S., Sucak, A., Gunel, M., Guney, G., Danisman, A. N.
(2010). Urinary complications of gynecologic surgery: iatrogenic urinary tract system
injuries in obstetrics and gynecology operations. Clinical and experimental obstetrics &
gynecology, 38(3), pp. 217-220.
13. De Cicco, C., Schonman, R., Craessaerts, M., Van Cleynenbreugel, B., Ussia, A.,
Koninckx, P. R. (2009). Laparoscopic management of ureteral lesions in gynecology.
Fertility and sterility, 92(4), pp. 1424-1427.
14. De Cicco, C., Dávalos, M. L. R., Van Cleynenbreugel, B., Verguts, J., Koninckx, P.
R. (2007). Iatrogenic ureteral lesions and repair: a review for gynecologists. Journal of
minimally invasive Gynecology, 14(4), pp. 428-435.
15. Odegard, S. E., Abernethy, M. G., & Mueller, E. R. (2015). Does Side Make a Difference?
Anatomical Differences Between the Left and Right Ureter. Female pelvic medicine &
reconstructive surgery, 21(5), pp. 249-251.
16. Ku, J. H., Kim, M. E., Jeon, Y. S., Lee, N. K., & Park, Y. H. (2003). Minimally invasive
management of ureteral injuries recognized late after obstetric and gynaecologic surgery.
Injury, 34(7), pp. 480-483.

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Treating genital prolaps revolutionary concept, 4


years from applying “Process Saba Nahedd’’ - 90
cases

SABA Nahedd1
1
“Prof. Dr. Alfred Rusescu” Institute for Mother and Child Protection, Bucharest, Polizu Clinical
Hospital, Bucharest
E-mail:sabanahedd@gmail.com

Abstract

Introduction
Genital prolapse is the collapse of a part of an organ, of an organ, or of more organs, due
to an ease of the fixing means. It’s a new concept for the treatment at the uterine prolapse,
cystocele voluminows, the rectocele and SUI. All these pathologies can be treated in a single
process, at the same operative session, without hysterectomy.

Materials and methods


This paper aims to evaluate the stage over a period of 4 years of the 90 cases, the accidents
and the immediate and delayed incidents, eventually the relapses of the uterine prolapse, of
the cystocele, or recurrences in other departments such as: uretrocel, rectocele, elitro-rectocel
Between 25.10.2012 and 15.08.2016 a total of 90 cases were hospitalized and operated in
“Polizu” Hospital with the new surgical procedure for anchoring uterine isthmus with strip
at the rectus abdominis muscle. These cases were hospitalized with a diagnosis of uterine
prolapse gr II - III cystocele per – magna. In the 90 cases we performed a new therapeutic
method for resolving uterine prolapse: “Anchoring uterine isthmus with strip at the rectus
abdominis muscle sheath,, Procedure Saba Nahedd “For this procedure I have invented a kit
“Saba’s Strips” which contains: a special isthmic strip, strip sub urethral, S&N clamp for
anchoring isthmus. Technical problems which resolve this procedure consist in: anchoring
the isthmic strip on the back of the isthmus uterine and the free part of the strip is fixed on
the front of the isthmus in order to prevent the slipping, so all the weight of the uterus is
maintained by the strip as a hammock. The second strip is attached to the junction sub urethral
and then anchored to the rectus abdominals muscle sheath by counter suprapubic incision. So
the repositioning of uterus in anatomical, intermedium, position without opening rectovaginal
space not to train elitro-rectocele.

Conclusions
The technique has the advantage of a complete and effective surgical treatment of uterine
prolapse gr.II and III and cystocele per magna because:
• It solved the uterus prolapse and cystocele per magna and brings back to its anatomical
position.

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• Placing the uterus in the intermediary, normal, position avoid the extension of rectovaginal
space and consequently prevents the occurrence of rectocele and elitrocel.
• Solve incontinence effort by using sub urethral strip.
• The use of the polypropylene material and the nonresorbable threads that fit at the rectus
abdominis sheath (an independent hormonal tissue) makes the chance of recurrence to
become almost inexistent, considering that in the 90 cases we performed the percentage
of recurrence of this compartment was “zero”.
Surgical approach is exclusively vaginal avoiding incidents and accidents when opening
peritoneal cavity.

Keywords: uterine prolapse, anchoring, uterine isthmus, Saba Nahedd procedure

Introduction

In the pelvic cavity, the uterus is supported by muscles, tissues and ligaments that form the
pelvic plate.
The uterus prolapse means the uterus descents into the vaginal axis and outside it,
accompanied by the movement, to the same direction, of the vagina walls and the adjacent
portions of the urinary bladder and rectum.
This means a progressive descend into the small basin of the uterus, as a consequence of
the relaxation of muscles and unextendable fiber tissues of the perineum (the muscles that form
the basin’s basis), as well as of the support means of the small basin’s organs. (2)
Causes and risk factors determining this pathology are: (3)
• Multiple births and difficult baby delivery of big weight babies are the main cause
triggering the muscle relaxation and weakening, leading to uterus prolapse.
• Loss of muscles tone associated to ageing and estrogen level lowering after menopause,
overweight, chronic cough, chronic constipation can contribute to or cause uterus prolapse.
This explains the herniation and uterus prolapse outside the vulvary isthmus in several
degrees, with clinical symptoms consisting of the weight sensation in the lower pelvis, lumbar
pain when walking, peeing, during sexual intercourse, the sensation that “something drops
outside”/“I’m sitting on a ball”, irritation of the introitus and ulcerations of the prolabed
organs, urinary effort incontinency (UEI).
All these symptoms create a biologic and social discomfort for the patients.
Uterine prolapse is often associated with urinary effort incontinence; urine drops loss on
effort (1), sometimes covered by the excessive prolabation of the uterus, by urethra folding.
UEI association is mentioned in 73% of the cases, and malfunctions of the urinary bladder
empting in 50 – 60%. respectively in the empty bladder dysfunction (4). In clinical practice
cystocele and UEI as well as loss of the support of the vagina posterior wall contribute to
urethral mobility and to etiopathogenic conditioning of UEI as a consequence IUE. (5) Is
mentioned that after any surgical treatment for correcting the uterus prolapse, there must also
be considered the correction of the stress urinary incontinence which is sometimes masked.

Materials and methods

This artwork aims to assess the stage ranging over a period of 4 years, of the 90 cases
operated for uterine prolapse, accidents and incidents and delayed, possibly recurrence of
uterine prolapse, cystocele, and other compartments: uretrocel, rectocele, elitro - rectocel.

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Between 25.10.2012 and 15.08.2016, 90 cases were hospitalized and operated in Polizu
Hopsital by means of the new procedure. These cases were hospitalized with a uterine prolapse
in 2nd and 3rd degree cystocele per-magna and benefitted from this technique after clinical
and paraclinical investigations: “mictional cystography” fractional biopsy curettage, resection
with cervical loop diathermy to exclude associated pathology – specifically the neoplasia.
A new correctional method was applied for the 90 cases in order to correct the uterine
prolapse: “anchoring the uterine isthmus with a strip at the rectus abdominal muscle sheath by
Saba N procedure”.
For this procedure I invented “SABA’s strips” kit (fig. 1) with the approval of OSIM
by Decisions no. 23012, 23013/30.12.2013, Licence no. 020476, USA approval no. US
2015/0335413A1, containing:
 One special isthmic strip made of polypropylene, 1.2 cm long (fig. 2), to the heads of
which an unabsorbable thread is tied, and from one of the strip’s ends another free strip is
connected forming an Y shape.
 One sub-urethral strip (fig. 3) of the same material, 10 cm long, one thread is connected
to each of its ends.
 One S&N clamp for anchoring isthmus. S&N clip to anchor the uterine isthmus (fig. 4)
with 2 arms connected between themselves, with 2 orifices on its top. The clip has an
additional ring to recover the angle necessary to form the tunnels. It also has 2 arms of 2.5
cm (right and left) showing the clip’s inclination towards the urethral meatus.

Fig. 1 The Saba Strips Fig. 2 Special isthmic Fig 3. Sub-urethral strip Fig. 4 S&N Clip to
Kit strip anchor the uterine
isthmus
The technical problems this procedures solves consist of anchoring the isthmic strip on the
posterior side of the uterine isthmus, as well as the free part of the strip is fixed on the anterior
side of the isthmus in order to stop its sliding, thus the entire uterus weight is supported like
a hammock, the second suburethral strip is fixed on the urethral junction and then anchored
to the abdominal straight muscle sheath by a horizontal suprapubic incision of around 5 cm.
Thus the uterus is replaced in its intramedian position without opening the rectovagina
space in order not to cause a elitro-rectocele.
The invented strips are related to Popa Petros’s Theory according to which the appearance
of prolapse is due to the alteration of the conjunctive tissue that needs to be strengthened with
these propylene implants.
The sub urethral strip forms the main pillar and anchors the weakened pubic urethral
ligaments, and the isthmic strip forms the second important pillar in teoria produl and anchors
the uterus sacra ligaments.

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Results and discussions

The lack of a consensus regarding the current existence of an optimum and efficient
surgical procedure in such an anatomic clinical morbid context made me elaborate this surgical
procedure with the following operational stages:
Time 1: The reversed “T” incision 1.5 cm off the external cervical orifice down to the
urethral tubercle (fig. 5).
Time 2: Cutting the bladder off the anterior vagina wall and the bladder off the cervix (fig. 6).
Time 3: Creating the retro pubic tunnels (fig. 7).
Time 4: Continuation of the circular incision on the posterior side of the cervix and cutting
of the vagina tread off the rectus (figure no. 8).

Fig. 5 The reversed “T” Fig. 6 Cutting the bladder Fig. 7 Creating the retro Fig. 8 Continuation of the
incision 1.5 cm off the off the anterior vagina pubic tunnels circular incision on the
external uterine orifice wall and the bladder off posterior side of the cervix
down to the urethral the cervix and cutting of the vagina
tuberculus tread off the rectus

Time 5: Clipping, sectioning and ligation of the cardinal ligaments of approximately 1 cm


(fig. 9).
Time 6: Fixing the “long” isthmic strip on the lateral sides and the posterior side of the
uterine isthmus (fig. 10).
Time 7: The “short” free part of the isthmic strip is fixed on the anterior side of the uterine
isthmus (fig. 11).
Time 8: Suprapubic transversal incision of 5 cm.
Time 9: The S&N clip the ends of the suburethral strip are fixed into the superior orifice, and
the ends of the isthmic strip into the inferior orifice passing them through the two previously
formed tunnels (fig. 12).

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Fig. 9 Clipping, Fig. 10 Fixing the Fig. 11 The “short” free Fig. 12 The S&N clip the ends
sectioning and ligation of “long” isthmic strip on part of the isthmic strip is of the suburethral strip are
the cardinal ligaments of the lateral sides and the fixed on the anterior side fixed into the superior orifice,
approximately 1 cm posterior side of the of the uterine isthmus and the ends of the isthmic
uterine isthmus strip into the inferior orifice
passing them through the two
previously formed tunnels

Time 10: Anchoring and ligation of the threads from the suburethral strip to the side
extremities of the straight abdominal muscles aponeurosis, under the guidance of a graded
urinary catheter until a 1.5 cm extension of the urethra is obtained (fig. 13).
Time 11: Anterior colpectomy followed by anterior colpography and suturation of the
cervix posterior incision (fig. 14).
Time 12: Median anchoring of the ends of the isthmic strip to the straight abdominal
muscles sheath (fig. 15).
Time 13: Tractioning and ligation of the threads on the uterine isthmus (fig. 16).
Time 14: Suture of the suprapubic incision.
Time15: Posterior Colpoperineorrhaphy with myography of the levator ani (fig. 17).

Fig. 13 Anchoring Fig. 14 Anterior Fig. 15 Median Fig. 16 Tractioning Fig. 17 Posterior
and ligation of the colpectomy anchoring of the and ligation of the olpoperineorrhaphy
threads from the followed by anterior ends of the isthmic threads on the uterine with myography of
suburethral strip to colpography and strip to the straight isthmus the levator ani
the side extremities suturation of the abdominal muscles
of the straight cervix posterior sheath
abdominal muscles incision
aponeurosis, under
the guidance of
a graded urinary
catheter until a 1.5
cm extension of the
urethra is obtained

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Cervix amputation can also be made on this technique when there are colposcopic lesions
or the hypertrophic extension of the cervix, then the previously mentioned operation times are
followed.
The 90 operated cases were aged between 31 and 81, most of them being aged around 60
(third age) Out of the total cases operated by the procedure “Anchoring the uterine isthmus to
the straight abdominal muscles sheath”, in 68 cases cervix amputation was necessary dues to
a marked colposcopic lesion or hypertrophic extension of the cervix.
In all the previously mentioned cases micturating cystopram was made before and after
operation. Micturating cystogram after operation reveals the inferior pole of the urinary
bladder, with an irregular contour and is placed at the level of the pubic symphysis, that is
the ascension of this pole which was much lowered under the inferior border of the pubic
symphysis.
Patients were released on the 6th or 7th day with a good urinary continence and bladder
residual between 0 and 40 ml, with the disappearance of all symptoms accused upon
hospitalization.
Right after the operation the foley urinary catheter was kept for 3-4 days, during the first
48 hours with a permanent draining, that is “with an ampoule at the end of the foley catheter”
in order to recover the urinary bladder. Meanwhile bladder instillation was applied with
Ampiciline 1 gr, hydrocortisone Hemisuccinate 1 ampoule, Xiline 1 ampoule, and during the
last 48 hours one ampoule of Miostin was added in the bladder instillation and one ampoule of
intra muscle Miostin in order to stimulate the contraction of the urinary bladder’s muscles. All
patients were called for a check-up 1 month, 3 months, 6 months later, and then 1 year after
the operation (fig. 18, 19).

Fig. 18 Before operation Fig. 19 After operation (2


years and 5 months later)

The clinical examination and questions revealed that the cervix is placed in a intramedian
position, with continence and during the valve handling.
It is worth mentioning that no case of uterine prolapse recurrence and cistoceluiui date.
Relapses in other compartments were uretrocel 1 case (1.11%); elitrorectocel 1 case
(1.11%) which was operated. And other 3 cases (3.33%) of rectocele of which only 1 case
required surgery remaining 2 cases present early rectocele that until the moment not require
surgery.
In one case we have dealt with the complication slip strip isthmus it causing minimal
bleeding vaginally and required cutting edge slip. Subsequently, the patient developed a
granuloma wire, which has been extracted.

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Difficulty in urination 2 cases (2.22%) immediate postoperative complication, which
required cutting the strip suburetrale.In 3 weeks during the two weeks following cases
resumed .A single case of urinating physiological exertion incontinence occurred in 1 year and
2 months after surgery, the patient was treated with Vesicare 5 mg for 3 months, after which
the symptoms improved.
Using isthmic and suburethral strip is more efficient because of their shape and quantity of
material polypropylene low compared to other meals .This cartoning did not cause the vaginal
walls, or vaginal erosions major difficulties sexual disparenurie, lubrication.
Mentioned that intraoperative complications were not the type of tunnels retropubiene
bleeding or bladder damage.

Conclusions

The technique has the advantage of a complete and efficient surgical treatment of the
uterine prolapse in 2nd and 3rd grade, and of the cystocele per-magna because:
 It solves the uterine prolapse and cystocele per-magna and brings it to its own anatomic
position.
 Placing the uterus in an intramedian normal position avoids increasing the rectovaginal
space and thus prevents the appearance of the rectocele and elitrocele.
 It solves urinary effort incontinence by using the suburethral strip.
 Using the polypropylene and unabsorbable threads fixed on the sheath of the straight
abdominal muscles, an independent hormonal tissue, makes the relapse chances be as
small as possible or almost absent, whereas relapse was “zero” in 31 cases.
 The surgical approach is exclusively vaginal thus avoiding incidents and accidents
common in case of peritoneal cavity opening.
This number of cases (90) is still small, the time is too short (4 years), but patients will be
followed along a 5-year period, even longer if necessary, in order to demonstrate that there
are no relapses to this technique if surgical stages are strictly respected, as the technique is
based on polypropylene material and unabsorbable threads anchored to the straight abdominal
muscles, an independent hormonal tissue, that is “it doesn’t relax with age”.

REFERENCES

1. Nicolae Poiana Nahedd George Saba - Incontinenta urinara de efort la femei, Editura
Universitara Carol Davila, Bucuresti, 2003 ISBN 973-8047-98-6.
2. Bratila Petre, Ovidiu Nicodin, Nicolae Niculescu, Alina Ursuleanu – Anatomia chirurgicala
a pelvisului, Editura Universitara Carol Davila, Bucuresti, 2002.
3. Rus O. – Indreptar practic de chirurgie ginecologie, 131-184, 1980.
4. Ellerkmann RM, Cundiff GW, Melick CF, Nihira MA, Leffler K, Bent AE. Correlation
of symptoms with location and severity of pelvic organ prolapse. Am J Obstet Gynecol.
2001; 185: 1332 - 7; 1337 - 8.
5. DeLancey JO, Trowbridge ER, Miller JM, Morgan DM, Guire K, Fenner DE, Weadock
WJ, Ashton-Miller JA. Stress urinary incontinence: relative importance of urethral support
and urethral closure pressure. J Urol. 2008; 179: 2286 - 90.

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The Management of Grade II/III Hydronephrosis


During Pregnancy

NASTAS Ana1, STANCULESCU Ruxandra1,2,


MEHEDINTU Claudia2,3, BERCEANU Costin4,
COMANDASU Diana-Elena1, CIRSTOIU Monica5,2,
BOHILTEA Roxana5,2, VLADAREANU Simona6,7,
PATRASCOIU Sorin8, NASTAS Alexandru9, BRATILA Elvira1,2
1
“Sf. Pantelimon” Clinical Emergency Hospital, Bucharest (ROMANIA)
2
“Carol Davila” University of Medicine and Pharmacy, Department of Obstetrics Gynecology,
Bucharest (ROMANIA)
3
“Nicolae Malaxa”, Clinical Emergency Hospital, Bucharest (ROMANIA)
4
Craiova University of Medicine and Pharmacy, Department of Obstetrics Gynecology, Craiova
(ROMANIA)
5
University Emergency Hospital, Bucharest (ROMANIA)
6
Elias Emergency Hospital, Bucharest (ROMANIA)
7
“Carol Davila” University of Medicine and Pharmacy, Department of Neonatology, Bucharest
(ROMANIA)
8
“Sf. Maria” Clinical Hospital, Bucharest (ROMANIA)
9
Fundeni Clinical Institute, Bucharest (ROMANIA)
E-mails: ana_cmd@yahoo.com, ruxandra_v_stanculescu@yahoo.com, claudiamehedintu@yahoo.
com, dr_berceanu@yahoo.com, diana.comandasu@yahoo.com, dr_cirstoiumonica@yahoo.com,
r.bohiltea@yahoo.com, simconst69@gmail.com, dr.sorinpatrascoiu@gmail.com, nastas_alex@yahoo.
com, elvirabarbulea@gmail.com

Abstract

Hydronephrosis (Hn) occurs commonly during pregnancy, its reported incidence is


between 43% and 100%, being 2 to 3 times more frequent on the right side. The symptoms
of Hn can initially manifest in the first trimester, evolving later in second and third trimester,
and the etiology is both hormonal and mechanical. It was hypothesized that the mechanism
of Hn in the first trimester is nonmecanic by increasing the level of progesterone, while after
20 weeks of gestation, the uterus becomes large enough to exert extrinsic compression on the
ureters. In the diagnosis and management of Hn the most important role belongs to ultrasound
examination. The methods of investigation recommended in Hn of lithiasic etiology are
computed tomography and magnetic resonance imaging. The purpose of this paper is to
present the management of grade II/III uretero-hydronephrosis in pregnancy, based on our
own experience and on the review of literature. The study included 122 pregnant women
that were supervised during 2015-2016 at the “St. Pantelimon” Hospital, Bucharest, Hn being
diagnosed in 12 patients (9.8%). Hn etiology was predominantly non-lithiasic, kidney stones
being present in four pregnant women (3.2%) in our study. The symptomatology was mostly
quiet, but there were cases of recurrent colicative pain during pregnancy, dysuria, and urinary

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frequency. The development of complications such as pyelonephritis or renal failure is rare,
in this study occurring only one case of acute pyelonephritis suggested by fever (0.8%). The
therapeutic management of grade II/III of non-lithiasic Hn was conservative, with close
monitoring of renal function, temperature and ultrasound surveillance of the evolution of Hn
at every 2 weeks. In cases of lithiasic Hn it was used a conservative treatment with drugs
that correct the urinary pH and contribute to the dissolution of microlithiasis. Interventional
methods (Cook stent insertion) were necessary in 2 cases (1.6%). Hydronephrosis in pregnant
women requires rigorous management according to the etiopathogenie of the disease and the
symptoms caused by it, the conservative treatment being effective in most cases.

Keywords: Hydronephrosis, pregnancy, lithiasis, renal colic, management

Introduction

Hydronephrosis is a common clinical condition defined as distention of the renal calyces


and pelvis with urine as a result of obstruction of the urine outflow distally to the renal pelvis.
Hn can be physiological or pathological, acute or chronic, mechanical (with obstruction) or
non-mechanical (without obstruction).
The pathophysiology of Hn consists of any anatomic or functional processes that are
interrupting the flow of urine. It can occur anywhere along the urinary tract (from renal calyces
to urethral meatus). An acute Hn can be associated with little anatomic disturbance to renal
parenchyma, and a chronic one may be associated with compression of the papillae, thinning
of the parenchyma around the calyces, and coalescence of the septa between calyces [1], [2].
Hydro-ureteronephrosis is a normal finding in pregnant women. It may initially manifest
in the first trimester, and it develops increasingly throughout the pregnancy. Faundes and
colleagues reported in a large prospective study that Hn was present in 15% of pregnant
women in the first trimester, in 20% of women in the second trimester and in 50% of women
during the third trimester. The degree of Hn also increased over gestation [Table 1], [1].
The increased renal blood flow leads to an increase in renal size of 1–1.5 cm, reaching the
maximal size by mid-pregnancy. The kidney, pelvis and calyceal systems dilate as a result of
the mechanical compression on the ureters at the pelvic brim. Progesterone, which reduces
ureteral tone, peristalsis and contraction pressure, mediates these anatomical changes and
supports the non-mechanical etiopathogenie of Hn observed in the first trimester [3], [4], [5].
The increase in renal size is associated with an increase in renal vasculature, interstitial
volume and urinary dead space. There is also dilation of the ureters, renal pelvis and calyces,
leading to physiological hydronephrosis in up to 80% of pregnant women [6]. There is often
a right-sided predominance of dilatation of the ureters and renal pelvis due to the anatomical
circumstances of the right ureter crossing the iliac and ovarian vessels at an angle before
entering the pelvis.
Urinary stasis in the dilated collecting system predisposes pregnant women with
asymptomatic bacteriuria to pyelonephritis [6], [7].

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Table 1. Observed and adjusted percentiles of maximal maternal calyceal diameter (mm) of
right and left kidneys according to gestational age [1]
Gestational Age (weeks) Observed Percentiles Adjusted Percentiles
RIGHT LEFT RIGHT LEFT
50th 75th 90th 90th 50th 75th 90th 90th
4-6 0.0 3.0 5.0 2.1 1.4 2.4 3.4 0.1
7-8 0.0 0.0 5.0 0.0 0.3 3.2 4.5 2.2
9-10 0.0 0.0 4.0 0.0 1.2 4.0 5.7 3.5
11-12 0.0 5.0 7.0 6.0 2.0 4.9 7.0 4.5
13-14 0.0 5.8 8.0 6.9 2.7 5.7 8.4 5.3
15-16 0.0 1.0 8.9 4.9 3.0 6.7 9.8 6.0
17-18 5.0 9.5 12.0 8.8 3.7 7.6 11.2 6.6
19-20 0.0 8.0 11.0 7.7 4.2 8.6 2.6 7.1
21-22 5.0 9.0 13.8 6.8 4.6 9.6 13.9 7.1
23-24 8.0 12.0 15.0 8.2 4.9 10.5 15.1 7.9
25-26 7.0 13.0 16.7 8.0 5.3 11.4 16.2 8.2
27-28 7.0 13.0 21.0 9.0 5.6 12.2 17.2 8.4
29-30 7.0 11.0 16.0 9.0 5.9 13.0 18.0 8.6
31-32 8.0 15.5 19.4 8.2 6.1 13.7 18.7 8.7
33-34 4.5 13.0 20.5 8.5 6.4 14.3 19.3 8.8
35-36 6.0 15.0 19.0 8.0 6.6 14.8 19.7 8.9
37-38 5.0 14.0 20.4 8.0 6.8 15.2 19.8 8.9
39-42 7.0 14.0 17.0 9.2 7.1 15.5 19.8 8.7
After delivery, Hn gradually resolves, one third of patients may still present persistent Hn
during the first postpartum week, but the condition disappears in the majority of cases within
6 weeks [1].
Hn during pregnancy is usually silent. However, some pregnant women with Hn present
symptomatology such as flank pain, pyelonephritis and renal failure. The diagnostic of Hn is
based on ultrasonography, which finds hydro-ureteronephrosis extending to the pelvic brim
[8], [9], [10]. If this dilatation is extended below the pelvic brim, then a different etiology of
obstruction (a ureteral stone) has to be considered. Diagnostic options for ureteral lithiasis
in pregnancy are limited to intravenous urography and low-energy CT. Magnetic resonance
urography has been mentioned to be a noninvasive, nonradiating method of assessing those
with Hn of pregnancy [11]. The presence of filling defects representing stones or soft tissue
may be seen on high-resolution T2 sequences [1]. However, despite the lack of any proven
adverse effects, the use of MRI with gadolinium contrast should be avoided because of the
crossing of the placental barrier [1].
In pregnancy, most of the patients with Hn can be treated with conservative measures, such
as proper oral hydration, intravenous hydration, analgesics, antibiotic therapy and drugs used
for dissolution of lithiasis [12], [13], [14]. When this conservative management is unsuccessful,
Cook stent placement may be necessary. During pregnancy calcium excretion increases, that is
why stents need to be changed frequently because of rapid stent encrustation [15], [16].

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Methodology and Results

We conducted a retrospective study which included 122 pregnant women (aged 16-38, of
white-caucasian race) that were supervised during 2015-2016 at the third degree hospital “Sf.
Pantelimon” in Bucharest. Grade II/III of Hn was diagnosed in 12 patients (9.8%) at renal
ultrasonography. The symptomatology was mostly quiet, but there were cases of recurrent
colicative flank pain during pregnancy, dysuria, and urinary frequency. The urine analysis
revealed no specific data; some of them had higher values of leucocytes, while some presented
higher quantities of epithelial cells sediment and oxalates. Hn etiology was predominantly non-
lithiasic, kidney stones being present in four pregnant women (3.2%), the biggest dimension
of the stones being 2.4 mm situated in the pielo-calyceal system. We had only one case of
complications development such as pyelonephritis, the patient presenting with abdominal and
flank pain, fever (38.6 °C), high values of leucocytes in peripheral blood and urine analysis and
positive E. coli culture in urine (0.8%).
The therapeutic management of grade II/III of non-lithiasic Hn was conservative, with
close monitoring of renal function, temperature and ultrasound surveillance of the evolution
of Hn at every 2 weeks, accompanied by standard obstetrical follow-up. Analgesics and
antispasmodics were used in the presence of flank pain. In cases of lithiasic Hn it was used a
conservative treatment with drugs that correct the urinary pH and contribute to the dissolution
of microlithiasis, 2 patients were administered Cystone® - Didymocarpus pedicellata, Saxifraga
ligulata, Rubia cordifolia and Cyperus scariosus extracts (1 tablet three times daily in the first
month, after that 1 tablet two times daily until delivery) and the other 2 patients with lithiasic
Hn and more severe symptomatology administered Cystone® (1 tablet two times daily until
delivery) in combination with Uralyt-U® – Potassium Sodium Hydrogen Citrate (administered
according to urine pH self-measured by sticks). Pyelonephritis was treated with antibiotics,
respectively Amoxicillin (500mg two times daily for 7 days, orally), intravenous hydration,
analgesics (Metamisole) and antispasmodics (Drotaverine). Interventional methods (Cook
stent insertion) were necessary in 2 cases (1.6%) of non-lithiasic Hn with grade III dilatation
and severe flank pain.

Conclusions

Hydronephrosis in pregnant women requires rigorous management according to the


etiopathogenie of the disease and the symptoms caused by it, the conservative treatment being
effective in most cases. Diagnosis of urolithiasis in pregnancy is complex but with prompt
evaluation and expeditious treatment, the prognosis is excellent.

References

1. Alan J. Wein MD phd (Hon) FACS, Louis R. Kavoussi MD MBA, Andrew C. Novick
MD, Alan W. Partin MD phd, Craig A. Peters MD, (2011). Campbell-Walsh Urology,
10th edition, pp. 1113-1114.
2. Pain VM, Strandhoy JW, Assimis, DG. Pathophysiology of urinary tract obstruction.
Kavoussi LR, Novick AC, Partin AW, Peters CA, Wein AJ, eds. Campbell-Walsh
Urology. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2007. Vol 2: 1227-73.

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3. Priya Soma-Pillay, Mb Chb, Mmed (O Et G) Pret, Fcog, Cert (Maternal And Foetal Med)
Sa, Nelson-Piercy Catherine, Ma, Frcp, Frcog, Heli Tolppanen, Md, Alexandre Mebazaa,
Md, Heli Tolppanen, Md, And Alexandre Mebazaa, Md. Physiological Changes In
Pregnancy. Cardiovasc J Afr. 2016 Mar-Apr; 27(2): 89–94.
4. Klahr S. Pathophysiology of obstructive nephropathy. Kidney Int. 1983 Feb. 23(2):414-
26.
5. Katharine L. Cheung and Richard A. Lafayette. Renal Physiology of Pregnancy. Adv
Chronic Kidney Dis. 2013 May; 20(3): 209–214.
6. Rasmussen PE, Nielsen FR. Hydronephrosis during pregnancy: a literature survey. Eur J
Obstet Gynecol Reprod Biol. 1988 Mar. 27(3):249-59.
7. Stothers L, Lee LM. Renal colic in pregnancy. J Urol. 1992 Nov. 148(5):1383-7.
8. Sternberg KM, Pais VM Jr, Larson T, Han J, Hernandez N, Eisner B. Is hydronephrosis on
ultrasound predictive of ureterolithiasis in patients with renal colic?. J Urol. 2016 May 3.
9. Webb JA. Ultrasonography in the diagnosis of renal obstruction. BMJ. 1990 Oct 27.
301(6758):944-6.
10. Gaspari RJ, Horst K. Emergency ultrasound and urinalysis in the evaluation of flank pain.
Acad Emerg Med. 2005 Dec. 12(12):1180-4.
11. Gordon I, Dhillon HK, Gatanash H, Peters AM. Antenatal diagnosis of pelvic
hydronephrosis: assessment of renal function and drainage as a guide to management. J
Nucl Med. 1991 Sep. 32(9):1649-54.
12. Josephson S. Antenatally detected pelvi-ureteric junction obstruction: concerns about
conservative management. BJU Int. 2000 May. 85(7):973.
13. Folger GK. Pain and pregnancy; treatment of painful states complicating pregnancy, with
particular emphasis on urinary calculi. Obstet Gynecol. 1955 Apr. 5(4):513-8.
14. Rodriguez PN, Klein AS. Management of urolithiasis during pregnancy. Surg Gynecol
Obstet. 1988 Feb. 166(2):103-6.
15. Drago JR, Rohner TJ, Chez RA. Management of urinary calculi in pregnancy. Urology.
1982 Dec. 20(6):578-81.
16. Biyani CS, Joyce AD. Urolithiasis in pregnancy. II: management. BJU Int. 2002 May.
89(8):819-23.

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Treatment of Interstitial Cystitis in Menopausal


Women

NASTAS Ana1, MEHEDINTU Claudia2,3, BERCEANU Costin4,


CIRSTOIU Monica2,5, BOHILTEA Roxana2,5,
COMANDASU Diana-Elena1, PATRASCOIU Sorin6,
NASTAS Alexandru7, BRATILA Elvira1,2
1
“St. Pantelimon” Clinical Emergency Hospital, Bucharest (ROMANIA)
2
“Carol Davila” University of Medicine and Pharmacy, Department of Obstetrics Gynecology,
Bucharest (ROMANIA)
3
“Nicolae Malaxa”, Clinical Emergency Hospital, Bucharest (ROMANIA)
4
Craiova University of Medicine and Pharmacy, Department of Obstetrics Gynecology, Craiova
(ROMANIA)
5
University Emergency Hospital, Bucharest (ROMANIA)
6
“Sf. Maria” Clinical Hospital, Bucharest (ROMANIA)
7
Fundeni Clinical Institute, Bucharest (ROMANIA)
E-mails: ana_cmd@yahoo.com, claudiamehedintu@yahoo.com, dr_berceanu@yahoo.com,
dr_cirstoiumonica@yahoo.com, r.bohiltea@yahoo.com, diana.comandasu@yahoo.com,
dr.sorinpatrascoiu@gmail.com, nastas_alex@yahoo.com, elvirabarbulea@gmail.com

Abstract

Interstitial cystitis (IC) or bladder pain syndrome is a chronic disease that has a multifactorial
etiology and is characterized by clinical symptoms such as urinary frequency, pain in the
bladder and pelvic region and nocturia. Although many pathophysiological theories have been
proposed, the primary mechanism of the development of IC remains still unclear. Temml has
shown that the prevalence of IC is bigger than the reported one, 306/100,000 women, more
than 50% being patients over 40 years old. Women’s estrogen reserves are steadily declining
with menopause, causing negative effects on the entire genitourinary tract. Based on our
review of the literature and personal experience, the study aims detailing the current treatment
options of IC and their specificity in menopause. The study included 614 women (aged 20-65
years) presented in 2014-2016 at the “St. Pantelimon” Hospital, Bucharest accusing urinary
symptoms suggestive for the clinical diagnosis of cystitis. In 90.2% (554 patients) the infectious
nature of cystitis was confirmed bacteriologically. In the other 60 cases, 10 were young
patients (in which after ultrasound investigations, MRI and laparoscopy pelvic endometriosis
was confirmed). 50 patients were menopausal (which were suspected for overactive bladder
syndrome and IC; following urodynamic investigations, it was established by exclusion that 15
postmenopausal women had IC - 2.44%). The management consisted of sanitary and dietary
measures (exclusion of food stimulants, sleep-wake rhythm compliance, regular emptying of
the bladder at every 2-3 hours, proper hydration), analgesic treatment, anti-inflammatory and
tricyclic antidepressants (IC symptoms reappeared at 6 months after the end of treatment),
vaginal mucosa estrogenisation and intravesical instillations with botulinum toxin type A (5

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women). The goal of IC treatment is symptomatic relief, with multiple therapeutic options:
non-pharmacological (stress reduction, special exercises, sanitary and dietary measures), oral
medications (amitriptyline, analgesics, antibiotics, other antidepressants, antihistamines),
intravesical instillation (silver nitrate, clorpactin, glycosaminoglycans - GAGs), intradetrusor
instillations with botulinum toxin type A, neuromodulating with electrical transcutaneous
nerve stimulation and surgery. The effectiveness of these therapies has been shown to be of
short-term despite their diversity.

Keywords: bladder pain syndrome, chronic pelvic pain, menopause, interstitial cystitis

Introduction

As a pathologic entity, IC was recognized during the 19th century. It has been defined and
redefined over the past 100 years [1]. The first definition given was by Skene (in 1887): “an
inflammation that has destroyed the mucous membrane partly or wholly and extended to the
muscular parietes” [2]. The last one, a more crystallized definition, is given by the Japanese
Urological Association (2009): “a disease of the urinary bladder diagnosed by three conditions:
(1) lower urinary tract symptoms such as urinary frequency, bladder hypersensitivity and/or
bladder pain; (2) bladder pathology proven endoscopically by Hunner ulcer and/or mucosal
bleeding after overdistension; and (3) exclusion of confusable diseases such as infection,
malignancy, or calculi of the urinary tract”. Prevalence studies show a wide variation, but
more modern studies tend to show higher values. The results of a 5-year epidemiology study of
the National Institutes of Health of America (2010) revealed that 2.5% to 6.5% of US women
present a high specificity symptom definition suggesting IC [3], [4]. People older than 50
years are at higher risk for IC. Mean age at diagnosis is 40–50 years [5]. The female to male
preponderance is 5:1 or greater. Men tend to be diagnosed at an older age and have a higher
percentage of Hunner ulcers.
It is very likely that IC has a multifactorial etiology [5], Fig.1. There are numerous
theories regarding its pathogenesis, such as „leaky epithelium”, mast cell activation and
neurogenic inflammation, or the combination of these factors. Excessive release of sensory
nerve neurotransmitters and mast cell inflammatory mediators is thought to be responsible
for the development and manifestation of symptoms. Inflammation results in altered nerve
growth factor content of the bladder and in morphologic changes in sensory and motor neurons
innervating the bladder. Neuroplasticity may be a possible explanation for the association of
bladder inflammation with long-term symptoms and pain after inflammation subsides.
Up to one third of IC patients may have an acute urinary tract infection that immediately
precedes the onset of chronic symptoms. This inflammation may be originating in organs
other than the bladder. Irritable bowel syndrome is associated with visceral hyperalgesia. The
possible explanation is viscero-visceral cross-sensitization, in which increased nociceptive
input from an inflamed pelvic organ sensitizes neurons that receive convergent input to the
same dorsal root ganglion from an unaffected visceral organ [6], [7]. Studies suggest that
IC is a syndrome with neural, immune and endocrine components in which activated mast
cells secrete proinflammatory mediators. The most important one of them is hystamine, which
can cause pain, hyperemia and fibrosis. Another role in the pathophysiology is the increased
epithelial permeability, which is nonspecific and is a consequence of bladder inflammation.
The potassium sensitivity test provokes pain in the patients with defect in the epithelial
permeability barrier of the bladder’ surface GAGs [8].

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Fig. 1 Hypothesis of etiology of interstitial cystitis (modified after Hanno P., 2009) [11]

There are 2 types of IC: non-ulcerative and ulcerative. 90% of IC patients have the non-
ulcerative form which presents with glomerulations into the bladder wall. The ulcerative form
of IC is characterized by the presence of Hunner’s lesions in the bladder wall.

Table 1. Recommended tests for Diagnosis of Interstitial Cystitis


Mandatory Recommended Optional
Clinical history Urine culture Ultrasonography
Physical examination Urine cytology Urodynamic study
Urine analysis Symptom scores Radiographic examination
Quality of life scores Potassium test
Frequency-volume chart Biopsy
Residual urine measurement
Cystoscopy
Hydrodistension

After the diagnosis has been made (Table 1), the patients may choose different types
of treatment in correlation with the severity of symptoms [9], [10], [11]. The first step is
the initiation of the conservative therapies. Stress reduction, exclusion of food stimulants,

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sleep-wake rhythm compliance, regular emptying of the bladder at every 2-3 hours, proper
hydration, soft tissue massage, all contribute overall to a normal quality of life [12], [13],
[14]. Patients are recommended to avoid tobacco, alcohol, caffeine, hot peppers and other
food products that acidify the urine and adversely affect the symptoms. Oral therapies used in
the treatment of IC are Amitriptyline (the major pharmacological effect is represented by the
antihistaminic property), other antidepressants (Benzydamine), analgesics (Acetaminophen,
non-steroidal anti-inflammatory drugs (NSAIDs), and antispasmodic agents), antibiotics
(Doxycycline), antihystamines (Hydroxyzine) [15]. Furthermore, there are also invasive
treatment solutions: intravesical instillation (silver nitrate, clorpactin, glycosaminoglycans),
intradetrusor instillations with botulinum toxin type A, neuromodulating with transcutaneous
electrical nerve stimulation and surgical therapy.

Methodology and Results

We conducted a study in the period of 2014-2016 at the third degree hospital “Sf.
Pantelimon” in Bucharest. We examined 614 women, aged 20-65, of white-caucasian race.
The patients presented with urinary symptoms, such as: chronic pelvic pain, urinary
frequency, persistent urge to void, nocturia and dyspareunia. Clinical history, physical
examination and general urine analysis were mandatory tests. The urine culture was
recommended and executed in 100% of patients. After the bacteriological results, 554 women
(90.2%) discovered that the urinary symptoms had an infectious nature (most of them had
positive E. Coli culture in urine and a few of them had Enteroccocus). Another recommended
examination used for differential diagnosis was transvaginal ultrasonography, which suspected
in 10 young patients from the remaining 60, pelvic endometriosis, confirmed after through RMI
and laparoscopy. The last 50 cases were menopausal women, aged 48-65, that were studied
urodinamically for exclusion of the overactive bladder syndrome. In summary, we obtained a
result of 15 postmenopausal women that had specific symptomatology for IC - 2.44%. Due to
insufficient funds and lack of necessary equipment, other optional examinations (cystoscopy,
hydrodistension, potassium test and biopsy) were not performed.
The therapeutical management consisted of conservative measures (exclusion of food
stimulants, stress reduction, warm tub baths, exercises, relaxing massage, sleep-wake rhythm
compliance, regular emptying of the bladder at every 2-3 hours, proper hydration with non-
acidifying urine beverages), analgesic treatment (with Acetaminophen), anti-inflammatory
(Aspirin, Ibuprofen, Piroxicam), antispasmodic agents (Drotaverine, Scopolamine) and
antidepressants (Amitriptyline). The conservative therapies were used as adjuvants for
increasing the quality of life. The use of Amitriptyline reached a ceiling for its maximum
analgesic effect in about 6 months after the end of the treatment. Intravesical instillations with
botulinum toxin type A have been administered to 5 women, which had more severe urinary
symptoms, with a positive feedback with improvement of symptomatology for about 3 to 8
months. Considering the decline of the estrogen reserves in menopause, the vaginal atrophy
caused by it worsens even more the dyspareunia from IC, therefore vaginal estrogenisation
was indicated to all our patients with IC.

Conclusions

Interstitial cystitis is a rare condition, which importantly alters the quality of life through

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its urinary symptoms; therefore it has to be well and promptly diagnosed in order to initiate a
specific treatment. The therapeutic challenge is to relief the symptoms, but the effectiveness
of these therapies have been shown to be of short-term despite their diversity. In this way,
patients need to be encouraged to maximize their activity and live a normal life as possible.

REFERENCES

1. Berry SH, Bogart LM, Pham C, Liu K, Nyberg L, Stoto M. Development, validation
and testing of an epidemiological case definition of interstitial cystitis/painful bladder
syndrome. J Urol. 2010 May. 183(5):1848-52.
2. Peeker R, Fall M. Toward a precise definition of interstitial cystitis: further evidence of
differences in classic and nonulcer disease. J Urol. 2002 Jun. 167(6):2470-2.
3. Berry SH, Elliott MN, Suttorp M, Bogart LM, Stoto MA, Eggers P. Prevalence of
symptoms of bladder pain syndrome/interstitial cystitis among adult females in the United
States. J Urol. 2011 Aug. 186(2):540-4.
4. Lifford KL, Curhan GC. Prevalence of painful bladder syndrome in older women.
Urology. 2009 Mar. 73(3):494-8.
5. Dimitrios-Anestis Moutzouris, Harissios Vliagoftis, Matthew E. Falagas. Interstitial
cystitis: an enigmatic disorder of unclear etiology. 2008 Jan. Oxford Journals. Medicine
& Health. Clinical Kidney Journal. Volume 1, Issue 2. Pp. 80-84.
6. Lorenzo Gómez MF, Gómez Castro S. Physiopathologic relationship between interstitial
cystitis and rheumatic, autoimmune, and chronic inflammatory diseases. Arch Esp Urol.
2004 Jan-Feb. 57(1):25-34.
7. Elliott CS, Payne CK. Interstitial cystitis and the overlap with overactive bladder. Curr
Urol Rep. 2012 Oct. 13(5):319-26.
8. Parsons CL, Boychuk D, Jones S, et al. Bladder surface glycosaminoglycans: an epithelial
permeability barrier. J Urol. 1990 Jan. 143(1):139-42.
9. Hanno PM, Burks DA, Clemens JQ, et al. AUA guideline for the diagnosis and treatment
of interstitial cystitis/bladder pain syndrome. J Urol. 2011 Jun. 185 (6):2162-70.
10. Alan J. Wein MD phd (Hon) FACS, Louis R. Kavoussi MD MBA, Andrew C. Novick
MD, Alan W. Partin MD phd, Craig A. Peters MD, (2011). Campbell-Walsh Urology,
10th edition, pp. 357-407.
11. Hanno PM, Burks DA, Clemens JQ, et al. Guideline. Diagnosis and Treatment of
Interstitial Cystitis/Bladder Pain Syndrome. American Urological Association. September
2015.
12. Bogart LM, Suttorp MJ, Elliott MN, et al. Validation of a quality-of-life scale for women
with bladder pain syndrome/interstitial cystitis. Qual Life Res. 2011 Dec 7.
13. Bogart LM, Suttorp MJ, Elliott MN, Clemens JQ, Berry SH. Validation of a quality-of-
life scale for women with bladder pain syndrome/interstitial cystitis. Qual Life Res. 2012
Nov. 21(9):1665-70.
14. Troxel WM, Booth M, Buysse DJ, Elliott MN, Suskind AM, Clemens JQ, et al. Sleep
disturbances and nocturnal symptoms: relationships with quality of life in a population-
based sample of women with interstitial cystitis/bladder pain syndrome. J Clin Sleep Med.
2014 Dec 15. 10 (12):1331-7.
15. Quillin RB, Erickson DR. Management of interstitial cystitis/bladder pain syndrome: a
urology perspective.Urol Clin North Am. 2012 Aug. 39(3):389-96.

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Female sexual dysfunction and pelvic floor surgery

NENCIU Cătălin George1, AFLOAREA Adina Elena1,


ALBU Ruxandra Andreea2, VOICU Diana1,
MUNTEANU Octavian2, VASILESCU Sorin1, ȘANDRU Florica2,
DUMITRAȘCU Mihai Cristian2
1
Obstetrics and Gynecology, University Emergency Hospital Bucharest, (Romania)
2
University of Medicine and Pharmacy ‘Carol Davila’, Bucharest (Romania)
Corresponding author: Afloarea Adina-Elena, E-mail: adina.afloarea@yahoo.com

Abstract

Pelvic floor disorders represent one of the most significant elements influencing the female
quality of life. There is a strong correlation between pathological signs and symptoms and
elements that determine the quality of life in all aspects. This is an issue that regards all ages,
no matter the beginning point. Nowadays we see an increasing consideration and a high interest
in female sexuality as a key point in good life standards and wellbeing. One of the factors that
influenced this rising interest is that the addressability over this matter became higher over the
years and the society brought into light the female sexuality. The correlation between pelvic
floor disorders followed by pelvic surgery and female sexual function is undeniable. Although
this association is a known fact, the literature does not offer a compact and uniform opinion
on this matter. The aim of this paper is to review the literature and to compare the data with
our clinic experience. In this view we realized a prospective observational study where we
followed-up women with pelvic floor disorders that underwent surgery.

Keywords: pelvic floor disorders, pelvic floor surgery, female sexual dysfunction, prospective
observational study

Introduction

Female sexuality had captured more and more interest because of its complexity and
implication in all aspects of life – social, psychological, physical, involving women and their
partners. Until now the female sexual dysfunction used to be take too lightly [1]. The female
sexual dysfunction is most frequently classified considering sexual activity stages (desire,
arousal, orgasm, sexual pain) [2] as shown in the classification proposed by World Health
Organization – ICD-10 (1992) and American Psychiatric Association- DSM-IV-TR (2000)
[3].
Pelvic organ prolapse and also pelvic floor surgery represent organic causes of sexual
dysfunction [1]. The prevalence of pelvic organ prolapse in women above 40 years is 41-50%
and 15-49 out of 10000 women undergo surgery annually and the percentage is estimated to
double within the next 30 years [4]. We can consider that this quality of life aspect is of rising
importance and must be evaluated in every case and explained to the patient.

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Literature review

There are many elements in this field of interest that need to be brought into attention
in order to evidentiate the intimate correlation between pelvic floor problems, their solution
and sexual function. The literature data reveal different grade of benefits from the surgical
treatment of pelvic organ prolapse and stress urinary incontinence. There are many variables
including grade of prolapse, symptomatology, lifestyle, age, sexual activity, patient evaluation
process which are discussed below. The anatomy of pelvic floor is significant modified in this
type of pathology with impact on life-quality [5].

Pacient evaluation

For evaluating the pelvic pathology the Pelvic Floor Disorders Inventory-20 [6] and the
Pelvic Organ Prolapse Quantification [7] can be successfully used. Some of the results of these
tests are conflicting. It must be taken into consideration the selected population regarding
the symptoms, the prolapse degree, the type of surgery and other variables in each patient
(age, parity, sexual activity etc.) [8, 9]. The Pelvic Organ prolapse/urinary incontinence sexual
function questionnaire (PISQ) can be used for evaluation of the sexual dysfunction before and
after the surgery. The type of gynaecological surgery must be taken in consideration.
In his review, Zippe [1] concluded that in simple hysterectomy sexual dysfunction has not
been reported and a positive result was determined by the disappearing of dyspareunia and
dysmenorrhoea and with no difference after abdominal or vaginal hysterectomy [10]. Also, he
stated that more extensive procedures like the ones for urogynecological cancers usually have
a bigger impact on sexual life in a negative way (lack of interest, physical problems, fear etc)
[1] with modification on anatomical plans and inervation.

Literature results

Pelvic floor symptoms are a major cause of reduced sexual arousal, difficulty in reaching
orgasm and dyspareunia as shown in Handa’s study [9] on 301 adult women. In this light, the
general trend in studies is that the surgeries for pelvic organ prolapse (POP) and stress urinary
incontinence (SUI) determine a significant correction of the scores in PISQ. In the study
realised by Ross et al. [10] 37 women undergoing surgery were analysed and the PISQ scores
improved but the data revealed a limited assessment of sexual function after surgery [11].
Lonnée-Hoffmann [12] states the improvement after POP and SUI surgery. Differences
were observed with specific predictive factors in each surgery type group. Overall the
upgrading was significant (p=0.000). A group of 68 women were evaluated in Brandner’s
study [13] and the results showed improvement for desire (p<0.001), satisfaction (p<0.0001)
and pain (p<0.0001) with no outcome on arousal, lubrication and orgasm.
In opposite with this view some authors met unexpected results at reevaluation. Feldman
[14] presents a case of increased sexual arousal in a mid-30s patient after rectal prolapse
repair. He stated that if the nerve supply is damaged it will cause sexual failure. In another
study, Tsung-Hsien Su [15] concludes that the POP treatment with mesh has an adverse effect
on short term sexual function, although the procedure is effective. The sexual function will
impove in time, after complete healing [16]. Clitoral pain after SUI treatment in a healthy
42-year-old patient is presented as an uncommon side effect [17].

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To sum up, POP and SUI are followed by sexual dysfunction proportional to the degree of
POP and SUI [1, 9, 11]. Different procedures will have different impact in sexual function, but
overall the effect is positive [11, 16] with significant improvement of body image perception
[17], sexual desire and satisfaction [13]. It must be taken into consideration that nerve damage
will have an important negative effect on arousal and inability to reach orgasm as shown.

Objective

The aim of the study was to obtain data on the quality of life and sexual function after POP
and SUI surgeries realised in our clinic and compare them with the literature results.

Methods

The study was designed as a prospective observational study in which we did a follow-up
on the women with pelvic floor disorders that underwent surgery in our clinic between 01
January 2015 and 31 December 2015. The reevaluation took place between 3-6 months after
surgery. The following criteria of inclusion were used: age above 40 years, surgical technique:
POP or SUI. Women who have never been sexually active were excluded. The pelvic floor
disorders were evaluated trough the Pelvic Floor Impact Questionnaire (PFIQ 7) [18] which
evaluates three aspects: Urinary Impact (UIQ-7), Colorectal-Anal Impact (CRAIQ-7) and
Pelvic Organ Prolapse Impact (POPIQ-7) associated with Pelvic Floor Distress Inventori-20
(PFDI-20) [18]. To evaluate the sexual function it was used the Female Sexual Function Index
(FSFI) [19]. The questionnaire evaluates the four items that could cause sexual dysfunction
– desire, arousal, orgasm and pain. All questionnaires were included in an interview that had
the purpose of better understanding the patient and the pathology for a unitary point of view.

Results

We selected 86 women aged between 40 and 83 years with a media of 60.12 years to
participate in this study. Most of the patients were above 60 years at the moment of surgery
(54.6%) and only 16.3% under 50 years. Among them 51 came from urban area and 35 form
rural areas. 49% had superior studies. Only 5 of the 86 patients were nulliparous and 39 had
a minimum of 3 pregnancies and at this point 64 patients were menopausal. The body mass
index was under 30 for 78% of the patients and comorbidities were present in 47%. The
demographics were resumed in Table 1.
For after surgery follow-up only 62 women were evaluated. In figure 1 it is shown the
distribution of the pelvic floor disorders on age groups. SUI was more often performed on
women between 40 and 60 year. POP with or without SUI was more common for patients
above 60 years. The surgical techniques consisted in vaginal hysterectomy, cystocele repair
(with or without mesh) and rectocele repair. The aim of this study was not to compare the
outcome of different types of procedures. The symptomatology was evaluated with PFIQ-7,
PFDI-20 and correlated with FSFI results. A high result in PFIQ-7 and PFDI-20 represents
an increased discomfort. These classes of patients also have poorer sexual function. For the
PFIQ-7 the mean value was 200.79 with standard deviation of 66.18 and for the PFDI-20 the
mean value was 195.968 with 82.38. Women with high scores on PFQI and PFDI had high
scores on sexual function FSFI. Sexual desire and interest were low on 56%, sexual arousal

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reduced in 61% and 71% reached orgasm less than half of time or almost never.

Table 1. Demographic characteristics of patient


Included (n=86) Follow-up evaluation (n=62)
Age (mean) 60.12 (40-83) 58.61 (40-83)
Urban area 51 (59.3%) 41 (66.12%)
Education (at least high school) 42 (49%) 34 (54.8%)
Parity Nulliparous 5 (6%) 5 (8.07%)
1-2 pregnancies 42 (49%) 35 (56.45%)
>3 pregnancies 39 (45%) 22 (35.48%)
Comorbidities (hypertension, 46 (53.5%) 32 (51.61%)
diabetes, cardiomyopathy,
cerebrovascular disease, etc.)
BMI kg/ <25 29 (33.7%) 20 (32.26%)
m2
25-30 38 (44.2%) 28 (41.16%)
>30 19 (22.1%) 14 (22.58%)

The 62 women were evaluated between 3 and 6 months after surgery, after a recommended
6 weeks period of abstinence. The scores in PFSI were improved in all four aspects and most
of all in self-perception of the body. This important psychological aspect is responsible for
the improvement of sexual desire and sexual arousal, the women being more open to engage
spontaneously in intercourse. From this 62 patients: 7 did not engage in sexual activities
because of fear of damaging the operation and the habitude of not having sexual activity, 32
had less than 3 sexual contacts and 23 had regular sexual contact. From the 55 patients that
engaged in sexual activity 3 reported dyspareunia and 5 lack of lubrication. For 24 patients
was easier to reach orgasm and for 31 women orgasm was reached more often. Overall, most
of the women related a state of relief with a healthier life, an improvement on body image and
felt more open to their partner. A side effect of a transvaginal mesh was reported. It consists
on the erosion of the vaginal wall and the protrusion of a small mesh border. The women and
her partners were highly satisfied about it and the impact on their sexual life. After 6 months

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the protruded mesh was removed and the integrity of the vaginal wall was restored. 43 women
stated that the disappearing of urinary incontinence during sexual intercourse made them more
relaxed and contributed to arousal.

Conclusion

An important aspect of life quality is the sexual component. Although not fully understood,
female sexuality is influenced by chronic health conditions. This can be easily seen in pelvic
floor disorders. The objective of this study was to correlate the pelvic floor surgery with the
improvement of sexual function. We did not take in consideration the type of procedure done
and we propose to evaluate this aspect in out clinic in the future. We showed trough FSFI
the positive effect of surgery on desire (by increasing self-esteem and self-body-perception),
arousal and orgasm (by increasing the sensitivity and the restoration of local anatomy). The
study had a short follow-up time (3-6 month) and some of the women had not resumed yet
sexual activity. A longer follow-up time can evaluate the sexual function more wildly but also
can be influenced by various factors not related to surgery. To conclude, sexual function should
be evaluated by clinicians who treat pelvic floor disorders and be open to patient counselling.
We propose in our clinic to further evaluate this aspect in other chronic conditions involving
the pelvic area and their surgical treatment.

REFERENCES

1. Graig D. Zippe, Kalyana C. Nandipati, Ashok Agarwal and Rupesh Raina (2005).
Female sexual dysfunction after pelvic surgery: the impact of surgical modification, BJU
international 96, pp. 959.
2. Basson R, Leiblum S, Brotto L, et al. (2004). Revised definitions of women’s sexual
dysfunctions. J Sex Med; 1(1) pp. 40-8.
3. Dinesh Bhugra, Gabriele Colombini (2013) Sexual dysfunction: classification and
assessment, Advances in Psychiatric Treatment, 19 (1) pp. 48-55.
4. Ash Monga, Stephen Dobbs (2011), Gynaecology by Ten Teachers, 19th Edition, pp. 154.
5. Klauss Goeshen, Peter Petros, Andrei Funogea, Elvira Brătilă, Petre Brătilă, Monica
Cîrstoiu (2016) Planșeul pelvic la femeie. Anatomia funcțională, diagnostic și tratament-
în acord cu teoria integrative- 708-894-9.
6. Adapted by Herman & Wallace Pelvic Rehabilitation institute from Barber, M., Walters,

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M. Et al. (2006) Short forms of two condition-specific quality of life questionnaires for
women with pelvic floor disorders (PFDI-20 and PFIQ-7), American Journal of Obstetrics
and Gynecology 193 pp. 103-113.
7. Persu C, Chapple CR, Caun V, Gutue S, Geavlete P (2011), Pelvic organ prolapse
quantification system (POP-Q)- a new era in pelvic prolapse staging, J Med Life 4(1) pp.
75-81.
8. Detollenaere, RJ (2016) The impact of Sacrospinous Hysteropexy and Vaginal
Hysterectomy with suspension of the uterosacral ligaments on sexual function in women
with uterine prolapse: a secondary analysis of a randomized comparative study, Journal
of Sexual Medicine 13(2).
9. Handa, V. L., Cundiff G.,Chang H. H., Helzlsouer K. J. (2008) Female sexual function
and pelvic floor disorders, NIH Public Access Author Manuscript Obstet Gynecol 111(5)
pp. 1045-1052.
10. El-Toukhy TA, Hefni M, Davies A, Mahadevan S. (2004) The effect of different types of
hysterectomy on urinary and sexual functions: a prospective study. J Obstetric Gynecol
24 pp. 420-5.
11. Ross AM, Thakar R, Sultan JW, Leeuw JW de, Paulus ATG (2013) The impact of pelvic
floor surgeru on female sexual function: a mixed quantitative and qualitative stuy, Royal
Cikkege of Obst and Gyneclogists.
12. Lonnée-Hoffmann RA1, Salvesen Ø, Mørkved S, Schei B. (2013) What predicts
improvement of sexual function after pelvic floor surgery? A follow-up study. Acta Obstet
Gynecol Scand.; 92(11) pp. 1304-12.
13. Brandner S1, Monga A, Mueller MD, Herrmann G, Kuhn A. (2011) Sexual function after
rectocele repair. J Sex Med.; 8(2) pp. 583-8.
14. M Feldman (2003) Unwanted sexual arousal after pelvic surgery, J R Soc Med.; 96(4)
pp. 190.
15. Tsung-Hsien Su, Hui-Hsuan Lau, Wen-Chu Huang, Shwu-Shiuang Chen, Tzu-Yin
Lin, Ching-Hung Hsieh, Ching-Ying Yeh (2009) Short Term Impact on Female Sexual
Function of Pelvic Floor Reconstruction with the Prolift Procedure, J Sex Med, 11(6) pp.
3201–3207.
16. Hoda MR, Wagner S, Greco F, Heynemann H, Fornara P. (2011) Prospective follow-up of
female sexual function after vaginal surgery for pelvic organ prolapse using transobturator
mesh implants, J Sex Med; 8(3) pp. 914-22.
17. Lowenstein L, Gamble T, Sanses TV, van Raalte H, Carberry C, Jakus S, Pham T, Nguyen
A, Hoskey K, Kenton K (2010) Changes in sexual function after treatment for prolapse
are related to the improvement in body image perception, J Sex Med; 7 pp. 23-8.
18. Barber M.D., Walters M. D, Bump R. C. (2005) Short forms of two condition-specific
quality-of-life questionnaires for women with pelvic floor disorders (PFDI-20 and PFIQ-
7) American Journal of Obstetrics and Gynecology 193 pp. 103–13.
19. IUGA-Revised (2009) PISQ-IR: Sexual Function for Women with: POP, Urinary
Incontinence and/or Fecal Incontinence International Urogynecology Journal.

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Modern Treatment In Pelvic Perineal Statics


Dysfunctions

SIMONA Niculescu¹, MIHAI Burniche¹, DAN Niculescu²

¹ 3rd Clinic of Obstetrics and Gynecology, Iași, (Romania)


² 2nd Clinic of Surgery UMF Iași, (Romania)

Abstract

The treatment of various pelvic perineal statics dysfunctions associated or not with stress
urinary incontinence (U.I.) has benefitted in the latest years by new indications and techniques
due to the use of polypropylene prosthetic devices, especially designed and placed through
minimally invasive procedures.

Material and method


In the period July 2007 – July 2015, the mentioned sections solved 165 cases of various
pelvic statics dysfunctions. Various procedures were performed on the female patients
included in the batch, either associated or in isolation, depending on their diagnosis, symptoms,
type of prolapse, age, their local anatomic situation and the presence or absence of sexual
activity. Thus, we have performed: - Tape urethrocystopexy with hammock-shaped four-arm
transobturator device – 82 cases; - sacrosciatic posterior colposuspension or the reconstruction
of anal lifting floor – 35 cases; - abdominal colpo-promontopexy in 48 cases out of which 28
required hysterectomy or the resection of remaining cervix. This procedure was associated
in 6 cases with polypropylene net implant at the anal lifting area and in 11 cases with sub-
urethral transobturator vaginal tape for urinary incontinence. The abdominal approach allows
the accurate skeletonization of the internal genital organs as well as of the retroverted vagina
avoiding urethra-bladder lesions, while the promontory fixation of the vaginal vault with a
polypropylene device ensures long-lasting results.

Results
Generally all cases registered simple immediate post-surgery evolution; however, we
have to mention three hematomas that required surgical evacuation and three cases of vaginal
mucosa necrosis, of which one required the suppression of the implanted device. The anatomic
and functional results on the long term were satisfactory.

Conclusion
To conclude, the use of bands, nets and polypropylene devices in the correction of various
pelvic perineal statics dysfunctions provide advantages related to the relatively easy execution,
shorter hospital stay and excellent results on the long term.

Keywords: genital prolapse, modern treatment

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Introduction

Pelvic perineal statics disorders occur due to the displacement of the organs normally
supported by the pelvic perineal floor, the anterior vaginal wall, which may eventually affect
the neighboring organs – the bladder, the urethra, the rectum [1].
We consider [2]:
- Anterior compartment prolapse – with the descent of the urethra bladder junction to more
than 3 centimeters above the hymen.
- Medium compartment prolapse – the descent of the vaginal arch to less than 2 centimeters
of the hymen.
- Posterior compartment prolapse – with the descent of half of the posterior vaginal wall at
less than 3 centimeters of the hymen. [3]
These pelvic perineal statics disorders are often associated with [4] stress urinary
incontinence. (U.I.)

Purpose

To support, based on personal experience, the use of modern techniques for the correction
of pelvic perineal statics dysfunctions consisting in implanting polypropylene devices.

Objectives

To list technical details related to the accurate placement of prosthesis in female genital
prolapse.
To describe cases from our personal experience in order to emphasize indications,
techniques and results deriving from these types of surgery.
To plead for the use on a larger scale of modern techniques in the treatment of pelvic
perineal statics dysfunctions.

Material and method

In the period July 2007 – July 2015 we have solved 165 cases of various pelvic statics
disorders using prostheses. Various procedures were performed on the female patients included
in the batch, either associated or in isolation, depending on their diagnosis, symptoms, type
of prolapse, age, their local anatomic situation and the presence or absence of sexual activity.
The diagnosis was established based on case history, clinical examination, echography and
functional analyses.
The clinical examination, our main diagnosis method, was performed in orthostasis and
in gynecological position, either with both valves or one valve, using procedures known for
causing the loss of urine or which would simulate the surgical correction of the incontinence.
[5]
As far as age was concerned, our patients were between 30 and 85 years of age; in over
50% of the cases, the patients were in their 50’s, 60’s and 70’s.
The diagnosis includes [5] besides a general biological evaluation, the echographic
dimensioning of the urethral-bladder junction position, the vaginal cytobacteriologic

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examination, microbiological culture and eventually establishing the surgery and anesthesia
related risks.
Last but not least it is mandatory to inform the patients and obtain their written consent on
specially conceived forms.
As required by each individual case [6] in the above mentioned batch of patients, we
performed the following procedures:
- Tape urethrocystopexy with hammock-shaped four-arm transobturator device – 82 cases;
- Sacrosciatic posterior colposuspension or the reconstruction of anal lifting floor – 35
cases;
- Abdominal colpo-promontopexy with polypropylene prosthesis – 48 cases.
Trans-obturator uretrocistopexy [7] was performed vaginally through a longitudinal
incision on the anterior vaginal wall, up to 1 centimeter from the meat, followed by the
lateral dissection of the vaginal wall and bladder until the inferior margin of the obturating
hole was released. A small 3 mm incision situated at 3-4 cm away from the median line
approximately midway between the meat and the clitoris allows the introduction of the guide
perforator through the obturating membrane at the limit of the superior osseous margin of the
ischiopubic ramus into the vagina through the specially designed breach. There we attach the
arm of the prosthesis which is then pulled outside and exteriorized through trans-obturation
to the tegument. [8] In order to place a sub-urethral hammock shaped four-arms device, the
intervention follows the same indications [9] except for the fact that the lateral dissection of
the vaginal wall has a more significant length, as well as the release of the ischiopubic margin,
and the tegument has another small incision, about four centimeters beneath the first one.
The device is tensioned gradually by pulling the external branches provided that a 2 mm
sub-urethral space is kept [10]. The closing of the vaginal plague is done similarly as in the
case of the simple tape.
Posterior colposuspension represents the optimal solution for the posterior compartment
prolapse. A longitudinal incision dissects the posterior vaginal wall laterally exposing the rectal
wall to the lifting area. The rectum is progressively pushed upwards towards the median area
until the sciatic spine is revealed and the sacrosciatic ligament is seen underneath. Through a
small incision situated at four centimeters laterally fom the anus we insert the guide perforator
through the newly created para-rectal space, which goes through the sacro-sciatic ligament
and then anchors and pulls from the inside towards the outside the arm of the polypropylene
prosthetic device. This has the shape of a “camisole” whose “shoulder strips” are brought to
the exterior with the help of the right and left para-anal perforator, the superior margin being
fixed at the posterior colpocervical limit, while the inferior margin can be adjusted at the
perineal resistance center. Hemostasis and the closing of the vaginal incision are the finishing
steps of the procedure.
Abdominal colpopromontopexy was performed in 48 cases, out of which 28 required
hysterectomy or the resection of the remaining cervix. This procedure was associated in 6
cases with polypropylene net implant at the anal lifting area and In 11 cases we associated the
vaginal introduction with sub-urethral transobturator tape for urinary incontinence, while 6 of
the cases required a trapezium prosthesis for the anal lifting muscles shown retrovaginally.
The presence of the cervix in vaginal vault prolapse cases after sub-total hysterectomy
(after Pap smear) required the ablation of the cervix.
We prefer to treat such cases through abdominal approach since it allows [11] accurate
skeletonization of the uterus and/or remaining cervix preventing urethra-bladder lesions
that can have a significantly modified position being caused by the retroverted vagina. The

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abdominal approach [12] is based on standardized procedures.
This intervention implies insignificant surgical risks and when accurate care before, during
and after surgery is provided the procedure can be successfully performed even on elderly
patients.

Results

In the correlation between the repair of the anterior compartment prolapse and urinary
incontinence the outcomes were good and very good, with a small number of complications
occurring during and after surgery (three cases of hematoma, two vaginal mucosa necrosis and
a suppuration that required the removal of the prosthesis after surgery).
With the posterior compartment prolapse the outcomes after surgery were very good, with
no significant complications.
With the medium compartment prolapse, the general results were satisfactory, except for
three of the cases where after surgery there occurred urinary incontinence that required after
thirty days the complementary intervention consisting in the vaginal placement of a sub-uterus
trans-filling band.
After surgery hospitalization was an average of ten days and subsequent check-ups after
two, six and twelve months indicated a satisfactory evolution from both the functional and
anatomic perspective.

Discussions

The International Continence Society defines stress urinary incontinence as “any


involuntary release of urine” (2002). It is considered that approximately 30% of the female
population experiences involuntary urine releases. [13]
Genital prolapse treatment associated with stress urinary incontinence included over one
hundred imagined procedures. [14]
There are currently new indications and modern techniques that use various polypropylene
prosthetic devices specially designed for the repair of pelvic statics disorders, either isolated
or associated with urinary incontinence. [15]
Besides the small percentage of complications [16] the use of these techniques provides
satisfactory anatomic and functional results on the long term.

Conclusions

The immediate and long-term favorable evolution of the cases confirms the necessity to
use different techniques, adapted to each particular case, supporting thus the idea that the use
of various polypropylene devices in minimally invasive techniques for the treatment of stress
urinary incontinence is fully justified.

REFERENCES

1. Pricop Mihai, Chirurgie Ginecologica., ed. Institutul European Iasi, 2006, pp. 136-148.
2. Bump RC, Mattiasson A, Bo K, et al: The standardization of terminology of female pelvic

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organ prolapsed and pelvic floor dysfunction. Am J Obstet Gynecol 1996; 175:1017.
3. Burbulea – Raducea E.: The standardization of terminology of female pelvic organ
prolapsed and pelvic floor dysfunction (POP-Q), Rom. J. Urogynec. Pelvic Floor
Disord.,2003, 1:41 – 54.
4. Bumbu G, Screening – Incontinenta. Tulburari urinare. Prolaps. Revista Romana de
Uroginecologie: 2006/1.
5. Bumbu G. Uroginecologie practica, Ed. Imprimeria de Vest – Oradea 2007, pp.107-147,
153-213.
6. Gh. Bumbu, T. T. Maghiar, L. Szilagy, V. Coltoiu, S. Leahu, A. Bumbu, M. Berechet,
C. Borza, D. Purza, Transobturatory approach and intra-coccigeal sacropexy with
polypropylene mesh for hight grade urogenital and vault prolapsed. XV Congresso
Nazionale Perugia 2006 Settembre, 12-16.
7. Bratila P., Nicodin O., Barbulea – Raducea E.,:Transvaginal sling procedure for urinary
incontinence due to intrinsic sphincterian deficiency, Rom. J. Urogynec. Pelvic Floor
Disord., 2004, 1:29-32.
8. Spinosa J. P., Dubuis P. Y., Riederer B.: Transobturator surgery for female urinary
incontinence: from outside to inside or from inside to outside: a comparative anatomic
study, Prog. Urol., 2005, 15:700-706.
9. Deval D., El Houari Y.,Raffi A., Frondes sous – uretro – vesicale et bandelettes sous –
uretrales: revuie de literature, J. Gynecol. Obstet. Biol. Reprod., 2002, 31:131-143.
10. Paick J. S., Oh J. G., Shin J. W.: Significance of tension-free mid-urethral sling procedures
a preliminary study Int. Urogynecol. J. Pelvic Floor Dysfunct., 2006, April 5 (in print).
11. Nichols DH: Central compartment defects. In: Rock JA Thompson JD (eds): TeLindes
Operative Gynecology 8th ed, Philadelphia, Lippincott – Raven, 1997, pp.1006-1030.
12. Toozs – Hobson P.H., Boos K., Cardozo L.: Management of vaginal vault prolapsed, Br.
J. Obstet. Gynaec., 1998, 105:13 – 17.
13. Gh. Bumbu: Indicatii chirurgicale actuale in incontinent urinara de efort si prolps
urogenital. Al III-lea Congres al Societatii Romane de Uroginecologie, Madeira, 2007
Iunie.
14. Petri E,: Micro-invasive surgical techniques for the treatment of urogynaecological
disorders: traditional procedures, Persperctives in Gynaecology and Obstetrics, The
Parthenon Publishing Group, 1999, 43-47.
15. Robert M., Farrell S. A., Easton W. A.: Choice of surgery of stress incontinence, J. Obstet.
Gynaecol. Can., 2005, 27:964-980.
16. Morey A. F., Medendrop A. R., Noller M. W.: Transobturator versus transabdominal
midurethral sling: a multi-institutional comparison of obstructive voiding complications,
J. Urol., 2006, 175:1014-1017.

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Colpopromontopexy. Vaginal apex in vault prolapse.

Posterior compartment prolapse–tuneller introduction for sacrosciatic suspension.

Total genital prolapse 4th degree.

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Assessing etiological prognostic factors associated with


preterm birth by a questionnaire-based risk score

OANCEA Alexandru1, FRANDES Mirela2, LUNGEANU Diana2,


ANASTASIU Doru3,4,*, STANESCU Casiana1,
ANASTASIU-POPOV Diana Maria3
1
Faculty of Medicine, “Vasile Goldis” Western University of Arad, Arad (ROMANIA)
2
Department of Functional Sciences/Medical Informatics and biostatistics, “Victor Babes” University
of Medicine and Pharmacy, Timisoara (ROMANIA)
3
Department XII Obstetrics, Gynecology and Neonatology, “Victor Babes” University of Medicine and
Pharmacy, Timisoara (ROMANIA)
4
Obstetrics and Gynecology, “Bega” Maternity Clinic, Timisoara (ROMANIA)
*
Correspondence author
E-mails: alexo89@yahoo.com, mirela.frandes@umft.ro, dlungeanu@umft.ro, doru_anastasiu@yahoo.
com*

Abstract

The objective of this study was to assess the etiological factors associated with preterm birth
by using an easily employable questionnaire among of a national sample. A cross-sectional
study was conducted at the “Bega” Maternity Clinic from Timisoara, Romania. A selected
sample of 102 women who underwent preterm birth was post-delivery questioned employing
a similar instrument to the Papiernik’s risk scoring method. Measured data included biological
description of both mother and new-born(s), birth conditions as well as etiological factors, e.g.
social and life conditions, obstetrical history, current pregnancy events, medical history.
A principal component analysis was conducted to determine etiological prognostic factors
for the risk of preterm birth. The analysis revealed that life conditions and pregnancy events,
together with medical and obstetrical history, do account for the risk of preterm birth.
The proposed score can be easily calculated by the pregnant herself, being an educational
and preventive instrument.

Keywords: preterm birth, etiological prognostic factors, risk score, questionnaire

Introduction

In the last decades, several European countries reported a grown rate of preterm birth. In
addition, it is estimated that the rate will still grow because of multiple pregnancy associated
to fertilization treatments as well as pregnancy at an older age. The rate of preterm birth for
multiple pregnancy is 40-60% higher than for single pregnancy [1]. On the other side, the
survival rate of preterm new-born grew lately because of improved neonatal care and treatment
with corticosteroids, which results in reduced syndrome of respiratory distress. Other factors

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influencing the risk of preterm birth are in-vitro fertilization, mother age, mother health status
(e.g. BMI).
Finding the factors which held to preterm birth may be difficult, most of the time remaining
a supposition or even unknown. Generally, in preterm birth etiology, there are several potential
influencing factors, e.g. medical, maternal, fetal, ovulatory, socio-economic, psychological
[2]. One classification can identify the following group factors: (i) factors concerning the
biological constitution of the pregnant, (ii) factors concerning the obstetrical antecedents of
the pregnant, (iii) social factors, (iv) factors concerning the ongoing pregnancy, (v) factors
concerning pregnancy associated pathologies.
The prophylaxis of preterm birth should be done from the very begging, when the pregnant
is taken in evidence. A better alternative would be to have prognostic methods which can
be employed by the pregnant herself on her own peace. Computing a risk score for preterm
birth based on a questionnaire was firstly proposed by Emile Papiernik in 1969, denoted “The
Coefficient of Premature Delivery Risk (CPDR)” [3]. Each included item was ranked, having
assigned a number of points (from 1 to 5) considering its contribution to the total risk.
Later the risk scoring system was modified by Creasy et al. [4]. The Papiernik-Creazy risk
scoring system was widely evaluated, mainly on U.S. populations, failing to identify at-risk
patients [5]. However, the poorer performance suggests that it may be more appropriate to
develop a risk scoring system specific for each population.
It was observed that preterm births can be classified into very and moderate according
to the associated risk factors [6]. Therefore, the gestational age can be indicator for preterm
births.
Prevalence and risk factors associated to preterm birth were investigated in [7], considering
the specific case of Ardabil’s (Iran) population.
Basically, the risk score system based on CPDR is understandable and easy to apply, but
it is not capable to make a continuous prediction of gestational age. Other factors may have
higher prediction power. However, measuring these factors demands medical investigations,
making it out of use for patients alone. Finally, this type of score can be easily applied as an
educational and preventive instrument, thus it would be useful to exist or the ones existing to
be improved.

Methodology

Risk score method based on CPDR


The employed risk scoring method is based on the CPDR system proposed by Papiernik at
el. [4]. It consists of a set of questions related to maternal characteristics, which are grouped
into four series of comparable variables (social status, obstetric history, work conditions,
pregnancy characteristics). A number of points varying from 1 to 5 according to the degree of
their importance is assigned to each characteristic. For example, for antecedents of preterm
birth, miscarriages, abortive disease, placenta Previa, heart disease, the number of points is
5. For stillbirth in history, short cervix, contractile uterus, diabetes, thyroid, pyelonephritis,
anemia, drugs consumption, the number of points is 4, while for hard work conditions, the
number of points is 3.

Data analysis
For categorical variables, description was done by their absolute frequencies and percent,

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for rang variables by median and inter-quartile range (IQR), and for the numerical ones by
mean and standard deviation. The applied statistical tests were Chi-square (Fisher-exact)
test for investigation of association between categorical variables; Mann-Whitney test for
investigation of differences between central tendency in case of rang variables; t-Student test
(unpaired) for comparing mean in case of numerical variables. Investigation of contributing
components to the CPDR score included the principal components analysis along with the
correlation matrix between the initial components and Bartlett-test for deciding if a change of
axis is statistically significant in case of data from the studied population. Factor rotation was
performed by Varimax method, with Kaiser normalization.
A limit of 0.05 was considered the statistical significance threshold, respectively 0.95 for
the confidence level. Statistical processing was performed with SPSS v17 (SPSS Inc., Chicago,
IL) and the R software packages v.3.2.5.

Results

Use as many sections and subsections as you need (e.g. Introduction, Methodology,
Results, Conclusions, etc.) and end the paper with the list of references.
The descriptive statistics of the sample data are presented in Table 1. We included
characteristics concerning the pregnant personal details (e.g. age, nationality, location area),
the new-born biological description (e.g. gender, weight, length) as well as the birth conditions
(e.g. gestational age, Apgar index).

Table 1. Characteristics of data


N total = 102 cases
Characteristic Description
Mother
Age [years] (a) 28.64 ± 5.79
1 (1%) → Roma ethnic, 16 years old; second pregnancy;
under age (b)
urban area; Apgar index=10
under 20 (b) 8 (7.8%)
older than 35 (b)
13 (12.7%)
Urban area(b) 62 (60.8%)
Romanian (b) 89 (87.3%)
Roma (b) 9 (8.8%)
Hungarian (b) 3 (2.9%)
New-born
46 (45.1%); one of the multiple pregnancies had
Gender (M) (b)
different-sex new-borns
Weight [g] (a) 1810 ± 614
Length [cm] (a)
44 ± 6.1
Deceased (b) 5 (4.9%)

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Gesta(c) 2 (1; 3)
Para(c) 2 (1; 2)
Birth
Natural (b) 28 (27.5%)
Multiple pregnancy (b)
8 (7.8%), one with triplets and 7 with twins

Gestational age [weeks] (a) 32.25 ± 1.11

Apgar index (c) 7 (6; 8) → (min-max) = (1-10)


CRNP score (c)
19 (13; 24)
(a)
m ± s; n (%); median
(b) (c)

(IQR)
We observed statistically significant differences between ages of women living in urban
area and rural area (t-test for independent samples): t = 2.19 (100 df), p = 0.031, 95% CI of the
difference (0.14; 4.82). The two samples presented equal variances (Levene’s test, p = 0.459).
Afterwards, we were probing for possible associations between medical/social condition
and the pregnancy outcome, or other birth-related characteristics. There were no statistically
significant differences between new-born weight and the birth approach (t-test, t = 373 (100
df), p = 0.71). The two samples had equal variances (Levene’s test, p = 0.584). Similarly, there
were no statistically significant differences new-born height and the birth approach (t-test, t =
-1.694 (91 df), p = 0.094). When comparing the Apgar index, we also obtained no significant
differences between the two birth approaches (Mann-Whitney, p=0.596). In addition, there
was no association between multiple pregnancy and C-section approach (Fisher’s-exact test,
p = 0.44).
Table 2. Etiological factors’ inter-correlation matrix
Obst Pregn Med
Phys Const LifeCond
History Events History
Phys constitution 1.000 .185 .094 -.11 .276
Correlation coefficient

Obst history 1.000 -.082 -.202 .05


Life conditions 1.000 -.05 .092
Pregnancy events 1.000 .188
Med history 1.000
significance)
(statistical

Phys constitution .031* .173 .135 .002**


p

Obst history .205 .021* .31


Life conditions .307 .179
Pregnancy events .029*
Med history
*
statistically significant; **statistically very significant;

The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy was 0.473, while the

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Bartlett’s test reached the statistical significance: X2 = 24.43 (10 df), p = 0.007. Though KMO
value is rather small, the Bartlett’s test proves an inter-correlation matrix statistically different
from an identity matrix (p < 0.01), so it makes sense to attempt a principal component analysis,
i.e. either a data reduction could be made or, at least, the underlying relationships between the
five etiological factors could be re-arranged. The inter-correlation matrix is presented in Table
2. The initial eigenvalues of the five components are presented in Table 3. We observed that
only the first three components had values above 1.

Table 3. Initial eigenvalues of the five components

Component Initial eigenvalues


Value % of variance Cumulative %
1 1.388 27.754 27.754 %
2 1.260 25.207 52.960 %
3 1.031 20.626 73.586 %
4 .719 14.378 87.964 %
5 .602 12.036 100.000 %

We subsequently generated the Varimax rotated component matrix by selecting the


Varimax rotation option that the factors are uncorrelated (technically orthogonal), as shown in
Table 4 and Figure 1.

Figure 1. Matrix of the three principal components’ contribution. There is no association


between these components, as it can be observed.

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Table 4. Varimax rotated component matrix, after the principal component analysis

Etiological factors/variables Component


1 2 3
Physical constitution .751 -.267 .097
Obstetrical history .378 -.587 -.417
Life conditions .138 -.069 .920
Pregnancy events .113 .852 -.149
Medical history .785 .353 .041

Based on eigenvalues and the scree plot, the first three components were extracted (Table
4), which accounted for almost 74% of the variance.

Conclusions

The risk score system based on CPDR is simple, easily understood, with good prevention
potential, and manageable in general practice or even by lay individuals. We still look forward
to finding a holistic reliable scoring for the gestational age.

REFERENCES

1. EURO-PERISTAT (2008). Better statistics for better health for pregnant women and their
babies in 2004. European Perinatal Report in collaboration with SCPE, EUROCAT and
EURONEOSTAT.
2. Larroque, B.; Ancel, P.Y.; Marret, S. et al. (2008) Neurodevelopment disabilities and
special care of 5-year-old children born before 33 weeks of gestation (the EPIPAGE
study): a longitudinal cohort study.
3. Papiernik-Berkhauer, E. (1969) Coefficient of premature delivery risk. Presse Med 77(21),
pp. 793–794.
4. Creasy, R.K.; Gumrner, B.A.; Liggins, G.C. (1980) Systems for predicting preterm birth.
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evaluation of a risk scoring system for predicting preterm delivery in black inner city
women. Obstet Gynecol 69(1), pp. 61-66.
6. Ancel, P.Y.; Saurel-Cubizolles, M.J.; Di Renzo, G.C.; Papiernik, E.; Breart, G. (1999)
Very and moderate preterm births: are the risk factors different? British Journal of
Obstetrics and Gynaecology 106, pp. 1162-1170.
7. Alija, R.; Hazrati, S.; Mirzarahimi, M.; Pourfarzi, F.; Hadi, P.A. (2014) Prevalence and
risk factors associated with preterm birth in Ardabil, Iran, Iran J Reprod Med 12(1), pp.
47-56.

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Associations between the risk of preterm birth,


gestational age at which the birth occurred and birth
weight of newborns

OANCEA A1, ANASTASIU D2, TOTH AG2, FRANDEȘ Mirela3,


STĂNESCU Casiana1, GLUHOVSCHI A2,
ANASTASIU-POPOV Diana Maria2
1
Faculty of Medicine, “Vasile Goldis” Western University of Arad, Arad (ROMANIA)
2
Department XII Obstetrics, Gynecology and Neonatology, “Victor Babes” University of Medicine and
Pharmacy, Timisoara (ROMANIA)
2
Obstetrics and Gynecology, “Bega” Maternity Clinic, Timisoara (ROMANIA)
3
Department of Functional Sciences/Medical Informatics and biostatistics, “Victor Babes” University of
Medicine and Pharmacy, Timisoara (ROMANIA)
E-mail: doru_anastasiu@yahoo.com

Introduction

Premature birth still remains a contemporary issue for obstetrics for its consequences it has
on infants, causing a high perinatal mortality and a high degree of late sequelarity. [1, 2, 5]
Premature birth occurs between 24 and 37 weeks of gestation when after birth in this period
there is a “fetal viability” where the fetus can survive outside the mother’s body. [7, 9]
The main concerns of obstetricians are to extend as far and in good conditions the pregnancy
so that it exceeds 37 weeks of gestation and fetal birth weight is over 2500g. [10, 11, 15]
These objectives can be achieved by tocolysis, prescription drugs, preventive measures
including the calculation of the premature birth risk rate (CRNP) which allows the identification
and removal of avoidable factors that favor premature birth. [22]

Material and method

A total of 2454 births occurred in the Obstetrics and Gynecology Hospital in Arad. There
were a total of 240 premature births resulting a prematurity index of 9,77%.
Of the total number of births 1605 (64,4%) were born by caesarean section and 849 (34,6%)
were born naturally.
We note that in cases of extreme prematurity of grades III and IV, they were routed from
start to grade III medical facilities.
The study included 300 unselected births of which 195 (65%) were born at term and 105
(35%) were premature births of varying degrees, this while the index of prematurity in the last
5 years oscilated between 7,48 – 10,34%. Of the total number of births that were born at term,
81 (41,53%) were born naturally and 114 (58,46%) were born by caesarean section. Out of the
105 premature births, 30 (28,57%) were born naturally and 75 (71,42%) by caesarean section,
also because in these cases there were a number of major indications for a caesarean section
such as pathologies associated with pregnancy but were also determinant factors of premature
birth such as preeclampsia, placenta praeviae, fetal distress.

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In these conditions we divided the study group into four categories:
1. Pregnant women who gave birth at term naturally 81 (27,1%)
2. Pregnant women who gave birth at term by caesarean section 114 (38%)
3. Pregnant women who gave birth prematurely naturally 30 (10%)
4. Pregnant women who gave birth prematurely by caesarean section 75 (25%)
All pregnant women have had their coefficient risk of premature birth (Papiernic)
calculated, knowing the fact that a CRNP>10 shows a high risk of premature birth, 5-10 there
is a potential risk of premature birth, and one under 5 excludes the risk of premature birth. [16,
18, 20]
We correlated the value of this coefficient with gestational age at birth and fetal weight at
birth. [3, 4]

Data analysis

For categorical variables, description was done by their absolute frequencies and percent,
for rang variables by median and inter-quartile range (IQR), and for the numerical ones by
mean and standard deviation. The applied statistical tests were Chi-square (Fisher-exact) test
for investigation of association between categorical variables.
A limit of 0.05 was considered the statistical significance threshold, respectively 0.95
for the confidence level. Statistical processing was performed with SPSS v17 (SPSS Inc.,
Chicago, IL).

Results

Table 1 presents the number of births along with the corresponding percentages from all
the four birth groups, in conjunction with the risk score of preterm birth and gestational age.

Group I Group II Group III Group IV

(N = 81) (N = 114) (N = 30) (N = 75)

GA [weeks] 38 - 40 38 - 40 29 - 34 30 - 34
Risk Score N % N % N % N %
0 25 30.86 8 7.02 0 0 0 0
1-5 27 33.33 56 49.12 2 6.67 3 4
6-10 19 23.46 38 33.33 10 33.33 13 17.33
11-15 9 11.11 10 8.77 13 43.33 33 44
16-20 1 1.24 2 1.75 2 6.67 19 25.33
>20 0 0 0 0 3 10 7 9.33
Table 1. Risk score for each birth group. The GA interval is indicated below the
corresponding group.

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Group I: Term birth, normal; Group II: Term birth, caesarian; Group III: Preterm birth,
normal; Group IV: Preterm birth, caesarian. GA: Gestational Age.

Table 2. New-born weight for each birth group. The GA interval is indicated below the
corresponding group

Group I Group II Group III Group IV

(N = 81) (N = 114) (N = 30) (N = 75)

GA [weeks] 38 - 40 38 - 40 29 - 34 30 - 34
New-born
N % N % N % N %
weight [gr]
>3400 49 60.49 108 94.74 0 0 0 0
3001 - 3400 25 30.86 6 5.26 0 0 0 0
2501 - 3000 5 6.17 0 0 0 0 0 0
2101 - 2500 2 2.47 0 0 28 93.33 48 64
2001 - 2100 0 0 0 0 0 0 14 18.67
1800 - 2000 0 0 0 0 2 6.67 0 0
<1800 0 0 0 0 0 0 13 17.33
Group I: Term birth, normal; Group II: Term birth, caesarian; Group III: Preterm birth,
normal; Group IV: Preterm birth, caesarian. GA: Gestational Age.

Table 2 presents the number of births along with the corresponding percentages from all
the four birth groups, in conjunction with birth weight and gestational age.

The births in Groups I and II were dominant at the lowest risk scores, attaining 81% and
19% from the total number of births without risk, respectively. On the contrary, at the highest
risk scores (>20), there were no births in Groups I and II, while the Groups III and IV were
dominant. At the median risk scores (between 6 and 10), all the birth groups presented almost
equal proportions (Figure 1).

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Figure 1. Percent of births from each group divided by risk score interval
We observed a highly statistically significant association between the four groups
distribution and the risk score of preterm birth (Chi-Square test for independence, X2 = 174.7,
df = 12, p < 0.001).

Figure 2. Percent of births from each group divided by the birth weight

The births in Groups I and II were dominant for a birth weight above 3400 grams, attaining
30.5% and 69.5% from the total number of births, respectively. On the contrary, at the lowest
birth weights (< 2100 grams), there were no births in Groups I and II, while the Groups III and
IV were dominant (Figure 2).

We observed a highly statistically significant association between the four groups


distribution and the birth weight (Fisher’s exact test for independence, F = 369.2, df = 12, p
< 0.001).

Discussions

The first group of pregnant women who gave birth naturally on term we found out that 79
(97,53%) were born on term and only 2 (2,46%) were born prematurely at a gestational age of
33-34 weeks of gestation, both having a CRNP >10.
From the entire group 79 (97,53%) were born at a gestational age of more than 37 weeks
of gestation, 49 (60,49%) having a birth weight of >3400g, 25 (30.86%) with a birth weight
between 3000 and 3400g at a gestational age of 38-40 weeks, 5 (6,17%) with 37 weeks
gestational age and a birth weight between 2500-3000g and two premature births 34-35 weeks
gestational age and birth weight of 2000-2500g.
We note that from the entire group 71 (87,65%) had an CRNP >10 excluding the possibility
of premature birth.
In both cases with fetuses born at term but with low birth weight was caused by a intrauterine
growth retardation although CRNP was lower than 10 in both cases.
In the second group we observe that 102 (89,47%) of pregnant women had a CRNP<10
excluding the risk of premature birth and 12 (10,52%) had a CRNP >10. The whole group gave
birth to live fetuses with weight over 3000g from which 108 (94,73%) with weight over 3400g.
The cases that had a CRNP >10 and were born on term were due to a correct hospitalization
of the pregnancy and removing the favoring factors for premature birth which led to a decrease
in the risk coefficient. During pregnancy this risk coefficient can oscillate up or down.
Third group a CRNP >10 was in 59,99% cases, representing 25 pregnant women. The

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entire group of 30 pregnant women gave birth prematurely. Gestational age at birth being
between 28-30 weeks and new born weight <2000g in 2 cases (2,66%) and between 31-34
weeks and new born weight of 2001-2500g in 28 (93,33%) of cases.
In this group there is a discordance in 12 cases (41,99%) CRNP which was under 10 and
the premature birth still occurred.
In the fourth group a number of 59 (79,45%) of pregnant women had a CRNP >15 of which
7 (9,33%) had a CRNP >20. We note that in these pregnant women CRNP was generated
mostly because of a disease caused by pregnancy or associated with pregnancy which required
delivery by caesarean section and not infrequently the premature extraction of the fetus in
cases of placenta praeviae, premature ruptured membranes, preeclampsia, isoimmunization
etc.

Fetuses resulting from these pregnancies were all premature as follows:


Premature Grade I 2001-2500g 48 (64%)
Premature Grade II 1501-2000g 1 (18,66%)
Premature Grade III 1001-1500g 7 (9,33%)
Premature Grade IV <1000g 5 (8%)

And in this case we have a discordance between CRNP and new born weight at birth in 16
cases representing 21,33%.

Without any special significance by nationality we note that the study group presented the
following ethnic composition:
Romanian 285 (95%)
Hungarian (2%)
German 1 (0,33%)
Roma 8 (2,66%)

Conclusion

1. The risk coefficient of premature birth faithfully represents the possibility of a premature
birth by identifying its favoring factors
2. Removal of avoidable predisposing factors of premature birth makes it possible to
decrease CRNP completely reducing the risk of premature birth
3. There is a direct proportion between CRNP and gestational age at which the birth might
occur and the birth weight of the newborn.
4. Calculation of CRNP since the registration of the pregnant woman and fetal monitoring
during pregnancy is a means of prevention for premature birth with chances of success in
prolonging gestational age.

REFERENCES

1. Anastasiu D. – Obstetrica vol. I, Ed. Victor Babes Timisoara, 2011, pag 209-221.
2. Anastasiu D. – Consultatia prenatala in V. Stoica, Scripcaru V. , Compediu de specialitate
medico-chirurgicale, Ed. Medicala, Bucuresti 2016 vol. II pag. 349-384.
3. Stavorachu Neda., Pricop Florentina, Crauciuc E. – Nou nascutul prematur in Munteanu
I. – Tratat Obstetrica Editia II-a, 2006, Bucuresti, Ed. Academiei Romane, pag 439-445.

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4. Pricop Florentina, Butureanu St., - Nasterea prematura in Munteanu I. – Tratat de
Obstetrica Editia II-a, Ed. Academiei Romane, Bucuresti, 2016, pag. 497-510.
5. Goldenberg Rh, Hauth J.C, Andrews WLW – Intrauterin infection and preterm delivery,
M.Enpl J Med, 2000, 342, pag 1500 -1507.
6. Grisby PL, Novy MJ, Waldorf KM, Sadowsky DW, Gravett MG – Choriodecidual
inflammation; a harbringer of the preterm labor syndrome, Reprod Sci, 2010, 17, pag.85-
94.
7. Shah PS – Induced termination of pregnancy and low analyses. Knowledge synthesis
group of determinants of preterm/LBW Birth, BJOG, 2009, 116, pag. 1425-1442Naeye
RL – Factors that predispose to premature rupture of the fetal membranes, Obstet.
Gynecol., 1982, 60, pag. 93-98.
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for the development of preterm premature rupture of the membranes after arrest of preterm
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9. Da Fonseca EB, Bittar RE, Carvalho MH, Zugaib M – Prophylactic administration of
progesterone by vaginal suppository to reduce the incidence of spontaneous preterm birth
in women at increased risk: a randomized placebo-controlled double-blind study, Am J
Obstet Gynecol, 2003, 88, 414-424.
10. Bezkowitz GS, Blackmore-Prince C, Lapinski RH – Risk factors for preterm birth
subtypes, Epidemiology, 1998, 9(3), pag. 279-285.
11. Danti L, Palai N, Ravelli V -Ultrasonography of the uterine cervix in pregnancy. Curve
of normality in a longitudinal and cross-sectional study, Minerva Ginecol, 1998, 50(10)
pag.397-404.
12. Delgado-Rodriguez M, Gomez Olmedo M – Comparison of 2 indexes of prenatal care and
risk of preterm delivery, Gac. Sanit., 1997, 11(3), pag. 136-142.
13. Dumitrache F., Sirota M., Pricop Florentina, Butureanu St., - Aprecieri clinico statistice
privind determinismul nasterii premature dupa studiul unei populatii feminine la o
intreprindere din municipiul Iasi, vol al IX-lea, Comp. Mat. Obst-Ginecol., Brasov, 1989,
pag.125.
14. Ioanid I., Mihailescu A., Butureanu St. – Prematuritatea- aspecte etiopatogenice si
profilactice, vol. a IX-lea, Comp. Mat. Obstet-Ginecol., Brasov, 1989, pag.125.
15. Kyrklund-Blomberg NB, Cnattingus S – Preterm birt hand maternal smoking; risks
related to gestational age and onset of delivery, Am. J. Obstet-Ginecol., 1998, 179(4),
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Gh. Peltean, Ed. Acad. Romane Buc., 2014, pag. 433-463.
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nifedipine or ritodrine: analysis of efficacy and maternal fetal and neonatal outcome, Am.
J. Obstet-Gynecol, 1990, 163, pag. 105-111.

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Repairing the vesicovaginal fistula by transvesical


(extraperitoneal) approach

PATRASCOIU Sorin1, BRATILA Elvira2, BRATILA Petre3,


STROESCU Cezar1, HANNA Adrian1, ZAMFIR Radu4,
MISCHIE Oana Gabriela5, POPA Laura6,
CONSTANTIN Carmen6, GILCA Iulian1, PUSCASU Ana1,
BIRCEANU Adelina7,GURAU Claudia8, COPCA Narcis1
1
Center of General Surgery and Transplant –Saint Mary Clinical Hospital, Bucharest, (ROMANIA)
2
“Carol Davila” University of Medicine and Pharmacy Bucharest/Gynecology Obstetrics Clinic
“Saint Pantelimon” Emergency Hospital Bucharest, (ROMANIA)
3
“Carol Davila” University of Medicine and Pharmacy (BUCHAREST)
4
Center of General Surgery and Liver Transplantation – Fundeni Clinical Institute Bucharest,
(ROMANIA)
5
Psychiatry Department – Montluçon Hospital, Montluçon, (FRANCE)
6
Anesthesiology and Intensive Care Unit–Saint Mary Clinical Hospital, Bucharest, (ROMANIA)
7
Pathology Department – Saint Mary Clinical Hospital, Bucharest, (ROMANIA)
8
student “Carol Davila” University of Medicine and Pharmacy Bucharest, (ROMANIA)
E-mails: dr.sorinpatrascoiu@gmail.com, gilcaiulian@gmail.com

Abstract

Vesicovaginal fistulae are perhaps the most feared complications of female pelvic surgery.
More than half occur after hysterectomy for benign diseases. Between January 2008 and July
2016 we operated 34 VVFs in two major hospitals in Bucharest – Fundeni Clinical Institute
and Saint Mary Clinical Hospital. We used the transvesical (extraperitoneal) approach in 14
cases. The etiology of the fistulae was in all cases after hysterectomy (12 open abdominal
approach, 2 laparoscopic approach) for benign conditions. The success rate after first attempt
was 87.21% (12 from 14 cases). The two failures were approached by transabdominal
transperitoneal approach with omental flap interposition and the result was favorable without
fistula reccurence.We should always remember that the first operation is the one most likely to
succeed. Transvesical approach is feasible and familiar for urologists. Also due to the fact that
the surgery is extraperitoneal, the recovery is relative quick.

Keywords: vesicovaginal fistula, transvesical repair, extraperitoneal

Introduction

Veiscovaginal fistula (VVF) is a type of female urogenital fistula, an abnormal fistulous


tract extending between the bladder and the vagina. This permits involuntary discharge of
urine into the vagina. Vesicovaginal fistulae are perhaps the most feared complications of
female pelvic surgery. More than half of such fistulae occur after hysterectomy for benign
diseases [1].

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There are several ways of repairing vesicovaginal fistulae, one of them being repairing the
vesicovaginal fistulae by transvesical (extraperitoneal) approach.

Material and methods

Between January 2008 and July 2016 we operated 34 VVFs in two major hospitals in
Bucharest – Fundeni Clinical Institute and Saint Mary Clinical Hospital. We used the
transvesical (extraperitoneal) approach in 14 cases. In all 14 cases, the fistulous tract appeared
after abdominal hysterectomy. Hysterectomies were performed in 12 cases by open abdominal
approach and by laparoscopic approach in 2 cases.
Further we will be describing the surgical technique used for repairing the vesicovaginal
fistula by transvesical (extraperitoneal) approach. The patient is positioned in a low lithotomy
position with access to vagina in the sterile operative field. A vaginal mesh is inserted. A
midline or Pfannenstiel incision can be used for opening the abdomen. The retropubic space is
opened and the bladder is mobilized anteriorly and laterally. A midline anterior cystotomy is
done. The fistula tract could be observed and bilateral ureteral catheters are inserted up to the
level of renal pelvises. A mucosal circumferential incision is carried out 3-4 mm away from
the fistula, excising it’s tract. Minimal dissection of the bladder from the vagina is needed in
order to allow a tension free suture of both the bladder and vaginal defects, wich are closed
separately. A Foley catheter is placed to further drain the bladder. The bladder is closed in two
layers. The Retzius space is drained and the wound is closed in layers in a standard manner.

Results

The etiology of the fistulae was in all cases after hysterectomy (12 open abdominal
approach, 2 laparoscopic approach) for benign conditions.
The median age of patients was 41 years, with range between 33 and 58 years.
In 2 cases, 14.28%, we noted fistula reccurence in the first 10 days from fistula repair. In both
cases we did a second succesfull attempt using a combined transvesical and transabdominal
approach with omental flap interposition at 2 and 3.5 months respectively distance from the
first attempt. No renal unit was lost.
The success rate after first attempt was 85.71%, and after the second attempt, with a
modified technique (O’Connor operation), 100%.
Total operative time was approximately 80 minutes. Blood loss during operation was
between 100 and 150 ml.
Ureteral catheter was removed in most cases after 8 days, with range between 5 and 14
days.
Urethral catheter was left in place for approximately 10 days, with range between 8 and
18 days.
During a median follow up period of 68 months, with range between 8 and 110 months, the
patients continued to void normally, without fistula recurrence and had sterile urine cultures.
The success rate after first attempt was 85.71% (12 from 14 cases).
The two failures were approached by transabdominal transperitoneal approach with
omental flap interposition and the result was favorable without fistula reccurence.

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Discussion

A vesicovaginal fistula is a passage formed between the vagina and the urinary bladder
consequently with spontaneous loss of urine through vagina. Open hysterectomy is linked
to most vesicovaginal fistulae. Other common possible causes of VVFs are obstetric trauma,
pelvic irradiation, endometriosis or genital neoplasia. Also there have been described VVFs
of uncommon etiology, for example erosion of foreign body such as pessary or vigorous
intercourse [2]; [3]; [4].
In cases of postoperative hematuria there is a posibility of developing VVF as a consequence
of bladder injury during surgery. Patients accuse urine loss that prove to be vaginally. This
might happen immediately after surgery, or more common, during the first 5 to 10 days
postoperative. In cases of a large fistula the urine loss can be total. When there is a small
fistula urine loss occurs especially with full blader. The differential diagnosis should be done
with stress urinary incontinence, vaginal drainage of peritoneal fluid, other forms of urogenital
fistulae such as ureterovaginal fistula, vesicouterine fistula or urethrovaginal fistula [5]; [6].
Before undertake curative surgery is important to evaluate the size, number and exact
location of fistula. Better preoperative diagnosis allows better surgical planning [7].
On vaginal examination, any fluid collection can be tested for urea, creatinine or potasium
concentration to determine the likelihood of a diagnosis of VVF as opposed to a possible
diagnosis of vaginitis [8].
The next step is to demonstrate that the vaginal leakage has it’s origin from the urinary
tract.
Indigo carmine dye can be given intravenously and if the dye appears in the vagina, a fistula
is confirmed [1]. Another way to establish the diagnosis of VVF is to fill the bladder with a
dilute solution of methylene blue. A tampon is placed into the vagina and if the tampon test
is positive, the fistula is confirmed [7]. Next, cystoscopy can clarify the exact anatomic origin
and the relation with ureteral orifices. Other diagnostic procedures may include retrograde and
voiding cystourethrography, intravenous pyelography and cystogram [7]. Other advanced but
more invasive or expensive techniques include combined vaginoscopy-cystoscopy, substraction
magnetic resonance fistulography and endocavitary ultrasound through transvaginal route with
or without Doppler or contrast agents [8]; [9]; [10].
There have been reported different techniques for repairing VVFs.
The conservative management is of low interest and may be applied in cases where the
surgery is very risky and if some clear indications are present, such as early diagnosis and
therapy within 7 days, small fisulae of less than 1 cm in size, no loss of urine after inserting the
bladder catheter, no previous radiation treatment or cancer surgery [11].
For the surgical treatment, although stressful for the patient, surgery should be delayed to
allow healing of the inflammatory tissue reaction around the fistula. The delay varies according
to different authors, from 3 months to even 12 months. Even a delay of 1-2 years is reasonable
after radiation damage [7]; [11].
There is a discussion to whether the abdominal or vaginal route is the most appropiate for
fistula repair.
Vaginal surgery is possible for uncomplicated and small vesicovaginal fistuale. The main
advantage of the vaginal approach is the low postoperative morbidity. Vaginal approach
reduces the rate of operative complications, the hospital stay, the blood loss and the pain
following the procedure. This route achieves success rates when compared with the abdominal
approach [12]. One of the disadvantages of this technique is vaginal shortening. Clear
contraindications to vaginal repair are repair requirin ureteral reimplantation, involvement of
other pelvic structures, vaginal stenosis or inability to obtain proper exposure [13]; [14]; [15].

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The abdominal approach is represented by the traditional O’Connor operation. This utilizes
suprapubic access for extraperitoneal dissection of the retropubic space to dissect the bladder,
followed by long sagital cystotomy until the fistula is reached and the fistulous tract is excised
and two-layer closure. The abdominal approach is more risky for the patient but necesary
after irradiation, after failed repair, high retracted fistula in a narrow vagina, fistulae wich are
proximal to the ureters, multiple fistulae, asociated pelvic pathology [7]; [11].
Another technique for repairing VVFs by abdominal way is the transvesical-transperitoneal
approach, having the advantage of using great omentum as interposition graft between bladder
and vagina. Also it is a technique of use when there is an intraperitoneal pathology assocciated.
The interposed graft serves to create an additional layer in the repair, to fill dead space and
to bring new blood supply into the area [7].
Some modern techniques use the laparoscopic repair of VVFs without opening the bladder.
This uses intracorporeal suturing and omentum interpostioning.
It’s a must, that once you have the diagnosis of vesicovaginal fistula, to put a Foley
catheter, start antibiotic and antispasmodic treatment and by some authors, estrogen therapy
for increasing local blood flow and epithelial trophicity. These are conservative measures.
Conservative treatment failure is the indication for surgery. Essential for the succes of
the operation are some factors that need to be taken into consideration. These are etiology
of the VVF, fistula duration, quality of tissues to be repaired and surgeon’s experience. Of
great importance are some surgical principles such as tension free sutures, not infected. There
principles must be respected, especially at the first intervention, that always had the greatest
chance of succes [16].

Conclusions

We should always remember that the first operation is the one most likely to succeed.
Transvesical approach is feasible and familiar for urologists. Also due to the fact that the
surgery is extraperitoneal, the recovery is relative quick.

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48(1):10-1.
15. Kapoor R, Ansari MS, Singh P, Gupta P, Khurana N, Mandhani A, Dubey D, Srivastava
A, Kumar A. Management of vesicovaginal fistula: an experience of 52 cases with a
rationalized algoritm for choosing the transvaginal or transabdominal approach. Indian J
Urol. 2007 Oct; 23(4):372-6.
16. Gerber GS, Schonberg HW. Femele urinary fistlas. J Urol 1993;149:229.

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Suburethral endometriosic cyst and stress urinary


incontinence

PATRASCOIU Sorin1, GILCA Iulian1, BRATILA Elvira2,


COPCA Narcis1, PIVNICERU Catalin1, STROESCU Cezar1,
CONSTANTINICA Victor1, ZAMFIR Radu3,
ROSULESCU Corneliu1, PRIE Ioan1, MISCHIE Oana Gabriela4,
BIRCEANU Adelina5, GURAU Claudia6
1
Center of General Surgery and Transplant – Saint Mary Clinical Hospital, Bucharest, (ROMANIA)
2
“Carol Davila” University of Medicine and Pharmacy Bucharest/Gynecology Obstetrics Clinic
“Saint Pantelimon” Emergency Hospital Bucharest, (ROMANIA)
3
Center of General Surgery and Liver Transplantation – Fundeni Clinical Institute Bucharest,
(ROMANIA)
4
Psychiatry Department – Montluçon Hospital, Montluçon, (FRANCE)
5
Pathology Department – Saint Mary Clinical Hospital, Bucharest, (ROMANIA)
6
student “Carol Davila” University of Medicine and Pharmacy Bucharest, (ROMANIA)
E-mails: dr.sorinpatrascoiu@gmail.com, gilcaiulian@gmail.com

Abstract

Endometriosis is an important gynecologic disorder primarily affecting women during


their reproductive years. Urethral endometriosis is a rare entity and only few cases have been
reported. We present the case of a suburethral endometrioma in a 54 year old patient with stress
urinary incontinence. The lesion was located to the level of the mid urethra. We proceded to
transvaginal resection of the mass and subsequently stress urinary incontinence cure by TOT
sling. Postoperative evolution was favorable and the pacient was discharged on the third day
postoperatively.No endometriosis or stress urinary incontinence recurrence were encountered.
Knowledge of the etiology, evaluation and treatment of cystic lesions of the vagina is
essential as these lesions are not very often encountered in urological practice.

Keywords: endometriosis, suburethral cyst, stress urinary incontinence

Introduction

Endometriosis is an important gynecologic disorder primarily affecting women during


their reproductive years. Classically it is defined as the growth of functional endometrial tissue
outside the uterine cavity [1]. Urethral endometriosis is a rare entity and only few cases have
been reported. It represents about 2% of all urinary tract involvements and is briefly mentioned
in the clinical guidlines and literatures. It may arise from suburethral location or within urethral
diverticula [6].

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Material and methods

We present the case of a suburethral endometrioma in a 54 year old patient.

A 54 year old woman with 1 children (vaginal delivery at the age of 30 years) presented
with stress urinary incontinence, urinary tract infections, mild disuria. She had no hematuria,
flank pain, or history of urinary calculi. Pelvic examination reveald a suburethral mass,
painless, mobile, two centimeters in diameter. No pus was expressed through the urethra
with cyst massage. Transvaginal ultrasound reveald a cystic lesionon the anterior aspect of
mid urethra. Uterine adenomyosis was noted.Intravenous urography showed no patological
changes. Cistoscopy showed that the cystic lesion did not commuicate with the urethral
lumen. Under spinal anesthesia we performed an urethrocystoscopy that did not reveald any
diverticular ostium. Then we proceded to transvaginal resection of the mass (Figure 1). The
lesion was located to the level of the mid urethra (Figure 2). The entire mass was resected
(Figure 3, 4, 5). The lesion contained a thick, dark liquid blood count. Intraoperative frozen
section histopathology showed endometriosis. Regarding the involuntary leakage of urine, we
continued the surgical intervention with the placement of a tension free transobturator tape
sling (Figure 6, 7). Final aspect of the operation is shown in Figure 8.


Figure 1. The transvaginal Figure 2. Mid urethral cyst
aproach of the cyst
Figure 3. Figure 4. Figure 5.


Figure 3 and 4. Intraoperative cyst excision Figure 5. Cyst
completely removed

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Results

Postoperative evolution was favorable and the pacient was discharged on the third day
postoperatively. The paraffin histopathology showed endometriosis (Figure 9). After surgery
the pacient was guided to the gynecology service for further investigation and medical
treatment on the endometriosis. At six months postoperative control the pacient was fully
recovered, with disappearence of stress urinary incontinence. No endometriosis recurrence
was encountered.

Figure 9. Hematoxylin and eosin 20X;


the classic endometriotic cyst is lined
by endometrial epithelium overlying
endometrial stroma and is associated
with many small blood vessels
haemorrhage and some fibroids.

Discussion

Endometriosis is the presence of endometrial tissue in extrauterine sites, typically in the


ovaries and peritoneal cavity. Implantation of endometrial tissue in the periurethral tissues
may occur during surgical procedures [2]. Lesions are treated with complete surgical resection
or removal by laser surgery and electrocautery [3].
The tissue responds to hormones in a similar manner to that of normally sited endometrium
and may result in cyclical symptoms including pain and bleeding during the menstural cycle
[4].
Three teories have been proposed to explain the origin of endometriosis. First is the
metastatic theory (retrograde menstrual implantation, vascular and lymphatic spread, and
intraoperative implantation); second is the metaplastic theory (differentiation of serosal
surfaces or mullerian remnant tissue) and third is the induction theory (combination of both
former theories) [5].
These ectopic endometrial implants are usually located in the pelvis, on the pelvic
peritoneum but may be also be found on the ovaries, rectovaginal septum, ureter, and rarely in
the bladder, pericardium, and pleura. More rarely, colon, small intestine, appendix, umbilical
scar and even lung and brain tissue may also be involved [1]. Classical symptoms associated
with endometriosis include infertility and pelvic pain, although unusual symptoms linked to
atypical location of disease can also occur, including dyspareunia, urinary and gastrointestinal
symptoms, what makes this diagnosis even more complicated [5].
Endometriotic lesions of the urinary tract are present in one to two percent of women with
endometriosis [6]. Although ureteral and bladder endometriosis both occur in the urinary tract,
they do not frequently coexist and their clinical presentation and management are different.
Bladder endometriosis often mimicks recurrent cystitis, but rarely results in severe

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sequelae. Ureteral endometriosis is often asymptomatic, but can lead to silent loss of renal
function. Renal and urethral involvements are rare and only as case reports [1].
The clinical symptoms are the same to other sites of implantation or similar to cystic
urethral or vaginal lesions. The differential diagnosis include cystic lesion of vagina wall,
cysts of Bartolin glands, vaginal adenosis and urethral diverticulum, anomalies (ectopic ureter)
[5].
Only 2% of the urinary tract endometriosis is represented by urethral endometriosis. This
localization often presents as suburethral cysts/endometriomas. Recommended diagnostic tools
are transvaginal and transperineal ultrasound, MRI, cistoscopy, urethrography coroborated
with clinical findings [7].
Suburethral cysts are rare. They are often formed from remnants of embyonic or blockage
of the paraurethral glands [8]. Differential diagnosis of cystic periurethral lesions include
vagynal cysts (Mullerian cyst; Gartner duct cyst; Epidermal inclusion cyst of the vagina),
Skene duct cyst, Bartholin gland cyst, endometrial cyst [9].
The diagnosis is clinical and radiological studies are needed to demonstrate the absence
of communication with the urethra being of great importance to show if the cystic lesion is
complicated with a urethral diverticulum [8].
Imaging of the female urethra with magnetic resonance imaging (MRI) has improved
significantly with the capacity to provide high-resolution multiplanar images, allowing
evaluation of various benign and malignant urethral and periurethral processes [10]. The
diagnosis of female disease in this anatomic region is challenging for clinicians because
patients present with nonspecific signs and symtoms, including pelvic pain, dysuria, urinary
frequency, urinary urgency, incontinence, urethral bleeding, and urinary tract infections [11].
Furthermore, physical examination can be unreliable in distinguishing among the many
types of urethral or vaginal wall masses. Although conventional imaging studies such as
voiding cystourethrography and retrograde double-balloon positive-pressure urethrography
are helpful, they are invasive and cannot help evaluate periurethral tissues. Misdiagnosis and
delayed management often occurred before the advent of high-resolution MR Imaging [12];
[13].
Transvaginal ultrasound should be the first-line imaging examination when the presenece
of endometriosis is suspected. MR imaging is an excellent method for identifying old
hemorrhagic content that characterizes endometriomas and for mapping multiple deeply
infiltrating endometrial implants, given its large field of view, multiplanar capabilities, and
outstanding contrast resolution [5]. The examination of choice for the assessment of the
urethra is the MRI. It has excellent sensitivity for the diagnosis of both, urethral diverticulum
or endometriosis [14]; [15].
The definitive diagnosis is by surgical excision or biopsy of the lesion. Histologically two
of the following three characteristics must be seen to make the diagnosis: endometrial glands,
stroma and hemosiderine laden macrophags. Foreign body giant cells may be also found.
The treatment of endometriosis depends on the age of the woman, the desire to maintain
fertility, the extent and location of outbreaks of disease, the degree of menstrual disorder,
sexual impact and the coexistence of other pelvic disease [16]; [17]; [18]; [19]. Therapy vary
from an expectant attitude (in asymptomatic cases), medical treatment or surgical excision or
destruction of isolated lesions, or radical hysterectomy with bilateral oophorectomy [16]; [19].
The endomterium is a tissue expressing hormonsensible estrogenic, progestogenic
and androgenic receptors. This tissue even in ectopic location, presents the three phases of
endometrial cycle: proliferation, secretion and decidual phase. It si typically in the decidual
phase, when cell necrosis and hemorrhage condition a volume increase endometrioma
and aggravation of the inflamatory process and local fibrotic, corresponding to a period of

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symptomatic exacerbation [16]; [19].
Several therapeutic regimens of hormonal manipulation have been applied to condition
a state of pseudo menopause. However, the treatment of choice for suburethral locations is
surgical excision. This simultaneously allows treatment and histological diagnosis [16]; [19].
In the cases described with urethral diverticulum or extension to the bladder neck, there
is a high risk of postoperative incontinence. This can be prevented (in the case of previous
incontinence) or subsequently corrected by placing a suburethral sling [16]; [20]; [21].

Conclusion

Although rare, endometriosis should be considered in the diagnostic evaluation of any


periurethral cystic mass, especially if it is associated with a history of pelvic pain, dyspareunia,
dysmenhorrea (or menstrual disorders), voiding difficulty or urinary incontinence.
Knowledge of the etiology, evaluation and treatment of cystic lesions of the vagina is
essential as these lesions are not very often encountered in urological practice [22].
Familiarity with the different types of cystic lesions is important for any clinician involved
in gynecological or female urological practice to arrive at the correct diagnosis and treatment
plan.
Also preneoplastic or neoplastic lesions should be taken into account.
Endometriosis may undergo malignant transformation, more commonly clear cell
carcinoma [23]; [24].

REFERENCES
1. Koel Chaudhury, Baidyanath Chakravarty. Endometriosis – Basic Concepts and Current
Research Trends. InTech 2012.
2. Liang CC, Tsai CC, Chen TC, Soong YK. Management of perineal endometriosis. Int J
Gynaecol Obstet 1996;53(3):261–265.
3. Eilber KS, Raz S. Benign cystic lesions of the vagina: a literature review. J Urol
2003;170(3):717–722.
4. Seydel SA, Sickel ZJ et al. Extrapelvic endometriosis: Diagnosis and treatment. The
American Journal of Surgery. 1996; 171(2):239-241.
5. M. D. S. Silva, B. F. Corgosinho, A. Kanas, M. Abrao, L. Mattos, M. T. Gomes. Lower
Urinary Tract Endometriosis. ECR 2016.
6. Stanley KE Jr, Utz DC, Dockerty MB. Clinically Significant Endometriosis Of The
Urinary Tract. Surg Gynecol Obstet. 1965; 120:491.
7. Liisu Saavalainen. Urinary tract endomteriosis. Gynekologisen Kirurgian Seura.
24.09.2015.
8. Romero Reyes R, Rodriguez Colorado S, Escobar del Barco L, Gorbea Chavez V.
Suburethral cyst. A case report. Ginecol Obstet Mex. 2009 Mar; 77(3):160-4.
9. 9.Lucioni A, Rapp DE, Gong EM et al. Diagnosis and management of periurethral cysts.
Urol. Int. 2007; 78(2):121-5.
10. Siegelman ES, Banner MP, Ramchandani P, Schnall MD. Multicoil MR imaging of
symptomatic female urethral and periurethral disease. RadioGraphics 1997;17(2):349–
365.
11. Handel LN, Leach GE. Current evaluation and management of female urethral diverticula.
Curr Urol Rep 2008;9(5):383–388.
12. Rufford J, Cardozo L. Urethral diverticula: a diagnostic dilemma. BJU Int 2004;94(7):1044–

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1047.
13. Vinika V. Chaudhari, MD, Maitraya K. Patel, MD, Michael Douek, MD, and Steven
S. Raman, MD. MR Imaging and US of Female Urethral and Periurethral Disease.
RadioGraphics. November 2010, Volume 30, Issue 7.
14. Arzoz Fabregas M, Ibarz Servio L, Areal Calama J, Saladie Roig JM. Divertículos de
uretra femenina. Arch Esp Urol 2004,57(4):381-388.
15. Zawin M, McCarthy S, Scout L, Comite F. Endometriosis: Appearance and detection at
MR imaging. Radiology 1989;171(3):693-696.
16. Cabral Ribiero J., Perez Garcia D., Martins Silva C., Ribeiro Santos A. Actas Urol Esp
vol. 31 no. 2 feb. 2007.
17. Bologna RA, Whitmore K. Genitourinary endometriosis. AUA Update series 2000; 32-
37.
18. Comiter CV. Endometriosis of the urinary tract. Urol Clin N Am 2002;29(3):625-635.
19. Frackiewicz EJ. Endometriosis: An overview of the disease and its treatment. J Am Pharm
Assoc 2000;40(5):645-657.
20. Romanzi LJ, Groutz A, Blaivas JG, Urethral diverticulum in women: Diverse presentations
resulting in diagnostic delay and mismanagement. J Urol. 2000;164(2):428-433.
21. Aspera AM, Rackley RR, Vasavada SP. Contemporary evaluation and management of the
female urethral diverticulum. Urol Clin North Am 2002;29(3):617-624.
22. Eliber KS, Raz S. Benign cystic lesions of the vagina: a literature review. J. Urol. 2003
Sep; 170(3): 717-22.
23. Oliva E, Young RH. Clear cell adenocarcinoma of the urethra: a clinicopathologicanalysis
of 19 cases. Mod Patho/1996;9:513-520.
24. Heiawi M, Drew PA, Pan CC, et al. Clear cell adenocarcinoma of the bladder and urethm:
cases diffusely mimicking nephrogenic adenoma. Hum Patho/20 1 0;41 :594 - 601.

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Management of vesicovaginal fistula by combined


transperitoneal and tansvesical approach

PATRASCOIU Sorin1, BRATILA Elvira2, BRATILA Petre3,


COPCA Narcis1, ZAMFIR Radu4, MISCHIE Oana Gabriela5,
PRIE Ioan1, GURAU Claudia6, ROSULESCU Corneliu1,
CONSTANTINICA Victor1, GILCA Iulian1
1
Center of General Surgery and Transplant – Saint Mary Clinical Hospital, Bucharest, (ROMANIA)
2
“Carol Davila” University of Medicine and Pharmacy Bucharest/Gynecology Obstetrics Clinic
“Saint Pantelimon” Emergency Hospital Bucharest, (ROMANIA)
3
“Carol Davila” University of Medicine and Pharmacy (BUCHAREST)
4
Center of General Surgery and Liver Transplantation – Fundeni Clinical Institute Bucharest,
(ROMANIA)
5
Psychiatry Department – Montluçon Hospital, Montluçon, (FRANCE)
6
Student “Carol Davila” University of Medicine and Pharmacy Bucharest, (ROMANIA)
E-mail: dr.sorinpatrascoiu@gmail.com

Abstract

Abdominal hysterectomy is the procedure most commonly implicated in the development


of vesicovaginal fistulae. We present a retrospective study on 10 patients with VVF treated
by combined transvesical and transabdominal approach. The success rate was 100%. During
a median follow up of 72 months the patients continued to void normally without fistula
recurrence. The combined approach transvesical and transabdominal represents a feasible
technique especially for large fistulae located high in a deep narrow vagina, in failures after
other approaches and also when we need to perform ureteral reimplantation.

Keywords: vesicovaginal fistula, transvesical transabdominal repair

Introduction

Vesicovaginal fistulas are perhaps the most feared complications of female pelvic surgery.
Abdominal hysterectomy is the procedure most commonly implicated with a risk of fistula
formation quoted as 1 in 1300 hysterectomies. [1-4]
The vast majority of fistulas after abdominal hysterectomy are located high in the vaginal
vault above the interureteric ridge and coinciding with the vaginal apex scar.
The abdominal approach is advantageous in several situation such as fistulas located high
at the vaginal cuff, when reimplantation is necessary or when other intraabdominal pathology
require repair.
In our experience large, complex or recurrent VVF are best approached abdominally as
well.
Our objective is to report results of combined transvesical and transabdominal VVF repair
(O’Connor operation) in 10 cases.

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Material and methods

We present a retrospective study based on the personal experience in the field of major
urologic surgery on a period of almost 10 years.
During Jan 2008 – July 2016 we operated (one surgeon SP) 34 VVFs in two major hospitals
in Bucharest – Fundeni Clinical Institute and Saint Mary Clinical Hospital.
We used the combined transvesical and transabdominal approach (O’Connor operation) in
10 cases of VVFs (8 primary, 2 recurrent).

Preoperative measures

Prior to repair a fistula should be very well characterized.


Complex fistulas with multiple tracts or ureterovaginal fistula should be identified.
A proper evaluation should include local exam, indigocarmine test (3 swab test), uro-CT
or IVP and cystoscopy.
Ureterovaginal fistulas are usually associated with a degree of hydronephrosis.
All this cases were repaired after at least 2 months after index surgery (between 2-4 months).
Surgery was delayed until the inflammatory process subsided and the demarcation between
healthy and ischemic fibrotic tissue could be easily identified.
All cases were reffered from other departments.

Indications for abdominal (transperitoneal) approach:


1. Fistula is located proximally in a narrow vagina;
2. Is in close proximity to the ureteral orifices;
3. A concomitant ureteric fistula is present;
4. Previous repairs of the fistula have been unsuccessful and the fistula is recurrent;
5. The vaginal walls are rigid with little mobility;
6. Fistula is large or complex in configuration or;
7. There is a need for an abdominal interposition graft.

Surgical technique

In all cases the repair was performed under general anaesthesia.


In order to facilitate intraoperative dissection we insert a ureteric stent cystoscopicaly
through the fistula from bladder and grasped with a right angle clamp inserted through vagina.
The patient is positioned in a low lithotomy position with access to vagina in the sterile
operative field.
We can use a midline or Pfannenstiel incision.
The retropubic space is opened and the bladder is mobilized anteriorly and laterally. Pouch
of Douglas, vaginal apex and the entire bladder should be exposed. The bowels are packed
away to keep it out the operative field.
A midline cystotomy should be carried posteriorly down to the fistula.
The fistulous tract is excised by circumscribing the bladder portion, dissecting it down to
the vaginal wall and removing it by a circumscribing incision in the vagina.
The preoperative stent is usefull in this step of the intervention.
We also use stay sutures on the bladder edges.
Apart from providing effective anchorage to lift up the posterior bladder wall, they also
provide hemostasis from cystotomy edges.

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The edges of the vaginal wall are freed up by sharp dissection to permit adequate
mobilization for closure in a tension free manner.
Well vascularized tissue should remain for closure of bladder and vagina.
Vagina is closed with separate absorbable suture.
An interpositional flap of greater omentum is highly recommended and we did this in all
cases [13]. The flap is secured 1 to 2 cm distally beyond the excised VVF tract.
Urethral catheter and long ureteral mono-J stents are placed, sometimes a suprapubic tube
could be usefull.Bladder is closed in two layers.
Retzius space and peritoneal cavity are drained. The wound is closed in layers in a standard
manner.

Results

Mean age of our patients was 39 years (range 31-54).


Fistula size unfortunately was not clear documented, but we treated fistulas from 0.5 cm
to 4.5 cm.
The etiology of the fistulas were: 7 cases (70%) after hysterectomy (3 open – abdominal;
2 laparoscopic); 3 cases (30%) after radiotherapy and Wertheim operation (2 open; 1
laparoscopic).
In two cases we performed ureteral reimplantation due to the fact that fistula tract was
encroaching the ureteric orifice.
In one case we performed preoperative nephrostomy drainage in order to preserve the renal
unit and at the time of fistula repair we reimplanted the ureter.No fistula reccurence was noted.
No renal unit was lost.
The success rate was 100%. We used omental flap in all cases. Due to it’s blood supply,
lymphatic drainage and immunological role it promotes healing and decrease fistula reccurence.
[13, 14, 15]
Mean operative time was aprox 120 min (range between 80 and 200 min).
Mean blood loss was 150ml (range between 100-600ml).
None of the patients required blood transfusions.
Mean hospital stay was 14 days (range between 12-22 days)
During a median follow up period 72 months (3-116 months) the patients continued to void
normally, without fistula recurrence and had sterile urine cultures.
In Figures a, b, c, d, e, f we present some intraoperative aspects.

a b c

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d e f

Intraoperative aspects:
a anterior cystotomy ureters are intubated with ureteral stents; yoy can see also the
ureteral stent passed through the fistula per urethra and exteriorized through vagina
b posterior cystotomy; bivalved bladder
c sharp dissection of the vagina from posterior bladder wall and fistula tract excision
d anterior cystoraphy
e posterior cystoraphy
f omental flap interposition

Discussions

Prevention - Intraoperative technique

Extirpative surgery especially pelvic surgery could be sometimes challenging.


Identification of vital structures should be done from the beginning such as iliac vessels
and ureters.
Careful mobilization of the tissues/organs to be spared versus tissues/organs to be resected
should be done properly.
Hemostasis is also very important in order to have a clear operatory field.
The time of unrecognized bladder injury is frequently during the dissection of the bladder
base from the underlying cervix and upper vagina.
During hysterectomy, wide, sharp dissection of the bladder from the cervix and upper
vagina is an essential step.
Before clamping the uterosacral ligaments, mobilization of the inferior and lateral aspects
of the bladder must be completed and the ligaments taken close to the uterus to avoid accidental
damage to the bladder [5].
The bladder should be dissected at least one centimeter beyond the planned line of
resection. [5]

Mechanisms for posthysterectomy vvf:


• Incidental unrecognized iatrogenic cystotomy near the vaginal cuff
• Tissue necrosis from cautery/lig-a-sure/ultrasonic scalpel/stapler device
• Suture placed through both the bladder and vaginal wall (during closure of vaginal cuff)
• Sutures in an unclear operatory field
• An attempt to control pelvic bleeding by suture ligature

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Postoperative measures

Nursing care during postoperative period (especially first 5 days) is extremely important.
The catheter must be secured and not allowed to kink or obstructed especially during night
when patient sleeps by compression.
Accurate fluid charts are essential: input and output should be charted hourly in the first
few days, with urine output maintained at 100ml/h until the urine becomes clear.
Staff must be alert to any evidence of a urethral or vaginal leak indicating that the catheter
is being bypassed.
If this occurs the catheter should be gently flushed with a small volume of sterile saline.
Only in rare cases and only with appropriate medical consultation is the catheter changed.
Well trained nurses and vigilant nursing care are so crucial to the success of the repair that
if there is understaffing or no trained staff available then this type of surgery should not be
attempted.

Medicolegal aspects

Injury to genitourinary tract was found to be the second major malpractice claim in
gynecology in a study of 500 claims in Atlanta, with VVF ranking as the second most common
injury. [6]
The subsequent urinary incontinence caused by VVFs has a profound affect on the patient’s
quality of life and is a common cause of medicolegal claims.
Areas identified by the Medical Defence Union as important in medicolegal claims were
communication, consent and case notes. [7]
When doctors communicate in a professional way with the patiens both before and after
surgery usually they feel adequately informed and the chances to claim in an unfavorable event
are less.
The informed consent should be obtained by a doctor sufficiently familiar with the
procedure to accurately describe its complications.
Specific complications after VVF repair include ureteric injury, especially when the fistula
is located in close proximity of ureteric orifices.
The patient should be informed about the possibility of unilateral or bilateral ureteral
reimplantation.
Due to the fact that is a reintervention, viscerolisis can result in enteroraphies , enterectomies
or rectal lessions cause sometimes the rectum is stuck to the vaginal vault.
Some patients may develop hyperactive bladder or stress urinary incontinence.
Vaginal stenosis with consequent dyspareunia is an uncommon complication but still can
happen. [8]
To avoid any medicolegal problems the patients should be informed of these specific
complications when consent is obtain for the repair.
Surgery can be undertaken by either an urologist or gynecologist, provided they are
specialists in this field.
It must also made clear to the patient before surgery that even in a specialist center these
repairs can have a 10% failure rate.
In the event of a failed repair further surgery is possible but the chance of success is
diminished to 60%. [7]
The patient and family should also be informed about sepsis, thrombo-embolic events and
even death considering this surgical intervention as a major one with quite long hospitalization.

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Good documentation of the case helps to avoid litigation and provides good defence in the
event of a claim. Detailed operative notes should be made by the surgeon who performed the
operation and not by assistant or other staff member.
Any deviation from standard evolution should be noted and the use of words such as
“routine, uncomplicated, uneventful, standard, straightforward” should be avoided.

Psychologic aspects

Gynecologic fistula patients had significantly higher depression and post traumatic stress
disorder (PTSD) symptoms compared to gynecology outpatients.
It is noteworthy that VVF patients report greater symptoms of depression and post traumatic
stress disorder (PTSD), even after controlling for underlying risk factors for psychopathology
(e.g., low socioeconomic status, lifetime traumatic events, and being a medical patient). PTSD
symptoms are generally grouped into four types: intrusive memories, avoidance, negative
changes in thinking and mood or changes in emotional reactions.
Since somatic symptoms have been cross-culturally linked to mental health distress [9,
10], it is also possible that long-term stress and psychological dysfunction have increased the
physical health complaints of fistula patients.
In some cases, the act of “giving up” or “denying reality” may characterize acceptance of
social isolation. It is possible that the presence of this type of coping could partially explain
variability in psychological distress in fistula patients. Furthermore, fistula patients who use
resignation coping strategies may be more likely to develop psychopathology.
Additionally, protective factors should be identified that explain resilience and absence of
psychological distress in some fistula patients. Such protective factors might include social
support, religious engagement, or self-compassion.

Conclusions

The principles of successful surgical repair are that it is tension-free, watertight and
uninfected, using a well-vascularized interposition flap if required.
We should always remember that the first operation is the one most likely to succeed.You
always should select an approach with which you feel confortable. [11, 12]
The combined approach transvesical and transperitoneal (O’Connor operation) represent a
feasible technique especially for large fistulae located high in a deep narrow vagina, in failures
after other approaches and also when we need to perform ureteral reimplantation.
The key to the operation is the mobilization of the bladder from the vagina caudal to
(beyond) the VVF tract.
Clinicians involved in surgery at risk of producing these fistulae must maintain a high
index of suspicion and if they don’t have enough expertise in this field should refer the patient
to a trained specialist for repair.
Nevertheless, minimizing patient discomfort, maintaining a positive and honest patient
–physician relationship while providing constant reassurance and finally pursuing optimal
successful treatment of the fistula will most often result in a satisfying long term outcome.

REFERENCES

1. Blandy JP, Badenoch DF, Fowler CG, Jenkins BJ, Thomas NWM. Early repair of
iatrogenic injury to the ureter or bladder after gynaecological surgery. J Urol 1991;146:

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761 5.
2. O’connor V. Review of experience with vesico-vaginal fistula repair. J Urol 1980;123:
367 9.
3. Tancer ML. The post-total hysterectomy (vault) vesicovaginal fistula. J Urol 1980;123:
839 40.
4. Tancer ML. Observations on prevention and management of vesico-vaginal fistulae after
total hysterectomy. Surg Gynaecol Obstet 1992; 175: 501 6.
5. Symmonds RE. Prevention and management of genitourinary fistula. JCE Obstet Gynecol
1979; 21(06):13-24.
6. Ward CJ. Analysis of 500 obstetric, gynecologic malpractice claims. Causes and
prevention. Am J Obstet Gynecol 1991; 165: 298 305.
7. Medical Defence Union. Risk management in obstetrics and gynaecology. J Med Def
Union 1991; 2: 36.
8. Schleicher DJ, Ojengbede OHA, Elkins TE. Urological evaluation after closure of vesico-
vaginal fistulas. Int Urogynaecol J 1993; 4: 262 5.
9. Kroenke K. Patients presenting with somatic complaints: epidemiology, psychiatric co-
morbidity and management. Int J Methods Psychiatr Res. 2003;12(1):34–43.
10. Kirmayer LJ. Cultural/variations in the clinical presentation of depression and anxiety:
Implications for diagnosis and treatment. Journal of Clinical Psychiatry. 2001; 62:22–30.
11. Leach GE & Trockman BASurgery for vesicovaginal and urethrovaginal fistula and
urethral diverticulum. In Walsh PC, Retik AB, Vaughan ED Jr, Wein AJ, eds. Campbell’s
Urology, 7th edn Philadephia: WB Saunders Co, 1998; 1135 53.
12. Elkins TE. Surgery for the obstetric vesicovaginal fistula: a review of 100 operations in 82
patients. Am J Obstet Gynecol 1994; 170: 1108 20.
13. KiricutaI,GoldsteinAM.The repair of extensive vesicovaginal fistulas with pedicled
omentum: a review of 27 cases. J Urol 1972; 108:724–7.
14. Evans DH, Madjar S, Politano VA, Bejany DE, Lynne CM, Gousse AE. Interposition
flaps in transabdominal vesicovaginal fistula repairs: Are they really necessary? Urology.
2001; 57:670–4.
15. Turner-Warwick RT, Wynne EJ, Handley-Ashken M. The use of the omental pedicle
graft in the repair and reconstruction of the urinary tract. Br J Surg. 1967; 54:849–53.

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Laparoscopic pectopexy: a new technique for the


treatment of vaginal apical prolapse

PIRTEA Laurentiu1, SECOSAN Cristina2, ILINA Razvan3,


SAS Ioan1, PIRTEA Marilena2, HORHAT Florin4,
JIANU Adelina5, GRIGORAS Dorin1
1
Department of Obstetrics and Gynecology, University of Medicine and Pharmacy “Victor Babeş”
Timişoara (ROMANIA)
2
Department of Obstetrics and Gynecology, County Hospital Timişoara (ROMANIA)
3
Department of Surgery, University of Medicine and Pharmacy “Victor Babeş” Timişoara
(ROMANIA)
4
Department of Microbiology, University of Medicine and Pharmacy “Victor Babeş” Timişoara
(ROMANIA)
5
Department of Anatomy and Embryology, University of Medicine and Pharmacy “Victor Babeş”
Timişoara (ROMANIA)
E-mails: laurentiupirtea@gmail.com, cristina.secosan@gmail.com, razvanilina@yahoo.co.uk,
sasioan56@yahoo.com, marilenapirtea@yahoo.com, horhatflorin@yahoo.com,
adelina.jianu@umft.ro, grigorasdorin@ymail.com

Abstract

Pelvic organ prolapse is defined as the abnormal descent of the pelvic organs from their
normal position in the pelvis. The prevalence of pelvic organ prolapse is hard to evaluate
since different authors report different data. It has been reported to be as high as 31 - 41.1%
in menopausal women according to larger observational studies and up to 50% in porous
women. The lifetime risk of requiring at least 1 operation to correct incontinence or prolapse is
estimated at approximately 11%. A new technique, the laparoscopic pectopexy, was described
by Noe et al in 2007, which can be considered an alternative to sacrocolpopexy (the current
gold standard for the treatment of pelvic organ prolapse). It was developed especially for
obese patients, in which the promontory dissection can be sometimes challenging. We report
five cases of laparoscopic pectopexy in obese patients (BMI over 30) with stage III genital
prolapse. Pelvic floor static was evaluated a 3 months, 6 months and 9 months after surgery.
The results were excellent with a normal position of the cervix.

Keywords: pelvic organ prolapse, laparoscopy, pectopexy, obesity

Introduction

Pelvic organ prolapse is defined as the abnormal descent of the pelvic organs from their
normal position in the pelvis. The prevalence of pelvic organ prolapse is hard to evaluate
since different authors report different data. It has been reported to be as high as 31 - 41.1% in
menopausal women according to larger observational studies and up to 50% in parous women
[1]. The lifetime risk of requiring at least 1 operation to correct incontinence or prolapse is

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estimated at approximately 11% [2].
The etiology is linked to obstetrical trauma, obesity and chronic constipation. Several
transvaginal and transabdominal procedures were described for the restoration of pelvic floor
statics. The development of minimally invasive surgery changed the surgical approach of
pelvic floor disorders. For instance, nowadays the gold standard for the treatment of vaginal
apical prolapse is considered the laparoscopic sacrocolpopexy. However, this technique can
be quite challenging in case of obese patients or in patients with a difficult dissection of the
promontory due to adhesions or diverticulitis.
A new technique, the laparoscopic pectopexy was described by Noe et al. that can be
considered an alternative to sacrocolpopexy [3]. The laparoscopic pectopexy aims to restore
the support of the vaginal apex. Thus, the indication for the laparoscopic pectopexy should
be the same as for the laparoscopic sacrocolpopexy. The laparoscopic pectopexy offers the
advantage of avoiding the dissection of the promontory. In obese patients the dissection of the
promontory is a lot more difficult than in patients with normal BMI.

Materials and methods

We report five cases of laparoscopic pectopexy in obese patients (BMI over 30) with stage
III genital prolapse. The procedure performed in all of the cases was laparoscopic pectopexy
associated with a prior laparoscopic supracervical hysterectomy. All surgeries were performed
by the same team. Patients were discharged at 48 hours after surgery. Pelvic floor static was
evaluated a 3 months, 6 months and 9 months after surgery. The results were excellent, with a
normal position of the cervix.

Fig. 1: Clinical aspect: a – before surgery; b – after surgery

Technique description

Preoperative preparation: Since the technique described preserves the cervix, a Pap smear
test was performed prior to surgery in each case in order to rule out cervical malignancy.
Also the endometrial thickness was assessed by transvaginal ultrasound in order to exclude
endometrial pathology. No special bowel preparation or diet was recommended or needed
prior to surgery.

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Fig. 2: Surgical procedure: a - dissection of ilio-pectineal ligament; b - passing the suture


through the ilio-pectineal ligament; c - fixation of the mesh on the ilio-pectineal ligament; d -
aspect of mesh in place before peritonization and after peritonization - e

Operative theatre settings

The patient is placed in a dorsal lithotomy position. A Foley catheter is inserted into the
bladder, and a uterine manipulator is placed trough the vagina. The surgery is performed under
general anesthesia.
Trocar placement: the trocars are placed as for routine hysterectomy. The optical trocar is
placed at the level of the umbilicus and 3 additional 5 mm trocars, two medial to the anterior
iliac spine on both sides and one on the midline are inserted. The intra-abdominal pressure is
set at 12 mmHg.
1. Step one: the surgery starts with de dissection of the lateral part of the ilio-pectineal
ligament. The main surgeon holds the bipolar forceps and the scissors and the assistant
holds an atraumatic grasper forceps. The parietal peritoneum in incised at the level of the
“V” formed by the obliterated umbilical artery and the round ligament. The lateral part
of the ilio-pectineal ligament is dissected under the external iliac vein. The structures
that can be damaged in this area are the external iliac vein, the obturatory pedicle and the
corona mortis vein. The procedure is repeated on the opposite side afterwards.
2. Step two: once the dissection is complete, the supracervical hysterectomy is performed.
3. Step three: mesh placement.
We used a square of polypropylene mesh that we tailored into a 15/2 cm inverted T shaped

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mesh. The middle of the mesh is wider and this represents the part that will be fixated on the
cervical stump. First, the mesh is fixed of the cervical stump. Then one of the mesh’s arms
is fixated with two non absorbable stitches to the ilio-pectineal ligament on one side, and
afterwards the other arm is tailored in order to remove the excess of mesh and the fixed at the
ligament on the other side.
The entire mesh is covered with peritoneum using absorbable stitches.

Discussion

In obese patients several aspects can make the access to the promontory and longitudinal
ligament more complicated, such as diverticulitis, previous surgeries, multiple adhesions,
large ileal loops or fat covering the peritoneum [3, 4]. All these factors can make the presacral
preparation extremely difficult, hence increasing the difficulty of performing a sacrocolpopexy.
Obesity is also a major risk factor for vaginal vault prolapse and, given the circumstances,
treating a patient with obesity and pelvic organ prolapse can represent a challenge even for
experienced surgeons. The pectopexy procedure comes as a well need alternative to the actual
gold standard, being developed especially for obese patients in which the dissection of the
promontory is difficult.
The laparoscopic pectopexy was not a procedure meant to replace the current gold standard,
but a procedure that, in certain cases, could offer an alternative to the standard treatment.
It has been demonstrated that in terms of efficiency, the pectopexy procedure is similar
to sacrocolpopexy and, as a benefit, reduces the risk of injury to the presacral venous plexus
and some postoperative complications, such as bowel infection or defecation disorders [5],
because of the placement of the mesh that does not constrict the pelvis.

Conclusions

Laparoscopic pectopexy is a reasonable alternative to the gold standard sacrocolpopexy,


given our own results and also the promising results showed in literature [5], the shorter
operating time and the reduced complication rate [5 - 7]. Also, the greatest advantage is that
it can be used in cases where promontory dissection could be difficult or hazardous. Since the
incidence of obesity is rising, we consider this procedure necessary in order to adapt to this
situation.
For the gynecological surgeon, it represents a procedure that enhances their portfolio of
surgical possibilities, allows them to adapt more easily to complex surgical conditions, and
nevertheless is relatively easy to learn, though it requires a certain degree of laparoscopic
suturing skills.

REFERENCES

1. Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B, Lee J, et al. (2010).
An International Urogynecological Association (IUGA)/International Continence Society
(ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol
Urodyn, 29(1):4-20.
2. Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. (1997). Epidemiology of
surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol, Apr.
89(4):501-6.
3. Noé KG, Spuntrup C, Anapolski M. (2012). Laparoscopic pectopexy: a randomised

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comparative clinical trial of standard laparoscopic sacral colpo-cervicopexy to the
new laparoscopic pectopexy. Short-term postoperative results. Arch Gynecol Obstet,
287(2):275–280.
4. Alkatout I, Mettler L, Peters G, Noé G, Holthaus B, Jonat W, Schollmeyer T. (2014).
Laparoscopic hysterectomy and prolapse: a multiprocedural concept. JSLS, Jan-
Mar;18(1):89-101. doi: 10.4293/108680813X13693422520846.
5. Noé KG, Anapolski M. (2014). Laparoscopic pectopexy versus sacropexy for apical
prolapse correction: The first randomized prospective controlled clinical trial. Geburtshilfe
Frauenheilkd, 74 - PO_Gyn_Uro01_14 DOI: 10.1055/s-0034-1388257.
6. Baessler K, Schuessler B. (2001). Abdominal sacrocolpopexy and anatomy and function
of the posterior compartment. Obstet Gynecol, May; 97(5 Pt 1):678-84.
7. Oh S, Shin SH, Kim JY, Lee M, Jeon MJ. (2015). Perioperative and postoperative
morbidity after sacrocolpopexy according to age in Korean women. Obstet Gynecol Sci,
Jan; 58(1):59-64. doi: 10.5468/ogs. 2015.58.1.59. Epub 2015 Jan 16.

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Transperineal Ultrasound Role for Pelvic Floor


Dysfunction Evaluation

PLES Liana1,2, SIMA Romina-Marina1,2, STANESCU Anca


Daniela1,2, POENARU Mircea Octavian1,2, MOGA Marius

1
University of Medicine and Pharmacy, “Carol Davila”, Bucharest, (ROMANIA)
2
“Bucur” Maternity, “Saint John” Hospital, Bucharest, (ROMANIA)
3
Transilvania University of Brasov, Faculty of Medicine, Brasov, Romania
E-mails: liaples@yahoo.com, romina.sima@yahoo.es, stanescuancadaniela@yahoo.com,
mpoenaru69@gmail.com, moga.og@gmail.com

Abstract
Introduction
Ultrasound can be a useful, reliable and reproducible diagnostic method for pelvic floor
dysfunction (PFD). Almost universally accepted trends involve introducing 3D-4D ultrasound
examination as standard for PFD. That will impose the training of specialists in this field to
achieve diagnosis and treatment optimization.

Material and Methods


We performed a prospective study on transperineal ultrasound evaluation of patients with
for pelvic floor dysfunction that were admitted in our clinic for surgical intervention. These
patients were investigated using ultrasound transperineal/translabial 2D/4D prior to operation
and 30 days after surgery.

Results
In this study we included a serie of 77 patients who were operated for pelvic floor dysfunction
and urinary stress incontinence. We structured the study group in patients with pelvic disorders
that involved the anterior pelvic compartment, central compartment and posterior pelvic
compartment. Ultrasound examination was performed at rest and during Valsalva maneuver.
Regarding demographics data we observed that: mean age was 64,5years, most patients
were multiparous (73.4%) and predominantly smokers (54%). A small percentage (5.7%)
of patients had a history of previous pelvic interventions. Ultrasound evaluation of anterior
pelvic compartment (30 patients) distinguished between the presence of cystocele with intact
retrovezical angle (12 patients) and cystouretrocele (18 patients). Clinically these distinctions
are not possible. Regarding to the central compartment (23 cases) differences were observed
in patients with retroverted uterus. For posterior perineal static disorders were classified by
transperineal ultrasound in rectocele (11) rectoenterocel (9) and isolated enterocel (4).

Conclusions
Assessment by transperineal ultrasound made it possible to distinguish between different
forms of static pelvic disorders which is not feasible and reproducible by clinical examination.
The consequence of these fine diagnoses leads to with differentiated surgical approach,

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individualized reconstructive surgery, early diagnosis and treatment of complications.

Keywords: transperineal ultrasound, cystocele, rectocele

Introduction
Pelvic floor dysfunction (PFD) was described as a frequent condition with important
lifestyle, medical and economic impact [1]. The pathophysiology of this disorder is not
completely known but, levator ani muscle defects are considered as the major etiological
factors of prolapse of pelvic organs, especially anterior and central compartment prolapse [2,
3, 4, 5].
Ultrasound can be a useful, reliable and reproducible diagnostic method for pelvic floor
dysfunction (PFD). It can offer valuable data about the integrity, dimensions and apperanace
of the pelvic muscles. The transperineal ultrasound technique is simple, safe and accessible to
clinicians [6].

Material and Methods


We performed a prospective study on transperineal ultrasound evaluation of patients
with pelvic floor dysfunction that were admitted in our clinic for surgical intervention. These
patients were investigated using ultrasound transperineal/translabial 2D/4D prior to operation
and 30 days after surgery.

Results
In this study we included a serie of 77 patients who underwent surgical procedures for pelvic
floor dysfunction and urinary stress incontinence. We structured the study group in patients
with pelvic disorders that involved the anterior pelvic compartment, central compartment
and posterior pelvic compartment. Ultrasound examination was performed at rest and during
Valsalva maneuver.
Regarding demographics data we observed that: mean age was 64,5 years, most patients
were multiparous (73.4%) and predominantly smokers (54%). There was no significant
difference in demographic data between patients with pelvic floor dysfunctions distributed
upon the affected pelvic compartment. A small percentage (5.7%) of patients had a history
of previous pelvic interventions. The majority had a history for surgical intervention for the
anterior compartment (3.6%).
Ultrasound evaluation of anterior pelvic compartment (30 patients) distinguished between
the presence of cystocele with intact retrovesical angle (12 patients) and cystouretrocele (18
patients). Clinically these distinctions were not possible. For to the central compartment (23
cases) differences were observed in patients with retroverted uterus. For posterior perineum
static disorders were classified by transperineal ultrasound in rectocele (11) rectoenterocel (9)
and isolated enterocel (4). All these patients had surgical intervention in our clinic. The majority
had classical abord (65,7%) and the others the surgical approach was using different types of
polypropilenic mesh. We had no laparoscopic approach for pelvic floor dysfunctions. The
mean hospitalization period was about 3 days. None of this patients registered postoperative
complication in the first month after the surgical intervention. The main symptoms such
as urinary stress incontinence and uterine prolapse disappeared after the surgical cure. For
symptoms such as dyspareunia and long term complications we need further follow up.

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Discussions
Clinical examination can’t realize a classification for anterior compartment prolapse, which
is generally described as ‘cystocele’. Ultrasound is able to identify different other entities that
are practically impossible to be distinguished only by clinically examination.
Using imaging it is possible to identify between two categories of cystocele with separate
functional implications. A cystocele with intact retrovesical angle is associated with voiding
dysfunction and a low likelihood of stress incontinence and a cystourethrocele is described
with above average flow rates and urodynamic stress incontinence. By clinical examination
these different entities are evaluated together, which is why reports of voiding dysfunction and
prolapse have yielded such varying results. In particular situations a cystocele will turn out to
be caused by a anterior enterocele, urethral diverticulum, a Gartner duct cyst, all likely to be
missed on clinical exploration.
Uterine prolapse is clinically obvious and makes the distinction between uterine and
vault descent. Transperineal ultrasound expose graphically the impact of an anteriorized
cervix in women with an enlarged, retroverted uterus and it explains symptoms of voiding
dysfunction, and supporting surgical intervention in order to improve voiding in someone with
an incarcerated retroverted fibroid uterus [7]. In our study we observed that the majority of the
patients included had pelvic anterior compartment dysfunction and transperineal ultrasound
distinguished the subclinical types.
For the posterior compartment, clinically we identified ‘rectocele’ without being capable
to distinguish the different conditions leading to downwards displacement of the posterior
vaginal wall. A rectocele can be due to a rectocele, in case of defect of the rectovaginal septum
[8], or it can be the result to an abnormally distensible with intact rectovaginal septum, an
associated rectoenterocele, an isolated enterocele (very rare) or a deficient perineum giving
the impression of a ‘bulge’ [9]. Furtheremore, using transperineal ultrasound it is obtained
a functional imaging of the anorectum, with rectal intussusception and prolapse observed on
Valsalva. It was proved that that women with a wide hiatus on Valsalva are at increased risk
of developing rectal prolapse after successful vaginal prolapse repair. Using this ultrasound
method we identified the rectocele, rectoenterocele and the enterocel, which is difficult to be
correct evaluated only by clinical approach.
Ultrasound can evaluate the presence of a sling, with the ability to distinguish between
transobturator and transrethzius slings [10]. It is considered that translabial and transperineal
ultrasound may identify foreign bodies or bladder tumors [11] and can be a useful method to
observe residual urine, applying a formula developed only for transvaginal ultrasound [12].

Conclusions
Assessment by transperineal ultrasound made it possible to distinguish between different
forms of static pelvic disorders which is not feasible and reproducible by clinical examination.
The consequence of these fine diagnoses leads to with differentiated surgical approach,
individualized reconstructive surgery, early diagnosis and treatment of complications.

Fig.1: Translabial ultrasound scan depicting a normal genital statica in a menopausal woman.
The main anatomic structures are /pubic bone, uretra, urinary bladder trigon, vagina, rectum.
In the B plane the uretra and the vaginal hiatus with the sling of the levator ani and the anal
strauctures are obvious.

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Fig. 2: Sagital section of the pelviperineal structures with a full baldder teh ROI for
aquisition of 3D image in order to evidentiate the posterior uretrocystic angle and the
eventual descent of the vesical posterior wall during Valsalva maneuver

Fig. 3: Sagital section at the pelviperineal level during rest and different degrees of strain
during Valsalva maneuver

Fig. 4: Sagital section at the pelviperineal level during and different degrees of strain during
Valsalva maneuver ilustrating the descent of the posterior bladder wall below the inferior
edge of the pubic simfizis

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Fig. 5: 3D rendering of the mentioned ROI during rest notice the appearence of the vaginal
opening

Fig. 6: 3D rendering of the mentioned ROI during Valsalva the bulging of the vaginal
opening and the asymetric appearence of the levator ani

Fig. 7: Suburetral mesh 4D – transperineal ultrasound aspect

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REFERENCES

1. DeLancey JO. (2005). The hidden epidemic of pelvic floor dysfunction: achievable goals
for improved prevention and treatment. Am J Obstet Gynecol; 192:1488-1495.
2. Ashton-Miller JA, Delancey JO. (2009). On the biomechanics of vaginal birth and
common sequelae. Annu Rev Biomed Eng; 11:163-176.
3. Dietz HP, Steensma AB. (2006). The prevalence of major abnormalities of the levator ani
in urogynaecological patients. BJOG; 113:225-230.
4. Weemhoff M, Vergeldt TF, Notten K, Serroyen J, Kampschoer PH, Roumen FJ. (2012).
Avulsion of puborectalis muscle and other risk factors for cystocele recurrence: a 2-year
follow-up study. Int Urogynecol J; 23:65-71.
5. Majida M, Braekken IH, Bo K, Engh ME. (2012). Levator hiatus dimensions and pelvic
floor function in women with and without major defects of the pubovisceral muscle. Int
Urogynecol J; 23:707-714.
6. Youssef A, Montaguti E, Sanlorenzo O, Cariello L, Awad EE, Pacella G, Ghi T, Pilu G,
Rizzo N. (2015). A new simple technique for 3-dimensional sonographic assessment of
the pelvic floor muscles. J Ultrasound Med; 34:65-72.
7. H. P. Dietz. (2006). Editorial. Why pelvic floor surgeons should utilize ultrasound imaging
Ultrasound Obstet Gynecol; 28: 629–634.DOI: 10.1002/uog.3828.
8. Dietz HP, Korda A. (2005). Which bowel symptoms are most strongly associated with a
true rectocele? Aust N Z J Obstet Gynaecol; 45: 505–508.
9. Dietz HP, Steensma AB. (2005). Posterior compartment prolapse on two-dimensional and
three-dimensional pelvic floor ultrasound: the distinction between true rectocele, perineal
hypermobility and enterocele. Ultrasound Obstet Gynecol; 26: 73–77.
10. Greenland H, Dietz H, Barry C, Rane A. (2005). An independent assessment of the
location of the transobturator tape (Monarc) in relation to the levator ani muscle using 3
dimensional scanning techniques. Int Urogynecol J; 16 (S2): S59.
11. Tunn R, Petri E. (2003). Introital and transvaginal ultrasound as the main tool in the
assessment of urogenital and pelvic floor dysfunction: an imaging panel and practical
approach. Ultrasound Obstet Gynecol; 22: 205–213.
12. 12Haylen BT, Frazer MI, Sutherst JR, West CR. (1989). Transvaginal ultrasound in the
assessment of bladder volumes in women. Preliminary report. Br J Urol; 63: 149–151.

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Comparison Between Classical and Protetic Surgical


Intervention for Pelvic Floor Dysfunctions and
Urinary Stress Incontinence

POENARU Mircea Octavian1,2, SIMA Romina-Marina1,2,


DAN Diana2, STANESCU Anca Daniela1,2, PLES Liana1,2

1
University of Medicine and Pharmacy, “Carol Davila”, Bucharest, (ROMANIA)
2
“Bucur” Maternity, “Saint John” Hospital, Bucharest, (ROMANIA)
E-mails: mpoenaru69@gmail.com, romina.sima@yahoo.es, nanuc90@yahoo.com,
stanescuancadaniela@yahoo.com, liaples@yahoo.com

Abstract

Introduction
Genital static disorders and urinary stress incontinence represents a significant percentage
of cases admitted in hospitals for surgical correction. Although, in Romania the actual
incidence of these diseases is unknown, but it is estimated that in the USA 1 in 4 women have
such symptoms.

Methods
We conducted a retrospective study on interventions for genital static disorders and urinary
stress incontinence performed in Bucur Maternity between 01.01.2013 - 31.12.2014. The most
relevant parameters analyzed were the type of intervention performed during hospitalization,
complications that have appeared and patients satisfaction 1 year later.

Results and discussions


The study included a number of 1,373 patients who underwent surgical intervention for
gynecological disorders in Bucur Maternity. A total of 178 patients undergone surgery in order
to correct urinary stress incontinence or various degrees of genital prolapse. We used two
evaluation systems to assess the anatomical changes POP-Q and the impact on quality of life
ICIQ – SF for patients with genital prolapse or stress urinary incontinence.
A number of 72 cases underwent surgery involving polypropylene prosthetic mesh: 20
uretropexyes-TOT, TOT cystopexyes 41 and 9 histerosacropexyes. There were 8 cases of
failure in the short and medium term, accounting 11%. A case imposed prosthetic intervention
abandon due to important intraoperative bleeding. In 4 cases, at 3 months after surgery, it
was recorded vaginal erosion because of polypropylene mesh. In 3 cases it was required
reintervention at 1 year, to correct uterine prolapse after cystopexy TOT in 2 cases and 1 case
of vaginal stump prolapse after total hysterectomy with cystopexy TOT.

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Conclusions
The analysis one year after surgery revealed that both classical and prosthetics techniques,
are equally effective, the second one recorded a higher rate of complications in the short and
medium term. Prosthetic techniques provided a higher quality of life with fewer symptoms
such as dyspareunia.

Keywords: genital prolapse, urinary stress incontinence, polypropilene mesh

Introduction

Genital static disorders and urinary stress incontinence represents a significant incidence
among the cases admitted in hospitals surgical correction. Although, in Romania the actual
incidence of these diseases is unknown, is estimated that in the USA 1 in 4 women have such
symptoms.
The correlation between obstetrical trauma and pelvic statics changes was proved. It is
considered also that a long menopause period disturb the integrity mechanisms of pelvic and
urinary contention [1].

Methods

We realized a retrospective study on interventions for genital static disorders and urinary
stress incontinence performed in Bucur Maternity between 01.01.2013 - 31.12.2014. We
analyzed a number of parameters and the most relevant were the type of intervention performed
during hospitalization, complications that have appeared and patients satisfaction 1 year later.

Results

The study included a number of 1,373 patients underwent surgical intervention for
gynecological disorders in Bucur Maternity. A total of 178 patients undergone surgery in
order to correct stress urinary incontinence or various degrees of genital prolapse. We used
two evaluation systems to assess the anatomical changes POP-Q and the impact on quality of
life ICIQ – SF for patients with genital prolapse or stress urinary incontinence.
A number of 72 cases underwent surgery involving prosthetic material polypropylene:
20 uretropexyes-TOT, TOT cystopexyes 41 and 9 histerosacropexyes. There were 8 cases of
failure in the short and medium term, accounting 11%. A case imposed prosthetic intervention
abandon due to important intraoperative bleeding. In 4 cases at 3 months after surgery it
was recorded, vaginal erosion because of polypropylene mesh. In 3 cases it was required
reintervention at 1 year, to correct uterine prolapse after cystopexy TOT in 2 cases and 1 case
of vaginal stump prolapse after total vaginal hysterectomy with cystopexy TOT.
There was one case of hematoma occurred in 36 hours after surgery, following defecation
effort. A surgical reintervention was necessary to evacuate the hematoma and realize the
hemostasis. Blood accumulation was between the prosthetic material and the bladder which
led to the mobilization of polypropylenemesh, and imposed it’s removal being relatively easy
technically.
106 cases have undergone the classic anterior colporafies, posterior colpoperineorafies
vaginal total hysterectomy and Kelly technique in case of urinary stress incontinence. Only

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56 cases were analyzed one year after surgery. Pelvic restraint appeared to be satisfactory
in all cases submitted for control. 22 patients described symptoms suggestive for detrusor
dyssynergia (6) or dyspareunia (16).

Discussions

Pelvic organ prolapse (POP) represents the herniation of the pelvic organs to or beyond the
vaginal walls, is a frequent condition. The majority of women with prolapse describe symptoms
that affect usual activities, body image, sexual function and exercise Treatment of this disorder
requires important healthcare resources and it is estimated that in the United States from 2005
to 2006 the annual cost of ambulatory care of pelvic floor disorders was almost $ 300 million
[2] and surgical intervention for prolapse was the most frequent procedure performed in
women older than 70 years from 1979 to 2006 [3].
Due to an increasing percentage in the growing population of elderly women it is observed
that the health care impact of prolapse is likely to expand [4].
For pelvic surgery the vaginal mesh were used at the beginning of the current century.
Many series of studies have demonstrated relevant results of its use in conservation the
uterus [5].
Uterine preservation in patients with important uterine prolapse undergoing POP
intervention without trocar vaginal mesh proved to be safe and effective. In a study, the
majority of the patients preferred to preserve the uterus in their post-reproductive age and they
were content with the operative results. Uterus conservative surgery has to be discussed with
each patient before surgery for POP [6].
However, the meshes utilization is not without risks or complications, the main concern is the
extrusion and postoperative dyspareunia [7]. The International Urogynecological Association
(IUGA) evaluated that the use of meshes in women who will underwent sacrospinous fixation,
as these women generally have advanced stage prolapse or apical prolapse, and the benefits
outweigh the risks under these conditions [8].
Mesh use for prolapse of pelvic organs surgery has been characterized with lot of criticism
because of the potential events associated to its use. The most common complaint described
situation is extrusion, which may cause to important disorders for cases with implication to an
organ. The literature estimated an extrusion, erosion or exposure rate of up to 29% with the
use of vaginal mesh [9]. The IUGA described that mesh erosion for asymptomatic women has
a good outcome applying conservative attitude [10].
Another described complication associated with the use of vaginal meshes is the occurrence
of vaginal discharge. A study that involved women that were diagnosed with mesh extrusion
reported that 30.9% of women reported vaginal discharge. However, in other study, few women
were evaluated for vaginal discharge after surgery and all of them underwent sacrospinous
ligament fixation [11].
The reported rate of complications following reintervention for vaginal mesh complication
and the total reintervention rate was highest for vaginal mesh kits even if was a lower
reintervention rate for prolapse recurrence and shorter overall follow-up [12].

Conclusions

The analysis one year after surgery revealed that both classical and prothetics techniques,

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are equally effective, the second one recorded a higher rate of complications in the short and
medium term. Prothetic techniques present the advantage of providing a better quality of life
with fewer symptoms such as dyspareunia.

REFERENCES

1. Lowder JL, Ghetti C, Nikolajski C, et al. (2011).Body image perceptions in women with
pelvic organ prolapse: a qualitative study. Am J Obstet Gynecol; 204:441.e1.
2. Sung VW, Washington B, Raker CA. (2010). Costs of ambulatory care related to female
pelvic floor disorders in the United States. Am J Obstet Gynecol; 202:483.e1.
3. Oliphant SS, Jones KA, Wang L, et al. (2010). Trends over time with commonly performed
obstetric and gynecologic inpatient procedures. Obstet Gynecol; 116:926.
4. Wu JM, Hundley AF, Fulton RG, Myers ER. (2009). Forecasting the prevalence of pelvic
floor disorders in U.S. Women: 2010 to 2050. Obstet Gynecol; 114:1278.
5. Gutman R, Maher C. (2013). Uterine-preserving POP surgery. Int Urogynecol J.;
24:1803–1813.
6. Fink K, Shachar IB, Braun NM. (2016). Uterine preservation for advanced pelvic organ
prolapse repair: Anatomical results and patient satisfaction.Int Braz J Urol. Jul-Aug;
42(4):773-8.
7. Abed H, Rahn DD, Lowenstein L, Balk EM, Clemons JL, Rogers RG, et al. (2011).
Incidence and management of graft erosion, wound granulation, and dyspareunia
following vaginal prolapse repair with graft materials: a systematic review. Int Urogynecol
J.; 22((7)):789–98.
8. 8Davila GW, Baessler K, Cosson M, Cardozo L. (2012). Selection of patients in whom
vaginal graft use may be appropriate. Consensus of the 2nd IUGA Grafts Roundtable:
optimizing safety and appropriateness of graft use in transvaginal pelvic reconstructive
surgery. Int Urogynecol J.; 23(Suppl 1):S7–14.
9. Abrams P, Andersson KE, Birder L, Brubaker L, Cardozo L, Chapple C, et al. (2010).
Fourth International Consultation on Incontinence Recommendations of the International
Scientific Committee: Evaluation and treatment of urinary incontinence, pelvic organ
prolapse, and fecal incontinence. Neurourol Urodyn.; 29((1)):213–40.
10. Batalden RP, Weinstein MM, Foust-Wright C, Alperin M, Wakamatsu MM, Pulliam
SJ. (2016). Clinical application of IUGA/ICS classification system for mesh erosion.
Neurourol Urodyn.; 35:589–94.
11. Hammett J, Peters A, Trowbridge E, Hullfish K. (2014). Short-term surgical outcomes
and characteristics of patients with mesh complications from pelvic organ prolapse and
stress urinary incontinence surgery. Int Urogynecol J.; 25(4):465–70.
12. Diwadkar GB, Barber MD, Feiner B, Maher C, Jelovsek JE. (2009). Complication and
reoperation rates after apical vaginal prolapse surgical repair: a systematic review.Obstet
Gynecol. Feb; 113(2 Pt 1): 367-73. doi: 10.1097/AOG.0b013e318195888d.

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Pregnancy complications in women with Abruptio


Placentae

SAGAIDAC Irina1, FRIPTU Valentin2


1
Assistant professor, State Medical and Pharmaceutical University (Republic of Moldova)
2
Professor, State Medical and Pharmaceutical University (Republic of Moldova)
E-mail: irinasagaidac@yahoo.com

Abstract

The aim of the present study is to determine the peculiarities of clinical evolution of
pregnancy and labor, the percentage of cesarean section in the study group and to collect
information regarding the intrauterine status of the fetus of women that were diagnosed with
Abruptio Placentae (AP). Statistically significant results were obtained in the study group in
case of imminent miscarriage (25.0±2.30% vs. 2.1±0.64%, p<0.001), vaginal bleeding during
pregnancy (5,6±1,22% vs. 1,7±0,68%, p <0.001), imminence of premature birth (19.7±2.11%
vs. 3.4±0.96%, p<0.001), polyhydramnios (6.5±1.31% vs. 2.5±0.83%, p<0.01), gestational
hypertension (25,1±1,86% vs. 1,1±0,55%, p<0,001), preeclampsia (8.5±1.48% vs. 1.4±1.62%,
p<0.001) and antiphospholipid syndrome (2.8±0.88% vs. 0.3±0.29% of cases, p<0.01).
Caesarean section was registered in the majority of cases in 91%, in the studied group, being
conditioned by the fetal hypoxia/circulatory insufficiency or continuous vaginal bleeding.

Keywords: abruptio placentae, vaginal bleeding, gestational hypertension

Introduction

One of the leading causes in the structure of maternal morbidity and mortality is determined
by abruptio placenta. The main cause of bleeding among antepartum hemorrhages is abruptio
placentae, being followed by bleeding caused by placenta praevia. The severity of the disease
is determined by the high morbidity among women and high morbidity and mortality among
newborns. Abruptio placentae (AP) is an obstetric emergency, having an acute debut usually,
being characterized by 4 main clinical symptoms: vaginal bleeding, abdominal pain, preterm
labor, or trauma [1]. At the same time chronic abruption is described by some authors as a
process in which women experience chronic and intermittent bleeding during pregnancy. The
aim of the present study is to determine the peculiarities of clinical evolution of pregnancy
and labor, the percentage of cesarean section in the study group and to collect information
regarding the intrauterine status of the fetus of women that were diagnosed with Abruptio
Placentae (AP) [1, 2, 3].

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Methodology

The research is a retrospective case-control, with two groups: exposed group - which
included 355 women with gestational age more than 22 weeks pregnancy whose pregnancy
and/or delivery was complicated by Abruptio Placentae (AP), and a control group or non-
exposed - 355 cases of women without AP. The control group was randomly selected by using
matched-pair groups similar by age and social status of patients. This study was conducted
in Mother and Child Institute and Municipal Clinical Hospital No. 1 (Republic of Moldova,
Chisinau), where in sum about one third of all births in the country occur. The study was
conducted in the period 2010-2014, a period of 5 years.

Results

We aimed to investigate how current pregnancy was carried in patients with AP, data
are presented in table 1. Thus, it has been found that every 4th pregnant was diagnosed with
signs of imminent miscarriage - 25.0±2.30% vs. 2.1±0.64%, p<0.001. In 5.6% of cases, there
were significant vaginal bleeding during pregnancy (1st and 2nd trimesters), which in most
cases have resulted in hospital admission, 5,6±1,22% vs. 1,7±0,68% of the total number of
patients included in the study, p<0.001. Diagnosis imminent preterm birth was registered in
19.7±2.11% vs. 3.4±0.96%, p<0.001. At the same time approximately half of births in the
research group were pre-term -177 (49.9±2.65%) cases.

Tab. 1 Complications of pregnancy in women with Abruptio Placentae


Study group Control group
(with AP) n1=355 (without AP) n0=355 t p
Abs. % ± Er Abs. % ± Er
Imminence of miscarriage 25 25,0 ±2,30% 6 2,1±0,64% 9,52 p<0,001
Vaginal bleeding during
pregnancy 20 5,6±1,22% 6 1,7±0,68% 2,79 p<0,001

Imminence of premature birth 70 19,7± 2,11% 12 3,4± 0,96% 7,02 p<0,001


Polyhydramnios 23 6,5± 1,31% 9 2,5± 0,83% 2,58 p<0,01
Oligohydramnios 6 1,7± 0,68% 5 1,4± 0,73% 0,29 p>0,05
Gestational hypertension 89 25,1±1,86% 4 1,1±0,55% 6,84 p<0,001
Preeclampsia 30 8,5±1,48% 5 1,4±1,62% 4,42 p<0,001
Eclampsia 3 0,8±0,15% 0 0% 0,53 p>0,05
HELLP syndrome 1 0,3±0,29% 0 0% 1,03 p>0,05
Antiphospholipid syndrome 10 2,8± 0,88% 1 0,3± 0,29% 2,71 p<0,01
Vaginal infection 9 2,5± 0,82% 4 1,1± 0,65% 1,32 p>0,05

Pathology of the amniotic fluid was identified in 30 cases, of which 23 cases as


polyhydramnios - 6.5±1.31% vs. 2.5±0.83%, p<0.01. Hypertensive conditions during
pregnancy were recorded in 34.4% of patients in the study group. Thus, gestational
hypertension was found in 88 (25,1±1,86% vs. 1,1±0,55%, p<0,001) cases, preeclampsia in 30

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cases (8.5±1.48% vs. 1.4±1.62%, p<0.001), and eclampsia in 3 (0.8±0.15% vs. 0%) cases. In
one case (0.3±0.29%) AP development was preceded by HELLP syndrome.
Attention has been paid to cases were women were diagnosed with antiphospholipid
syndrome, 2.8±0.88% vs. 0.3±0.29% of cases, p<0.01, were recorded in the studied groups.
We believe that because the diagnosis of this pathology requires access to additional
laboratory investigations (not covered by insurance) probably in some cases the diagnosis has
not been determined, although in the research group there were women who had a history of
more than 3 spontaneous abortions, including in the 2nd trimester.
The data regarding the intrauterine fetal conditions are presented in table 2. Intrauterine
growth restriction of the fetus was recorded in 5.9±1.25% vs. 2.0±0.74%, p<0.01. Fetal
circulatory insufficiency of various degrees was confirmed by ultrasound examination in
3.1±0.92% vs. 0.3±0.29% of cases, p<0.01. The diagnosis of intrauterine fetal hypoxia was
done in 11.8±1.71% vs. 2.0± 0.74%, p<0.001, 5 times more frequent than in the control group.

Table 2. Intrauterine condition of fetus, studied in both groups


Study group Control group
(with AP) n1=355 (without AP) 0=355 t p
Abs. % ± Er Abs. % ± Er
Intrauterine growth
restriction 21 5,9±1,25% 7 2,0±0,74% 2,68 p<0,01
Fetal circulatory
insufficiency 11 3,1±0,92% 1 0,3±0,29% 2,9 p<0,01
Acute intrauterine
hypoxia 42 11,8±1,71% 7 2,0±0,74% 5,25 p<0,001

The research group included 355 cases with Abruptio placentae, which occurred at different
weeks of gestation. Study data showed that AP occurred in 50.1% of cases the pregnancy to
term (37-42 weeks) and in 49.9% of cases - the gestational age below 37 weeks, data are
shown in table 3. To establish a possible correlation between pregnancy and the occurrence of
AP, the linear correlation coefficient was calculated - Pearson rxy=0.658, proving that there
is a substantial association, directly dependent. The value of the determining coefficient was
determined, 0.433 (R2), thereby variation of occurrence of AP in 43% is determined by the
variation of the pregnancy term, AP and delivery was produced.

Table 3. Distribution of Abruptio placentae cases according to gestation age


Study group Control group
(with AP) n1=355 (without AP) 0=355 t p
Gestational age Abs. % ± Er Abs. % ± Er

22-27 weeks 27 25,0 ±2,30% 5 2,1±0,64% 9,52 p<0,001


28-31 weeks 39 5,6±1,22% 4 1,7±0,68% 2,79 p<0,001
32-36 weeks 111 19,7± 2,11% 15 3,4± 0,96% 7,02 p<0,001
37-40 weeks 156 6,5± 1,31% 292 2,5± 0,83% 2,58 p<0,01

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41-42 weeks 22 1,7± 0,68% 39 1,4± 0,73% 0,29 p>0,05


Total 355 355

A polymorphism of clinical signs, made it difficult sometimes to establish correctly and


promptly the diagnosis. Thus, in 62.1±2.57% (222 cases), vaginal bleeding was the only sign
of onset of AP, in 18.6±2.06% (65 cases) pregnant women complained about abdominal pain,
in 9.0±1.51% (32 cases) accused a marked hypertonus of the uterus. Also, we would like to
mention that the classical triad of vaginal bleeding associated with abdominal pain and uterine
hypertonus was recorded in only 36 (11.0±1.66%) cases of all women with AP, (Figure 1).

Fig. 1 Clinical signs of Abruptio placentae

Some of the patients developed or were diagnosed with AP, while being admitted in the
hospital for various reasons (126 patients from totally 355 patients in the studied group).
Special attention was given to cases of premature rupture of membranes in patients with AP.
Out of 126 (35.5%) cases of hospital admission in 43 cases (12.2%), patients were admitted
and supervised because of preterm membrane rupture. In total, in the study group, amniotic
sac rupture was diagnosed in 66 (18.6±2.07%) cases, compared with 50 control group
(14.1±1.85%) cases, p>0.05, the difference being statistically not significantly.
Once AP was diagnosed, delivery as fast as possible was recommended, thus caesarean
section was performed in 323 (91.0±1.52%) cases, compared with 32 (20.6±2.15%) cases in
the control group (p<0.001), in 80 (22,4%) cases fetal acute hypoxia being diagnosed (Table
4).

Table 4. Distribution of patients in the studied groups according to vaginal or operative of


delivery
Study group Control group
(with AP) n1=355 (without AP) 0=355 t p
Abs. % ± Er Abs. % ± Er
Caesarian
323 91,0±1,52% 73 20,6±2,15% 26,77 p<0.001
section
Vaginal delivery 32 9,0±1,52% 282 79,4±2,15% 26,77 p<0.001
Total 355 355

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Of particular interest are cases in which pregnancy was finalized by vaginal delivery, which
occurred in 32 (9.0±1.52%) cases. In 50% cases deliveries occurred preterm (16 cases) and in
other 50% of cases the birth was registered between 37 and 41 weeks. In 7 (1.97%) cases it was
decided in favour of vaginal delivery because antenatal fetal death was diagnosed.
In 16 (4.5%) cases AP was diagnosed at the end of 1st period of gestation, at complete
dilation of the cervix. Also in cases of AP, but in the presence of satisfactory intrauterine fetal
status the birth was finalized per vias naturalis. In other 5 (1.4%) cases, AP was diagnosed
during the expulsion of the fetus and the birth was finalized by emergency vacuum extraction
or forceps application.

Conclusion

The present study had the aim to analyze the evolution of pregnancy in women that
subsequently developed AP, comparing it with women without AP. It was determined that in
case of imminent of miscarriage, vaginal bleeding during pregnancy, imminence of premature
birth, polyhydramnios, gestational hypertension, preeclampsia and antiphospholipid syndrome,
statistical significant differences were obtained between groups. Three main conditions of the
fetus, were analyzed: intrauterine growth restriction, fetal circulatory insufficiency and acute
intrauterine hypoxia – all 3 being diagnosed several times more frequently in women with
AP, then in the control group. A high rate of Caesarean section in the studied group (91%),
is explained by the fact that Abruptio placentae is a major emergency situation that involves
resolving pregnancy as quickly as possible for both fetal and maternal interest.

REFERENCES

1. Ananth V Cande, VanderWeele J Tyler. Placental Abruption and Perinatal Mortality


With Preterm Delivery as a Mediator: Disentangling Direct and Indirect Effects. Am J
Epidemiol. 2011;174(1):99–108.
2. Bener A, Saleh NM, Yousafzai MT. Prevalence and associated risk factors of antepartum
hemorrhage age among Arab women in an economically fast growing society. Niger J
Clin Pract 2012;15:1859.
3. Charnock-Jones D.S., Kaufmann P., Mayhew T.M. Aspects of human fetoplacental
vasculogenesis and angiogenesis. I. Molecular regulation // Placenta. – 2004. – Vol. 5. –
Р. 103-113.

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Up-date Concerning Medical Drugs Useful To Treat


Urinary Incontinence

STANCULESCU Ruxandra1, COMANDASU Diana-Elena1,


BAUSIC Vasilica1, BRATILA Elvira1
1
“Carol Davila” University of Medicine and Pharmacy, Obstetric and Gynecology Department,
“St. Pantelimon” Emergency Clinical Hospital, Bucharest (ROMANIA)
E-mails: ruxandra_v_stanculescu@yahoo.com, diana.comandasu@yahoo.com, valibausic@gmail.
com, elvirabarbulea@gmail.com

Abstract

The Aim
The purpose of the present work is to reaveal the benefits and limits of the medical drugs
used to treat stress urinary incontinence.

Material and method


The analysis of the articles and guidelines published in the domain of urinary incontinence
on databases such as Pub Med, Scopus, Thomson Reuters.

Results
The data showed that sometimes there is a better solution to improve the stress urinary
incontinence symptoms by association with medical therapy. The duration of the treatment and
the persistance of the corrected symptoms are also variable. On the other hand we observed
that there are secundary adverse effects which limit the recomandation of these drugs. Among
these systemic negative effects there are heart failure, dry eyes, blurred vision, dry mouth,
constipation, increased heart rate or orthostatic hypotension, all with negative impact on the
efficacity of the drug therapy.

Conclusion
A review of the literature as regards the knownledges concerning the efficacy of this kind
of terapeutic attitude allows us to choose the best drug fit to every pacient in order to increase
the quality of life.

Keywords: Stress Urinary Incontinence, Overactive Bladder, Anticolinergic drugs, Estrogen therapy,
Tricyclic antidepressants, Capsaicin

Introduction

The urinary incontinence recognises two main causes: on one hand is expressed by

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overactive bladder (OAB) and on the other hand by the weakness of the pelvic floor and urethral
sphincter [1]. The clinical features of the OAB are urgency of micturition, urge incontinence
and/or urinary frequency. The changes in pelvic floor and urethral sphincter structure lead to
the involuntary passage of urine when the intra-abdominal pressure is raised, especialy when
women who cough or sneez frequenty. Women’s stress urinary incontinence is known such
as urge incontinence and/or urinary frequency. The Stress Urinary Incontinence (SUI) occurs
when the pressure within the bladder is higher than the total uretheral resistance. This situation
leads to the leackadge of the urine flow beyond the urinary sphincter. The SUI involves the loss
of accomodation between the intravesical pressure and the urethral resistence. For a normal
function of the micturition it is necessary to have a full concordance among the integrity of
many anatomophysiological structures, such as bladder structure, urethral sphincter function,
pelvic floor muscular activity and a good reactivity of centrally mediated neural reflexes. The
normal function of mechanism of urinary continence requires the closure of urethral sphincter
during the periods of increased abdominal pressure. On the other hand, the relaxion of the
pelvic floor musculature and urinary sphincter is necessary when the bladder is full with urine
and the intravesical pressure is increased. A significant role in the maintenace of the urine
within the bladder and the function of urethral sphincter is played by the estrogens and alfa-
adrenergic receptors number. All these conditions are able to create the possibility of urine to
flow from the bladder into the urethra and to empty the bladder almost completely [2], [3], [4].
The treatment of the SUI is a challange both for women and doctor, which must together
choose the most adequate option for the pacient’s behaviour. To choose between non-surgical
or surgical treatment is not so easy. The difference between these options is influenced. by
factors such as age or association with others pathologies. The purpose of the present work
is to update the possibilities of medical therapies able to treat the SUI. To review this type of
therapy we performed a deep analysis of the literature published in international databases
such as Pub Med, Scopus, Thomson Reuters in the domain of stress urinary incontinence.
We resumed only to the pharmacologic therapy by exclusion of the behavioral therapeutical
options.

Medical treatment of Stress Urinary Incontinence

The pick up of data highlights that there are many possibilies of pharmacologic therapy
able to correct the stress urinary incontinence. The goal of this therapy is to facilitate urine
storage by decreasing bladder contractility, incresing outlet resistance, enhancement of the
urethral sphincter clossure, decrease in the strengh of involuntary contractions, improvement
of the genitourinary atrophy, and correction of detrusor overactivity.
These kinds of therapies include antispasmodic drugs, anticolinergic agents, natural and
sintetic estrogens with phitoestrogen therapy alternatives/options, tricyclic antidepressants,
botulinum toxin and intravesical therapy. The present work analysed the most important
characteristics of these drugs.
Antispasmodic drugs inhibit the action of acetylcholine by stopping the transmission of
parasympathetic nerve impulse to the smooth muscle of the bladder and so, these are able to
correct the disturbances of the bladder contractility. Among these drugs we accord attention
to some drugs such as oxybutynin, dicyclomine and flavoxate. The last two drugs have weak
anticolinergic properties. As regards the dosage used to treat the SUI by the aforementioned
anticolinergic drugs the clinical trials have shown that it is necessary to recommend oxybutynin
5 mg, 2-4 times daily, dicyclomine 10-20mg, or flavoxate, 100 -200 mg, both 3 times per day.

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For Europe it is approved the use of oxybutyin under different types of administration such as
tablets, syrup, transdermal delivery system or patch. The dose must not excede 30mg daily.
The use of these anticolinergic drugs in clinical practice have proved an improvement
in qulity of life due to the decrease of the number of micturition, but with little benefit in
the correction of urge incontinence [5], [6]. Concerning the anticolinergic agents, they could
influence the hyperdynamic bladder by blocking the cholinergic receptors. This action allows
to achieve a higher capacity for urine continence. By increasing the volume of bladder the
threshold for initiation of the involuntary contractions is higher. Among the anticolinergic drugs
we highlight some drugs such as propantheline bromide, tolterodine, trospium, darifenacin,
solifenancin. These drugs are recommended to treat detrusor overactivity. The usual dose of
solifenancin is 5 mg per day, but the dose could arise to 10 mg per day.
Estrogen therapy is efficient in the treatment of SUI which occurs in eldery women or
women with hystory of total hysterectomy associated with oophorectomies. The mechanism
induced by estrogen therapy mainly involves the increase of the number of alpha receptors
in urethra and the increase of the urethral mucosa vascularisation. Due to these effects many
clinical physicians have belived that the estrogen therapy improved the ability of bladder to
perform a better urine continence. Controversely, large studies such as Heart and Estrogen/
Progestin Replacement Study and the Women`Health Initiative Study demonstrated that oral
estrogen therapy isn`t useful for the treatment of SUI [7], [8], [9]. Thereby, the efficacy of
oral estrogen for the improvement of the urinary discomfort was demonstrated by the increase
of urethral pressure and a better continence of the urine within the bladder for women who
undergo this therapy. So, the benefit of these therapy is due to some mechanisms which
we have described such as raising the number of estrogen receptors inside the bladder and
urethra, increasing the sensitivity of the alpha adrenoreceptors in urethral smooth muscle and
correction of the uro-genital atrophy [10]. On the other hand, there is a contrary option based
on the review of the literature performed by Hextall and Anderson which have highlighted
that the use of estrogens in these purpose is not properly [11]. The results of the researches
undertaken along the years have demonstrated that exogenous estrogens are able to reduce
collagen concentration, decrease the cross-linking of collagen and increase the levels of
collagen turnover in peri-urethral tissues [12], [13]. The studies concerning the impact of
phytoestrogens on the SUI have shown that the phytoestrogen class represented by isoflavones,
coumestrol and ligans don’t have any beneficial influence on the urinary tract. This idea was
supported by results of a deep analysis on Asian and non -Asian women groups concerning
different diet traditions with many or few phytoestrogens intake [14].
For women who don’t respond to the anticolinergic therapy or idiopathic bladder over-
activity the use of onabotulinum toxin A is a solution able to correct these discomfort with at
least 12 weeks elapse between treatments [15], [16].
Intravesical therapy may be an option to treat neurogenic detrusor overactivity using 50-
100 ml of capsaicin solution left in the bladder for 30 minutes by the use of an urethral catheter
able to prevent the urine leakage.
Among others possibilities to treat SUI there are the tricyclic antidepressants. These
drugs have an alpha-adrenergic effect on the bladder neck and an antispastic action on the
detrusor muscle. One of the most known tricyclic antidepressant is Amitriptyline, (25-100 mg
daily), which is able to restore serotonin levels and to break the pelvic floor muscle spasms.

Adverse effects

The prescription of drugs able to correct SUI must take into account that these drugs have

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adverse effects. The usual negative effects are orthostatic hypotension, blurred vision, dry
mouth, tachycardia, heart failure. Physicians must avoid recommending anticolinergic agents
to patients with closed-angle glaucoma or with heart diseases. Solifenancin known under
Vesicare name, must not to be recommended to women with glaucoma, ulcerative colitis,
myasthenia gravis, severe liver disease or undergoing kidney dialysis. On the other hand,
physicians must avoid increasing the toxicity induced by the association between anticolinergic
drugs. When the physicians prescribe tricyclic antidepressants they must take into account that
these drugs are able to increase the risk of suicid.
As regards of the possibility to improve the action of the drugs able to treat SUI the data
showed that the association between some drugs such as imiprapine with oxybutynin leads to
an improvement of the results therapy. The duration of the treatment and the persistance of the
corrected symptoms are variable too.

Conclusion

A review of the literature as regards the knownledges concerning the efficacity of this type
of terapeutic attitude allows us to choose the best drug fit to the pacient in order to increase
the quality of life of women with the SUI but the phisicyans must always keep in memory that
these drugs must be recomanded with caution due to possible adverse effects, sometimes more
dangerous than the clinical benefit.

REFERENCES

1. Royal College of Obstetricians and Gynaecologists (UK); 2013 Sep. Urinary Incontinence
in Women: The Management of Urinary Incontinence in Women. National Collaborating
Centre for Women’s and Children’s Health (UK); NICE Clinical Guidelines, No. 171.
London.
2. Alan J. Wein, Karl-Erik Andersson, Marcus J. Drake, Roger R. Dmochowski. Relevant
Anatomy, Physology and Pharmacology; Bladder Dysfunction in the Adult: The Basis for
Clinical Management , 2014 – Chapter 1; ISBN 978-1-4939-0853-0 (eBook) Ed. Springer
3. Delancey JO, Ashton-Miller JA. Pathophysiology of adult urinary incontinence.
Gastroenterology. 2004 Jan. 126(1 Suppl 1):S23-32.
4. Petros PE, Woodman PJ. The Integral Theory of continence. Int Urogynecol J Pelvic
Floor Dysfunct. 2008 Jan. 19(1):35-40.
5. Appell RA, Sand P, Dmochowski R, Anderson R, Zinner N, Lama D, et al. Prospective
randomized controlled trial of extended-release oxybutynin chloride and tolterodine
tartrate in the treatment of overactive bladder: results of the OBJECT Study. Mayo Clin
Proc. 2001 Apr. 76(4):358-63.
6. Fehrmann-Zumpe P, Karbe K, Blessman G. Using flavoxate as primary medication for
patients suffering from urge symptomatology. Int Urogynecol J Pelvic Floor Dysfunct.
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Robotic Assisted Sacrocolpopexy: operative technique


and post-operative outcomes for a single center
experience in a series of 158 patients

STANIMIR Marius1, BENIJTS Jan1, TWAHIRWA Michael1,


CHIUȚU Luminița2, NEMEȘ Răducu3, MITROI George4,
ASSENMACHER Christophe1
1
Department of Urology, Clinics of Europe Hospital, Saint-Elisabeth Site, Brussels, Belgium
2
Department of Anesthesiology and Intensive Care of the County Emergency Hospital of Craiova,
Romania. University of Medicine and Pharmacy, Craiova, Romania.
3
Department of Surgery, University of Medicine and Pharmacy, Craiova, Romania.
4
Department of Urology, of the County Emergency Hospital of Craiova, Romania. University of
Medicine and Pharmacy, Craiova, Romania.
E-mails: stanimir.marius@yahoo.com, jan.benijts@gmail.com, mtwahirwa@gmail.com, luminita.
chiutu@gmail.com, raducunemes@yahoo.com, gmitroi@yahoo.com, christophe.assenmacher@gmail.
com

Abstract

The aim of the current study is to describe the surgical technique and to report the post-
operative outcomes obtained after Robotic Assisted Laparoscopic Sacrocolpopexy (RASC) in
our institution and to compare them with the data from the literature.
The current ‘gold standard’ for the treatment of pelvic organ prolapse (POP) is the open
abdominal mesh sacrcolpopexy. The robotic approach is an option as a minimally invasive
technique and it is considered to be a success technique among the pelvic floor surgeons.
We retrospectively analyzed the clinical data from 158 female patients who underwent
RASC in our department between January 2008 and October 2015. All the patients were adult
women with symptomatic stage II, III or IV POP according to Baden-Walker classification.
All the patients underwent RALSCP via a transperitoneal approach and the patients with
SUI underwent a tension-free vaginal tape-obturator (TVT-O) procedure in the same operative
time.
Some studies in the literature that compared the RASC with the other surgical technics
used for the treatment of POP showed similar outcomes, with an advantage of the RASC over
the open surgery included decreased of blood loss and shorter hospital stay.
Our study also highlights the effectiveness and low morbidity of RASC for the treatment
of pelvic organ prolapse.

Keywords: Pelvic Organ Prolapse, Robotic Assisted Sacrocolpopexy, Mesh Sacrocolpopexy

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Introduction

Female pelvic floor disorders are rank amongst the most common disorders affecting
women and include conditions such as urinary incontinence (UI) and pelvic organ prolapse
(POP) [1]. Given the aging of the population, the complaints related to the pelvic floor disorders
are increasing.
Pelvic organ prolapse occurs in up to 50% of parous women and may be associated with
a variety of urinary, bowel and sexual symptoms [1]. The prevalence of POP is currently
increased, and the risk of requiring surgery for POP is more than 10% [2].
We retrospectively collected the clinical data from 158 female patients who underwent
RALSC in our department between January 2008 and October 2015. All the patients were
adult women with symptomatic stage II, III or IV of vaginal vault prolapsed according to
Baden-Walker classification.
The goal of surgical repair for POP is to return the pelvic organs to their native anatomic
position and to improve the quality of life (QoL) of the patients [1]. Ideally, there are four main
goals concerning the results of the treatment: no anatomic prolapse, no functional symptoms,
patient satisfaction and avoidance of complications [4].
Randomized trials have shown that sacrocolpopexy offers lower recurrence rates and less
dyspareunia than sacrospinous fixation, but at the expense of a longer recovery time [5]. Open
abdominal sacrocolpopexy (ASC) was the established ‘gold standard’ procedure. It is indicated
when we are talking about a prolapse of the anterior and/or apical vaginal wall compartments
[6]. Laparoscopic sacrocolpopexy (LSC) has not been widely adopted. This is the background
upon which the rise of robotic surgery has taken place [1].
The aim of the current study is to describe the surgical technique and to report the post-
operative outcomes and complications obtained after Robotic Assisted Sacrocolpopexy
(RASC) in our institution as well to make comparison with the data from the literature.

Materials and methods

We retrospectively analyzed the clinical data from 158 female patients who underwent
robotic assisted laparoscopic sacrocolpopexy (RALSC) in our department between January
2008 and October 2015. All the patients were adult women with symptomatic stage II, III or
IV POP according to Baden-Walker classification. As a preoperative work-up, all the patients
underwent symptom assessment using a systematic uro-gynecological physical examination
to assess the type and the severity of the prolapse according to the Baden-Walker classification
[7], urine analysis, cystoscopy and urodynamic studies [8]. To detect occult stress urinary
incontinence (SUI), prolapse was systematically repositioned into the correct anatomical site
with a sponge-holding forceps. Concomitant or occult clinical SUI was then assessed using
the Bonney maneuver and all the patients underwent urodynamic study. The following data
were collected: the age, the menopause status, the surgical history, body mass index (BDI)
and the existence of urinary incontinence. We also recorded concomitant procedure (such as
TVT-O and/or total or subtotal hysterectomy), length of catheterization and type of analgesia
according to the World Health Organization (WHO) classification (Level 1, 2 or 3).

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Patients’ characteristics

The mean age of the patients was 70,8 (40-92) years and the mean number of the delivery
was 2.32 (1-4). The mean BMI of these patients was 25,6 (19.1-34.4). In terms of the grade
of the prolapse, which was assessed according to Baden-Walker classification we noted
30 patients (18,98%) with 2nd grade, 93 patients (58,86%) with 3rd grade and 35 of them
(22,15%) with 4th grade. The majority of the patients, 118 (75%), were post-menopausal. The
Bonney test and urodynamic studies were positive for SUI in 54 patients (34,17%) and for
overactive bladder in 7 cases (4,43%). All the patients suffering of SUI underwent a tension-
free vaginal tape (TVT-O) procedure simultaneous with the RALSC. Furthermore, 24 patients
(48%) underwent total or subtotal hysterectomy in the same operating session. Regarding
the surgical history, 16 patients (10,16%) previously had a surgery (colporaphy, cistopexy,
sacrocolpopexy) for the treatement of the POP.

Operative technique

All the patients underwent RALSC via a trans-peritoneal approach. A single shot
intravenous Cefazolin (2g) was routinely given at least 30 minutes preoperatively. We used the
4-arms daVinci® robotic surgical system and a trans-peritoneal five-port technique. Briefly, the
procedure starts by introducing of a 12 mm trocar trough an incision above the umbilicus and
creating the pneumoperitoneum at 14 mmHg pressure. The rest of the trocars are introduced
under direct vision: one robotic trocar (right hand of the surgeon) and one auxiliary 12 mm