Experimental models of atrial fibrillation--what have we learned?

The first pubovaginal fascial sling was reported in 1907, however, until recently this procedure was rarely utilized except after other incontinence procedures had failed. Currently, a pubovaginal sling is indicated as the primary incontinence procedure if intrinsic sphincter deficiency or coexisting intrinsic sphincter deficiency and urethral hypermobility are diagnosed preoperatively. Additionally, incontinence secondary to urethral hypermobility should be treated with a pubovaginal sling if the patient has a high risk of postoperative failure due to obesity, chronic cough, or repetitive strenuous activity. Pubovaginal slings are relatively easy to perform and yield reliably good results with minimal morbidity. We describe our current technique and results using pubovaginal slings for stress incontinence in women.     

Our experience with pubovaginal slings in patients with stress urinary incontinence

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

Pubovaginal sling using polypropylene mesh and Vesica bone anchors

OBJECTIVES: To report preliminary results from a modified pubovaginal sling procedure using polypropylene mesh as the sling suspended by nonabsorbable sutures anchored to the pubic tubercle with Vesica bone anchors. METHODS: Thirty-five women with type III stress urinary incontinence (SUI) (with or without associated urethral hypermobility) or type II SUI with additional risk factors such as obesity, chronic obstructive pulmonary disease, or failed prior incontinence-correcting procedures underwent this modified pubovaginal sling procedure. Postoperative voiding status was evaluated during office follow-up visits and telephone surveys. RESULTS: With a mean follow-up of 8.4 months (range 2 to 18), 32 women (91.4%) were dry, 1 improved, and 2 remained incontinent. The pubovaginal sling procedure was the only operation performed in 46% of patients, with a mean operative time of 72 minutes, a mean estimated blood loss of 137 mL, and a mean hospital period of 2.3 days. Patients on whom concomitant gynecologic procedures were performed had a mean duration of surgery of 122 minutes, a mean estimated blood loss of 202 mL, and a mean hospitalization period of 2.9 days. Thirteen women had preoperative urgency that persisted in 31% of patients. De novo urgency developed in 3 patients. Seven women required prolonged suprapubic tube drainage but no patient remained in permanent retention. There has been no infection or erosion. CONCLUSIONS: Our experience with this modified pubovaginal sling procedure using polypropylene mesh and Vesica bone anchors showed excellent results with greater technical ease, minimal morbidity, and decreased hospitalization period when compared to a traditional pubovaginal sling performed in our hands. Additional follow-up will be needed to assess long-term efficacy.     

Use of synthetic material in sling surgery: a minimally invasive approach

Traditionally, autologous material has been favored over synthetic material in the construction of pubovaginal slings for the treatment of female stress urinary incontinence (SUI). This preference arose largely because of concern about an increased incidence of infection or sling erosion when synthetic materials are used. However, when care is taken to minimize the amount of synthetic material, reduce total operative time, and limit exposure of the material to the operative field, female SUI can be treated effectively with synthetic material with an acceptably low complication rate. Furthermore, utilization of slings constructed with artificial graft material can be minimally invasive, cost effective, and well tolerated.     

The fascia lata suburethral sling for treating recurrent urinary stress incontinence

OBJECTIVE: The purpose of this study was to evaluate the effectiveness of the fascia lata suburethral sling procedure in the treatment of recurrent genuine urinary stress incontinence. STUDY DESIGN: This study was a retrospective analysis of 60 patients who had a suburethral fascia lata sling placement between January 1992 and December 1995. Follow-up ranged from 6 months to 3.5 years. The database was obtained by a retrospective chart review, a written questionnaire, and telephone interview. RESULTS: Between January 1992 and December 1995, 72 patients who had at least one previous incontinence procedure were assessed by urodynamic testing and cystourethroscopic examination before undergoing a fascia lata sling placement. Of this population, 60 were available for follow-up. Of this 60, 54, or 90%, had complete cure or marked improvement in the urinary incontinence. There were six failures, two of which had no bladder neck mobility and two of which had detrusor instability and were unable to take medication because of medical contraindications. In addition, two slings were sacrificed because of postoperative complications. The most common postoperative complication was urinary retention, which resulted in eight, or 13.4%, of slings needing to be released. CONCLUSION: Our data support the use of the suburethral fascia lata sling as an effective method for the treatment of recurrent genuine urinary stress incontinence, with urinary retention being the most common postoperative complication.     

Pubovaginal fascial sling for all types of stress urinary incontinence: long-term analysis

PURPOSE: There is a lack of consensus regarding indications and long-term efficacy of the many surgical techniques for treating stress incontinence. Historically pubovaginal sling has been reserved for cases of intrinsic sphincter deficiency or prior surgical failure. Transvaginal needle and retropubic suspensions have been used mainly for sphincteric incontinence unassociated with intrinsic sphincter deficiency. We report the long-term results of pubovaginal sling for all types of stress incontinence. MATERIALS AND METHODS: A total of 251 consecutive women with all types of stress incontinence who underwent pubovaginal fascial sling by a single surgeon were retrospectively and prospectively reviewed. Patients were evaluated preoperatively with history, physical examination, standardized symptom questionnaire, voiding diary, pad test, uroflow, post-void residual urine, video urodynamics and cystoscopy. Postoperatively women with at least 1-year followup were assessed by an independent third party (J. R.) who had no prior knowledge of them, and who recorded the parameters of the questionnaire, examination with a full bladder, voiding diary, pad test, uroflow and post-void residual urine. RESULTS: Overall stress incontinence was cured or improved in 92% of the patients with at least 1-year followup (median 3.1 years, range 1 to 15). The majority of patients with postoperative incontinence had de novo (3%) or persistent (23%) urge incontinence. Permanent urinary retention developed in 4 patients (2%). CONCLUSIONS: Fascial pubovaginal sling is an effective treatment for all types of stress incontinence with acceptable long-term efficacy.     

The value of intraoperative cystoscopy in urogynecologic and reconstructive pelvic surgery

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

Transvaginal urethrolysis for urethral obstruction after anti-incontinence surgery

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

Stress urinary incontinence in women caused by severe sphincter hypotonia. Goebbel-Stoeckel intervention as alternative to artificial sphincter. Apropos of 26 cases treated between January 1985 and January 1994

Stress urinary incontinence with low urethral closure pressure and urethral mobility is often treated by artificial urinary sphincter. Our retrospective report in 19 patients evaluates the sling procedure as an alternative to the artificial urinary sphincter (7 patients). All patients had a preoperative clinical and urodynamic evaluation. 13 patients were continent (68.4%) in the sling procedure group and 5 in the sphincter group. Continence remained stable with a mean follow-up of 77 months (range: 39-110 months). 2 patients had urgency and none had dysuria. The sling procedure gave us the same results as sphincter with less morbidity.     

Removal of an infected silicone rod frontalis sling without recurrence of ptosis

We examined a child with congenital ptosis. She underwent a bilateral silicone rod frontalis sling operation. One of the slings became infected and necessitated removal. We noticed no recurrence of her ptosis after sling removal. Removal of a frontalis sling does not invariably lead to recurrence of ptosis. We hypothesize that a scar tract formed in the plane of tissue from which the sling was removed. This band of scar tissue can act as a frontalis sling to elevate the eyelid.     

Neurologic consultation practice in a general hospital of a rural area

The purpose of this ongoing study is to evaluate the safety and efficacy of new minimally invasive pervaginam cystourethropexy and sling procedures for the treatment of female genuine stress urinary incontinence. A total of 75 women (mean age, 52.8 years) underwent either a cystourethropexy or a sling procedure. A miniature bone anchor and a staple-like bone anchor driver were used for the fixation of periurethral tissue or a xenogenic sling to the pubic bone. With a mean follow-up of eight months, 61 patients (82%) were completely cured of stress incontinence, 10 (14%) reported a more than 50% decrease in pad usage, and 4 patients showed failure early following surgery. The exclusively pervaginam cystourethropexy and sling procedures are minimally invasive, safe, and effective. Further experience and longer follow-up are necessary to establish their role in the treatment of women with stress urinary incontinence.     

Banked human fascia lata for the suburethral sling procedure: a preliminary report

OBJECTIVE: To report our initial experience with allogenic (human cadaver donor) fascia lata for the suburethral sling procedure. METHODS: Allogenic fascia lata for the suburethral sling procedure has been used in our practice since July 1994. Fascial grafts were obtained from licensed tissue banks. Women who underwent this procedure were followed prospectively to determine the incidence of perioperative complications, the incidence of local wound complications at the sling insertion site, and the subjective and objective cure rates. RESULTS: Sixteen women underwent the suburethral sling procedure with allogenic fascia. Fourteen had genuine stress urinary incontinence and two required replacement of a previously placed synthetic graft because of chronic infection. Follow-up ranged from 6 months to 1 year. No patient developed sinus tract formation or persistent granulation tissue. Two of 16 patients (12%) developed abdominal wound infections, which resolved with local care. The mean duration of postoperative bladder drainage was 29 days. One patient continued to require intermittent catheterization at 187 days. Among the 14 women with preoperative genuine stress incontinence, the subjective cure rate was 86% and the objective cure rate was 79%. The two patients who required replacement of a chronically infected synthetic graft remained subjectively continent. CONCLUSIONS: These preliminary data suggest that allogenic fascia lata is an acceptable material for the suburethral sling procedure. This material may be considered as an alternative to autologous fascia, which must be harvested from the patient intraoperatively, and to synthetic materials, which have been associated with local complications in up to 40% of cases.     

The UCLA surgical approach to sphincteric incontinence in women

Stress urinary incontinence (SUI) in the female may be treated by a variety of non-surgical and surgical therapies. However, once the patient has chosen to undergo operative repair the ideal procedure is based on three considerations: the degree of anterior vaginal wall prolapse, the degree of incontinence and associated anatomic abnormalities requiring surgical repair. In the vast majority of cases vaginal wall sling is our procedure of choice for the surgical treatment of SUI in the female. Vaginal wall sling is based on sound anatomic principles, may be performed as an outpatient procedure and is equally efficacious for the treatment of SUI due to anatomic incontinence (urethral hypermobility) and intrinsic sphincter deficiency. Since vaginal wall sling is performed through a transvaginal approach, other associated manifestations of pelvic floor prolapse such as rectocele can be addressed and repaired simultaneously. When necessary the vaginal wall sling can be easily modified to repair large grade cystoceles.     

Birth order in homosexual versus heterosexual sex offenders against children, pubescents, and adults

OBJECTIVE: The selection of patients amenable to treatment with a bladder neck sling remains a controversy. In this paper we review our experience with this technique and describe our patient selection criteria. METHODS: Since 1991, 30 patients (24 females and 6 males) aged 4 to 20 years (mean 10) received a bladder neck sling as part of the surgical treatment for their urinary incontinence. The cause of incontinence was neurogenic in 28 of the 30 patients. The 6 male patients were prepuberal. All patients had a preoperative video urodynamic study. The criteria for increasing cervico-urethral resistance included a passive leak point pressure of < 50 cm H2O, stress leak point pressure of < 100 cm H2O, radiological evidence of an open bladder neck and stress incontinence regardless of the other urodynamic and radiologic parameters. The technical aspects of the procedure are described in detail. Augmentation cystoplasty was performed concomitantly in 29 patients. RESULTS: Patient follow-up ranged from 2 to 70 months (mean 37.6). Twenty-eight patients (93%) were continent postoperatively. Two female patients remained incontinent at low leak point pressures. All patients emptied the bladder by intermittent catheterization. Twelve patients perform catheterization through the urethra without difficulty. CONCLUSION: The rectus fascia sling has several advantages over other surgical methods for increasing the cervico-urethral resistance. It is simple, effective, low-cost and has a low complication rate. In our view, the sling is the technique of choice for increasing cervico-urethral resistance in female and prepuberal male patients requiring a cystoplasty concomitantly.     

Posthysterectomy vaginal cuff fistula: diagnosis and management of an unusual cause of "incontinence"

OBJECTIVES: Connection between the vaginal cuff and the peritoneal cavity after hysterectomy is a rare event that can mimic urinary incontinence. The appropriate evaluation and treatment of these patients is discussed. METHODS: Five patients underwent excision of the vaginal cuff during a 12-month period. All of these patients had a negative workup for urinary incontinence, except for 1 patient who also had stress incontinence and required a vaginal wall sling at the time of cuff excision. RESULTS: All 5 patients are presently free of excess vaginal drainage or significantly improved, with a mean follow-up of 6 months. One patient developed stress incontinence after cuff excision and later required a vaginal wall sling. There have been no perioperative complications and no evidence of recurrent fistula. CONCLUSIONS: Fistula of the vaginal cuff is a diagnosis of exclusion after urinary incontinence has been ruled out. A high index of suspicion is often required to make the diagnosis because these patients often present with symptoms highly suggestive of urinary leakage. Fistula of the vaginal cuff is successfully treated with excision of the vaginal cuff and the fistulous tract (if identified), with minimal morbidity.     

大电炉炉壳吊具制作工艺

大电炉炉壳吊具，结构复杂，材质特殊，外形尺寸大，对母材和焊接质量要求严，对焊后的形位公差要求高，制作难度大，本文从工艺试验开始，详细介绍大吊具的制作过程。     

The effect of intrathecal and epidural narcotic analgesia on the length of labor

OBJECTIVE: Long-term results after different types of operations for urinary stress incontinence (minimum follow-up: 18 months) as well as multiple risk factors for the pelvic floor were analysed in a retrospective study. STUDY DESIGN: Between 1980 and 1992 1283 patients underwent surgery because of urinary stress incontinence at the University Women's Hospital in Heidelberg. The data of 478 patients, 430 of these after primary and 48 after recurrent surgery, were evaluated by questionnaires with regard to the long-term-results. RESULTS: 57% of patients after primary surgical therapy and 37% after recurrent surgery were cured for longer than 5 years or since the operation. A cure or improvement of the incontinence could be observed in 80% after primary and in 73% after recurrent surgery. Among the vaginal approaches for primary surgery the hysterectomy combined with colporrhaphy was most successful (60% cured or more than 5 years continent, 80.5% at least improved). The Burch colposuspension revealed even better results among the abdominal approaches (64% cured or longer than 5 years continent, 86% at least improved) compared to the Marshall-Marchetti-Krantz procedure with a cure rate of 33%. For therapy of the recurrent urinary incontinence the abdominal Burch colposuspension showed the best results with cure rates of 50% and cure or improvement in 75%. Therefore the abdominal approach seems to be superior to vaginal techniques such as sling operations (33% cure rate, 67% at least improved) or only re-colporrhaphy (27% cure rate, 78% at least improved). CONCLUSION: For primary incontinence the hysterectomy with vaginal repair or the Burch colposuspension have proved to be most successful. For recurrent urinary incontinence the abdominal colposuspension (Burch procedure) seems to be superior to other approaches.     

Mechanism for the increase of brain 5-hydroxy-tryptamine and 5-hydroxyindoleacetic acid following delta9-tetrahydrocannabinol administration to rats

Use of dermal graft for a urethral sling in treating urinary stress incontinence is described. This tissue has potential advantages of availability, strength, and freedom from side effects.     

Evaluation of the platysma interlocking suture sling for rhytidectomy

PURPOSE: The purpose of this study was to evaluate the complication rate and the clinical results of the platysma interlocking suture sling for rhytidectomy patients. PATIENTS AND METHODS: In the first part of this study, the charts and photographs of 29 patients who underwent rhytidectomy with the platysma interlocking suture sling were reviewed for complications. The parameters included infection, rupture of the sutures, extrusion of the sutures, prolonged tightness around the neck, and nerve injury. In the second part, the patients' neck deformities were classified into three types: mild (type 1), moderate (type 2), and severe (type 3). The changes in the preoperative and postoperative cervicomental angles were compared between the patients who underwent rhytidectomies with the platysma interlocking suture sling (group 1) and those patients who underwent rhytidectomies only (group 2). RESULTS: The complication rate was found to be minimal. Only one case of prolonged tightness around the neck was noted; there was no other complication. All of the patients, regardless of neck classifications, benefited from rhytidectomy, whether or not the platysma interlocking suture sling was used. However, when comparisons were made between group 1 and group 2 patients in their specific neck deformity categories, it was found that the patients with the severe (type 3) neck deformity benefited most when the platysma interlocking suture sling was used in conjunction with the rhytidectomy procedure. CONCLUSION: The platysma interlocking suture sling has a low morbidity rate and is helpful in reconstruction of patients with the type 3 neck deformity.     

Urethral reconstruction by pedicled labial flap in the treatment of extensive urethral lesions after obstetrical injury. Apropos of 34 cases

Reported here is our experience with a new procedure using a pedicled labial flap for urethral reconstruction in patients treated for extensive urethral damage after obstetrical injury. From January 1992 to January 1996, 31 cases of urethral damage in African female patients, with an average age of 18-years-old were treated by pedicled labial urethroplasty. This procedure was done by using a pedicled flap obtained from the major labia. The flap was then introduced as in a tunnel beneath the vaginal epithelium reaching the damaged urethra. A variety of techniques were used: the patch to lengthen sufficiency (13 cases), or the tubularized flap following complete reconstruction of the urethra (21 cases). Good quality urine continence was obtained by using the suburethral Martius' sling procedure. In 6 cases, we combined the treatment with a colposuspension procedure. The average follow-up is 14 months (ranging from 6 to 37 months). Recovery of normal micturition with absence of urinary leak was obtained in 21/30 cases (70%). While 5 moderate failures occurred, 4 cases were considered complete failures. In view of the high success rate, the authors consider that the one-stage procedure by the use of a pedicled labial flap is a choice treatment and highly suitable procedure for the management of extensive urethral cervical damage after obstetrical injury.