Biomedical subjects

John R Miklos

Publications and source records attributed to John R Miklos.

11 recordsLinked to original sources

PubMed2006

Tension-free vaginal tape sling for recurrent stress incontinence after transobturator tape sling failure.

The transobturator tape (TOT) sling is a new minimally invasive technique to treat stress urinary incontinence (SUI). Short-term follow-up studies show high success rates; however, as with any surgical treatment of SUI, failures are known to occur. The treatment of recurrent or persistent stress urinary incontinence after a TOT sling is therefore a new dilemma as well. In this paper, we describe the successful use of a retropubic tension-free vaginal tape (TVT) sling in five patients after failed TOT sling. We present case series of five patients who had TOT slings placed for stress incontinence that failed and subsequently had TVT slings placed for persistent SUI. The TVT slings were placed under local/regional anesthesia without removal of the TOT sling. Retrospective chart review of office and hospital charts was completed, and both objective and subjective data were collected. Five patients had TVT slings placed 6-30 weeks after early failure of TOT slings that were placed for stress urinary incontinence. Postoperatively, all patients with urodynamic testing showed evidence of intrinsic sphincter deficiency; however, all maintained urethral mobility of 30 degrees . All five patients had successful treatment of their incontinence with the retropubic tension-free sling procedure with a mean follow-up of 17 months. Recurrent or persistent stress urinary incontinence after TOT sling may be treated with TVT sling without removal of the TOT sling. Further studies with larger numbers and longer-term follow-up is warranted.

Aged↗

PubMed2006

Osteomyelitis secondary to sacral colpopexy mesh erosion requiring laminectomy.

BACKGROUND: Severe infectious morbidity associated with the use of synthetic mesh and abdominal sacral colpopexy is rare. Pelvic abscess, sinus tract formation, enterovaginal fistula, and osteomyelitis have been reported. CASE: This case involves a patient who presented with staphylococcal bacteremia and vaginal erosion of a sacral colpopexy synthetic mesh. Despite prolonged courses of intravenous antibiotics and complete removal of the mesh material, she developed osteomyelitis. Progressive neurologic symptoms required a decompression laminectomy to facilitate a complete recovery and resolution of symptoms. CONCLUSION: In the treatment of abdominal sacral colpopexy mesh erosion, we recommend maintaining a high index of suspicion for secondary infections.

Bacteremia↗

PubMed2006

Incidence of concomitant surgery for pelvic organ prolapse in patients surgically treated for stress urinary incontinence.

OBJECTIVE: To examine the concomitant incidence of surgery for pelvic organ prolapse in patients undergoing a surgical procedure to correct stress urinary incontinence in both an academic and private urogynecology practices. STUDY DESIGN: A retrospective chart review was performed on all patients undergoing surgical correction of stress urinary incontinence over a 1-year period at 2 centers. RESULTS: Among 150 surgical procedures for stress urinary incontinence in the academic practice, 116 (77%) patients underwent at least 1 additional procedure for a pelvic support defect, and 72 (48%) patients required 2 or more concomitant reconstructive pelvic procedures. In the private urogynecology practice, 182 surgical procedures for stress urinary incontinence were performed, 153 (84%) patients required at least 1 additional procedure for a pelvic support defect, and 86 (47%) patients required 2 or more concomitant reconstructive pelvic procedures. CONCLUSION: Women who require surgical correction of stress urinary incontinence have a high incidence of concomitant pelvic support defects that require surgical repair. The incidence of concomitant surgery for pelvic organ prolapse between the 2 sites was not significantly different.

Cohort Studies↗

PubMed2005

Perisurgical smoking cessation and reduction of postoperative complications.

OBJECTIVE: The purpose of this study was to determine if a perisurgical smoking cessation program reduces smoking-related postoperative complications in urogynecologic surgery. STUDY DESIGN: A review of patients that underwent pelvic reconstructive surgery from 1998 to 2003 was performed. All smokers underwent a perisurgical smoking cessation program of their choice for at least 1 month before surgery, and continued for 1 month after surgery. Complications unrelated to smoking (cystotomy, enterotomy, urethral obstruction, etc) were excluded in the smoking-potentiated complications. Problems considered to be potentiated by smoking were: wound, pulmonary, cardiac, and febrile morbidity. RESULTS: Eight hundred eighty-seven patients were included. There were 233 smoker cessation patients (SC) and 654 nonsmokers (NS). The total number of complications in the SC group was 61 (61/233, 26%) compared with 172 (172/654, 29%) in the NS group: (chi-square, P = .97). When looking at smoking-potentiated complications only, there were 34 (34/61, 56%) patients in the SC group and 90 (90/172, 52%) in the NS group (chi-square, P = .75). CONCLUSION: There are no differences in smoking-potentiated complications between nonsmoking patients and patients who undergo a perisurgical smoking cessation program.

Aged↗

PubMed2004

Laparoscopic pelvic floor repair.

Articles on laparoscopic approach to pelvic floor reconstruction continue to proliferate throughout the worldwide literature. Although procedures like laparoscopic Burch seem to be fading fast, other procedures like the laparoscopic paravaginal repair and sacral colpopexy seem to be more common and visible in the literature. This article reviews the pertinent anatomy, surgical procedures, and literature concerning the laparoscopic approach to pelvic floor reconstruction.

Female↗

PubMed2004

Rectovaginal fistula repair using a porcine dermal graft.

BACKGROUND: Rectovaginal fistula repair is commonly performed through a vaginal route. In many cases, healthy tissue such as an autologous fat pad may be interposed between the suture lines and the vaginal epithelium to facilitate healing and prevent recurrence. We present a simple alternative to autologous flaps with the use of porcine dermal grafts in the repair of rectovaginal fistulae. CASES: Two patients are presented with rectovaginal fistulae. In both cases the patients were found to have insufficient native tissue to achieve an adequate traditional multilayered closure, and therefore an acellular collagen porcine dermal graft was used as an interposition graft between the rectum and the vaginal epithelium in the repair. CONCLUSION: Porcine dermal grafts may be a viable alternative to traditional autologous flaps or human dermal grafts for the repair of rectovaginal fistula.

Adult↗

PubMed2003

The tensile strength of uterosacral ligament sutures: a comparison of vaginal and laparoscopic techniques.

OBJECTIVE: To compare the tensile strength of two approaches for uterosacral ligament suturing using a cadaver model. METHODS: In 12 unembalmed cadavers, four polytetrafluoroethylene sutures were placed through the uterosacral ligaments. In each cadaver, two sutures were placed laparoscopically, and two more were placed vaginally. A single, experienced surgeon placed all laparoscopic sutures (n = 23), and another experienced surgeon placed all vaginal sutures (n = 22). A blinded team of investigators measured the distance from each suture to the ipsilateral ischial spine; determined whether any sutures incorporated ureters, viscera, or large vessels; and then passed the sutures through an apical vaginal incision. Using a hand-held tensiometer, progressive tensile load was then applied to these sutures along the axis of the vagina until they either broke or were completely dislodged from the ligaments. RESULTS: The average peak tension required to break or dislodge the sutures was 26.2 +/- 8.8 psi (laparoscopic) and 22.5 +/- 7.4 psi (vaginal) (P =.14, 95% confidence interval [CI] -1.2, 8.6). The average force required for suture breakage (n = 28) was 28 +/- 7 psi, and the average force applied when ligament failure occurred (n = 17) was 18.5 +/- 6 psi (P <.001, 95% CI -13.8, -5.2). The average distance from a laparoscopic or vaginal suture to the ipsilateral ischial spine was 19.1 +/- 7 mm and 17.4 +/- 6 mm, respectively (P =.46, 95% CI -3.0, 6.4). None of the sutures from either technique were found to incorporate a visceral structure, ureter, or great vessel. CONCLUSION: These suturing techniques appear to be equal in tensile strength.

Aged↗

PubMed2003

Colpocleisis and tension-free vaginal tape sling for severe uterine and vaginal prolapse and stress urinary incontinence under local anesthesia.

STUDY OBJECTIVE: To describe the technique, complications, and outcomes of vaginal repair of concomitant advanced uterine and vaginal prolapse and stress urinary incontinence using colpocleisis and tension-free vaginal tape (TVT) and pubovaginal sling under intravenous sedation and local anesthesia in elderly and/or medically compromised patients. DESIGN: Retrospective analysis (Canadian Task Force classification III). SETTING: Large tertiary care hospital with university affiliation. PATIENTS: Thirty consecutive women. INTERVENTION: Colpocleisis and TVT-pubovaginal sling. MEASUREMENTS AND MAIN RESULTS: Data were obtained by retrospective chart review of office and surgical records and follow-up physical examinations. All 30 patients had the procedure completed without general anesthesia. Mean estimated blood loss was 56 ml (range 10-150 ml), mean operating time 97.3 minutes (range 65-135 min), and mean hospital stay 1.62 days (range 1-12 days). No intraoperative complications occurred, although one woman experienced a postoperative myocardial infarction. Average follow-up was 19.1 months. Three women required reoperation for minor prolapse (2 posterior repairs, 1 anteroposterior repair) and 94% were cured of stress incontinence. CONCLUSION: Preliminary data suggest that surgical correction of concomitant severe pelvic organ relaxation and stress urinary incontinence using a proved procedure (pubovaginal sling) coupled with colpocliesis can be performed rapidly and safely with local anesthesia and mild sedation, thus limiting the potential risks of general anesthesia and more invasive surgical procedures.

Age Factors↗

PubMed2003

Duloxetine versus placebo for the treatment of North American women with stress urinary incontinence.

PURPOSE: Duloxetine, a selective serotonin and norepinephrine reuptake inhibitor, increases rhabdosphincter contractility via the stimulation of pudendal motor neuron alpha-1 adrenergic and 5-hydroxytryptamine-2 receptors. In this first phase 3 study we assessed the efficacy and safety of duloxetine in women with stress urinary incontinence (SUI). MATERIALS AND METHODS: A total of 683 North American women 22 to 84 years old were enrolled in this double-blind, placebo controlled study. The case definition included a predominant symptom of SUI with a weekly incontinence episode frequency (IEF) of 7 or greater, the absence of predominant symptoms of urge incontinence, normal diurnal and nocturnal frequency, a bladder capacity of 400 ml or greater, and a positive cough stress test and stress pad test. After a 2-week placebo lead-in period subjects were randomly assigned to receive placebo (339) or 80 mg duloxetine daily (344) as 40 mg twice daily for 12 weeks. Primary outcome variables included IEF and an incontinence quality of life questionnaire. Van Elteren's test was used to analyze percent changes in IEF with a stratification variable of weekly baseline IEF (less than 14 and 14 or greater). ANCOVA was used to analyze incontinence quality of life scores. RESULTS: Mean baseline IEF was 18 weekly and 436 subjects (64%) had a baseline IEF of 14 or greater. There was a significant decrease in IEF with duloxetine compared with placebo (50% vs 27%, p <0.001) with comparably significant improvements in quality of life (11.0 vs 6.8, p <0.001). Of subjects on duloxetine 51% had a 50% to 100% decrease in IEF compared with 34% of those on placebo (p <0.001). These improvements with duloxetine were associated with a significant increases in the voiding interval compared with placebo (20 vs 2 minutes, p <0.001) and they were observed across the spectrum of incontinence severity. The discontinuation rate for adverse events was 4% for placebo and 24% for duloxetine (p <0.001) with nausea the most common reason for discontinuation (6.4%). Nausea, which was also the most common side effect, tended to be mild to moderate and transient, usually resolving after 1 week to 1 month. Of the 78 women who experienced treatment emergent nausea while taking duloxetine 58 (74%) completed the trial. CONCLUSIONS: These phase 3 data are consistent with phase 2 data and they provide further evidence for the safety and efficacy of duloxetine as a pharmacological agent for the treatment of women with SUI.

Adult↗

PubMed2002

Laparoscopic surgery for pelvic support defects.

Reconstructive pelvic surgery for the treatment of vaginal prolapse continues to evolve as surgeons continue their quest for definitive surgical cure. Though there are three primary routes of access to reconstructive pelvic surgery (abdominal, vaginal and laparoscopic) it is the laparoscopic approach that appears to be the least utilized. This is in part due to the great degree of technical difficulty associated with laparoscopic suturing. This paper reviews the general principles and functional anatomy associated with normal vaginal support as well as the laparoscopic surgical approach to pelvic floor support defects.

Female↗

PubMedDate not supplied

Laparoscopic removal of pubovaginal polypropylene tension-free tape slings.

OBJECTIVES: Complications of polypropylene pubovaginal tension-free tape slings (TVT, SPARC, and others), such as erosion into the bladder or chronic pain attributed to the mesh sling are rare events; however, when they occur, it may necessitate removal of the sling. To date, removal through a laparotomy incision or by operative cystoscopy has been the most common approach. We present 5 cases of a laparoscopic approach for removal of polypropylene pubovaginal tension-free tape slings. METHODS: We report 5 cases of laparoscopic removal of TVT mesh. Three were removed for mesh erosion into the bladder, and 2 were removed secondary to the patients having persistent pain and discomfort attributed to the sling. An intraperitoneal approach was used to enter the retropubic space to remove the sling. Dissection was completed with a Harmonic scalpel blade as well as blunt dissection to identify the mesh sling retropubically. Average operating time was 104 minutes. Average blood loss was 70 mL. Average hospital stay was <23 hours. Postoperative courses were uneventful; however, 4 of the 5 patients continue to have urgency and frequency symptoms following sling removal. CONCLUSION: These cases illustrate the use of laparoscopy in the removal of polypropylene pubovaginal tension-free tape slings for bladder erosion or persistent pain, or both, attributed to the sling. Erosion and pain are known complications of polypropylene pubovaginal slings and may cause significant morbidity like persistent detrusor instability or urge incontinence, or both. Patients must be informed of these risks and possible complications before making their decision to undergo surgery.

Adult↗