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Biomedical subjects

M D Walters

Publications and source records attributed to M D Walters.

At least 19 recordsLinked to original sources
PubMed2002

The cost-effectiveness of preoperative testing (basic office assessment vs. urodynamics) for stress urinary incontinence in women.

OBJECTIVE: To compare the cost-effectiveness of preoperative testing strategies in women with stress incontinence symptoms, as although urodynamic testing is used to improve the diagnostic accuracy in women with incontinence, the clinical and economic consequences of different levels of testing have not been evaluated. MATERIALS AND METHODS: Decision analysis was used to evaluate basic office assessment (BOA) and urodynamic testing for women with stress incontinence symptoms who were candidates for primary surgical treatment. Costs were calculated using the Federal Register. Parameter estimates for the effectiveness of treatment for different diagnoses of incontinence were based on published reports. Incremental cost-effectiveness was defined as the cost in dollars per additional patient cured of incontinence. RESULTS: Urodynamics did not improve the effectiveness of treatment; both strategies of a BOA and urodynamic testing resulted in a cure rate of 96% after initial and secondary treatments. The mean cost of care (including initial and secondary treatments and outcomes) was similar for the two strategies ($5042 for BOA, $5046 for urodynamic testing). With BOA reduced testing costs were balanced by increased costs for patients who failed the initial treatment. Under baseline assumptions, one additional cure of incontinence (incremental cost-effectiveness) using the urodynamic strategy cost $3847, compared with BOA. By sensitivity analyses, BOA was less costly than urodynamics when the prevalence of genuine stress incontinence was > or = 80%. CONCLUSION: These findings do not support the routine use of urodynamics before surgery in women likely to have genuine stress incontinence, and provide the justification for randomized trials of preoperative testing strategies.

Aged↗
PubMed2001

Gross and histologic characteristics of laparoscopic injuries with four different energy sources.

OBJECTIVE: To compare the gross and histologic effects of bipolar and monopolar cautery, ultrasonic scalpel, and CO(2) laser on porcine ureter, bladder, and rectum. DESIGN: Experimental prospective study. SETTING: Cleveland Clinic Foundation Animal Research Laboratory, Cleveland, Ohio. ANIMAL(S): Nonpregnant adult female pigs. INTERVENTION(S): The rectum, bladder, and ureters of 12 female pigs were injured with four different laparoscopic energy sources. MAIN OUTCOME MEASURE(S): Gross measurements of injured tissue and histologic analysis of the depth of the tissue injury. RESULT(S): Gross assessment results were that monopolar injuries of the bowel and bladder were significantly longer than ultrasonic injuries (P<0.01). Injuries were generally manifest as coagulative denaturation of collagen bundles. This resulted in an eosinophilic homogenization of tissue. Nuclei were retained in the injured tissue, although in most cases they had a pyknotic, streamed appearance. The CO(2) laser caused no deep-tissue injury. CONCLUSION(S): Laparoscopic energy sources injure tissue differently. Monopolar cautery appears to have the most lateral spread of thermal energy. The CO(2) laser appears to cause the least deep-tissue injury.

Animals↗
PubMed2001

Determinants of voiding after three types of incontinence surgery: a multivariable analysis.

OBJECTIVE: To determine the time to normal voiding in women after various surgical procedures for genuine stress urinary incontinence (GSUI) or urethral hypermobility. METHODS: One hundred one women had bladder neck suspensions. Suprapubic catheters were used in 94 women and intermittent self-catheterization in seven to manage urinary retention after surgery. We used a standardized protocol to record days to adequate postoperative voiding. Univariable and multivariable regression analyses were used to determine clinical, urodynamic, and surgical factors that independently influenced time to adequate postoperative voiding. RESULTS: Women met the criteria for adequate voiding a mean of 7.1 days after modified open Burch procedures (n = 43), 9.5 days after anterior colporrhaphies with suburethral plication (n = 24), and 19.1 days after vaginal wall sling procedures (n = 34). The type of bladder neck suspension was independently associated with increasing time to void (P =.001). Multivariable regression analysis determined other factors significantly associated with longer time to adequate postoperative voiding: advancing age, previous vaginal bladder neck suspension, increasing volume at first sensation on bladder filling, higher postvoid residual urine volume (preoperative), and postoperative cystitis. Detrusor pressure, abdominal straining on pressure flow voiding study, and other concurrent surgeries were not significantly associated with postoperative voiding time in this model. CONCLUSIONS: Time to adequate voiding after bladder neck suspension was influenced by type of surgical procedure, postoperative cystitis, and several demographic and urodynamic factors. This study does not support using pressure flow studies to predict women at risk of voiding dysfunction.

Adult↗
PubMed2001

Enterocele: is there a histologic defect?

OBJECTIVE: To examine the histology of the vaginal wall in women with an enterocele confirmed by physical examination, cystoproctography, and intraoperative exploration. METHODS: Thirteen women with posthysterectomy apical and posterior wall prolapse were evaluated with a detailed physical examination, cystoproctography, and intraoperative exploration. All women had enterocele repair. A specimen of full thickness vaginal wall from the leading edge of the enterocele was excised and examined histologically. The histology of these patients was compared with the histology of two comparison groups, five women undergoing hysterectomy without prolapse and 13 women undergoing radical hysterectomy. RESULTS: One woman with an enterocele repaired intraoperatively did not have an enterocele by cystoproctography. One woman with an enterocele repaired intraoperatively did not have an enterocele detected by physical examination. All women with an enterocele repaired had an intact vaginal wall muscularis. No woman had vaginal wall epithelium in direct contact with the peritoneum. The average vaginal wall muscularis thickness in women with enteroceles was 3.5 +/- 1.4 mm, in women with no prolapse 3.2 +/- 0.8 mm, and in women undergoing radical hysterectomy 2.8 +/- 0.9 mm. CONCLUSION: Women with enteroceles have a well-defined vaginal muscularis between the peritoneum and vaginal epithelium.

Aged↗
PubMed2001

Vascular injury during tension-free vaginal tape procedure for stress urinary incontinence.

BACKGROUND: Tension-free vaginal tape procedure is a popular surgical treatment of genuine stress urinary incontinence. CASES: Two cases of retropubic hematoma after tension-free vaginal tape procedure are reported. One woman with an 8 x 10 cm hematoma localized to the retropubic space required transfusion of two units of packed red blood cells for symptomatic relief. Neither case required reoperation, and both patients' hematomas resolved over 6 months without treatment. Both patients were continent 9-12 months after surgery. CONCLUSION: Although the tension-free vaginal tape procedure is a minimally invasive operation for stress urinary incontinence and appears to be effective, significant vascular complications can result.

Aged↗
PubMed2001

Anterior colporrhaphy: a randomized trial of three surgical techniques.

OBJECTIVE: The purpose of this study was to compare outcomes after anterior colporrhaphy with the use of 3 different surgical techniques. STUDY DESIGN: One hundred fourteen women with anterior vaginal prolapse were randomly assigned to undergo anterior repair by one of 3 techniques: standard, standard plus polyglactin 910 mesh, or ultralateral anterior colporrhaphy. Before and after operation, patients underwent physical examination staging of prolapse; the International Continence Society system was used. Symptoms were assessed by questionnaire and visual analog scales. We defined "cure" as satisfactory (stage I) or optimal (stage 0) outcome at points Aa and Ba. RESULTS: Of 114 patients who were originally enrolled, 109 patients underwent operation, and 83 patients (76%) returned for follow-up. Mean age (+/- SD) was 64.7 +/- 11.1 years. At entry, 7 patients (7%) had stage I anterior vaginal prolapse; 35 patients (37%) had stage II anterior vaginal prolapse; 51 patients (54%) had stage III anterior vaginal prolapse; and 2 patients (2%) had stage IV anterior vaginal prolapse. At a median length of follow-up of 23.3 months, 10 of 33 patients (30%) who were randomly assigned to the standard anterior colporrhaphy group experienced satisfactory or optimal anatomic results, compared with 11 of 26 patients (42%) with standard plus mesh and with 11 of 24 patients (46%) with ultralateral anterior colporrhaphy. The severity of symptoms that were related to prolapse improved markedly (preoperative score, 6.9 +/- 2.7; postoperative score, 1.1 +/- 0.8). Twenty-three of 24 patients (96%) no longer required manual pressure to void after operation. CONCLUSION: These 3 techniques of anterior colporrhaphy provided similar anatomic cure rates and symptom resolution for anterior vaginal prolapse repair. The addition of polyglactin 910 mesh did not improve the cure rate compared with standard anterior colporrhaphy.

Aged↗
PubMed2000

Cost effectiveness of expanded antenatal HIV testing in London.

BACKGROUND: Recently the Department of Health announced the introduction in England of voluntary universal HIV screening in early pregnancy to prevent vertical transmission. New data have shown the importance of HIV infection in infants born to mothers who were HIV-negative in early pregnancy and who acquired HIV later in pregnancy or during lactation. This requires consideration of repeat testing in late pregnancy and testing of partners of pregnant women (expanded antenatal HIV testing). OBJECTIVE: To estimate cost effectiveness of expanded antenatal HIV testing in London (England) within the framework of universal voluntary HIV screening in early pregnancy. DESIGN: Incremental cost-effectiveness analysis. METHODS: Cost estimates of service provision for HIV-positive children and adults by stage of HIV infection were combined with estimates of health benefits for infants and parents and with costs of counselling and testing (testing costs). In a pharmacoeconomic model cost effectiveness was estimated for expanded antenatal HIV testing in London for universal and selective strategies. RESULTS: Testing costs in the plausible range of pounds sterling 4 to pounds sterling 40 translate into favourable incremental cost-effectiveness estimates for expanded antenatal HIV testing in London which is already at low numbers of vertical transmissions averted per 100000 pregnant women who test HIV-negative in early pregnancy. Favourable cost effectiveness for universal expanded testing would require testing costs in the lower range, whereas selective expanded testing may produce favourable cost effectiveness at testing costs close to pounds sterling 40. CONCLUSION: Based on pharmaco-economic considerations, the authors believe that implementation of expanded HIV testing in London should be considered.

Adult↗
PubMed2000

Burch procedure compared with sling for stress urinary incontinence: a decision analysis.

OBJECTIVE: To compare the relative risks and benefits of Burch colposuspension and sling procedure for primary genuine stress urinary incontinence in women. METHODS: We developed a decision analytic model to compare Burch procedure and sling for primary surgical treatment of genuine stress incontinence with urethral hypermobility in women. Risks and benefits were estimated from published literature. The main outcome measure was effectiveness of treatment, defined as cure of incontinence after initial and secondary treatments. We considered four outcomes of primary surgical treatment: cure, persistent incontinence (either caused by intrinsic sphincter deficiency without urethral hypermobility or genuine stress incontinence with hypermobility), de novo detrusor instability, and permanent urinary retention. Secondary treatment included repeated surgery for genuine stress incontinence, collagen injection for intrinsic sphincter deficiency, medical treatment for detrusor instability, and urethrolysis for retention. One-way sensitivity analyses were used to estimate the effect of varying each characteristic through its range; all other characteristics were fixed at their baseline values. RESULTS: The overall effectiveness of Burch and sling operations (percentages of women cured after initial and secondary treatments) was similar (94.8% and 95.3%, respectively). In sensitivity analyses, the Burch arm of the model was more effective than sling when the risk of retention after sling was higher than 9.0% or when the risk of de novo detrusor instability after sling was higher than 10.3%. Conversely, when the risk of de novo detrusor instability after Burch was higher than 6.8%, the sling arm of the model was more effective. CONCLUSION: The Burch and sling procedures are similarly effective for primary surgical treatment of genuine stress incontinence in women. Overall effectiveness is substantially influenced by relative rates of complications.

Decision Support Techniques↗
PubMed2000

Intraoperative cystoscopy in conjunction with anti-incontinence surgery.

OBJECTIVE: To determine the frequency of lower urinary tract injury detected by routine intraoperative cystoscopy after anti-incontinence surgery. METHODS: We reviewed charts from women who had anti-incontinence surgery and routine intraoperative cystoscopy done by a single surgeon from June 1, 1995, to June 1, 1998, and assessed preoperative and intraoperative variables. RESULTS: We reviewed 351 patient records. Four records were incomplete and there were nine injuries in the other 347 cases (2.6%, 95% confidence interval [CI] 1.2, 4.9). Four cystotomies occurred during laparoscopic Burch procedures and were detected before cystoscopy. Five injuries were detected at cystoscopy, a rate of 1.5% (95% CI 0. 5, 3.4). Four injuries occurred during 161 pubovaginal sling procedures (2.5%, 95% CI 0.7, 6.2). One woman had sutures in her bladder from a prior procedure detected at cystoscopy. In 186 Burch procedures (48 laparoscopic, 138 open), there were no previously unrecognized injuries detected by cystoscopy. All injuries were repaired during original surgery. It was not possible to assess preoperative and intraoperative risk factors because of the low rate of injury. CONCLUSION: The rate of injury to the lower urinary tract during anti-incontinence surgery in this series was 2.6% (95% CI 1.2, 4.9). Injuries during Burch procedures were all detected before cystoscopy.

Aged↗
PubMed2000

Risk of sick leave associated with outdoor air supply rate, humidification, and occupant complaints.

We analyzed 1994 sick leave for 3,720 hourly employees of a large Massachusetts manufacturer, in 40 buildings with 115 independently ventilated work areas. Corporate records identified building characteristics and IEQ complaints. We rated ventilation as moderate (approximately 25 cfm/person, 12 ls-1) or high (approximately 50 cfm/person, 24 ls-1) outdoor air supply based on knowledge of ventilation systems and CO2 measurements on a subset of work areas, and used Poisson regression to analyze sick leave controlled for age, gender, seniority, hours of non-illness absence, shift, ethnicity, crowding, and type of job (office, technical, or manufacturing worker). We found consistent associations of increased sick leave with lower levels of outdoor air supply and IEQ complaints. Among office workers, the relative risk for short-term sick leave was 1.53 (95% confidence 1.22-1.92) with lower ventilation, and 1.52 (1.18-1.97) in areas with IEQ complaints. The effect of ventilation was independent of IEQ complaints and among those exposed to lower outdoor air supply rates the attributable risk of short-term sick leave was 35%. The cost of sick leave attributable to ventilation at current recommended rates was estimated as $480 per employee per year at Polaroid. These findings suggest that net savings of $400 per employee per year may be obtained with increased ventilation. Thus, currently recommended levels of outdoor air supply may be associated with significant morbidity, and lost productivity on a national scale could be as much as $22.8 billion per year. Additional studies of IEQ impacts on productivity and sick leave, and the mechanisms underlying the apparent association are needed.

Adult↗
PubMed2000

Sexual function and vaginal anatomy in women before and after surgery for pelvic organ prolapse and urinary incontinence.

OBJECTIVE: We sought to describe sexual function in women before and after surgery for either prolapse or urinary incontinence, or both. STUDY DESIGN: Women completed questionnaires, and vaginal dimensions were measured before and at least 6 months after surgery for prolapse or incontinence. Comparisons were made with signed-rank tests or the McNemar test. RESULTS: Eighty-one (49%) of 165 women were sexually active before and after surgery; their mean age was 54. 0 +/- 9.9 years. Mean frequency of intercourse did not change. Dyspareunia was reported by 6 (8%) women preoperatively and 15 (19%) women after surgery; dyspareunia persisted postoperatively in 1 woman, developed in 14, and resolved in 5 (P =.04). Dyspareunia occurred in 14 (26%) of 53 women after posterior colporrhaphy (P =. 01) and in 8 (38%) of 21 women who had Burch colposusupension and posterior colporrhaphy performed together (P =.02). Vaginal dimensions decreased slightly after surgery; however, this did not correlate with any change in sexual function. Preoperatively, 66 (82%) women were satisfied with their sexual relationships, compared with 71 (89%) who were satisfied postoperatively. CONCLUSION: Sexual function and satisfaction improved or did not change in most women after surgery for either prolapse or urinary incontinence, or both. However, the combination of Burch colposusupension and posterior colporrhaphy was especially likely to result in dyspareunia.

Adult↗
PubMed2000

Cost-effectiveness of urodynamic testing before surgery for women with pelvic organ prolapse and stress urinary incontinence.

OBJECTIVE: This study was undertaken to compare cost-effectiveness between 2 preoperative testing strategies for women with pelvic organ prolapse and stress urinary incontinence symptoms. STUDY DESIGN: We developed decision-analytic models that evaluated the cost-effectiveness of basic office evaluation before surgery in women with prolapse and stress urinary incontinence symptoms and contrasted it with that of urodynamic testing. Costs were obtained from the Federal Register; effectiveness of treatment for urinary incontinence was based on the published literature. RESULTS: The strategies of basic office evaluation and urodynamic testing had the same cure rate of urinary incontinence (96%) after initial and secondary treatment. Under baseline assumptions incremental cost-effectiveness (cost for single extra cure of urinary incontinence) of urodynamic testing was $328,601. According to sensitivity analyses, basic office evaluation was more cost-effective than urodynamic testing when the prevalence of pure detrusor instability was <8% or when the cost of urodynamic testing was >$103. CONCLUSION: Urodynamic testing before surgery in women with prolapse and stress urinary incontinence symptoms is not cost-effective relative to basic office evaluation.

Cost-Benefit Analysis↗
PubMed2000

Use and cost of hospital and community service provision for children with HIV infection at an English HIV referral centre.

OBJECTIVE: To describe the use of hospital and community services for children infected with HIV and estimate the cost per patient-year by stage of HIV infection during the era of antiretroviral monotherapy. DESIGN: Data on the use of hospital services were collected from case notes; the use of statutory and nonstatutory community services was recorded through diaries and interviews. Total cost estimates were calculated from unit costs from relevant hospital departments and community organisations. SETTING: Children managed at St. Mary's Hospital (London, England) between 1 January 1986 and 31 December 1994, some of whom used statutory and nonstatutory community services in South East England between 1 November 1994 and 31 May 1996. PATIENTS AND PARTICIPANTS: 118 children with positive HIV antibody status. MAIN OUTCOME MEASURES AND RESULTS: Mean inpatient days, outpatient visits, tests and procedures performed, drugs prescribed, community services used, associated unit costs and average cost estimates per patient-year by stage of HIV infection (1995/1996 values), and lifetime costs. Service provision during the study period was predominantly hospital-based. The use of services increased for different stages of HIV infection and increased with increasing severity of HIV infection. A shift from an inpatient-based to an outpatient-based service was seen between the periods 1986 to 1991 and 1992 to 1994. As symptoms evolved, children used more hospital inpatient services, with an accompanying shift in the use of community services from general services, such as schooling, to increased use of nurses, social care and home help. The estimated total cost of hospital and community care was 18,600 Pounds per symptomatic non-AIDS patient per year and 46,600 Pounds per AIDS patient per year. Similar estimates for children with indeterminate HIV infection and asymptomatic infection amounted to 8300 Pounds and 4800 Pounds per patient-year, respectively. Nondiscounted lifetime costs for hospital care amounted to 152,400 Pounds (44,300 Pounds to 266,800 Pounds) compared with discounted lifetime costs of 122,700 Pounds (42,000 Pounds to 182,200 Pounds); nondiscounted lifetime costs for community care amounted to 24,300 Pounds (7900 Pounds to 41,600 Pounds) compared with discounted lifetime costs of 21,000 Pounds (6800 Pounds to 32,000 Pounds). CONCLUSIONS: The continued emphasis on the use of hospital services may be due to the small number of children infected with HIV, most of whom lived in the London metropolitan area where specialist care was concentrated in a few centres. A shift from an inpatient- to an outpatient-based service was observed over time; the advent of the use of combination antiretroviral therapy in this population may further facilitate a shift in service provision and promote shared care between specialist centres, local hospital and community-based services.

Anti-HIV Agents↗
PubMed1999

Universal HIV screening of pregnant women in England: cost effectiveness analysis.

OBJECTIVE: To estimate the cost effectiveness of universal, voluntary HIV screening of pregnant women in England. DESIGN: Cost effectiveness analysis. Cost estimates of caring for HIV positive children were based on the stage of HIV infection and calculated using data obtained from a London hospital between 1986 and 1996. These were combined with estimates of the health benefits and costs of antenatal screening so that the cost effectiveness of universal, voluntary antenatal screening for HIV infection in England could be estimated. MAIN OUTCOME MEASURES: Lifetime, direct costs of medical care of childhood HIV infection; life years gained as a result of the screening programme; net cost per life year gained for different pretest counselling costs; and different prevalence rates of pregnant women who were unaware that they were HIV positive. RESULTS: Estimated direct lifetime medical and social care costs of childhood HIV infection were pound178 300 using a 5% discount rate for time preference (1995-6 prices). In high prevalence areas screening pregnant women for HIV is estimated to be a cost effective intervention with a net cost of less than pound4000 for each life year gained. For areas with comparatively low prevalence rates, cost effectiveness could be less than pound20 000 per life year gained, depending on the number of pregnant women who are unaware that they are infected and local screening costs. CONCLUSIONS: Our results confirm recent recommendations that universal, voluntary antenatal HIV screening should be implemented in the London area. Serious consideration of the policy should be given for other areas in England depending on local prevalence and screening costs.

AIDS Serodiagnosis↗
PubMed1999

Laparoscopic surgery for enterocele, vaginal apex prolapse and rectocele.

Laparoscopy has been applied to all aspects of gynecologic surgery, but few investigators have reported the repair of vaginal apex prolapse, enterocele and rectocele via the laparoscopic route. This article reviews the indications, anatomy, operative technique, clinical results and complications of laparoscopic culdeplasty, enterocele repair, posterior repair, sacral colpopexy and vaginal vault-uterosacral ligament suspension.

Female↗
PubMed1999

Laparoscopic surgery for genuine stress incontinence.

Laparoscopic Burch colposuspension has rapidly become one of the primary surgical treatment options for genuine stress incontinence. The procedure has been modified by some investigators because of technical difficulty with laparoscopic suturing, but should be identical to the conventional open Burch procedure. This article reviews the indications, operative technique, clinical results, complications and learning curve for laparoscopic retropubic surgical procedures.

Clinical Competence↗
PubMed1999

Functional outcomes and satisfaction after abdominal hysterectomy.

OBJECTIVES: Our aim was to compare urinary, lower gastrointestinal, and sexual function and to describe patients' expectations and satisfaction before and after hysterectomy. STUDY DESIGN: Forty-three women completed questionnaires before and about 1 year after abdominal hysterectomy for benign gynecologic conditions. Symptoms related to urinary, lower gastrointestinal, and sexual function and satisfaction with treatment were assessed. To account for multiple comparisons, only P </=.002 was considered statistically significant. RESULTS: There were no statistically significant changes in urinary or bowel symptoms before and after hysterectomy, with preoperative symptoms resolving in some women after surgery and developing in others. Sexual function including orgasmic ability did not change in the 34 sexually active women. The level of satisfaction with treatment was very high. CONCLUSIONS: Women experience high degrees of satisfaction and no consistent changes in urinary, lower gastrointestinal, or sexual function after abdominal hysterectomy for benign gynecologic conditions.

Adult↗