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Biomedical subjects

P L Dwyer

Publications and source records attributed to P L Dwyer.

At least 19 recordsLinked to original sources
PubMed2006

Laparoscopic versus open Burch colposuspension: a randomised controlled trial.

OBJECTIVE: To compare perioperative characteristics, short-term, and long-term outcomes for laparoscopic Burch colposuspension (LBC) and open Burch colposuspension (OBC) for the treatment of urinary stress incontinence. DESIGN: Randomised surgical trial with single blinding. SETTING: Three tertiary level teaching hospitals involving seven surgeons of varying skill levels. POPULATION: Two hundred women with urodynamic stress incontinence (USI). METHODS: The two groups were treated in identical fashion, except for the laparoscopic or open approach to surgery. Attempts were made to blind the subjects and the observers obtaining outcome data to treatment group. Analyses were adjusted for surgeon experience. MAIN OUTCOME MEASURES: Absence of USI 6 months following surgery, postoperative pain, time spent in hospital, and time to return to activities of normal daily living. RESULTS: There were no significant differences in objective and subjective measures of cure and in patient satisfaction at 6 months, 24 months, or 3-5 years of follow up between laparoscopic and open colposuspension groups. Laparoscopic colposuspension took longer time to perform (87 versus 42 minutes, P< 0.0001) but was associated with less blood loss (P = 0.03), less pain (P = 0.02), and quicker return to normal activities (P = 0.01). CONCLUSION: LBC has significant advantages over traditional OBC, without any apparent compromise in short-term and long-term outcomes. To compare perioperative characteristics, short-term, and long-term outcomes for laparoscopic Burch colposuspension (LBC) and open Burch colposuspension (OBC) for the treatment of urinary stress incontinence. Randomised surgical trial with single blinding. Three tertiary level teaching hospitals involving seven surgeons of varying skill levels. Two hundred women with urodynamic stress incontinence (USI). The two groups were treated in identical fashion, except for the laparoscopic or open approach to surgery. Attempts were made to blind the subjects and the observers obtaining outcome data to treatment group. Analyses were adjusted for surgeon experience. Absence of USI 6 months following surgery, postoperative pain, time spent in hospital, and time to return to activities of normal daily living. There were no significant differences in objective and subjective measures of cure and in patient satisfaction at 6 months, 24 months, or 3-5 years of follow up between laparoscopic and open colposuspension groups. Laparoscopic colposuspension took longer time to perform (87 versus 42 minutes, P < 0.0001) but was associated with less blood loss (P= 0.03), less pain (P= 0.02), and quicker return to normal activities (P= 0.01). LBC has significant advantages over traditional OBC, without any apparent compromise in short-term and long-term outcomes.

Female↗
PubMed2004

Differentiating stress urinary incontinence from urge urinary incontinence.

Urinary incontinence (UI) is any involuntary leakage of urine and can be further defined according to the patient's symptoms or complaints. Stress urinary incontinence (SUI) is the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing. Urge urinary incontinence (UUI) is characterized by the complaint of involuntary leakage accompanied by or immediately preceded by urgency. Mixed urinary incontinence (MUI) is the presence of both SUI and UUI symptoms. In order to effectively treat UI, an accurate diagnosis is necessary since treatment of SUI or UUI is very different. Assessment obtaining a detailed medical history includes making general assessments taking into account quality of life (QoL), performing an appropriate physical examination with cough stress test; and simple investigations namely a urinary diary, urine analysis and post-void residual assessment and, occasionally, simple urodynamics. These assessments should suffice to commence conservative treatment. Multichannel urodynamics are required in patients presenting with more complicated UI and prior to surgery.

Cough↗
PubMed2004

Transdermal posterior tibial nerve laser therapy is not effective in women with interstitial cystitis.

PURPOSE: Interstitial cystitis (IC) is a debilitating condition which causes irritative bladder symptoms, pain and a decrease in health status. The pathophysiology is poorly understood so therapeutic options are diverse. Percutaneous posterior tibial nerve stimulation is an effective treatment and pulsed transdermal laser stimulation is an established technique for pain management. We evaluated the efficacy of transdermal laser stimulation of the posterior tibial nerve for patients with IC. MATERIALS AND METHODS: Women meeting the National Institutes of Health National Institute for Diabetes and Digestive and Kidney Diseases criteria for IC were prospectively recruited and randomized to treatment (29) or placebo (27) cohorts in a double-blind trial. At home the patient performed laser therapy daily for 30 seconds over the SP6 acupuncture point for 12 weeks. Measures at baseline and at 84-day followup included the 7-day voiding diary, the Interstitial Cystitis Problem Index, Interstitial Cystitis Symptom Index and RAND 36-Item Health Survey questionnaires. RESULTS: There were no significant differences between the treatment and control cohorts on any of the measures. However, there was a significant decrease between baseline and 12-week followup in the amount voided, symptom problems and severity, and on all 8 SF-36 scales. There was no significant effect of fluid intake. CONCLUSIONS: This study demonstrated no difference between the active and sham device. However, it is interesting that treatment and control cohorts experienced similar improvements, suggesting that the control cohort improvements may have been due to participants' belief that they were receiving active treatment from the stimulator. These findings provide support for investigating placebo effects in randomized trials.

Cystitis, Interstitial↗
PubMed2001

Iliococcygeus or sacrospinous fixation for vaginal vault prolapse.

OBJECTIVE: To compare iliococcygeus (prespinous) and sacrospinous fixation for vaginal vault prolapse. METHODS: Between 1994 and 1998, 78 women underwent sacrospinous colpopexy and 50 underwent iliococcygeus fixation for the management of symptomatic vaginal vault prolapse. A matched case-control study was designed to compare the two approaches. The matched variables included age, parity, body mass index, degree of vault prolapse, menopause, sexual activity, constipation, previous prolapse or continence surgery, stress incontinence, and length of review. Thirty-six matched pairs were isolated, resulting in a study with a power of 50% to detect a 20% difference in the success rates between the two groups. RESULTS: The subjective success rate for the iliococcygeus group was 91%; it was 94% for the sacrospinous group (P =.73). The objective success rate was 53% and 67% (P =.36), and the patient satisfaction with surgery was 78 of 100 and 91 of 100 (P =.01) on a visual analogue scale. The mean length of postoperative follow-up was 21 months for the iliococcygeus group and 19 months for the sacrospinous group (P =.52). The recovery time was 54 days in the iliococcygeus group and 39 days in the sacrospinous group (P =.04). No significant difference was seen in the incidence of postoperative cystoceles or damage to the pudendal neurovascular bundle. CONCLUSION: Sacrospinous and iliococcygeus fixation are equally effective procedures for vaginal vault prolapse and have similar rates of postoperative cystocele, buttock pain, and hemorrhage requiring transfusion. The sacrospinous ligament fixation should not be discarded in favor of the iliococcygeus fixation in the management of vaginal vault prolapse.

Adult↗
PubMed2001

Urinary levels of substance P and its metabolites are not increased in interstitial cystitis.

OBJECTIVES: To determine whether interstitial cystitis is associated with the increased release of substance P from the bladder wall into urine, by measuring urinary excretion rates of substance P and its metabolites in women with interstitial cystitis and in a control group of women with stress incontinence and normal bladder function. PATIENTS AND METHODS: Catheter urine was collected from 13 patients and 10 controls during a water diuresis ( approximately 10 mL/min) before and after instilling the bladder with 100 mL of water. The contribution of the bladder wall to urinary substance P peptides was assessed by measuring the change in substance P peptide levels after 2 min of bladder stasis before and after instillation. RESULTS: Absolute substance P excretion rates were similar in patients with interstitial cystitis and controls; 2 min of bladder stasis reduced the substance P excretion rate (P = 0.03) and increased the excretion rate of substance P metabolites (P = 0.01). CONCLUSIONS: The release of substance P from the bladder wall was not increased in patients with interstitial cystitis.

Chromatography, High Pressure Liquid↗
PubMed2001

Genital prolapse: vaginal versus abdominal route of repair.

In the presence of an ageing population, we can expect to see a dramatic increase in the prevalence of genital prolapse including vault and recurrent vaginal prolapse. The best approach for managing upper genital prolapse remains controversial. We review the surgical management of genital prolapse, with a focus on comparing the vaginal and abdominal approaches.

Female↗
PubMed2001

Percutaneous sacral nerve root neuromodulation for intractable interstitial cystitis.

PURPOSE: We evaluated the efficacy of percutaneous sacral nerve root neuromodulation in women with refractory interstitial cystitis. MATERIAL AND METHODS: We prospectively evaluated 15 consecutive women with a mean age of 62 years who had refractory interstitial cystitis to determine the efficacy of percutaneous stimulation of the S3 sacral roots. The mean duration of symptoms before evaluation was 5.2 years. All women fulfilled the National Institute of Arthritis, Diabetes and Digestive and Kidney Diseases criteria for the diagnosis of interstitial cystitis and were unresponsive to standard oral or intravesical therapy. The response to treatment was assessed using pain scores, urinary diary variables and quality of life surveys. RESULTS: Mean voided volume during treatment increased from 90 to 143 ml. (p <0.001). Mean daytime frequency and nocturia decreased from 20 to 11 and 6 to 2 times (p = 0.012 and 0.007, respectively). Mean bladder pain decreased from 8.9 to 2.4 points on a scale of 0 to 10 (p <0.001). As indicated by the Short Urinary Distress Inventory and SF-36 Health Survey, the quality of life parameters of social functioning, bodily pain and general health significantly improved during the stimulation period. Of the women 73% requested to proceed to complete sacral nerve root implantation. CONCLUSION: Women with intractable interstitial cystitis respond favorably to percutaneous sacral stimulation with significant improvement in pelvic pain, daytime frequency, nocturia, urgency and average voided volume. Permanent sacral implantation may be an effective treatment modality in refractory interstitial cystitis but further long-term evaluation is required.

Adult↗
PubMed2000

A prospective evaluation of the pathogenesis of detrusor instability in women, using electron microscopy and immunohistochemistry.

OBJECTIVE: To characterize the types of detrusor smooth muscle junctions in the bladders of women with detrusor instability and in a control group without, and to assess whether there are differences in the cell junctions between these groups. PATIENTS AND METHODS: The study included 13 women with detrusor instability (median age 57 years, range 32-86) and 11 control women (median age 50 years, range 33-62). Bladder biopsies were taken from each participant, processed for electron microscopy and immunohistochemistry (using a labelled antibody to vinculin) and analysed by investigators who were unaware of the patients' diagnoses. RESULTS: Adherens (intermediate) junctions in classic and rudimentary forms were present in all biopsies from patients and controls. Adherens junctions and dense plaques occupied almost the complete cell border in most samples. Complete immunohistochemistry was possible in seven patients and five controls. In almost every detrusor smooth muscle cell studied, there was staining of the entire cell border with labelled antibody to vinculin in all biopsies. CONCLUSIONS: This study provides evidence against an ultrastructural basis for idiopathic detrusor instability based on possible differences in detrusor smooth muscle intercellular junctions. Virtually the entire cell membrane of detrusor smooth muscle fibres is occupied by adherens junctions in classic and rudimentary forms, and with dense plaques present in samples from women with an unstable bladder and from controls. There was no junction detected in those with instability that was not present in the control group. The adherens junctions in the bladder facilitate mechanical coupling between cells.

Adult↗
PubMed2000

Pathophysiology of interstitial cystitis.

Despite being described over 80 years ago, interstitial cystitis remains a disease of undetermined aetiology and poor treatment outcomes. Generally agreed diagnostic criteria of this condition, which occurs primarily in females, are frequency, urgency and pain, a low-capacity hypersensitive bladder, and mucosal haemorrhages and tearing on bladder distention. Although current theories of pathophysiology are predominantly conjecture, important elements of the disease process are increased afferent and efferent neuronal activity, an excess of inflammatory mediators, increased epithelial permeability and possibly reduced bladder vascularity. Improved treatment outcome will follow a better understanding of pathophysiology.

Cystitis, Interstitial↗
PubMed1999

Suture injury to the urinary tract in urethral suspension procedures for stress incontinence.

The case histories of women attending the Urogynecology Department at the Royal Women's Hospital and Mercy Hospital for Women were reviewed between 1986 and 1998 to determine the incidence and postoperative morbidity caused by suture injury to the urinary tract following urethral suspension surgery for stress incontinence. In our department 1103 Burch colposuspensions and 61 Stamey urethral suspensions have been performed. Intraoperative cystourethroscopy was performed routinely for the early detection and treatment of urinary tract injury. Intravesical sutures were found by routine intraoperative cystoscopy in 1 Stamey suspension, 1 open Burch colposuspension and 3 laparoscopic Burch colposuspensions. Ureteric suture ligation was diagnosed in 2 women intraoperatively and 1 women postoperatively after laparoscopic Burch colposuspension. Two women presented with late complications from intravesical sutures following open Burch colposuspension. A further 7 women referred with urinary symptoms were found to have intravesical sutures, 2 following Burch colposuspension, 4 following Stamey urethral suspension and 1 following the Marshall-Marchetti-Kranz procedure. Seven of the 9 women diagnosed with intravesical sutures presented with bladder or pelvic pain, frequency or urinary tract infection. Two women had recurrent stress incontinence and were found to have a intravesical suture on routine cystoscopy at the time of stress incontinence surgery. Suture removal, with any accompanying calculus, was achieved cystoscopically with almost immediate resolution of symptoms without loss of urinary control in all cases. Non-absorbable intravesical sutures occurring as a result of suture misplacement or erosion is an infrequent but important complication of stress incontinence surgery, but should be suspected if pain and irritative bladder symptoms or recurrent urinary infection occur postoperatively. Cystourethroscopy performed intra-operatively or postoperatively is essential for early diagnosis and treatment.

Adult↗
PubMed1999

Colposuspension or sling for low urethral pressure stress incontinence?

The aim of this study was to compare Burch colposuspension with the pubovaginal sling in the management of low urethral pressure urinary stress incontinence. Forty-five women with low urethral pressure stress incontinence were retrospectively reviewed: 21 underwent colposuspension and 24 a pubovaginal sling. The subjective success rate of the Burch colposuspension and the pubovaginal sling was 90% and 71% (P = 0.12), respectively; the objective success rate was 67% and 50% (P = 0.26), respectively. The incidence of postoperative complications, including de novo detrusor instability and symptomatic voiding dysfunction following the colposuspension, was 5% compared to 25% following the pubovaginal sling (P = 0.06). Colposuspension should be considered in the management of women undergoing surgical correction of low urethral pressure stress incontinence. In a clinically similar group of women, the Burch colposuspension had a superior subjective and objective success rate with a lower incidence of complications than did the pubovaginal sling. Although these differences failed to reach statistical significance, colposuspension can be safely considered in the management of women with low urethral pressure GSI.

Female↗
PubMed1999

Lower urinary tract injury during gynecologic surgery and its detection by intraoperative cystoscopy.

OBJECTIVE: To review the frequency of lower urinary tract injuries after major gynecologic surgery and the role of routine intraoperative cystoscopy during major gynecologic surgery in the detection of lower urinary tract injuries. DATA SOURCES: We combined a MEDLINE search for reports from 1966 to October 1998, using the terms "urinary tract injury," "ureter/ureteric/ureteral obstruction/fistula/injury," "bladder fistula/injury," and "vesico-vaginal fistula," with a second search for all reports of gynecologic surgical procedures. Additional references were obtained from relevant articles and review articles. METHODS OF STUDY SELECTION: Included were all English language articles on the frequency of unintentional urinary tract injuries identified during or after benign gynecologic surgery. There were 22 reports on the frequency of lower urinary tract injuries after gynecologic surgery and eight on the use of routine cystoscopy during gynecologic surgery to diagnose unsuspected injuries. TABULATION, INTEGRATION, AND RESULTS: In the reports of studies not involving routine cystoscopy, the frequency of ureteral injury varied from 0 to 14.6 injuries per 1000 operations, with an overall frequency of 1.6 per 1000. The frequency of bladder injury varied from 0.2 to 19.5 per 1000, with an overall frequency of 2.6 per 1000. Only 11.5% of ureteral injuries and 51.6% of bladder injuries were identified and managed intraoperatively. In the reports of studies involving routine cystoscopy, the frequency of ureteral injury varied from 0 to 26.8 per 1000, with an overall frequency of 6.2 per 1000. The frequency of bladder injury varied from 0 to 29.2 per 1000, with an overall frequency of 10.4 per 1000. Up to 90% of unsuspected ureteral injuries and 85% of unsuspected bladder injuries were identified with the use of cystoscopy and were managed successfully intraoperatively. In 69% of the unsuspected ureteral and bladder injuries, the intraoperative management consisted of removing and replacing sutures or repairing unintentional cystotomies. CONCLUSION: Use of routine intraoperative cystoscopy during major gynecologic and urogynecologic surgery might prevent sequelae from lower urinary tract injuries.

Cystoscopy↗
PubMed1999

Urinary leakage during coitus in women.

During a 4-year period from 1993 to 1997, a total of 2153 women were referred to our urogynaecology clinic complaining of urinary incontinence. Of these women, 228 (10.6%) admitted to coital incontinence. Only 22 of these 228 women complained of this symptom without direct questioning. Urine loss occurred during penetration in 158 women, during orgasm in 45 women and during both in 25 women. Comparison of these groups showed few other differences in their presenting symptoms, examination findings, urodynamic data or diagnosis. Genuine stress incontinence was present in 79.8% of women with urinary leakage during penetration, in 93.2% with leak on orgasm and in 92.0% who leaked on both. Detrusor instability was uncommon. In most women who complain of urinary leakage during sexual intercourse, the underlying pathophysiological mechanism is urethral sphincter incompetence. Compared with women presenting with urinary incontinence in the absence of coital incontinence, women with coital leakage had a higher incidence of stress and urge incontinence, and a significantly greater incidence of anterior vaginal wall prolapse and demonstrable stress incontinence on examination.

Journal Article↗
PubMed1999

Burch colposuspension for the treatment of coital urinary leakage secondary to genuine stress incontinence.

The efficacy of Burch colposuspension in treating the symptom of coital urinary leakage in women with genuine stress incontinence has to date never been reported. Women who presented to our clinic with regular coital urinary leakage and urodynamically proven genuine stress incontinence between 1993 and 1997, and who proceeded to a Burch colposuspension procedure, were reviewed to determine the outcome of surgery. Fifty-five women were identified (mean age 46.1 years) with a mean follow-up interval after surgery of 18 months (range 3-42 months). All 55 women had symptoms of stress, urge and coital incontinence preoperatively. Following colposuspension, the subjective cure rates for stress and urge incontinence were 84% and 85%, respectively. Of 52 women that were sexually active after surgery, 81% described no further coital incontinence. The success or failure of surgery was not influenced by whether leakage occurred with penetration or orgasm preoperatively.

Journal Article↗
PubMed1999

Activation of the kallikrein kinin system in interstitial cystitis.

PURPOSE: We investigated whether the kallikrein kinin system is activated in interstitial cystitis by measuring urinary excretion rates of kinin peptides, active and total kallikrein, and the kininase neutral endopeptidase in women with interstitial cystitis. We compared these excretion rates to a control group of women with stress incontinence and normal bladder function. MATERIALS AND METHODS: Catheter urine was collected from subjects during a water diuresis (approximately 10 ml. per minute) before and after distention of the bladder with 100 ml. water. The contribution of the bladder wall to urinary kinins was assessed by measuring the change in kinin levels after 2 minutes of bladder stasis before and after distention. RESULTS: Absolute bradykinin and kallidin excretion rates were similar in women with interstitial cystitis and control subjects. Two minutes of bladder stasis after bladder distention increased urinary bradykinin (p = 0.02) but not kallidin excretion rates. Active and total kallikrein excretion rates were similar in patients with interstitial cystitis and control subjects. Neutral endopeptidase excretion rates were reduced in the initial urine collection from subjects with interstitial cystitis but were similar in both groups during later collection periods. CONCLUSIONS: These data provide evidence for increased bradykinin levels in the bladder wall of subjects with interstitial cystitis, which may be due in part to reduced neutral endopeptidase levels. These increased bradykinin levels may participate in the pathogenesis and symptomatology of interstitial cystitis.

Adult↗
PubMed1999

Oral methotrexate in the management of refractory interstitial cystitis.

To establish the safety and efficacy of low-dose oral methotrexate in treating refractory interstitial cystitis, 9 women who fulfilled internationally accepted criteria for the diagnosis of interstitial cystitis were enrolled in a prospective study. All had proven unresponsive to conventional treatment modalities. Assessment by pain score and frequency volume charts was performed pretreatment and up to 6 months during therapy. No significant adverse side effects were noted. At the end of follow-up, 4 women had noted a subjective improvement in bladder pain and wished to continue on methotrexate, 4 women noted little change and 1 woman reported a worsening of symptoms. Overall there was a significant reduction in pain score (p = 0.047) posttreatment. However, there was no significant difference in urinary frequency per 24 hours (p = 0.40), maximum voided volume (p = 0.089) or mean voided volume (p = 0.59). Methotrexate significantly improved bladder pain in women with interstitial cystitis, although no significant change was found in voiding pattern.

Adult↗