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R J Scotti

Publications and source records attributed to R J Scotti.

At least 19 recordsLinked to original sources
PubMed2001

Persistent site-specific defects after reconstructive pelvic surgery.

Our objective was to determine the persistence rates of site-specific defects after reconstructive pelvic surgery. We conducted a retrospective analysis of the post-operative outcome for 77 patients with pelvic support defects. Forty-five patients in the abdominal group underwent a Burch procedure, paravaginal repair and sacral colpopexy when indicated; 32 patients in the vaginal group had a sacrospinous vault fixation with or without colporrhaphy. A chi2 test, Wilcoxon's two-sample test. Wilcoxon's signed-rank test and multivariate logistic regression model were used for data analysis. The two groups were similar in age, weight, parity and menopausal status. There was significant improvement of all defects except in the vaginal group, which showed a higher rate of persistent paravaginal defects (68.7 vs. 13.3%, P = 0.001). After adjusting for potential confounders, there was no difference in the rates of apical and anterior wall defects between the two groups. The odds ratio for persistent paravaginal defects in the vaginal group was 8.9 (95% CI: 2.3-34). The choice of surgical procedure is the most important factor determining the rate of persistent pelvic support defects. Lateral wall defects must be addressed at the time of reconstructive surgery.

Adult↗
PubMed2000

Characterizing and reporting pelvic floor defects: the revised New York classification system.

The authors have devised a conceptual model and reporting system for characterizing, grading and staging pelvic floor defects. The system is user friendly and simple to learn and apply. It is based on commonly known anatomic landmarks and can be performed without memorizing or referring to a separate characterization and reporting plan. Completing the accompanying forms is self-explanatory and provides the information needed for proper comprehension and recording of anatomic defects. The model and reporting format have been used at our institutions for 5 years by medical students, residents, fellows and attendings. It has several advantages over the Pelvic Organ Prolapse Quantitation (POPQ) system: (1) it uses known anatomic landmarks rather than alphabetic labels; (2) it grades lateral wall defects which the POPQ system omits; (3) it recognizes and reports isolated defects or tears which present as bulges in the vaginal walls without downward linear descent (prolapse); (4) it uses a one-page reporting form and a one-page checklist and vaginal profile; (5) it can be done easily in both the supine and the standing positions; (6) it requires simple instruments and a disposable measuring tape available in most office settings; (7) it includes urethral hypermobility in its reporting scheme; (8) it includes cervical length, perineal descent and other measurements in its reporting scheme; and (9) it is similar enough to the POPQ system that easy conversion to, and integration with, the POPQ reporting form and vaginal profile is possible. Prospective trials testing the validity of this system and comparing it with the POPQ system for validity, reliability, reproducibility, test-retest analysis, and interobserver and intraobserver variance are warranted.

Female↗
PubMed1998

Paravaginal repair of lateral vaginal wall defects by fixation to the ischial periosteum and obturator membrane.

OBJECTIVE: The aim of the study was to evaluate the anatomic basis, efficacy, and safety of a technique for correcting lateral wall vaginal defects. STUDY DESIGN: Phase I was cadaveric dissection carried out to ascertain the strength and position of structures likely to support lateral vaginal wall defects. The ischial periosteum just anterior to the ischial spine was found to be strong tissue, relatively free of nerves and vessels. In phase II, paravaginal defects were repaired by placing sutures through the arcus tendineus and underlying obturator fascia, obturator membrane, and ischial periosteum. Other defects and urinary incontinence were corrected within the same surgical setting. Forty patients were followed up for an average of 39 months (range 7-52 months). Preoperative evaluation consisted of an extensive history, cough stress test, spontaneous uroflowmetry, postvoid residual urine determination, urethral axis determination, site-specific pelvic floor defect evaluation, and multichannel urodynamic studies. After the operation patients underwent evaluations at 3 months, at 6 months, and then annually. RESULTS: Objective site-specific re-examination of the 40 patients revealed the following recurrences: lateral wall in 1 of 40 procedures, anterior wall in 3 of 35 procedures, posterior wall in 1 of 36 procedures, and apical wall in 1 of 27 procedures. Thirty-four of 36 women (94.4%) with urodynamically confirmed genuine stress incontinence or potential incontinence achieved cure (P <.001). CONCLUSIONS: (1) The ischial periosteum and obturator membrane are consistently strong reattachment sites. (2) Repair of paravaginal defects with these tissues is effective and safe. (3) Urodynamic parameters were unchanged after the operation except for measures of incontinence, which were improved (P <.001). (4) Performing other pelvic procedures did not negatively alter the success rates of paravaginal repair. (5) The urethral axis was favorably altered after the operation (P <.01).

Abdomen↗
PubMed1998

Antecedent history as a predictor of surgical cure of urgency symptoms in mixed incontinence.

OBJECTIVE: To determine the cure rate of urge incontinence after Burch colposuspension in patients with mixed incontinence diagnosed urodynamically, to determine if cure rates were different when the onset of urge symptoms antedated or postdated the symptoms of stress incontinence, and to propose appropriate preoperative counseling of patients based on this information. METHODS: Forty-six women with urodynamically diagnosed genuine stress incontinence and detrusor instability underwent Burch colposuspension. History of chronologic onset of stress incontinence or urge incontinence was recorded. Detailed history, clinical examination, and multichannel urodynamic and other functional studies were carried out on each patient preoperatively and postoperatively. Postoperative urodynamic studies were performed only in patients with persistent symptoms. Patients were assigned to the antecedent stress or antecedent urge group depending on which symptom(s) occurred first. Cure rates in each group were calculated and compared with history of incontinence. RESULTS: Fifty-eight of 82 patients with complaints of both stress and urge incontinence were diagnosed urodynamically as having mixed incontinence; 46 of them met the study criteria and underwent Burch colposuspension. Stress incontinence preceded urgency in 28 of the 46 patients (61%); urgency occurred first in the remaining 18 (39%). The cure rate of 78.6% (22 of 28) for urge incontinence was statistically significantly greater in the antecedent stress group compared with 22.2% (four of 18) in the antecedent urge group (P < .001). CONCLUSION: Patients with a primary presenting symptom of stress incontinence who later develop urge incontinence are 2.5 times more likely to be cured of urge incontinence by Burch colposuspension than patients whose primary presenting symptom is urge incontinence.

Adult↗
PubMed1995

Ability of visual tests to predict underlying cervical neoplasia. Colposcopy and speculoscopy.

OBJECTIVE: To describe the attributes of colposcopy and a low-power, magnified examination that utilizes chemiluminescent illumination (speculoscopy) in the visualization of cervical epithelium in a predefined, high-risk population and to compare how the two tests predict cervical histology. STUDY DESIGN: During this multicenter, prospective study, 395 women who were referred to our colposcopy clinic underwent a repeat cervical smear and speculoscopy followed immediately by colposcopy. Abnormal colposcopic lesions were biopsied and endocervical curettage performed when indicated. Histologic diagnoses were compared with cytology, speculoscopy and colposcopy results. RESULTS: Colposcopy was more sensitive than speculoscopy in the detection of cervical neoplasia (97% vs. 82%) (P < .001) and was superior in visualizing focal lesions and vascular patterns. An antecedent acetowhite abnormality detected during speculoscopy was highly predictive of subsequent abnormal colposcopy (97% positive predictive value). The "overall" rate of acetowhite lesions during speculoscopy was nearly half the rate during colposcopy (P < .001). CONCLUSION: Colposcopy is better suited than speculoscopy to the follow-up of patients with abnormal cervical cytology because it facilitates lesion grading and assists in directing biopsies. Speculoscopy is best utilized as a dichotomous screening test based on the presence or absence of at least one well-demarcated acetowhite lesion and may be more suitable than colposcopy as an adjunct to cervical cancer screening due to its lower overcall rate. The biophysical properties of blue-white chemiluminescent light as it relates to the diagnosis of cervical neoplasia are discussed.

Adult↗
PubMed1995

Acute urinary retention and the incarcerated, retroverted, gravid uterus. A case report.

A case of urinary retention was associated with an incarcerated, retroverted, gravid uterus. In a literature review of the English language we encountered 26 similar cases. Although no series of cases has allowed evaluation of a specific protocol for evaluation and management or analysis of outcomes, a review of the literature does outline certain diagnostic tests and treatment modalities that may be useful when one is faced with this uncommon condition.

Female↗
PubMed1995

Compliance with the 24-hour, in-house attending coverage requirement. A survey.

Fifty-six residency training programs in Region I Council on Resident Education in Obstetrics and Gynecology/Association of Professors in Gynecology and Obstetrics were surveyed for compliance with the 24-hour, in-house attending coverage requirement, which took effect July 1991. Forty-six program directors responded to a questionnaire, for a response rate of 82.1%. Each had plans to implement this coverage in the 1991-1992 academic year. Two programs were unable to implement coverage because of inadequate financing or insufficient staffing. There were no differences in the types of programs (community, university, public or private university, or New York State program) in respondents as compared to non respondents. All the programs had overnight staff coverage for an average of 13 hours (range, 12-15) and had 24-hour, continuous coverage on the weekend. There was a wide variation in the attending/resident ratio. Twenty-eight programs (60.8%) reported that they compensated their attendings. Revenue for this compensation came from the hospitals (14), direct billing (8), faculty practice plans (6) or New York State (3). Of the 28 programs that offered compensation, 20 were private community hospitals, 6 were private university programs, 1 was a public university program and 1 was a public community hospital. Of the 28 programs compensating faculty, 17 were able to cite figures that had been approved by their respective institutions or practice plans. The annual cost ranged from $130,300 to $901,887 per program for institutions that compensated their attendings (mean, $340,402).

Gynecology↗
PubMed1994

Formal resident training in urogynecology and pelvic floor disorders. A six-year survey.

An observational study reviewed the efficacy of resident training in urogynecology and pelvic floor disorders. After instituting a formal urogynecology rotation consisting of two one-month rotations in the second and third years at a major inner city county hospital, 24 residents were prospectively followed to assess their cognitive and clinical skills, including endoscopic, urodynamic and surgical competence. They were evaluated by objective testing and close observation. The results showed 41.875% (+/- 16.669 SD) entry level objective correct answers as compared to 82.083% (+/- 10.206) upon completion of the rotation. Residents were observed and graded over the six-year period by one (occasionally two) faculty members for successful task completion. The residents' mastery of surgical, endoscopic and urodynamic skills was deemed acceptable through a subjective evaluation by urogynecology faculty members based on satisfactory completion of 80% of the assigned task. Formal urogynecologic training by a knowledgeable subspecialist is a useful adjunct to the obstetrics-and-gynecology residency program.

Clinical Competence↗
PubMed1993

Use of speculoscopy in the evaluation of women with atypical Papanicolaou smears. Improved cost effectiveness by selective colposcopy.

Since up to 45% of patients with atypical Papanicolaou smears have been shown to have significant pathology, women with persistent atypia are usually referred for colposcopy. This study evaluated the use of a new adjunctive screening test, speculoscopy, in selecting women with atypical Papanicolaou smears who would most benefit from referral for colposcopy. Both screening and referral patients were evaluated with the Papanicolaou smear, speculoscopy and colposcopy at 10 study centers. Biopsies were obtained from most women with positive colposcopy. The results in patients with atypical smears were used to perform a cost-benefit analysis of each of three management protocols. Using the results of speculoscopy to select women with atypical Papanicolaou smears for colposcopy provided a cost-effective alternative to performing colposcopy either on all women or on those with persistent atypia following treatment. Even when all women undergo speculoscopy at the time of screening, this protocol provides a cost savings of up to 24% and no significant loss of diagnostic accuracy. These data suggest that speculoscopy performed at the time of initial screening can accurately select women with atypical Papanicolaou smears who require colposcopy for diagnostic biopsy in a cost-effective manner.

Biopsy↗
PubMed1993

A comparison of the cough stress test and single-channel cystometry with multichannel urodynamic evaluation in genuine stress incontinence.

OBJECTIVE: To assess the predictability and accuracy of a simplified approach--the cough stress test and single-channel cystometry--in the diagnosis of genuine stress incontinence (GSI) by comparing these tests to the more complex multichannel cough urethral pressure profile and urethrocystometry. Conversely, we assessed the predictability and accuracy of the multichannel approach--the cough urethral pressure profile and urethrocystometry--in GSI by comparing these tests to the cough stress test and single-channel cystometry. METHODS: Prospectively, 145 women with complaints of urinary incontinence underwent a complete urogynecologic evaluation. All patients underwent single-channel cystometry with cough stress test and multichannel urethrocystometry with cough urethral pressure profiles in the erect position. Genuine stress incontinence was diagnosed if 1) the patient was seen to spurt urine per urethra with cough at full cystometric capacity in the absence of vesical instability as determined by single-channel cystometry, or 2) the cough urethral pressure profile demonstrated pressure equalization in the absence of vesical instability as determined by multichannel urethrocystometry. Statistical values were calculated for both the simplified and the multichannel methods, and measures of validity were compared statistically. RESULTS: For the diagnosis of GSI, the simplified method had a positive predictive rate of 87.2% and a negative predictive rate of 80.6%. The multichannel method had a positive predictive rate of 84.0% and a negative predictive rate of 84.4%. CONCLUSION: For the diagnosis of GSI, the simplified method of the cough stress test and single-channel cystometry is as accurate and predictive as the multichannel method.

Cough↗
PubMed1991

Repair of genitourinary prolapse in women.

One hundred thirty-five cases of urogenital prolapse repair are reviewed from the literature over a period from October 1989 to July 1990. Different techniques and their complications are reviewed and compared. These include colposacropexy and sacrospinous ligament fixation with various techniques and materials. Recommendations are also made for prevention of failures. The necessity for preoperative urodynamic evaluation is discussed with suggestions for proper utilization. The data are summarized and critically reviewed, and recommendations are made for appropriate selection of technique, with a discussion of advantages, disadvantages, and prevention of complications.

Female↗
PubMed1991

Massive evisceration: a complication following sacrospinous vaginal vault fixation.

This report describes a spontaneous vaginal vault prolapse in association with massive evisceration following sacrospinous vaginal vault fixation. Careful attention to surgical technique is critical to the success of the operation. In particular, good apposition of the vaginal vault to the sacrospinous ligament and adequate repair of an enterocele should avoid this complication.

Female↗
PubMed1990

Predictive value of urethroscopy as compared to urodynamics in the diagnosis of genuine stress incontinence.

A retrospective chart review was undertaken of 204 patients who underwent dynamic urethroscopy. Ninety-nine patients with a diagnosis of genuine stress incontinence were evaluated urodynamically and urethroscopically to determine the predictive accuracy of the sensitivity and specificity of each of these diagnostic modalities. The urodynamic cough profile was both highly reactive and specific for genuine stress incontinence, with sensitivity and specificity of 95% and 100%, respectively, whereas dynamic urethroscopy yielded sensitivity and specificity of 60.2% and 79.1%, respectively. Dynamic urethroscopy is a relatively insensitive predictor of genuine stress incontinence, with many equivocal findings (11%) as well. The urodynamic cough urethral pressure profile is recommended for diagnosing this condition.

Adult↗
PubMed1989

Surgical management of uterine prolapse in young women.

A new procedure was developed for the management of uterine prolapse in young women. Transvaginal sacrospinous uterine fixation was employed successfully in five patients. The advantages of the procedure are that it avoids surgical trauma to the cervix, can be accomplished entirely vaginally, maintains the normal vaginal axis and obliterates the space for potential enterocele.

Adult↗
PubMed1986

Urodynamic changes in urethrovesical function after radical hysterectomy.

Twelve patients undergoing radical hysterectomy were comprehensively evaluated urodynamically pre- and postoperatively using sensitive instrumentation, including microtip transducers. Five patients developed genuine stress incontinence, four developed loss of bladder compliance, three developed motor deficits consisting of either inability to relax the urethra or inability to initiate or maintain a vesical contraction, two developed impaired urinary flow, three had persistent excessive residual urine volumes, and two developed bladder sensory loss. These changes persisted beyond the one-year follow-up period. The degree of urethrovesical dysfunction bore no significant relationship to the radicality of the hysterectomy.

Adult↗