319 research outputs found
Mesh in prolapse surgery
No full textProlapse repair with synthetic mesh has become an area of debate in the last few years. The rationale for mesh use in prolapse surgery, the surgical outcomes and its complication profile will help us to understand the concerns and controversies regarding it. The lifetime risk of undergoing surgery for prolapse by age 80 is around 11 % and reoperation rate is quoted around 29 % [1]. The recurrence risk and the need for reoperation in nearly one-third to one-fourth of patients with prolapse surgeries means there is a need for more robust techniques in prolapse repair. Our understanding of pelvic floor anatomy changed dramatically since the description of "levels of pelvic organ support" by John DeLancey [2]. In order to fully understand the dynamics of prolapse surgery, both native tissue and mesh repair, it is important to have a brief overview of the functional anatomy of the pelvic floor, which has been covered adequately in an earlier chapter of this textbook. Many of the treatments for pelvic organ prolapse (POP) offered today have been developed bearing in mind this renewed understanding of pelvic floor anatomy
Management of sling surgery complications
No full textThe management of urodynamically proven stress urinary incontinence underwent a paradigm shift with the focus changing from bladder neck suspension to support of the mid-urethra in the last two decades. This has resulted in the replacement of Burch colposuspension and pubo-vaginal slings to synthetic mid-urethral slings as the primary surgical option in women with stress urinary incontinence (SUI). The introduction of synthetic mid-urethral slings has resulted in good objective and subjective cure rates but can be associated with complications that pose a challenge to the treating surgeon. Surgical treatment for SUI has rapidly evolved, and the initially introduced mid-urethral sling, retropubic tension-free vaginal tape (TVT), is accepted worldwide as a standard treatment for women suffering from SUI. However, slings have been associated with a few early and delayed complications which may result in varying degrees of morbidity. Serious complications such as bowel injury, major vascular injury, and even death have been reported with mid-urethral sling procedures.
Sling complications are related to the sling type, surgical technique and time elapsed postsurgery. Though there are numerous devices available in the market, three different types of mid-urethral slings are commonly described in current practice, namely-retropubic slings (TVT, GYNECARE TM; AMS TM, RetroArc), transobturator slings (AMS TM, Monarc; TVT-O, GYNECARE TM ) and single-incision mini-slings (AMS TM, MiniArc). The rationale for choice of sling has been discussed elsewhere in this book and the surgical technique varies with the type of sling chosen which in turn is intricately related to type of complications seen with slings. This chapter deals with the management of synthetic mid-urethral sling complications in the intra-operative and postoperative period
Does posture affect micturition?
No full textPosture during toileting and its effect on toileting has been under scrutiny for more than 7000 years. With the advent of the western toilet in the 19th century and a more closeted approach to toileting, the effects of posture became even more important to study because the visual one to one education of children, regarding toileting became less and less. Wennergren in her study of children demonstrated the value of foot support to relax the pelvic floor during urination in children. Moore in her study showed that a majority of British women will not sit on the toilet outside their house and would 'hover' to pass urine. A Taiwanese study showed a similar trend except that young students would precariously perch in a squat over a western toilet than sit on it for hygiene reasons. All these studies stimulated the generation of this thesis.
PRINCIPAL OBJECTIVES AND SCOPE OF THE STUDY
The principal objectives of these investigations were to study
- The effect of the 'lean forward' position on the western toilet (WT) compared to the 'sit upright position' during micturition.
- The effect of the 'raised knee' position on the western toilet compared to the 'lean forward' position during micturition.
- The effect of squatting on a custom built Asian toilet compared to 'lean forward' position on the western toilet.
What was learnt led to numerous 'sub-studies' on squatting which included -
- Study of squatting in volunteers leading to a 'squatability' index
- Study of school children and their ability to squat
- Study of abdominal pressures in squatting and sitting positions at rest and during Valsalva manoeuvre
- Study of the levator hiatus during squatting and lying down at rest
- Possible design of a retro fit device to aid toileting on the western toilet called Duneze
METHODOLOGY
All toileting parameters were studied using uroflowmetry which was used as standard, as in previous studies. [1-6]
Support for Uroflowmetry, which is a simple non-invasive measurement of urine flow over time and an indication in screening for voiding difficulty, as a screening test for voiding dysfunction has become stronger over time, [7-9] measuring some of the key components of the micturition process. [10] An abnormally slow urine flow suggests a provisional diagnosis of voiding difficulty subject to test repetition, post-void residual bladder volume (PVRBV) measurement and possible voiding cystometry.
Post Void Residual Urine Volume Measurement of post void residual urine volume (PVRBV), the amount of residual urine in the bladder after a voluntary void, is another non-invasive screening test for evaluating voiding dysfunction. Most urologists agree that volumes of 50 mL to 100 mL constitute the lower threshold defining abnormal residual urine volume PVRBV measurement. There are 2 methods of measuring PVRBV: sterile catheterization and bladder ultrasound. Although sterile catheterization provides a urine sample, there are many disadvantages associated with the procedure: it causes patient discomfort, carries a risk of urethral trauma and introducing an UTI, is time-consuming, and may not be necessary. [11]
In contrast, bladder ultrasound can be performed with a portable device. It is noninvasive and time-efficient, minimizes medical waste and supplies, and determines when catheterization is medically appropriate. However, a urine specimen cannot be obtained during this procedure. Portable 3-dimensional ultrasound devices have been shown to provide highly accurate measurement of bladder volume. Coombes and Millard compared the BladderScanTM BVI 2500 series (Diagnostic Ultrasound, Bothell, Wash) with catheterization for the measurement of bladder volume with no significant difference in estimates being demonstrated. The overall accuracy (94%), sensitivity (97%), and specificity (91%) of the BVI 2500+ were encouraging. [11] The current accuracy of modern uroflowmeters in measuring urine voided over time (flow rate) is approximately ± 2–5%, despite the fact that a variety of different physical measurement principles are being used. This accuracy compares favourably with the ± 20–25% for the most accurate ultrasonic techniques for PVR measurement with the potential error using urethral catheterisation being much higher. [12]
After obtaining Institutional ethics approval for all studies, volunteers recruited from nursing staff and medical students participated in these studies coached either by Audrey Corstiaans (AC) or Professor Ajay Rane (AR).
SUMMARY OF RESULTS
STUDY ONE: There was a statistically significant difference in the peak and average urine flow rates in the lean forward position when compared to the sit back posture (p<0.0054 and p<0.0097 respectively).
STUDY TWO: There was a statistically significant difference in uroflowmetric parameters i.e. the peak (p=0.01) and average flow rates (p=0.043), when tested in the lean forward position as compared to the knee raised position respectively. Hence the importance of knee raising or leaning forward with feet stability was deemed equally important when toileting.
STUDY THREE: This was the most challenging of studies. In summary, only 46% of our volunteers from a cohort of 125 could actually squat (with feet flat for more than 30 seconds). [13] Although not statistically significant, in volunteers who could squat there was a trend to better urine flows especially the "time to maximum flow" (p=0.003) in the squatting position when compared to the lean forward position.
The results of the Study One encouraged us to consider the possibility that an alternative position during toileting would be beneficial in effecting voiding. This lead to the evaluation of Uroflowmetric parameters in the lean forward and raised knee position (Study Two). Encouraged by the results of Study Two we raised the bar even higher and asked patients to squat during the act of voiding. Although no firm conclusions could be drawn from this study the main challenge arose from the fact that less than half of our volunteers could not squat.
PRINCIPAL CONCLUSIONS
The main conclusions derived from these studies are:
- Posture on the toilet affects bladder function
- On the western toilet the lean forward position with foot support is the most optimal
- Squatting position is difficult to assume in a majority of the population who do not routinely use squat toilets
A comparison of bladder neck movement and elevation after tension free vaginal tape and colposuspension
No full textEnhanced recovery after surgery: Perspective in elder women
No full textEnhanced recovery after surgery (ERAS) is a multimodal convention first reported for colorectal and gynecologic procedures. The main benefits have been a shorter length of stay and reduced complications, leading to improved clinical outcomes and cost savings substantially. With increase in life expectancy, recent years has shown a significant rise in advanced age population, and similarly, a rise in age-related disorders requiring surgical management. Due to pathophysiological and metabolic changes in geriatric age group with increased incidence of medical comorbidities, there is higher risk of enhanced surgical stress response with undesirable postoperative morbidity, complications, prolonged immobility, and extended convalescence. The feasibility and effectiveness of ERAS protocols have been well researched and documented among all age groups, including the geriatric high-risk population.[1] Adhering to ERAS protocols after colorectal surgery showed no significant difference in postoperative complications, hospital stay, or readmission rate among various age groups.[2] A recent report mentions the safety and benefits following ERAS guidelines with reduced length of stay in elderly patients with short-level lumbar fusion surgery.[3] The concept of prehabilitation has evolved as an integral part of ERAS to build up physiological reserve, especially in geriatric high-risk group, and to adapt better to surgical stress.[4] High levels of compliance with ERAS interventions combined with prehabilitation can be achieved when a dedicated multidisciplinary team is involved in care of these high-risk patients
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