Abstracts 

Sophia Drinis, MD
Submitted to AUA meeting May, 2006

Pelvic floor prolapse (PFP) anterior repair (AR) and concomitant antiincontinence procedures: Our initial experience with the Perigee transobturator (TO) device with polypropylene mesh and the Capio sacrospinous ligament fixation (CSLF) with graft reinforcement
Sophia Drinis, MD

Introduction and Objective

Minimally invasive procedures (MIP) have played a role in the treatment of female stress urinary incontinence (SUI) over the past decade. Modifications have been introduced in the field of PFP. Graft material remains controversial. The therapeutic potential and toxicity of these techniques in unknown. We reviewed our initial experience and perioperative outcomes regarding efficacy and complication.

Methods

Using a de-identified quality improvement clinical database, various patient and surgical characteristics and clinical endpoints, including, post void residual (PVR), intermittent catheterization (CIC), pad use, hospitalization, wound infections and pain were collected at baseline and at subsequent follow up (FU) visits. Cure was defined as voluntary control of micturition and adequate emptying.

Results

14 patients were reviewed. 8 underwent the Monarc TO sling (MTOS) and Perigee PFP AR. 6 underwent the MTOS and CSLF with either repliform or pelvicol grafts. Mean age was 56.14 (range 32- 77). F/U ranged 1 week- 1 year. All had SUI and incomplete bladder emptying as a primary complaint. 7 had prior pelvic floor surgeries (range 1- 8). All had preoperative pad use (range 2- 12/day). 9 (66%) had vaginal atrophy. Baseline urodynamic parameters were documented. There were 2 bladder denudements in the Capio group that required transvaginal repair and catheterization. There were no wound infections, urethral or vaginal erosions. None required mesh or graft removal or readjustments. 6 (48%) required recatheterizations. 1 is on CIC at 3 weeks. None use pads postoperatively. All report a subjective improvement in bladder emptying, continence and quality of life. Wound pain was transient. None report de novo urgency. 2 continue with preoperative anticholinergics. 12 (71%) have resumed full activities. Others are limited by immediate postoperative instructions. All were performed as outpatients. 2 (14%) required prolonged hospitalization secondary to comorbidities. 2 were readmitted for unrelated events. All were discharged with 2- 4 weeks of oral flouroquinolones.

Conclusions

Short term data on these MIP would indicate high efficacy rates and low patient toxicity with both techniques. Graft material is based on surgeon preference. Long term FU and larger patient sampling is required for definitive conclusions.

Transobturator (TO) pelvic floor prolapse (PFP) anterior repair (AR), PFP posterior repair (PR) and concomittant antiicontinence procedures with polypropylene mesh: Our initial experience with the Perigee, Apogee and Monarc devices
Sophia Drinis*

Introduction and Objective

Minimally invasive procedures (MIP) have played a role in the treatment of female stress urinary incontinence (SUI) over the past decade with reported success. Modifications to these MIP are now being explored and applied in the field of PFP. In order to define the therapeutic potential and toxicity profile of these MIP, we reviewed our initial experience and perioperative outcomes regarding efficacy and complications.

Methods

Using a de-identified quality improvement clinical database, various patient and surgical characteristics and clinical endpoints, including, post void residual (PVR), intermittent catheterization (CIC), pad use, hospitalization, wound infections, pain and ambulation were collected at baseline and at subsequent follow up (FU) visits. Cure was defined as voluntary control of micturition and adequate emptying.

Results

17 patients were reviewed. 8 underwent a Monarc TO sling (MTOS) and Perigee PFP AR. 1 underwent a MTOS and Apogee PR. 8 underwent a MTOS, Perigee AR and Apogee PR. Mean age was 63.82 years (range 40-77). FU ranged 1 week- 7 months. All had SUI and incomplete bladder emptying as a primary complaint. 10 had prior pelvic floor surgeries (range 1- 8). All had preoperative pad use (range 2- 12/day). 14 (82%) had vaginal atrophy. Baseline urodynamic parameters were documented. There were no urethral, bladder or vascular injuries. All were outpatient procedures. 2 (12%) required prolonged hospitalization secondary to comorbidities. There were no wound infections, urethral or vaginal erosions. None have required mesh removal or readjustment. 1 had perineal ecchymosis. 6 (35%) required recatheterization. 1 is on CIC at 3 weeks. None report postoperative pad use. All report a subjective improvement in bladder emptying, continence and quality of life. Wound pain was transient. None report de novo urgency. 12 (71%) have resumed full activities. Others are limited by immediate postoperative instructions. 2 were readmitted for unrelated events. Both discharged the following day. All were discharged with 2- 4 weeks of oral flouroquinolones.

Conclusions

Short term data on these MIP, even in a complex patient population, would indicate high efficacy rates with low patient toxicity in the simultaneous operative management of SUI and PFP. Long term FU and larger patient sampling is required for definitive conclusions.

Poster presentation at the AUA Metting May, 2005

Repair of complex urethral strictures: a look at buccal mucosa graft (BMG) onlay, circular skin island flap (CSIF) and tubed skin island flap (TSIF) to a perineal urethrostomy (PU).
Sophia Drinis*, Danville, PA; Gerald H Jordan, Norfolk, VA

Introduction and Objective

Urethral reconstruction in patients with pananterior urethral strictures (AUS) can be complicated by multiple factors, such as, insufficient genital skin for reconstruction and extensive life-threatening comorbidities. This is further complicated by the fact that most patients with complex strictures have undergone previous urethral reconstruction and the vascularity of the tissue is unhealthy and less than desirable. We evaluated our 5 year experience in managing complex AUS’s previously managed with dilations, urethrotomies (DVIU) and/or failed attempts at urethroplasty, with the technique of dorsal BMG onlay and CSIF reconstruction to a PU. Prior reports have documented the limitations of diverting cutaneous urethrostomies (CU) and circumferential TSIF’s. The technique of dorsal BMG onlay and CSIF reconstruction represents recent developments in the treatment of complex pananterior urethral strictures.

Methods

We reviewed the results of our experience with 7 males, mean age 62 (range 47- 80) during a 63 month period from 4/99 to 7/04, who presented to our center and underwent treatment for complex pan AUS’s. 6 of 7 (85.7%) patients had undergone previous urethral surgeries, such as urethrotomies, dilations, failed trial of self urethral balloon dilation and/or prior attempts at an open reconstruction. All patients had preoperative suprapubic tube urinary diversions. The primary etiology of stricture was traumatic in 3 cases, inflammatory in 3 and 1 patient with squamous cell carcinoma of the glans who required a partial penectomy. At the time of initial evaluation imaging included retrograde urethrogram, voiding urethrogram (VCUG). Urethroscopy and endoscopy., was performed via the suprapubic tract. Urethral strictures and/or obliterations ranged from 6-22 cm. in length. Patients comorbidities included, end stage liver disease awaiting liver transplantation, thrombocytopenia, lymphoma, morbid obesity, severe balanitis xerotica obliterans, diabetes, necrotizing fasciitis, end stage renal disease awaiting kidney transplantation, coronay artery disease, cardiomyopathy and penile cancer status post topical chemotherapy.

Results

One patient underwent a penile circular skin island mobilized on a dartos fascial flap configured into a tubed flap (TSIF) segment then spatulated onto his perineum as a PU.  One patient underwent a CSIF reconstruction to a PU. 5 patients underwent harvesting of a BMG for a BMG dorsal onlay urethral reconstruction to a PU. Of these, 1 had a concomitant distal urethrectomy and partial penectomy, and 1 had split thickness skin grafting to the penis. A 6-7 cm x 2.4 cm buccal mucosal graft was harvested from the left inner cheek, spread and fixed to the triangular ligament and to the corporal bodies with a running 6-zero polyglactin suture, with good spatulation achieved proximally to the spatulated membranous urethra. The corpus spongiosum and the urethra are tacked to the edges of the spread graft. The graft is mattressed up the midline and pie crusted. All patients were completed in one stage repairs. A final successful outcome was defined as no complication, such as recurrent stricture disease, fistula, diverticula, graft breakdown, wound infection, incontinence or need for repeat operation for relief of obstruction. All the patients are stricture free at mean followup of 15 months (range 2- 63). The skin island was tubularized for a length of 3-4 cm and a width of 3 cm. 5 patients had an exaggerated posteriorly based inverted U- shaped flap elevated on Colles fascia with the arms of the U inside the ischial tuberosities. The U flap creating the posterior lip of the urethrostomy, sutured to the spatulated corpus spongiosum. One patient was approached via an H- shaped incision on the perineum with a posteriorly based U flap and releasing incisions along the crease of the scrotum and perineum. One patient required a modified lambda incision created in the perineum in order to create a posterior flap to spatulate into a PU due to extensive perineal scarring. All had a 14 Fr. silicone stenting catheter and a 16 Fr. suprapubic tube to gravity drainage. 3 patients required no perineal drain placement due to lack of dead space. 2 patients required one drain and 2 required 2 drains. Ambulation began on mean postoperative day (POD) 3, (range 3- 6). All patients received 72 hours of postoperative culture specific antibiotics and discharged with suppressive coverage pending their trial of voids. Patients were discharged from the hospital on mean postoperative day 4 (range 3- 6). Voiding cystourethrograms were performed at the time of the trial of voiding which was performed on mean postoperative day 24 (range14- 28). Cystoscopy is performed in 6 month intervals for the first year. Repeat cystoscopy is not performed unless the patient is symptomatic.

Conclusions

In our series, early data depicits a good durable response which is encouraging and suggests an excellent reliable single stage alternative for patients with complex pan AUS with previously instrumented unreliable proximal anterior urethras, who would otherwise require multiple staged procedures, who may now lack genital skin for complex staged repairs, who may not be completely reconstructible along the entire length of their anterior urethra enabling voiding with standing and/or who are not candidates due to preexisting comorbidities but wish to be dry, tube and bag free, with the concomitant avoidance of classic complications related to cutaneous urethrostomies or tubed skin reconstructions, such as, risks of recurrent stricturing and need for further instrumentation, and who are not bothered by the need to sit to void or retrograde ejaculation. These techniques imply decreased operative time, patient time in lithotomy and associated morbidity compared to staged repairs.  Nevertheless, these patients should be advised of the possible need for revisions. The improved outcome rate of revision in these procedures compared with the increased rate of revision in diverting cutaneous urethrostomies and tubed skin grafts appears to be related to the benefit of supplying improved vascularity, healthy tissue, and a tension free anastomosis rather than due to surgeon experience. The complication and reoperation rate of BMG onlay and CSIF to a PU is currently nonexistent in our series at 63 month followup. BMG has been shown to be as good as any other material for substitution urethroplasty with fewer complications and more reliable than tubed skin flaps (TSIF). For those undergoing the latter and diverting cutaneous urethrostomis, they should be counseled to the risk of restenosis following relief of distal obstruction. The reliability of the proximal anterior urethra (PAU) is determined intraoperatively during cystoscopy and calibration. Distal diverting cutaneous urethrostomy (CU) provides the simpliest procedure for a relatively successful relief of obstruction in view of a healthy proximal anterior urethra in those patients requesting more definitive treatment than urethral balloon dilation.

Source of Funding: None

Research

Dr. Drinis has been involved in basic and clinical research throughout her residency career. Currently she is interested in the development of new treatment modalities for female antiincontinence and pelvic floor reconstruction. This interest is manifest by the application of robotic laparoscopic assisted approaches for female antiincontinence repairs under the immediate guidance of Dr. Rukstalis.  She has developed prospective quality improvement data bases for pelvic floor incontinence and prolapse repairs.

She is particularly interested in examining the efficacy and adverse events comparisons between biologic and synthetic grafts in the application of pelvic floor reconstruction. She is also investigating the retrospective cost comparisons of the current techniques applied to pelvic floor reconstruction within our female incontinence center.