The changing face of urinary continence surgery in England: A perspective from the Hospital Episode Statistics database purchase 4mg montelukast visa asthma treatment in jabalpur. Long-term follow-up studies in pelvic floor dysfunction: The Holy Grail or a realistic aim? Urethrovaginal fixation to Cooper’s ligament for correction of stress incontinence purchase montelukast with paypal asthma 16 month old, cystocele order cheap montelukast on-line asthma symptoms 4 dpo, and prolapse. Simplification of laparoscopic extraperitoneal colposuspension: Results of two- port technique. Comparative outcome analysis of laparoscopic colposuspension, abdominal colposuspension and vaginal needle suspension for female urinary incontinence. Correction of stress urinary incontinence: Laparoscopy combined with vaginal suturing. Laparoscopic Burch procedure for stress urinary incontinence: The Carter modification. A prospective multisite study of radiofrequency bipolar energy for treatment of genuine stress incontinence. Laparoscopic paravaginal repair plus burch colposuspension: Review and descriptive technique. Preventing Entry-Related Gynaecological Laparoscopic Injuries, Green-top Guideline No. Is naso-gastric tube insertion necessary to reduce the risk of gastric injury at subcostal laparoscopic insufflation? Risk factors and the prevalence of trocar site herniation after laparoscopic fundoplication. The location of abdominal wall blood vessels in relationship to abdominal landmarks apparent at laparoscopy. Anatomic guidelines for the prevention of abdominal wall hematoma induced by trocar placement. Incisional hernia following laparoscopy: A survey of the American Association of Gynecologic Laparoscopists. Laparoscopic hysteropexy: The initial results of a uterine suspension procedure for uterovaginal prolapse. Long-term effectiveness of the Burch colposuspension in female urinary stress incontinence. Minimally invasive synthetic suburethral sling operations for stress urinary incontinence in women. Laparoscopic Burch colposuspension after failed sub-urethral tape procedures: A retrospective audit. Staff perceptions of the effects of an integrated laparoscopic theatre environment on teamwork. Laparoscopic Burch colposuspension: A randomized controlled trial comparing two transperitoneal surgical techniques. A three-armed randomized trial comparing open Burch colposuspension using sutures with laparoscopic colposuspension using sutures and laparoscopic colposuspension using mesh and staples in women with stress urinary incontinence. A randomised trial comparing open Burch colposuspension using sutures with laparoscopic colposuspension using mesh and staples in women with stress urinary incontinence. The efficacy of laparoscopic mesh colposuspension: Results of a prospective controlled study. Laparoscopic Burch repair compared to laparotomy Burch for cure of urinary stress incontinence. Two techniques of laparoscopic Burch repair for stress incontinence: A prospective randomized study. The cost-effectiveness of laparoscopic versus abdominal Burch procedures in women with urinary stress incontinence. Multichannel urodynamic evaluation of laparoscopic Burch colposuspension for genuine stress incontinence. Five years follow up of laparoscopic burch colposuspension for stress urinary incontinence in Thai women. A surgical technique to adjust bladder neck suspension in laparoscopic Burch colposuspension. Stress urinary incontinence: Long-term results of laparoscopic Burch colposuspension. Long-term results of laparoscopic Burch colposuspension for stress urinary incontinence in women. Laparoscopic Burch colposuspension for stress urinary incontinence: A randomized comparison of one or two sutures on each side of the urethra. Frequency of lower urinary tract injury at laparoscopic burch and paravaginal repair. Lower urinary tract injury during the Burch procedure: Is there a role for routine cystoscopy? A three year prospective randomized urodynamic study comparing open and laparoscopic colposuspension. Prospective comparison of laparoscopic and traditional colposuspensions in the treatment of genuine stress incontinence. Prospective randomised controlled trial comparing laparoscopic and open colposuspension. Comparison of open retropubic and laparoscopic colposuspension for treatment of stress urinary incontinence. Extraperitoneal laparoscopic colposuspension: Short-term cure rate, complications, and duration of hospital stay in comparison with Burch colposuspension. Anatomic comparison between laparoscopic and open Burch colposuspension for primary stress urinary incontinence. Laparoscopic versus open colposuspension—Results of a prospective randomised controlled trial. Randomized comparison of laparoscopic and transabdominal burch urethropexy for the treatment of genuine stress incontinence (abstract). Randomized comparison of Burch urethropexy procedures concomitant with gynecologic operations. Laparoscopic burch colposuspension compared to laparotomy for treatment urinary stress incontinence. Comparison of two different surgical approaches in the treatment of stress urinary incontinence: Open and laparoscopic burch colposuspension. Cost-effectiveness analysis of open colposuspension versus laparoscopic colposuspension in the treatment of urodynamic stress incontinence. Open compared with laparoscopic approach to Burch colposuspension: A cost analysis. Cost-analyzes based on a prospective, randomized study comparing laparoscopic colposuspension with a tension-free vaginal tape procedure. Comparison of health care costs for open Burch colposuspension, laparoscopic colposuspension and tension-free vaginal tape in the treatment of female urinary incontinence. Cost comparison of the laparoscopic burch colposuspension, laparoscopic two-team sling procedure, and the transobturator tape procedure for the treatment of stress urinary incontinence. A prospective randomised study of Burch laparoscopy versus tension-free vaginal tape: 2 year follow-up (Italian).
Lower urinary tract symptoms order montelukast amex asthma treatment 911, such as urinary frequency and urgency can coexist with urogenital fistulas purchase montelukast 4 mg asthma treatment webmd. Urodynamics can identify the presence of detrusor overactivity and/or concomitant intrinsic sphincter deficiency buy cheap montelukast on line asthma bronchiale. Similarly, bladder outlet obstruction can coexist with urethrovaginal fistulas due to scarring, stricture formation, bladder neck disruption, and/or the presence of foreign material (i. Urodynamics can also identify small capacity or poorly compliant bladders in patients with a history of pelvic irradiation and other risk factors for poor compliance , thereby identifying patients that may require a concomitant augmentation cystoplasty procedure  or alternatively require a urinary diversion [63,86]. Bladder capacity should be established in any patient who may require ureteral 1570 reimplantation, in the event a psoas hitch is needed . There are a variety of strategies that can be employed to allow adequate bladder filling during the test. First, vaginal packing can be placed at the beginning of the study, during catheter placement to slow the leakage of fluid per vagina. Second, the patient can be placed in the supine position, rather than sitting or standing. If these maneuvers fail, the clinician can attempt to place an 8 French Foley catheter through the large fistula tract. If the fistula is distal, the urodynamics catheter can be placed alongside a small urethrally placed Foley catheter. The Foley balloon will, in some cases, sufficiently obstruct the fistulous tract to allow bladder filling. Whether iatrogenic or obstetrical in origin, the clinician must maintain a high index of suspicion in any patient with continuous leakage of urine per vagina. A thorough history and physical examination will often identify the location and mechanism of fistula formation. Appropriate imaging and endoscopic evaluation can provide valuable information needed to determine the size, number, and location of the fistulous tract. Urodynamics can help establish baseline capacity, compliance, as well as bladder and urethral function if the fistula is small enough to occlude. A high index of suspicion is needed to ensure that all fistulous communications are identified, including those that communicate with nonuro- genital organs or structures. Epidemiological and surgical aspects of urogenital fistulae: A review of 25 years’ experience in southeast Nigeria. Observations on prevention and management of vesicovaginal fistula after total hysterectomy. Obstructed labor injury complex: Obstetric fistula formation and the multifaceted morbidity of maternal birth trauma in the developing world. Uretero-fallopian fistula after gynecological surgery for endometriosis: A case report. Uretero-fallopian tube fistula secondary to laparoscopic fulguration of pelvic endometriosis. Ten-year experience with transvaginal vesicovaginal fistula repair using tissue interposition. The incidence of urinary tract injury during hysterectomy: A prospective analysis based on universal cystoscopy. Lower urinary tract injury during gynecologic surgery and its detection by intraoperative cystoscopy. Vesicouterine fistulas following cesarean section: Report on a case, review and update of the literature. The risk of vesicovaginal and urethrovaginal fistula after hysterectomy performed in the English National Health Service—A retrospective cohort study examining patterns of care between 2000 and 2008. Impact of dose in outcome of irradiation alone in carcinoma of the uterine cervix: Analysis of two different methods. A quantified approach to the analysis and prevention of urinary complications in radiotherapeutic treatment of cancer of the cervix. Radiation therapy morbidity in carcinoma of the uterine cervix: Dosimetric and clinical correlation. Vesicovaginal fistula and mesh erosion after perigee (transobturator polypropylene mesh anterior repair). Efficacy and safety of using mesh or grafts in surgery for anterior and/or posterior vaginal wall prolapse: Systematic review and meta-analysis. Evaluation and treatment of iatrogenic ureteral injuries during obstetric and gynecologic operations for nonmalignant conditions. Acute renal failure and multiple fistulae formation related to an unusual vaginal foreign 1572 body. Vesicovaginal fistula caused by a vaginal foreign body in a 72-year-old woman: Case report and literature review. Combined vesicovaginal-ureterovaginal fistulas associated with a vaginal foreign body. Urethral injury associated with minimally invasive mid-urethral sling procedures for the treatment of stress urinary incontinence: A case series and systematic literature search. Simultaneous urethral erosion of tension-free vaginal tape and woven polyester pubovaginal sling. An uncommon case of urethrovaginal fistula resulting from tension-free vaginal tape. Delayed presentation of an enterocutaneous fistula after tension-free vaginal tape sling. Congenital vesicovaginal fistula with transverse vaginal septum presenting as menouria—A rare case report and brief review. Ureterouterine and vesicoureterovaginal fistulas as a complication of cesarean section. A simple means of making the differential diagnosis of ureterouterine and vesicouterine fistula. Vesicouterine fistula after manual removal of placenta in a woman with previous cesarean section. Combined vaginoscopy-cystoscopy: A novel simultaneous approach improving vesicovaginal fistula evaluation. Urinary diversion in the vesico-vaginal fistula patient: General considerations regarding feasibility, safety, and follow-up. It is difficult to know the true incidence of urogenital fistula formation; the generally accepted incidence is derived from surgeries to correct these fistulas and approximates 1% or less of all genitourinary operations . According to the World Health Organization, it estimates that there are more than 2 million women worldwide affected by obstetric fistula and more than 100,000 new cases of urogenital fistula occurring per year worldwide . Urogenital fistula may be classified by anatomic communication, size, location, complexity, and extent of involvement (Table 107. In developed countries, the most common cause of urogenital fistula is hysterectomy .
This technique has many advantages: it is a less invasive procedure discount montelukast 5 mg online asthma symptoms 8-10, thanks to the Coleman cannulae; a more natural result is obtained and the absence of rejection because it can Fig cheap montelukast on line asthma treatment success rates. Another peculiarity of this procedure is that it can be repeated any time it is desired to increase the volume buy 10mg montelukast with amex asthma treatment homeopathy, when the results of the ﬁrst session are suboptimal . Another technique is the one developed by Carraway, which differs from the previous way the harvested tissue is processed. It is more practical and quick, since the tissue is simply washed with Lactated Ringer’s or saline in a speciﬁc net strainer, before being transferred in the syringes for grafting (Fig. This system allows preparation of bigger quantities in lesser time compared to the Coleman’s tech- nique . A disadvantage of these techniques, on the other hand, is that the grafted fat tissue unavoidably undergoes a certain resorption. The author’s experience, gained in many years in many anatomical regions of the body , allows us to afﬁrm Fig. A completely different situation is that of the lips, where the initial resorp- syringe, which the operator uses in a way that does not dam- tion is much more than in other facial districts. The common goal of all the different harvesting tech- The fat tissue harvested is subsequently centrifuged for niques is to obtain small particles of fat tissue, or groups of about 3 min at 3,000 rpm (Fig. Even if a small number of The tissue is then implanted in facial zones to treat, by studies notes differences in viability and quality of the means of 1-ml syringes connected to a very thin (1. To facilitate men, ﬂanks, thighs and knees, provide the same proportion maximal healing of the graft, the fat tissue is injected at vari- of viable cells . The amount of inﬁltrated solution depends on the fat tis- sue volume we want to remove and usually is in a 1:1 ratio with the aspirated volume. The inﬁltration is performed with a 14-gauge needle, and before beginning the liposuction, we wait 10 min for its effect. The cannula we prefer is the blunt- pointed Mercedes type, because it minimises tissue disrup- tion and trauma to ﬁbrous septa, neurovascular bundles and derma. The most important variable in this harvesting is the maximal negative pressure that we apply. Usually, 300–350 mmHg are the maximum negative pressure we can use for liposuction in the preparation of a lipoﬁlling. This technique involves the localised fat masses, from which it is possible to harvest the use of lipoﬁlling enriched with regenerative cells and stem needed amount of tissue. Barberi remaining harvested tissue is collected in a closed system sterile bag (Puregraft), in which a lipodialysis is performed by means of a bilaminar membrane system. The ﬁrst mem- brane performs selective ﬁltration, which allows the pas- sage of exfoliating cells, red blood cells and ﬂuids, including the inﬁltration substances, which are collected in a bag. The second membrane, sort of a “U-ﬂux” ﬁlter, allows the elimination of the elements to discard and keeps the puriﬁed fat tissue. The system reduces the liquid con- tent of the tissue to implant, which is proportional to the drainage time to which it undergoes, to obtain a graft that is more or less dense, depending on the surgical needs. It does not need centrifugation, and it is possible to process 100 cc in about 10 min. Concerning the lipoﬁlling enriched with regenerative and stem cells, this is a technique that nowadays ﬁnds an ideal use in breast and buttocks lipoﬁlling. The following facial regions are usually treated and remodelled with lipoﬁlling: • Frontal area: the glabella is a generally convex zone, which loses this appearance with ageing and becomes concave. The skin of the glabella, moreover, often shows wrinkles sustained by corrugator and procerus muscles. In correcting the glabella, it is enlarge the zygoma without resorting to prostheses, and best to associate also repeated injections of botulinic the result will be more natural, with a less sharp and more toxin, which allow the reduction of the wrinkles. In less evident cases, the temporal region undergoes lipoatrophy and forms a lipoﬁlling is performed through a medial approach depressed area that underlines the temporal ridge and (Fig. Sometimes external canthus, as always in the face creating the it underlines also the supraorbital border, which becomes approach with an 18-G needle and then with a curved or protruding and is a feature of ageing. The • The fat tissue pattern depends as well on the surgeon’s implanted fat tissue volume ranges between 2 and 6 cc, aesthetic sense, since he must ideally remodel the by means of a Coleman style I cannula, starting the injec- zygomatic area. In cases of more advanced ageing, lipo- tion from the deepest bony plan to the most superﬁcial ﬁlling is associated to face lifting . To achieve a good correc- pose tissue for eyelid lipoﬁlling involves using the tion and reduce the depth of naso-labial and “marionette” inﬁltration 1. The upper eyelid may have a dermal dissection of ﬁbrous attachments between skin skin and fat excess in its medial portion, but often in and underlying structures should be performed avoiding the ageing process, lipoatrophy occurs which causes a any skin incision. The dissection is carried with an 18-G hollowed eye, due to the presence of shadows. The area treated with preseptal will be possible to ﬁll the furrow’s depression, prevent- implant and always under orbicular muscle extends ing recurring adhesions. The upper part of the naso-labial from the superior palpebral groove to the superior and “marionette” furrow is treated injecting along the orbital border, with a lateral, medial and superior furrow’s axis, as well as perpendicularly to it (Fig. The injected adi- • The lower eyelids are mostly characterised by the pres- pose tissue varies between 2 and 6 cc for each furrow, ence of the tear trough, a deformity that marks the so- and 1–3 cc for the marionette’s, with a Coleman style I called eye bags (excessive depression of orbital furrow) cannula. The distance between the columella and the ver- starting from the malar zone, sustain and push up the million of the upper lip margin should be determined. Ideally the distance between the colu- the cheek and inferior to internal canthus, the entire mella and Cupid’s arc in the woman is 14 mm. The shape of the upper lip is and under the orbicular muscle, performing various to fuller in Cupid’s arc, and the normal vertical distance and fro movements with the syringe, to avoid creating of the upper lip is 10 mm, while that of lower lip is elevated masses and protrusions (eyelid skin is very 12 mm (Fig. It is frequently • Chin: The chin can be smaller, due to lipoatrophy or bone necessary to associate a liposuction in the submandibular resorption of the mandible, and thus is augmented in zone to the injection of adipose tissue at the mandibular facial rejuvenation procedures. With accesses at the ante- margin and the lipostructure at the junction between the rior third of mandibular margin and medially submental, mandibular margin and the anterior cervical region (Fig. In secondary cases, with adherent and scarred skin, the greatest care must be taken during the dissection; to avoid lesions to the skin, it’s most important 6 Local Anaesthesia with Sedation to perform inﬁltration with local anaesthetics, which eases this dissection. Also very important is the improved In most cases, patients undergo local anaesthesia with seda- skin quality produced by the lipoﬁlling. Due to very tion; only in some cases, and in association with face liftings, ﬁbrous scarred zones, this site quite often necessitates we use general anaesthesia. The techniques discussed its blood pressure and oxygen saturation; sedation is achieved Facial Lipoﬁlling 1041 Fig. In dibular contour; and the supratrochlear and supraorbital the eyelids, oedema can persist longer, and lymph drainage is nerves for the region of the superior palpebral orbital margin often prescribed to speed up the recovery. Upper and lower eyelids are always inﬁl- Nervous lesions are quite uncommon, because in the dan- trated with a local anaesthetic and vasoconstrictor solution, gerous areas the blunt cannula prevents problems, and any with a 30-G needle, while we try not to inﬁltrate the other palsy normally resolves in 60 days. Barberi Informed Consent Form for Lipoﬁlling Surgical • What happens after the lipoﬁlling? Procedure After the procedure, the patients are immediately able to perform daily activities. Results are achieve a more harmonious contour, during a liposculp- stable after the ﬁrst month and are permanent. These depressions can be corrected in the most natural and safe way by using the transfer of own fat • Possible complications tissue. Oedema, hematoma, rare asymmetries, exceptional cases Fat transfer, also called autologous fat graft or lipoﬁlling, of fat embolism and very rare nervous lesions restores the volume of face and body features with the patient’s own fat and represents an alternative to other Informed Consent treatments for ﬁlling.
The second technique and its variations are performed with a standard electrode catheter (Fig generic montelukast 5mg visa mild asthma definition. The catheter is then gently withdrawn so that the loop opens in the right ventricle with the tip resting in a position to record the His bundle electrogram buy montelukast pills in toronto asthma definition ppt. Recordings obtained in this fashion are comparable to those obtained by the standard femoral route (Fig purchase genuine montelukast on line asthma definition quadrilateral. As an alternative to any venous route, the His bundle electrogram may be recorded by a retrograde arterial catheter passed through the noncoronary (posterior) sinus of Valsalva, just above the aortic valve or just below the valve along the intraventricular septum (Fig. Risks and Complications In electrophysiologic studies, even the most sophisticated ones requiring the use of multiple catheters, left ventricular mapping and cardioversion should be associated with a low morbidity. We have performed approximately 12,000 procedures in our electrophysiology laboratories with a single death (a women with acute myocardial infarction, cardiogenic shock, and ventricular tachycardia) and with an overall complication rate of less than 2%. Complications that may arise from the catheterization procedure itself or from the consequences of electrical stimulation are discussed in the following sections. In general, the complication rates are higher in elderly patients and those undergoing catheter ablation than in patients less than 20-years old undergoing diagnostic procedures alone. Complications in diagnostic studies were approximately 1% and in ablation studies were approximately 2. The danger of hemorrhage is greater when the femoral artery is used, particularly in the obese patient. The danger can be minimized by: (a) maintaining firm manual pressure on puncture sites for 10 to 20 minutes after the catheters are withdrawn; (b) having the patient rest in bed with minimal motion of the legs for 12 to 24 hours after the study; (c) having a 5-pound sandbag placed on the affected femoral region for approximately 4 hours after manual compression is discontinued; and (d) careful nursing observation of the patient after the study. Thromboembolism In situ thrombosis at the catheter entry sites or thromboembolism from the catheter is a possibility. We do, as noted previously, however, recommend systemic heparinization for all procedures, particularly those in which a catheter is used in left-sided studies and in right-sided studies of very long duration, especially in a patient with a history of or high risk for thromboembolism. Note that the electrograms obtained from the His bundle catheters placed from the upper and lower extremities are nearly identical. Phlebitis Significant deep vein phlebitis, either sterile or septic, has not been a serious problem in our practice (it has occurred in 0. We do not routinely use antibiotics prophylactically, although in certain selected patients (e. Arrhythmias Arrhythmias induced during electrophysiologic stimulation are common; indeed, induction of spontaneous arrhythmias is often the purpose of the study. A wide variety of reentrant tachycardias may be induced by atrial and/or ventricular stimulation; these often can be terminated by stimulation as well. The risk of ventricular fibrillation can be minimized by stimulating the ventricle at twice the threshold using pulse widths of ≤2 msec. Complications of Left Ventricular Studies Left ventricular studies have additional complications, including strokes, systemic emboli, and protamine reactions during reversal of heparinization. Loss of pulse and arterial fistulas may also occur, but with care and attention, the total complication rate should 18 be less than 1%. No death occurred in their series due to intravascular catheterization, including thromboembolism, local or systemic infections, and pneumothorax. Tamponade Perforation of the ventricle or atrium resulting in tamponade is a possibility and has occurred clinically in <0. All required pericardiocentesis; one required an intraoperative repair of a torn coronary sinus. The right ventricle is more likely to perforate than the left ventricle because it is thinner. Perforation of the atrium or coronary sinus is more likely to occur as the result of ablation procedures in these structures for atrial arrhythmias and bypass tracts (see Chapter 14). Perforation with or without tamponade is more frequent during procedures involving ablation (approximately 0. The safety of electrophysiologic studies has been confirmed in other laboratories and in published reviews of this 17 18 type. Sixty-cycle interference from line currents should be eliminated by proper grounding of equipment and by shielding and suspension of wires and cables. Turning off fluoroscopic equipment (including the x-ray generator) once the catheters are in place may further improve the tracings. Use of notch filters can rid the signal of 60-cycle 7 interference but will alter the electrogram size and shape (see Fig. Tremor in the patient can be dealt with by reassurance and by maintaining a quiet, warm laboratory; when necessary, small doses of an intravenous benzodiazepam may be necessary. Occasionally, the recording of extraneous electrical events, especially repolarization, can confound the interpretation of some tracings (Fig. From top to bottom: standard leads 1, 2, and V1, high-right atrial, His bundle, and right ventricular electrograms, and time lines at 10 msec and 100 msec. In the His bundle electrogram tracing, the sharp spike that occurs in the middle of electrical diastole could lead to confusion. Catheter ablation for cardiac arrhythmias: clinical applications, personnel and facilities. Guidelines for clinical intracardiac electrophysiological and catheter ablation procedures. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Clinical Intracardiac Electrophysiologic and Catheter Ablation Procedures), developed in collaboration with the North American Society of Pacing and Electrophysiology. Task Force 6: training in specialized electrophysiology, cardiac pacing and arrhythmia management. American College of Cardiology/American Heart Association clinical competence statement on invasive electrophysiology studies, catheter ablation, and cardioversion. A report of the American College of Cardiology/American Heart Association/American College of Physicians– American Society of Internal Medicine Task Force on clinical competence. Guidance of radiofrequency endocardial ablation with real-time three-dimensional magnetic navigation system. Reconstruction of endocardial potentials and activation sequences from intracavitary probe measurements. The pathophysiologic basis of fractionated and complex electrograms and the impact of recording techniques on their detection and interpretation. Clinical significance of ventricular fibrillation-flutter induced by ventricular programmed stimulation. Considerations regarding the technique for transseptal left heart catheterization. Complications of diagnostic electrophysiologic studies and radiofrequency catheter ablation in patients with tachyarrhythmias: an eight-year survey of 3,966 consecutive procedures in a tertiary referral center. To perform and interpret the study correctly, one must understand certain concepts and methods, including the different types of electrogram recordings, measurement of atrioventricular (A-V) conduction intervals, activation mapping, and response to programmed electrical stimulation. Knowledge of the significance of the various responses, particularly to aggressive stimulation protocols, is mandatory before employing such responses to make clinical judgments. Although each electrophysiologic study should be tailored to answer a specific question for the individual patient, understanding the spontaneous electrophysiologic events and responses to programmed stimulation is necessary to make sound conclusions. Electrogram Recordings As discussed in Chapter 1, electrograms can be recorded as unfiltered or filtered unipolar signal or bipolar signals. When unfiltered, significant far field activity is recorded that can make it difficult to see small local unipolar signals without increasing the size of the signal so much it swamps the amplifier.