Joseph A. Worrall, MD, RDMS

A 27-year study of 1300 women undergoing retropubic cystourethropexy using 	either the modified Marshall-Marchetti-Krantz procedure or the modified Pereyra procedure compares long-term results 	when the type of surgery is selected on the basis of patient criteria.

 (SUI) is one of the most common yet complex problems confronting physicians who 	provide primary care for female patients. Nearly 40% (13 million) of all adult American women will experience various 	degrees of SUI during their lifetime.

 Symptoms can range from occasional leakage of a few drops of 	urine to complete loss of urine under certain conditions of stress. Although nonsurgical methods such as dietary 	changes, bladder retraining, Kegel exercises, biofeedback, pessaries, electrostimulation, and drug therapies have 	been used successfully to treat these women, many patients eventually require surgical repair to relieve their 	symptoms.

Over the past century, many surgical procedures have been developed to correct SUI. Kelly and Dumm

 	first described the traditional Kelly plication and anterior vaginal repair in 1914. The procedure was performed 	for more than half a century for patients with SUI, and many surgeons still employ the Kelly technique with various 	modifications. However, studies indicate that the operation has a success rate of only 60% to 70%.

Many types of retropubic procedures have been devised in an attempt to improve the cure rate of the standard 	Kelly repair. Abdominal procedures include the paravaginal repair, Burch procedure, and modified Marshall-Marchetti-Krantz 	(MMMK) procedure. Vaginal retropubic cystourethropexies include the Stamey, Raz, Gittes, Cobb-Ragde, and modified 	Pereyra (MP) procedures. Most of the studies involving these procedures have been restricted to short-term follow-up. 	Our first study

 followed some patients for up to 16 years, and this report is a continuation that includes 	follow-up of 27 years in some cases.

The type of surgery was dictated by patient criteria as opposed to random selection. Patients who presented 	with indications for abdominal surgery and associated SUI underwent the appropriate abdominal procedure followed 	by an MMMK procedure.

 Patients with indications for vaginal surgery and associated SUI underwent an 	MP procedure followed by an anterior and posterior vaginal repair.

 The study sought to determine 	whether equally good long-term results could be achieved with the procedure performed via either route.

Over a period of 27 years, between January 1966 and December 1993, 727 patients underwent an MMMK procedure 	and 660 patients underwent an MP procedure combined with anterior colporrhaphy and associated vaginal surgery. 	Complete follow-up was not possible in 87 patients because either they left the area or no accurate records were 	available; these patients were not included in the current study. To date, 675 patients have been included in the 	MMMK group and 625 patients in the MP group, totaling 1300 patients with accurate records and follow-up.

All patients underwent a thorough history, with physical and pelvic examinations and basic office urinary stress 	testing. A history of involuntary loss of urine secondary to increased intra-abdominal pressure while coughing, 	sneezing, laughing, or straining was noted. The number of tampons, pads, or other protective devices was recorded 	as well. Patients with transient causes of urinary 

incontinence (eg, urinary tract infections, hypoestrogenism, 	cholinergic-stimulating medications, psychological disorders) were excluded from consideration. Likewise, patients 	whose incontinence was not bothersome did not undergo surgery. Only women whose symptoms disrupted their daily 	activities were considered as candidates for surgical correction. More than 300 patients were excluded owing to 	poor medical condition or various other reasons; whenever possible, a pessary was used in these cases.

The physical assessment focused on the abdomen and pelvis. Patients were examined with the bladder empty and 	then reexamined with a full bladder, usually in both the standing and supine positions. Degrees of uterine or vaginal 	prolapse were documented, including cystocele, enterocele, and rectocele. All patients underwent a lubricated cotton-swab 	test, bulbocavernosus reflex test, and Bonney-Marshall test.

The most important observation was actual visualization of loss of urine with coughing and/or straining. Especially 	in the early years of this study, it was felt that patients who easily demonstrated loss of urine did not require 	expensive urodynamic procedures that were not the standard of care at the time. However, any patient with no obvious 	SUI, a neurologic disorder, or a prior failed incontinence procedure was referred to a urologist for supplemental 	urodynamic evaluation to differentiate among urge, overflow, stress, or mixed incontinence. Only patients with 	genuine SUI were considered for surgical correction; women with other types of incontinence were treated by a urologist. 	Patients who demonstrated genuine SUI were subdivided into those who needed retropubic cystourethropexy combined 	with a vaginal surgical procedure or those who required retropubic cystourethropexy combined with an abdominal 	approach.

If there was a significant degree of uterine prolapse with associated cystocele and/or rectocele, a standard 	vaginal hysterectomy was usually performed. This was followed by an MP procedure as described by Pereyra and Lebherz

 	with some minor modifications, along with anterior and posterior vaginal repair, when indicated.

Our modification of the original Pereyra procedure places #1 chromic sutures on a #885 needle vertically through 	the posterior pubourethral ligaments. The vertical sutures are placed in three or four consecutive, nonlocking 	bites, starting 1 cm down from and 1 cm lateral to the external urethral orifice and extending to the urethrovesical 	junction on each side. This technique differs from the horizontal helical sutures originally described by Pereyra 	and Lebherz.

 It is important to note that the Pereyra needle is continuously held against the index 	finger as it is advanced downward through the urogenital diaphragm to avoid possible puncture of the bladder or 	urethra. After the suture is carried through retro-pubically, the sutures are held above with hemostats on each 	side of the lateral edge of the incision until placement of the Kelly plication sutures. The sutures are then pulled 	upward to elevate the urethra and bladder neck and tied tautly across the suprapubic fascia, making sure to avoid 	strangulation of the tissue. The formation of a new posterior urethrovesical angle is readily apparent as it rises 	behind the pubic bone (Figure 1). The bladder is filled with 300 mL of sterile water so that a suprapubic catheter 	can be placed 1 inch above the suprapubic incision.

The MMMK procedure is performed as described originally in 1949,

 with some minor modifications. 	The appropriate abdominal surgery is performed, followed by closure of the anterior parietal peritoneum. A #1 chromic 	suture on a #885 needle is placed perpendicularly 1 cm lateral to the midurethra, and a second bite of the same 	suture is placed deeper into the same area to include a portion of the vaginal wall. This differs from the original 	Marshall-Marchetti-Krantz procedure in that the suture is placed into the midportion of the fibrocartilage of the 	median raphae of the symphysis pubis rather than into the periosteum, eliminating the potential for osteisis pubis. 	In another departure from the original technique, a second suture is positioned on each side 1 cm lateral to the 	urethrovesical junction. This suture is placed into the upper portion of the fibrocartilage of the median raphae 	of the symphysis pubis, or through the rectus fascia above the same area. The sutures are tied on each side while 	elevating the urethra toward the retropubic position (Figure 2).

The combined study from 1966 to 1993 (27 years) includes 1387 retropubic procedures except for 87 patients who 	were lost to follow-up. The current combined study includes 675 MMMK procedures and 625 MP procedures, totaling 	1300 retropubic cystourethropexies for which records and information were available.
 	The combined clinical cure rate for the two procedures was 86.1%, with improvement in 7.6% of cases and failure 	in 6.3%. There were 56 failures in the MMMK group and 29 in the MP group. After complete urologic evaluation, 55 	of the 85 failed patients underwent repeat operations. For various reasons, 30 patients in the failed group did 	not undergo repeat surgery.

Articles

A 27-year study of 1300 women undergoing retropubic cystourethropexy using either the modified Marshall-Marchetti-Krantz procedure or the modified Pereyra procedure compares long-term results when the type of surgery is selected on the basis of patient criteria.

Update on Retropubic Incontinence Surgery

This is a 21 year old G3 P1 SAB2 (both at about 12 weeks, each with a D&C)  who was sent to me for an ultrasound because she was bleeding. The LMP was  unknown, and the pregnancy test had been positive several days before. She is Rh  negative. She had a LEEP in 1994 for CIN 1 of the cervix.

This was the first ultrasound I had done with our new ATL HDI 5000, and we  had not yet had our visit from the applications specialist. For reasons that are  not clear to me now, I did not videotape this exam.

I found dichorionic twins, one with a heartbeat, the other without a  heartbeat. There was a large subchorionic hemorrhage (~ 35 percent of the living  twin chorion separated, less from the dead twin). The living twin measured at  6w3d with the embryonic heart rate 125 to 133, normal for 45 days menstrual age.

The best way to present the chronology is to list the ultrasound exams done.

11/16/98 6w3d, bleeding, dichorionic twins with one dead twin,  	subchorionic hemorrhage of both chorions, the living sac with a larger  	hemorrhage than the dead sac.

11/20/98 7w2d (7w0d by the first ultrasound), living twin doing well,  	subchorionic hemorrhage present. 	

(click on each image to view  				larger version)

11/25/98 8w2d (7w5d by the first ultrasound). The dead sac is  	collapsing, less subchorionic hemorrhage, the living twin is doing well.

12/2/98 9w1d (8w5d by the first ultrasound), patient had an acute  	bleeding episode. No subchorionic hemorrhage seen, the dead sac almost gone,  	the living twin doing well. The cervix was long and closed. 	

12/16/98 11w6d (11w0d by the first ultrasound), dead sac gone, living  	twin doing well.

12/31/98 ultrasound done at the radiology department, Fairbanks Memorial  	Hospital (a visit to the emergency room because of bleeding), 14w1d (12w6d  	by the first sono). A myoma is seen, with a small subchorionic hemorrhage  	seen near the myoma. (I suspect the myoma may have been a focal myometrial  	contraction).

2/25/99 21w6d (20w6d by the first ultrasound). Normal growth and  	development of the fetus. Marked funneling and shortening of the cervix  	noted. 	

(On 3/1/99 a Shirodkar cervical cerclage was done using a Mersilene  	strip).

4/8/99 26w6d (26w2d by first sono). The cervix looks about the same as  	it did on 2/25/99 except we can now see the Mersilene. 	

The patient went into labor, and attempts to stop the labor were not  successful. On 4/12/99 a C-Section was done. The membranes were intact at the  time of the Section, and the amniotic fluid was very foul smelling. Cultures  grew several organisms, including peptococcus. The Shirodkar suture was removed  at the time of the Section.

At the time of the Section the gestational age, based on the first  ultrasound, was 27w4d. However, the baby weighed 3 pounds 4 ounces, and was  considered 31 weeks after pediatric assessment.

The baby is still in the hospital and is doing well.

 IS – all done in the same  lab) from the early first trimester:

Our conventional wisdom tells us the quantitative HCG should double in 3  days. "Always give the pregnancy the benefit of the doubt".

In addition to the basic theme of "Never Give Up", what are the interesting  points of this case presentation?

In view of the size of the baby at delivery, could the gestational age early  in the first trimester have been underestimated? Could the surviving embryo have  been poorly grown because of all the stress (bleeding, subchorionic hemorrhage,  and death of a twin)?

Or, does it make more sense to say the maturity of the surviving fetus was  accelerated by all the stress shortly before birth (surgery, anesthesia,  steroids, and chorioamnionitis)?

Or, could each factor have contributed to the final estimate of the neonatal  gestational age?

How accurate is the neonatal assessment of gestational age by the  pediatrician? Could our determination of gestational age by ultrasound at around  6 to 7 weeks menstrual age have underestimated the gestational age by 3 or 4  weeks? This seems very unlikely to me.

Obviously the quantitative HCG does not always double in three days, so we  should be cautious about applying this "rule".

Did the chorioamnionitis (with intact membranes) come from the Shirodkar  cerclage? This seems to be the most likely explanation.

This is a 21 year old G3 P1 SAB2 (both at about 12 weeks, each with a D&C) who was sent to me for an ultrasound because she was bleeding. The LMP was unknown, and the pregnancy test had been positive several days before. She is Rh negative. She had a LEEP in 1994 for CIN 1 of the cervix.

Don’t Ever Give Up!

The stuck twin is part of the twin-twin transfusion syndrome. The easiest-to-understand explanation is that within the single placenta of a monochorionic twin pair, there are arteriorvenous communications between the circulation’s of the twins. One twin (the donor) shunts blood to the other (recipient) twin. The donor does not grow well, it looses its amniotic fluid, thus cannot swallow, cannot urinate, and eventually it is shrink-wrapped in its amnion.

The recipient twin becomes plethoric in a polyhydramniotic sac, bounces around a great deal, swallows and urinates up a storm, and may develop cardiovascular disease.

This explanation is too simplistic. Certainly this problem occurs almost exclusively in monochorionic situations, but there are various theories as to the vascular mechanism. Also be aware that there are other causes of stuck twin and discordant growth: aneuploidy, infection, and structural defects.

The first and most important role of the sonographer is to make the diagnosis of monochorionic twins. This can best be done before 10 or 11 menstrual weeks, when you will clearly see one gestational sac and two amnions if the pregnancy is monochorionic and diamniotic. If it is dichorionic, you will clearly see two separate gestational sacs in the uterus.

Later in pregnancy the diagnosis of chorionicity becomes a little problematic. The most important thing is to be aware that it is your job (with twins) to make some comment about chorionicity. I have seen ultrasound reports that do not mention the subject. It is of vital importance, because monochorionic twins have a much higher rate of complications (including TTTS, but there are others) than dichorionic twins.

See your standard references if necessary to review how to make your best guess as to chorionicity later in pregnancy. If you diagnose boy and girl, it is not monochorionic, but if the twins are the same sex they are not necessarily monochorionic. The intertwin membrane, twin peak sign, status of the placentas all help in making your best guess. But before 11 weeks you can usually be certain.

TTTS is a very serious problem, occurs in about 32% of monochorionic pregnancies, and if untreated has as much as an 80% fetal mortality rate.

The most used treatment is serial amniocentesis of the recipient’s sac.

This case was a 26 year old LPN employee of our Clinic. She had one previous C Section, and that baby had renal UPJ stenosis, but did well.

The diagnosis of monochorionicity was made at the first transvaginal scan at 10 weeks 1 day menstrual age (it helps to work in a clinic). The next scan was done at about 20 weeks. We noticed that there was lots of fluid, which made for great imaging. We noticed that one baby, the one with the big stomach, full bladder that never seemed to empty (it takes us about two hours to scan twins), the thick cord, and the bilateral pyelectasis, was jumping all over the place. And the other twin was barely moving, and we could not find the stomach and the bladder. Suddenly a light went on! From then on our scans were trying to prove our idea that this was a stuck twin.

We never did find any amnion or intertwin membrane. The babies were just about the same size. And they both had upper limits of normal cerebral atria.

The mom was sent to an Army teaching hospital in the Northwest, and the only follow-up I received was when she telephoned her friends here at the Clinic. She stayed in the hospital for the rest of the pregnancy, did have serial decompression amniocenteses, the stuck twin became unstuck, and she delivered by C-Section at 33 weeks. Both babies weighed about 3.5 pounds. One was on a ventilator, and the other had too many platelets, had some blood removed, and saline infused. Both had normal karyotype.

I subsequently heard that one of the babies had to be cared for in an institution, and died about age 10 months. I have not heard about the other baby, and I do not know for sure if the "bad" baby was the donor or the recipient.

It is a difficult task to demonstrate a stuck twin on a still image. If you have the opportunity, try to do it. Try to show amnion stretching from promontory to promontory, such as knee to elbow. I was not able to find any sign of an amnion, anywhere.

Two references that I think are good (and it is a good idea to review the entire subject of twins) are: "Ultrasound and Multifetal Pregnancy", Edited by A Monteagudo and I. E. Timor-Tritsch, published by Parthenon 1998, part of Parthenon’s "Progress in Obstetric and Gynecologic Sonography Series".

Callen’s "Ultrasound in Obstetrics and Gynecology", Third Edition, Chapter Eight, "Ultrasound Evaluation in Multiple Gestation" by Harris J. Finberg.

(click on each image to view larger version)

The stuck twin is part of the twin-twin transfusion syndrome. The easiest-to-understand explanation is that within the single placenta of a monochorionic twin pair, there are arteriorvenous communications between the circulation’s of the twins.

Stuck Twin

Ob/Gyn Ultrasound at the Fairbanks Clinic

Nuchal translucency is the swelling just under the skin at the back of the   fetal neck. It is important because if the fetus has a greater-than-normal   amount of swelling at the back of the neck, there is a high likelihood that   the baby will have Down Syndrome or a major heart problem or both.

Most of us in the business of prenatal diagnosis believe it is desirable to   discover before birth the defects that a baby might have. Not all people   believe this however. Nuchal translucency takes its place with the triple   screen blood test (a screen for abnormal chromosomes, such as Down Syndrome,   and also a screen for neural tube defects such as spina bifida) and prenatal   ultrasound anatomic survey as the methods we use to look for abnormalities in   the unborn.

Nuchal translucency must be done between 11 weeks 0 days and 13 weeks 6   days menstrual gestational age. The swelling is transient and may be gone if   you look after 14 weeks. This time window in the pregnancy is a little too   early to do the anatomical survey, but it is a good time to do not only nuchal   translucency, but also date the pregnancy, see if there are twins, and look   for gross abnormalities.

If money were no problem, the ideal thing would be to have two ultrasounds   during your pregnancy, one around 11 weeks, and another around 22 weeks. It is   best to have the nuchal translucency done early in the 3-week window, because   it is not always possible to obtain the correct view of the fetus, and if you   are early in the window, we can have you return to try again. If you have your   nuchal translucency scan at 13 weeks 4 days, and we cannot obtain the view we   want, we do not have much time to try again.

The view has to be right along the middle and length of the fetus. We can   try to do it through the abdomen or through the vagina. I prefer the vaginal   approach at this time in pregnancy because we have so much better resolution   than through the abdomen. This is particularly true if the patient is on the   heavy side. But we have very little room to maneuver the transducer through   the vagina, and if the baby is not in just the correct position, we will then   try from the abdomen.

So what is one to do if they have to pay for their own prenatal ultrasound,   or they have a third party payer that will pay for only one ultrasound in the   pregnancy? If you are young (under age 35) you would probably be better off   getting the ultrasound done at 20-22 weeks. If you are 35 or older I cannot   tell you what would be best: your risk of having a baby with a chromosomal   abnormality (such as Down syndrome) increases with your age, so you really   ought to have both the nuchal translucency testing and the anatomical survey.   Babies with abnormal chromosomes have a high incidence of anatomical   abnormalities, such as congenital heart disease.

HOWEVER (we can go round and round on this) the majority of Down babies are   born to low risk young women, because young women have far more babies than   older women. So it is very difficult to say that a young woman does not need   to have nuchal translucency measured. And most obstetrical providers are   obtaining triple screens on all pregnant women regardless of their risk   category. The difference is that ultrasound cost more than the triple screen   blood test.

The ideal thing would be if we providers charged a flat rate for all the   obstetrical ultrasound a patient needed during a given pregnancy. One scan or   ten scans: all the same price. Or even better, if all the necessary   ultrasounds were included in the obstetrical package fee. I have not seen any   movement in this direction, but it makes sense to me.

If your obstetric provider is going to order a first trimester ultrasound,   and there is no particular reason why it should be done at 7, 8 or 9 weeks,   you could suggest that you wait until 11 weeks 0 days. You will have not only   the benefits of an early ultrasound, but also the nuchal translucency   measurement. We do not charge extra for doing a nuchal translucency

Nuchal translucency is the swelling just under the skin at the back of the fetal neck. It is important because if the fetus has a greater-than-normal amount of swelling at the back of the neck, there is a high likelihood that the baby will have Down Syndrome or a major heart problem or both.

Joseph A. Worrall, MD, RDMS

Articles

Update on Retropubic Incontinence Surgery

Don’t Ever Give Up!

Stuck Twin

Nuchal Translucency: What is it and where does it fit in Prenatal Sonography