By J. Joey. Sterling College, Sterling Kansas.
The ment (interdomal ligament or Pitanguy’s ligament) that is skin is normally thinner and smoother buy cheap prednisone 40mg on line, with less subcutaneous important for tip suspension (Fig discount 5mg prednisone otc. Its thickness is important because it allows us to area of the external vestibule of the nose that must be pre- predict the degree of adjustment of the cutaneous and subcuta- served in nasal incisions proven prednisone 20mg. The columella extends from the lobule to the labial phil- A thinner skin exhibits more imperfections; a thicker skin trum generic 20 mg prednisone overnight delivery. It consists, anteriorly, of the intermediate crus and the two medial crura, which are intimately connected in the front part and diverge posteriorly, forming an open angle where the cartilaginous septum and the nasal spine bone are placed. Internal valve Fibrous connections Piriform opening Suspensory ligament Fibrous External valves of the lip ligaments Fig. Internal become part of the nasal musculature of the medial orbicu- valve laris and the zygomatic minor muscles. The depressor septi nasi may be more or less repre- sented, and has been described in three variations: one in External which the ﬁbers end on the orbiculari oris, another in which valve the ﬁbers end on the periosteum, and a third, rudimentary type consisting predominantly of a rudimentary ﬁbroapo- neurotic beam. In certain cases, the section of the distal part of the septum depressor and their subsequent suture allows better visualization of the upper lip area, to maintain constant the rotation and projection of the nose even during movement. All of the aforementioned muscles participate actively in nostril movement during breathing [1, 4, 12, 15, 16 ]. The ophthalmic artery is the ﬁrst branch of the inter- Below the subcutaneous mantle, the presence of muscle nal carotid artery distal to the cavernous sinus and terminates aponeurotic structures involved in nasal scaffolding, and in two branches, the supratrochlear (or frontal) artery and the their mobility, is also important. The latter exits the orbit medially, run- The nasal muscles can be divided according to their ning laterally to the nasal bones until the nose tip. It supplies function: the proximal portion of the nose and contributes to the sup- ply of the subdermal plexus of the tip. The • Compressor: transverse nasalis lateral nasal artery is a branch of the facial artery, arising later- • Dilators: dilator naris anterior and posterior ally to the nasal ala, which runs downward laterally to the alar cartilages until the nostrils where, with some small branches, They can be also divided into intrinsic muscles (which it contributes to the blood supply of this area. Both the ophthalmic and the facial arteries, with their The nasal muscle consists of two parts, transverse and branches, supply the subdermal system (Fig. The transverse part arises from the maxilla, above and lateral to the incisive fossa; its ﬁbers proceed upward 4. The alar part is attached by one end to the greater alar major veins of the nose and runs along the nasal vault cartilage and by the other to the integument at the point of perichondrium. The lym- extrinsic muscles; it dilates the nostril and elevates the upper phatic drainage takes place laterally to the nose, above the lip, enabling one to snarl, and in some individuals it may lateral crus, throughout the piriformis opening, and through Basic Rhinoplasty 597 allow air humidiﬁcation. The goblet cells are intercalated among the others and are responsible for mucous secretion. The lamina propria is looser on the outer surface, with Angular lymphocyte clusters, and is dense and more adherent to the nasal artery periosteum or perichondrium on the inner part. Tubule aci- nar glands with serum mucosa secretion are present in the underlying connective tissue. The role of nasal secretion is Arches to trap foreign particles and protect against infectious agents such as fungi, bacteria, and viruses via the presence of lysozyme, a lytic bacterial wall enzyme, and immuno- Angular artery globulin A (IgA). Vessels arising perpendicularly from the deep branches of the periosteum guarantee the vascularization of the respira- Facial artery tory mucosa. They form a ﬁrst deep network in the lamina Branch for propria and a second network at the subepithelial level. The columella region has no There is a rich venous cavernosus plexus at the level of lymphatic drainage. The tip is supplied by two arterial vascular systems, the lat- In a wide zone of the septum called the locus Valsalvae, eral nasal artery being the most important. This explains why mucosa continues with skin and the lamina propria takes the open technique, if properly executed, can scarcely create tip the appearance of well-vascularized papillae, reaching the necrosis, as it affects only the columellar artery. For this reason, epistaxis is quite common in should be taken if the patient has undergone interventions that this area. The same artery will also be damaged if the surgeon does not preserve 2 mm of the alar cartilage while performing a surgical incision. The olfactory mucosa is a specialized epithelium that covers Defatting of the tip must be performed with caution, as it the lamina cribrosa of the ethmoid, the upper part of the sep- is vascularized by the subdermal plexus. In this areas of the mucosa, such as on the nasal conchae, a stratiﬁed part of the mucosa, the lamina propria is characterized by squamous epithelium may be present. A personal history of consumption of these drugs is important because of their signiﬁcant anticoagulant effect. Each day All compounds containing aspirin should be suspended for about 10,000–20,000 L of air passes through the respiratory at least 10 days before surgery. The quality and quantity of airﬂow depend on the A history of allergic diseases, such as vasomotor rhinitis, integrity of the nasal anatomical structures and the environ- alerts the surgeon because these patients may suffer worsen- mental and endogenous factors that inﬂuence it. External temperature, tobacco smoke, inﬂammatory pro- Therefore the surgeon must warn the patient that the inter- cesses, infections, and stress may all inﬂuence nasal airﬂow. Otherwise, which over time has been reduced, localizing mainly at the the surgery should be delayed in the case of a respiratory level of the mucosa of the lamina cribrosa of the ethmoid. The high specialization of the nasal mucosa explains the A history of traumas of various type and gravity alerts the important respiratory, olfactory, and immunological roles surgeon because of the possibility of ﬁnding diverted and/or played by the nose. Instrumental tests are use- While passing through the nasal cavities, air is cleaned ful to highlight these conditions, and are recommended and ﬁltered from corpuscular particles captured by the before surgery. Initially Furthermore, personal information about any drug abuse the air has a swirling ﬂow that is converted in the lamina by should be comprehensive. The increasingly and extensive ﬁne vibrating cilia movements, and is heated and humidi- nasal use in today’s society of drugs, such as cocaine, can ﬁed by these vibrating cilia depending on the external cause avascular necrosis and perforation of the septum, in temperature. The lysozyme, together with IgA, plays a primary non- Last but not least, patients who have taken psychotropic speciﬁc immune function of defense in the nasal secretions. The olfactory function is chological history should always be reported and psychiatric strictly dependent on the airﬂow, and voice resonance varies patients, especially those who are dysmorphophobic, must be in cases of important nasal obstruction. The nasal valve is the narrowest portion and, thus, con- Physical examination of the nose starts peremptorily from fers greater resistance to airﬂow. This rule is are negative pressures, with positive pressure during exha- often not well considered, although it is crucial for maintain- lation. Surgical alterations of the nasal valve can seriously ing harmony of the overall framework of the face. Weakness or deformity of the alar The shape, the position, the size and volume of the fore- cartilage can reduce the size of the nasal valve [3, 5, 17]. Any eventual face asymmetry should be pointed 6 Preoperative Evaluation out to the patient [6 ]. Examination Physical examination of the nose proﬁle allows evalua- tion of the nasion point, the nasofrontal angle, and the naso- The medical history of a patient undergoing rhinoplasty is facial angle, and whether the dorsum is kyphotic or “saddle. Family history of bleeding and a personal history of One then continues by evaluating the supralobular incisors, bruising or bleeding may imply a blood dyscrasia. Even the tip along with the projection–nose length relationship, women who do not present with true hemophilia can be carri- the columellar–lobular complex with columellar shape and ers, and may show a tendency toward serious and dangerous protrusion, and the columellar–lobular angle. Whenever there is the slightest suspicion of a bleeding ten- The front and oblique (three-quarters) views allow study dency, as in these cases, a careful study of the clotting time of the nose root, highlighting its symmetry, width, projec- and all coagulation parameters becomes mandatory. Finally, • Presence of tumors and pathological tissue observation of the nose with the head extended allows evalu- • Presence of foreign bodies ation of the nostrils, columella, lobule, and wings, with vari- ous features such as their insertions, dimensions, and However, anterior rhinoscopy often does not allow obser- orientations. It should be kept in mind that the female nose vation of the vault and the rear wall of the nasal cavity, has a better deﬁnition than the male nose [19 ]. Skin examination plays a major role: a thick, seborrheic skin retracts soon after the intervention, in an unpredictable way. The skin’s appearance is strictly related to the patient’s age and to any previous rhinoplasties regarding Plain radiographs of the skull in anteroposterior, lateral, and the presence of atrophies, adhesions, and/or retractions. One may mid, evaluating its length in comparison with the cartilagi- also require a particular low-energy X-ray or “soft ray” image nous portion of the nasal pyramid and the width of the lateral of the skull to better study the cartilaginous components. The transnasal pressure is measured by tive visit, is performed through a nasal speculum and a coaxial comparing the nasopharyngeal pressure with that in the light source. The rhinoscope is introduced with the tip directed external nostril, which usually corresponds to the atmo- slightly laterally in the nasal vestibule. The airﬂow volume passing through the nose maneuver can cause discomfort to the patient when the nasal during active nasal breathing is registered together with the speculum is in contact with the sensitive respiratory mucosa of differential pressure of the nose. Initially the patient’s head is held x–y diagram or as two separate sine waves on an oscillo- in a vertical position to allow the examiner’s eyes to be parallel scope. By convention, upper right and lower left slightly to allow the upper part of the nose to be examined. The quadrants are used for nasal airﬂow, and upper left and lower medial cavity and the turbinates are thus highlighted. The ﬂow–pres- The maximum backward tilt permits exposure of the eth- sure line is curved because at high levels of resistance, the moid region and the olfactory ﬁssures.
Topical regimens are well tolerated with few adverse effects purchase prednisone 5mg mastercard, although burning may occasionally occur buy discount prednisone 5 mg. Under these circumstances generic 20mg prednisone free shipping, patients respond to all azoles cheap prednisone 10 mg fast delivery, topical or systemic, with a success rate in excess rate of 90% regardless of duration of therapy (Table 57. Accordingly, a compromised host women with severe vaginitis should receive more prolonged, conventional antimycotic therapy usually requiring up to 7 days of treatment [13–16]. Treatment of women infected with non-albicans Candida species remains problematic. Somewhat improved results are achieved with vaginal boric acid and with 60%–70% eradication rates [17,18]. The latter has to be compounded, is not available commercially, and is extremely expensive. More important than selecting an antifungal agent is deciding whether to treat vulvovaginal symptoms in the presence of culture-positive C. Moreover, even when successful, organism elimination is not accompanied by concomitant relief or eradication of symptoms. Nevertheless, when no other explanation for symptoms is available, a trial of therapy is clearly justified, but clinicians should not trivialize the complex relationship between this yeast and vulvovaginal symptoms. It is likely that genetic factors are operative in the overwhelming majority of such patients. Nevertheless, secondary precipitating mechanisms are frequently present and vary from patient to patient. Thus, while all patients share an underlying genetic predisposition, triggers to symptomatic episodes vary considerably. Before embarking on any treatment protocol, the diagnosis must be confirmed by the presence of culture, which includes organism speciation. Fungal susceptibility tests are not routinely indicated unless drug breakthrough infection or refractory disease occurs with appropriate azole therapy. Every effort should be made to control trigger mechanisms including the use of antibiotics, control of diabetes, and local predisposing factors such as concomitant vulvar dermatosis. Once these factors have been excluded or treated, an induction regimen with an antimycotic followed by a long-term suppressive maintenance regimen is indicated. While this can be accomplished with topical regimens, because of the duration and frequency of therapy, oral therapy is more convenient and offers a more realistic solution. The use of long-term suppressive maintenance regimens has been confirmed in several prospective controlled studies [19,20]. Accordingly, after an induction regimen of fluconazole 150 mg given every 72 hours for 3 doses, a weekly maintenance regimen of fluconazole 150 mg once weekly is suggested. Complete resolution of symptoms follows within a matter of weeks, and the patients remain asymptomatic for the duration of therapy, which is recommended for 6 months. During this period, the patient invariably remains culture negative and asymptomatic. However, 50% of patients will return to an attack-free life with risks similar to low-risk women. Should symptomatic recurrence rapidly follow discontinuation of therapy, repeat reinduction and maintenance therapy is recommended this time for at least 12 months. Frequently, even longer prolonged maintenance regimens are recommended and required. It has been diagnosed in 17%–19% of women seeking gynecological care in family practice or student health-care settings . The worldwide prevalence ranges from 11% to 48% of women of reproductive age, with variation according to population studied . Gardnerella vaginalis has been found in 10%–31% of virgin adolescent girls but is found significantly more frequently among sexually active women, reaching a prevalence of 50%–60% in some at-risk populations. There is little inflammation, and the disorder represents a disturbance of the vaginal microbial ecosystem rather than a true infection of tissues. The overgrowth of mixed flora is associated with a loss of the normal Lactobacillus sp. Theories include increased substrate availability, increased pH, and loss of the restraining effects of the predominant Lactobacillus sp. Volatile amines in the presence of increased vaginal pH produce the typical fishy odor, which is also produced when 10% potassium hydroxide is added to vaginal secretions. The adherence of Gardnerella organisms results in the formation of the pathognomonic clue cells. Although not proven to be sexually transmitted, barrier contraception may reduce occurrence and avoiding douching is recommended. An abnormal malodorous vaginal discharge, often described as fishy, that is infrequently profuse and often appears after unprotected coitus is usually described. Obstetric complications include chorioamnionitis, preterm labor, prematurity, and postpartum fever . Gynecological sequelae are postabortion fever, posthysterectomy fever, cuff infection, and chronic mast cell endometritis. The clinical diagnosis can reliably be made in the presence of at least three of the following objective criteria: 1. Positive amine test, with release of fishy odor on addition of 10% potassium hydroxide to vaginal secretions 3. Presence of clue cells on light microscopy These Amsel features are simple and reliable, and tests for them are easy to perform. The offensive fishy odor may be apparent during the physical examination or may become apparent only during the amine test. Gram strain of vaginal secretions is extremely valuable in diagnosis, with a sensitivity of 93% and specificity of 70%. Diagnostic tests are now available for rapid diagnosis measuring pH, amines, or sialidase. Management The most widely used oral therapy remains to be metronidazole or tinidazole . Most studies using multiple divided dose metronidazole regimens of 800–1200 mg/day for 1 week achieved clinical cure rates in excess of 90% immediately, and of approximately 80% at 4 weeks. Although single-dose therapy with 2 g metronidazole achieves comparable immediate clinical response rates, higher recurrence rates have been reported. The beneficial effect of metronidazole results predominantly from its antianaerobic activity and because G. Although Mycoplasma hominis and Mobiluncus curtisii are resistant to metronidazole, the organisms are usually not detected at follow-up visits of successfully treated patients. Similarly, metronidazole and tinidazole are considered therapeutical equivalent, although tinidazole has fewer of the commonly experienced side effects. Topical therapy with 2% clindamycin cream once daily for 7 days, clindamycin ovules for 3 days, or metronidazole gel 0. After therapy with oral metronidazole, approximately 30% of patients initially responding experience recurrence of symptoms within 3 months. Reasons for recurrence are unclear, including the possibility of reinfection, but recurrence more likely reflects vaginal relapse, with failure to eradicate the offending organisms and reestablish the normal protective Lactobacillus sp. Maintenance antimicrobial agents administered twice weekly for 4–6 months have been reasonably effective but results less than desirable . In many industrialized countries, recent surveys indicate a decline in the incidence of trichomoniasis. Pathogenesis and Pathology Sexual transmission is the dominant method of introduction of Trichomonas vaginalis into the vagina. There is also a high prevalence of gonorrhea in women with trichomoniasis, and both of these are significantly associated with the use of nonbarrier methods of contraception. Recurrent trichomoniasis is common and is indicative of lack of significant protective immunity. Antitrichomonal IgA has been detected in vaginal secretions, but a protective role is not defined. The urethral, paraurethral, Bartholin’s, and Skeene’s glands are infected in the majority of patients, and organisms are occasionally isolated from bladder urine.
During orthodromic activation buy 5 mg prednisone overnight delivery, the stimulus to local electrogram interval is greater than during antidromic capture (Fig discount prednisone 20mg overnight delivery. Note that in Figure 11-180 the interval from the stimulus to local presystolic electrogram remains flat over a period of cycle lengths during both orthodromic and antidromic activation discount prednisone 40mg visa, suggesting that no decremental conduction was present purchase prednisone 20 mg overnight delivery. Although others have “demonstrated” the so- 326 327 335 342 343 called “decremental properties” in the orthodromic limb, , , , , this concept is misleading. Slowing is secondary to interval-dependent conduction delay through tissue that has only partially recovered excitability when the ( n + 1)th stimulus reached the circuit. As noted earlier one can observe a flat resetting curve in response to single extrastimuli, yet when rapid pacing is initiated, following the first extrastimulus producing resetting ( nth stimulus) the subsequent stimuli can occur during the relative refractory period of the excitable gap and prolong the return cycle. This prolonged stimulus to presystolic electrogram compared to a single extrastimulus does not imply decremental properties analogous to that of the A-V node (Fig. If it arrives at a fully excitable state, the stimulus to local electrogram will be the same as observed using a single extrastimulus regardless of the cycle length of pacing. This is demonstrated in analog records in Figure 11-176 and in graphic representation in Figure 11-180. The prolongation of the stimulus to local electrogram interval at shorter cycle length means that the ( n + 1)th stimulus has encountered partially excitable tissue in the reentrant circuit. The circles represent sites within the reentrant circuit just proximal to the exit site from the presystolic electrogram is recorded. Note the premature penetration of the stimulus into the entrance of the tachycardia circuit so that the tachycardia is advanced to the paced cycle length. During entrainment, collision occurs between the entrance and exit of the tachycardia circuit. The presystolic electrogram is activated by the wavefront entering the circuit and propagating antegradely (orthodromically). Thus, the initial morphology of this electrogram does not change during pacing, and the impulse can exit to produce a fusion complex. However, as depicted in the panel on the right, during pacing at a shorter cycle length, retrograde collision between the stimulated wavefront and the previous tachycardia (or stimulated wavefront) occurs before the point at which the tachycardia can exit the reentrant circuit. The solid electrogram recorded from the reentrant circuit is now activated in a retrograde fashion and is therefore changed in morphology. The open electrogram, however, is still activated in an antegrade fashion (with no change in its initial morphology). Because the presystolic solid electrogram is captured retrogradely, the preceding impulse with which it collides can never exit the circuit; therefore, fusion is impossible during entrainment with retrograde capture of the presystolic electrogram. Entrainment of ventricular tachycardia: explanation for surface electrocardiographic phenomena by analysis of electrograms recorded within the tachycardia circuit. Conversely, however, the absence of a change in morphology of the presystolic electrogram recorded from the tachycardia circuit did not always predict the presence of surface electrocardiographic fusion. Entrainment of ventricular tachycardia: explanation for surface electrocardiographic phenomena by analysis of electrograms recorded within the tachycardia circuit. This obviously requires a constant stimulus to local presystolic electrocardiogram conduction time in the orthodromic direction (e. The Xs represent the conduction time from the stimulus to the left ventricular electrogram in the presence of a change in the initial component of this electrogram. Note that there is no significant change in conduction time over a range of cycle lengths when the morphology of the electrogram is preserved. Although there is dramatic change in conduction time from the stimulus to the left ventricular electrogram at the site of origin when there is a change in the morphology of this electrogram, once the electrogram has changed in morphology, the conduction time remains stable over a wide range of paced cycle lengths. Entrainment of ventricular tachycardia: explanation for surface electrocardiographic phenomena by analysis of electrograms recorded within the tachycardia circuit. To reiterate, when an increase in orthodromic conduction is observed during overdrive pacing resetting of the reentrant circuit is taking place. It is only when a stable state of orthodromic conduction follows an incremental number of paced complexes that entrainment is said to be present. Examples of atrial pacing entraining tachycardias are shown in Figures 11-181 and 11-182. This ultimately results in total supraventricular capture with appropriate A-H and H-V intervals. Following termination of pacing, the tachycardia resumes with a prolonged return cycle. Thus, I believe that slow conduction in the orthodromic direction is likely due to the nonuniform anisotropic characteristics and abnormalities of gap junctions of the circuit. Although depolarized fibers using partially inactivated sodium channels are associated with slow conduction, such fibers also demonstrate decremental properties. As noted earlier in the chapter, the response of the arrhythmogenic substrate to pharmacologic agents is most consistent with normally polarized 54 myocardial fibers. It is also theoretically possible that the prolonged conduction time reflects a longer pathway of activation in the orthodromic direction and is unrelated to conduction velocity per se. Interval-dependent conduction delays may be seen in ventricular muscle and the His–Purkinje system, both of which are not considered to have “decremental” properties. Overdrive acceleration has been observed during rapid pacing, but in this instance, a more rapid rhythm ensues on cessation of rapid pacing without acceleration or deceleration during that tachycardia. In this instance, it is as if the rapid pacing decreases the size of the reentrant circuit or produces double wave reentry. It is also consonant with the functional nature of 320 barriers as demonstrated by different resetting curves from different sites of stimulation. They include tachycardia cycle length, refractoriness at the stimulation site, conduction time from the stimulation site to the site of origin of the tachycardia, and in the case of reentrant arrhythmias, the duration of the excitable gap. The hemodynamic tolerance of the tachycardia also determines whether pacing modalities or direct current cardioversion is used to terminate the rhythm. Other factors such as the presence of antiarrhythmic agents can influence the ability to terminate the tachycardia both favorably and unfavorably (see subsequent paragraphs). Although certain generalizations can be made, much of the subsequent discussion relates to personal experience with the tachycardias studied in our laboratory. The tachycardia cycle length seems to be the main determinant of whether the tachycardia can be terminated by 322 323 324 325 some form of programmed stimulation or pacing or will require cardioversion. Regardless of the mode of stimulation used, termination is usually abrupt, which distinguishes it from termination of triggered activity. The tachycardia cycle length has the most marked influence on the mode of termination. In a consecutive series of patients, we found that rapid ventricular pacing was the most efficacious way of 322 terminating the tachycardia (Table 11-14). Although we did not compare the use of single, double, or triple extrastimuli and/or rapid pacing in each patient, the success of termination was directly related to the number of 1 122 194 195 322 323 324 325 extrastimuli used. In fact, 80% of tachycardias terminated by single extrastimuli had cycle lengths of >400 msec (Fig. Nonetheless, occasionally, tachycardias with cycle lengths between 300 and 350 msec can be terminated by single extrastimuli (Fig. Occasionally two extrastimuli are required to terminate tachycardias that are not too rapid P. Rapid pacing is the most effective form of termination, regardless of tachycardia cycle length (Fig. In fact, all tachycardias that are terminable by single or double extrastimuli can be terminated by rapid pacing. Failure of rapid pacing to terminate an arrhythmia that has previously been shown to be terminated by single or double extrastimuli suggests that the tachycardia was terminated then reinitiated before discontinuation of pacing. Thus, care must be taken to begin ventricular pacing at long cycle lengths and continue for a variable number of complexes before cessation of pacing. This probably occurs by creating “double wave reentry,” in which two wavelengths can fit in the same circuit previously used by 51 351 a single wavelength. We have arbitrarily defined acceleration of a tachycardia as a sustained shortening of the tachycardia cycle length by >30 msec following cessation of pacing. In our experience, this 322 323 324 325 occurs in approximately 25% of tachycardias. Acceleration is rare, using single or double 322 323 324 325 extrastimuli (<5%) but approaches 35% during rapid pacing. In one-half of these patients, the accelerated tachycardia may be terminated by even faster pacing. Thus, approximately 50% of patients with tachycardias having cycle lengths <300 msec will require cardioversion either due to rapid hemodynamic collapse without any attempts at termination by pacing or as a result of acceleration of the tachycardia (approximately evenly divided).
Our experience with pubovaginal slings in patients with stress urinary incontinence cheap prednisone 10mg visa. Pubovaginal sling surgery for simple stress urinary incontinence: Analysis by an outcome score buy prednisone 20mg without prescription. Long-term outcome and quality of life after modified pubovaginal sling for intrinsic sphincteric deficiency prednisone 5 mg cheap. Long term follow up of the cruciate fascial sling for women with genuine stress incontinence generic prednisone 10mg with visa. Pubovaginal cutaneous fascial sling procedure for stress urinary incontinence: 10 years’ experience. Expanded indications for the pubovaginal sling: Treatment of type 2 or 3 stress incontinence. Comparison of the treatment outcome of pubovaginal sling, tension-free vaginal tape, and transobturator tape for stress urinary incontinence with intrinsic sphincter deficiency. Comparison of autologous rectus fascia and cadaveric fascia in pubovaginal sling continence outcomes. Pubovaginal sling using allograft fascia lata versus autograft fascia for all types of stress urinary incontinence: 2-year minimum followup. The long-term results of pubovaginal sling surgery using acellular cross-linked porcine dermis in the treatment of urodynamic stress incontinence. Pubofascial versus vaginal sling operation for the treatment of stress urinary incontinence: A prospective study. Tissue strength analysis of autologous and cadaveric allografts for the pubovaginal sling. Patch procedure: Modified transvaginal fascia lata sling for recurrent or severe stress urinary incontinence. The fascia lata sling procedure for treating recurrent genuine stress incontinence of urine. Cadaveric fascia lata versus intravaginal slingplasty for the pubovaginal sling: Surgical outcome, overall success and patient satisfaction rates. Medium-term follow-up on use of freeze-dried, irradiated donor fascia for sacrocolpopexy and sling procedures. Outcome in 104 pubovaginal slings using freeze-dried allograft fascia lata from a single tissue bank. High failure rate using allograft fascia lata in pubovaginal sling surgery for female stress urinary incontinence. Comparison of solvent-dehydrated allograft dermis and autograft rectus fascia for pubovaginal sling: Questionnaire-based analysis. Cadaveric fascia lata sling for stress urinary incontinence: A prospective quality-of-life analysis. Cadaveric fascia lata pubovaginal slings: Early results on safety, efficacy and patient satisfaction. Pubovaginal sling using Duraderm graft: Intermediate follow-up and patient satisfaction. Pubovaginal sling using cadaveric allograft fascia for the treatment of intrinsic sphincter deficiency. Cadaveric versus autologous fascia lata for the pubovaginal sling: Surgical outcome and patient satisfaction. Pubovaginal sling using cadaveric allograft fascia for the treatment of female urinary incontinence. Vaginal paravaginal repair with porcine dermal reinforcement: Correction of advanced anterior vaginal prolapse. Solvent-dehydrated cadaveric dermis: A new allograft for pubovaginal sling surgery. Urodynamic and clinical assessment of the Lyodura sling operation for urinary stress incontinence. Comparison of Burch and Lyodura sling procedures for repair of unsuccessful incontinence surgery. Clinical and urodynamic assessment of the porcine dermis bladder sling in the treatment of genuine stress incontinence. Comparative analysis of urinary incontinence severity after autologous fascia pubovaginal sling, pubovaginal sling and tension-free vaginal tape. Porcine small intestinal submucosa as a percutaneous mid-urethral sling: 2- year results. Small intestinal submucosa for pubourethral sling suspension for the treatment of stress incontinence: First histopathological results in humans. Intense inflammatory reaction with porcine small intestine submucosa pubovaginal sling or tape for stress urinary incontinence. Minimally invasive synthetic sling suburethral sling operations for stress urinary incontinence in women. Deux incontinence apres adenonectomie queries par injection de paraffine daris de perinee. Transurethral polytetrafluoroethylene injection in female patients with urinary continence. Disappointing effect of endoscopic teflon injection for female stress incontinence. Pulmonary teflon granulomas following periurethral teflon injection for urinary incontinence. Pulmonary migration following periurethral polytetrafluoroethylene injection for urinary incontinence. Long-term follow-up of women treated with periurethral teflon injections for stress incontinence. Endoscopic injection of autologous adipose tissue in the treatment of female incontinence. Treatment of urinary stress incontinence using paraurethral injection of autologous fat. Periurethral injection of autologous fat for the treatment of sphincteric incontinence. Periurethral autologous fat injection as treatment for female stress urinary incontinence: A randomized double-blind controlled trial. A diagnosis of urodynamic stress incontinence can only be made after urodynamic investigation, and this is defined as the involuntary leakage of urine during increased abdominal pressure in the absence of a detrusor contraction . Stress incontinence is the most commonly reported type of urinary incontinence in women. In a large epidemiological study of 27,936 women from Norway , overall, 25% of women reported urinary incontinence, of whom 7% considered it to be significant, and the prevalence of incontinence increased with age. When considering the type of incontinence, 50% of women complained of stress, 11% urge, and 36% mixed incontinence. The prevalence of urinary incontinence among nulliparous women ranged from 8% to 32% and increased with age. In general, parity was associated with incontinence, and the first delivery was the most significant. There was a similar association for mixed incontinence although not for urge incontinence . The bladder neck and proximal urethra are normally situated in an intra-abdominal position above the pelvic floor and are supported by the pubourethral ligaments. Damage to either the pelvic floor musculature (levator ani) or pubourethral ligaments may result in descent of the proximal urethra such that it is no longer an intra-abdominal organ, and this results in leakage of urine per urethram during stress. This theory has given rise to the concept of the “hammock hypothesis,” which suggests that the posterior position of the vagina provides a backboard against which increasing intra-abdominal forces compress the urethra . This is supported by the fact that continent women experience an increase in intraurethral closure pressure during coughing . This pressure rise is lost in women with stress incontinence although it may be restored following successful continence surgery . In order to distinguish this type of stress incontinence from that caused by descent and rotation of the bladder neck during straining, the Blaivas Classification has been described based on videocystourethrographic observations . More recently, the “midurethral theory” or “integral theory” has been described by Petros and Ulmsten . This concept is based on earlier studies suggesting that the distal and midurethra play an important role in the continence mechanism  and that the maximal urethral closure pressure is at the mid-urethral point . This theory proposes that damage to the pubourethral ligaments supporting the urethra, impaired support of the anterior vaginal wall to the mid-urethra, and weakened function of part of the pubococcygeal muscles, that insert adjacent to the urethra, are responsible for causing stress incontinence.