No abstract

Combined stress urinary incontinence (SUI) and genital prolapse after fracture of the female pelvis has not been well described to date; four such cases are reported. Three of the patients had undergone reconstructive urogynecologic surgery prior to referral. None of the patients had a history of urinary incontinence or genital prolapse prior to injury. In order to correct persistent urinary incontinence and prolapse the following operations were performed: pubovaginal sling and transvaginal cystocele repair, Raz needle suspension and rectus muscle graft to the pelvic floor followed by a unilateral Burch colposuspension. On follow-up at a mean interval of 14.2 months (range 12-17), 2 have mild SUI and all 4 are without significant genital prolapse.

We report on 2 patients, one female and one male transsexual; in both, Type III stress urinary incontinence developed after gender reassignment surgery. Both patients were treated by periurethral injection of gluteraldehyde cross-linked collagen resulting in a marked symptomatic improvement in association with a significant rise in abdominal leak point pressures. We believe these are the first reported cases of collagen injection being used for urinary incontinence after gender reassignment surgery.

A variety of plastic surgical techniques may be used in the repair of vesicovaginal fistulas. The indication for their use include: (a) diameter greater than 4 cm; (b) involvement of the bladder neck/proximal urethra; (c) radiation-induced fistulas; and (d) previous failed repair(s). In the developing world the vast majority of complex fistulas are caused by obstetric trauma; elsewhere they occur mainly following radiotherapy or radical surgery for gynecologic malignancy. The majority of complex fistulas requiring tissue donation may be effectively treated using a vaginal approach and a modified Martius graft. There is probably little or no advantage in encorporating bulbocavernosus muscle fibers in this graft. Although some concern exists regarding the long-term viability of these grafts in radiation-induced fistulas, in view of the relatively simple operative technique, together with the low associated morbidity, modified Martius grafts may be deemed suitable for first-time repairs. The gracilis muscle graft should be considered next in cases of exclusive transvaginal repair. The omental graft is undoubtedly the most versatile: it can be used in both abdominal and combined abdominovaginal procedures. The recently described posterosuperior sliding bladder flaps warrant further evaluation. For most fistulas involving the bladder neck/proximal urethra, there is no clear advantage in bladder flap reconstruction over vaginal flap reconstruction, the latter being augmented by an anti-stress incontinence procedure were appropriate. When continent urinary diversion is required, the Indiana pouch appears preferable to the Kock pouch; ureterosigmoidostomy is, however, technically