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Both the maximum and average urine flow rates in the aforementioned study were found to have a strong and essentially equal dependence on voided volume buy voltaren 50mg cheap arthritis medication for heart patients. However buy voltaren 50mg line arthritis medication starting with s, the centile lines onto which the maximum and average urine flow rates respectively fall for the same voided volume (centile rankings) are not interchangeable in an individual instance due to wide variations in urine flow patterns trileptal 600 mg without prescription. The closer the urine flow pattern comes to the “ideal” flow time curve seen in Figure 53. No systematic deterioration of either flow rate at higher voided volumes was discernible from this population study. The same studies also found that there was no significant effect of parity on urine flow rates in normal women. Repeated Voiding There was a remarkable consistency in the centile rankings of the paired first and second voids in the study of Haylen et al. This consistency is further witnessed in the multiple voids from a single 25- year-old normal female volunteer (Figure 53. Clinically, in the majority of normal women, the centile rankings of successive voids will not differ widely. It is uncertain, at present, whether this is also true for women with lower urinary tract dysfunction. As suggested previously, abnormal or unusual flow rates or curves merit repeating the study. Presence of a Catheter The aforementioned nomograms refer to free flowmetry voids; they are not applicable where pressure of another catheter is present in the urethra. All urethral catheters can be expected to have the effect of decreasing urinary flow rates for the equivalent voided volume. By necessity, potentially unfavorable environmental and psychological factors are introduced when catheterization flowmetry is performed. Ryall and Marshall  suggested that the reduction is maximum urinary flow rate caused by the fine (diameter = 2 mm) urethral catheter used in their study of 147 symptomatic men was of the order of several mL/sec. Though small, this reduction was enough to change the diagnostic categorization of one-third of their subjects. Normal Female Urine Flow Rates Female urine flow rates are higher than those of men [10,15,24]. The other study  was limited to the effect of final urodynamic diagnosis on urine flow rates. Three studies indicated that symptomatic women had slower urine flow rates than normal women with one study  showing no difference. The flow data for these women were converted to centiles from the Liverpool Nomograms for the following analyses of their median values: A Comparison of the Urine Flow Rates of Symptomatic and Asymptomatic Women Table 53. There was a close agreement between the studies with the 1990 study  performed in a different country to the 1995 study . Effect of the Presence of Genital Prolapse on Urine Flow Rates in Symptomatic Women A generally progressive decline in the maximum and average urine flow rates (median centiles) of symptomatic women  with increasing grades of genital prolapse was noted.
Ureteric injuries related to concomitant laparoscopic hysterectomy usually require ureteric reimplantation by urological colleagues buy voltaren on line amex arthritis in back of neck symptoms. One small study retrospectively compared laparoscopic hysterectomy performed with and without ureteric catheters and suggested that ureteric catheters may decrease the risk of ureteric injury  generic 50mg voltaren amex cherry juice arthritis pain. Just less than 10 minutes was required to place the catheters order altace 5 mg visa, but no other prospective evaluation of routine ureteric catheters at laparoscopic pelvic floor surgery is available. The presacral fascia covers and protects the underlying plexus, which consists of venous network both on and beneath the surface of the sacral periosteum as seen in Figure 102. Inadvertent manipulation outside this avascular presacral space may tear the fascia and cause damage of underlying thin-walled veins, which are devoid of valves. It is well documented that conventional measures for hemostasis are ineffective in managing presacral hemorrhage . Coagulation and suturing should be avoided because they can aggravate bleeding resulting in significant blood loss. Surgeons should have a planned approach to this problem, and the author initially applies immediate direct pressure over the bleeding site using small tampon gauze for 5 minutes to temporarily control the bleeding. If bleeding persists, traditionally pelvic packing and the use of sterile metallic or titanium thumbtacks are employed (Figure 102. Packing has the disadvantage of reoperation for removing the packs and risk of rebleeding . More recently, surgeons have reported successfully using a hemostatic matrix agent such as FloSeal (Baxter, United States) or Surgicel Fibrillar (Ethicon, United States) followed by gauze pressure for 5 minutes  (Figure 102. Although a rare condition, it has been reported after the use of both sutures and tacks into the sacrum and after open laparoscopic and robotic approaches. Potential exacerbating factors include concomitant hysterectomy, mesh exposure, the use of braided sutures or the placement of sutures and tackers deep into the periosteum at robotic sacral colpopexy without tactile feedback , and fixation into the L5–S1 intervertebral disc . We perform minimal sacral dissection and simply attach the mesh at the most prominent site on the sacral promontory that appears to compliment Good’s recommendation. Some surgeons attach the mesh to the lower part of the body of the L5 because of easier access. Leaks to the extraperitoneal tissues can occur at entry, with opening of extraperitoneal spaces or through existing undetected hernia. Significant or sudden subcutaneous emphysema around the face, neck, and chest must alert to the possibility of mediastinal emphysema. This usually arises from a congenital defect of the diaphragm but can also occur after trauma associated with upper abdominal surgery. Gas embolism can occur if gas enters the vascular system and usually occurs during or shortly after insufflation. The sudden development of hypotension, bradycardia, or arrhythmias at this time should immediately raise suspicion of gas embolism. The pneumoperitoneum should be released and the procedure abandoned as soon as feasible.