There are many causes for urinary incontinence in women including :

• Overactive bladder: This refers to the bladder contracting and pushing the urine out before it becomes full . This may be due to inflammed bladder as in bladder infection which can be treated with antibiotics or due to a bladder non-bacterial inflammatory process called  interstitial cystitis which can be treated with a combination of medications. In older women ,overactive bladder could improve with local hormonal treatment.  On many occasions, no specfic cause is found and the condition is treated with medications that help the bladder relax.
• Stress incontinence: This refers to involuntary leakage of urine when pressure inside the abdomen is increased such as while coughing or sneezing or lifting heavy objects. This is usually due to a mobile urethra due to its detachment from its natural attachments in the pelvis. In severe cases , the urethra is not only mobile but its muscles are also weak ( Intrinsic sphinctor defeciency) . Weak urethral muscles could be due to advanced age or due to previous surgery or difficult vaginal delivery.  Mild cases can be improved by pelvic muscles exercises while more severe cases will need surgical intervention . The surgical options include 2 common procedures:

1- Tension free vaginal tape (TVT) . This involves placing a tape under the urethra to provide support to muscles and reduce urethral mobility. This is accomplished through a 1 inch incision under the urethra in the vaginal wall and 2 other small incisions either on the inner thighs or in abdomen just above pubic bone (suprapubic). This procedure is a same day procedure . It does not require laparoscopy and works well for incontinence due to hypermobility alone or due to hypermobility and weakness of urethral muscles (Intrinsic sphincter defeciency). When intrinsic sphincter deficiency is present , the tape should be placed -preferably-utilizing the suprapubic approach .

2- laparoscopic Burch procedure. This procedure works very well for incontinence due to hypermobile urethra but it is not as good when there is weak urethral muscles ( intrinsic sphincter deficiency). It is a procedure where sutures are placed on the sides of the urethra on one end and to a pelvic ligament on the otherend to limit hypermobility of the urethra.

It is usually used when other laparoscopic pelvic procedures are performed at the same time such as laparoscopic uterine suspension.

The following video is a laparoscopic Burch procedure.

www.youtube.com/watch?v=HjB3q600CN0

3- Urethral bulking: When urethral muscles are weak but with out hypermobility of the urethra, a situation that may arise from old age or previous multiple surgical interventions , injecting a bulking material into the proximal part of urethra at its junction with bladder helps control the symptoms for about a year or so after which re-injection may be necessary.

The substance injected could be patient’s own body fat or other substances not very different from ones used in plastic surgery to augment lips and cheek albight last for longer periods of time.

A repeat injection may be needed once a year.

The following is a video of urethral bulking using Bulkamid- a synthetic bulking agent

www.youtube.com/watch?v=TMZeOeHmRXE

4- Vesicovaginal fistula: An abnormal opening between the bladder and vagina causing continuous leakage of urine from the vagina. This is usually due to pelvic surgery , radiation or a complicated child birth.

Treatment is by repairing (closing) the fistula . This can be performed vaginally for a low fistula or laparoscopically for a high fistula. This surgery is not common since vesicovaginal fistula is not a common condition.
In the following video , you can see part of the urinary catheter showing through a vesicovaginal fistula. Tissue from inside the right labia majora (Bulbocavernosus flap)is being prepared to be placed between the bladder and the vagina at the site of fistula to help prevent recurrence.

Fibroids can be totally asymptomic and only discvered on ultrasound examination or can be symptomatic causing heavy menstrual bleeding, pelvic pain , and severe dysmenorrhea. The larger fibroid can cause abdominal swelling , urinary and gastrointestinal symptoms due to pressure on bladder , ureters and rectum. During pregnancy, fibroids tend to grow and can lead to complications such as spontaneous abortion , preterm labor and acute abdominal pain.

Management of fibroids varies depending on many factors, if small and asymptomaticthey may be observed avoiding surgical intervention unless they enlarge and cause symptoms or they can be surgically removed as a preemptive measure. Such decision will need a thorough discussion between the patient and her doctor including the pros and cons of either approach . Hormonal therapy may control the bleeding and dysmenorrhea in some women but at the same time long term hormonal treatment may facilitate further fibroid growth.

Fibroids can be surgically removed by a procedure called myomectomy in which the fibroid is shelled out of the uterine wall. Repair of the uterine muscle is then accomplished with sutures  unless the fibroid is completely protruding to the outside of the uterine wall (subserosal) or completely protruding to the uterine cavity (submucosal) in which case repair is not needed.

The decision on how to perform the myomectomy depends on the size, number, and location of the fibroids.A fibroid protruding into the uterine cavity can be removed by hysteroscopic resection ,  a procedure in which a hysteroscope is introduced into the uterine cavity via the vagina and cervical canal allowing the surgeon to see the fibroid inside the cavity on a monitor and then remove it under visual control with special instruments designed to pass through the hysteroscope.

On the other hand if the fibroid is within the uterine muscle (intramural) or protruding to the outside (subserosal) then either laparoscopy or laparotomy will be needed for removl.

With the current advances in laparoscopic surgery, the vast majority of fibroid surgery can be accomplished via the laparoscope avoiding the large laparotomy incision.

The procedure is performed usually under general anesthesia and requires 3-4 small incisions in the skin of the abdominal wall , each incision is 0.5 cm to 1.2 cm through which the camera and surgical instruments are introduced and through which the fibroid tissue is removed after morcellation which is done using a device that cuts the fibroid tissue into strips and then be removed through one of the small incisions. The laparoscopic myomectomy is usually performed as an outpatient procedure with discharge from hospital within less than 24 hours.

Another option for management of fibroids is uterine artery embolisation which reduces blood flow to the fibroid by occluding the supplying vessels with particles injected via a vascular catheter inserted through the thigh vessels. The procedure is helpful to those with large symptomatic fibroids who do not desire having surgical removal. The fibroids shrink and their symptoms are reduced. Because of concern of the procedure effect on the integrity on the uterine wall,the embolisation procedure is considered relatively contraindicated for women who desire childbirth inspite of the fact that pregnancies after embolisation have been documented.

Our final thoughts is that women with fibroids have several minimally invasive management options that can be tailored to the specifics of each patient’s condition with quick recovery and resumption of normal physical activities.

The following are video clips of  laparoscopic myomectomy procedures:

• Laparoscopic myomectomy of an 8 cm low  posterior fibroid with audio

www.youtube.com/watch?v=B5FJBV-SkDI

• Laparoscopic myomectomy of a7cm intramural fibroid

www.youtube.com/watch?v=z-i3gMTQlpI

• Laparoscopic myomectomy of a 15 cm  cervical fibroid

www.youtube.com/watch?v=OqRPP9PlGL4

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The following is a video clip for laparoscopic surgery for a moderate degree endometriosis performeb by Dr.Badran

www.youtube.com/watch?v=ekbdoxcESNU

Many of the women in need for a hysterectomy are candidates for TLH . The word “Total” refers to removing the body of the uterus and the cervix.  It is an alternative to the total abdominal hysterectomy which requires a 5-7 inch incision. In the united states, about 70% of the hysterectomies are performed as total abdominal hysterectomies. Most of these can be accomplished laparoscopically when performed by an experienced laparoscopic surgeon.

• Subtotal (Supracervical) laparoscopic Hysterectomy

In the absence of cervical pathology, the body of the uterus can be removed leaving the healthy cervix in place. This procedure requires less surgery than the hysterectomy that includes removal of the cervix .

In addition , some doctors believe that preserving the cervix may help maintain a normal sexual function and normal pelvic support  since the nerves and blood supply to the cervix and upper vagina are not interrupted.

The following link is a video for the Total laparoscopic hysterectomy procedure -with bilateral salpingo-oophorectomy

www.youtube.com/watch?v=YcBzrGZjbAs

The following are video clips of procedures on the ovary and tube performed by Dr.Badran

• Laparoscopic resection of a right ovarian dermoid cyst

www.youtube.com/watch?v=Y3MMi89pTl4

• Laparoscopic right salpingostomy for right tubal ectopic pregnancy

www.youtube.com/watch?v=M3j8ClZ55VE

• Laparoscopic management of left ovarian torsion

www.youtube.com/watch?v=199gkbLfqoI

• Laparoscopic tubal patency dye test study

www.youtube.com/watch?v=qjrkZIUBd44

It is appropriate to utilize the vaginal hysterectomy technique when the pathology is known to be confined to the uterus with no need for operating on other pelvic organs.

If deemed appropriate ,the ovaries and tubes may be removed via the vaginal approach at the time of hysterectomy.

The following is a video clip of vaginal hysterectomy performed by Dr.Badran:

She provides comperhensive care to couples seeking assisted reproduction and I.V.F . 

 Dr.Othman utilizes the I.V.F unit at the Arab hospital and medical center, a state of the art facility in western Amman.

Dr.Othman provides a full range of assisted reproduction services including:

1-Intrauterine Insemination (I.U.I)

2-Invitro Fertilization (I.V.F)

3-Intracytoplasmic Sperm Injection (ICSI)

4-Frozen Embryo Replacement Cycle 

5-Assisted Hatching

Hysteroscopic endometrial resection may be performed to induce amenorrhea (no menses) or hypomenorrhea (light menses) in women who have menorrhagia (heavy menses) when no specific pathology is present.

Other methods of treatment of menorrhagia include non-hysteroscopic endometrial ablation methods such as the use of the Thermachoice balloon ablation.

The following are video clips of hysteroscopic procedures performed by Dr.Badran:

• Hysteroscopic resection of uterine septum with audio

www.youtube.com/watch?v=8qJZLY2CdBM

• Hysteroscopic resection of uterine septum and submucus fibroid

www.youtube.com/watch?v=i-s_cIS3qtc

• Hysteroscopic myomectomy of a 4.5 cm submucus fibroid

www.youtube.com/watch?v=9LsBhwxBRLw

This refers to a buldge protruding through the vagina. The buldge can be the uterus (uterine prolapse), the bladder (cystocele),the urethra (urethrocele),the rectum (rectocele), the vaginal apex (vaginal vault prolapse), or bowel (enterocele). Usually it is a combination of these conditions. The symptoms are pelvic pressure and pain , dysparunia , difficulty in voiding , urinary incontinence, difficulty in having bowel movements and fecal incontinence. The protruding mass ,if neglected, can bleed, get ulcerated and infected.
The surgery can be performed utilizing the laparoscopic approach or vaginal approach depending on the details of the clinical picture.  It  involves using  sutures or mesh to reattach the vaginal wall to its natural pelvic location . Hysterectomy is not necessary for treatment of pelvic prolapse, the uterus can be preserved by re-attaching it to its normal pelvic location . The medical terms used to describe these procedures include the following:

• Uterine suspension /Sacral hysteropexy (treatment of uterine prolapse).
• Vaginal vault suspension /Sacral colpopexy (treatment of posthysterectomy vaginal vault prolapse ).
• Paravaginal suspension (treatment of cystocele).
•  Bladder neck suspension by Burch procedure and Tension free vaginal tape (T.V.T) -Treatments of urinary incontinence.
• Enterocele repair.(treatment of a hernia in the  deep end of vagina)
• Fistula repair (Vesicovaginal or rectovaginal ). Fistula is an abnormal opening between bladder and vagina or rectum and vagina due to either previous surgery , diffficult delivery or certain medical conditions such as crohn’s disease.

The following is  video clips  for reconstructive pelvic procedure    performed by Dr. Badran:

1- laparoscopic uterine suspension with mesh (for uterine prolapse):

This is a laparoscopic approach to repositioning the uterus to its normal pelvic location. A mesh tape is attached to uterine cervix at one end and to the fibrous ligament covering the sacrum.

www.youtube.com/watch?v=z0-h_cMIfUE

2-vaginal repair with mesh (posterior intravaginal slingoplasty):

This is a procedure that utilizes synthetic mesh to support apex of vagina, uterus and posterior vaginal wall in recurrent or advanced stages of pelvic prolapse. A similar procedure can be utilized to the prolapse of the anterior vaginal wall and bladder .

3- Laparoscopic paravaginal repair for cystocele (Bladder drop) with audio

www.youtube.com/watch?v=C9opG-kR6Iw

The following are videos of  cancer related procedures performed by Dr.Badran

• Laparoscopic pelvic lymphnode dissection

www.youtube.com/watch?v=Hg2la6Fseik

• Laparoscopic para- aortic lymphnode dissection with audio

www.youtube.com/watch?v=-twz4Au9eyE

• Laparoscopic Omentectomy

www.youtube.com/watch?v=sJ-FaYSuxgM