Surgical management of pelvic organ prolapse

Pelvic organ prolapse is a common condition which can have a profound effect on health-related quality of life. The lifetime risk of surgery for pelvic organ prolapse for all women is around 10–12%, making prolapse surgery one of the most commonly performed operations of all. Surgery is generally offered only to women to do not respond to conservative measures such as physiotherapy and/or vaginal pessaries. It is very important to ensure excellent clinical governance around the decision-making process for this elective surgical problem, and this may include the use of written information, face to face and telephone consultations, patient reported outcome measures and patient decision aids. This chapter will cover all the different techniques for prolapse surgery including conventional approaches using native tissue, uterus conserving prolapse surgery and surgery for post-hysterectomy vault prolapse. This will also include laparoscopic prolapse surgery. The role of mesh in prolapse surgery will also be discussed and this chapter will cover important topics including patient selection and preparation for prolapse surgery, shared decision making and how best to facilitate this, patient preparation before prolapse surgery and follow-up post operation.     

Pelvic organ prolapse repair-relapse risk factors: A 10-year retrospective study

ObjectivesPelvic organ prolapse (POP) is a common problem among older female. The usual treatment for POP is surgery but there are high recurrence rates, with a 29% reoperation rate. This study aims to identify risk factors for both primary prolapse and recurrence after surgical treatment.MethodsRetrospectively assessment of clinical records of patients who underwent surgery for POP in a 10-year period. Statistical analysis was performed using the version 26.0 of Statistical Package for the Social Science (SPSS®) software.Results746 women entered our study. The population was predominantly post-menopausal, multiparous, and obese/overweight. The most affected compartment was the anterior. Almost 90% of the patient presented with major prolapse. Being overweight or obese, having apical compartment POP, major POP or all compartment POP were risk factors for recurrence with statistical significance. The recurrence rate was nearly one-third but the reoperation incidence was low, reaching less than 6%.ConclusionsPOP surgery has a high satisfaction rate. The only modifiable risk factor for recurrence is being overweight/obese and a nutritional plan should be considered before surgery so we can achieve the best possible results.     

Preclinical approaches to assess potential kinase inhibitor‐induced cardiac toxicity: Past,present and future

Over a decade ago, use of tyrosine kinase inhibitors (TKIs) for the treatment of malignancies was found to cause left ventricular dysfunction, a finding that was unexpected and not well predicted by standard preclinical studies. Subsequently, several preclinical approaches were proposed to address this issue. Over the last 5 years, several approaches for preclinical evaluation of cardiac function using isolated perfused hearts, engineered heart tissue and human‐induced pluripotent stem cell‐derived cardiac myocytes have been shown to be relatively predictive of the cardiotoxic potential of TKIs. Further, preclinical studies submitted for regulatory review for recently approved KIs have demonstrated various forms of KI‐induced cardiotoxicity. Thus, early identification and assessment of cardiotoxicity in the preclinical setting is now possible. Given that kinases are involved in diverse cellular processes common to both normal and tumor cells, KI‐induced toxicity, particularly in the heart, appears difficult to avoid. To develop drugs with fewer adverse effects, better efficacy and safety assessments, such as pharmacological separation of targets for cancer from heart, and/or wider separation of the drug concentrations for antitumor activity from cardiac toxicity, may be helpful. Additional preclinical approaches for assessing drug efficacy and toxicity in parallel may include use of animal cancer models and a 3D integrated in vitro model of perfused tumor and heart tissues. Minimizing and predicting potential KI‐induced cardiotoxicity is still an important regulatory challenge, and better preclinical approaches may help achieve this goal.     

目标不等于目的——浅谈镇痛镇静的器官保护作用

镇痛镇静治疗的目的在于保护器官的形态与功能储备。在能够满足全身各组织器官代谢最低需求的循环灌注与氧合的基础上,让器官尽量休息且功能和谐匹配,以最大限度地节约和保护器官的储备功能,使得危重患者康复后能够尽可能保持较好的生活质量,是重症医学可持续发展的重要基础。在达到镇痛镇静治疗目的的过程中,需要根据患者的病情、基础状态、器官功能等个体化设置不同的镇痛镇静目标,而不宜简单机械地强调“深镇静”或“浅镇静”。镇痛镇静治疗是一把双刃剑,无监测,勿镇痛镇静;实施镇痛镇静治疗时需要对治疗是否已顺序达到镇痛镇静目标,并趋近器官功能保护目的进行连续的监测与评估,但此监测与评估不能仅局限于对患者疼痛和意识及认知状态的了解,还必须包括对患者基本生命体征的动态变化以及器官功能的储备代偿能力判断,运用监测评估的手段,使机体各器官达到休整生息、尽量多保留储备功能、减少慢重症、提高生活质量之目的。     

Synergism of amlodipine and candesartan on blood pressure reduction and organ protection in hypertensive rats

This study was designed to investigate the possible synergism of amlodipine and candesartan on the reduction of blood pressure (BP) in hypertensive rats. The end organ protection was also observed. In acute experiment, spontaneously hypertensive rats (SHRs) were treated with intragastric administration of amlodipine (0.5, 1, 2, 3 mg/kg), candesartan (1, 2, 3, 4, 6, 8 mg/kg), and 14 different combinations to find the possible ratio of synergistic interaction. In two kidneys, one clip (2K1C) rats, the effects of amlodipine (1 mg/kg), canderastan (2 mg/kg) and their combination on BP reduction were also observed. In chronic study, SHRs were treated with amlodipine (1 mg/kg), candesartan (2 mg/kg), and their combination for 5 months. Organ damage evaluation was performed after BP recording. The probability sum test (q test) was used to evaluate the synergistic action. There is a synergistic interaction between amlodipine and candesartan on BP reduction. The optimal dose ratio is 1:2. The synergistic effect was also confirmed by 2K1C hypertensive rats. In chronic study, this combination (1:2) possessed an obvious synergism on the reduction of BP and BP variability (BPV) and protection on end organs. Multiple regression analysis showed that heart and aortic hypertrophy indexes and glomerular damage parameters were positively related to BP and BPV. In conclusion, combination of amlodipine and candesartan exhibited a potent antihypertensive effect and possessed an obvious synergism on BP reduction and organ protection in hypertension. The optimal proportion was 1:2. BP and BPV reduction may both importantly contribute to end organ protection.     

腹腔镜子宫(阴道)骶骨固定术与改良全盆底重建术治疗盆腔脏器脱垂的临床疗效观察

目的探讨经腹腔镜子宫(阴道)骶骨固定术及改良全盆底重建术用于治疗中盆腔缺陷为主的盆腔脏器脱垂(POP)患者的临床疗效。方法纳入2012年3月-2015年3月住院的中盆腔脏器脱垂达到POP-Q分期Ⅱ~Ⅲ期的患者169例,根据手术方式分为改良全盆底重建组81例和腹腔镜下骶骨固定术组88例。按照规范化标准为患者实施手术,手术中对合并盆底功能障碍进行对应处理。围手术期记录患者相应情况,检测手术主客观满意度。所有患者纳入随访,填写盆底功能障碍及性生活质量评估量表。结果骶骨固定术组平均年龄比较[(43.78±7.63)岁vs.(53.01±10.50)岁],两组绝经概率比较(33.0%vs.60.5%),术前压力性尿失禁(SUI)概率比较(46.1%vs.65.4%)显著低于改良全盆底重建组,差异有统计学意义(P<0.05)。与改良全盆底重建组相比,骶骨固定组手术出血量[(60.32±30.27)mlvs.(98.35±40.28)ml]、尿管留置时间[(1.90±0.90)dvs.(2.50±1.10)d]及子宫切除比例(30.7%vs.60.5%)更低,差异有统计学意义(P<0.05)。两组患者手术后12个月时PFIQ-7及PFQI-20评分均较手术前显著下降(P<0.05)。术后12个月时,骶骨固定组的PISQ-12评分显著高于手术前(P<0.05)。结论骶骨固定术及改良全盆底重建术治疗POP患者均具有较好的疗效及安全性,远期预后良好。骶骨固定术改善POP患者性生活质量更为显著。