Intravaginal brachytherapy in surgically treated uterine cancer

We analyzed retrospectively the clinical outcome of 108 patients with endometrial carcinoma operated at the Department of Obstetrics and Gynecology of Düsseldorf University regarding the effect of additional intravaginal brachytherapy. In 67 patients, we only performed an intraoperative rinsing of the vagina with alcohol and sutured the cervical canal to prevent vaginal recurrences. 41 patients received additional intravaginal brachytherapy. We observed only two vaginal recurrences in the 108 patients. There was no major difference in survival for patients with versus without additional intravaginal brachytherapy. We reviewed published studies critically regarding the efficacy and complications of intravaginal brachytherapy in operated endometrial cancer. These studies indicate that additional intravaginal brachytherapy can lower the rate of vaginal recurrences and that patients with dedifferentiated tumors, deep myometrial invasion and higher FIGO-stages might benefit most of this treatment modality.     

Laparoscopic surgical staging of stage I primary squamous cell carcinoma of the vagina

Vaginal carcinoma is an uncommon malignancy and one of the few gynecologic malignancies that is still clinically staged. Clinical staging, which can be difficult in some instances, is potentially inaccurate, as it has been shown to be in early endometrial and ovarian carcinoma. In addition, clinical staging can result in over- or undertreatment of the disease. The lack of standardization of treatment further compounds the issue, particularly for patients with small-volume disease. We report three patients with grade 2 or 3 small-volume primary squamous cell carcinoma of the vagina who underwent pelvic lymph node sampling for staging purposes. Each patient had lesions small enough to be considered for brachytherapy only. An average of 12 lymph nodes were removed with an average operative time of 72 minutes. All procedures were performed on an outpatient basis, and there were no intraoperative or postoperative complications. In one patient, teletherapy was added to the brachytherapy because a microscopic focus of squamous cell carcinoma was discovered in an obturator lymph node. Our initial experience indicates that laparoscopic sampling of lymph nodes in patients with early vaginal carcinoma may be helpful in preventing undertreatment of these women. Individualization of treatment can be accomplished quickly and safely on an outpatient basis, and initiation of treatment is not delayed. We believe further evaluation of laparoscopic staging of primary vaginal carcinoma is indicated.     

Endoscopic balloon hydrodilatation and endoprosthetic treatment of esophageal and esophageal anastomotic strictures

In 37 patients with benign stenosis of the esophagus and esophageal anastomoses, the method of dilatation using special balloon catheters under endoscopic control was employed, and adequate dilatation of the stenotic region accomplished. In comparison with balloon dilators, bougies exert forces along the radial axis, and no tension is applied to the esophagus along the longitudinal axis. To obtain prolonged remission and decrease the number of "supporting" dilatations of esophageal benign stenosis and esophageal anastomoses, temporary intubation of the esophagus with a silicone prosthesis was performed in 7 patients. Further clinical application, and a study of the long-term results of endoscopic balloon hydro-dilatation and endoprosthesis for treating esophageal and anastomotic esophageal strictures, will help to elaborate more precise indications for the combined use of these methods.     

Accurate model-based segmentation of gynecologic brachytherapy catheter collections in MRI-images

The gynecological cancer mortality rate, including cervical, ovarian, vaginal and vulvar cancers, is more than 20,000 annually in the US alone. In many countries, including the US, external-beam radiotherapy followed by high dose rate brachytherapy is the standard-of-care. The superior ability of MR to visualize soft tissue has led to an increase in its usage in planning and delivering brachytherapy treatment. A technical challenge associated with the use of MRI imaging for brachytherapy, in contrast to that of CT imaging, is the visualization of catheters that are used to place radiation sources into cancerous tissue. We describe here a precise, accurate method for achieving catheter segmentation and visualization. The algorithm, with the assistance of manually provided tip locations, performs segmentation using image-features, and is guided by a catheter-specific, estimated mechanical model. A final quality control step removes outliers or conflicting catheter trajectories. The mean Hausdorff error on a 54 patient, 760 catheter reference database was 1.49 mm; 51 of the outliers deviated more than two catheter widths (3.4 mm) from the gold standard, corresponding to catheter identification accuracy of 93% in a Syed–Neblett template. In a multi-user simulation experiment for evaluating RMS precision by simulating varying manually-provided superior tip positions, 3σ maximum errors were 2.44 mm. The average segmentation time for a single catheter was 3 s on a standard PC. The segmentation time, accuracy and precision, are promising indicators of the value of this method for clinical translation of MR-guidance in gynecologic brachytherapy and other catheter-based interventional procedures.     

筋膜扩张器治疗男性尿道狭窄的临床疗效

[目的]探讨筋膜扩张器治疗男性尿道狭窄的效果.[方法]应用筋膜扩张器对27例尿道狭窄患者行尿道狭窄扩张术.患者均在输尿管镜直视下直接留置斑马导丝穿过狭窄孔并在其引导下循序用8F至16F筋膜扩张器扩张狭窄尿道.[结果]27例手术均成功.术后无尿道穿孔、撕裂、假道形成.随访6～24个月,均排尿良好,最大尿流率由治疗前2.20～9.00(5.60±3.40)mL/s上升至18.20～33.60(25.40±8.20)mL/s,B超测定膀胱无残余尿.[结论]利用筋膜扩张器行尿道狭窄治疗是简单、易行、安全,有效的新方法,值得在临床治疗中应用.     

Comparison of health‐related quality of life between subjects treated with radical prostatectomy and brachytherapy

Aims and objectives. To evaluate the symptoms and self‐assessment of quality of life in men with localised prostate cancer after having had a radical prostatectomy or brachytherapy treatment. Background. Prostate cancer is a significant growing disease among men in Taiwan. Quality of life issues for the men who are living with this disease and the consequences of treatment. Design. A postal questionnaire survey. Methods. The study population came from one 1170‐bed hospital in Kaohsiung County, Taiwan. Data was collected from 20 August 2007–20 November 2009. Seventy‐eight men met the inclusion criteria. The researchers mailed a survey to each participant, which they completed at home and returned in a pre‐stamped, addressed envelope. Sixty‐four subjects participated and self‐reported using a structured questionnaire. The reliability of overall prostate cancer index was 0·90 and 0·85, 0·93 and 0·72 for each subscale, respectively. Results. The results indicate that the number of months post‐treatment was positively correlated with urinary function and age was negatively correlated with sexual, bowel function and bowel bothers. One predictor (month post‐treatment) was related to urinary function; one predictor (treatment method) was related to bowel function and four predictors (marital status, age, treatment method and month post‐treatment) were related to sexual function. Findings showed that patients who received brachytherapy have better urinary functions, as compared with prostatectomy patients. Conclusion. Study findings suggest that healthcare providers should have a better understanding of patients’ complications after treatment and this can ultimately raise the quality of life for prostate cancer patients. Relevance to clinical practice. The impact of quality of life among post prostate cancer treatment is common. Urological nurses should therefore take the responsibility regarding the consequence of urinary incontinence and sexual function and seeking appropriate nursing interventions for these complications.     

Evaluation and Management of Pelvic Organ Prolapse

Pelvic organ prolapse (POP) is a common clinical entity that can have a significant impact on a patient’s quality of life secondary to symptoms of pelvic pressure, vaginal bulge, urinary and bowel dysfunction, or sexual dysfunction. It is highly prevalent, with roughly 13% of women undergoing surgery for prolapse in their lifetime. Vaginal prolapse is diagnosed by history and physical examination. Additional testing may be indicated for evaluation of bowel and bladder symptoms. On examination, prolapse can represent descent of the anterior vaginal wall, vaginal apex (cervix/uterus or vaginal cuff scar after hysterectomy), or posterior vaginal wall, although it represents a combination of these in many cases. Treatment options for POP include observation, pelvic floor physical therapy, pessary use, and surgery. In patients with asymptomatic POP, observation is typically used. In those not desiring or medically unfit for surgery, pessaries are an effective nonsurgical option. When it is indicated, surgery can be performed through transvaginal, laparoscopic/robotic, or open approaches, using either the patient’s own tissue or mesh augmentation. Deciding between these is based on the compartments involved, extent of prolapse, medical and surgical comorbidities, differences in durability and risk between operations, and shared decision-making with the patient. Here, we review pertinent clinical considerations in the evaluation and management of POP.     

Efficacy of percutaneous mitral balloon valvuloplasty with the inoue balloon

Percutaneous mitral balloon valvuloplasty has become an accepted technique for use in selected patients with severe, symptomatic mitral stenosis. Recently, a new balloon catheter with an "hourglass" shape and specially designed guidewires and dilators has become available (Inoue balloon). The design of this balloon provides ease of manipulation and self-stabilization across the mitral valve during inflation. These features should decrease the incidence of complications associated with the procedure. Preliminary results in 12 consecutive patients who underwent percutaneous mitral balloon valvuloplasty with the Inoue balloon are presented. The mitral valve area increased from 0.92 +/- 0.21 cm2 before the procedure to 1.75 +/- 0.40 cm2 after the procedure. No complications occurred from the procedure, including no increase in severity of mitral regurgitation or creation of an atrial septal defect. Further follow-up is necessary to determine the long-term efficacy with this new balloon. Nonetheless, the preliminary results are encouraging.     

Discussing sexual function in the cardiology practice

Background

In patients with cardiovascular disease, sexual dysfunction is frequently encountered. Erectile dysfunction shares the same modifiable risk factors as coronary artery disease and the fear of triggering cardiovascular events can create stress and anxiety impacting the sexual lives of patients and their partners. To optimise healthcare, knowledge of cardiologists’ attitude and practice patterns regarding the discussion about sexual function is essential.

Methods

A 31-itemed anonymous questionnaire was mailed to 980 members of the Netherlands Society of Cardiology (cardiologists and residents in cardiology training). The questionnaire addressed awareness, knowledge and practice patterns about sexual dysfunction in cardiac patients.

Results

Of the cardiologists 53.9 % responded. Sixteen percent stated to discuss sexual function regularly. In the past year, an estimated mean of 2 % of patients was referred for help with a sexual problem. The majority (70 %) of cardiologists advised patients never or seldom about resuming sexual activity after myocardial infarction. PDE5-inhibitor use was assessed by 19.4 % of the cardiologists. Important reasons not to discuss sexual function were lack of initiative of the patient (54 %), time constraints (43 %) and lack of training on dealing with SD (35 %). Sixty-three percent of the cardiologists stated they would be helped with a directory of sexual healthcare professionals where they can refer patients to.

Conclusion

Sexuality is not routinely discussed in the cardiology practice. Explanations for the lack of attention toward sexual matters are ambiguities about responsibility and a lack of time, training and experience regarding the communication and treatment of sexual dysfunction.     

Barrier methods of contraception

Barrier methods of contraception make up an essential part of the present contraceptive range, and doctors need to know in detail how to choose and fit them as well as how to instruct patients in their use. This discussion reviews the mode of action of the barrier method and then focuses on the vaginal diaphragm, the cervical or vault cap, the collatex (Today) sponge, condoms, emotionl problems associated with the use of barrier methods, advantages of barrier methods, and future developments. Barrier methods of contraception are only effective if used consistently and carefully. Failure rates vary greatly between studies, but in selected populations the failure rate for the diaphragm with spermicide can be as low as 1.9/100 woman years (wy) and for the condom 3.6 per 100wy (Vessey et al., 1982). If known user failures are removed, the figure for the condom can drop to as low as 0.4 per 100wy (John, 1973), which compares favorably with that of the combined oral contraceptive. Other studies quote failure rates of 10 per 100wy or more. These methods call for considerable participation by the patient at or before each act of intercourse and there is, therefore, great scope for inefficient use, either as a result of poor instruction or because couples find that they interfere with happy, relaxed sexual activity -- or fear that they may do so. Doctors need to understand the feelings of their patients before recommending them. The aim of a barrier method is to prevent live sperm from meeting the ovum. This is accomplished by the combination of a physical barrier with a spermicide. In the case of the condom, the integrity of the physical barrier is the most important factor, although some patients feel more secure with an additional spermicide. The vaginal barriers used at present do not produce a "water-tight" fit, and the principle is that the spermicide is held over the cervix by the barrier. It is also possible that the device acts partially by holding the alkaline cervical mucus necessary for sperm transportation away from the acid vagina where the sperm is delayed and killed. The choice of available vaginal diaphragms is increasing. Despite some suggestion that the "fit" of a diaphragm is not crucial, supported by the argument that the vagina increses greatly in volume during intercourse, the best available figures for reliability are from studies of family planning clinic patients who have traditionally been fitted with great care. There are no good data about the effectiveness of the cervical and vault caps, and it is better to fit a diaphragm if this is possible. The Today polyurethane foam sponge is impregnated with the spermicide nonoxynol-9 and, as marketed, it is for use as often as desired up to 24 hours, plus 6 hours before final removal to ensure all vaginal sperm are killed. Condoms bearing the British Standards Institute Kitemark have been tested to a high standard an in view of the good results that can be obtained it seems likely that most failures are due to inefficient use. Advantages of barrier methods include some portection from sexually transmitted diseases and a reduction in the incidence of pelvic inflammatory disease.     

Tracheal stenosis and obliteration above the tracheostoma after percutaneous dilational tracheostomy

Percutaneous dilational tracheotomy (PDT) as opposed to the conventional surgical tracheostomy is a procedure that allows airway control in critically ill patients without surgical exposure of the trachea. Based on the Seldinger technique, dilators are passed along a guiding wire through a small neck incision into the trachea under endoscopic surveillance. This separates the tracheal rings and results in a stoma. As opposed to the regular surgical tracheostoma, a PDT-stoma is not epithelialized. The procedure is cost effective and little time consuming. Considering the increasing number of performed PDTs in the last few years, we feel a need to be aware of possible long-term complications. Thus, in this report, we describe three cases of tracheal stenosis/obliteration after a PDT procedure. In all cases, tracheal narrowing occurred above the level of the stoma. This suggests a procedure-related mechanism, i.e., tracheal ring invagination and the consecutive development of granulation tissue, rather than a mechanism based on the duration of the cannula's placement, which would normally produce the stenosis below the stoma in the area of the cuff. Toward the end of the article, we provide evidence for this hypothesis and thus present a new subset of long-term complications after PDT.     

Percutaneous tracheostomy: comparison of Ciaglia and Griggs techniques

Endoscopic percutaneous dilatational tracheostomy is at least as safe as standard open tracheostomy in the operating room (OR). Recently, a single dilator was introduced to accomplish dilatation of the tracheal aperture in one step, thus obviating the need for multiple graduated dilators. Experience with endoscopic percutaneous tracheostomy (PCT) using the single dilator in 40 patients to date supports the premise that the procedure is safe, rapid, and technically simple. In the study by Añon et al, two very different techniques, are compared: the Ciaglia percutaneous dilatational tracheostomy technique using multiple dilators and the Griggs percutaneous technique using guidewire-dilating forceps. Although relative complication rates for the two techniques are not significantly different, both procedures are performed in a 'blind' fashion, without the benefit of a bronchoscope. The reported incidence of serious complications in this study is high, and almost certainly avoidable with the addition of direct bronchoscopic visualization. Operative time is reported to be shorter with the Griggs technique, but this finding is unlikely to hold true for the single dilator technique, which reduces procedure time to less than 15 min. This author's experience with bedside endoscopic PCT using the single dilator indicates that it is a safe, rapid and cost-effective procedure with a low complication rate.     

Dapoxetine for premature ejaculation

Premature ejaculation (PE) is the most common form of male sexual dysfunction, with an estimated worldwide prevalence of 20–30%.1 Although PE is not life threatening, it has significant impact on quality of life. The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)defines PE as “persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it” that “causes marked distress or interpersonal difficulty” and “is not due exclusively to the direct effects of a substance.”2 The International Society for Sexual Medicine, which recently modified the definition to include the threshold ejaculatory latency time, defines PEas “male sexual dysfunction characterized by ejaculation which always or nearly always occurs prior to or within 1 min of vaginal penetration; the inability to delay ejaculation on all or nearly all vaginal penetrations; and negative personal consequences such as distress, bother, frustration, and/or the avoidance of sexual intimacy.”3 The lack of ejaculatory control is consistent among all clinical definitions of PE and is a highly sensitive predictor of the condition.     

Radiation-induced bronchial stenosis: a new cause of platypnea-orthodeoxia.

Platypnea-orthodeoxia is encountered in a variety of cardiac, pulmonary, and hepatic disorders. We report its occurrence in a 59-year-old man who had had combined external-beam and high dose-rate iridium brachytherapy for a stage I non-small-cell carcinoma of the right upper lobe 2 years earlier. The post-radiation course was complicated by a severe radiation bronchitis; the onset of platypnea-orthodeoxia signalled the development of severe bronchial stenosis that was transiently relieved, initially by dilatation, and later by stent placement, though the patient ultimately died of a pulmonary hemorrhage. The dosage of brachytherapy given, the combined external-beam therapy, and the long survival after completion of radiation therapy were likely factors in the development of bronchial stenosis. We discuss the tomographic and bronchoscopic features of radiation-induced bronchial stenosis.     

Routine pharyngeal cultures may not be useful in pediatric victims of sexual assault.

INTRODUCTION: This study was conducted to determine the usefulness of routine pharyngeal cultures in pediatric sexual assault victims. METHODS: A retrospective chart review was conducted to examine incidence data. The study was conducted in a 656-bed tertiary care hospital with 60,000 ED visits and approximately 350 pediatric sexual assault examinations annually. Records of all pediatric sexual assault examinations completed between 12:01 AM January 1, 1994, and 12:01 AM January 1, 1997, were retrospectively reviewed for inclusion. Subjects were included if they were younger than 15 years and had a nonacute examination for a suspected sexual assault. The final sample included 370 females and 81 males (total n=451 children). Oral and anal cultures were obtained on all patients. In addition, female patients had vaginal cultures and male patients had penile cultures performed. Culture specimens were sent for detection of chlamydia and gonococcus organisms. RESULTS: Of the 451 sets of cultures examined, there were 6 patients with one or more positive culture results. The 6 patients yielded a total of 10 positive culture results: 1 anal only, 1 vaginal only, and 4 both anal and vaginal. This was a positive culture rate of 1.3% overall. The positive culture result rates by site were oral 0%, vaginal 1.6%, anal 1.1%, and penile 0%. The ages of patients with positive culture results ranged from 2 to 13 years; all of those with positive culture results were female. DISCUSSION: The incidence of positive oral culture results in this sample was zero. This finding supports a more limited approach to standard sexually transmitted disease screening in pediatric sexual assault victims. The elimination of routine oral cultures in pediatric victims without alleged oral contact decreases the examination time, decreases the number of invasive procedures associated with the examination, and decreases the cost of the examination without negatively affecting patient care.     

腹腔镜子宫切除阴道残端骶韧带悬吊的应用

目的前瞻性的探究腹腔镜下全子宫切除术中阴道残端骶韧带悬吊对子宫良性肿瘤患者中术后盆底功能及生活质量的影响。方法选取2014年1月-2015年6月来该院就诊的子宫良性肿瘤患者共98例,利用随机数表的方法将所有患者分为两组,分别为对照组和试验组,每组各49例。对照组采取常规腹腔镜子宫全切术,试验组采取阴道残端骶韧带悬吊式腹腔镜下全子宫切除术,比较两组患者手术时间、术中出血量。治疗后进行随访2年,通过比较两组患者术后6个月、术后12个月和术后2年盆底功能障碍问卷(PFDI-20)评分、阴道长度变化、性生活恢复情况以及阴道残端脱垂来判断临床疗效。结果试验组患者手术时间与对照组相比差异无统计学意义(P0.05),但术中出血量明显低于对照组患者(P0.05)。对照组患者全部使用镇痛药,而试验组患者镇痛药使用率为91.84%,明显低于对照组(P0.05)。对照组阴道缩短长度为(2.11±0.97)cm,试验组为(1.05±0.74)cm,与对照组相比,试验组阴道缩短程度更小且差异有统计学意义(P0.05);对照组性生活恢复时间为(71.33±10.32)d,试验组为(61.29±10.82)d,两组比较差异有统计学意义(P0.05)。治疗前两组患者PFDI-20评分差异无统计学意义,治疗后对照组术后6、12和24个月评分为(45.6±9.2)、(42.5±7.4)和(41.2±6.1)分,而试验组术后6、12和24个月PFDI-20评分分别为(41.3±8.4)、(36.8±4.9)和(32.8±6.7)分,试验组数据明显低于对照组数据(P0.05)。结论腹腔镜下全子宫切除术时阴道残端预防性骶韧带悬吊可有效防止阴道残端脱垂,对盆底功能起到一定的支持作用,减少术后阴道缩短长度,有利于患者的预后,减少术中出血量。     

Efficacy and safety of prolonged-release hyaluronic acid derivative vaginal application in the postpartum period: a prospective randomised clinical trial

IntroductionIn puerperium, the hypoestrogenic state induced by delivery and subsequently sustained by lactation may lead to vaginal dryness, burning, and itching sensation, contributing to the onset of sexual dysfunction.Material and methodsThis was a prospective, randomized, controlled, open-label study (NCT04560283) for evaluating the effects of application of a prolonged-release hyaluronic acid derivative vaginal gel in restoring sexual function during the postpartum period. Eighty-five patients were randomized to apply prolonged-release Hydeal-D 0.2% vaginal gel (Fidia Farmaceutici, Abano Terme, Italy; n = 43) every three days for 12 consecutive weeks or expectant management (n = 42).ResultsWomen undergoing treatment had a more elevate increase in Female Sexual Function Index (FSFI) total score (+15.1 ± 11.9 vs +6.5 ± 8.9, p < 0.001) and a higher decrease in vaginal pH (−1.2 ± 0.7 vs −0.2 ± 1.1; p < 0.001). Moreover, the proportion of vaginal smears with maturation index (VMI) >65 was significantly higher in patients treated (80.6% vs 35.3%; p = 0.004). Edinburgh Postnatal Depression Scale (EPDS) decreased significantly in both groups with no inter-group difference (p = 0.459). Only two cases (4.8%) of moderate vaginal burning sensation were reported in patients undergoing local vaginal therapy.ConclusionsThe results of our study demonstrated that hyaluronic acid derivative vaginal gel (Hydeal-D) was able to improve sexual function of puerperal women in the short-term treatment.

KEY MESSAGE

• In the puerperium, the hypoestrogenic state induced by delivery and subsequently sustained by lactation may lead to vaginal dryness, burning, and itching sensation, contributing to the onset of sexual dysfunction.
• Hydeal-D is a prolonged-release hyaluronic acid derivative characterised by elevated resistance to enzymatic breakdown. During puerperium, its local application may improve the vaginal microenvironment by ensuring a better migration and proliferation of cells involved in local tissue repair.
• Among puerperal women, Hydeal-D vaginal gel causes a significant improvement of sexual function, including desire, arousal, and lubrification, compared to expectant management. Furthermore, it leads to a decrease in vaginal pH and an increase of the trophic status of vaginal epithelium.

     

腹腔镜协助阴式子宫切除术154例分析

探讨腹腔镜协助阴式子宫切除术的临床应用价值。方法；比较ＬＡＶＨ组１５３例和腹式全宫切除术组１８２组的临床疗效。结果；两种术式的手术时间，术后排气时间，术后并发症，住院天数等有显著差异。     

Sexuality following hematopoietic cell transplantation

Hematopoietic cell transplantation (HCT) is a therapeutic modality used to treat a variety of malignant and nonmalignant disorders. Because HCT often involves the use of high-dose radiation and chemotherapy, it is associated with numerous toxicities and effects, including changes in sexuality and sexual functioning. These changes may include decreased libido, erectile and ejaculatory dysfunction, premature menopause, vaginal alterations, dyspareunia, and infertility. Psychosocial factors, such as anxiety, depression, and concurrent life stressors, also may affect sexuality and sexual functioning. Healthcare providers caring for patients undergoing HCT need to initiate discussions about the impact of HCT on sexuality pretransplant and continue those discussions throughout and following the treatment process.