A 5-year prospective study of vaginal pessary use for pelvic organ prolapse

Objective

To evaluate prospectively the use of vaginal pessaries for pelvic organ prolapse (POP) and to identify complications and reasons for discontinuing pessary use over a 5-year period.

Methods

A prospective observational study was conducted among all women with POP referred to the urogynecology clinic of a UK hospital between June 2002 and June 2005 who opted to use a vaginal pessary. Patients were followed-up for 5 years.

Results

Of the 246 women who chose to use a vaginal pessary, 187 successfully retained the pessary 4 weeks after insertion. Over a 5-year period, 36 (19.3%) of the 187 women were lost to follow-up. Of the 151 women included in the analysis, 21 (13.9%) discontinued use at some point after 4 weeks, whereas 130 (86.1%) used the pessary successfully over 5 years. Overall, 12.1% of the women experienced minor complications (6.9% pain or discomfort, 3.2% excoriation or bleeding, and 2.0% disimpaction or constipation). Most failures (73.8%) occurred within 4 weeks of pessary insertion. After cessation of pessary use, 70 (28.5%) of the 246 women chose surgery and 10 (4.1%) chose no further treatment.

Conclusion

If treatment of POP with a vaginal pessary is successful at 4 weeks, most women will continue to use the pessary over 5 years without a concomitant increase in complications.     

Association between gestational age and induction-to-abortion interval in mid-trimester pregnancy termination using misoprostol

Objective

The study was aimed to evaluate the effectiveness, outcome, and pain intensity of the vaginal administration of misoprostol for the induction of abortion between 13 and 24 gestational weeks.

Study design

A retrospective study was conducted at our tertiary medical center from January 2006 to December 2009 on 122 consecutive women who underwent termination of pregnancy (TOP) in the mid-trimester. They were given 400 mcg of vaginal misoprostol every 6 h, up to four doses. The induction-to-abortion interval and the level of pain experienced during the process were assessed. Success was defined by the fetus being expelled within 48 h.

Results

Vaginal misoprostol was effective in 84% (98/122) of patients. The median duration of the induction-to-abortion interval was 16 (5-48) h. The induction-to-abortion interval was correlated with gestational age, while inversely correlated with parity. A correlation was also found between gestational age and pain intensity at 12 h from induction.

Conclusion

Misoprostol is safe and effective in mid-trimester abortion induction. The induction-to-abortion interval is shorter and abortion less painful with lower gestational age. Higher parity is also associated with shorter induction to abortion interval.     

Improved quality of life is partly explained by fewer symptoms after treatment of fibroids with mifepristone

Objective

To examine mediators of mifepristone treatment on improvements in health-related quality of life (HRQOL) among women with symptomatic fibroids.

Methods

The study sample included women with symptomatic uterine fibroids who were treated with 5 mg or 2.5 mg of mifepristone or placebo. Assessments of uterine size (ultrasound), pain (McGill pain questionnaire), bleeding (diary), anemia (gm/dL), and HRQOL measured using the uterine fibroid symptom quality of life scale were done at baseline, 3 months, and 6 months. The improvements in HRQOL that could be explained by changes in these clinical factors were assessed.

Results

The final sample included 62 women. Treatment with mifepristone was associated with significant improvement in HRQOL, which was explained in part by reduction in pain (28%, P < 0.001) and bleeding (18%, P < 0.001). Reduction in uterine volume was of marginal significance (P = 0.05) and was associated with a decrease in HRQOL (7%). Much of the impact of treatment on HRQOL (61%) remained unexplained in this model.

Conclusions

Improvements in HRQOL after treatment with mifepristone are partly explained by improvements in pain and bleeding, but not uterine size. However, most of the improvement in HRQOL is not explained by improvements in these clinical parameters.     

Transobturator tape procedure versus tension-free vaginal tape for treatment of stress urinary incontinence

Objective

To compare the efficacy and safety of the tension-free vaginal tape (TVT) and inside-out transobturator tape (TVT-O) procedures for the treatment of stress urinary incontinence (SUI).

Methods

A total of 315 women with or without concomitant pelvic organ prolapse repairs were randomly allocated to undergo a TVT or TVT-O procedure. Demographic data, intra- and postoperative complications, and surgical outcomes were analyzed.

Results

Fifteen patients were lost to follow-up. There were no significant differences in cure rates between the 2 groups at 6, 12, 24, and 36 months' follow-up. Hematomas occurred in 4 patients and there were 6 vaginal tape erosions. Urinary retention and de novo urinary urgency were similar in both groups. The operative time was significantly shorter for TVT-O than for TVT without other procedures (P < 0.001) and postoperative groin/thigh pain was higher (P < 0.05) in the TVT-O group.

Conclusion

Both techniques appear equally effective for the treatment of SUI. However, TVT-O had a shorter operative time and a higher rate of groin/thigh pain.     

Vaginal mesh colpopexy for the treatment of concomitant full thickness rectal and pelvic organ prolapse: a case series

Objective

To present our case series of concomitant rectal and pelvic organ prolapse (POP) treated with vaginal colpopexy with synthetic mesh.

Study design

Charts of patients with full thickness rectal prolapse and POP were reviewed for presenting symptoms, physical examination with POP-Q including rectal prolapse evaluation, and perioperative complications and outcomes.

Results

Four patients aged 63-78 were identified with full thickness rectal prolapse and POP. All of them had symptoms related to both conditions. Rectal prolapse protrusion ranged from 2 cm to 3 cm outside the anus. All patients had vaginal mesh colpopexy; two of them with anterior and posterior vaginal mesh and 2 with posterior mesh only. At a follow-up of 6-44 months, all patients had resolution of both POP and rectal prolapse signs and symptoms.

Conclusion

Vaginal colpopexy with mesh may be a unique treatment to address both POP and full thickness rectal prolapse in selected patients. Further research is needed to determine the safety and efficacy of this method.     

The efficacy and tolerability of short-term low-dose estrogen-only add-back therapy during post-operative GnRH agonist treatment for endometriosis

Objective

To evaluate the efficacy and tolerability of a low-dose estrogen-only regimen as a short-term add-back therapy during post-operative GnRH agonist (GnRHa) treatment of patients with endometriosis.

Study design

Retrospective cohort study. One hundred seventeen women of reproductive age who were treated with post-operative GnRHa after conservative laparoscopic surgery for endometrioma were eligible for this study. The patients were divided into two groups: group A (n = 56) received tibolone (2.5 mg) between 2002 and 2004 and group B (n = 61) received estradiol valerate (1 mg) between 2005 and 2007 as an add-back therapy for five months, beginning at the time of the second injection of a GnRHa. The incidence of hypoestrogenic symptoms and the degree of pelvic pain according to a verbal rating scale (VRS) scoring system, the incidence and patterns of uterine bleeding during add-back therapy, the endometrial thickness by ultrasonography two months after the last GnRHa treatment, and the serum CA-125 level were evaluated.

Results

The incidence of uterine bleeding, hypoestrogenic symptoms such as hot flashes and sweating, and pelvic pain did not differ significantly between the two treatment groups. However, the endometrium was thicker in group A than group B (p = 0.022). In group B, the frequency of uterine bleeding was lower from the second month after starting add-back therapy than in group A, but without statistical significance (at the sixth month, p = 0.086).

Conclusion

The low-dose estrogen-only regimen was efficacious and tolerable as a short-term add-back therapy during post-operative GnRHa treatment after surgery for endometriosis.     

Specific exercises to treat pregnancy-related low back pain in a South African population

Objective

To investigate the effect of an exercise program, including specific stabilizing exercises, on pain intensity and functional ability in women with pregnancy-related low back pain.

Methods

Fifty women between 16 and 24 weeks of pregnancy were recruited at Tygerberg and Paarl Hospitals, Western Cape, South Africa. Twenty-six women were randomized to a 10-week exercise program and 24 were randomized as controls.

Results

Overall, the most frequent type of back pain experienced was lumbar pain (36 [72.0%]). Pain intensity (P = 0.76) and functional ability (P = 0.29) were comparable between the groups on study entry. In the study group, there was a significant improvement in pain intensity (P < 0.01) and an improvement in functional ability (P = 0.06) at the end of the study. In the control group, there were no significant changes in pain intensity (P = 0.89) or functional ability (P = 0.70) at the end of the study.

Conclusion

A specific exercise program decreased back pain intensity and increased functional ability during pregnancy in South African women with lumbar and pelvic girdle pain.     

Histopathology-based combined surgical approach to rectovaginal endometriosis

Objective

To describe a new surgical approach to rectovaginal endometriosis. Rectovaginal endometriosis can be infiltrative or superficial involving the bowel. Only infiltrative disease should be treated by intestinal resection. However, infiltration of endometriosis cannot be confirmed by preoperative imaging techniques.

Methods

A total of 48 women with infiltrative rectovaginal endometriosis were included in this prospective study. Surgery was performed using a newly developed technique. All bowel resections were indicated according to operative findings and not on the basis of preoperative imaging technique results.

Results

The decision for rectosigmoidal resection was based on the results of the intraoperative dissection of the rectovaginal septum. Histologically, infiltration of the ventral bowel wall was confirmed in all cases.

Conclusion

This new surgical technique for the treatment of rectovaginal endometriosis allows precise diagnosis and treatment with low morbidity. A resection of the mesorectum is not necessary because the endometriotic nodules are always located on the antimesenteric surface of the bowel.     

Primary repair of rectovaginal fistulas complicating pelvic surgery by gracilis myocutaneous flap

Objectives

Complex rectovaginal fistulas repair are extremely challenging. Various surgical options have been suggested; nevertheless, none had been universally accepted as the procedure of choice. This prospective study discusses a novel surgical technique using gracilis myocutaneous flap interposition.

Methods

Eleven patients had fistulas post-resection of pelvic malignancy (n = 10) and rectal endometriosis (n = 1). Primary treatment was pelvic resection; nevertheless, 6 cases had adjuvant chemo-irradiation, 2 cases had post-operative irradiation and 2 patients had chemotherapy only. Fistulas mean diameter was 2 ± 0.24 cm (1-3) and 8 patients (72.7%) had their fistulas in the middle vaginal third.Repair was wide debridement of fistulas margins followed by gracilis myocutaneous flap interposition with synchronous diverting stomas. Success was defined as healing of fistula after stomal closure.

Results

Five patients were repaired by single gracilis myocutaneous flaps, 2 cases by simple gracilis muscle and 4 cases by double gracilis myocutaneous flaps. Patients had a mean follow-up time of 34.8 ± 5.03 months (12-67) and all patients had definitive healing of their fistulas (100%). Median time to stoma closure was 2 months (1-5). Four women (36.4%) had at least one early postoperative complications including temporary leak (n = 3), vaginal sepsis (n = 1), partial skin paddle necrosis (n = 1) and donor limb deep venous thrombosis (n = 1). Late morbidities were seen in 3 cases (27.3%) including vaginal stricture, anorectal anastomotic stricture and anastomotic tumor recurrence.

Conclusion

Rectovaginal septum repair requires adequate debridement of necrotic devascularized tissues, tissue transposition and reconstruction of vaginal wall. Gracilis myocutaneous flaps are ideal for this issue.     

A simple procedure to prevent chronic vaginal colpotomy wound bleeding after laparoscopically assisted vaginal hysterectomy

Objective

To determine whether injecting the colpotomy wound with diluted vasopressin decreases vaginal bleeding after laparoscopically assisted vaginal hysterectomy (LAVH).

Methods

In this prospective controlled study 100 patients who underwent LAVH from July 1, 2005 to June 30, 2007, were randomized to receive an injection of vasopressin (n = 50) or normal saline (n = 50) solution in the colpotomy wound.

Results

In the vasopressin group, bleeding from the colpotomy wound occurred for more than 7 days in 9 patients (18%), and none was bleeding after 1 month; in the control group, the corresponding values were 29 (58%) and 2 (4%). Compared with the study group, the control group had a significantly higher rate of chronic bleeding from the colpotomy wound for more than 7 days and for more than 14 days after LAVH (P < 0.001 for both).

Conclusion

Infiltrating the colpotomy wound with diluted vasopressin was found to prevent chronic vaginal bleeding, which frequently occurs following LAVH.     

Comparison of the PainMatcher and the Visual Analogue Scale for assessment of labour pain following administered pain relief treatment

Objective

during childbirth, it is necessary to assess and monitor experienced pain and to evaluate the effect of pain relief treatment. The aim of this study was to compare the PainMatcher^® (PM) with the Visual Analogue Scale (VAS) for the assessment of labour pain and the effect of pain relief treatment.

Design

randomised controlled trial.

Setting

labour ward with approximately 2500 childbirths per year in western Sweden.

Participants

57 women with labour pain treated with acupuncture or sterile water injections scored their electrical pain threshold and pain intensity with the PM. Pain intensity was also assessed with the VAS. Electrical pain threshold and pain intensity were assessed immediately after a uterine contraction before and 30, 60, 90, 120, 150 and 180 minutes after treatment.

Measurements and findings

the results showed a weak correlation (r=0.13, p<0.05) between the pain intensity scores on the PM and the VAS. The PM detected changes (decrease) in pain intensity to a lower degree than the VAS. Surprisingly, in over 10% of sessions, women scored their pain intensity during a uterine contraction lower than their electrical pain threshold with the PM. However, electrical pain thresholds with the PM correlated well throughout all measurements.

Conclusions

the PM is a reliable tool for the assessment of electrical pain threshold; however, the VAS is more sensitive than the PM for recording changes in pain intensity when assessing the effects of treatment on labour pain.

Implications for practice

the PM and the VAS are not interchangeable in the case of labour pain, and there is still a need for research in this area to find a more suitable assessment instrument for the evaluation of labour pain.     

Comparing effectiveness of combined transobturator tension-free vaginal mesh (Perigee) and transobturator tension-free vaginal tape (TVT-O) versus anterior colporrhaphy and TVT-O for associated cystocele and urodynamic stress incontinence

Objective

To evaluate the efficacy and safety of transobturator tension-free vaginal mesh (Perigee) and concomitant transobturator tension-free vaginal tape (TVT-O) for treating cystocele with urodynamic stress incontinence (UDSI).

Study design

A retrospective study of 115 patients with symptomatic stages 2-3 cystocele and UDSI who were treated with a Perigee system (Group I, n = 68) plus TVT-O procedure or traditional anterior colporrhaphy (Group II, n = 47) plus TVT-O procedure. All patients were followed up for more than one year. Objective and subjective symptoms were evaluated at one year postoperatively. Statistical analysis was performed using SPSS software.

Results

The objective cure rates for cystocele at one year were significantly higher in Group I than in Group II (98.5% and 86.9%, P = 0.018), respectively. The cure rates for UDSI in the two groups were 91.0% vs. 91.3% (P = 1.000). Symptomatic improvement of frequency was better in Group I than Group II (87.7% vs. 70.0%, P = 0.030). There were no significant differences with regard to intraoperative and postoperative complications between the two groups.

Conclusions

The combination of the Perigee system and TVT-O offers a safe and effective treatment for cystocele with UDSI and may be performed as first-line treatment.     

Wide genital hiatus is a risk factor for recurrence following anterior vaginal repair

Objective

To determine if a wide genital hiatus is a risk factor for recurrence of anterior vaginal wall prolapse following anterior vaginal repair.

Methods

A retrospective cohort study was performed on patients who had undergone an anterior vaginal wall repair. Patients were placed into 1 of 2 groups: wide genital hiatus (≥ 5 cm) or normal genital hiatus (< 5 cm). The wide genital hiatus group (n = 35) was compared with the normal genital hiatus group (n = 30) for surgical failure.

Results

There were no significant differences between the 2 groups in demographic data, additional operative procedures, or apical suspensions. The rate of postoperative anterior vaginal wall prolapse was greater in patients with a wide genital hiatus compared with those with a normal genital hiatus (34.3% vs 10% respectively; odds ratio 4.7 [95% confidence interval, 1.0-24.1]; P = 0.02).

Conclusion

The rate of recurrent anterior vaginal wall prolapse is higher in patients with a wide genital hiatus.     

Location of aortic node metastases in locally advanced cervical cancer

Background

To assess the location of aortic node metastasis in patients with locally advanced cervical cancer undergoing extraperitoneal aortic lymphadenectomy to define the extent of the aortic lymphadenectomy.

Material and methods

Between August 2001 and December 2010, 100 consecutive patients with primary locally advanced cervical cancer underwent extraperitoneal laparoscopic aortic and common iliac lymphadenectomy. The location of aortic node metastases, inframesenteric or infrarenal was noted.

Results

The mean number ± standard deviation (SD) of aortic nodes removed was 15.9 ± 7.8 (range 4-62). The mean number ± SD of inframesenteric (including common iliac) nodes removed was 8.8 ± 4.5 (range 2-41) and the mean number ± SD of infrarenal nodes removed was 7.8 ± 4.1 (range 2-21). Positive aortic nodes were observed in 16 patients, and in 5 (31.2%) of them the infrarenal nodes were the only nodes involved, with negative inframesenteric nodes.

Conclusion

Inframesenteric aortic nodes are negative in the presence of positive infrarenal nodes in about one third of patients with locally advanced cervical cancer and aortic metastases.     

Epidemiology of mixed urinary incontinence in China

Objectives

To determine the prevalence and risk factors for mixed urinary incontinence (MUI) among Chinese women.

Method

In this cross-sectional survey study we analyzed the answers to a modified Bristol Female Lower Urinary Tract Symptoms questionnaire provided by 19 024 women older than 20 years and from 6 regions in China.

Results

The overall prevalence of MUI was 9.4%. The prevalence of MUI increased with age and reached 24.1% among women older than 70 years. Multivariable logistic regression analysis revealed that age, vaginal delivery, chronic constipation, pelvic organ prolapse, chronic pelvic pain, respiratory system disease, menstrual disorder, urinary system disease, alcohol consumption, pelvic surgery, obesity, and a low educational level were independent risk factors for MUI.

Conclusion

We found age, vaginal delivery, and chronic constipation to be the main risk factors for MUI among adult women in China.     

Goserelin versus leuprolide before hysterectomy for uterine fibroids

Objective

To compare goserelin and leuprolide given before hysterectomy for symptomatic large fibroid uteri.

Methods

A randomized study of 66 premenopausal women with fibroid uteri at least 14 weeks of gestation in a gravid uterus. Women were randomized to receive either subcutaneous depot 3.6 mg goserelin or 3.75 mg leuprolide every 4 weeks for a total of 3 doses. Hysterectomy was performed within 1 month of the last dose.

Results

A total of 34 women randomized to the goserelin group and 31 women to the leuprolide group were available for analysis. Preoperative hemoglobin level (P = 0.89), operative blood loss (P = 0.72), and operating time (P = 0.39) were not different between the 2 groups. Postoperative hemoglobin was higher in the leuprolide group (P = 0.003), but blood transfusion requirement was not different between the groups (P = 1.0). Other outcomes and side effects of the drugs were similar.

Conclusions

Goserelin and leuprolide administered before hysterectomy for uterine fibroids have similar perioperative outcomes.     

Uterine artery embolization versus laparoscopic occlusion of uterine vessels for management of symptomatic uterine fibroids

Objective

To evaluate the efficacy and complications of uterine artery embolization (UAE) versus laparoscopic occlusion of uterine vessels (LOUV) in the management of symptomatic fibroids.

Methods

A pilot randomized clinical trial in which 20 patients with symptomatic fibroids were randomly allocated into two groups. Ten women underwent UAE, and 10 women underwent LOUV. Symptomatic improvement in menorrhagia and reduction in the volumes of the uterus and the fibroid were assessed at 3 and 6 months.

Results

The patients were comparable with regard to age and parity. At 6 months, there was no significant difference in the mean reduction in menstrual blood loss, uterine volume, and volume of the dominant fibroid between the two groups (P = 0.436, P = 0.796, P = 1.00, respectively). However, higher pain scores were recorded on day 1 in the UAE group compared with the LOUV group (P = 0.0002).

Conclusions

The effects of UAE and LOUV in the management of symptomatic fibroids are comparable. The main advantage of LOUV is less postoperative pain compared with UAE.     

Feasibility of same-day discharge after laparoscopic surgery in gynecologic oncology

Objectives

To characterize the post-operative care of BRCA1 and BRCA2 mutation carriers who undergo risk-reducing salpingo-oophorectomy (RRSO).

Methods

BRCA1 and BRCA2 mutation carriers from our Cancer Risk Program who elected RRSO were sent questionnaires regarding their post-surgical surveillance and treatment for menopause symptoms, primary peritoneal cancer and bone loss.

Results

In 51 mutation carriers who were surveyed a median of 6 years after RRSO, 24 (47%) received dual-energy X-ray absorptiometry (DXA) testing, yearly CA-125 serum testing and yearly pelvic examination. Three women received none of these examinations in follow-up. Respondents reported an average of 3.5 menopausal symptoms (range 0-9). The mean number of menopausal symptoms reported by respondents using HRT was 2.8, compared to 3.9 symptoms reported by women not using HRT (p = 0.06). Six of 10 (60%) subjects who reported no history of DXA bone scan, and 10 of 15 (67%) subjects who reported no post-surgical CA-125 serum monitoring noted that their physicians “did not recommend” testing. Two out of six symptomatic women who were younger than 50 (33%) who had no other contraindication to the use of HRT reported their non-use was because their care providers “advised against” HRT use.

Conclusion

We believe that the lack of post-RRSO health care guidelines has resulted in inconsistent care for this cohort of patients. We proposed that national guidelines be developed to standardize care with the goal of optimizing long term survival in this unique cohort of young cancer previvors.     

3D conformal postoperative radiotherapy with concomitant boost in uterine cancer: results of a phase I-II study (ADA-RT-1)

Objective

A phase I-II prospective clinical trial of adjuvant accelerated radiation therapy (ADA-RT-1 trial) was set up in order to investigate the feasibility and efficacy of a pelvic conformal radiotherapy technique with concomitant boost (CB technique) to the vaginal vault in high-risk uterine cancers.

Methods

Patients with uterine (endometrial cancer and sarcomas) and cervical neoplasm received external radiotherapy delivered in a short overall treatment time with a CB technique. The prescribed radiotherapy doses were 45/1.8 Gy/fraction to the pelvis and 55/2.2 Gy/fraction to the upper two-thirds of vagina plus resection lines in the parametria, respectively; treatment was administered in 25 fractions along 5 weeks.

Results

This study included 91 consecutive gynecological cancer patients (endometrial = 72; cervical = 10; sarcoma = 9; median follow-up: 25 months, range: 5-72 months). Acute toxicity requiring treatment interruption (≥ grade 3) was observed in 7 patients (7.7%). No case of vaginal recurrence was documented. Actuarial 3-year loco-regional control rate was 97.7%, whereas 3-year disease-free survival and overall survival rates were 88.5% and 94.0%, respectively.

Conclusion

In summary, the CB technique provides a high probability of local control with acceptable toxicity and shortening of the overall treatment time; moreover, it may offer some advantages to resource constrained medical environments.     

Symptomatic pelvic hematoma following transvaginal reconstructive pelvic surgery: incidence, clinical presentation, risk factors, and outcome

Objective

To assess the incidence, clinical presentation, risk factors and outcome of symptomatic pelvic hematomas following transvaginal pelvic reconstructive surgery.

Materials and methods

We reviewed the medical records of all women undergoing transvaginal reconstructive pelvic surgery in our institution between January 2006 and July 2009.

Results

462 patients underwent pelvic reconstructive surgery, of whom 28 (6%) presented with symptomatic pelvic hematomas. All cases occurred after transvaginal hysterectomy, 25 (90%) presented with fever, 20 (71%) with pelvic pain and 5 (20%) with urinary retention. All hematomas were diagnosed by ultrasound. They were located at the vaginal cuff in 18 (64%), anterior vaginal wall in six (21%) and posterior vaginal wall in four patients (14%), and had a mean volume of 590 ± 140 cm³. Laboratory data included leukocytosis (71%), thrombocytosis (57%) and elevated liver enzymes (18%). Nine patients (33%) required ultrasound-guided drainage of the hematoma, which resulted in marked clinical improvement. Surgical outcome was not affected by the presence of pelvic hematoma.

Conclusions

A postoperative symptomatic pelvic hematoma is not rare and is closely related to transvaginal hysterectomy. Its clinical presentation includes fever, pelvic pain, leukocytosis, thrombocytosis and occasionally liver dysfunction. Surgical outcome is generally unaffected.