M Alcalay, P K Thompson, and T B Boone (Houstan, Texas)
Ball urethroplasty combined with Marshall-Marchetti-Krantz urethropexy versus suburethral sling in patients with intrinsic sphincter deficiency and urethral hypermobility.
Am J Obstet Gynecol, Dec.2000, 813: 1348-54
Objective: It was our goal to compare the efficacy of a suburethral fascial sling with that of a combination of Marshall-Marchetti-Krantz urethropexy and Ball urethroplasty in patients with intrinsic sphincter deficiency and urethral hypermobility.
Study Design: This study consisted of a retrospective observational evaluation of patients from 2 separate practice sites. Preoperative and postoperative data were collected from patients medical records. The long-term results were based on a mailed questionnaire addressing bladder symptoms and quality-of-life issues.
Results: Among a total of 48 patients, 37(77.1%) responded in the group undergoing Marshall-Marchetti-Krantz urethropexy combined with Ball urethroplasty, and 30 out of 35 (85.7%) patients replied in the suburethral fascial sling group. The mean length of follow-up was 2.7 years (range, 1-5 years). The patients were similar in age, hormonal status, parity, and previous bladder neck surgery. Similar cure and improvement were demonstrated in both groups (86.6% in the suburethral fascia group and 89.2% in the group with the Marshall-Marchetti-Krantz procedure combined with Ball urethroplasty). No significant differences were found in urinary incontinence types, irritable bladder symptoms, voiding difficulties, or quality-of-life measures.
Conclusion: The suburethral fascial sling and a procedure consisting of Marshall-Marchetti-Krantz urethropexy combined with Ball urethroplasty have similar results in patients with intrinsic sphincter and urethral hypermobility.
I M E Sundstrom, M Bixo, I Bjorn and M Astrom (Umea and Pitea, Sweden)
Prevalence of Psychiatric Disorders in Gynecologic Outpatients
Am J Obstet Gynecol, Jan. 2001; 184: 8-13
Objective: This study was undertaken to determine the point prevalence of psychiatric disorders in an unselected gynecologic population.
Results: Overall, 897 patients (88.5%) filled in the diagnostic tool’s patient questionnaire. Psychiatric disorders were present in 30.5% of the patients. Mood disorders were most common; major depression was prevalent in 10.1% of patients and minor depression was seen in 12.4% of patients. Anxiety disorders were also common and were encountered in 12.1% of patients. Among patients with a diagnosis only 21.4% had some form of treatment.
Conclusions: The prevalence of mood and anxiety disorders in an outpatient gynecology clinic is high. The majority of women with a diagnosis based on the diagnostic tool did not have a previous diagnosis and were untreated.
H E Richter, R E Varner, E Sanders, et al (Birmingham, Alabama)
Effects of pubovaginal sling procedure on patients with urethral hypermobility and intrinsic sphincteric deficiency: Would they do it again?
Am J Obstet Gynecol, Jan.2001; 184: 14 -19
Objective: This study was undertaken to assess the cure rate of stress urinary incontinence, long-term effects on other lower urinary tract symptoms, and quality of life in a cohort of patients who underwent pubovaginal sling procedures for treatment of incontinence related to intrinsic sphincteric deficiency and urethral hypermobility.
Study Design: This was a retrospective analysis of 57 patients with 90% follow-up who underwent pubovaginal autologus fascial sling procedures for stress urinary incontinence related to urethral hypermobility and intrinsic sphincteric deficiency. Objective postoperative urodynamic evaluation was performed in 34 (60%) of the cases.
Results: The mean follow-up period was 42 months and the median follow-up period was 34 months, with a range of 0.5 to 134 months. The age at the time of the sling procedure ranged from 18 to 84 years, with a median parity of 3.0 (range, 0-6). Preoperative body mass index ranged from 19.5 to 39.1 kg/m2. Five percent of patients had detrusor instability before the operation. Forty-one percent (41%) of the patients who underwent postoperative urodynamic evaluation had voiding dysfunction. The postoperative objective curer rate for stress urinary incontinence was 97%. Of all patients, 88% indicated that the sling had improved the quality of life, 84% indicated that the sling relieved the incontinence in the long-term, and 82% would choose to undergo the procedure again.
Conclusion: Construction of a pubovaginal sling is an effective technique for relief of severe stress urinary incontinence. Voiding dysfunction is a common side effect. Despite this problem, a significant number of patients would elect to undergo the procedure again.
P.D. Delmas, B Pornel , et al (Lyon, France, Brussels, Belgium, Berlin, Germany, Haugesund, Norway and Warsaw, Poland)
Three-year follow-up of the use of transdermal 17b-estradiol (Menorest) participated in open-label extensions for a third year
Am J Obstet Gynecol, Jan.2001; 184: 32- 40
Study Design: Those patients originally randomly assigned to receive 17b-estradiol continued active treatment with dosage of 25, 50, 75, or 100 mg/d, whereas those originally randomly assigned to receive a placebo patch were switched to an active patch of identical size that delivered 17 b-estradiol at 25, 50, 75, or 100 mg/d. Follow up was conducted, and bone density and other parameters were compared.
Conclusion: The Menorest formulation of transdermal 17b-estradiol maintained bone mineral density gains in postmenopausal women and was well tolerated through a 3-year treatment period. It was also effective in reversing the initial bone loss associated with late commencement of therapy.
M B Sorensen, T Fritz-Hansen, et al (Copenhagen, Denmark)
Temporal changes in cardiac function and cerebral blood flow during sequential postmenopausal hormone replacement.
Am J Obstet Gynecol, Jan.2001; 184: 41-47
Objective: The purpose was to assess the temporal changes in cardiac function and cerebral blood flow during postmenopausal administration of estrogen with and without progestogen.
Study design: Sixteen postmenopausal volunteers were assessed during estradiol plus sequential norethindrone acetate and placebo in two 12 week periods. Temporal changes were measured by magnetic resonance flow mapping 8 times.
Results: Systemic vascular resistance was reduced during estradiol (-6.9%); P<.05), declined further during the addition of norethindrone acetate, and was accompanied by an increase in stroke volume (maximum increase, 5.2%; P<.05) without fluid retention. Both systolic (-5mm Hg; P=.03) and diastolic (-3mm Hg; P=.03) blood pressure were reduced during estradiol. Cerebral blood flow was reduced after 9 weeks of hormone replacement therapy (-37mL/min; P=.01) but increased to baseline after the addition of norethindrone acetate.
Comments: The addition of norethindrone acetate did not reduce the improved cardiac function induced by E2, which supports the use of this progestogen in women with heart disease.
Progestogen withdrawal is known to cause vasoconstriction in hormone-sensitive tissue such as the endometrium during the menstrual phase.
An overall neutral effect of combined HRT on the cerebrovascular circulation is supported by observational data.
Conclusions: Sequential hormone replacement therapy is associated with changes in cardiac function, which are of therapeutic potential in cardiovascular disorders. Sequential hormone replacement therapy exhibits an overall neutral effect on cerebral blood flow.
A C Fleischer, J E Wheeler, et al (Nashville, Tennessee, Philadelphia and Collegeville, Pennsylvania, Detroit, Michigan, and London, United Kingdom.
An assessment of the value of ultrasonographic screening for endometrial disease in postmenopausal women without symptoms.
Am J Obstet Gynecol, Jan 2001; 184: 70-74
Objective: To evaluate the use of transvaginal ultrasonography for the detection of endometrial disease in a population of postmenopausal women who were without symptoms.
Study Design: Postmenopausal women were screened for potential inclusion in 2 multicenter, double-blind, placebo-controlled studies of 2 years’ duration to evaluate the safety and efficacy of idoxifene in the prevention of osteoporosis. Baseline endometrial evaluation was performed by transvaginal ultrasonography and aspiration biopsy of the endometrium.
Results: A total of 1926 women were screened by transvaginal ultrasonography, and 1833 of them had endometrial thickness £6mm. Five cases of endometrial abnormality (adenocarcinoma (n=1) and atypical hyperplasia (n=4) were detected in the 1750 women from this cohort who underwent biopsy. The negative predictive value was >99%. One case of adenocarcinoma was detected in the 42 women who had endometrial trial thickness >6mm and underwent biopsy. However, the sampling rate (45%) of women with endometrial thickness >6mm was too low for confidence in the positive predictive value of 2%.
Comment: This is the largest comparison of transvaginal ultrasonography and endometrial biopsy yet reported and indicates that in untreated postmenopausal women without symptoms the prevalence of endometrial abnormality is <1%. Therefore the use of a 6-mm threshold for endometrial thickness has very high specificity and negative predictive value because the vast majority of women in this population have atrophic endometrium.
In contrast to the data in women without symptoms, transvaginal ultrasonography has a high positive predictive value for the presence of endometrial abnormality in women with postmenopausal bleeding.
Conclusions: Despite a high negative predictive value, transvaginal ultrasonography may not be an effective screening procedure for detection of endometrial abnormality in untreated postmenopausal women who are without symptoms.
D Hubacher, R Lara-Ricalde, D J Taylor et al
Use of Copper Intrauterine Devices and The Risk of Tubal Infertility among Nulligravid Women.
N. Eng.Jr. Med., vol. 345, No.8, Aug.23, 2001, p.561-7
P. D. Darney (Univ. of California, San Francisco)
Time to Pardon the IUD.
N Eng.J Med. Vol.345, No.8, Aug.23, 2001, p.608
Intrauterine device (IUD) has been used for years as contraceptive device. They can be made of either copper or plastic. Their main drawbacks of IUDs are local infection, inflammation and permanent infertility.
A survey conducted showed that the copper IUDs do not carry the risk of permanent infertility but the plastic ones do.
A. Duerr, B. Kieke, D. Warren, K. Shah, R. Burk, J. F. Peipert, P. Schuman, and R. S. Klein for the Human Immunodeficiency Virus Epidemiology Research (HER) Study (Atlanta, Georgia, Baltimore, Maryland, Bronx, New York, Providence, Rhode Island, and Detroit, Michigan)
Human Papillomavirus-associated Cervical Cytologic Abnormalities Among Women With or at Risk of Infection with Human Immunodeficiency Virus
Am J Obstet Gynecol March. 2001; 184: 584-90
Objective : Correlates of abnormal human immunodeficiency virus cervical cytologic findings were examined among women infected with human immunodeficiency virus and uninfected women.
Study Design : A cross-sectional analysis of baseline data was performed on demographically similar women with infection or risk factors for it.
Conclusion : Squamous intraepithelial lesions are more common among human immunodeficiency virus-infected women and are associated most commonly with high- and intermediate-risk human papillomavirus types and secondarily with human immunodeficiency virus-associated immune compromise.
A J Walter, J G Hentz, P M Magtibay, et al (Scottsdale, Arizona)
Endometriosis: Correlation Between Histologic and Visual Findings at Laparoscopy
Am J Obstet Gynecol, June 2001; 184: 1407-13
Objective : The purpose of this study was to correlate the diagnosis of endometriosis on the basis of visualization at laparoscopy with the pathologic diagnosis.
Study Design : A prospective study of 44 patients undergoing laparoscopy for the evaluation of chronic pelvic pain was carried out. All areas suggestive of endometriosis were excised and examined pathologically. Peritoneal biopsy specimens were obtained from areas of normal-appearing peritoneum to rule out microscopic endometriosis. All lesions were identified by anatomic site. Visual and histologic American Fertility Society scores were compared. The positive predictive value, sensitivity, negative predictive value, specificity were determined for visually identified endometriosis versus the histologic correlate.
Results : The mean prevalence of abnormalities visually consistent with endometriosis was 36%, with 18% confirmed histologically. The positive predictive value was 45%; sensitivity, 97%; negative predictive value, 99%; and specificity, 77%; for visual versus histologic diagnosis of endometriosis. Thirty-six percent of the diagnoses were downstaged on the basis of histologic findings.
Conclusion : A diagnosis of endometriosis should be established only after histologic confirmation.
P K Sand, S Koduri, R W Lobel, et al (Evanston, Illinois)
Prospective Randomized Trial of Polyglactin 910 Mesh to Prevent Recurrence of Cystoceles and Rectoceles.
Am J Obstet Gynecol, June 2001; 184: 1357-64
Objective : To evaluate the efficacy of polyglactin 910 mesh in preventing recurrent cystoceles and rectoceles.
Study Design : In a prospective, randomized controlled trial, patients undergoing vaginal reconstructive surgery with cystoceles to the hymenal ring and beyond were randomly selected to undergo anterior and posterior colporrhaphy with or without polyglactin 910 mesh reinforcement. Results were evaluated preoperatively and at 2, 6, 12, and 52 weeks postoperatively.
Conclusion : Polyglactin 910 mesh was found to be useful in the prevention of recurrent cystoceles.
Comment : Recently, many surgeons have adapted the hypothesis of Richardson et al that paravaginal defects are responsible for most recurrent cystoceles.
R C Doucette, H T Sharp and S C Alder (Bountiful and Salt Lake City, Utah)
Challenging Generally Accepted Contraindications To Vaginal Hysterectomy
Am J Obstet Gynecol, June 2001; 184: 1386-91
Objective : A number of preexisting clinical conditions are generally accepted as contraindications to vaginal hysterectomy. The purpose of this study was to evaluate the validity of this concept.
Study Design : The study vaginal hysterectomy group consisted of 250 consecutive patients undergoing vaginal hysterectomy. These patients (1) had a large uterus (>180 g), (2) either were nulliparous or had no previous vaginal delivery, or (3) had a previous cesarean delivery or pelvic laparotomy. Three control groups used for comparison underwent (1) laparoscopically assisted vaginal hysterectomy, (2) vaginal hysterectomy, or (3) abdominal hysterectomy. The records for all patients were analyzed for age, weight, parity, primary diagnosis, uterine size, operative time, blood loss, analgesia, hospital stay, resumption of diet, incidence of morcellation, and surgical complications. Sample size calculations were based on previous studies of complications associated with vaginal hysterectomy (a= .05; b = .20).
Results : Hysterectomy was successfully completed by the intended vaginal route in all study patients. Major and minor complications (3.2%) were significantly less (P< .001) than in the other groups as follows: vaginal hysterectomy, 10.4%; laparoscopically assisted vaginal hysterectomy, 11.6%; and abdominal hysterectomy, 13.6%. The decrease in hematocrit was 5.7% in the study vaginal hysterectomy group compared with 6.2% for vaginal hysterectomy, 6.5% for abdominal hysterectomy (P = .009), and 6.6% for laparoscopically assisted vaginal hysterectomy (P=.002). Hospital stay was shorter for the study group (2.1 days) than for vaginal hysterectomy (2.3 days; P < .001) and abdominal hysterectomy (2.7 days; P < .001). Operative time was shorter in the study vaginal hysterectomy group (49 minutes) than with laparoscopically assisted vaginal hysterectomy (76 minutes; P< .001) or abdominal hysterectomy (61 minutes; P< .001), although morcellation was carried out more frequently in the study group (34%) than with vaginal hysterectomy (4%) or laparoscopically assisted vaginal hysterectomy (11%).
Conclusion : This data indicates that a large uterus, nulliparity, previous cesarean delivery, and pelvic laparotomy rarely constitute contraindications to vaginal hysterectomy.
Dr. Doucette’s Comments : The 1000 cases in this study were performed by 7 board-certified gynecologists who assisted each other at surgery. Senior residents (assisted by the authors) performed 25 of the study vaginal hysterectomies. One explanation for the shorter hospital stay data may be that, from 1994 to 1996, 3 health maintenance organizations restricted both LAVH and VH patients to a 24-hour stay.
There were fewer colporrhaphies in the study group (52%) than in the standard group (74%). The study group included 17 nulliparous patients and 36 patients delivered by cesarean with no vaginal deliveries.
R. Ansbacher (Ann Arbor, Michigan)
The Pharmacokinetics and Efficacy of Different Estrogens are not Equivalent
Am J Obstet Gynecol February 2001; 184: 255-63
In the next decade many women will turn to the medical community for advice on maintaining or improving health after menopause. Estrogen replacement therapy, with or without progestins, alleviates menopausal symptoms, prevents or manages osteoporosis, and reduces the increased cardiovascular disease risk that results from estrogen deficiency caused by ovarian decline.
Although several estrogen replacement products are available, the pharmacokinetics and efficacy of these products may vary depending on either the estrogen formulation or the route of administration, or both. For example, oral estrogens, which elicit a marked hepatic response, induce greater beneficial effects on serum lipoproteins than transdermal estrogens, which circumvent first-pass liver metabolism. Oral conjugated estrogens and transdermal estradiol increase bone density and prevent bone loss. This article summarizes the studies comparing estrogen formulations and discusses the differential effects of various estrogen products that promote postmenopausal health.
M. Goldenberg, S. B. Cohen, et al (Tel-Hashomer and Tel-Aviv, Israel)
A Randomized Prospective Comparative Study of General Versus Epidural Anesthesia for Transcervical Hysteroscopic Endometrial Resection
Am J Obstet Gynecol February 2001; 184: 273-6
Conclusion : A significantly lower amount of glycine distention fluid was absorbed during endometrial resection in women who underwent the procedure with general rather than epidural anesthesia.
D. I. Gonzalez, C. M. Zahn, et al (San Antonio, Texas)
Recurrence of Dysplasia After Loop Electrosurgical Excision Procedures with Long-term Follow-up
Am J Obstet Gynecol February 2001; 184: 315-21
Objective : The aim of this study was to determine the rates of recurrent dysplasia with longer follow-up durations and to determine whether margin status and other variables were associated with recurrence.
Study Design : A retrospective chart review was performed for all women who underwent a loop electrosurgical excision procedure at Wilford Hall Medical Center, Lackland Air Force Base, Texas, between January 1993 and December 1994. Extracted information included age, parity, indication for the loop electrosurgical excision procedure, histologic classification of the loop electrosurgical excision procedure specimen, margin status, and whether a “deep” (endocervical) pass had been performed. Follow-up data included findings of repeated cytologic examination, colposcopy, and biopsy if performed.
Conclusion : With comprehensive long-term follow-up, positive margins on loop electrosurgical excision procedure specimens were shown to be a risk factor for recurrence of cervical dysplasia, particularly when high-grade lesions were seen at the margin. Recurrence was also considerable among women with negative margins. Women should be counseled regarding this risk, and the importance of follow-up should be emphasized.
J. A. Cohn, S. Gagnon, et al (Baltimore, Maryland, et al)
The Role of Human Papillomavirus Deoxyribonucleic Acid Assay and Repeated Cervical Cytologic Examination in the Detection of Cervical Intraepithelial Neoplasia Among Human Immunodeficiency Virus-Infected Women
Am J Obstet Gynecol February 2001; 184: 322-30
Objectives : The authors’ sought to measure the characteristics of a quantitative human papillomavirus deoxyribonucleic acid assay and repeated cervical cytologic examination in screening for cervical intraepithelial neoplasia among human immunodeficiency virus-infected women.
Study Design : Human immunodeficiency virus-infected women with screening CD4+ lymphocyte counts of £500 cells/mm3 (n=103) were examined by quantitative human papillomavirus deoxyribonucleic acid assay and serial cervical cytologic examination and by colposcopy with biopsy and endocervical curettage during the course of 1 year.
Conclusion : Human immunodeficiency virus-infected women with at least mild immunosuppression have a high incidence of cervical intraepithelial neoplasia, which warrants close follow-up. Those with high baseline human papillomavirus deoxyribonucleic acid levels may be at the highest risk for incident cervical intraepithelial neoplasia.
V. D. Leo, A. L. Marca, et al (Siena, Italy)
Randomized Control Study of the Effects of Raloxifene on Serum Lipids and Homocysteine in Older Women
Am J Obstet Gynecol February 2001; 184: 350-3
Objective(s) : Raloxifene, a selective estrogen receptor modulator, has beneficial estrogen agonist effects on bone and cardiovascular risk factors and estrogen antagonist effects on the breast and uterus. Limited clinical data have shown a sustained decrease in total cholesterol, low-density lipoprotein cholesterol, and homocysteine levels; an elevated homocysteine level is an independent risk factor for atherosclerosis. All of these studies were conducted in relatively young populations of women (mean age, 52-54 years). Raloxifene does not affect hot flushes, a major immediate symptom of menopause. This drug may therefore be useful in older women to prevent osteoporosis and cardiovascular disease. The aim of this clinical study was to evaluate the effects of raloxifene on plasma lipids and homocysteine in older women.
Study Design : The subjects were 45 healthy postmenopausal women, aged 60 to 70 years. The women were randomly assigned to therapy with raloxifene or placebo, 60 mg/d for 1 year. Twenty-six women received raloxifene and 19 received placebo. Checkups were performed every 3 months. At baseline and after 3, 6, 9, and 12 months of treatment, homocysteine was measured, total serum cholesterol, triglycerides, and both high-density lipoprotein and low-density lipoprotein cholesterol.
Results : An effect on lipids was evident by 3 months with no significant additional modification at 12 months. Mean low-density lipoprotein cholesterol levels were lowered by 15% and total cholesterol was lowered by 8.5%. No reduction in high-density lipoprotein cholesterol or triglycerides was observed. After 3 months of therapy, homocysteine was significantly lower than at baseline (9.9 ± 1.6 vs 11 ± 2.1 mmol/L; P < .05). The greatest reduction with respect to baseline was reached after 6 months of therapy (-19.5% ± 3%; P < .05).
Conclusion(s) : The results of this study shows that raloxifene at a dose of 60 mg/d reduces serum concentrations of low-density lipoprotein cholesterol and total cholesterol in healthy older women. This study shows that in older women raloxifene leads to a 19.5% ± 3% reduction in fasting homocysteine levels. Raloxifene may have a favorable effect on the incidence of cardiovascular disease in older women.
N. Colacuri, F. Fornaro, et al (Institute of Gynecology and Obstetrics, School of Medicine, and Second University of Naples, Naples, Italy)
Effects of a Short-term Suspension of Hormone Replacement Therapy on Mammographic Density
Fertil Steril, September 2001; Vol. 76(3): 451-5
Objective : To evaluate the effects of hormone replacement therapy (HRT) and of a short-term suspension of HRT on mammographic density.
Design : Prospective clinical study.
Setting : Outpatient menopausal clinic of the Second University of Naples.
Intervention(s) : Thirty-nine menopausal women with intact uterus (group A) were treated with continuous transdermal E2 plus acetate nomegestrolo sequentially added, 37 women in surgical menopause (group B) were treated with transdermal E2 continuously administered, and 21 menopausal women did not receive any medication (group C). At the entry and after 12 months, a mammography was performed without suspension of HRT (group A1: 19 women; group B1: 19 women) or after a short-term suspension (group A2: 20 women; group B2: 18 women).
Result(s) : At the second mammography, seven patients in group A1, four patients in group B1, and one patient in both groups A2 and B2 showed an increase in mammographic density, whereas no mammographic density increase was observed in patients in group C. A statistically significant difference in the mammographic density increase was found between group A1 and group A2; no difference was found between group B1 and B2.
Conclusion(s) : Suspension of HRT for about 3 weeks may reverse mammographic density increase associated with its use.
Comments : Some studies have reported that the use of HRT may be associated with a reduction in specificity and sensitivity of screening mammography.
Short-term HRT cessation could avoid unnecessary biopsy and improve mammographic specificity. This retrospective study suggests that mammographic changes induced by hormonal replacement may be rapidly reversible.
In conclusion, the results of this preliminary study suggest that a short-term suspension of HRT before mammographic screening may reverse mammographic density increases associated with its use.
In this light, the authors believe that the cessation of the replacement therapy for a brief period may be useful for enhancing the sensitivity of the mammographic test, especially when a progestin is added to the estrogen.
However, further studies are necessary to establish whether time length of HRT influences this utility.
D. Thiboutot, D. F. Archer, et al (Pennsylvania State University, Hershey, Pennsylvania; et al)
A Randomized, Controlled Trial of a Low-dose Contraceptive Containing 20 mg of Ethinyl Estradiol and 100 mg of Levonorgestrel for Acne Treatment
Fertil Steril, September 2001; Vol. 76(3): 461-8
Objective : To evaluate the efficacy of a low-dose oral contraceptive (OC) containing 100 mg of levonorgestrel (LNG) and 20 mg of ethinyl estradiol (EE) compared with placebo for the treatment of moderate acne.
Design : Multicenter, randomized, double-blind, placebo-controlled clinical trial.
Setting : Outpatient dermatology clinics.
Patients(s) : Women (³ 14 years old; n=350) with normal menstrual cycles and moderate acne were randomized to receive LNG/EE or placebo for six cycles.
Intervention(s) : Twenty mg of EE and 100 mg of LNG.
Main Outcome Measure(s) : Acne lesion counts and clinician global assessment were performed at baseline and at each cycle. Patient self-assessment was carried out at baseline and at cycles 4 and 6; blood pressure and weight were measured at baseline and at cycles 1, 3, and 6.
Result(s) : Inflammatory, noninflammatory, and total lesion counts at cycle 6 with LNG/EE were significantly lower compared to placebo. Patients in the LNG/EE group had significantly better clinician global and patient self-assessment scores than those in the placebo group at cycle. Changes in weight from baseline were similar between patients in the LNG/EE and placebo groups at all measured time points.
Conclusion(s) : This double-blind, placebo-controlled study demonstrates that a low-dose OC containing 20 mg of EE and 100 mg of LNG is an effective and safe treatment for moderate acne.
M. Perrotti, L. Bahamondes, et al (Human Reproduction Unit, Department of Obstetrics and Gynecology, et al)
Forearm Bone Density in Long-term Users of Oral Combined Contraceptives and Depot Medroxyprogesterone Acetate
Fertil Steril, September 2001; Vol. 76(3): 469-73
Objective : To compare the bone mineral density of users of combined oral contraceptives (OC) or depot medroxyprogesterone acetate (depot-MPA) with women who have never used a hormonal contraceptive method.
Design : Cross-sectional study.
Setting : Academic tertiary-care hospital.
Patient(s) : A total of 189 women, aged 30 to 34 years old, were allocated to three groups: 63 who had used OC for at least 2 years; 63 who had used depot-MPA for at least 2 years; and 63 control women who had never used hormonal contraceptive methods.
In addition, BMD was similar between OC users and depot-MPA users. The multiple linear regression analysis showed that the variables associated with BMD were weight, number of pregnancies, and the womans occupation.
Conclusion(s) : Women aged 30 to 34 years who have used OC or depot-MPA have similar BMD as control women. These findings suggest that the use of OC or depot-MPA does not effect the BMD of women in this age group.
J. Levron, A. Aviram-Goldring, et al (The Chaim Sheba Medical Center, Tel-Hashomer, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel)
Sperm Chromosome Abnormalities in Men with Severe Male Factor Infertility Who Are Undergoing In Vitro Fertilization with Intracytoplasmic Sperm Injection
Fertil Steril, September 2001; Vol. 76(3): 479-84
Objective : To investigate the potential paternal contribution to the risk of fetal chromosomal anomalies after intracytoplasmic sperm injection (ICSI).
Design : Spermatozoa isolated from testicular tissue and ejaculated specimens of consenting patients undergoing testicular biopsy and ICSI were analyzed for chromosomes X, and Y, and 18 by FISH.
Setting : Assisted reproductive technology program.
Patient(s) : Consenting patients undergoing testicular biopsy and ICSI, severe oligozoospermic patients, and normal fertile donors.
Intervention(s) : None
Main Outcome Measure(s) : The rate of chromosome abnormalities in testicular sperm with regard to the type of azoospermia and ejaculated sperm compared to healthy men.
Result(s) : The mean serum levels of FSH in the groups with nonobstructive azoospermia (n=9), obstructive azoospermia (n=10), severe oligozoospermia (n=9), and the normal donors (n=6) were 17.5 ± 8.2 (P< .05), 3.5 ± 2.6, 14.6 ± 3.5 (P< .05), and 3.1 ± 0.4 IU/mL, respectively.
The corresponding rates of sperm chromosome abnormalities among these groups were 19.6% (P< .001), 8.2% (P< .001), 13.0% (P< .001), and 1.6%, respectively. The corresponding rates of disomy among these groups were 7.8% (12 of 153 spermatozoa), 4.9% (18 of 367), 6.2% (109 of 1,751), and 1% (5 of 500 spermatozoa), respectively. Errors in chromosomes X and Y were significantly more common than in chromosome 18.
Conclusion(s) : The present findings demonstrate a linkage between gonadal failure (high serum FSH levels) and the occurrence of sperm chromosome aneuploidies. The findings may explain the increased incidence of sex chromosome abnormalities found after IVF in the severe male factor patient population.
Genetic screening during pregnancy or before embryo replacement should be considered carefully.
A. Raziel, S. Friedler, et al (Assaf Harofeh Medical Center, Tel-Aviv University, Zerifin, Israel)
Influence of a Short or Long Abstinence Period on Semen Parameters in the Ejaculate of Patients with Nonobstructive Azoospermia
Fertil Steril, September 2001; Vol. 76(3): 485-90
Objective : To compare the effect of a short (4 days) or a long (14 days) abstinence period on sperm retrieval by extended sperm preparation in patients with nonobstructive azoospermia scheduled for testicular biopsy and intracytoplasmic sperm injection (ICSI).
Design : A prospective case control study.
Setting : Male infertility clinic in a university hospital.
Patient(s) : Fifty male patients with nonobstructive azoospermia, scheduled for testicular biopsy for ICSI.
Intervention(s) : Diagnosis of nonobstructive azoospermia and a thorough microscopic search for sperm cells (extended sperm preparation).
Main Outcome Measure(s) : The number of sperm cells collected, sperm motility, and total motile sperm count after short and long abstinence periods.
Result(s) : There was a significant difference between long and short abstinence with an increase in sperm count (log-to-log transformed analysis of variance P< .025) and total motile sperm (P < .025 analysis of variance, P < .02 paired Students t-test) in the former group, but no significant change in sperm motility (Wilcoxon and paired Students t-test). In 18 patients, sperm concentration and sperm motility were similar in a second collection, done after the same abstinence period, compared with the same parameters in the first sample.
When at least 10 motile sperm were defined as the cutoff number, allowing ICSI without testicular biopsy, no significant differences were found between the abstinence periods. No clinical or laboratory male characteristic could predict the detection of 10 motile sperm by extended sperm preparation either after a short or long abstinence period.
Conclusion(s) : Sperm count and total motile sperm were increased after a long abstinence period, with no change in sperm motility. No additional advantages were conferred by long abstinence as opposed to short abstinence when 10 motile sperm were defined as the cutoff number for ICSI. The recommended period of abstinence for extended sperm preparation and ICSI, whether short or long, should be individualized for each patient.
R. Luboshitzky, G. Qupti, et al (Endocrine Institute, Haemek Medical Center, et al)
Increased 6-Sulfatoxymelatonin Excretion in Women with Polycystic Ovary Syndrome
Fertil Steril, September 2001; Vol. 76(3): 506-10
Objective : To determine melatonin production in hyperandrogenic women.
Design : Controlled prospective study.
Setting : Outpatients in an academic medical center.
Patient(s) : Twenty-two women with polycystic ovary syndrome (PCOS), 20 women with idiopathic hirsutism, and 15 age-matched individuals who had similar body mass indexes as controls.
Intervention(s) : Fasting blood samples and 24-hour urinary samples were obtained from all participants.
Main Outcome Measure(s) : All participants provided serum samples for the measurement of LH, FSH, testosterone, E2, DHEAS, 17 a-hydroxyprogesterone (17-OHP), and insulin levels, as well as urinary 6-sulfatoxymelatonin (aMT6s).
Result(s) : Women with PCOS had higher aMT6s, testosterone, LH/FSH ratio, and insulin values than either women with idiopathic hirsutism or control women. Testosterone inversely correlated with aMT6s in PCOS. Regression analysis revealed that only testosterone was an important determinant of aMT6s in PCOS.
Conclusion(s) : Women with PCOS have increased melatonin production.
Comments : Because hyperinsulinemia has been suggested to play a role in the pathogenesis of androgen excess in PCOS (19, 20), insulin should be considered as a potential candidate involved in the modulation of melatonin in PCOS.
Insulin was shown to stimulate androgen synthesis in ovarian thecal cells, decrease free androgen levels, and potentiate ACTH-stimulated adrenal androgens (20).
In conclusion, women with ovarian hyperandorgenism have increased melatonin production, whereas melatonin secretion is normal in women who are hyperandorgenic due to idiopathic hirsutism.
G. R. Attia, W. E. Rainey, et al (Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, et al)
Metformin Directly Inhibits Androgen Production in Human Thecal Cells
Fertil Steril, September 2001; Vol. 76(3): 517-24
Objective : To examine the direct effect of metformin on thecal cell androgen production.
Setting : Basic science research laboratory, University of Texas Southwestern, Dallas, Texas.
Intervention(s) : Human ovarian theca-like tumor cells were treated with various concentrations of metformin in the presence and absence of forskolin for 48 hours.
Main Outcome Measure(s) : Media were collected, and radioimmunoassay (RIA) for progesterone, 17a-hydroxyprogesterone (17OHP), androstenedione, and testosterone was performed.
The effect of metformin on the expression of various enzymes involved in theca cell steroidogenesis was examined.
Conclusion(s) : The results suggest the metformin may have a direct effect on thecal cells androgen production.
C. R. Molinas, O. Mynbaev, et al (Center for Surgical Technologies, Katholieke Universiteit Leuven, Leuven, Belgium)
Peritoneal Mesothelial Hypoxia During Pneumoperitoneum is a Cofactor in Adhesion Formation in a Laparoscopic Mouse Model
Fertil Steril, September 2001; Vol. 76(3): 560-7
Objective : To develop a laparoscopic mouse model to evaluate the hypothesis that mesothelial hypoxia during pneumoperitoneum is a cofactor in adhesion formation.
Design : Prospective randomized trials.
Setting : Academic research center.
Animal(s) : One hundred thirty female Naval Medical Research Institute (NMRI) mice.
Intervention(s) : Adhesions were included by opposing monopolar lesions in uterine horns and pelvic side walls during laparoscopy and evaluated after 7 or 28 days under microscopic vision during laparotomy.
The following pneumoperitoneum variables were assessed: duration (10 or 60 minutes), insufflation pressure (5 or 15 cm of water), insufflation gas (CO2 or helium), and addition of oxygen (0-12%).
Main Outcome Measure(s) : Adhesions were scored quantitatively and qualitatively for extent, type, and tenacity.
Result(s) : Scoring of adhesions 7 or 28 days after laparoscopic surgery was comparable. Adhesions increased with duration of pneumoperitoneum and with insufflation pressure and decreased with the addition of oxygen.
Half-maximal reduction of adhesions was obtained at 1.5% oxygen, whereas a maximal reduction required only 2%-3%. The effect of CO2 and helium was similar.
Conclusion(s) : These data demonstrate the feasibility of the intubated laparoscopic mouse model and confirm previous observations in rabbits, indicating that mesothelial hypoxia plays a key role in adhesion formation.
M. Dueholm, E. Lundorf, et al (Aarhus Universtiy and Hospital , Aarhus, Denmark)
Magnetic Resonance Imaging and Transvaginal Ultrasonography for the Diagnosis Of Adenomyosis
Fertil Steril, September 2001; Vol. 76(3): 588-94
Objective : To compare the diagnostic potential of magnetic resonance imaging (MRI) and transvaginal ultrasonography (TVS) in the diagnosis of adenomyosis.
Adenomyosis cannot be accurately diagnosed on clinical criteria alone. Yet, hysterectomy is frequently performed merely on the basis of suspected symptoms. Better preoperative diagnostic tools are required to avoid unnecessary hysterectomy and, if possible, to investigate nonsurgical alternatives.
Moreover, diagnosis of adenomyosis before hysteroscopic surgery for abnormal uterine bleeding is important because its presence reduces the effect of endometrial ablation and because focal adenomyosis must be separated from myomas before myomectomy.
Conclusion(s) : Magnetic resonance imaging was superior to TVS for the diagnosis of adenomyosis. Magnetic resonance imaging had a higher specificity than TVS, but their sensitivities were in line. The diagnostic accuracy of MRI, as that of TVS, was at an intermediate level, but the diagnostic accuracy of the former improved by exclusion of uteri >400 mL.
The combination of MRI and TVS produced the highest level of accuracy for exclusion of adenomyosis, but the low specificity may necessitate further investigation of positive findings. Measurement of the difference in junctional zone thickness may optimize the diagnosis of adenomyosis at MRI.
Donghai Dai, Nirmala S Kumar, Douglas M Wolf and Kimberly K Leslie (Denver, Colorado)
Molecular tools to reestablish progestin control of endometrial cancer cell proliferation.
Am J Obstet Gynecol, April 2001;184: 790-7.
Objective: Endometrial cancers often arise in a setting of estrogen stimulation unopposed by the differentiating effects of progesterone. The purpose of these studies was to reestablish high progesterone receptor isoform A and B gene expressions in such endometrial cancer cells and to examine the effects of progestin treatment on cell growth and metastatic potential after this transformation.
Study Design: To induce high levels of expression of the progesterone receptor isoforms in KLE and Hec50 endometrial cancer cells, adenoviral vectors encoding the genes for progesterone receptor isoforms A and B were created. The characteristic ability of cancer cells to grow independently of anchorage to the surrounding solid matrix was measured by counting colony formation on soft agar for 8 to 14 days. Cell proliferation in response to a time course of progestin treatment was tested with flow cytometry.
Results: After treatment with a control vector without a progesterone receptor-encoding insert, no effect of progestin treatment on cell proliferation was found; after treatment with vectors encoding progesterone receptor isoform A or B, however, progestin treatment resulted in significant inhibition of cell growth. The anchorage-independent cell growth on soft agar assay showed that by 8 to 14 days the number of cell colonies was reduced by 50% relative to control prepara9tions in the presence of progesterone receptor isoform A plus isoform B plus progestin (P<.0001, both Hec50 and KLE cell lines) and by 90% in the presence of progesterone receptor isoform] B plus progestin (P<.0001, both Hec50 and KLE cell lines). Progestin treatment also resulted in a time-dependent reduction in cell prolifertion as measured by flow cytometry. Although transfection with both progesterone receptor isoforms A and B reduced cell proliferation according to the assays, progesterone receptor isoform B caused a much more dramatic decrease in cell growth (P=.001, Hec50 cells; P<.0001, KLE cells)
Conclusion: In poorly differentiated endometrial cancer cells that are resistant to progestin therapy, adenovirus-induced expressions of progesterone receptors A and B reestablish progestin control of endometrial cancer cell proliferation.
Bruno Cacciatore, Ilari Paakkari, Rene Hasselblatt et al (Helsinki, Finland)
Randomized comparison between orally and transdermally administered hormone replacement therapy regimens of long-term effects on 24-hour ambulatory blood pressure in postmenopausal women.
Am J Obstet Gynecol, 2001, 184(5), pg. 904-9
Objective: The aim of this study was to assess whether oral delivery and transdermal delivery of sequentially combined hormone replacement therapy have similar effects on systemic blood pressure, as measured by 24-hour automated ambulatory recordings.
Study Design: Eighty-two healthy postmenopausal women, of whom 73 completed the study, were randomly assigned to start hormone replacement therapy with either orally (n=38) or transdermally (n=35) administered medication. Ambulatory blood pressure was recorded for a 24-hour period before the start of hormone replacement therapy and again 2 and 6 months later. Analysis of variance was used for data analysis.
Conclusion: Sequential combined hormone replacement therapy delivered by both oral and transdermal routes caused significant falls in the daytime ambulatory blood pressure of normotensive postmenopausal women at 2 months of treatment. This fall persisted as long as 6 months of treatment in the oral treatment group but not in the transdermal treatment group.
Sheila G West, Alan L Hinderliter, et al (University Park, Pennsylvania,)
Transdermal estrogen reduces vascular resistance and serum cholesterol in postmenopausal women
Am J Obstet Gynecol, 2001; 184: 926-33
Objective: To compare the effects of transdermal versus oral estrogens on vascular resistance index, mean arterial pressure, serum lipid concentrations, norepinephrine, and left ventricular structure.
Study Design: Ten postmenopausal women received transdermal estradiol (0.05mg/d) plus cyclic oral progesterone for 6 months. Responses were compared with those of 23 women receiving oral conjugated estrogens (0.625mg/d) plus cyclic progesterone and with those of 9 subjects receiving placebo in a concurrent randomized trial. The vascular resistance index was assessed and the mean arterial pressure at rest and during behavioral stressors.
Results: Oral and transdermal estrogen significantly decreased the vascular resistance index, mean arterial pressure, norepinephrine and total and low-density lipoprotein cholesterol to a similar extent. Changes in the vascular resistance index and mean arterial pressure were equally evident at rest and during stress. Although both treatments reduced left ventricular mass (-4% to -6%) and relative wall thickness (-3% to -5%), these changes were not statistically significant.
Conclusions: Equivalent reductions in vascular resistance index, norepinephrine, mean arterial pressure, and cholesterol were observed with transdermal and oral estrogens. Future studies comparing novel hormone regimens with oral hormone replacement therapy should include multiple risk markers to allow better assessment of their potential impact on coronary artery health.
Cheng-Tao Lin, Chih-Jen Seng, et al (Taoyuan, Taiwan)
Value of human papillomavirus deoxyribonucleic acid testing after conization in the prediction of residual disease in the subsequent hysterectomy specimen.
Am J Obstet Gynecol, 2001; 184: 940-5
Objective: To evaluate human papillomavirus deoxyribonucleic acid testing after conization in predicting residual disease in the subsequent hysterectomy specimen.
Study Design: A prospective study was conducted on 75 patients with grade 3 cervical intraepithelial neoplasia who had cone margins or endocervical curettage specimens showing disease and who elected to undergo hysterectomy after conization. All patients underwent high-risk human papillomavirus deoxyribonucleic acid testing by the Hybrid Capture II (Digene Corporation, Gaithersburg, MD) system before conization and at the time of hysterectomy (within 2-7weeks after conization). The presence of human papillomavirus deoxyribonucleic acid in cells obtained by endocervical brush before hysterectomy was correlated with residual disease in the hysterectomy specimens.
Results: Of the 92 patients enrolled, 75 were eligible. Of these 75 patients, 52(69.3%) had persistent human papillomavirus deoxyribonucleic acid after conization, and 27(36.0%) of the 75 patients had residual cervical neoplasia in the hysterectomy specimens. Those with negative results for human papillmavirus deoxyribonucleic acid after conization were all (23/23) without residual disease in the uterus (100% negative predictive value). All those who had residual disease (27/27) had positive results for human papillomavirus deoxyribonucleic acid at the time of hysterectomy (100% sensitivity). Postconization human papillomavirus deoxyribonucleic acid status (odds ratio, 4,000; 95% confidence interval, 1.531-10.449; P =.005) and grade of dysplasia after endocervical curettage (classified as grade 2 cervical intraepithelial neoplasia or less severe disease vs grade 3 cervical intraepithelial neoplasia: odds ratio, 6.612; 95% confidence interval, 2.837-15.409; P =.0002) were significantly associated with residual tumor in the uterus.
Conclusions: This prospective study confirms an excellent sensitivity and negative predictive value of human papillomavirus deoxyribonucleic acid testing after conization in predicting residual cervical neoplasia. A strategy of managing patients with grade 3 cervical intraepithelial neoplasia, based on postconization human papillomavirus deoxyribonucleic acid findings and endocervical curettage results, is proposed.
Maciej Jozwik, & Marwin Jozwik (Inst. Of Obstetrics & Gynaecology, Bialystok Medical Universtiy, Bialystok, Poland)
The physiological basis of pelvic floor exercises in the treatment of stress urinary incontinence
Br. J Obstet.& Gynec. Vol.1, 1999, p.4
Complications are rare, expensive urodynamic testing before pelvic floor exercises is probably not necessary, and the woman herself undertakes the treatment in the privacy of her home. There is evidence that with pelvic floor exercises some women are cured, thus avoiding surgery. Some authors feel that pre-operative pelvic floor exercises may improve the outcome of surgery.
Improvement is more common than cure. A summary of the long-term results of pelvic floor exercises showed an average cure rate of 50%.
The aim of pelvic floor exercises in stress urinary incontinence is to achieve continence using the striated muscle of the pelvic floor. The periurethral bundles of the levator ani muscles have been identified as the primary continence mechanism during straining. This indicates that the muscular occlusive mechanism of the urethra during straining is present in women with stress incontinence, but is inefficient.
Skeletal muscle in adults contains two types of fibre: type I (slow twitch) fibres, capable of longer but quite weak contractions, and type II (fast twitch) but quite weak contractions, and type II (fast twitch) fibres, among which the IIB subgroup are capable of very short but powerful contractions.
The anterior part of the levator ani is the puborectalis muscle, also referred to as the pubovaginalis muscle. Medial bundles of the puborectalis (the fibres of Luschka) terminate at their upper end on the posterior surface of the public bones at the level of the urethra; yet they do not penetrate the urethral wall. These fibres exert an indirect external occlusive effect on the urethral lumen. This can be achieved at three degrees of intensity:
1. Involuntary, at rest (which represents continuous tonic low-level activation via type I fibres).
2. Reflex, on straining (type II fibres)
3. Voluntary (probably both type I and type II fibres)
Basal tonic activity was confirmed in a number of studies, and was measured electromyographically; it is approximately 150 µV. In one study perineal contraction during coughing produced a pressure increase within the urethra of 10 to 20mmHg, while voluntary contraction resulted in a similar increase of about 20 mm Hg.
Koelbl et al, estimated the puborectalis type II content to be 19%; however in this study the sampling was done remotely from the urethra. A quantitative estimation of periurethral fast-twitch fibre content, in post-mortem specimens showed that they account for only 4% of the fibre population, a very small proportion when compared with other muscles and a logical adaptation to low-level contractions. Since periurethral type II fibres have larger diameters (mean 60 µm) than type 1 (mean 45 µm), their contribution to the bulk of the normal muscle at the level of the urethra is slightly higher than 4%. Interestingly, a diminished number of fast-twitch fibres in the levator ani muscles was consistently reported in stress incontinence.
Furthermore, the morphology of the medial bundles of the levator ani muscle was found to be reasonably or closely associated with the outcome of surgery for stress incontinence. Ultrasound may be important as an indirect measure of the function of levator ani. Two reports came from one institution and referred to the overall thickness of the pelvic floor (mean 9.4mm).
Surgical observations on the anterior paravaginal fascial defects seen in women with stress incontinence are also important. The initial report by Richardson et al was confirmed by other authors, and the high cure rates of stress incontinence with fascial repair underline the importance of the attachment of the upper puborectalis muscle. Indeed, if the vaginal and paravaginal tissue are torn from the stabilizing arcus tendineus fasciae pelvis, the effect of the puborectalis on the urethra may be diminished.
In some women with stress incontinence both histological studies and magnetic resonance imaging have shown differences in the concentration of skeletal muscle fibres between the left and right sides of the levator ani muscles.
The prerequisite for proper contraction in skeletal muscle is the integrity of its motor units (individual motor neurons and the muscle fibres they innervate), and for pelvic floor exercises to be effective significant denervation of the levator ani should not have occurred. The available evidence suggests that in stress incontinence denervation is only partial. As the puborectalis muscle is situated in the immediate proximity of the vagina and is thus stretched during childbirth, vaginal delivery may be a predisposing factor to denervation of the puborectalis.
Compression of the pudendal nerve inside the pudendal canal can also be responsible for stress incontinence. Of note, in the study of Sultan et al neurological damage to the pudendal nerve after vaginal delivery was more pronounced on the left side.
Allen et al found that 80% of 66 women had re-innervation of the pelvic floor after vaginal delivery, as measured by the increased duration of individual motor unit potentials with concentric needle electromyography. These findings suggest that the pattern of denervation may vary and that the re-innervated and hypertrophied type II fibres are not functionally equal to normal fibres.
The pelvic floor muscles and intramuscular connective tissue contain intracellular oestrogen and progesterone receptors which are also present in the surrounding connective tissue, indicating that the puborecatalis muscles and their fascial neighbourhood are targets for steroid hormones. More pronounced degenerative changes in the levator ani were observed in postmenopausal than in premenopausal women with stress incontinence.
Action of Pelvic floor exercises
Authors believe that physiologically pelvic floor exercises should have two main goals: stimulation of existing fast-twitch fibres; and transition of the predominant type I fibre into type II.
In 22 of 28 samples of puborectalis muscle, authors found significant glycogenolysis with the activation of hydrolytic decomposition of glycogen. This observation was suggestive of intracellular acidosis, being a possible biochemical background for fibre type transitions.
This research into the basic science of stress incontinence and skeletal muscle physiology implies that pelvic floor exercises should not be of the endurance type. In women, there is an inverse relationship between the concentration of fast-twitch fibres and muscle power, suggesting that in pelvic floor exercises the induced contractions should be short and repeated, but not necessarily powerful.
Skeletal muscle performs work in a similar pattern. There are two phases during muscular contraction: the isometric phase, where muscle tension increases without change in length; and the isotonic phase where muscle tension is static with decreasing length.
Recent research has shown that the cross-sectional area of each type of fibre is an important determinant of the power of muscular contraction.
Both the initial length and the cross-sectional area of fibres of the puborectalis muscle are altered in women with stress incontinence.
It should be noted that voluntary contraction of the pelvic floor is an action distinct from Valsalva’s manoeuvre and from abdominal straining with bearing down. Pelvic floor exercises should concentrate on the anterior part of the pelvic floor, not the posterior.
Conclusion: Future studies should evaluate subpopulations A, B and C of the type II fibres of the puborectalis muscle in health and disease. Findings of acidosis in the medial bundles of the levator ani muscles in stress incontinence need confirmation by other authors, perhaps using different techniques. Ultrasound may be a useful clinical investigation because it is generally available, whereas magnetic resonance imaging is likely to be confined to research, owing to its expense.
A. M. Weber, M. D. Walters, et al (Cleveland, Ohio)
Anterior colporrhaphy: A randomized trial of three surgical techniques
Am J Obstet Gynecol, Dec.2001, 185:1299-306
Objective: the purpose of this study was to compare outcomes after anterior colporrhaphy with the use of 3 different surgical techniques.
Study Design: One hundred fourteen women with anterior vaginal prolapse were randomly assigned to undergo anterior repair by one of 3 techniques: standard, standard plus polyglactin 910 mesh, or ultralateral anterior colporrhaphy. Before and after operation, patients underwent physical examination staging of prolapse; the International Continence Society system was used. Symptoms were assessed by questionnaire and visual analog scales. Authors defined “cure” as satisfactory (stage 1) or optimal (stage 0) outcome at points Aa and Ba.
Results: Of 114 patients who were originally enrolled, 109 patients underwent operation, and 83 patients (76%) returned for follow-up. Mean age (± SD) was 64.7 ± 11.1 years. At entry, 7 patients (7%) had stage I anterior vaginal prolapse; 35 patients (37%) had stage II anterior vaginal prolapse; 51 patients (54%) had stage III anterior vaginal prolapse; and 2 patients (2%) has stage IV anterior vaginal prolapse. At a median length of follow-up of 23.3 months, 10 of 33 patients (30%) who were randomly assigned to the standard anterior colporrhaphy group experienced satisfactory or optimal anatomic results, compared with 11 of 26 patients (46%) with ultralateral anterior colporrhaphy. The severity of symptoms that were related to prolapse improved markedly (preoperative score, 6.9 ± 2.7; postoperative score, 1.1 ± 0.8). Twenty-three of 24 patients (96%) no longer required manual pressure to void after operation.
Conclusion: These 3 techniques of anterior colporrhaphy provided similar anatomic cure rates and symptom resolution for anterior vaginal prolapse repair. The addition of polyglactin 910 mesh did not improve the cure rate compared with standard anterior colporrhaphy.
Roger P Goldberg, Sumana Koduri et al
Protective effect of suburethral slings on postoperative cystocele recurrence after reconstructive pelvic operation
Am J Obstet Gynecol, Dec.2001; 185: 1307-13
Objective: The purpose of this study was to evaluate the independent effect of suburethral sling placement on the risk of cystocele recurrence after pelvic reconstructive operation.
Study Design: One hundred forty-eight women with cystoceles to or beyond the hymenal ring underwent pelvic reconstructive operation. With or without incontinence procedures, and were evaluated at 12 and 52 weeks after operation with a standardized pelvic examination. Rates of recurrent prolapse, at all sites, were statistically compared between subjects with and without suburethral slings. A multiple regression analysis was used to determine the independent effect of sling placement on the risk of recurrent cystoceles.
Results: Suburethral sling placement was associated with a 54.8% reduction in the mean rate of postoperative cystocele recurrence (P=.004). This protective effect was observed as early as 12 weeks and remained significant at 1-year follow up (42% vs 19%). A markedly reduced risk of cystocele recurrence was observed when women with sling procedures were compared with all other women, with those women who underwent other incontinence operations, and even with those women who had undergone prolapse repair with no incontinence procedure. The protective effect of the sling procedure remained highly significant (odds ratio, 0.29; P=.003), even after controlling for potentially confounding variables in a multiple logistic regression model.
Conclusion: Suburethral sling procedures appear to significantly reduce the risk of cystocele recurrence after pelvic reconstructive operation, in contrast with the effect of retropubic urethropexy and needle suspensions. These findings should be considered when the surgical treatment of stress incontinence that accompanies pelvic organ prolapse is being planned.
Lily A Arya, Neil D Jackson, et al (Providence, RI)
Risk of new-onset urinary incontinence after forceps and vacuum delivery in primiparous women.
Am J Obstet Gynecol, Dec.2001, 185: 1318-24
Objective: To determine the incidence of new-onset urinary incontinence after forceps and vacuum delivery compared with spontaneous vaginal delivery.
Study Design: A propective study in primiparous women delivered by forceps (n=90), vacuum (n=75); or spontaneous vaginal delivery (n=150) was performed. Follow-up for urinary incontinence was at 2 weeks, 3 months, and 1 year after delivery.
Results: The incidence of urinary incontinence was similar in the 3 groups at 2 weeks after delivery. The proportion of women developing new-onset urinary incontinence decreased significantly over time in the spontaneous vaginal (P=.003) and vacuum delivery groups (P=.009) but not in the forceps group (P=.2). No relationship of urinary incontinence with vaginal lacerations, epidural anesthesia, length of second stage of labor, or infant birth weight was seen.
Conclusion: In primiparous women, urinary incontinence after forceps delivery is more likely to persist compared with spontaneous vaginal or vacuum delivery.
Comment: However 3 months and 1 year after delivery both incidence and severity of stress incontinence after forceps delivery were significantly greater compared with spontaneous vaginal or vacuum delivery.
The mechanism of injury caused by forceps delivery is not clear, but it is likely to be multifactorial. Using perineal sonography, Meyer et al have demonstrated that there is increased descent of the urethrovesical junction in relation to symphysis pubis after forceps delivery compared with nulliparous continent women.
The lower risk of urinary incontinence after vacuum extraction compared with forceps delivery in the study may be caused by the avoidance of insertion of space-occupying blades within the vagina and the ability to rotate the fetal head without impinging upon maternal soft tissues.
M Karram, S Goldwasser S Kleeman, et al
High uterosacral vaginal vault suspension with fascial reconstruction for vaginal repair of enterocele and vaginal vault prolapse.
Am J Obstet Gynecol, Dec.2001; 185:1339-43.
Objective: The purpose of this study was to review retrospectively the functional and anatomic outcomes of women who underwent vaginal repair of enterocele and vault prolapse with the use of an intraperitoneal suspension of the vaginal vault to the uterosacral ligaments in conjunction with fascial reconstruction of the anterior and posterior vaginal wall.
Results: Eighty-nine percent of the women expressed satisfaction with the results of the procedure. Ten women (5.5%) underwent a repeat operation (by the authors) for recurrence of prolapse in one or more segments of the pelvic floor. Quality of life assessment revealed a significant reduction in all aspects of daily living, when the short forms of the incontinence impact questionnaire and urogenital distress inventory were evaluated before and after the operation. Major intraoperative complications included 5 cases (2.4%) of ureteral injury, 1 case of a small bowel injury, and 1 case of a pelvic abscess that required abdominal exploratory operation and diversion of the colon.
Conclusion: High uterosacral ligament vaginal vault suspension with fascial reconstruction would seem to provide a durable anatomic repair with good functional improvement in patients with significant complex uterine or vaginal vault prolapse.
Carla P Roberts, Michael J Habe and John A Rock
Vaginal creation for mullerian agenesis
Am J Obstet Gynecol, 2001; 185: 1349-53
Objective: The purpose of this study was to determine the effectiveness of passive vaginal dilation and McIndoe vaginoplasty in the creation of a neovagina for patients with mullerian agenesis.
Study Design: Fifty-one patients with Mayer-Rokitansky-Kuster Hauser syndrome were treated for vaginal agenesis at either Johns Hopkins Hospital or Emory University. These historic prospective data were obtained by a review of medical records and a current office or telephone consultation. Initial office visits dated from November 18, 1983, through June 6, 1998. Their progress towards both anatomic and function success was followed through August 1, 2000, which was a range of 2 to 16.8 years. One-way analysis of variance, Student t test, and logistic regression analysis were performed when appropriate.
Conclusion: These data reveal that passive dilation with the Ingram method is capable of creating an adequate vaginal canal in patients with vaginal agenesis, with respect to both function and anatomy even in those patients with a previous hymenotomy and resultant scar formation. Modified McIndoe procedure has proved to be an excellent option for patients for whom conservative dilation techniques failed and who refuse to attempt any dilation. Interestingly, data indicate that patients may now be trending toward immediate surgical correction rather than diligently using dilation technique to create a vaginal space.
Stephen B Young, Jennifer J Daman and Laura G Bony (Worcester, Mass)
Vaginal paravaginal repair: One-year outcomes
Am J Obstet Gynecol, 2001: 185: 1360-7
Objective: This study was carried out to determine the efficacy and safety of the vaginal approach to paravaginal repair of symptomatic paravaginal defect cytocele.
Methods: This study is an observational case series of 100 consecutive women, referred from December 1996 to August 2000, with symptomatic grade II to IV paravaginal defect cystocele. Preoperative and postoperative pelvic evaluations were performed with the Baden-Walker halfway system. The same surgeon performed all repairs. Fourteen patients had prior anterior repairs, and 530 concomitant procedures were performed. The vaginal approach consisted of a thorough entry from the vesicovaginal space under the inferior pubic ramus into the retropubic space, widely exposing the area of the arcus tendineus. A repair was done bilaterally in 95 patients and unilaterally in 5. Between 1 and 6 Gore-tex CV-0 sutures were placed widely around the arcus tendineus on either side and fixed to appropriate locations on the bladder fascia and anterior vaginal walls. Tying these sutures resulted in dramatic elevation of the lateral superior sulci. Patients were followed up for 1 to 36 months, with a mean of 10.6 months. Criteria for objective cure were defined as the lateral sulci of the anterior vaginal walls being at grade 0 and firmly apposed to the lateral pelvic sidewalls.
Conclusions: The vaginal approach to the correction of paravaginal defect cytocele is highly effective in our population at a mean of 11 months after the operation. Frequent complications do occur but are largely manageable.