Acute Bartholin's abscess: microbial spectrum, patient characteristics, clinical manifestation, and surgical outcomes.

The purpose of this investigation was to evaluate the patient characteristics, clinical manifestations, microbiology, and modes of treatment of a large cohort of women with acute Bartholin's abscess, from a single medical center. A retrospective study was undertaken of all women diagnosed with acute Bartholin's gland abscess who were admitted to the gynecology department in a university-affiliated tertiary hospital in central Israel from January 2004 to December 2013. A total of 267 women were included in the study. The mean age at diagnosis was 33.5 ± 12.1 years and the mean hospitalization period was 1.4 ± 0.9 days. Pain presented in 152 (56.9 %), swelling in 81 (30.3 %), and fever in 34 (12.7 %). Leukocytosis was detected in 149 (55.8 %). The three main treatment modalities were: antibiotics (75.7 %), abscess drainage (19.1 %), and marsupialization (80.9 %). Bacterial infections were detected in 154 (57.7 %) cultures, Escherichia coli presented in 59 (22.1 %), and Streptococcus species in 27 (10.1 %). The clinical and patient characteristics were similar between women with bacterial and sterile Bartholin's abscesses, though leukocytosis was more prevalent among women with bacterial infections. E. coli was the single most frequent pathogen in cultures of acute Bartholin's abscess. Respiratory tract-associated organisms were also common. This study indicates the polymicrobial spectrum of acute Bartholin's abscess.

Long term subjective cure rate, urinary tract symptoms and dyspareunia following mesh augmented anterior vaginal wall prolapse repair.

INTRODUCTION: The aim of this study was to assess patient-centered long term outcomes following anterior vaginal repair with mesh. METHODS: In January 2015, we identified 124 women who underwent anterior pelvic floor repair with mesh between January 2006 and February 2009. Patient records were reviewed and demographic, clinical, intra-operative and post-operative follow-up data retrieved. Telephone interviews were conducted to access information on clinical outcomes. Associations between baseline characteristics and long term symptoms were assessed by multivariable logistic regression models. RESULTS: Seventy-nine women were reached and consented to participate. Patients were interviewed 79-104 months after surgery. Their mean age at the time of surgery was 62.48 ± 9.53 years; all had stage III cystocele with a mean POP Q point Ba of 5.32 ± 1.47. Twenty-four (30%) had a previous hysterectomy and 26 (33%) had a previous pelvic organ prolapse or stress urinary incontinence operation. At telephone interviews, recurrence of prolapse symptoms was reported by 11 (13.9%) patients, mostly in the posterior compartment. Only 6 needed a corrective procedure. One patient had her mesh removed due to dyspareunia. Eleven (13.9%) reported lower urinary tract symptoms other than prolapse, as follows: stress urinary incontinence (1), overactive bladder (8) and dyspareunia (2). CONCLUSION: Long term rates of recurrent prolapse, dyspareunia and lower urinary tract symptoms were low for patients who underwent anterior vaginal wall mesh augmentation surgery for symptomatic cystoceles.

Robotic blue-dye sentinel lymph node detection for endometrial cancer - Factors predicting successful mapping.

OBJECTIVE: Sentinel lymph node (SLN) mapping has emerged as a viable option for the treatment of patients with endometrial cancer. We report our initial experience with SLN mapping algorithm, and examine the factors predicting successful SLN mapping. METHODS: We analyzed all data recorded in our institute on robotic blue-dye SLN detection mapping from the time it was first introduced to our department in January 2012-December 2014. Data included patient demographics, SLN allocation, operating room times, and pathology results. RESULTS: During the study period, 74 patients had robotic assisted surgery for endometrial cancer with attempted SLN mapping. SLN was found overall in 46 patients (62.1%). At first, SLN was detected in only 50% of cases, but after performing 30 cases, detection rates rose to 84.6% (OR = 3.34, CI 1.28-8.71; p = 0.003). Univariate analysis showed a higher detection rate with methylene blue than patent blue dye, 74.3% vs. 52.3% (OR = 2.744, 95% CI 1.026-7.344; p = 0.042). In multivariate analysis, high body mass index (BMI) was associated with failed mapping (OR = 0.899; 95% CI 0.808-1.00), as was the presence of lymph-vascular space invasion (LVSI) (OR = 0.126; 95% CI 0.24-0.658) and few cases per surgeon (OR = 1.083, 95% CI 1.032-1.118). Factors related to uterine pathology itself, including tumor histology, grade, method of diagnosis, the presence of an endometrial polyp, and lower uterine segment involvement were not found to be associated with successful mapping. CONCLUSIONS: Surgeon experience, BMI and LVSI may affect the success rate of SLN mapping for endometrial cancer. These factors should be investigated further in future studies.

Risk factors for recurrence after Le Fort colpocleisis for severe pelvic organ prolapse in elderly women.

INTRODUCTION: We investigated parameters associated with recurrence after partial (Le Fort) colpocleisis surgery for severe pelvic organ prolapse (POP) in elderly women. METHODS: A retrospective cohort study included all women who underwent partial colpocleisis in a single tertiary center from February 2007 through July 2013 for stage 3 or 4 triple compartment prolapse. Inclusion criteria were age over 60, sexually inactive, medical comorbidities, increased risk for comprehensive reconstructive pelvic surgery, and refusal or failure to use a pessary as a conservative non-surgical treatment. Exclusion criteria were post-menopausal bleeding, pelvic malignancy, and the desire to preserve coital function. RESULTS: The study group included 47 women of mean age 77.3 ± 8.2 (range 61-91 years). All had medical comorbidities. Fourteen patients (29.8%) had undergone previous hysterectomy. All patients underwent partial colpocleisis and perineorrhaphy. Seven women (14.9%) underwent mid-urethral sling for urinary incontinence. Mean follow-up was 14.8 ± 10.3 months (range, 2-37 months) and mean hospitalization, 3.5 ± 1.5 days (range, 2-9 days). There were no intraoperative complications. Postoperative complications comprised lower urinary tract infection (n = 2). Objective cure (according to vaginal examination) was 80.9% (38/47), and subjective (according to symptoms), 91.5% (43/47). No patient regretted the loss of sexual function. The main reasons for prolapse recurrence were statistically significant longer post-operative vaginal length and wider genital hiatus. CONCLUSIONS: Objective and subjective cure rates of Le Fort colpocleisis for the treatment of severe POP were high with low morbidity. Parameters associated with prolapse recurrence were longer postoperative vaginal length and wider genital hiatus.

Perineal stapled prolapse resection (PSPR) in elderly patients for external rectal prolapse: early experience.

BACKGROUND: Full-thickness rectal prolapse in frail elderly patients is often treated by a perineal approach with considerable attendant morbidity. We report our preliminary results of the perineal stapled prolapse resection (PSPR) technique for resection of full-thickness external rectal prolapse using a new reloadable Contour(®) Transtar™ stapler (Ethicon Endo-Surgery) device. METHODS: Fourteen elderly high-risk patients with an external prolapse up to 10 cm in length were treated between April 2010 and October 2011, and operative factors, outcome and recurrence rates were assessed. RESULTS: There were no intraoperative difficulties and no perioperative morbidity. The median operating time was 35 min (range 25-45 min) with a median hospital stay of 3 days (range 3-5 days). Four patients developed early recurrence over a median follow-up of 32 months (range 25-41 months). CONCLUSIONS: PSPR is safer, faster and easier to perform than other conventional perineal prolapse procedures and is suitable for elderly, high-risk patients for whom an abdominal approach under general anesthesia is not advisable.

Disrupted abdominal laparotomy wounds in gynaecologic oncology patients: benefits of active surgical re-closure.

OBJECTIVE: To assess the outcome of active management of disrupted wounds through surgical approximation and re-closure. METHOD: A prospective, non-comparative study, on all consecutive patients with disrupted laparotomy wounds treated at a tertiary medical centre, from November 2009 to December 2011. Data on patient demographics, diagnosis, type of abdominal incision, initial closure technique, infections and results of secondary re-closure were collected from the medical files. All patients underwent bedside closure with an en bloc mass suture mattress technique, performed by two attending gynaecologic oncologists. RESULTS: Of 197 patients who underwent abdominal laparotomy during the study period, 31 (16%) had a disrupted wound. Following surgical re-closure, 26 wounds (84%) were completely healed or needed only minor additional care by follow up on day 10. Five wounds (16%) failed primary management and required re-suturing; all subsequently healed. There were no long-term complications. CONCLUSION: Active surgical re-closure of disrupted abdominal laparotomy wounds is safe and effective in patients after treatment surgically for Müllerian malignancies.

Keratinocyte growth factor and its receptor in human ovaries from fetuses, girls and women.

Keratinocyte growth factor (KGF) promotes growth of rat pre-antral follicles. There is limited information regarding its presence or that of its unique receptor (KGFR) in human ovaries, specifically in pre-antral follicles. The aim of the study was to investigate the expression of KGF and KGFR in ovarian samples from human fetuses and girls/women. The samples were prepared for immunohistochemical study of the KGF protein and for in situ hybridization to localize mRNA transcripts of KGFR. Total RNA was extracted from frozen ovarian samples, and the expression of KGF mRNA transcripts was investigated by reverse transcriptase polymerase chain reaction. In both fetuses and girls/women, the protein for KGF was detected from primordial stages in oocytes, granulosa cells (GCs) and stroma cells. Its mRNA transcripts were also detected in all extracts. The mRNA transcripts for KGFR were detected mainly in stroma cells in ovarian samples from both sources; in 10% of the samples, follicular staining was noted also in oocytes and GCs. Further studies adding KGF to the culture medium are needed to elucidate its putative role in human primordial follicle activation.

Platelet-derived growth factors (PDGF-A and -B) and their receptors in human fetal and adult ovaries.

There is no information regarding the presence of platelet-derived growth factors (PDGFs) and their receptors in human ovaries. The expression of PDGF-A, -B and their two receptors, PDGFR-alpha and -beta, was investigated in ovarian samples from women/girls and from human fetuses, at the protein and mRNA levels. The samples were prepared for immunohistochemical staining for PDGF-A and -B and their two receptors and in situ hybridization for the detection of the mRNA transcripts of the receptors. Total RNA was extracted from frozen ovarian samples, and the expression of PDGF-A and -B was investigated by reverse transcription-polymerase chain reaction. The proteins for PDGF-A and -B were detected in oocytes, and in granulosa cells (GC) of 50% of the follicles from women/girls. The proteins and mRNA transcripts for the two receptors were detected in oocytes (mRNA for PDGFR-beta only in 25% of the oocytes). PDGFR-alpha mRNA was expressed in GC of a minority of the samples from women/girls, whereas PDGFR-beta protein and mRNA were identified in over 50% of the GC from this source. PDGF-A and -B transcripts were identified in all the extracts. The presence of the receptors in GC suggests that PDGFs might be involved in the activation of primordial follicles.

Tyrosine kinase B receptor and its activated neurotrophins in ovaries from human fetuses and adults.

The signals initiating the growth of primordial follicles are unknown. Growth factors such as neurotrophin 4/5 (NT-4/5) and brain-derived neurotrophic factor (BDNF) may play a role in this process. To investigate the expression of NT-4/5 and BDNF and their receptor tyrosine kinase B (TrkB) in the early developing follicles, we fixed and froze 12 ovarian samples from adolescents/adults and 31 ovaries from human fetuses. The fixed samples were prepared for immunohistochemical staining for NT-4/5, BDNF and the TrkB receptor. Total RNA was extracted from the frozen ovarian samples, and the expression of NT-4/5, BDNF and the TrkB receptor (full length and two truncated isoforms) was investigated by RT-PCR. Products were resolved by 1% agarose gel electrophoresis and image analysis. Immunohistochemical staining revealed the expression of NT-4/5 and BDNF mainly in oocytes and, in a minority of samples, also in the granulosa cells (GCs); TrkB receptor was identified in oocytes and GCs. Transcripts of NT-4/5, BDNF and all forms of TrkB receptor were identified in the samples. To elucidate whether indeed NT-4/5 and BDNF are involved in growth initiation of human primordial follicles, they should be added to the culture medium.

Effect of contaminated preprocessed semen on fertilization rate and embryo quality in assisted reproductive techniques.

We aimed to identify the sources and prevalence of semen contamination from mastrubation and determine the effect of bacterospermia on fertilization rate and embryo quality in standard in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). This was a prospective controlled study, in an IVF unit of a university teaching hospital, of 93 consecutive couples undergoing IVF-embryo transfer cycles. We evaluated handwashing; semen collection and processing; and assisted reproductive technology using semen provided by masturbation. The main outcome measures were presence and type of micro-organisms in the semen samples and embryo culture medium; the effect of hand washing on rate of contamination; and the effect of semen contamination on fertilization rate and embryo quality. The first consecutive 52 men of the 93 couples were not instructed to wash their hands before masturbation, and the remainder were so instructed. Forty-nine semen cultures (94.2%) in the first group were contaminated compared to only 16 (39%) in the second (p < 0.016); 27 of the 65 positive cultures (41.5%) were contaminated by more than one organism. The most common contaminators were bacteria usually found on the skin. All but four embryo medium cultures were negative. There was no significant difference in fertilization rate and embryo quality by culture findings in either the IVF or the ICSI procedures. We found that a high percentage of manually obtained semen for standard IVF or ICSI procedures was contaminated, but this had no effect on fertilization rate and embryo quality.

Immunocytochemical detection and RT-PCR expression of leukaemia inhibitory factor and its receptor in human fetal and adult ovaries.

The ability to mature human primordial follicles in vitro would assist fertility restoration. However, the signals initiating growth of primordial follicles are unknown. Growth factors such as leukaemia inhibitory factor (LIF) may play a role in this process. To investigate the expression of LIF and its receptor in early developing follicles, nine ovarian samples from adolescents/adults aged 13-43 years and 23 ovaries from human fetuses aged 19-33 gestational weeks were immediately fixed or frozen. The fixed samples were prepared for a study of immunocytochemical staining of LIF and its two receptor units (LIF-R and gp 130). mRNA was extracted from the frozen ovarian samples, and the expression of LIF, LIF-R and gp 130 was investigated by RT-PCR. Products were resolved by 10% polyacrylamide gel electrophoresis and image analysis. There was strong to moderate immunocytochemical staining for LIF and LIF-R in oocytes from the primordial follicular stages onwards, and very weak to moderate staining for gp 130. LIF-R was also detected in granulosa cells of primary and secondary follicles from adolescents/adults. Transcripts of LIF, LIF-R and gp 130 RNA were identified by RT-PCR in all samples. The immunocytochemical staining and mRNA expression of LIF and its receptor are consistent with the concept that LIF might be involved in growth initiation of human primordial follicles through its receptor.

Sonographic diagnosis of pelvic adhesions in patients after ovum pickup.

OBJECTIVE: To evaluate the use of transvaginal sonography for the detection of pelvic adhesions by using clear free fluid in the pouch of Douglas found after ovum pickup. METHODS: A prospective clinical study was performed in an infertility unit of an academic research facility. Sonography was performed in 50 women with infertility 3 days after ovum pickup, and the visceral peritoneum of the uterus, the ovaries, and the fallopian tubes was scanned for possible pelvic adhesions. RESULTS: The serosal surfaces of the uterus, ovaries, and fallopian tubes were successfully observed for the presence of adhesions in 86%, 68%, and 20% of the patients, respectively. Improved visualization was associated with an increased amount of pelvic fluid for the uterus (P = .01) but not for the ovaries and fallopian tubes. The amount of fluid in the pelvis correlated with an increased number of retrieved oocytes (P = .07) and a decreased need for manual manipulation to achieve proper imaging of the uterus (P = .001). CONCLUSION: Transvaginal sonography performed in the presence of fluid in the pelvis may show adhesions mainly attached to the uterus and ovaries. Assessment of possible mechanical factors is important in planning treatment of patients with infertility.

Fallopian tube torsion: laparoscopic evaluation and treatment of a rare gynecological entity.

BACKGROUND: Fallopian tube torsion is a cause for acute low abdominal pain that is difficult to diagnose. The purpose of this article is to review the available data on and to update clinicians regarding its diagnosis and treatment in the era of laparoscopic surgery. METHODS: We searched in MEDLINE and EMBASE and reviewed the lists of references. The keywords used were "laparoscopy," "fallopian tube," and "torsion." RESULTS AND CONCLUSION: Fallopian tube torsion is an uncommon cause for acute low abdominal pain in women. Because it has no pathognomonic clinical symptoms or findings on imaging or laboratory studies, a history of current or past pelvic pathologic conditions or surgery, as well as pregnancy, should draw the attention of the attending physician to its occurrence. Early laparoscopy is the reference standard in the diagnosis and treatment.

Triple-test screening in in vitro fertilization pregnancies.

PURPOSE: To determine whether the results of triple-test analysis differ between spontaneous and IVF pregnancies. METHODS: The study population consisted of 140 women with singleton pregnancies, 70 by IVF, and 70 by spontaneous conception. The groups were matched for maternal age, gestational week, and laboratory batch. The levels of all triple-test markers--alpha-fetoprotein (AFP), human chorionic gonadotropin (HCG), and unconjugated estriol (u-E3)--were compared between the groups. RESULTS: Significantly higher HCG levels were detected in the patients with IVF pregnancies than in the control group (1.31 +/- 0.8 vs. 0.95 +/- 0.5 multiple of the medians, respectively, (p < 0.006), but there were no significant differences in AFP or u-E3 levels. Overall, 18.5% of the IVF group were found to be screen-positive as compared with 11.4% of the control group (difference not statistically significant). Only 8 IVF pregnancies (11.4%) reached the lowest calculated risk possible (1:9999) compared with 17 (24.2%) in the control group (p < 0.05). CONCLUSIONS: Our findings support previous data demonstrating elevated maternal serum HCG in IVF patients in comparison with spontaneous ones.

Modified hysterosalpingography during infertility work-up: use of contrast medium and saline to investigate mechanical factors.

OBJECTIVE: To evaluate the effectiveness of modified hysterosalpingography using <3 mL amount of contrast medium followed by injection of saline to minimize the adverse effects associated with the procedure. DESIGN: For modified hysterosalpingography, 1-2 mL of water-soluble contrast medium were injected to visualize the uterine cavity, followed by injection of 10 mL of saline to check tubal patency and spillage. A control group of patients underwent hysterosalpingography with undiluted contrast medium. SETTING: Teaching hospital. PATIENT(S): Seventy-eight infertile women [study (n = 40)/control (n = 38) groups]. INTERVENTION(S): Modified and standard hysterosalpingography. MAIN OUTCOME MEASURE(S): Assessment of uterine cavity, tubal patency, and sensation of pain during modified hysterosalpingography was compared with that during standard hysterosalpingography. RESULT(S): Uterine cavity and tubal patency were properly visualized during modified hysterosalpingography. Saline pushed the contrast medium successfully from the uterine cavity through the open fallopian tubes and into the pelvic cavity. The study group reported significantly less pain than did the control group. Between-group differences were statistically significant when pain perception (no pain vs. minimal pain vs. severe pain; no pain vs. any kind of pain) was analyzed by type of adnexal pathology (bilateral passage or unilateral passage). CONCLUSION(S): Modified hysterosalpingography was sufficient to diagnose tubal and pelvic mechanical factors. The procedure was associated with a significant reduction in self-reported pain and no medical complications.

Fibrin glue improves pregnancy rates in women of advanced reproductive age and in patients in whom in vitro fertilization attempts repeatedly fail.

OBJECTIVE: To evaluate the possible contribution of fibrin sealant to the ET stage of IVF. DESIGN: Case-control study. SETTING: An assisted reproductive technology unit that performed 2,535 treatment cycles from 1996-1997. PATIENT(S): All consecutively seen patients who underwent ET from January 1996 to September 1997. INTERVENTION(S): All women who underwent ET with the aid of fibrin sealant during the study period were compared with those who underwent standard ET (controls). Thereafter, a case-control study was conducted on the first consecutively seen 174 women who underwent ET with fibrin sealant and a control group that was matched for age and number of previous unsuccessful cycles. MAIN OUTCOME MEASURE(S): Patient age, number of previous unsuccessful IVF attempts, number of embryos transferred, and pregnancy rates. RESULT(S): During the study period, ET was performed with fibrin sealant in 265 women and by the standard procedure in 1,402 women. Women in the fibrin sealant group were significantly older. The pregnancy rate was not significantly different between the groups in the whole-cohort study (20.4% versus 23.1%), but it was significantly higher in the fibrin sealant group in the case-control study (25.3% versus 14.9%). This also was true when the older women (>35 years) and the women with > or =4 previous failed IVF attempts were analyzed separately (23.2% versus 9.8% and 26.1% versus 13.4%, respectively). CONCLUSION(S): The use of fibrin sealant in ET appears to be beneficial in women of advanced reproductive age and in patients in whom IVF attempts repeatedly fail.