Pelvic organ prolapse in Caucasian and East Asian women: a comparative study.

OBJECTIVE: Ethnicity has been suggested to be a significant risk factor for pelvic organ prolapse (POP); yet, pelvic organ descent in different ethnic groups, especially in Asian populations, is not well studied. The aim of this study was to compare prolapse stages, pelvic organ descent and hiatal dimensions between East Asian and Caucasian women presenting with symptoms of POP. METHODS: This was a prospective observational study of East Asian and Caucasian women presenting with symptoms of POP to a tertiary urogynecology clinic in, respectively, Hong Kong and Sydney. Demographic data, prolapse symptoms and prolapse stage were assessed. Physical examination was performed using the pelvic organ prolapse quantification (POP-Q) system. All women underwent transperineal ultrasound using Voluson systems. Offline analysis of four-dimensional ultrasound volume data was performed at a later date, by one operator blinded to all clinical data, to ascertain pelvic organ descent and hiatal dimensions on Valsalva maneuver. Levator muscle avulsion was assessed in volumes obtained on pelvic floor muscle contraction. Multiple logistic regression analysis was performed to assess factors associated with prolapse on clinical and ultrasound examinations. RESULTS: A total of 225 East Asian women were included between July 2012 and February 2014 from the Hong Kong clinic and 206 Caucasian women between January 2015 and July 2016 from the Sydney clinic. There was no significant difference in the overall staging of prolapse. However, in East Asian women, compared with Caucasians, apical compartment prolapse was more common (99.6% vs 71.8%, P < 0.001) and posterior compartment prolapse less common (16.9% vs 48.5%, P < 0.001) on POP-Q examination. On Valsalva maneuver, the position of the uterus was lower in East Asian than in Caucasian women (-11.3 vs 1.35 mm, P < 0.001), while the rectal ampulla position was lower in Caucasians than in East Asians (-10.6 vs - 4.1 mm, P < 0.001). On multiple regression analysis, Caucasian ethnicity was a significant factor for lower risk of apical compartment prolapse on clinical assessment (odds ratio (OR), 0.01; P < 0.001) and on ultrasound (OR, 0.13; P < 0.001), and for a higher risk of posterior compartment prolapse on clinical assessment (OR, 4.36; P < 0.001) and of true rectocele on ultrasound (OR, 8.14; P < 0.001). CONCLUSIONS: East Asian women present more commonly with uterine prolapse while Caucasians show more often posterior compartment prolapse. Ethnicity was a significant predictor of type of prolapse on multivariate analysis. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Longitudinal pelvic floor biometry: which factors affect it?

OBJECTIVES: To evaluate pelvic floor biometry of women 3-5 years after their first delivery. The effect of a subsequent delivery and the mode of delivery on pelvic floor biometry were also studied. METHODS: Three-hundred and twenty-eight women who had been examined by translabial ultrasound during their first singleton pregnancy and at 8 weeks and 1 year postpartum, were invited for a follow-up 3-5 years later. The positions of the bladder neck, cervix, anorectal junction and hiatal area (HA) were evaluated using translabial ultrasound. The effects of parity, mode of delivery and levator ani muscle avulsion were studied. RESULTS: A total of 240 women completed the study. Of these, 179 had one or more vaginal deliveries (VD) (VD-only group), 52 had one or more Cesarean sections (CS) (CS-only group) and nine had both VD and CS at follow-up. The mean interval between the first delivery and follow-up was 3.8 years. A significantly lower bladder neck and anorectal junction on Valsalva, a lower cervix at rest, on Valsalva and pelvic floor muscle contraction, and a greater HA were observed in the VD-only group at follow-up, compared with findings at 1 year of follow-up or in the first pregnancy. The findings were similar in the CS-only group, except without a lower anorectal junction on Valsalva. Compared with the primiparous VD-only group, a greater HA at rest was observed in the multiparous VD-only group (P = 0.027). The VD-only group had a greater HA than the CS-only group. CONCLUSIONS: At 3-5 years after first delivery, a lower bladder neck, cervix and anorectal junction, and a greater HA were observed compared with findings in the first trimester and at 1 year of follow-up, regardless of parity or mode of delivery. Women with two or more VDs had a greater HA compared with those who had only one VD, and women with at least one VD had a greater HA compared with those who delivered by CS only. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

A loop of cancer-stroma-cancer interaction promotes peritoneal metastasis of ovarian cancer via TNFα-TGFα-EGFR.

Peritoneum is the most common site for ovarian cancer metastasis. Here we investigate how cancer epigenetics regulates reciprocal tumor-stromal interactions in peritoneal metastasis of ovarian cancer. Firstly, we find that omental stromal fibroblasts enhance colony formation of metastatic ovarian cancer cells, and de novo expression of transforming growth factor-alpha (TGF-α) is induced in stromal fibroblasts co-cultured with ovarian cancer cells. We also observed an over-expression of tumor necrosis factor-alpha (TNF-α) in ovarian cancer cells, which is regulated by promoter DNA hypomethylation as well as chromatin remodeling. Interestingly, this ovarian cancer-derived TNF-α induces TGF-α transcription in stromal fibroblasts through nuclear factor-κB (NF-κB). We further show that TGF-α secreted by stromal fibroblasts in turn promotes peritoneal metastasis of ovarian cancer through epidermal growth factor receptor (EGFR) signaling. Finally, we identify a TNFα-TGFα-EGFR interacting loop between tumor and stromal compartments of human omental metastases. Our results therefore demonstrate cancer epigenetics induces a loop of cancer-stroma-cancer interaction in omental microenvironment that promotes peritoneal metastasis of ovarian cancer cells via TNFα-TGFα-EGFR.

Levator ani muscle avulsion is a risk factor for expulsion within 1 year of vaginal pessary placed for pelvic organ prolapse.

OBJECTIVE: The aim of this study was to investigate whether the presence of levator ani muscle (LAM) avulsion is associated with expulsion within 1 year of a vaginal pessary placed for pelvic organ prolapse (POP). METHODS: This was a prospective observational study of consecutive women with symptomatic POP, who had not received treatment for the condition before the consultation and opted for vaginal pessary placement in our center. Volume acquisition was performed before pessary insertion and offline analysis of the 3D/4D transperineal ultrasound volume data was performed. LAM was assessed on maximum pelvic floor muscle contraction (PFMC) and hiatal dimensions were assessed at rest, on PFMC and on maximum Valsalva. Results were compared between women in whom the pessary was retained for 1 year and those in whom the pessary was expelled within 1 year. RESULTS: The datasets of 255 women were analyzed including 147 (57.6%) women who had a vaginal pessary continuously in place over 1 year and 108 (42.4%) with pessary expulsion. Mean age was 63.2 (SD, 9.9) years and median parity was 3 (2-4). Eighteen (7.1%) had Stage I, 164 (64.3%) Stage II, 67 (26.3%) Stage III and six (2.4%) Stage IV POP. Women with vaginal pessary expulsion within 1 year had significantly larger hiatal dimensions at rest and on Valsalva, larger hiatal area during rest, PFMC and Valsalva and higher rate of LAM avulsion (53.7% vs 27.2%, P < 0.01) compared with women in whom the pessary was retained for 1 year. After controlling for potential confounders, LAM avulsion remained a risk factor (OR, 3.18, P < 0.01) of vaginal pessary expulsion within 1 year. CONCLUSIONS: Women in whom a vaginal pessary was expelled within 1 year of placement for POP had a larger hiatus. Presence of LAM avulsion was associated with a three-fold increase in the risk of expulsion of a vaginal pessary within 1 year. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Longitudinal follow-up of levator ani muscle avulsion: does a second delivery affect it?

OBJECTIVES: To evaluate the morphological outcome of levator ani muscle (LAM) avulsion 3-5 years after a first delivery and to assess the effect of a second delivery on this condition. The impact of LAM avulsion on pelvic floor disorders was also studied. METHODS: Six hundred and sixty-six women who had been assessed for LAM avulsion 8 weeks after their first delivery were invited for a follow-up examination 3-5 years later. Women completed the Pelvic Floor Distress Inventory including the Urinary Distress Inventory (UDI) and Pelvic Organ Prolapse Distress Inventory (POPDI) questionnaires to explore symptoms of pelvic floor disorders, and the pelvic floor was examined using three-dimensional translabial ultrasound and assessed using the pelvic organ prolapse quantification system. RESULTS: Three hundred and ninety-nine women completed the study, of whom 151 were multiparous. Mean interval between first delivery and follow-up was 42.3 ± 7.6 months. Among 69 women who had LAM avulsion 8 weeks after their first delivery, nine (13.0%) had no LAM avulsion at follow-up. One (0.9%) woman had a new LAM avulsion after her second vaginal delivery. A greater proportion of women with LAM avulsion reported symptoms of stress urinary incontinence (SUI) (adjusted odds ratio, 2.09 (95% CI, 1.18-3.70); P = 0.01) and symptoms of prolapse than did women without avulsion; however, this difference did not reach statistical significance (P = 0.61). Women with LAM avulsion had higher UDI and POPDI scores than did women without avulsion (median UDI score, 17.7 (interquartile range (IQR), 5.0-32.4) vs 9.2 (IQR, 0.0-22.1); P = 0.045 and median POPDI score, 20.8 (IQR, 8.8-40.5) vs 10.7 (IQR, 0.0-32.8); P = 0.021). CONCLUSIONS: The risk of developing new LAM avulsion after a second vaginal delivery is low (0.9%). Healing of LAM avulsion was observed in 13% of women who had at least one vaginal delivery. At 3-5 years after delivery, women with LAM avulsion reported symptoms of SUI more often than did those without, and had higher UDI and POPDI scores, implying more bothersome symptoms. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Antenatal pelvic floor biometry is related to levator ani muscle injury.

OBJECTIVE: To evaluate the relationship between antenatal pelvic floor biometry and levator ani muscle (LAM) injury in Chinese women. METHODS: Three-dimensional transperineal ultrasound was performed in nulliparous Chinese women with a singleton pregnancy at 9-12 weeks, 26-28 weeks and 36-38 weeks of gestation and again at 12 months after delivery. Hiatal anteroposterior (AP) diameter, transverse diameter and area were measured on the antenatal ultrasound volumes obtained at rest, on Valsalva maneuver and during pelvic floor muscle contraction (PFMC). LAM injury was evaluated using ultrasound volumes obtained during PFMC at 12 months after delivery. RESULTS: In total, 328 women completed the study. At 12 months after delivery, 38 (14.8% of those who delivered vaginally) women had LAM injury; 28 were unilateral (14 right- and 14 left-sided) and 10 were bilateral. In all three trimesters there was smaller hiatal AP diameter and hiatal area in women with LAM injury when compared with women without injury. On multivariable analysis of the three factors, hiatal AP diameter at rest, hiatal area at rest and operative vaginal delivery, only hiatal AP diameter at rest in all three trimesters was an independent factor of LAM injury. A larger hiatal AP diameter at rest in the first, second and third trimesters reduced the likelihood of LAM injury with odds ratios of 0.21, 0.15 and 0.21, respectively. CONCLUSIONS: A smaller antenatal hiatal AP diameter at rest is a risk factor for LAM injury. The hiatal AP diameter is relatively simple to measure and the error in measurement is relatively small. A prospective study to confirm this relationship and to explore whether this measurement, performed in the midsagittal plane, is repeatable should be performed. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Pelvic floor muscle biometry and pelvic organ mobility in East Asian and Caucasian nulliparae.

OBJECTIVE: To compare the differences in levator ani muscle biometry and hiatal dimensions between pregnant nulliparous Caucasian and East Asian women. METHODS: Offline analysis of three/four-dimensional ultrasound volume data obtained from two groups of pregnant nulliparous women, Caucasian and East Asian, was performed. Volume acquisition was performed in the late third trimester using the same method in both groups, in the context of two prospective observational studies with identical entry criteria. Pelvic organ descent and levator hiatal dimensions were assessed using the volumes acquired on Valsalva maneuver, and pubovisceral muscle thickness was measured from the volumes obtained on pelvic floor muscle contraction (PFMC). RESULTS: Datasets of 200 East Asian and 168 Caucasian women were analyzed. Compared with Caucasian women, East Asian women had a significantly lower body mass index. All indices of pelvic organ descent were significantly higher in the Caucasian group than in the East Asian group. The difference, expressed as a percentage, in levator hiatal area on both Valsalva maneuver and PFMC was markedly greater in Caucasian (32% vs. 19%; P < 0.001) than in East Asian (24% vs. 20%; P = 0.01) women. After controlling for potential confounders using multivariate regression analysis, racial origin remained the only significant factor associated with differences in pelvic organ descent and hiatal dimensions. The thickness and area of pubovisceral muscle were significantly higher in the East Asian group. CONCLUSIONS: Pregnant women of East Asian racial origin have a thicker pubovisceral muscle, smaller hiatus and less mobility of pelvic organs than do pregnant Caucasian women.

Prevalence of levator ani muscle injury and health-related quality of life in primiparous Chinese women after instrumental delivery.

OBJECTIVES: Levator ani muscle (LAM) injury is common after first vaginal delivery, and a higher incidence is associated with instrumental delivery. This study was conducted to compare the incidence of LAM injury after forceps or ventouse extraction in primiparous Chinese women, and to study their subsequent health-related quality of life. METHODS: This prospective observational study was conducted between 1 September 2011 and 31 May 2012 in a tertiary obstetric unit. All eligible primiparous women who had undergone instrumental delivery were recruited 1 to 3 days following delivery. The subjects completed the Pelvic Floor Distress Inventory questionnaire and Pelvic Floor Impact Questionnaire, and translabial ultrasound was performed 8 weeks' postpartum to determine whether the subjects had suffered LAM injury. RESULTS: Among the 289 women who completed the study, 247 (85.5%) had ventouse extraction and 42 (14.5%) had forceps delivery. Subsequent translabial ultrasound identified a total of 58 women with LAM injury. The prevalence of LAM injury after ventouse extraction and forceps delivery was 16.6% (95% CI, 12.0-21.2%) (41/247) and 40.5% (95% CI, 25.6-55.4%) (17/42), respectively (P = 0.001). Forceps delivery was identified as a risk factor for LAM injury, with an odds ratio of 3.54. No statistically significant differences were observed between the quality of life in women who underwent ventouse extraction and those with forceps delivery or between the quality of life in women with a unilateral or bilateral LAM injury. CONCLUSIONS: In our cohort of primiparous Chinese women, 20.1% (58/289) had LAM injury after instrumental delivery, and forceps delivery was identified as the only risk factor.

The impact of supportive counselling on women's psychological wellbeing after miscarriage--a randomised controlled trial.

OBJECTIVE: To assess the effectiveness of supportive counselling after miscarriage. DESIGN: Randomised controlled trial. SETTING: University hospital. SAMPLE: Two hundred and eighty women with miscarriage. METHOD: Women were randomised to receive supportive counselling from a nurse (at diagnosis and 2 weeks later) or routine care. Psychological wellbeing was measured with the General Health Questionnaire (GHQ-12) and Beck Depression Inventory (BDI). MAIN OUTCOME MEASURES: Primary outcome measured the proportion of women suffering psychological distress (GHQ-12 score ≥4) at 3 months after miscarriage. Secondary outcomes were GHQ-12 and BDI scores at 6 weeks, 3 and 6 months. RESULTS: There was no difference in the proportion of women suffering psychological distress at 3 months after miscarriage (17.1% in counselling group versus 24.4% in control group; 95% CI -0.034 to 0.177; P = 0.19). However, for the subgroup of women (n = 152) with high baseline GHQ-12 scores, the median GHQ-12 score in the counselling group was significantly lower than the control group at 6 weeks (median score 3 versus 4.5 in counselling and control groups; P = 0.04) and 3 months (median score 1 versus 2.5 in counselling and control groups; P = 0.03). Similarly, for women with high baseline BDI scores (BDI > 12), the proportion for women continuing to score high was significantly lower in the counselling group 6 weeks after miscarriage (33.3 versus 61.1% in counselling group and control group; P = 0.03). CONCLUSIONS: Although the results of current study do not justify routine counselling of all women following miscarriage, a supportive counselling programme for selected women with high levels of psychological distress is promising and merits further investigation.

Pelvic floor biometry in Chinese primiparous women 1 year after delivery: a prospective observational study.

OBJECTIVES: To evaluate pelvic floor biometry in Chinese women 1 year following childbirth and to explore factors that affect it. METHODS: Translabial ultrasound examination was performed at rest, on Valsalva maneuver (VM) and on pelvic floor muscle contraction (PFMC) in the first, second and third trimesters of pregnancy and at 8 weeks, 6 months and 12 months after delivery in a cohort of women delivering at term their first child. Offline analysis was undertaken to measure the position of the bladder neck, cervix, anorectal junction and hiatal dimensions at each posture and at each visit, and to detect levator ani muscle (LAM) injury on PFMC 8 weeks and 12 months after delivery. Results were analyzed according to mode of delivery. RESULTS: We recruited 442 women, of whom 328 (74.2%) completed the study; there was LAM injury in 48 women at 8 weeks and in only 38 women at 12 months. When comparing first-trimester biometry to that at 12 months after delivery, the bladder neck was more distal on VM and bladder neck displacement was increased, and the cervix was lower at rest and on VM in the vaginal delivery group. In the Cesarean section group, bladder neck and anorectal junction were more distal on VM, the cervix was lower at rest, on VM and on PFMC, and the hiatal area was increased on VM. There was a greater increase in hiatal area after vaginal delivery. Overall, 34.8% had irreversible hiatal distension (> 20% increase in hiatal area after delivery as compared to first trimester). LAM injury was significantly associated with irreversible hiatal distension (odds ratios, 5.2-9.5 at different postures). CONCLUSIONS: Pregnancy beyond 35 weeks of gestation has an effect on the pelvic floor of Chinese women, irrespective of mode of delivery. The pelvic organs remain more mobile after delivery when compared to in the first trimester, and there is no clear difference between the findings observed following vaginal delivery or Cesarean section, except in hiatal distension, which is greater after vaginal delivery. LAM injury is the factor most strongly associated with irreversible hiatal distension.

Pelvic floor biometry during a first singleton pregnancy and the relationship with symptoms of pelvic floor disorders: a prospective observational study.

OBJECTIVE: To assess pelvic floor biometry during pregnancy and the correlation with symptoms of pelvic floor disorders in women. DESIGN: A prospective observational study. SETTING: Antenatal clinic between August 2009 and May 2011. POPULATION: Nulliparous women in their first pregnancy. METHODS: Pelvic floor was assessed by translabial ultrasound and symptoms of pelvic floor disorders were explored with a standardised questionnaire at each trimester. MAIN OUTCOME MEASURES: Pelvic floor biometry during pregnancy. RESULTS: A total of 405 (91.6%) women completed the study. As the pregnancy advanced, there was significant descent of the bladder neck (BN), cervix, and anorectal junction. The hiatal area (HA) was significantly enlarged, with a mean increase of 15.1 ± 24.8% at rest, and 24.7 ± 28.5% at Valsalva, at third trimester when compared with first trimester. Risk factors for stress urinary incontinence (SUI) were: descent of BN at Valsalva (OR 3.2, 95% CI 1.2-8.5), increase in HA at pelvic floor contraction (PFMC; OR 1.3, 95% CI 1.0-1.6), and increase in maternal age (OR 1.1, 95% CI 1.0-1.2), at first trimester; increase in HA at PFMC (OR 1.3, 95% CI 1.1-1.5) at second trimester; and descent of BN at rest (OR 2.3, 95% CI 1.1-4.9) and increase in maternal age (OR 1.1, 95% CI 1.02-1.2) at third trimester. Descent of anorectal junction (OR 1.5, 95% CI 1.1-1.9) and increase in HA at rest (OR 1.2, 95% CI 1.0-1.3) were factors for prolapse symptoms at second and third trimester, respectively. CONCLUSIONS: Pelvic floor changes begin during pregnancy. There was significant descent of the BN, cervix, and anorectal junction, and enlargement of the hiatal area, as the pregnancy advanced. SUI was associated with descent of the BN, and prolapse symptoms were associated with an increase in the hiatal area.

Dysregulation of microRNA-204 mediates migration and invasion of endometrial cancer by regulating FOXC1.

MicroRNAs (miRNAs) regulate mRNA stability and protein expression, and certain miRNAs have been demonstrated to act either as oncogenes or tumor suppressors. Differential miRNA expression signatures have been documented in many human cancers but the role of miRNAs in endometrioid endometrial cancer (EEC) remains poorly understood. This study identifies significantly dysregulated miRNAs of EEC cells, and characterizes their impact on the malignant phenotype. We studied the expression of 365 human miRNAs using Taqman low density arrays in EECs and normal endometriums. Candidate differentially expressed miRNAs were validated by quantitative real-time PCR. Expression of highly dysregulated miRNAs was examined in vitro through the effect of anti-/pre-miRNA transfection on the malignant phenotype. We identified 16 significantly dysregulated miRNAs in EEC and 7 of these are novel findings with respect to EEC. Antagonizing the function of miR-7, miR-194 and miR-449b, or overexpressing miR-204, repressed migration, invasion and extracellular matrix-adhesion in HEC1A endometrial cancer cells. FOXC1 was determined as a target gene of miR-204, and two binding sites in the 3'-untranslated region were validated by dual luciferase reporter assay. FOXC1 expression was inversely related to miR-204 expression in EEC. Functional analysis revealed the involvement of FOXC1 in migration and invasion of HEC1A cells. Our results present dysfunctional miRNAs in endometrial cancer and identify a crucial role for miR-204-FOXC1 interaction in endometrial cancer progression. This miRNA signature offers a potential biomarker for predicting EEC outcomes, and targeting of these cancer progression- and metastasis-related miRNAs offers a novel potential therapeutic strategy for the disease.

Prevalence of levator ani muscle injury in Chinese women after first delivery.

OBJECTIVES: To assess the prevalence of levator ani muscle injury in Chinese women after their first delivery and investigate associated factors. METHODS: A prospective observational study was conducted involving Chinese nulliparous women recruited in the first trimester of pregnancy. Translabial ultrasound was performed at 35-38 weeks' gestation and 8 weeks postpartum and three-dimensional volume datasets were obtained. Offline analysis to detect levator ani muscle injury was performed by investigators blinded to the delivery details. RESULTS: 339 women, with a mean age of 30.6 ± 3.9 years, completed the study. Overall, 201 (59.3%) had a spontaneous vaginal delivery, 62 (18.3%) an operative vaginal delivery (48 ventouse extraction and 14 forceps delivery), 14 (4.1%) an elective Cesarean section and 62 (18.3%) an emergency Cesarean section. No levator ani muscle injury was detected in any woman antenatally. After vaginal delivery, 57 (21.7% (95% CI, 16.7-26.7%)) women had levator ani muscle injury. The rates of injury for spontaneous vaginal delivery, ventouse extraction and forceps delivery were 15.4%, 33.3% and 71.4%, respectively. There was no levator ani muscle injury in the Cesarean section groups. Logistic regression analysis showed that only operative vaginal delivery (odds ratio, 3.09) was associated with an independent increase in the likelihood of levator ani muscle injury. Intrapartum epidural analgesics, duration of second stage of labor and infant birth weight were not independently associated with levator ani muscle injury. CONCLUSIONS: The prevalence of levator ani muscle injury in Chinese women after their first vaginal delivery was 21.7% (95% CI, 16.7-26.7%). Operative vaginal delivery was found to increase the likelihood of women suffering such injury. A longer follow-up of these women and future studies on the effects of episiotomy are proposed.

Urinary symptoms and impaired quality of life in female ketamine users: persistence after cessation of use.

OBJECTIVE: To compare the urinary symptoms and quality of life in ex-ketamine abusers and controls. DESIGN: Prospective observational study. SETTING: A hospital in Hong Kong. PATIENTS: Female ex-ketamine abusers admitted to a local drug rehabilitation centre and age-matched controls attending a general gynaecology clinic between December 2009 and April 2010. MAIN OUTCOME MEASURES: Evaluation of urinary symptoms based on a 3-day bladder diary, and responses to the Urogenital Distress Inventory Short Form (UDI-6) and the Incontinence Impact Questionnaire Short Form (IIQ-7). The study group had repeat measurements 3 months later. RESULTS: Overall, 90% of ex-ketamine abusers had active urinary symptoms. On average, they had increased 24-hour urinary frequency (10.0 vs 5.8; P=0.001) and lower maximum voided volume (253.3 mL vs 401.9 mL; P<0.001) compared to controls. Correspondingly, the median functional bladder capacity was smaller (195.3 mL vs 261.2 mL; P=0.011) and the mean UDI-6 and IIQ-7 scores were higher (P<0.001). Among those who abused ketamine for 2 years or more, the mean UDI-6 and IIQ-7 scores were higher (P=0.03, P=0.02 respectively). When they stopped abusing ketamine for 3 months or more, their mean 24-hour urinary frequency had decreased (P=0.03), the maximum voided volume had increased (P=0.03) and the mean UDI-6 and IIQ-7 scores had decreased (P=0.04, P=0.02 respectively), although they were still higher than in controls. After 3 more months, in the ex-ketamine abusers there had been a further decrease in 24-hour urinary frequency (P=0.01) and a further improvement in quality of life based on mean UDI-6 scores (P=0.04) but nevertheless poorer than the control group (P<0.01). CONCLUSION: Female ex-ketamine abusers had significant urinary symptoms affecting their quality of life when studied at a mean of 8 (range, 0.5-48) months after cessation of use. The symptom severity was inversely correlated with the duration of cessation; though they improved with time, some still persisted.

Laparoscopic sacrocolpopexy for the treatment of vaginal vault prolapse: with or without robotic assistance.

OBJECTIVE: To assess perioperative and medium-term outcome after laparoscopic sacrocolpopexy with or without robotic assistance for vaginal vault prolapse in a Hong Kong tertiary centre. DESIGN: Retrospective study. SETTING: An urogynaecology unit in Hong Kong. PATIENTS: All women who underwent laparoscopic sacrocolpopexy with or without robotic assistance for vaginal vault prolapse from March 2005 to May 2010. MAIN OUTCOME MEASURES: The perioperative and medium-term outcomes. RESULTS: A total of 36 women underwent the operation during the study period. The mean operating time was 205 minutes, mean blood loss was 144 mL. The median hospital stay was 4 days. Two women required early re-operation but recovered fully. In all, 35 women were followed up for 29 (standard deviation, 19) months. Three of them (9%) had a recurrence of stage II prolapse, but there was statistically significant improvement in the pelvic organ prolapse quantification assessment for all three compartments of the vagina, and the length of vagina was well preserved. There were no mesh exposure or erosions. The overall objective cure rate of 91% (32/35) was high, and 91% (32/35) were satisfied with the operative outcome. Stress incontinence and voiding difficulty were significantly reduced. CONCLUSION: Laparoscopic sacrocolpopexy for vaginal vault prolapse is safe, although complications arising from concomitant surgery should not be neglected. High rates of objective cures and patient satisfaction were achieved. There were no mesh exposure or erosions. Laparoscopic sacrocolpopexy should be considered an option for women with vaginal vault prolapse.

Gender comparison of psychological reaction after miscarriage-a 1-year longitudinal study.

OBJECTIVE: To explore men's psychological reaction and its evolutionary course over 1 year after miscarriage, to compare this reaction with that of their female partners and to investigate the possible correlation of psychological states between partners. DESIGN: Prospective 1-year longitudinal observational study. SETTING: A university-affiliated tertiary referral hospital in Hong Kong. Sample Eighty-three miscarrying couples. METHODS: The psychological reactions of miscarrying women and their male partners were assessed immediately and at 3, 6 and 12 months after miscarriage. MAIN OUTCOME MEASURES: Psychological outcomes were assessed using the 12-item General Health Questionnaire (GHQ-12) and Beck Depression Inventory (BDI). RESULTS: A substantial proportion of men (43.4%) scored high in GHQ-12 and 16.9% scored high in BDI immediately after miscarriage. In men, both psychometric scores decreased sharply within the first 3 months and reached a plateau. When compared with women, men scored significantly lower in GHQ-12 and BDI during the 1-year course after miscarriage. A planned pregnancy was a significant risk factor (P = 0.008) associated with an initial high BDI score in men. There was a significant positive correlation between couples in both GHQ-12 and BDI scores throughout the longitudinal course. CONCLUSIONS: Although the psychological impact of miscarriage on men was less enduring when compared with that on women, a significant proportion of men demonstrated psychological distress after miscarriage. The significant positive correlation in a couple's psychological reaction indicated that psychological morbidity was not confined only to a woman's own experience, but also affected her relationship with her male partner.

A randomized, double-blind, placebo-controlled study of the effect of a Chinese herbal medicine preparation (Dang Gui Buxue Tang) on menopausal symptoms in Hong Kong Chinese women.

OBJECTIVE: Many complementary or alternative medicines are being used for the treatment of menopausal symptoms but most have not been properly tested for efficacy or for safety. This study examined the effect of a Chinese herbal preparation (Dang Gui Buxue Tang) on menopausal symptoms in Hong Kong Chinese women. METHODS: A 6-month randomized, double-blind, placebo-controlled study of the effect of Dang Gui Buxue Tang (a 1 : 5 combination of Dang Gui (Angelicae sinensis) and Huang Qi (Astragalus membranaceus)) on acute menopausal symptoms. A total of 103 symptomatic women were enrolled. Three failed to meet inclusion criteria, leaving 50 subjects for inclusion in each group. RESULTS: Overall, mild hot flushes were reported more frequently than either moderate or severe flushes. In analysis by severity of flushes, there was a significant reduction in the number of mild hot flushes per month in the treatment group but not in the placebo group (from 18.9 +/- 23.5 at baseline to 8.6 +/- 17.1 at 6 months in the treatment group (p < 0.01) and from 26.0 +/- 43.5 to 12.4 +/- 17.6 in the placebo group (p = 0.062)). For moderate flushes, there was a significant reduction in the placebo group compared with the treatment group (from 18.9 +/- 28.7 at baseline to 11.1 +/- 29.9 at 6 months in the placebo group (p < 0.05) and from 10.5 +/- 22.3 to 6.0 +/- 16.0 in the treatment group (p = 0.107)). There was no significant change in either treatment or placebo groups in the reporting of severe hot flushes. Episodes of night sweats decreased significantly in the placebo but not in the treatment group (from 6.8 +/- 10.0 at baseline to 1.9 +/- 5.7 at 6 months in the placebo group (p < 0.05) and from 5.4 +/- 8.9 to 3.2 +/- 8.5 in the treatment group (p = 0.471)). In the vasomotor domain of the Menopause Specific Quality of Life, there was a significant reduction in scoring in the placebo group (from 2.8 +/- 1.6 to 1.7 +/- 1.3, p < 0.01) but not in the treatment group (from 2.8 +/- 2.1 to 2.3 +/- 1.6, p = 0.247). CONCLUSIONS: This study found overall no significant difference between Dang Gui Buxue Tang and placebo in the treatment of vasomotor symptoms in Hong Kong Chinese women. The frequency of mild, moderate and severe hot flushes decreased in both treatment and placebo groups, but Dang Gui Buxue Tang was statistically superior to placebo only in the treatment of mild hot flushes. There were no serious adverse events attributable to treatment during the study period.

Is aortic lymphadenectomy necessary in the management of endometrial carcinoma?

OBJECTIVE: To evaluate the role of aortic lymphadenectomy in the management of endometrial carcinoma. METHODS: Clinical notes of 163 patients with endometrial carcinoma were reviewed. All patients had peritoneal cytology, total abdominal hysterectomy, bilateral salpingo-oophorectomy and pelvic lymphadenectomy with or without aortic lymphadenectomy. RESULTS: Seventy-five (46.0%) patients had pelvic lymphadenectomy alone whereas 88 (54.0%) had both pelvic and aortic lymphadenectomy. Thirty-five (21.5%) patients had nodal metastases with positive pelvic and aortic nodes in 26 (16.0%) and 24 (27.3%) patients, respectively. Isolated aortic metastases were found in 17 cases (19.3%). Among 35 patients with nodal metastases, recurrence developed in 15 (42.9%) patients and all except one died within five to 50 months. The remaining patients had a median disease-free period of 55 months (13-93 months). The recurrence rate was higher (63.6%) among patients with upper aortic lymph node metastases, and all those who recurred died of disease within seven to 28 months. CONCLUSIONS: Our data suggest that aortic lymphadenectomy provides both diagnostic and therapeutic value in the management of endometrial carcinoma with high metastatic risk. After surgical removal and adjuvant radiotherapy, patients with nodal metastases achieved a better survival chance.

Identification of molecular markers and signaling pathway in endometrial cancer in Hong Kong Chinese women by genome-wide gene expression profiling.

Endometrial cancer is the third most common gynecologic malignancy and the ninth most common malignancy for females overall in Hong Kong. Approximately 80% or more of these cancers are endometrioid endometrial adenocarcinomas. The aim of this study was to reveal genes contributing to the development of endometrioid endometrial cancer, which may impact diagnosis, prognosis and treatment of the disease. Whole-genome gene expression analysis was completed for a set of 55 microdissected sporadic endometrioid endometrial adenocarcinomas and 29 microdissected normal endometrium specimens using the Affymetrix Human U133 Plus 2.0 oligonucleotide microarray. Selected genes of interest were validated by quantitative real-time-polymerase chain reaction (qRT-PCR). Pathway analysis was performed to reveal gene interactions involved in endometrial tumorigenesis. Unsupervised hierarchical clustering displayed a distinct separation between the endometrioid adenocarcinomas and normal endometrium samples. Supervised analysis identified 117 highly differentially regulated genes (>or=4.0-fold change), which distinguished the endometrial cancer specimens from normal endometrium. Twelve novel genes including DKK4, ZIC1, KIF1A, SAA2, LOC16378, ALPP2, CCL20, CXCL5, BST2, OLFM1, KLRC1 and MBC45780 were deregulated in the endometrial cancer, and further validated in an independent set of 56 cancer and 29 normal samples using qRT-PCR. In addition, 10 genes were differentially regulated in late-stage cancer, as compared to early-stage disease, and may be involved in tumor progression. Pathway analysis of the expression data from this tumor revealed an interconnected network consisting of 21 aberrantly regulated genes involved in angiogenesis, cell proliferation and chromosomal instability. The results of this study highlight the molecular features of endometrioid endometrial cancer and provide insight into the events underlying the development and progression of endometrioid endometrial cancer.