One-year follow-up after sacrospinous hysteropexy and vaginal hysterectomy for uterine descent: a randomized study.

INTRODUCTION AND HYPOTHESIS: In a retrospective study, the sacrospinous hysteropexy was associated with a shorter recovery time compared to a vaginal hysterectomy with no differences in anatomical outcomes. No randomized trials are performed. METHODS: Sixty-six women with stage 2-4 uterine descent were randomized for vaginal hysterectomy(31) or sacrospinous hysteropexy(35). Recovery time, anatomical outcomes, functional outcomes, and quality of life were measured. RESULTS: Length of time to return to work was shorter after a sacrospinous hysteropexy (43 versus 66 days, p = 0.02). The difference in risk for recurrent prolapse stage 2 or more of the apical compartment at 1-year follow-up was 17% (95% confidence interval, 2 to 30) in favor of the vaginal hysterectomy. No differences in quality of life and urogenital symptoms were found. CONCLUSIONS: The sacrospinous hysteropexy for uterine descent is associated with an earlier recovery time, more recurrent apical prolapses but no differences in functional outcomes, and quality of life.

Non-commercial surrogacy: an account of patient management in the first Dutch Centre for IVF Surrogacy, from 1997 to 2004.

BACKGROUND: Surrogacy was prohibited in the Netherlands until 1994, at which time the Dutch law was changed from the general prohibition of surrogacy to the prohibition of commercial surrogacy. This paper describes the results from the first and only Dutch Centre for Non-commercial IVF Surrogacy between 1997 and 2004. METHODS: A prospective study was conducted of all intended parents, and surrogate mothers and their partners (if present), in which medical, psychological and legal aspects of patient selection were assessed by questionnaires and interviews developed for this study. RESULTS: More than 500 couples enquired about surrogacy by telephone or e-mail. More than 200 couples applied for surrogacy in the Centre, of which, after extensive screening, 35 couples actually entered the IVF programme and 24 completed the treatment, resulting in 16 children being born to 13 women. Recommendations for non-commercial surrogacy are given, including abandoning the 1-year waiting period before adoption, currently dictated by law, avoiding a period of unnecessary psychological distress. CONCLUSIONS: Our study has shown that non-commercial IVF surrogacy is feasible, with good results in terms of pregnancy outcome and psychological outcome for all parents, and with no legal problems relating to the adoption procedures arising. The extensive screening of medical, psychological and legal aspects was a key element in helping to ensure the safety and success of the procedure.

Functional outcome after sacrospinous hysteropexy for uterine descensus.

The study aimed to evaluate urogenital symptoms, defecatory symptoms and quality of life before and after a sacrospinous hysteropexy for uterovaginal prolapse. Seventy-two women with symptomatic uterovaginal prolapse were treated with sacrospinous hysteropexy. Before and after surgery, urogenital and defecatory symptoms and quality of life were assessed with a validated questionnaire. Anatomical outcome was assessed by means of pelvic examination before and after surgery. The mean follow-up time was 12.7 months. Scores on all domains of urogenital symptoms and defecatory symptoms, except for the pain and fecal incontinence domain, improved significantly. Also, quality of life improved on all domains. No major complications were encountered.

Microscopic diagnosis of vulvovaginal candidiasis in stained vaginal smears by Dutch general practitioners.

OBJECTIVE: To determine the accuracy of the microscopic diagnosis of vulvovaginal candidiasis (presence of [pseudo] hyphae and blastospores) in stained vaginal smears in clinical practice. STUDY DESIGN: General practitioners trained in diagnosing vulvovaginal candidiasis performed microscopy of 324 stained vaginal smears. These smears were sent to the pathologist for confirmation of the microscopic diagnosis of the clinician; cytologic diagnosis by the pathologist was considered the gold standard. RESULTS: In 104 of the 342 cases Candida was established by the pathologist. The clinicians made 24 false positive and 50 false negative diagnoses of Candida. Sensitivity and specificity of the microscopic diagnoses of the clinicians were 52% and 89%, respectively. The most frequent reason for a false positive diagnosis was presence of hairs, whereas the most frequent reason for a false negative diagnosis was understaining of the smear. CONCLUSION: This study shows that even in stained smears it is difficult for clinicians to recognize blastospores and (pseudo)hyphae. Efforts are clearly needed to improve the quality of the clinical diagnosis of vulvovaginal candidiasis.

The outcomes of ovarian cancer treatment are better when provided by gynecologic oncologists and in specialized hospitals: a systematic review.

OBJECTIVE: There is much debate on the effect of specialized care for ovarian cancer patients. In this review we present an overview and summary of the recent literature on this subject. METHODS: The Pubmed database was searched for studies on the relationship between care setting (type of gynecologist or hospital) and care outcomes which were published between January 1991 and November 2006. Studies were included if they were of sufficient quality and included patients treated from 1990 onwards. RESULTS: Nineteen articles were retrieved. There were no randomized controlled trials on this subject. Staging and debulking were consistently found to be performed more adequately by gynecologic oncologists (pooled relative risk of optimal debulking by a gynecologic oncologist to <2 cm residual disease 1.4 (95%CI 1.2-1.5) and to no macroscopic disease 2.3 (95%CI 1.5-3.5)) and in specialized hospitals (odds ratios for optimal debulking varied between 1.9 and 6.0). There were no differences in postoperative complication rates between different providers. Chemotherapy was given 1-15% more often in specialized settings. Differences in chemotherapy did not lead to differences in survival of patients treated by gynecologic oncologists, but did influence the effect of hospital on survival. Long-term survival was better after treatment in a specialized hospital. Surgery by a gynecologic oncologist resulted in longer survival in subgroups of patients, leading to a 5- to 8-month median survival benefit for patients with advanced stage disease. CONCLUSIONS: The outcome of ovarian cancer is better when treatment is provided by a gynecologic oncologist or in a specialized hospital.

The effectiveness of the sacrospinous hysteropexy for the primary treatment of uterovaginal prolapse.

The objective of this study was to assess the effectiveness of sacrospinous ligament fixation of the uterus as a primary treatment of uterovaginal prolapse. In this observational study, 133 women underwent a sacrospinous hysteropexy. Data were obtained from their medical records, and standardized questionnaires about urogenital symptoms and quality of life were used. All women were invited for gynecological examination, using the Pelvic Organ Prolapse Quantification score. Ninety-nine women responded by returning the questionnaire (mean age, 59.2 and follow-up time, 22.5 months); 60 of these women underwent gynecologic examination. Eighty-four percent of women were highly satisfied about the outcome of the procedure. Serious complications were rare. The recurrence rate of descensus uteri that needed surgical treatment was 2.3%. The recurrence of cystoceles after surgery was 35%, but there were no differences in urogenital symptoms between women with or without a cystocele.

Effects of genital prolapse surgery on sexuality.

OBJECTIVE: A prospective study was performed to evaluate the effects of genital prolapse surgery on sexuality. Additionally we investigated which variables are risk factors for persistence or development of sexual problems after surgery. METHODS: All 82 patients participating in a randomized trial comparing vaginal and abdominal surgical correction of descensus uteri, were asked to complete the Questionnaire for screening Sexual Dysfunctions (QSD) before and at six months and one year after surgery. RESULTS: Sixty-two patients completed the questionnaire. General satisfaction about sexuality was significantly improved after surgery. Of 41 patients who were sexually active both before surgery and at one year after surgery, 28 (68.3%) patients reported sexual problems before surgery. In 13 (46.4%) of these patients, all sexual problems disappeared. Of the 13 patients without sexual problems before surgery, two patients reported de novo sexual problems. The relative risk on disappearance of sexual problems in patients with large cystocele was 1.5 (95% confidence interval 1.1-2.1) times higher than the risk in patients without large cystocele. CONCLUSION: Satisfaction about sexuality increases and the prevalence of sexual problems decreases in patients undergoing surgical correction of descensus uteri.

The pre-operative assessment of the adnexal mass: the accuracy of clinical estimates versus clinical prediction rules.

OBJECTIVE: To evaluate the reproducibility of the clinical judgement of gynaecologists, gynaecologists in training and gynaecologic oncologists and to compare the predictive performance of the offhand assessment with the predictive performance of existing mathematical models for the pre-operative assessment of the adnexal mass. DESIGN: Questionnaire with paper cases of women operated on for an adnexal mass. SETTING: Gynaecological unit in a teaching hospital in the South of The Netherlands. POPULATION: Women who underwent surgery for adnexal mass between January 1991 and December 1998. METHODS: We offered 45 gynaecologists five different sets of 34 cases, with data on female age and menopausal status, a written description of the sonography, Doppler flow measurement and serum CA125 measurement. Nine observers for every set were asked to estimate the probability of malignancy. MAIN OUTCOME MEASURES: The reproducibility of the risk estimates as made by the participants was expressed with an intraclass correlation coefficients. The accuracy of the judgement of the clinicians and the result of mathematical models in the prediction of malignancy were expressed with sensitivity, specificity, and receiver-operating characteristic curves. RESULTS: Neither clinically relevant nor statistically significant differences could be found between the accuracy of the risk assessments made by the clinicians and the accuracy of the risk assessments made by prediction models. CONCLUSION: This study demonstrates that at this moment there is no need to introduce complicated predictive scoring systems such as neural networks or logistic regression models for the pre-operative assessment of the adnexal masses.