Paravaginal defect: A new classification of fascial and muscle tears in the paravaginal region.

The lateral support of the vaginal wall depends on the integrity of the paravaginal section of the visceral pelvic fascia, levator ani, and their connection. Various defects of the muscle and fascia can result in identical clinical findings-ie, the descent of the lateral vaginal sulcus. In this study, we created a realistic scheme for classifying paravaginal defects, based on the complex relationship of the pelvic fascia with the levator ani. Surgical observations, cadaver examinations, and a complex magnetic resonance imaging (MRI)-based 3-dimensional (3D) model were used to analyze the spatial relationships of normal and defective anatomy of the female pelvic floor. Descent of the lateral vaginal sulcus can result from a defect in the paravaginal visceral pelvic fascia, levator ani, or both. The fascial defect can be partial or complete, and the muscle defect can vary in location. A detailed illustrated classification is presented. We present a new model of the pathology that underlies a common clinical finding.

TVT and TVT-O for surgical treatment of primary stress urinary incontinence: prospective randomized trial.

INTRODUCTION AND HYPOTHESIS: A study was conducted to compare the efficacy and complications of TVT and TVT-O. METHODS: This study is a prospective randomized trial involving 300 women with primary SUI; 149 received TVT, and 151 patients were treated with TVT-O. At the 1 year follow-up, 141 TVT patients and 147 TVT-O patients (dropout, 5.3% and 2.6%) were evaluated using urodynamic studies, validated questionnaires, and a 1-h pad test. RESULTS: The mean operating time was shorter in the TVT-O group (p < 0.001). Urinary retention was not significantly different (p > 0.05). Inner thigh discomfort was reported by 5.4% of TVT-O patients. In the TVT and the TVT-O groups, respectively, 90.1% and 88.4% women were objectively cured. The satisfaction with the surgical outcome reflects the significant decrease in the questionnaire mean symptom scores in both groups. Postoperative de novo urgency was significantly more common in the TVT-O patients (p = 0.015). CONCLUSION: The groups showed comparable objective and subjective cure rates.

TVT-S for surgical treatment of stress urinary incontinence: prospective trial, 1-year follow-up.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to evaluate the effectiveness of and morbidity associated with the tension-free vaginal tape-secur (TVT-S) procedure in women with stress urinary incontinence (SUI). METHODS: We performed a prospective trial, examining 86 women with primary SUI. Eighty-two patients had a 1-year follow-up (dropout rate = 4.6%). The preoperative evaluation included urinalysis, urodynamic studies, and validated questionnaires. The 1-year outcome evaluation also included a 1-h pad testing. RESULTS: At the 1-year follow-up, 43 (52.4%) women were objectively cured, and 14 (17.1%) women were objectively improved. Subjectively, 49 (59.7%) patients did not experience urine loss, and 18 (22.2%) women improved in this respect. Postoperative de novo urge incontinence symptoms developed in 24.4% (n = 20) of patients. Vaginal defect healing occurred in 6.1% (n = 5) of patients, and one (1.2%) case of urethral erosion was reported. CONCLUSION: Objective and subjective cure rates following TVT-S are inferior to other tape procedures.

Women with incorrect pelvic floor statics: a biomechanical answer to the mechanical loading of the vagina-endopelvic fascia complex.

OBJECTIVE: This work focuses on finding method for detecting the elementary mechanical characteristics of the vagina-endopelvic fascia complex, aimed at providing results for use in optimizing solutions for stability defects of the pelvic floor. MATERIALS AND METHODS: Two experiments have already been carried out that have enabled monitoring of the reaction of tissue complex samples to a selected load. The elastic properties of samples under a simple pull load were evaluated. The monitored property in the first experiment was the maximum reference tension at the moment of rupture of the sample in relation to the non-deformed section. We evaluated data from measurements on 11 samples within the scope of the first experiment. For data processing from the second experiment we used a linear-elastic model of the sample, formed by parallel connection of basic mechanical elements - springs - that represented the endopelvic fascia and the vaginal wall. The relevant rigidities were used for a description of their properties. Five samples were used for this experiment. RESULTS: An important discovery was that the endopelvic fascia tears apart after a longer period of time than the vaginal wall during the pull test. The results show considerable variability among individuals, but the pattern of curves is similar in all test cases. In all measured data we found a rigidity increase zone, a maximum rigidity zone and a gradual rigidity decrease zone before terminal damage in the response. CONCLUSIONS: The results presented here show quite broad interindividual variability of the mechanical properties of the vaginal wall-endopelvic fascia complex. It appears that the mechanical properties of the tissue complex change with number of pregnancies, and are affected by diseases, by physical load or by the presence of other factors, e.g. obesity.

Endopelvic fascia in women: shape and relation to parietal pelvic structures.

OBJECTIVE: The endopelvic fascia is a confluent suspensory apparatus of the female pelvic organs. The aim of the study was to construct a three-dimensional model of the endopelvic fascia, defining its shape and its connections to the surrounding parietal structures. METHODS: We created a three-dimensional multiple-source computer model to simultaneously visualize and analyze all the structures within the female pelvic floor. This model integrates data from magnetic resonance imaging of 15 nulliparas under age 30 with no symptoms of pelvic floor dysfunction. The model also includes data from direct observation in the dissection laboratory and in surgical rooms, together with the relevant scientific literature. RESULTS: The endopelvic fascia has the shape of a semifrontally oriented septum, which surrounds the vagina and part of the uterine cervix and divides the pelvic floor into the anterior and posterior compartments. This confluent septum has specific connections to the pubic bone, anterior perineal membrane, perineal body, and superior fascia of the levator ani muscle. Additionally, the uterosacral part of the septum has three subdivisions- the "vascular part," the "neural part," and the true uterosacral ligament. Each of these subdivisions has a different physical link to the parietal structures. Three-dimensional illustrations and schemes were created to facilitate the understanding of the anatomy of these complex structures. CONCLUSION: Connecting descriptions of the geometry of the organs visible by magnetic resonance imaging with descriptions of their individual connections to the endopelvic fascia gave us unique information about the three-dimensional representation of the anatomy of the female lesser pelvis. The endopelvic fascia divides the lesser pelvis in a manner that is similar to the way the urorectal septum divides the embryonic cloaca.

Comparison of labor course and women's sexuality in planned and unplanned pregnancy.

OBJECTIVE: This study compares several parameters of sexual life and course of labor in women with planned and unplanned pregnancy. METHODS: 339 primiparas participated in our study; they filled in a questionnaire concerning their sexual life during pregnancy on the second or third day after the delivery. One question also stressed planning of pregnancy. 246 women (i.e., 72.6%) indicated planned pregnancy, 93 pregnancies (i.e., 27.4%) were not planned. RESULTS: Significant decrease of coital activity and number of orgasms and increase of sexual dysfunctions were observed in the whole study group during pregnancy. Significant differences between women with planned and unplanned pregnancy were observed only in frequency of vaginal dryness and pelvic pain. CONCLUSIONS: According to the results of this study, unplanned pregnancy has no adverse effect on parameters of the labor. The equal rate of partner's presence at delivery shows a high involvement of the partners of unmarried women.

New approach to the urogynecological ultrasound examination.

OBJECTIVE: To evaluate a new system for the ultrasound evaluation of urethral mobility. STUDY DESIGN: We studied the structure of interpubic disc and found landmarks that can be used to align different images and set up an universal system of coordinates. The method for capturing and post-processing of the introital ultrasound examination is described. The urethra in its entire course is evaluated. Ten patients were examined and some important points at the interpubic disc and the urethra were traced to assess the reproducibility of the method. RESULTS: The mean intra-observer difference for x and y coordinates were 1.88 mm (S.D. 1.53) and 2.00 mm (S.D. 1.54), respectively. The inter-observer difference was 2.30 mm (S.D. 1.64) and 2.50 mm (S.D. 1.79), respectively for x and y coordinates. CONCLUSION: The method shows good inter- and intra-observer correlation and presents data that can be further used for biomechanical analysis.

Pudendal nerve in pelvic bone fractures.

INTRODUCTION: Pelvic ring injuries rank among the most serious skeletal injuries. According to published data, pelvic fractures constitute 3-8% of all fractures. There has been a threefold increase in the number of these fractures over the last 10 years. A significant factor determining the choice of the therapeutic procedure, timing and sequence of individual steps, and also the prognosis of the patient with a fractured pelvis, are associated injuries defined as injuries to the organs and anatomical structures found in the pelvic region. Published data describes the incidence of injury to neurogenic structures as ranging between 9 and 21%, to the urogenital tract between 5 and 11%, to the gastrointestinal tract in 3-17% and to the gynecologic organs up to 1%. The pathway of the pudendal nerve may be affected in types B and C fractures where the root fibers emerge from the foramina sacralia and plexus sacralis is formed, on the one hand, and in types A, B and C fractures during the nerve's course alongside the inferior pubic ramus. MATERIALS AND METHODS: In order to determine the frequency of potential injury to the pudendal nerve, a set of 225 pelvic fractures treated between 2007 and 2009 was assessed; 38 fixed hemipelves were also used to study the length of the course of the pudendal nerve alongside the inferior pubic ramus, on the one hand, and the distances from the symphysis pubica at the crossing of the branches of the n. pudendus-n. dorsalis penis and the branches for the muscles of the diaphragma urogenitale on the other hand. CONCLUSION: The work elucidated the selected distances and discuss their possible clinical relevance for evaluation of the seriousness of pelvic fractures from the perspective of late sequelae in the region innervated by the pudendal nerve.

Breast cancer characteristics-comparison of preoperative and postoperative values.

Breast cancer characteristics obtained at the time of diagnosis are important for setting the basic strategy of the treatment. Reliability of preoperative investigation differs for various features of the disease. The aim of this study was to ascertain the agreements and differences between preoperative and postoperative values. This retrospective study analyzed the results of 617 women with primary surgery of the breast and axilla. Cohen's kappa coefficient has been employed to measure the degree of agreement between preoperative and postoperative values. Substantial or "almost perfect" agreement has been documented for the histological type of the tumors, their histopathological grade, proliferation index Ki67, as well as for estrogen, progesterone, and HER-2/neu receptors. Substantial differences exist between preoperative and postoperative diagnoses of invasiveness of the tumor, determination of the size of the tumors, and the number of tumor foci. Preoperative imaging and clinical examination of lymph nodes exhibited unacceptably high false negative rates. Heterogeneity of breast cancer cell population, methodology of histology examinations, and insufficient imaging of lymph nodes are the major limitations precluding satisfactory accuracy of preoperative diagnosis. Preoperatively diagnosed in situ carcinomas, as well as multifocal lesions, were the most often sources of diagnostic failures.

A prospective randomized comparison of vaginal hysterectomy, laparoscopically assisted vaginal hysterectomy, and total laparoscopic hysterectomy in women with benign uterine disease.

OBJECTIVES: To compare the clinical results of three minimally invasive hysterectomy techniques: vaginal hysterectomy (VH), laparoscopically assisted vaginal hysterectomy (LAVH), and total laparoscopic hysterectomy (TLH). STUDY DESIGN: A prospective, randomized study was performed at a tertiary care center between March 2004 and October 2005. A total of 125 women indicated to undergo hysterectomy for benign uterine disease were randomly assigned to three different groups (40 VH, 44 LAVH, and 41 TLH). Outcome measures, including operating time, blood loss, rate of complications, inflammatory response, febrile morbidity, consumption of analgesics, and length of hospital stay, were assessed and compared between groups. RESULTS: Vaginal hysterectomy had the shortest operating time (66 min) and smallest drop in hemoglobin. However, there were technical problems with salpingo-oophorectomy from the vaginal approach (3/20 cases) and this group had a significantly higher rate of febrile complications (20%) compared to LAVH (2.3%) and TLH (7.3%). The increase in inflammatory markers was higher in vaginal hysterectomy patients. Laparoscopically assisted vaginal hysterectomy had an acceptable operating time (85 min), a low complication rate, lack of severe post-operative complications, and the lowest consumption of analgesics. However, it had the highest blood loss. Total laparoscopic hysterectomy had the longest operating time (111 min) and severe complications occurred only in this group. Conversions to another hysterectomy method occurred in all three groups, most of these conversions were to LAVH. CONCLUSIONS: Based on our results, in women with non-malignant disease of the uterus, LAVH and VH seem to be the preferred hysterectomy techniques for general gynecological surgeons. Vaginal hysterectomy had the shortest operating time and least drop in hemoglobin, making it a suitable method for women for whom the shortest duration of surgery and anesthesia is optimal. LAVH is a versatile procedure, combining the advantages of both the vaginal and laparoscopic approach, and is preferable in cases when oophorectomy is required. Total laparoscopic hysterectomy did not appear to offer any significant benefits over the other two methods and should be strictly indicated in women where neither VH nor LAVH are feasible and should only be performed by very experienced laparoscopists.

Pubococcygeus-puborectalis trauma after forceps delivery: evaluation of the levator ani muscle with 3D/4D ultrasound.

INTRODUCTION AND HYPOTHESIS: This study seeks to assess the effects of forceps-assisted delivery on the levator hiatus. METHODS: Seventy-six women were investigated 12 months after forceps-assisted delivery. Introital three-/four-dimensional ultrasound measured volumes at rest and during the Valsalva maneuver. Morphological parameters analyzed were angle gamma, hiatal area, pubovisceral angle, and continuity between the muscle and pelvic sidewall. Avulsion was diagnosed by loss of continuity. RESULTS: Forty-eight women had avulsion injuries, 23 had bilateral, and 25 had unilateral. Bilateral avulsion increased hiatal area during straining and at rest and was associated with changes in bladder neck position at rest. Unilateral avulsion injury was associated with a higher pubovisceral angle on the side of the avulsion. CONCLUSION: Forceps-assisted vaginal delivery is associated with levator ani injury. Avulsion of the pubovisceral muscle seems more common after forceps delivery than after spontaneous vaginal delivery. Avulsion alters hiatal shape and area and influences the position and mobility of the anterior compartment.