Transvaginal repair of a urethrovaginal fistula using the Latzko technique with a bulbocavernosus (Martius) flap.

INTRODUCTION AND HYPOTHESIS: Urethrovaginal fistula is a rare disorder that may occur following sling procedures for stress urinary incontinence, excision of a urethral diverticulum, anterior vaginal wall repair, radiation therapy, and prolonged indwelling urethral catheter. The most common clinical manifestation is continuous urinary leakage through the vagina, aggravated by an increase in the intra-abdominal pressure. Appropriate management, including timing of the surgical intervention and the preferred technique, remains controversial. METHODS: This video presentation describes the transvaginal repair of a urethrovaginal fistula using the Latzko technique and a bulbocavernosus (Martius) flap. RESULTS: The patient's postoperative course was uneventful. At her follow-up visit 2 months later, she was free of urinary leakage, and a pelvic examination revealed excellent healing, with complete closure of the fistula. CONCLUSIONS: Transvaginal repair using the Latzko technique with a vascular bulbocavernosus (Martius) flap is an effective and safe mode of treatment.

[Urogynecology: from past to future].

Over the last decade, the field of urogynecologic surgery has been subject to deep changes. A thorough understanding of the injury mechanisms responsible for pelvic organ prolapse (POP) and urinary incontinence in women, greatly contributed to the development of innovative surgical techniques and changing therapeutic approaches. The variety of treatment options to correct POP and incontinence has greatly expanded, partly thanks to the development of several advanced surgical kits by biotechnology companies. This review describes the evolution of surgical techniques in the field of pelvic floor reconstruction during the last century and raises questions regarding the safety and efficacy of the various techniques available in this field. This paper summarizes the "state of the art" for POP and the incontinence surgery approach in Western countries. It also provides a number of general recommendations based on the authors personal experience [expert opinion]. Such recommendations with slight variations appear in position statements of professional societies worldwide.

Sexual function and quality of life of women with stress urinary incontinence: a randomized controlled trial comparing the Paula method (circular muscle exercises) to pelvic floor muscle training (PFMT) exercises.

AIM: To compare the effectiveness of the Paula method (circular muscle exercises) vs. pelvic floor muscle training (PFMT) exercises on sexual function (SF) and quality of life (QoL) of women with stress urinary incontinence (SUI). METHODS: A randomized controlled trial (RCT) was conducted in outpatient urban community clinics serving diverse socioeconomic populations between September 2004 and July 2005. The intervention included two exercise regimens: Paula method--12 weeks of private 45 minutes sessions; PFMT--12 weeks of group (up to 10 participants) sessions of 30 minutes in length once a week, for 4 weeks plus two additional sessions, 3 weeks apart. MAIN OUTCOME MEASURES: The Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire; the Incontinence Quality of Life Questionnaire; 1-hour clinic pad test; gynecological examination; demographic/health history. RESULTS: Sixty-six women in the Paula group and 60 women in the PFMT group. The mean SF scores post interventions were 38.72 (5.35) in the Paula group and 38.07 (5.80) in the PFMT group. SF score improvement was found to be significant in both groups (Paula, P = 0.01; PFMT, P = 0.05), as was in the QoL scores (Paula, P < 0.001; PFMT, P ≤ 0.001), with no significant difference between groups. There was a significant correlation between the mean SF score and the mean QoL score after the intervention (Paula: r = 0.4, P = 0.002; PFMT: r = 0.4, P = 0.009). A mild to moderate significant correlation was also found between the SF score and pad test results in both groups post intervention (r = -0.3, P = 0.02; r = -0.3, P = 0.04, respectively). CONCLUSION: This RCT study demonstrated the effectiveness of two exercise methods on SF and QoL in women suffering from SUI. The Paula method of exercise was presented for the first time in the literature as a conservative noninvasive treatment for SUI and SF.

Can pelvic floor injury secondary to delivery be prevented?

The number of women suffering from pelvic floor disorders (PFD) is likely to grow significantly in the coming years with a growing older population. There is an urgent need to investigate factors contributing to the development of PFD and develop preventative strategies. We have reviewed the literature and analyzed results from our own study regarding the association between delivery mode, obstetrical practice and fetal measurements, and damage to the pelvic floor. Based on our findings, we have suggested a flowchart helping the obstetrician to conduct vaginal delivery with minimal pelvic floor insult. Primiparity, instrumental delivery, large fetal head circumference, and prolonged second stage of delivery are risk factors for PFD. Pelvic floor integrity should always be seriously considered in every primiparous woman. All efforts should be aimed at minimizing any insult, which might have a significant impact on the woman's pelvic integrity and future quality of life.

Women's well-being after Manchester procedure for pelvic reconstruction with uterine preservation: a follow-up study.

PURPOSE: This study describes the outcomes of a modified Manchester procedure on the quality of life and sexual functioning of women with elongation of the uterine cervix with or without pelvic organ prolapse (POP). METHODS: Data on medical and demographic variables were collected from medical files and then women were invited to for follow-up examination and data collection. RESULTS: Follow-up data were collected from 53 out of 87 women who underwent reconstructive surgery with modified Manchester procedure (60.9% of the women). Prior the surgery, all women in this sample (n = 53) were medically examined and found to have uterine cervix elongation, 40/53 (75.4%) women also had cystocele, 10/53 women (18.8%) had uterine prolapse and 8/53 women (15.1%) had rectocele (all stages II-IV). On follow-up examination, all the cervical stumps were satisfactorily situated, recurrent cystocele was found among 12/53 women (22.6%) women; 13/53 (24.5%) had rectocele; and none of these women had uterine prolapse. Women with POP (cystocele and rectocele) (24/53) had less operative satisfaction (p = 0.004), lower quality of life (p < 0.05 in 3 out of 8 domains), and poorer sexual function (p = 0.03) compared to women without POP (29/53). CONCLUSION: The modified Manchester procedure including reconstructive surgery for women with cervix elongation, with or without POP, prevented recurrent uterine prolapse and was well received in terms of patient's satisfaction, quality of life, and sexual function.

Thromboembolic events in pregnant and puerperal women after COVID-19 lockdowns: A retrospective cohort study.

OBJECTIVE: To explore the indirect impact of the COVID-19 pandemic on patterns of pregnancy-related venous thromboembolism (VTE) events, mediated by population mobility restrictions during lockdown periods. METHODS: Pregnancy-related VTE hospitalizations were identified through a code-targeted search of the Hadassah Medical Center's computerized database. A manual analysis of relevant medical records was performed, and cases diagnosed throughout the year 2020 were compared to those diagnosed during 2019 and 2018. Statistical analyses studied obstetrical outcomes, as well as the extent and treatment of VTE events during the COVID-19 pandemic compared to those of preceding years, stratified by pre-, intra-, and post-lockdown periods. RESULTS: The incidence of pregnancy-related thromboembolic events during 2020 was 0.16% of all deliveries, significantly higher than in 2018 and 2019 (0.06% and 0.1%, respectively; P < 0.05). Higher rates of VTE events were found during post-lockdown periods in 2020, compared with corresponding time periods in 2019 and 2018. CONCLUSION: The present data suggest that lockdown periods impact pregnancy-related VTE hospitalizations, possibly as a result of restricted population mobility. Increased awareness of this undesirable outcome may aid health policymakers in the continuing struggle with epidemics.

Polymorphism in a gene coding for the inflammasome component NALP3 and recurrent vulvovaginal candidiasis in women with vulvar vestibulitis syndrome.

OBJECTIVE: Patients with vulvar vestibulitis syndrome (VVS) and control subjects were tested for a polymorphism in the gene coding for the NALP3 component of inflammasomes, cytoplasmic structures regulating interleukin (IL)-1beta production. STUDY DESIGN: DNA from 143 women with VVS and 182 control women were tested for a length polymorphism in intron 4 of the gene (CIAS1) that codes for NALP3. Vestibular tissue was examined for NALP3 expression. Whole blood cultures were tested for Candida albicans-induced IL-1beta production. RESULTS: The allele 12 frequency was higher in control subjects than in the patients with VVS (P = .02). Among patients with VVS and a self-reported history of recurrent vulvovaginal candidiasis (RVVC), the allele 7 frequency was 43.9% as compared with 30.8% in patients with no history of RVVC and 26.9% in control women (P = .035 vs other patients and .001 vs control subjects). NALP3 was identified in vestibular tissue. C albicans-induced IL-1beta production was reduced in samples from women with the 7,7 genotype (P = .030). CONCLUSION: Polymorphism in the CIAS1 gene may play a central role in the triggering of VVS in a subset of patients.

Fetal head circumference and length of second stage of labor are risk factors for levator ani muscle injury, diagnosed by 3-dimensional transperineal ultrasound in primiparous women.

OBJECTIVE: We evaluated rate of levator ani muscle (LAM) avulsion among primiparae using 3-dimensional transperineal ultrasound to identify possible risk factors for such trauma. STUDY DESIGN: We conducted a prospective observational study. Three-dimensional transperineal ultrasound was performed on all subjects. Primiparae were evaluated 24-72 hours after vaginal delivery. In all, 32 nulliparous gravidae (35-41 weeks) and 15 elective cesarean delivery primiparae were evaluated as methodological controls. We compared newborn head circumference (HC), birthweight, second stage duration, maternal age, baby sex, episiotomy, and instrumental delivery. RESULTS: LAM trauma was observed in 39 of 210 (18.8%) patients and no controls. Odds ratio for LAM trauma when newborn HC >or= 35.5 cm was 3.343 (95% confidence interval, 1.33-8.42); when second stage duration >or= 110 minutes, odds ratio was 2.27 (95% confidence interval, 1.07-4.81). Logistic regression showed that HC >or= 35.5 and second stage duration >or= 110 minutes increased odds of LAM trauma by a factor of 5.32. CONCLUSION: Large HC and prolonged second stage duration are risk factors in LAM trauma. Elective cesarean delivery may prevent LAM trauma.

[Different interventions during birth and delivery and their connection to pelvic floor damage].

Pelvic floor may be affected by birth and delivery since these are risk factors for muscles, connective tissue and nerve damage. Women with pelvic floor injuries may suffer in the long term from pelvic floor organs prolapse as well as from functional impairment such as urinary and fecal incontinence or other disturbances such as pain and sexual dysfunction. Several interventions have been conducted through birth and delivery by the midwifery team, in order to alleviate discomfort from the mother and to promote mother and infant wellness. Interventions pertaining to the mother's posture, mode of pushing or warm compresses can have an immediate affect and create complications at a later stage. This review aims to examine these interventions and possible pelvic floor damage, based on clinical trials. The authors assume that relying on evidence based practice during labour may promote women's health in both the short and long term.

Urinary incontinence type, symptoms, and quality of life: A comparison between grand multipara and non-grand multipara women aged ≥50 years.

AIM: Parity and age are risk factors for urinary incontinence (UI). The aim of this study was to compare grand multipara women (GMP) to non-grand multipara (NGMP) women concerning UI types (stress urinary incontinence [SUI], urge urinary incontinence [UUI]), symptoms, and quality of life. METHODS: This correlation-comparative study used three tools: a demographic/health questionnaire, Questionnaire for Urinary Incontinence Diagnosis (QUID), and Incontinence Quality of Life (I-QOL). RESULTS: The sample included 132 women, from 50-88 years of age: 65 NGMP women (mean age: 67.23 years) and 67 GMP women (mean age: 65.04 years). The GMP group had a higher score, compared to the NGMP group, for UI type (by QUID) and a lower QOL (by I-QOL) , with none of the scores found to be statistically significant. By dividing the sample into age groups, 50-59 and ≥60 years, the interaction between the parity and the age groups was found to be significant for both the SUI and UUI. CONCLUSION: The innovation of this study is the in-depth insight into the association between parity and age regarding UI type.

Pivotal role of CEACAM1 protein in the inhibition of activated decidual lymphocyte functions.

Lymphocytes in direct contact with embryonic extravillous trophoblasts constitute more than 40% of decidual cells and appear to play major roles in implantation and early gestation. A unique subset of NK cells, making up 70-80% of decidual lymphocytes, express high levels of CD56 but lack CD16. We have recently demonstrated a novel class I MHC-independent inhibitory mechanism of NK cell cytotoxicity that is mediated by CEACAM1 homotypic interactions. This mechanism is used by some melanoma cells to avoid attack, mainly by CD16(-) NK cells. We now demonstrate that CEACAM1 is expressed on primary extravillous trophoblasts and is upregulated on the vast majority of IL-2-activated decidual lymphocytes, including NK, T, and NKT cells. Importantly, we present evidence that CEACAM1 interactions inhibit the lysis, proliferation, and cytokine secretion of activated decidual NK, T, and NKT cells, respectively. In vivo analysis of decidual lymphocytes isolated from cytomegalovirus-infected (CMV-infected) pregnant women revealed a dramatic increase in the expression of CEACAM1. Finally, we suggest that a novel ligand for this adhesion molecule is present on the surface of CMV-infected fibroblasts. These combined results demonstrate a major role for the CEACAM1 protein in controlling local decidual immune responses.

[Posterior intra-vaginal sling (PIVS) for vaginal vault prolapse after hysterectomy: preliminary results of the first 80 operations with a novel procedure].

BACKGROUND: One of the most significant challenges in surgical gynecology during the last decade was the treatment of vaginal vault prolapse after hysterectomy. Difficult extensive procedures have been advocated for this purpose. The posterior intra-vaginal slingplasty (PIVS) has recently been introduced. This procedure is based on the integral theory of pelvic floor stability and the use of mesh implants to achieve more reliable tissue stability than attaching the prolapsed tissue to the pelvic bones and ligaments. AIM: To evaluate the therapeutic outcome, safety and complications of the PIVS procedure. METHODS: A total of 80 post hysterectomy patients with vagina vault prolapse underwent PIVS operation within one year. RESULTS: All patients but one expressed satisfaction with the 12 months therapeutic results. The PIVS procedure does not require either laparotomy or deep trans-vaginal dissection. CONCLUSIONS: The PIVS was shown to be safe, effective and minimally invasive, and is therefore recommended as another treatment option for women with post hysterectomy vaginal vault prolapse.

Vaginal vault prolapse: choice of operation.

The surgeon who faces a patient with vaginal vault prolapse is dealing with a complex and intriguing challenge. Part of the complexity is due to the lack of standardization and routine application of tools to assess pre- and postoperative anatomical and functional outcomes. Patient satisfaction is a major endpoint for surgical success; thus all aspects of the prolapse pathology and the patient's lifestyle should be considered. The surgeon needs to be well versed and flexible in order to choose the most appropriate operative approach to achieve optimal results for an individual patient. In this chapter we present the vaginal and abdominal approaches for the correction of vaginal vault prolapse, with discussion of the surgical outcomes and complications for each technique. A comprehensive comparison of the various techniques is offered on the basis of current published literature. In addition, we focus on various controversies, including the prevention of vault prolapse at the time of hysterectomy, issues regarding uterine preservation, the management of overt or occult concomitant stress incontinence, and the place-if any-for combined anti-incontinence procedures at the time of prolapse surgery. New minimally invasive techniques for vault prolapse are also reviewed. We emphasize areas that call for further research and for standardized outcome criteria.

Modified vulvar vestibulectomy: simple and effective surgery for the treatment of vulvar vestibulitis.

OBJECTIVE: To evaluate the success of a simple modified vestibulectomy in treating vulvar vestibulitis. STUDY DESIGN: Fifty-nine patients with vulvar vestibulitis refractory to nonsurgical treatment underwent modified vestibulectomy. Response was defined as return to normal coitus and was graded as complete, partial or non-responsive. RESULTS: The postoperative follow-up period was 6 months-10 years. Thirty-nine (73.6%) patients reported complete response, 7 (13.2%) had partial response, and 7 (13.2%) were non-responsive to surgery. CONCLUSION: Surgery is an effective treatment for vulvar vestibulitis refractory to conservative treatment. Simple modified vestibulectomy is considerably less invasive, technically simpler and probably less time consuming. Postoperative results employing this surgical procedure are found to be in line with postoperative results reported by others who employ surgical methods that are more extensive.

[TVT-Obturator: preliminary results of the first 100 operations with a novel procedure for the treatment of female urinary stress incontinence].

BACKGROUND: Facing the fact that 20% of the parturient women suffer urinary stress incontinence, urogynecologists are constantly searching for simple, safe and effective ways to cure the underlying pelvic floor herniation. A novel surgical technique was reported lately to entail both high therapeutic rates and low complication rates. AIM: To evaluate preliminary data from the first 100 TVT-Obturator patient series. METHODS: A total of 100 patients with urodynamically proven USI underwent the TVT-Obturator operations. RESULTS: The TVT-Obturator procedure did not require bladder catheterization or intra-operative diagnostic cystoscopy. Operative complications were not recorded. Ninety-three patients reported cure, six patients had minimal residual urinary leak and one patient reported therapeutic failure. CONCLUSIONS: The TVT-Obturator is a novel mid urethral sling, designed to cure female urinary stress incoritinence and reduce peri-operative complications. These results agree with the previously reported efficacy, safety and simplicity of this procedure. However, long-term data is required prior to incorporating this operative technique within the armamentarium of anti-incontinence procedures.

Degree of bother from pelvic floor dysfunction in women one year after first delivery.

OBJECTIVE: To investigate rates and range of pelvic floor dysfunction complaints, including anterior and posterior compartments and sexual function, in an unselected population of primiparous women one year from delivery, and examine the degree of bother they cause. STUDY DESIGN: Cross sectional study. Primiparous women who delivered their first child in our delivery wards 10-14 months previously, were approached by phone and asked to complete the Pelvic Floor Symptom Bother Questionnaire (PFBQ) and provide general demographic information. Details regarding participants' labor and delivery were extracted from electronic medical records. PFBQ score was correlated to demographic and labor and delivery parameters. RESULTS: 198 women completed the questionnaire. Response rate was 94%. Scores ranged from 0 to 44.4 (out of a possible 100). At least one symptom of PFD was reported by 64% of respondents. Various degrees of urinary incontinence were reported by 9.1-12.1% of women. Some degree of fecal or flatus incontinence was reported by 10.1% of women; 11.1% reported some degree of obstructed defecation. Severe degree of bother from one or more PFD symptoms was reported by 40.1-90.9%. Some level of dyspareunia was reported by 37.3%. A "dose response" trend between mode of delivery and rate of dyspareunia was observed. CONCLUSIONS: Two-thirds of primiparous women one year after delivery suffer PFD symptoms that cause some degree of bother. When asked, women are willing to discuss pelvic floor function; caregivers should initiate discussion and refer women promptly to interventions where necessary.

Should laparoscopy be a mandatory component of the infertility evaluation in infertile women with normal hysterosalpingogram or suspected unilateral distal tubal pathology?

OBJECTIVE: To assess the diagnostic benefit of laparoscopy in infertile women with normal hysterosalpingography (HSG) or suspected unilateral pathology on HSG. STUDY DESIGN: Charts of infertile women that underwent complete infertility evaluation between 1996 and 1998 were retrospectively reviewed. Eighty-six patients in whom both HSG and laparoscopy were performed were included in the study. HSG results were compared with laparoscopic findings and the suggested treatment based on HSG results was compared with the treatment plan based on laparoscopic findings. RESULTS: Among 63 patients with a normal HSG or suspected unilateral tubal pathology, who were assigned to ovulation induction and intrauterine insemination (IUI), 60 patients were found to have laparoscopic findings that did not necessitate any change in the original treatment plan. In three patients (4.8%), abnormalities discovered at laparoscopy were of such an extent that a change in the original treatment regimen and referral to in vitro fertilization (IVF) was needed. Among 23 patients with suspected bilateral tubal occlusion on HSG, 16 patients (69.6%) were found to have an abnormal laparoscopy with bilateral tubal adhesions, 6 patients (26%) had unilateral tubal adhesions, and 1 patient (4.3%) had pelvic adhesions with no obstruction. These latter findings led to changes in the original treatment plan of these seven patients from IVF to ovulation induction and IUI. CONCLUSIONS: Laparoscopy may be omitted in women with normal HSG or suspected unilateral distal tubal pathology on HSG, since it was not shown to change the original treatment plan indicated by HSG in 95% of the patients. However, laparoscopy should be recommended in cases with suspected bilateral tubal occlusion on HSG, since it altered the original treatment plan in 30% of the patients from IVF to induction of ovulation with IUI. The reassuring results found in the present study may be related to the low prevalence of pelvic inflammatory diseases and endometriosis in our population.

[Review of risk factors for breast cancer--what's new?].

Breast cancer is the most common malignancy in women and constitutes 18% of all cancers in women. Female gender, age and country of birth are the strongest determinants of disease risk. Family history and mutations in tumor suppressor genes BRCA1 and BRCA2 are important correlates of lifetime risk. Genetic polymorphisms associated with estrogen synthesis and metabolism are viewed as major factors in breast cancer prevalence in specific populations. Atypical hyperplasia and ductal/lobular carcinoma in situ although uncommon, are considered as pre-malignant conditions as well as markers for invasive breast cancer. Lately, increased bone density and high breast tissue density on mammogram in postmenopausal women have been reported in association with increased risk of breast carcinoma, probably attributable to increased levels of endogenous estrogen. Serum estrogen levels are higher in breast cancer cases as compared with controls. Current use of oral contraceptives and prolonged, current or recent use of postmenopausal hormonal replacement therapy are also considered as risk factors for breast cancer. Tamoxifen and raloxifene, selective estrogen receptor modulators, were shown to reduce breast cancer risk among high-risk women. Various nutrients were evaluated for their possible effect on breast cancer risk but further studies are needed. High socioeconomic status is found to be associated with increased risk of breast malignancy for as yet unestablished reasons. Studying breast cancer risk factors and further research into the molecular etiology of the disease will enable early diagnosis and detection of high-risk women and ultimately improve prognosis.

[Fallopian tube prolapse after hysterectomy].

Fallopian tube prolapse is a rare complication of hysterectomy, characterized by vaginal discharge, abdominal pain, pelvic inflammatory disease and vaginal bleeding. The diagnosis is often delayed, and is usually done after an histopathological examination identifies fallopian tube on biopsy. The advised treatment is surgical resection, which can be done through vaginal incision, abdominally or by laparoscopy. We report a case of fallopian tube prolapse after vaginal hysterectomy in 47-year-old patient in whom the prolapsed-tube was successfully resected vaginally, and review the presentation and surgical methods to correct this rare complication.