How common is ballooning? Hiatal area on 3D transperineal ultrasound in urogynecological patients and its association with lower urinary tract symptoms.

INTRODUCTION: Pelvic floor ultrasound plays a major role in urogynecologic diagnostics. Using 3D ultrasound we can identify integrity of levator ani and measure hiatal area in the axial plane. The main goal of our study was to measure hiatal area on Valsalva in a cohort of urogynecological patients. Furthermore, we aimed to correlate hiatal area with urogynecological symptoms, levator integrity and evaluate cut-off values for pelvic organ prolapse. MATERIALS AND METHODS: In a retrospective analysis, we included 246 patients seen for urogynecological problems in our tertiary urogynecological unit. After a standardized interview and physical examination, a 3D pelvic floor ultrasound was performed. According to the cardinal urogynecological symptoms and signs, patients were categorized into three groups: pelvic organ prolapse, stress urinary incontinence and overactive bladder symptoms. RESULTS: Median age of our study population was 66 (range 29-94) years, median parity was 2.1 (range 0-9) with 17 (6.9 %) nulliparous women. Symptoms of overactive bladder in 71.1 % were most common, followed by 54.5 % symptoms of stress incontinence and 32.1 % symptoms of prolapse. On examination 49.2 % showed signs of prolapse. Levator avulsions on 3D ultrasound were detected in 20.7 %. Hiatal area was normally distributed with a median of 28.7 cm2 (range 10.4-50.0 cm2). Patients with levator avulsion had a significantly larger hiatal area (p < 0.001). Also patients with signs of prolapse had a significantly larger hiatal area (p < 0.001). There was no correlation between hiatal area and symptoms of overactive bladder (p = 0.374). Although not reaching statistical significance there was evidence of a smaller hiatal area for patients with stress incontinence (p = 0.016). In our cohort there were 33.7 % (83) women without ballooning, 27.2 % (67) showed mild, 18.3 % (45) moderate, 12.3 % (30) marked and 8.5 % (21) severe ballooning. The ROC curve analysis for hiatal area on patients with prolapse yielded an AUC of 0.755 [95 % CI (0.696-0.814)]. Using the Youden-Index we obtained 27.53 cm2 as a cut-off with a sensitivity of 0.70 and a specificity of 0.69. DISCUSSION: Hiatal area is a new repeatable diagnostic parameter. Its clinical application could improve our understanding of the pathophysiology of pelvic organ prolapse as a form of hiatal hernia.

Supraclavicular Metastases from Distant Primary Solid Tumours: A Retrospective Study of 41 Years.

OBJECTIVES: Approximately 1 % of all malignant solid tumours of the head and neck area are metastases from primary tumours beneath the clavicles. The aim of this study was to analyse the distribution of primary tumours since meta-analyses might have been biased due to the usually extraordinary character of case reports. MATERIALS AND METHODS: All patient files from 1970 to 2012 from the Oral and Maxillofacial Surgery unit at a University Hospital were analysed regarding the existence of metastases to the head and neck area from distant primaries. RESULTS: Of the seventy-three patients 18 had breast cancers (25 %), 9 melanomas (12 %), 8 tumours of the kidneys and 8 of the lungs (each 12 %), 3 colon cancers (6 %), 2 prostate cancers (3 %), 2 Ewing sarcomas (3 %), and 1 each of liposarcoma, esophagus, rectum, hepatocellular carcinoma, vulva, ovarian and testicular cancer. In 15 cases, a cancer of unknown primary was diagnosed. In 28 cases the metastasis was the initial sign of the malignant disease. Skeletal metastasis occurred in 37 cases and a soft tissue metastasis in 36 patients. CONCLUSION: The different primaries seem to metastasize in different frequencies to the head and neck area. The relatively common prostate cancer rarely seems to produce metastases in the head and neck area compared to cancers arising in the kidneys. In case of a malignant tumour of unknown primary, osseous metastases most often are caused by breast or lung cancer or renal cell carcinoma. Soft tissue metastases are most often caused by breast cancer.

The effect of hormonal status on the expression of estrogen and progesterone receptor in vaginal wall and periurethral tissue in urogynecological patients.

OBJECTIVE: Our objective was to study the expression of estrogen receptor (ER) isoforms ER alpha (α) and ER beta (ß) and of progesterone receptor (PR) in the vaginal wall and in periurethral tissue of women who underwent urogynecological surgical treatment with reference to estrogen status. STUDY DESIGN: The study included 89 patients undergoing vaginal surgery for urogynecological conditions. Patients' history and clinical data including estrogen status and body mass index (BMI) were evaluated. Biopsies from the vaginal wall and from periurethral tissue were obtained during surgery. The expression of ER α and ß and of PR in vaginal wall and periurethral tissue was measured by RT-PCR. RESULTS: Nine patients were premenopausal. Eighty women were menopausal, of whom 21 were taking estrogen/progestin replacement therapy (HRT), 20 used local estrogen, and 39 had no endocrine treatment. Neither BMI nor age had any influence on the expression of ER and PR. Menopausal women showed a higher amount of PR expression in vaginal tissue than premenopausal women. Women with no endocrine treatment showed a lower amount of ER ß expression in vaginal tissue. CONCLUSION: Steroid receptors are expressed in periurethral and vaginal tissue. The receptor expression varies with hormonal changes only in vaginal tissue. Vaginal tissue seems to be more sensitive to estrogen than periurethral tissue.

Isolation of fibroblasts for coating of meshes for reconstructive surgery: differences between mesh types.

AIMS: An extensive colonization of surgical meshes with autologous fibroblasts may reduce complications. Therefore, we aimed to establish a technique that allows isolation and propagation of fibroblasts from vaginal biopsies. Using these cells we tested the applicability of several clinically applied meshes for fibroblast coating. MATERIALS & METHODS: Fibroblasts were isolated from vaginal tissue after digestion with collagenase. Characterization was performed by immunostaining for cytokeratin 5, 6 and 14, smooth muscle actin and vimentin. A semiquantitative technique was applied to determine the degree of mesh coating 5 h and 5 weeks after seeding of fibroblasts. Seven meshes of different mesh types have been tested. RESULTS: Cells with a fibroblast-like morphology have been isolated from vaginal tissue and could be propagated for at least 12 passages, resulting in a total number of 1.2 x 10(7) cells. Immunostaining showed that cells were positive for the mesenchymal cell marker vimentin and negative for smooth muscle actin, as well as the epithelial cell markers cytokeratin 5, 6 and 14, supporting their classification as fibroblasts. Clear differences in fibroblast colonization between the seven tested mesh types have been observed. Polypropylene mesh Obtape showed an acceptable covering with fibroblasts. The best coating was obtained for xenograft-based meshes, but under cell-culture conditions the mesh showed signs of decomposition. CONCLUSION: We have established a technique that allows isolation and propagation of vaginal fibroblasts. The result of vaginal fibroblast colonization of allograft-based meshes strongly depends on the mesh type, whereby the best coating could be achieved for a polypropylene mesh.