Nd:YAG/Er:YAG dual laser compared with topical steroid to treat vulvar lichen sclerosus: A randomised controlled trial.

OBJECTIVE: To evaluate the efficacy and safety of a novel non-ablative Nd:YAG/Er:YAG dual laser treatment for vulvar lichen sclerosus (LS) in comparison with the recommended first-line therapy with topical steroid. DESIGN: A randomised investigator-initiated active-controlled trial. SETTING: Single tertiary referral centre. POPULATION: Women with vulvar LS. METHODS: Randomisation (2:1) to Nd:YAG/Er:YAG laser therapy or topical clobetasol proprionate therapy. Four laser treatments at 0, 1, 2 and 4 months or decreasing doses of steroid for 6 months. MAIN OUTCOME MEASURES: The primary outcome was the change in objective validated clinical LS score in the laser arm between baseline and 6 months. Secondary outcomes were laser tolerability/safety, symptom scores and patient satisfaction. RESULTS: Sixty-six women were included, 44 in the laser group and 22 in the steroid group. The total LS score decreased by -2.34 ± 1.20 (95% CI -2.71 to -1.98) in women treated with laser compared with a decrease of -0.95 ± 0.90 (95% CI -1.35 to -0.56) in those receiving steroid applications (p < 0.001). Laser treatment was safe and well tolerated. Subjective severity scores (on visual analogue scale) and vulvovaginal symptoms questionnaire scores improved similarly for the laser and steroid arms without significant differences between the two treatments. Patient satisfaction was higher in the laser arm than in the steroid arm (p = 0.035). CONCLUSIONS: Non-ablative dual Nd:YAG/Er:YAG laser therapy was safe and significantly improved clinical outcome and subjective symptoms at the 6-month follow up. This suggests that laser may be a promising alternative to corticosteroid therapy. However, the authors caution regular follow ups because of the premalignant nature of the disease.

Combination therapy with botulinum toxin and bulking agent-An efficient, sustainable, and safe method to treat elderly women with mixed urinary incontinence.

AIMS: To evaluate the efficacy, sustainability and safety of combined botulinum toxin and polyacrylamide hydrogel (PAHG) therapy to treat urgency and stress components of therapy-refractory mixed urinary incontinence (MUI) in an elderly study population. METHODS: Fifty-five women with therapy-refractory MUI were treated with botulinum toxin and PAHG in one surgical procedure. Urgency urinary incontinence (UUI) and stress urinary incontinence (SUI) outcomes were separately assessed after 4 and 12 months by objective UUI episodes/24 h and cough test, subjective impact of UUI and SUI on quality of life, and subjective International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF). MUI outcome was calculated by combining UUI and SUI outcomes. Complications were monitored throughout the study. RESULTS: At 4 months, objective cure rates were 73%, 53%, and 42%, and subjective cure rates were 71%, 52%, and 50% for SUI, UUI, and MUI. At 12 months, objective cure rates were 73%, 56%, 50% and subjective cure rates were 78%, 42%, and 40% for SUI, UUI, and MUI. The ICIQ-UI SF score decreased by 9.0 and 8.7 points after 4 and 12 months. All complications were transient and included 22% clean intermittent catheterization immediately after surgery, 33% postvoid residual volumes >100 ml at 14 days, and 13% symptomatic urinary tract infection within the first postoperative month. CONCLUSIONS: The combination of botulinum toxin and PAHG is effective, sustainable and safe to treat therapy-refractory MUI, even in an elderly and frail study population. Patients benefit from the short surgical procedure without the need for general anaesthesia or discontinuation of anticoagulation.

Current Treatment Concepts for Stress Urinary Incontinence.

Initially, stress urinary incontinence should be treated by conservative measures, such as weight reduction, hormonal substitution, physiotherapy, pelvic floor exercise and/or the use of pessaries. Incontinence surgeries are only recommended in case of unsuccessful conservative therapy. Today, tension-free suburethral sling insertions represent the gold standard of incontinence surgery yielding very good outcomes (cure rates of 80­90 %). Pelvic-floor sonography provides important information on decision of surgical methods and the management of complications. Furthermore, intra- or paraurethral injection of bulking agents is a promising, minimally invasive surgical alternative. This article discusses treatment concepts, pre-, intra- and post-operative examinations, decision on surgical methods, operational details for surgical success, and the prevention and management of complications.

Bladder perforation after TVT-Secur procedure: how secure is TVT-Secur?

BACKGROUND: A rare but challenging complication of midurethral tape procedures is perforation of the tape through the bladder wall. CASES: We saw three patients in whom unrecognized bladder perforation during TVT-Secur procedures occurred. It took an average follow-up time of 11 months before the bladder perforations were identified by introital ultrasound. Complete excision of the mesh was achieved endoscopically (TURP resectoscope) and/or by traditional vaginal tape removal techniques. Following tape removal, there has been no recurrence of urinary tract infections, and the irritative voiding symptoms have resolved in all three cases. CONCLUSIONS: Bladder perforation after mini-sling procedures can be managed using a combined transurethral/vaginal approach. This technique is minimally invasive, safe, and successful. Careful introital ultrasound should be performed in patients presenting with new lower urinary tract symptoms after sling surgery to avoid delays in diagnosing bladder perforation.

Institutional conditions and individual experiences in the career-entry period of Swiss medical residents--a qualitative study.

BACKGROUND AND OBJECTIVES: The study investigated first-year residents' career entry experiences according to gender, clinical field and type of training hospital. In addition to quantitatively assessed workplace experiences, this paper reports qualitative data on institutional conditions as well as interpersonal and individual experiences encountered by junior physicians during their first year of residency. METHODS: The present study is part of the longitudinal Swiss physicians' career development study. After their first year of residency, participants were interviewed for the second time. The qualitative data of this second assessment are reported in this paper. A total of 1861 terms were given by 342 junior physicians working in the two main clinical fields (internal medicine and surgical fields) with regard to positive and negative experiences in the career entry period. The answers were assigned to 12 categories (according to Mayring's content analysis). These categories were then allocated to three superordinate subject areas: Institutional conditions, Interpersonal experiences, and Individual experiences. RESULTS: Institutional conditions accounted for 17% of all entries, with negative experiences in particular, high workload - predominating. Within Interpersonal workplace experiences (41% of all responses), relationship experiences accounted for the largest proportion of all statements (25.7%), which were mainly positive. Individual experiences (42%) were assessed both positively (professional competence, learning, responsibility, and pleasure) and negatively (working under pressure and curtailment of one's private life). Female and male residents reported similar workplace experiences. Residents in surgical fields more often complained of a lack of professional support than those in internal medicine. Physicians working in university or big county hospitals had more negative experiences with regard to teaching than residents at smaller hospitals. CONCLUSION: The junior physicians' career-entry experiences indicated that a genuine concept of education and training would greatly improve their workplace experiences. Furthermore, senior physicians should bear in mind that they are important role models for the junior staff.