Postmenopausal labial agglutination mimics urinary incontinence and hidden vaginal lesion.

Labial agglutination has rarely been reported in postmenopausal women and its treatment has been based on experience with prepubertal girls. We describe an 83-year-old woman who presented with labial agglutination and severe urinary incontinence. She had been treated intermittently with a topical estrogen cream for 3 years, but her symptoms persisted. Surgery was performed and her urinary incontinence was instantly resolved. Incidental vaginal low-grade squamous intraepithelial neoplasia was noted. Later, the lesion progressed and was confirmed to be condyloma acuminata. No recurrence of labial agglutination was noted 3 months after the surgery. We emphasize that surgical intervention should be the first consideration for labial agglutination with urinary symptoms in postmenopausal women. This case also highlights that surgery can not only resolve patients' symptoms early, but can also enable access to the region for essential gynecologic procedures.

Pain in the enthesis of levator ani muscle: A novel source of chronic pelvic pain.

BACKGROUND: Managing chronic pelvic pain (CPP) remains a challenge due to its diverse range of causes. A newly identified anatomical entity known as the enthesis of the levator ani muscle (LAM) and its associated disorders might play a role. This paper describes a novel insight into CPP's origin, aiming to improve accurate diagnosis and treatment. METHODS: Data were collected from medical records (paper or electronic) retrospectively. The study included 112 patients meeting the criteria, divided into CPP and non-CPP groups. Clinical symptoms, including location of LAM enthesis, referred pain from pain in LAM enthesis, and related lower urinary tract symptoms (LUTSs) were discussed. To identify differences in symptoms between the groups, a Chi-squared test and descriptive analyses were conducted. RESULTS: Bimanual examination revealed tender sites in the attachment of the LAM to the pubic bone. LAM enthesis pain presumably caused referred pain in at least 10 areas, primarily in the lower abdominal quadrate (40.2%-47.3%) followed by the inguinal area (8.9%-15.1%). Multiple LUTSs were observed, including urinary frequency (72.3%), urgency (42.9%), nocturia (53.6%), residual urine sensation (64.3%), urinary incontinence (30.3%), painful bladder (34.8%), and weak urine stream (47.9%). Patients in the CPP groups experienced significant residual urine sensation (53.6%) and bearing-down sensation (42%) compared to the non-CPP group. CONCLUSION: Pain in LAM enthesis is a novel cause of pelvic pain and LUTSs that warrants attention for the evaluation and management of CPP.

Sacral Magnetic Neuromodulation with Intermittent Theta Burst Waveform Enhances Overactive Bladder: In Vivo Study.

BACKGROUND: The current treatment options for overactive bladder (OAB) continue to pose challenges for refractory cases and may involve invasive procedures. To assess the potential benefit of non-invasive repetitive peripheral magnetic stimulation (rPMS) on sacral roots using intermittent theta burst stimulation (iTBS) as treatment option for OAB. The study involved a total of 33 rats, which were divided into three different experimental phases. MATERIALS AND METHODS: To induce bladder overactivity rats were pretreated with a continuous transvesical infusion of 0.5% acetic acid (AA). During bladder infusion, the intravesical pressure was recorded using cystometrography (CMG) to investigate the effects of AA pretreatment and the therapeutic intervention of acute sacral rPMS using iTBS. RESULTS: Pre-application of rPMS with iTBS at a 100% intensity significantly extended the mean first voiding time (Tv) in normal healthy rats to 132%. Acute rPMS iTBS at a 100% intensity resulted in a significant increase of the inter-contraction interval (ICI) to 121%. An AA model was established with continuous saline infusion after 0.5% AA treatment and resulted in significant reductions of Tv to 42% and ICI to 56% of the corresponding control values. Subsequently, rPMS iTBS at a 100% intensity on the sacral nerve effectively inhibited AA-induced bladder overactivity and significantly increased the ICI to 167%∼222%. No significant changes in maximum bladder pressure (Pmax) were found. CONCLUSIONS: Sacral nerve rPMS with iTBS demonstrated the ability to suppress AA-induced bladder overactivity. This promising modality could be developed as an alternative approach to enhance bladder continence in OAB syndrome patients.

Overactive bladder with urodynamic study-induced bladder pain: An overactive bladder subtype with symptoms similar to those of interstitial cystitis/painful bladder syndrome.

Overactive bladder (OAB) and interstitial cystitis/painful bladder syndrome (IC/PBS) are 2 lower urinary tract disorders with urgency and bladder pain for diagnosis and with several other shared symptoms. Because of their overlapping symptoms, precise differential diagnosis of OAB and IC/PBS remains difficult. Thus, we characterize a subgroup of OAB with bladder pain (OAB-BP) that can be differentiated from OAB alone by urodynamic study (UDS) findings. We also further examined the clinical presentations and urodynamic parameters of OAB alone, OAB-BP, and IC/PBS. Data were collected between September 2018 and April 2019. Patients were categorized into 3 groups, OAB-alone (no bladder pain during UDS, n = 39), OAB-BP (with bladder pain during UDS, n = 35), and IC/PBS (the comparator, n = 39). Chi-square tests were used to compare OAB alone, OAB-BP, and IC/PBS with respect to their clinical presentations and urodynamic parameters. Factors with P < .05 were further analyzed through post hoc comparisons with Bonferroni adjustment. An unique subgroup of OAB patients was identified (i.e., OAB-BP), bladder pain can only be induced at maximal cytometric capacity during UDS. We also identified that the case histories and UDS parameters (e.g., low first desire, normal desire, and maximum cytometric capacity) of the OAB-BP group were more similar to those of the IC/PBS group than to those of the OAB-alone group. The OAB-BP group and the IC/PBS group reported more intrusive, longer-lasting symptoms before their final diagnoses, more extensive family history of urinary tract disorder, and more associated comorbidities (e.g., irritable bowel syndrome, and myofascial pain) than the OAB-alone group. The UDS assessment induced bladder pain in the OAB-BP group to reveal their hidden symptoms. Careful attention to patient history and sophisticated UDS evaluation may help to identify this unique OAB group.

Paraurethral striated muscular structures and pelvic floor muscles contribute to resting urethral closure pressure in rats.

INTRODUCTION AND HYPOTHESIS: We investigated physiological functions of the extraordinary muscular structure in the paraurethral area with pelvic floor muscle and the impact of these muscular structures on the resting maximal urethral closure pressure (MUCP) in rats. METHODS: Sixteen female Wister rats were divided into four groups: Groups I and II rats received 5 and 2.5 IU botulinum toxin A (BoNT-A), respectively, injected into the bilateral paraurethral striated muscles. Group III rats received 2.5 IU BoNT-A injected into the bilateral pelvic floor muscles, and group IV rats received 2.5 IU BoNT-A injected into the unilateral pelvic floor muscles. Measurements of MUCP were made at different time points after BoNT-A injection. RESULTS: All groups showed a rapid reduction in average MUCP by 70-80 % after BoNT-A injection, regardless of injection site or side. CONCLUSIONS: Paraurethral striated muscular structures and the pelvic floor muscles possess the function of maintaining resting MUCP in rats.

Physical Agent-Based Treatments for Overactive Bladder: A Review.

Almost one-fifth of the people in the world experience a decrease in quality of life due to overactive bladder (OAB) syndrome. The main bothersome symptoms are urgency accompanied by urinary frequency and nocturia. This chronic, disabling condition is first managed by reducing fluid intake and pelvic floor muscle training, supplemented with antimuscarinic drugs, if necessary. However, refractory cases often still occur. In more severe cases, invasive surgical interventions can be considered; yet, the success rate is still inconsistent, and there is a high complication rate. This condition is frustrating for patients and challenging for the medical staff involved. Although its pathophysiology has not been fully elucidated, peripheral autonomic somatic and sensory afferent receptors are considered to be involved in this condition. Hence, currently, physical agent-based treatments such as neuromodulation have taken a significant place in the third-line therapy of OAB. The efficacy and safety profiles of electrical and magnetic stimulation continue to evolve. Physical-based agents provide an appealing option owing to their effectiveness and minimal side effects. In addition, more physical therapies using light and shock energy are currently being investigated. Thus, a comprehensive understanding of these modalities is an extremely important aspect to provide the most suitable modalities for patients.

Overactive bladder syndrome is associated with detrusor overactivity and abnormal voiding pattern in nulliparous women.

BACKGROUND: Pregnancy and childbirth are frequently associated with overactive bladder syndrome (OAB). However, the role of parous effects in OAB among nulliparous (NP) women remains controversial. METHODS: This study investigated abnormal voiding patterns and detrusor overactivity (DO) among NP women with OAB in comparison with parous women. From August 2011 to December 2018, 906 patients met the inclusion criteria for participation and were divided into three groups: 221 patients in the NP group, 571 patients in the normal spontaneous delivery (NSD) group, and 114 patients in the cesarean section (CS) group. Urodynamic study examinations were performed, and the presence of DO, abnormal voiding patterns, and maximum urethral closure pressure (MUCP) was recorded. Data were analyzed using analysis of variance, χ2 tests, and independent t tests. RESULTS: Compared with parous women in the NSD and CS groups, patients in the NP group had a significantly higher prevalence of abnormal voiding patterns, DO, and MUCP. Furthermore, abnormal voiding patterns were significantly associated with DO and MUCP, respectively, especially in the NP group. CONCLUSION: We hypothesized that hypertonicity or poor relaxation of the pelvic muscle in NP women may cause functional BOO, which is related to their OAB.

Attachment of the levator ani muscle extends to the superior ramus of the pubic bone through electrophysiological and anatomical examinations.

Myofascial pelvic pain (MFPP) of pelvic floor muscles is a common cause of chronic pelvic pain (CPP). The pathological mechanisms and treatments of MFPP are complex and still unclear until now. The levator ani muscle (LAM) is the major pelvic floor muscle. The purpose of this study was to examine the fascia and attachment of LAM through the electromyogram (EMG) and cadaver dissection. Electrophysiological stimulation of the obturator fascia above the arcus tendinous levator ani (ATLA) could trigger contraction and electrophysiological changes in LAM insertion. The LAM of embalmed adult cadavers was examined especially in the area above the ATLA. Some skeletal muscle fibers were found above the ATLA within the obturator fascia and were confirmed by Masson's trichrome section staining. Our electromyography (EMG) and anatomical data implied that the attachment of LAM aponeurosis extended beyond ATLA to the inferior border of the superior ramus of the pubic bone. The new discovered attachment of LAM could provide a reference position for clinical diagnosis and treatment of MFPP or CPP.

Lifestyle and behavioral modifications made by patients with interstitial cystitis.

Interstitial cystitis/bladder pain syndrome (IC/BPS) negatively affects the quality of life. In this study, we investigated the lifestyle behavioral changes patients with IC/BPS make to cope with their symptoms. This prospective study was conducted between August 2018 and June 2019. All patients had a primary symptom of suprapubic pain with a full bladder and other lower urinary tract symptoms for more than 6 weeks as well as cystoscopic findings. All participants completed our self-developed questionnaire, which included informations about their living and work environment, occupational garments, dietary habits, and personal habits. Continuous variables were compared using an independent sample t test, and categorical variables were compared using a chi-square test. We recruited 86 patients with IC/BPS and age-matched 86 controls without IC/BPS. In our study, patients with IC/BPS had more cranberry intake (45.34% vs. 5.81%, P < 0.05) than non-IC/BPS controls; the IC/BPS group had decreased consumption of coffee and spicy food; and wore less makeup or special work garments. In conclusion, patients with IC/BPS tend to make several lifestyle behavioral changes to cope with their symptoms.

Interstitial cystitis/bladder pain syndrome patient is associated with subsequent increased risks of outpatient visits and hospitalizations: A population-based study.

Interstitial cystitis/bladder pain syndrome (IC/BPS) is not only a chronic urinary bladder pain syndrome but is also associated with multifactorial etiology. Our study aimed to test the hypothesis that IC/BPS is associated with subsequent increased risks of outpatient visits and hospitalizations. Using nationwide database, the diagnoses were based on the International Classification Codes (ICD-9-CM) (595.1) of at least three outpatient services during 2002-2008, (n = 27,990) and cystoscopic finding Hunner type and/or glomerulation with pre-audit criteria. All recruited cases monitored for subsequent outpatient visits and hospitalizations for 2 years, including all-cause and specialty-specific departments, were classified according to medical specialty and age group (<40, 40-60, ≥60 years of age). IC/BPS patients have more overall outpatient department (OPD) visits and an overall adjusted incidence rate ratio (IRR) of 1.64. As for specialty, IRRs were higher in psychiatry (2.75), Chinese medicine (2.01), and emergency medicine (2.00), besides urology and gynecology. The IRRs decreased as age advanced (2.01, 1.71, and 1.44, respectively), except for gynecology (2.42, 2.52, and 2.81). A similar phenomenon happens in hospitalization with IRR of 1.69. Due to claim data characteristics, whether ulcer type IC/BPS findings can be deductive to non-ulcer type remains inclusive. Current results indicate the impacts of healthcare burden in broad spectrum about IC/PBS patients. IC/BPS has been suggested to be associated with lower threshold of healthcare visits and some coexisting disease and is comprised of systemic dysregulation, and is beyond the scope of local bladder-urethra disease. Adequate recognition of associated or comorbid factors and possible recommendation or referral for IC/BPS patients can help provide better healthcare quality.

Extraordinary muscular structure leads to urethral injury after vaginal delivery in animal study.

INTRODUCTION AND HYPOTHESIS: The aim of this study is to explore causality of birth trauma after vaginal delivery and anatomical findings. METHODS: A total of 28 virgin mice were studied. Treatment groups received vaginal distention. Specimens were collected and subjected to the following fluorescence stains: progenitor cell (c-kit), smooth muscle (SMA), fibroblast (vimentin), and skeleton muscle (Masson's trichrome). Confocal microscopy was used to screen all of the urogenital tissue to localize the stained cells. RESULTS: Fibroblasts were spread all over perivaginal and urethral surroundings. Progenitor cells appeared at urethral-vagina intersection and urethral circle. They were noticeable only within smooth muscle layer. Two extraordinary skeleton muscle bands appeared on the urethra bilaterally. CONCLUSIONS: Our study demonstrates existence of muscle bands at the bilateral urethra. They can limit the mobility of urethra during vaginal delivery and thereby cause urethra injury. Progenitor cells are located only in the smooth muscle of the urethral circle.

Efficacy of Deep Brain Stimulation on the Improvement of the Bladder Functions in Traumatic Brain Injured Rats.

OBJECTIVE: Traumatic brain injuries (TBIs) are a prime public health challenge with a high incidence of mortality, and also reflect severe economic impacts. One of their severe symptoms is bladder dysfunction. Conventional therapeutic methods are not effective in managing bladder dysfunction. Henceforth, a research endeavor was attempted to explore a new therapeutic approach for bladder dysfunction through deep brain stimulation (DBS) procedures in a TBI animal model. METHODS: TBI in this animal model was induced by the weight-drop method. All rats with an induced TBI were housed for 4 weeks to allow severe bladder dysfunction to develop. Subsequently, an initial urodynamic measurement, the simultaneous recording of cystometric (CMG) and external urethral sphincter electromyography (EUS-EMG) activity was conducted to evaluate bladder function. Further, standard DBS procedures with varying electrical stimulation parameters were executed in the target area of the pedunculopontine tegmental nucleus (PPTg). Simultaneously, urodynamic measurements were re-established to compare the effects of DBS interventions on bladder functions. RESULTS: From the variable combinations of electrical stimulation, DBS at 50 Hz and 2.0 V, significantly reverted the voiding efficiency from 39% to 69% in TBI rats. Furthermore, MRI studies revealed the precise localization of the DBS electrode in the target area. CONCLUSIONS: The results we obtained showed an insightful understanding of PPTg-DBS and its therapeutic applications in alleviating bladder dysfunction in rats with a TBI. Hence, the present study suggests that PPTg-DBS is an effective therapeutic strategy for treating bladder dysfunction.

Deep Brain Stimulation of the Pedunculopontine Tegmental Nucleus Renders Neuroprotection through the Suppression of Hippocampal Apoptosis: An Experimental Animal Study.

The core objective of this study was to determine the neuroprotective properties of deep brain stimulation of the pedunculopontine tegmental nucleus on the apoptosis of the hippocampus. The pedunculopontine tegmental nucleus is a prime target for Parkinson's disease and is a crucial component in a feedback loop connected with the hippocampus. Deep brain stimulation was employed as a potential tool to evaluate the neuroprotective properties of hippocampal apoptosis. Deep brain stimulation was applied to the experimental animals for an hour. Henceforth, the activity of Caspase-3, myelin basic protein, Bcl-2, BAX level, lipid peroxidation, interleukin-6 levels, and brain-derived neurotrophic factor levels were evaluated at hours 1, 3 and 6 and compared with the sham group of animals. Herein, decreased levels of caspases activity and elevated levels of Bcl-2 expressions and inhibited BAX expressions were observed in experimental animals at the aforementioned time intervals. Furthermore, the ratio of Bcl-2/BAX was increased, and interleukin -6, lipid peroxidation levels were not affected by deep brain stimulation in the experimental animals. These affirmative results have explained the neuroprotection rendered by hippocampus apoptosis as a result of deep brain stimulation. Deep brain stimulation is widely used to manage neuro-motor disorders. Nevertheless, this novel study will be a revelation for a better understanding of neuromodulatory management and encourage further research with new dimensions in the field of neuroscience.

Improved voiding function by deep brain stimulation in traumatic brain-injured animals with bladder dysfunctions.

OBJECTIVE: Traumatic brain injury (TBI) is a global scenario with high mortality and disability, which does not have an effectual and approved therapy till now. Bladder dysfunction is a major symptom after TBI, and this study deals with the alleviation of bladder function in TBI rats, with the aid of deep brain stimulations (DBS). METHODS: TBI was induced by weight drop model (WDM) and standardized with the experimental subjects with variable heights for weight dropping. The rats survived after TBI were considered for bladder dysfunction observations. DBS with variable stimulation parameters like cystometric analysis and MRI studies were also performed. RESULTS: After experimental studies, TBI 2-m-height crash was determined as suitable parameter due to minimal mortality rate and significant reduction in the voiding efficiency from 67 to 28%, whereas DBS significantly reversed the value of voiding efficiency to 65-84%. MRI studies revealed the severity of TBI impact and DBS localization. CONCLUSION: The results showed profound therapeutic effect of PnO-DBS on voiding functions and bladder control on TBI rats.

Cystometric Measurements in Rats with an Experimentally Induced Traumatic Brain Injury and Voiding Dysfunction: A Time-Course Study.

Traumatic brain injuries (TBIs) are a serious public health issue worldwide with increased mortality as well as severe disabilities and injuries caused by falls and road accidents. Unfortunately, there is no approved therapy for TBIs, and bladder dysfunction is a striking symptom. Accordingly, we attempted to analyze bladder dysfunction and voiding efficiency in rats with a TBI at different time-course intervals. Time-dependent analyses were scheduled from the next day until four weeks after a TBI. Experimental animals were grouped and analyzed under the above conditions. Cystometric measurements were used for this analysis and were further elaborated as external urethral sphincter electromyographic (EUS-EMG) activity and cystometrogram (CMG) measurements. Moreover, magnetic resonance imaging (MRI) studies were conducted to investigate secondary injury progression in TBI rats, and results were compared to normal control (NC) rats. Results of EUS-EMG revealed that the burst period, active period, and silent period in TBI rats were drastically reduced compared to NC rats, but they increased later and reached a stagnant phase. Likewise, in CMG measurements, bladder function, the voided volume, and voiding efficiency decreased immediately after the TBI, and other parameters like the volume threshold, inter-contraction interval, and residual volume drastically increased. Later, those levels changed, and all observed results were compared to NC rats. MRI results revealed the prevalence of cerebral edema and the progression of secondary injury. All of the above-stated results of the experiments were extensively substantiated. Thus, these innovative findings of our study model will surely pave the way for new therapeutic interventions for TBI treatment and prominently highlight their applications in the field of neuroscience in the future.

Improvement of overactive bladder symptoms: Is correction of the paravaginal defect in anterior vaginal wall prolapse necessary?

BACKGROUND: To explore the relationship between overactive bladder (OAB) symptoms and paravaginal defects (PVDs), and to identify the necessity of PVD repair by transvaginal mesh (TVM) for the treatment of OAB symptoms. METHODS: A retrospective clinical study of 30 women with advanced cystocele with limited apical and posterior vaginal wall prolapse was conducted to identify any changes in OAB symptoms following a single Perigee procedure. Prolapse was assessed using the pelvic organ prolapse quantification (POP-Q) system, and paravaginal defects were identified by sonography. Complete urodynamic examination was performed prior to and one year after operation. All patients completed the overactive bladder questionnaire pre- and postoperatively for a quantitative assessment of OAB symptoms. RESULTS: All patients showed a significant improvement at points Aa and Ba in the POP-Q system. The results of the administered questionnaire revealed statistically significant improvement postoperatively. The difference of OAB symptoms between the group with PVDs and that with central defects was not statistically significant (p = 0.67). Moreover, no statistically significant improvement of OAB symptoms in the group with repaired PVDs was observed postoperatively (p = 0.42). CONCLUSION: Statistical improvements of symptoms exist after Aa and Ba points recovery as evaluated by POP-Q system regardless of PVD existence identified by sonography. Repairing PVD did not show significantly improve the severity of OAB symptoms in objective urodynamic data or subjective questionnaire data. The superiority of TVM in PVD repair to manage OAB symptoms seems not manifest.

Exploring the dynamics of progenitor cells in the urethra after simulated birth trauma in mice.

OBJECTIVE: To examine the alteration in the cellular dynamics of the urethral tissue after a simulated birth trauma in a mouse model. MATERIALS AND METHODS: A total of 36 B6 mice received vaginal distention treatment, and four untreated mice were used as controls. Specimens were collected every 24 hours after the injury for 9 consecutive days and examined using immunofluorescent staining for cell markers including c-kit, smooth muscle actin (SMA), and vimentin. Confocal microscopy was used to localize the stained cells and determine the cell number. RESULTS: The number of c-kit positive cells increased after the 1st day and peaked on the 3rd day. The amount of SMA positive cells rapidly reduced to its lowest count on the 1st day and maintained a statistically significant low cell number than that at the basal level for 4 days after vaginal distension. The cell number finally returned to basal level on the 9th day. The amount of vimentin positive cells increased dramatically after the 1st day and plateaued from the 3rd day to the 9th day. The number of vimentin positive cells in the plateau phase was significantly higher than that of the control group. CONCLUSION: Our study confirmed that the dynamic change in different cell types after the urethral injury was dependent on the nature and physiology of the wound repairing cells during the tissue healing process. It might be a simple animal model to study birth trauma repair; however, the varied progenitor cell activity in different species should also be considered.

Pills-related severe adverse events: A case report in Taiwan.

OBJECTIVE: To review and evaluate the potential adverse effects of these oral contraceptives (OCP) to overweight women. CASE REPORT: A 19-year-old college student, with a body mass index (BMI) of 35.2 kg/m(2), who received 2 months of OCP containing cyproterone and ethinyl estradiol for polycystic ovary syndrome (PCOS)-related menstrual problems was complicated with a thromboembolism-related life-threatened disease. After intensive care, including the use of an extracorporeal membrane oxygenation system, thrombolytic treatment, anticoagulant, and inferior vena filter, she recovered well without significant sequelae. CONCLUSION: This case illustrates the risk of using OCPs, especially for those containing cyproterone and ethinyl estradiol components, as a treatment for menstrual problems in young women with PCOS and a high BMI.

Ovarian abscess from Salmonella: a case report.

BACKGROUND: An ovarian site of Salmonella bacteremia is rare. The contents of a teratoma may hide the organisms easily. Clinicians should be alert to this possibility when the patient had a teratoma with Salmonella infection. CASE: A 19-year-old woman presented with a missed menstrual period. An adnexal mass was found during a routine gynecologic examination. The patient had had gastroenteritis 2 months earlier but did not complain of a gastrointestinal problem at presentation. Exploratory laparotomy was performed for a suspected ovarian tumor. An infective teratoma was considered, but the infection source was unknown until the culture report showed a Salmonella infection. CONCLUSION: Salmonella infection is a self-limiting, febrile disease and is unlikely to involve organs other than the gut. A nontyphoid ovarian abscess became a rare late complication of acute gastroenteritis. Clinicians should pay special attention to the differential diagnosis of ovarian tumor in patients with a history of Salmonella infection, especially those with such ovarian lesions as endometrioma or teratoma and with recent abdominal pain, as noted in this case.

Laparoscopic-assisted vaginal myomectomy through an anterior approach.

BACKGROUND: To evaluate the safety and efficacy of a combined laparoscopic and vaginal approach through the anterior cul-de-sac in dealing with fundal and/or anterior wall uterine myomata. PATIENTS AND METHODS: Seven women with symptomatic fundal and/or anterior wall uterine myomata were enrolled in this study. After laparoscopic identification of the location of the myomata, a guiding suture brought the dominant myoma down through the anterior cul-de-sac into the vagina via an anterior colpotomy. Resection and suturing were then performed transvaginally. RESULTS: Mean +/- standard deviation (SD) operative time, blood loss, and the length of hospital stay were 88.1 +/- 27.8 minutes, 278.6 +/- 131.8 mL, and 2.9 +/- 0.7 days, respectively. No patients developed serious complications, and only four transient macroscopic hematuria occurred intra- and postoperatively. CONCLUSION: Although transient hematuria may occur, a combined laparoscopy and vaginal approach in dealing with fundal and/or anterior wall uterine fibroids through the anterior cul-de-sac is an alternative to pure laparoscopic myomectomy.