Pelvic organ prolapse in young women.

OBJECTIVE: To determine differences in the characteristics and type of genital prolapse in young women compared with older women. METHODS: A retrospective analysis was performed, identifying 647 women who underwent surgical repair of various types of genital prolapse for the years 1979-1991. One hundred ninety-one patients met our inclusion criteria, having well-documented genital prolapse to or beyond the hymen. Patients were stratified into two age groups, those over 35 years and those 35 or younger. The patients were compared regarding "complexity" of prolapse (ie, the total number of deficient sites per patient), grade of prolapse, parity and coexistent medical conditions. RESULTS: During the study period, 27 young women (mean age +/- standard deviation [SD] 30.3 +/- 3.4 years) and 164 older women (mean age +/- SD 60.6 +/- 11.9 years) met our criteria. Young women were more likely than older women to have 1) potential predisposing medical conditions (congenital anomalies or neurologic or connective tissue diseases) (22.2% versus 6.7%, P < .05), 2) lower mean parity (2.8 versus 3.4, P < .05), 3) only one site of prolapse (56% versus 23%, P < .01), and 4) lower grade of prolapse (33% versus 87% grade 3 or higher, P < .001). CONCLUSION: Young patients undergoing surgery for genital prolapse were more likely to have lower parity and single-site and lower-grade prolapse. A higher than expected prevalence of congenital anomalies, as well as rheumatologic and neurologic diseases in the younger women is intriguing, but further study is necessary before these conditions can be implicated in the genesis of genital prolapse.

Magnetic resonance imaging of the levator ani with anatomic correlation.

OBJECTIVE: To define in women the anatomy of the levator ani muscle visible on magnetic resonance imaging (MRI) so these muscles can be studied in women with prolapse or incontinence. METHODS: Multiplanar T1- and T2-weighted MRI was obtained of two female pelvic cadaver specimens, ages 25 and 33. One specimen was hemisected, with half sectioned in the axial plane and the other half in the coronal plane. The other specimen was sectioned in the coronal plane. Anatomic cross sections of these specimens were correlated with the cadaver MRI and MRI of living patients. One sagittal and two axial series of anatomic sections not imaged were also used for comparison. RESULTS: Serial sagittal and axial MRI demonstrates the pubovisceralis ("pubococcygeus") muscle as it originates from the pubic bone, passes alongside the urethra, vagina, and rectum, and then dorsal to the anorectum. Its muscle bulk, attachment to the distal half of the vagina, and insertion between the internal and external anal sphincters can be seen on axial views. The origin of the iliococcygeus muscle at the arcus tendineus levator ani is seen in axial and coronal images. Coronal and sagittal images demonstrate the relative thickness and medial position of the pubovisceralis muscle compared with the thin, diaphragm-like lateral iliococcygeus muscle. CONCLUSION: Magnetic resonance imaging of the cadaver pelvis demonstrates the detailed anatomy of the levator ani muscle. This is an important precursor to future research of the structure, bulk, and orientation of the levator ani in living women with prolapse.

Relative morbidity of abdominal hysterectomy and myomectomy for management of uterine leiomyomas.

OBJECTIVE: To compare the morbidity of total abdominal hysterectomy and abdominal myomectomy in the surgical management of uterine leiomyomas. METHODS: Hospital records were reviewed for all women who underwent hysterectomy (n = 89) or myomectomy (n = 103) between May 1, 1988, and May 1, 1993, for the preoperative diagnosis of leiomyoma. RESULTS: There were significant differences between the two groups for average age (hysterectomy 39.2 years, myomectomy 34.4 years; mean difference 4.8, 95% confidence interval [CI] of difference 3.7-5.9), uterine size (hysterectomy 15.2, myomectomy 11.5 weeks; mean difference 3.8, 95% CI of difference 2.0-5.4) and use of a GnRH agonist (hysterectomy 23.6%, myomectomy 55.3%; relative risk [RR] 0.4, 95% CI 0.3-0.6). Myomectomy was associated with decreased estimated blood loss (hysterectomy 796 mL, myomectomy 464 mL; mean difference 331, 95% CI 121-542) and febrile morbidity (risk of temperature 38C or 48 or more hours postoperatively: for hysterectomy 49.4%, for myomectomy 32%; RR 1.5, 95% CI 1.1-2.2). Using multivariate linear regression, estimated blood loss was similar between the groups after controlling for uterine size. There was no difference in blood transfusion rates. There were two ureteral, one bladder, one bowel, and one femoral nerve injury in the hysterectomy group, and there were no intraoperative visceral injuries in the myomectomy group. CONCLUSION: Myomectomy compares favorably to hysterectomy in the surgical management of leiomyomas, with a possible decreased risk for visceral injury and infection.

Magnetic resonance imaging anatomy of the female urethra: a direct histologic comparison.

OBJECTIVE: To define the urethral structures visible on magnetic resonance imaging (MRI) relevant to stress urinary incontinence. METHODS: The urethra and surrounding tissues were harvested from 13 female cadavers (ages 21-81) and fixed in 10% buffered formalin. High-resolution T1- and T2-weighted images were obtained at 1.5 tesla. Mallory trichrome-stained histologic sections were prepared in corresponding planes from the cadaveric specimens. Immunohistologic stains for smooth muscle (actin) and vascular endothelium (CD-34 and factor VIII) were obtained on two specimens. Histology and MRI were compared using side-by-side correlation of projected images and by superimposing projected images. Comparison was also made to a non-cadaveric urethral MRI of a 29-year-old woman and to the MRI of another specimen imaged pre- and post-fixation. RESULTS: Distinct layers of the cadaveric urethra were seen best on proton density and T2-weighted images. From the center to the periphery, a series of concentric rings were visible: an inner bright ring, the mucosa; a dark ring, the submucosa; an outer bright ring, the smooth muscle of the urethra in a loose connective tissue matrix; and a peripheral dark ring, the striated urogenital sphincter muscle of the urethra in dense connective tissue. No significant alterations were caused by fixation. These cadaveric images matched the non-cadaveric MRI of the 29-year-old woman. CONCLUSION: The internal urethral anatomy visible on high-resolution MRI can be identified and confirmed histologically, and these findings may form the basis for future anatomic investigation of stress urinary incontinence and other urethral abnormalities.

Myomectomy fever: testing the dogma.

OBJECTIVE: To test the hypothesis that elevated temperature is more common after abdominal myomectomy than after hysterectomy. DESIGN: Retrospective cohort study. SETTING: Academic medical center. PATIENT(S): One hundred one women who underwent abdominal myomectomy and 160 women who underwent total abdominal hysterectomy for benign disease from 1988-1993. INTERVENTION(S): Abdominal myomectomy. MAIN OUTCOME MEASURE(S): Temperature of > or = 38.5 degrees C within 48 hours after operation. RESULT(S): Although univariate analysis showed that the incidence of elevated temperature was slightly greater among patients who underwent myomectomy (33% versus 26%, relative risk 1.29, 95% confidence interval 0.88-1.90), multivariate logistic regression analysis showed a 3.29 relative risk of elevated temperature (95% confidence interval 1.56-6.96) with myomectomy after controlling for age, parity, estimated blood loss, and treatment by the general gynecology service. CONCLUSION(S): After controlling for confounders, myomectomy was found to be an independent predictor for fever in the first 48 hours after operation.

The vesico-urethral pressuregram analysis of urethral function under stress.

About one-third of older multiparous women are prone to stress urinary incontinence (SUI): unwanted urine loss during activities which suddenly raise intra-abdominal pressure. In this paper we describe and test a method for visualizing and analyzing the function of the urinary continence control system (CCS) under stress. Intravesical and intraurethral pressure changes from the resting state were recorded at proximal, mid-, and distal urethral locations during increasingly severe coughs and cross-plotted on a 'vesico-urethral pressuregram.' The slope (alpha) and intercept (chi zero) resulting from a linear regression analysis of these data were used to develop a continence equation which can be used to predict the equilibrium point pressure (PE): the intravesical pressure at which urine will leak to the intraurethral pressure recording site. We tested the null hypothesis that these parameters would not differ in six young, nulliparous continent women (mean +/- S.D. age: 30 +/- 3.5 yr) and six multiparous SUI women (52.3 +/- 8.0 yr, parity: 1.7 +/- 0.8), or between urethral locations. Significant differences in continence equation parameters were found between groups and in different urethral locations. In the SUI group static factors calculated from the term (1 - alpha) contributed 27% of the mean (S.D.) midurethral PE value, 145 (46) cm H2O, while dynamic factors, estimated from alpha, contributed 73% of this value. Valuable insights for improving the diagnosis and treatment of SUI may be obtained by analyzing the relative contributions of alpha and chi 0 to urethral closure during physical stress.

Normal pelvic floor anatomy.

The anatomy of the pelvic floor includes structures responsible for active and passive support of the urethrovesical junction, vagina, and anorectum. Intrinsic and extrinsic properties of the urethrovesical neck and anorectum allow maintenance of urinary and anal continence at rest and with activity. Damage to these structures may lead to loss of support and loss of normal function of the urethra, bladder, and anorectum. Over time, this damage can result in isolated or combined pelvic organ prolapse, urinary incontinence, and anal incontinence.

Pitfalls in the diagnosis of nonconjoined monoamniotic twins.

The morbidity and mortality of monoamniotic twins are high. Despite recent advances in imaging, the definitive diagnosis of monoamniotic twins remains elusive. When monoamniotic twins are suspected, the optimal antepartum management is uncertain. A false-positive diagnosis of monoamniotic twins by computed tomographic amniography was investigated. By a Medline search the literature on monoamnionicity from 1966 to January 1994 was reviewed. All reports including diagnostic methods and management of monoamniotic twins were reviewed. All five previous case reports of computed tomographic amniography correctly identified amnionicity in cases in which amnionicity was unclear. Four cases confirmed monoamnionicity and one case excluded monoamnionicity. Four recent series that used ultrasonography revealed a low predictive accuracy (9% to 25%) for the establishment of monoamnionicity when intervening membranes were absent. One recent prospective series revealed a positive predictive value of 80% among five monoamniotic twin pairs with the use of first-trimester ultrasonography. The methods available to diagnose monoamniotic twins are improving. The complications that result from a false-positive diagnosis are discussed and the management and diagnosis of monoamniotic twins are reviewed.

Closure of the subcutaneous dead space and wound disruption after Cesarean delivery.

OBJECTIVE: To determine whether suture closure of subcutaneous dead space decreases wound disruption after Cesarean delivery. METHODS: All patients undergoing Cesarean delivery at the New England Medical Center from September 1995 to June 1997 were eligible. One group (162 patients) was randomly assigned to have the subcutaneous fat layer closed with a running 3-0 plain suture. The other group (165 patients) had this layer left unclosed. Both groups had careful hemostasis of this layer with cautery and copious irrigation. All laboring and ruptured patients received prophylactic antibiotics. The patients were followed for 6 weeks after delivery for wound disruption. RESULTS: No significant differences were noted between the two groups with respect to demographic, obstetric, or surgical characteristics or loss to follow-up. Excluding those lost to follow-up (27 closed vs. 22 unclosed), there was no difference in wound infection (11 (8.1%) closed vs. 13 (9.1%) unclosed, RR 0.90, 95% CI 0.14, 2.08). There were decreases in risk of skin separation (three (2.2%) vs. six (4.2%), RR 0.53, 95% CI 0.42, 1.93) and seroma or hematoma formation (two (1.5%) vs. seven (4.9%), RR 0.30, 95% CI 0.06, 1.43) that were not statistically significant. Decreases that were not statistically significant were also noted for any wound disruption (14 (10.4%) vs. 21 (14.7%), RR 0.71, 95% CI 0.37, 1.33) and non-infected wound complication (three (2.2%) vs. eight (5.6%), RR 0.40, 95% CI 0.11, 1.47). Increasing gravidity and parity, and Cesarean delivery performed for failure to progress were independent risk factors for any wound complication. Controlling for these factors did not alter the effect of subcutaneous closure. CONCLUSIONS: Closure of the subcutaneous space does not increase and may protect against wound complications in patients undergoing Cesarean delivery.

Current-mode subthreshold MOS circuits for analog VLSI neural systems.

An overview of the current-mode approach for designing analog VLSI neural systems in subthreshold CMOS technology is presented. Emphasis is given to design techniques at the device level using the current-controlled current conveyor and the translinear principle. Circuits for associative memory and silicon retina systems are used as examples. The design methodology and how it relates to actual biological microcircuits are discussed.

Managed care in reconstructive pelvic surgery and urogynecology.

While demographic changes in future decades should expand the need for subspecialists in reconstructive pelvic surgery and urogynecology, managed care will probably limit access of patients to specialists in this field. Much of the evaluation and treatment for women with prolapse and incontinence will be provided by primary care providers.

Comparison of ureteral and cervical descents during vaginal hysterectomy for uterine prolapse.

OBJECTIVE: The study measured ureteral and cervical locations during vaginal hysterectomy for prolapse and the extent of parametrial ligament shortening possible. STUDY DESIGN: Cervical and ureteral position were measured in 26 women undergoing uterine prolapse correction. Parametrial clamp tip location was also measured. RESULTS: The cervix lay between 0 and -14.5 cm (below) the hymen (mean +/- SD -5.35 +/- 3.96 cm) and the ureters lay +5.0 to -4.0 cm (mean +/- SD +1.89 +/- 1.99 cm). Correlation of ureteral with cervical position was 0.69 (P <.01) and correlation with ipsilateral uterosacral ligament clamp positions was 0.80 (P <.01). Regression line slope relating cervical descent and cervix to ureter distance was 0.65, indicating that for every 3 cm of cervical descent there was 2 cm widening of the gap between the cervix and ureters and 1 cm descent of the ureter. CONCLUSION: For every 3 cm of cervical descent the ureters descend 1 cm, thereby widening the ureterocervical gap and permitting ligament shortening during vaginal hysterectomy.