The Correlation Between the Sonographic Course of Transobturator Slings and Sling-Related Pain.

OBJECTIVES: To determine whether transobturator slings follow a consistent path and whether there is an association between ultrasonographically visualized sling pattern or position with sling-related pain. METHODS: This was a cross-sectional retrospective pilot study. We evaluated women who were presented to our clinic for pain or other urogynecologic symptoms following transobturator sling placement between 2009 and 2014. Patients had undergone a 3-dimensional endovaginal pelvic floor ultrasound, assessing minimal levator hiatus, antero-posterior diameter, left-right diameter, and the hiatal shape. The mesh patterns were categorized as seagull patterns (normal), lopsided, flat, and convoluted. RESULTS: A total of 68 cases were reviewed. Fifty patients reported pain, and 18 did not. There were wide variations in the course of the slings. The sling center- minimal levator hiatus position ranged 14.8 mm below and 17.9 mm above the minimal levator hiatus. The lateral arm insertion points ranged between 17.1 mm below and 16.6 mm above the minimal levator hiatus. The right arm insertion points ranged between 9.6 mm below and 18.8 mm above the minimal levator hiatus. Thirty-five of 68 (70%) patients with pain and 13 of 18 (72.2%) without had abnormal sling patterns. The abnormal sling shape was not correlated with pain (P = 1). The levator shape trended toward a statistical significant correlation with sling shape abnormality (P = .084). CONCLUSIONS: This population of women with transobturator sling complications demonstrated wide variations in anatomic paths. Neither the abnormal sling shape nor the distance of the center of the tape from the minimal levator hiatus level were correlated with pain.

Identification of Candidate Biomarker and Drug Targets for Improving Endometrial Cancer Racial Disparities.

Racial disparities in incidence and survival exist for many human cancers. Racial disparities are undoubtedly multifactorial and due in part to differences in socioeconomic factors, access to care, and comorbidities. Within the U.S., fundamental causes of health inequalities, including socio-economic factors, insurance status, access to healthcare and screening and treatment biases, are issues that contribute to cancer disparities. Yet even these epidemiologic differences do not fully account for survival disparities, as for nearly every stage, grade and histologic subtype, survival among Black women is significantly lower than their White counterparts. To address this, we sought to investigate the proteomic profiling molecular features of endometrial cancer in order to detect modifiable and targetable elements of endometrial cancer in different racial groups, which could be essential for treatment planning. The majority of proteins identified to be significantly altered among the racial groups and that can be regulated by existing drugs or investigational agents are enzymes that regulate metabolism and protein synthesis. These drugs have the potential to improve the worse outcomes of endometrial cancer patients based on race.

Endometrial Carcinoma and its Precursors.

This chapter focuses on premalignant and malignant diseases of the endometrium (lining of the uterus). Endometrial carcinoma is the most common gynecologic cancer in the United States. Women have a 1 in 40 lifetime risk of being diagnosed with endometrial cancer, the fourth most common malignancy among women. An estimated 61,880 new diagnoses of uterine cancer and 12,160 deaths from the disease occurred in 2019 in the United States (American Cancer Society, Facts & Figures, https://www.cdc.gov/cancer/uterine/statistics/index.htm , 2019).

Robotic-Assisted Laparoscopic Cervicovaginal Myomectomy.

STUDY OBJECTIVE: To illustrate a robotic-assisted laparoscopic resection for cervicovaginal myomectomy. DESIGN: Step-wise instruction using video and case report (Canadian Task Force classification III). SETTING: A tertiary referral center. PATIENT: A 39-year-old woman. INTERVENTION: Robotic-assisted laparoscopy resection of leiomyoma. MEASUREMENTS AND MAIN RESULTS: A 39-year-old woman, gravida 0, body mass index of 23.0 kg/m2, with a known cervicovaginal myoma that in the past underwent uterine artery embolization, presented with recurrence of her severe abnormal vaginal bleeding. She was referred for surgical resection of the mass. Magnetic resonance imaging revealed a 5-cm posterior cervicovaginal leiomyoma. The patient wanted to preserve her reproductive organs. A total robotic procedure lasted 123 minutes, with an estimated blood loss of 100 mL. She was discharged uneventfully on the day 0 postoperatively. Pathology results showed a 37-g leiomyoma of the uterus. The patient presented at her 2-weeks postoperative visit with no more complaint of vaginal bleeding. CONCLUSION: Robot-assisted laparoscopic surgery is a feasible approach for cervicovaginal myoma with minimal complications.

How does 3D endovaginal ultrasound compare to magnetic resonance imaging in the evaluation of levator ani anatomy?

INTRODUCTION AND HYPOTHESIS: To compare magnetic resonance imaging (MRI) to 3D endovaginal ultrasound (EVUS) in the evaluation of major levator ani defects in women with pelvic floor disorders. METHODS: A total of 21 subjects with pelvic floor with complaints of pelvic floor disorders were included in this study. EVUS imaging of the levator ani muscle (LAM) was performed in all subjects, and the LA muscle groups of interest evaluated were the puboanalis (PA), puborectalis (PR), and pubovisceralis (PV) muscles. The right and left subdivisions were evaluated separately, and classified as (i) normal, normal with only minor irregularities, grossly abnormal, or absent, or (ii) by the levator ani deficiency (LAD) score and classified by no defect (complete attachment of muscle to the pubic bone), <50% detachment or loss, >50% detachment or loss, and completely detached or complete muscle loss. Paired data were analyzed with McNemar's test or Bowker's test of symmetry. RESULTS: When unilateral LAM subdivisions were classified as "normal," "normal with minor irregularity," "grossly abnormal," and "absent," there were no significant differences between MRI and EVUS by categorization of LAM defects. Comparing "normal" versus "abnormal," there was no difference between imaging modalities. When compared by LAD score evaluation, there were no differences in the categorization of unilateral defects between MRI and EVUS. CONCLUSIONS: Endovaginal 3D US is comparable to MRI in its ability to identify both normal and abnormal LAM anatomy. Neurourol. Urodynam. 36:409-413, 2017. © 2015 Wiley Periodicals, Inc.

Estimated combined cardiac output and laser therapy for twin-twin transfusion syndrome.

INTRODUCTION: Twin-twin transfusion syndrome (TTTS) is the major cause for fetal demise in monochorionic diamniotic pregnancies. Estimated combined cardiac output (CCO) has not been studied in this setting. The primary aims of this study were to compare CCO in twin donor and recipient fetuses and assess differences in CCO before and after laser coagulation therapy. A secondary aim was to evaluate the relationship of CCO with perinatal mortality, defined as intrauterine or neonatal mortality (≤30 days of age) in fetuses that underwent laser coagulation therapy. METHODS: We performed a retrospective review of fetuses with TTTS who received echocardiograms prior to laser therapy. Prelaser echocardiograms were performed in 66 fetuses, of which 45 (21 donor and 24 recipient) survived to the postlaser echocardiogram. RESULTS: Donor CCO increased from a mean of 487±137 mL/min/kg prelaser to 592±128 mL/min/kg postlaser (P=.025). There was no significant change in mean recipient CCO from prelaser 551±165 mL/min/kg to postlaser 575±112 mL/min/kg (P=.564). In recipient fetuses, higher prelaser CCO correlated with increasing Quintero stage (P=.010) and perinatal mortality (P=.003). Thirty-day postnatal outcome data were available for 38 fetuses, of whom 34 (89%) survived. Amongst survivors, 25 (74%) experienced an increase in CCO, while 9 (26%) experienced a decrease in CCO (P=.010). Donor fetuses had higher CCO after laser therapy. CONCLUSIONS: Higher prelaser CCO in recipient fetuses may indicate more advanced disease. Fetuses who exhibit a decrease in CCO after therapy laser may be at higher risk for perinatal mortality.

Maternal morbidity in patients with morbidly adherent placenta treated with and without a standardized multidisciplinary approach.

OBJECTIVE: The purpose of this study was to test the hypothesis that a standardized multidisciplinary treatment approach in patients with morbidly adherent placenta, which includes accreta, increta, and percreta, is associated with less maternal morbidity than when such an approach is not used (nonmultidisciplinary approach). STUDY DESIGN: A retrospective cohort study was conducted with patients from 3 tertiary care hospitals from July 2000 to September 2013. Patients with histologically confirmed placenta accreta, increta, and percreta were included in this study. A formal program that used a standardized multidisciplinary management approach was introduced in 2011. Before 2011, patients were treated on a case-by-case basis by individual physicians without a specific protocol (nonmultidisciplinary group). Estimated blood loss, transfusion of packed red blood cells, intraoperative complications (eg, vascular, bladder, ureteral, and bowel injury), neonatal outcome, and maternal postoperative length of hospital stay were compared between the 2 groups. RESULTS: Of 90 patients with placenta accreta, 57 women (63%) were in the multidisciplinary group, and 33 women (37%) were in the nonmultidisciplinary group. The multidisciplinary group had more cases with percreta (P = .008) but experienced less estimated blood loss (P = .025), with a trend to fewer blood transfusions (P = .06), and were less likely to be delivered emergently (P = .001) compared with the nonmultidisciplinary group. Despite an approach of indicated preterm delivery at 34-35 weeks of gestation, neonatal outcomes were similar between the 2 groups. CONCLUSION: The institution of a standardized approach for patients with morbidly adherent placentation by a specific multidisciplinary team was associated with improved maternal outcomes, particularly in cases with more aggressive placental invasion (increta or percreta), compared with a historic nonmultidisciplinary approach. Our standardized approach was associated with fewer emergency deliveries.

Comparison between laparoscopically assisted and standard fetoscopic laser ablation in patients with anterior and posterior placentation in twin-twin transfusion syndrome: a single center study.

BACKGROUND: The objective of our study was to compare outcomes following laparoscopically assisted procedure (LAP group) with those seen following a standard approach used in patients with either an anterior placenta (SAP group) or posterior placenta (SPP group). METHOD: This was a retrospective review of all the cases of twin-twin transfusion syndrome treated in our fetal center from October 2011 to July 2013. Technical characteristics of the procedure, perinatal survival outcome, and maternal morbidity were compared. RESULTS: The laser procedure time was significantly longer in the SAP group (44 ± 10 min) in contrast with SPP (19.3 ± 13.9 min, p < 0.001) and LAP group (32 ± 11 min, p: 0.012). Preterm premature rupture of membranes (PPROM) before 32 and 34 weeks of pregnancy was significantly more common with LAP versus SAP and SPP (90 vs 33.3 and 70.8% for 32 weeks respectively, p: 0.015; 100 vs 50 and 79.1% for 34 weeks respectively, p: 0.021). In terms of maternal morbidity and neonatal outcome, there were no significant differences between the three groups. CONCLUSION: LAP may be useful in cases where SAP is not feasible. Despite the increased risk of PPROM with LAP, perinatal survival and maternal outcomes are similar to that seen in SAP and SPP patients.

Surgical Care Processing in Major Oklholma City Hosptal: The Surgeons' Perspective.

PURPOSE: This study aimed to assess processing of surgical care provided at major Oklahoma City hospitals based on surgeons'perception. METHODS: A questionnaire was sent out to Oklahoma County Medical Society surgeons using survey monkey to assess surgeons' perception of surgical care provided by major hospitals in Oklahoma City metropolitan area. The email contained a short introduction of study and the general aim of the study. Student t test was applied to compare groups mean. P value <0.05 was considered significant. RESULTS: 79 valid responses were identified. 25% of surgeons scored that their patients waited in the post-op recovery area between 31-60 minutes before they were roomed, with a 90% surgeon satisfaction rate. Compared to the longer waiting times this satisfaction rate was significantly higher (P < 0.0001). 64.6% of surgeons reported 31-60 minutes turn-over time between cases with only an 8% satisfaction rate. 10-30 minutes turnover time was reported in 13.9% of participants with 72.7% satisfaction rate which was significant when compared to the former group. The surgeons scored that their patients presented to the hospital 1-2 hours before surgery 55.7% of the times and 92.7% of the surgeons were satisfied with this process (P < 0.0001). CONCLUSION: Surgeons'satisfaction increases with decreased patients processing times.

Reference charts for fetal biometric parameters in twin pregnancies according to chorionicity.

OBJECTIVE: The objective of this article is to determine reference values for fetal biometric parameters in twin pregnancies and to compare these values between monochorionic and dichorionic pregnancies. METHODS: A retrospective cross-sectional study was conducted among 157 monochorionic and 176 dichorionic twin pregnancies between 14 and 38 weeks of gestation. Biometric measurements included the biparietal diameter (BPD), abdominal circumference (AC), femurs length (FL) and estimated fetal weight (EFW). To evaluate the correlation between biometric parameters and gestational age, polynomial regression models were created, with adjustments using the coefficient of determination (R(2) ). Comparison between monochorionic and dichorionic pregnancies was performed using analysis of covariance. RESULTS: The mean BPD, AC, FL and EFW for the dichorionic pregnancies were 56.16 mm, 191.1 mm, 41.08 mm and 816.1 g, respectively. The mean BPD, AC, FL and EFW for the monochorionic pregnancies were 57.14 mm, 184.2 mm, 39.29 mm and 723.4 g, respectively. There was a statistical difference between mono and dichorionic pregnancies for all the biometric parameters (BPD p = 0.012; AC p = 0.047; FL p = 0.007; EFW p = 0.011). CONCLUSION: Reference curves of biometric parameters in twin pregnancies were determined. Biometric parameters were statistically different between monochorionic and dichorionic pregnancies.

Does early second-trimester sonography predict adverse perinatal outcomes in monochorionic diamniotic twin pregnancies?

OBJECTIVES: To determine whether intertwin discordant abdominal circumference, femur length, head circumference, and estimated fetal weight sonographic measurements in early second-trimester monochorionic diamniotic twins predict adverse obstetric and neonatal outcomes. METHODS: We conducted a multicenter retrospective cohort study involving 9 regional perinatal centers in the United States. We examined the records of all monochorionic diamniotic twin pregnancies with two live fetuses at the 16- to 18-week sonographic examination who had serial follow-up sonography until delivery. The intertwin discordance in abdominal circumference, femur length, head circumference, and estimated fetal weight was calculated as the difference between the two fetuses, expressed as a percentage of the larger using the 16- to 18-week sonographic measurements. An adverse composite obstetric outcome was defined as the occurrence of 1 or more of the following in either fetus: intrauterine growth restriction, twin-twin transfusion syndrome, intrauterine fetal death, abnormal growth discordance (≥20% difference), and very preterm birth at or before 28 weeks. An adverse composite neonatal outcome was defined as the occurrence of 1 or more of the following: respiratory distress syndrome, any stage of intraventricular hemorrhage, 5-minute Apgar score less than 7, necrotizing enterocolitis, culture-proven early-onset sepsis, and neonatal death. Receiver operating characteristic and logistic regression-with-generalized estimating equation analyses were constructed. RESULTS: Among the 177 monochorionic diamniotic twin pregnancies analyzed, intertwin abdominal circumference and estimated fetal weight discordances were only predictive of adverse composite obstetric outcomes (areas under the curve, 79% and 80%, respectively). Receiver operating characteristic curves showed that intertwin discordances in abdominal circumference, femur length, head circumference, and estimated fetal weight were not acceptable predictors of twin-twin transfusion syndrome or adverse neonatal outcomes. CONCLUSIONS: In our cohort, only second-trimester abdominal circumference and estimated fetal weight discordances in monochorionic diamniotic twin pregnancies were predictive of adverse composite obstetric outcomes. Twin-twin transfusion syndrome and adverse neonatal outcomes were not predicted by any of the intertwin discordances measured.

Evaluation of the American College of Surgeons National Surgical Quality Improvement Program Risk Calculator to predict outcomes after hysterectomies.

OBJECTIVE: To evaluate the American College of Surgeons (ACS) surgical risk calculator's reliability in predicting outcomes in hysterectomies. METHODS: This is a prospective cohort study at a large community-based hospital. Twenty-one preoperative and postoperative criteria were abstracted from the electronic medical record and entered into the online ACS calculator to determine a risk score. Logistical regression was used to determine the association between risk score and actual outcome. The prediction capability was analyzed with c-statistic, Hosmer-Lemeshow, and Brier score. RESULTS: A total of 634 hysterectomies were performed during the study period from January to April 2019. Patients were predominantly 55 years old, white (53%) and overweight (body mass index 30). Predicted perioperative adverse events were significantly higher than actual adverse events across all domains. In all, 54/634 (8.5%) patients experienced postoperative urinary tract infection. C-statistics for return to operating room, renal failure, and readmission were 0.607 (95% C Statistic index [CI] 0.370-0.845), 0.882 (95% CI 0.802-0.962), 0.637 (95% CI 0.524-0.750), respectively. Brier scores approached one in all categorical domains. CONCLUSION: The ACS surgical risk calculator holds the promise of predicting postoperative complications or length of stay for patients undergoing hysterectomy. Further adjustment to this tool is required before it can be advocated for use in the clinical setting.

Stress urinary incontinence: pre-pregnancy history and effects of mode of delivery on its postpartum persistency.

INTRODUCTION AND HYPOTHESIS: We aimed to determine the prevalence of mild stress urinary incontinence (SUI) 1 year postpartum in relation to mode of delivery and pre-pregnancy SUI. METHODS: This cohort study was performed on 618 primiparous women who delivered by elective cesarean section and NVD. Development of SUI during pregnancy till 12 months after delivery was studied. Frequency of mild SUI among patients with and without pre-pregnancy SUI was compared at the ante-partum (RR, 5.75), 40 days postpartum (RR, 9.3), 3 months postpartum (RR, 10.1), 6 months postpartum (RR, 10.1), and 12 months postpartum (RR, 16.8). RESULTS: Regarding the mode of delivery, incidence of SUI showed significant difference at 40 days, 3 and 6 months postpartum in both patients with and without pre-pregnancy history of SUI (P<0.05, all groups). CONCLUSION: The mode of delivery had significant effect on the persistency of SUI up to 6 months postpartum, while pre-pregnancy SUI revealed such effect till 1 year.

Histopathologic, Genetic and Molecular Characterization of Endometrial Cancer Racial Disparity.

In contrast to the decline in incidence and mortality of most other cancers, these rates are rising for endometrial cancer. Black women with endometrial cancer have earlier diagnosis, more aggressive histology, advanced stage and worse outcomes compared with their White counterparts. Socioeconomic status, a higher incidence of aggressive histology, and comorbid conditions are known factors leading to racial disparity in patients with endometrial cancer; nevertheless, they do not account for the entire racial disparity; which emphasizes the roles of molecular, histopathological and genetic factors. We performed a comprehensive review of all published scientific literature up to January 2021 reporting histopathologic, genetic and molecular factors associated with racial disparities in patients with endometrial cancer. The interactions and pathways of molecules reported to have significant differential expression in endometrial cancers from Black and White patients were identified with Ingenuity Pathway Analysis. The majority of studies compared Black and White patients; however, limited data are available for other racial and ethnic groups. Reported differences that could account for the worse survival of Black endometrial cancer patients include more aggressive histopathologies and molecular alterations, including upregulation of molecules driving cell cycle progression, and p53 and HER2/NEU signaling. Several of these molecules are targeted by existing pharmaceuticals. These findings encourage further study and the development of race-specific treatment strategies.

Similarities and Differences of Hsp70, hsc70, Grp78 and Mortalin as Cancer Biomarkers and Drug Targets.

Background: Upregulation of Heath Shock Protein 70 (HSP70) chaperones supports cancer cell survival. Their high homology causes a challenge to differentiate them in experimental or prevention and treatment strategies. The objective of this investigation was to determine similarities and differences of Hsp70, hsc70, Grp78 and Mortalin members of the HSP70 family encoded by HSPA1, HSPA8, HSPA5 and HSPA9 genes, respectively. Methods: Literature reviews were conducted using HSPA1, HSPA5, HSPA8 and HSPA9 gene or protein names or synonyms combined with biological or cancer-relevant terms. Ingenuity Pathway Analysis was used to identify and compare profiles of proteins that directly bind individual chaperones and their associated pathways. TCGA data was probed to identify associations of hsc70 with cancer patient survival. ClinicalTrials.gov was used to identify HSP70 family studies. Results: The chaperones have similar protein folding functions. Their different cellular effects are determined by co-chaperones and client proteins combined with their intra- and extra-cellular localizations. Their upregulation is associated with worse patient prognosis in multiple cancers and can stimulate tumor immune responses or drug resistance. Their inhibition selectively kills cancer over healthy cells. Conclusions: Differences in Hsp70, hsc70, Grp78 and mortalin provide opportunities to calibrate HSP70 inhibitors for individual cancers and combination therapies.

Indicated and non-indicated antibiotic administration during pregnancy and its effect on pregnancy outcomes: Role of inflammation.

The objective of this study was to compare the release of endotoxin and pro-inflammatory cytokines as well as pregnancy outcomes after antibiotic exposure in healthy and bacterial infected pregnant rats. Thirty female Wistar pregnant rats were divided into five groups. Group A considered as control and received intraperitoneal saline 0.9% on 17th day of gestation or DG) and groups B and C treated with 20 mg/kg/day intravenous ceftriaxone and ceftazidime, respectively (DG: 18-20). Groups D and E received intraperitoneal E. coli and LPS on 17th DG respectively. Also, groups F and G received the same treatment as group D but they treated with the exact antibiotics mentioned for groups B and C (same dose and duration). Pregnancy outcomes as well as maternal sera levels of endotoxin, tumor necrosis factor α (TNF-α), interleukin 1ß (IL-1ß), and IL-6 were assessed using enzyme-linked immunosorbent assay. It was shown that group B had a higher IL-1ß (P = 0.003) and TNF-α (P = 0.003) levels compared to the controls (CTC). Group C expressed a lower gestational duration (P = 0.007) as well as higher IL-6 (P = 0.025) and TNF-α (P < 0.001) levels CTC. Interestingly, both group B (P = 0.021) and C (P < 0.001) had a higher rate of endotoxin release CTC. Moreover, in group C, IL-6 (P < 0.0001 and r = -0.941) had a significant correlation with gestational duration. As the results showed, antibiotic administration in non-indication condition seems to be associated with significantly higher production of endotoxin and inflammatory cytokines which increase the risk of poor pregnancy outcomes.

Ultrasound Indicators of Rectal Support Defect in Women With Obstructive Defecatory Symptoms.

OBJECTIVE: The anatomic and physiologic pathophysiology of obstructive defecatory symptoms is complex and poorly understood. As a consequence, there is no one surgical method that can achieve overall superiority. We aimed to investigate rectal architectural change in women with obstructive defecatory symptoms using three-dimensional pelvic floor ultrasound. METHODS: This retrospective cohort study included 65 women who were referred to our urogynecology clinic because of varied pelvic floor disorders between January 2013 and January 2014. Patients completed a standardized interview including PFDI-20 questionnaire and received a standard examination and assessment of pelvic floor by three-dimensional endovaginal ultrasound. Women were categorized to case and control based on their answers to questions 7, 8, and 14 on PFDI-20 (Colorectal and Anal Distress Index) questionnaire. In ultrasound images, levator plate descent angle, levator plate-probe distance, and rectal area have been measured and values have been compared among symptomatic and asymptomatic patients. RESULTS: Forty-five women with obstructive defecatory symptoms and 20 asymptomatic women entered the study. There was no significant difference in mean (SD) age (56.55 [SD] 13.29 vs 51.8 [15], P = 0.2), mean (SD) body mass index (27.39 [6.7] vs 24.2 [4.08], P = 0.11), and median (range) parity (3 [1-7] vs 2 [1-6], P = 0.15) among categories. There was significant difference in ultrasound measurements, levator plate descent angle, levator plate-probe distance, and rectal area, between women with obstructive defecatory symptoms and asymptomatic women. CONCLUSIONS: Women with obstructive defecatory symptoms have wider rectum and descendent levator plate regardless of the stage of prolapse as measured by POPQ or the severity of rectocele.

The Disability Impact and Associated Cost per Disability in Women Who Underwent Surgical Revision of Transvaginal Mesh Kits for Prolapse Repair.

OBJECTIVES: The aim of this study was to investigate disability impact in patients and cost to the families of patients who have had complications of transvaginal prolapse mesh kits and underwent surgical revision. METHODS: Patients who developed complications of transvaginal mesh kits for prolapse and who had undergone vaginal prolapse mesh surgical revision/removal in 2009 to 2014 at a single institution were identified by Current Procedural Terminology codes. The group was invited to complete a phone survey pertaining to the initial vaginal mesh used for prolapse surgery utilizing Sheehan Disability Scale (scale 0-10) and Years of life Lived with Disability (YLDs) questionnaires. The data collected were used to estimate the disability and cost analysis. We used our data to estimate the economic and quality-of-life impact of vaginal mesh complications on patients in the United States RESULTS: Sixty-two patients (62/198 [31.2%]) were consented to participate and completed the questionnaires by phone. Extremely disabled patients were 18 (29%) of 62 of whole cases, and 5 (8%) of 62 reported that they had no disability after vaginal mesh surgery. The median for overall disability score after vaginal mesh procedure was 8 (which reflects marked disability on a scale of 0-10). The majority of patients missed a median of 12 months of their school or work because of their mesh complications. Thirty-seven (59.6%) of 62 did not improve after mesh removal. Twenty-one (33.9%) of 62 stated that their family income dropped because of productivity loss related to mesh complications. The mean time between vaginal mesh surgery and mesh removal procedure was 4.7 years. Sheehan Disability Scale scores are significantly correlated with YLDs outcomes. Patients' overall disability score showed a significant correlation with YLDs scores (P < 0.0001). CONCLUSIONS: Vaginal mesh for prolapse reduction complications had a sustained disability impact that continued despite mesh removal. Likewise, the complications were associated with increased economic burden on the families of the effected individuals and a drop in the family income in more than one third of the families.

In Vivo Ultrasound Characteristics of Vaginal Mesh Kit Complications.

OBJECTIVE: The objective of this study was to investigate the ultrasound characteristics of vaginal mesh in women with vaginal mesh complications. METHODS: This was a cross-sectional study of women presenting with extrusion complications from vaginal mesh kit for prolapse at our tertiary care center between years 2009 and 2014. We included women who concurrently underwent a 3-dimensional endovaginal ultrasound (EVUS) as part of the clinical evaluation. We excluded women with incomplete charts and poor imaging quality. Subjects were categorized by the presence or absence of associated pelvic pain. Based on ultrasound findings, we compared the location of mesh, the appearance of mesh pattern (flat, folding, prominence, convoluted), and other EVUS characteristics of mesh. RESULTS: Forty-six women with vaginal mesh complications and good image quality were included. When comparing mesh length between posterior and anterior compartments, the posterior meshes were significantly longer than the anterior meshes (42.1 [SD, 11.9] mm vs 25.8 [SD, 9] mm; P < 0.0001) and more often associated with pain. In the posterior compartment, the mean mesh length seen on EVUS was significantly longer in women with pain than in women without pain (46.5 [SD, 9] mm vs 31.8 [SD, 12.1] mm; P = 0.0001). There was also a higher proportion of a "flat" mesh pattern, 14 (58.3%) of 25, in the posterior compartment associated with the presence of pain (P = 0.013). In the posterior compartment, a smaller distance between the distal edge of the mesh and the anal sphincter was significantly associated with the presence of pain (8 mm [0-37] vs 21 mm [8-35], P = 0.024). In both compartments, the EVUS had 100% sensitivity for detection of mesh extrusions. CONCLUSIONS: In this population of patients presenting with mesh complications, the posterior meshes were more often visualized as a "flat" pattern with a higher frequency of pain. Mesh complications of the anterior compartment had a higher frequency of folding and shrinkage.

Prenatal Therapy of Large Placental Chorioangiomas: Case Report and Review of the Literature.

Objective To review techniques and outcomes of different prenatal treatments for large placental chorioangiomas. Study Design Presentation of a case of laparoscopic-assisted laser coagulation and a systematic review of the literature for articles related to intervention for placental chorioangioma. Results A total of 37 cases of definitive (n = 23) and supportive therapy (n = 14) were evaluated, including one case treated in our center. Approximately 35% of the patients had a spontaneous preterm delivery in definitive treatment group versus 36% in the supportive group. The infant survival rates were 65 and 71% in the two groups, respectively. We further compared the two types of laser ablation (fetoscopic [n = 10] and interstitial [n = 4]). Approximately 30% of the patients in the fetoscopic and 25% in interstitial group, had a spontaneous preterm delivery. Survival rates were 60 and 100% in fetoscopic and interstitial groups, respectively. Conclusion Laser ablation and embolization of chorioangiomas via minimally invasive approach may prevent or reverse fetal hydrops due to high cardiac states. However, further studies are needed to refine the appropriate selection criteria that will justify the risk of this invasive in utero therapy for chorioangiomas.