Association of vitamin D deficiency and pelvic organ prolapse in postmenopausal women: a cross-sectional study.

BACKGROUND: Vitamin D is vital for skeletal integrity as well as optimal muscle work. High incidence and prevalence of vitamin D deficiency as well as pelvic organ prolapse are found in postmenopausal women, thus raising the question of whether the entities could be related. METHODS: We compared 50 postmenopausal women aged 50 to 75 years with pelvic organ prolapse (POP) with 48 women of same age without POP. The clinical assessment of the disorder was performed using the Pelvic Organ Prolapse Quantification system (POP-Q). An anamnestic questionnaire was filled out by the participants on their anthropometric data, life habits, reproductive history, previous and actual diseases. A blood sample was collected for determination of 25-OH-vitamin D as well as calcium and phosphorus concentrations. RESULTS: The group with POP and the control group were comparable in body mass index, physical activity, life habits and general health, but differed significantly in parity (being higher in POP) and vitamin D blood level concentrations, being lower in POP patients. A significantly higher prevalence of vitamin D deficiency (25-OH-vitamin D < 50 nmol/l) was found in the POP group compared to controls. Taking into account the confounding variables the logistic regression model confirmed the significant role of vitamin D for POP. CONCLUSIONS: Vitamin D deficiency might be an important systemic factor associated to pelvic organ prolapse. The determination of vitamin D levels in postmenopausal women and replenishing its deficiency might also be of importance for the pelvic floor.

Effectiveness of Magnetic Stimulation in the Treatment of Urinary Incontinence: A Systematic Review and Results of Our Study.

Urinary incontinence (UI) is becoming an increasingly common health problem. UI treatment can be conservative or surgical. This paper focuses on the effectiveness of magnetic stimulation (MS) in the treatment of UI. We performed a systematic review in order to combine and compare results with results from our clinical study. A clinical prospective non-randomized study was carried out at the Ljubljana University Medical Center's Gynecology Division. It included 82 randomly selected female patients, irrespective of their UI type. The success rate of using MS in treating UI was based on standardized ICIQ-UI SF questionnaires. Patients completed 10 therapy sessions on MS, and follow-up was performed 3 months after the last therapy session. UI improved after treatment with MS. The ICIQ-UI SF score improved in patients regardless of the type of UI. However, the greatest decrease in post-treatment assessment ICIQ-UI SF scores was seen in patients with stress urinary incontinence (SUI). Based on the findings described above, it can be concluded that MS is a successful non-invasive conservative method for treating UI. Future studies are necessary, all of which should include a large sample size, a control group, an optimal research protocol, pre-treatment analyses, standardization, and longer follow-ups.

Single-Incision Mini-Sling for the Treatment of Female Stress Urinary Incontinence: Is it Actually Inferior to Transobturator Vaginal Tape and Tension-Free Vaginal Tape?

OBJECTIVES: The aim of the study was to report the extended long-term results of the use of single-incision mini-sling (SIMS), tension-free vaginal tape (TVT), and transobturator tape (TOT) for the treatment of female stress urinary incontinence (SUI) at the Department of Gynecology and Obstetrics of the University Medical Center Ljubljana. MATERIALS AND METHODS: Enrolled women were evaluated by Patient Global Impression of Severity (PGI-S), Patient Global Impression of Improvement (PGI-I), Sandvik severity scale, Urogenital Distress Inventory (UDI-6), Incontinence Impact Questionnaire (IIQ-7), and Incontinence Questionnaire-Urinary Incontinence (ICIQ-UI) Short Form and data about diagnosis, procedures, complications, reoperations, postoperative results, and satisfaction with procedure were recorded. RESULTS: In analyzed group of patients (n = 357), 116 (32%) underwent SIMS procedure, 189 (53%) TOT, and 52 (15%) TVT. The SIMS, TOT, and TVT groups did not differ significantly from each other in PGI-S, PGI-I, Sandvik severity scale, UDI-6, IIQ-7, and ICIQ-UI Short Form or in postoperative complication rate. Repeat surgery was needed in 9.5% after SIMS, in 13.2% of TOT patients and in 23.1% of TVT patients (P = 0.194). Urinary retention occurred in 9.5% of the SIMS patients, in 9.5% of the TOT patients, and in 13.5% of the TVT patients (P = 0.682). Mesh erosion/inflammation occurred in 3.4% of the SIMS patients, in 6.3% of the TOT patients, and in 3.8% of the TVT patients (P = 0.485). CONCLUSION: The efficacy and safety of SIMS, TOT, and TVT in the surgical treatment of SUI are comparable. The choice of the technique should be based on the relative pros and cons of techniques and the surgeon's experience.

Primary debulking surgery versus primary neoadjuvant chemotherapy for high grade advanced stage ovarian cancer: comparison of survivals.

Background The aim of the study was to analyze the overall survival (OS) and progression free survival (PFS) of patients with high grade and advanced stage epithelial ovarian cancer (EOC) with at least 60 months of follow-up treated in a single gynecologic oncology institute. We compared primary debulking surgery (PDS) versus neoadjuvant chemotherapy plus interval debulking surgery (NACT + IDS) stratifying data based on residual disease with the intent to identify the rationale for therapeutic option decision and the role of laparoscopic evaluation of resectability for that intention. Patients and methods This is observational retrospective study on consecutive patients with diagnosis of high grade and International Federation of Gynecology and Obstetrics (FIGO) stage III/IV EOC referred to our center between January 2008 and May 2012. We selected only patients with a follow-up of at least 60 months. Primary endpoint was to compare PDS versus NACT + IDS in term of progression free survival (PFS) and overall survival (OS). Secondary endpoints were PFS and OS stratifying data according to residual disease after surgery in patients receiving PDS versus NACT + IDS. Finally, through Cox hazards models, we tested the prognostic value of different variables (patient age at diagnosis, residual disease after debulking, American Society of Anesthesiologists (ASA) stage, number of adjuvant-chemotherapy cycles) for predicting OS. Results A total number of 157 patients were included in data analysis. Comparing PDS arm (108 patients) and NACT + IDS arm (49 patients) we found no significant differences in term of OS (41.3 versus 34.5 months, respectively) and PFS (17.3 versus 18.3 months, respectively). According to residual disease we found no significant differences in term of OS between NACT + IDS patients with residual disease = 0 and PDS patients with residual disease = 0 or residual disease = 1, as well as no significant differences in PFS were found comparing NACT + IDS patients with residual disease = 0 and PDS patients with residual disease = 0; contrarily, median PFS resulted significantly lower in PDS patients receiving optimal debulking (residual disease = 1) in comparison to NACT + IDS patients receiving complete debulking (residual disease = 0). PDS arm was affected by a significant higher rate of severe post-operative complications (grade 3 and 4). Diagnostic laparoscopy before surgery was significantly associated with complete debulking. Conclusions We confirm previous findings concerning the non-superiority of NACT + IDS compared to PDS for the treatment of EOC, even if NACT + IDS treatment was associated with significant lower rate of post-operative complications. On the other hand, selecting patients for NACT + IDS, based on laparoscopic evaluation of resectabilty prolongs the PFS and does not worse the OS compared to the patients not completely debulked with PDS.

Ureteral injuries during different types of hysterecomy: A 7-year series at a single university center.

OBJECTIVES: Accidental ureteral injury with gynaecologic surgery, especially hysterectomy, represents a high risk of patient morbidity. The incidence may vary from centre to centre. As the introduction of new minimally invasive surgical techniques and instruments may have affected the incidence of ureteral injury, we de novo analysed the incidence data for the last seven years. STUDY DESIGN: Incidence of ureteral injury was analysed stratifying the data according to the type of hysterectomy (n = 3071). The incidence rate was reported as a confidence interval (CI). Ureteral injuries were classified as direct or indirect. RESULTS: Fifteen ureteral injuries were registered. The highest incidence was evidenced for radical hysterectomy (CI: 0.82-3.99), followed by laparoscopic radical hysterectomy (CI: 0-11.9). The incidence of direct ureteral injury was 26.6%, half of which were identified during the operative procedure. In 26.7% of the operations resulting in ureteral injury, heat-generating instruments were used. CONCLUSIONS: The incidence of ureteral injury during different types of hysterectomy was low. The majority of injuries were indirect. These were injuries which resulted from a micro-trauma, and developed due to the delayed necrosis of the ureteral wall. Laparoscopic approach to radical and simple hysterectomy didn't substantially raise the incidence of ureteral injury.

Long-term self-assessment of urinary continence after stress urinary incontinence surgery.

OBJECTIVES: To evaluate the long-term subjective urinary continence status and quality of life after 3 types of primary operation for stress urinary incontinence. METHODS: One hundred thirty-four consecutive patients who underwent anti-incontinence surgery (laparoscopic colposuspension, classic tension-free vaginal tape procedure, or open colposuspension) 6 to 9 years ago were mailed short-form questionnaires of the International Consultation on Incontinence Questionnaire-Urinary Incontinence. For statistical analysis, the Student t test, the χ test, and the analysis-of-variance test were used. RESULTS: Eighty-seven patients (64.9%) returned the questionnaire. The mean follow-up was 7.48 years (range, 6-9 years). Patients in the tension-free vaginal tape group were significantly older (P < 0.001). After primary operation, 7.4% (2 of the 27 patients) in the laparoscopic colposuspension group, 23.53% (8/34) in the classic tension-free vaginal tape group, and 11.5% (3/26) in the open colposuspension group were continent. Repeated operative treatment was more frequent in the laparoscopic colposuspension (18.5%) and open colposuspension (30%) groups compared with the tension-free vaginal tape group (0%; P ≤ 0.003). Calculated scores from the questionnaire from all 3 groups indicated moderate to severe recurrent urinary incontinence with equal prevalence of symptoms of stress, urge, or mixed urinary incontinence. CONCLUSIONS: Subjective urinary continence 6 to 9 years after primary operative treatment was low for all analyzed procedures.

Correlations between the ICIQ-UI short form and urodynamic diagnosis.

AIMS: Urinary incontinence is a common symptom in many diseases as well as in general population. To measure the impact of urinary incontinence (UI) on individual's quality of life the English short form International Consultation on Incontinence questionnaire (ICIQ-UI Short Form) has been developed, which consists of three scored and one self-diagnostic question. Our aim was to translate the ICIQ-UI Short Form into Slovene, re-validate it, and test the diagnostic value of the questionnaire in determining the type of UI. METHODS: ICIQ-UI Short Form was translated into Slovene and re-validated. In the validation process we included urology and gynecology outpatient clinics attendants, elderly institutionalized patients, and a community sample. One group of patients underwent urodynamic testing and the results were compared to their responses to question six of the ICIQ-UI Short Form. Both sets of answers were compared using the Kappa (kappa) statistics. RESULTS: The Slovene version of the ICIQ-UI Short Form was found to be valid (excellent test-retest reliability, good internal consistency, good responsiveness to change, and reflected well underlying theories). The questionnaire correlated well with urodynamic findings. The perceived cause of leakage (Question 6) was a good indicator of objectively proven cause of incontinence (Kappa value 0.77). CONCLUSIONS: We found that the Slovene version of the ICIQ-UI Short Form is a valid and reliable questionnaire for assessment of UI. In addition to its ability to assess the impact of UI on individual's quality of life it also has a diagnostic value of the cause of incontinence.

Non-neurogenic urinary retention (Fowler's syndrome) in two sisters.

AIMS: To report for the first time occurrence of obstructed voiding due to excessive activity of the urethral sphincter (US) muscle in two sisters with polycystic ovaries (Fowler's syndrome). METHODS: In both patients precise micturition history was obtained. In addition, clinical neurological and gynecological examinations, cystometry, urethral pressure profile measurements, gynecological ultrasound, measurement of gonadotropic hormone levels, and concentric needle electromyography (EMG) of the US muscle were performed. RESULTS: Both sisters reported symptoms of severely obstructed voiding. Clinical examination, and filling cystometries were normal. Urethral pressures were increased (99-134 cm water). The first sister was not able to void, and the urinary flow was slow and intermittent in the second on voiding studies. Profuse complex repetitive discharges and decelerating burst activity were found on concentric needle EMG of the US in both of them. Both sisters had increased LH/FSH ratio (2.96 and 2.64), and ultrasonographic abnormalities compatible with polycystic ovaries. CONCLUSIONS: Diagnosis of Fowler's syndrome was made in both sisters. Due to very low incidence rate of this syndrome (0.2/100.000 per year), we think that it is highly unlikely to find it in two sisters just by chance. We suggest that the probable explanation is a genetic predisposition to polycystic ovaries, with which this condition has been shown to be associated.

Lymph node mapping and sentinel node detection in patients with cervical carcinoma: a 2-year experience.

OBJECTIVE: To describe our experience with the sentinel lymph node biopsy in cervical cancer patients, using a laparotomic approach and blue dye technique. METHODS: Between January 2003 and January 2005, patients with histologically proven FIGO stage IA2 to IIA carcinoma of the uterine cervix were submitted to SLN procedure if they were scheduled to have radical abdominal hysterectomy and pelvic lymphadenectomy. The SLN mapping was done after intracervical methylene blue (4 ml) injection. Final pathologic evaluation of SLNs included serial step sections and wide spectrum cytokeratin immunohistochemical analysis. RESULTS: Fifty patients were accrued to this prospective observational double-center study. A total of 86 SLNs (mean 1.9) were identified in the 45 patients with fruitful quest for SLN detection. The SLN detection rate per patient was 90%, and for the side of dissection, 72%. Bilateral SLNs were detected in 60% of cases. SLNs were identified in the external iliac and obturator areas in 55% and 38%, respectively; 5 isolated SLNs were discovered in the common iliac region. Ten patients (20%) had lymph node metastases; one of these had false-negative SLN. The false-negative rate and the negative predictive value, calculated by patient and by side of dissection, were 10% and 97.2%, and 8.3% and 98.4%, respectively. CONCLUSIONS: SLN detection with blue dye is a feasible procedure, particularly useful as a surgical staging procedure in young patients with small tumors. The true morbidity-sparing role of this technique in cervical cancer treatment is yet to be found.

Compliance of the bladder neck supporting structures: importance of activity pattern of levator ani muscle and content of elastic fibers of endopelvic fascia.

AIMS: Firm bladder neck support during cough, suggested to be needed for effective abdominal pressure transmission to the urethra, might depend on activity of the levator ani muscle and elasticity of endopelvic fascia. METHODS: The study group of 32 patients with stress urinary incontinence and hypermobile bladder neck, but without genitourinary prolapse, were compared with the control group of 28 continent women with stable bladder neck. The height of the bladder neck (HBN) and compliance of the bladder neck support (C) were assessed, the latter by the quotient of the bladder neck mobility during cough and the change in abdominal pressure. By using wire electrodes, the integrated full-wave rectified electromyographic (EMGave) signal of the levator ani muscle was recorded simultaneously with urethral and bladder pressures. The pressure transmission ratio (PTR), time interval between the onset of muscle activation and bladder pressure increment (DeltaT), and area under the EMGave curve during cough (EMGcough) were calculated. From bioptic samples of endopelvic fascia connecting the vaginal wall and levator ani muscle, elastic fiber content was assessed by point counting method. Mann-Whitney test was used to compare all the variables. Correlations between the parameters were evaluated by using the Spearman correlation coefficient. RESULTS: In the study group, HBN was significantly lower (P < 0.001), C was significantly greater (P < 0.001), and PTR was significantly lower (P < 0.001). In the study group, the muscular activation started later (median, DeltaT(l), -0.147 second; DeltaT(r), -0.150 second), and in the control group, it preceded (DeltaT(l), 0.025 second; P < 0.001; DeltaT(r), 0.050 second; P < 0.001) the bladder pressure increment. EMGcough on the left side was significantly greater in the study group (P < 0.046). Elastic fiber content showed no difference between the groups. The analysis of all patients revealed negative correlations between C and PTR (r = -0.546; P < 0.001) and between C and DeltaT(l) (r = -0.316; P < 0.018). CONCLUSIONS: Firm bladder neck support enables effective pressure transmission. Timely activation of the levator ani seems to be an important feature.

Differences in the quantity of elastic fibres and collagen type I and type III in endopelvic fascia between women with stress urinary incontinence and controls.

The aim of this study was to evaluate whether differences in the quantity of elastic fibres, collagen type I and collagen type III in the endopelvic fascia occur with female stress urinary incontinence (SUI). A total of 54 patients participated in the study. They were divided into two groups (continent and incontinent) that were comparable with respect to age and parity. All patients underwent gynaecologic surgical procedures and biopsies from the endopelvic fascia were obtained. Histological slides were stained with haematoxylin and eosin and Masson trichrome or Weigert's techniques and immunohistochemistry for either collagen type I or type III were performed. The elastic fibres constituted 3.81+/-0.6% and 5.93+/-0.92% of the cross-sectional area of the endopelvic fascia in incontinent and control groups of patients, respectively. Collagen type I and type III were not significantly reduced in patients with SUI. Our results suggest that the quantity of elastic and collagen fibres in the endopelvic fascia does not play a significant role in continence.