[Clinicopathological and molecular genetic features of confined placental mosaicism].

Objective: To investigate the clinicopathological and genetic features of confined placental mosaicism (CPM) and its effect on fetal intrauterine growth. Methods: Fourteen CPM cases of Haidian Maternal and Children Health Hospital were collected from May 2018 to March 2022. Clinicopathological examination on placental specimens and molecular genetic analysis were performed. Results: The age of the parturient women ranged from 27 to 34 years, with an average age of (30.0±3.54) years. The gestational weeks ranged from 35+1 to 41+2 weeks. There were 4 premature births and 10 term births, among which 6 were female and 8 were male fetuses. Nine cases (9/14) had adverse pregnancy outcomes, including 7 cases of fetal growth restriction. The weight of CPM placenta decreased, with 6 cases below the 10th percentile of weight standards and 5 cases between the 10th and 25th percentile. All 14 CPM placental specimens showed morphological changes of perfusion dysfunction to varying degrees, with mainly placental-maternal vascular malperfusion followed by placental-fetal vascular malperfusion. The mosaic chromosomes in different CPM cases varied, with 16-trisomy/monosomy mosaicism being the most common followed by 7-trisomy and 21-trisomy/monosomy mosaicism. The mosaic proportion was unequal in different parts of the same CPM placenta, with the mosaic proportion of umbilical cord, fetal membranes, fetal surface, maternal surface, and edge ranging from 1% to 70%. Conclusions: The mosaic chromosomes in different CPM cases vary, and the mosaic proportion is unequal in different parts of the same CPM placenta. The pathological morphology is mainly manifested as perfusion dysfunction, which can lead to adverse pregnancy outcomes such as fetal growth restriction and preterm birth.

[Autopsies and placental examinations of perinatal fetal deaths: a clinicopathological analysis of 105 cases].

Objective: To summarize the clinicopathological factors related to perinatal fetal death and to evaluate importance of fetal autopsy and placental pathology. Methods: The clinicopathological data of 105 perinatal fetal deaths in Beijing Haidian Maternal and Child Health Hospital from November 2012 to December 2020 were retrospectively analyzed. Relevant literature was also reviewed. Results: The maternal age of the deceased fetuses ranged from 22 to 43 years with the average (31.35±4.04 years), and the gestational weeks were 28-40+6 weeks. Among them, 101 were singleton cases and 4 twin cases. 103 fetuses died in uterus and 2 died during delivery. Relevant factors analysis of the 105 perinatal fetal deaths showed that 86 cases (81.9%, 86/105) were related to umbilical cord/placental abnormality, 10 cases (9.5%, 10/105) uterine infection, 6 cases (5.7%, 6/105) fetal factors, 1 case was fetal maternal blood transfusion syndrome, 1 case twin blood transfusion syndrome, and 1 case died of complete uterine rupture. Among the 86 cases related to umbilical cord/placental abnormality, the diagnosis was most often based on the gross examination of placenta. The most common cause of death was umbilical cord torsion with thin root, followed by placental abruption, tight umbilical cord winding, vascular rupture and umbilical cord true knot. The morphology of placenta revealed mainly functional changes. Among the 10 cases related to intrauterine infections, the placenta generally showed lobular placental edema. The morphological characteristics of ascending infection were mainly acute chorioamnionitis, and the morphological characteristics of blood-borne infection were mainly acute or chronic villitis, as well as villous interstitial inflammation. Identification of viral inclusions suggested viral etiology, while the final diagnosis was relied on laboratory testing. Among the 6 cases related to fetal abnormality, the diagnostic value of placenta was limited and the diagnosis could be made with fetal autopsy. Conclusion: The causes of perinatal fetal death are complex, diverse, and often the synergistic result of multiple factors. Fetal autopsy and placental pathology are the key technical means to identify the cause of death and deserve more attention and utilization.

[Singleton placentas with abnormal shape: a clinicopathological analysis of 130 cases].

Objective: To investigate the pathological characteristics of singleton placenta with abnormal shape and its influence on the outcome of maternal-fetal pregnancy. Methods: The clinicopathological data of singleton placentas with abnormal shape from January 2014 to December 2020 in the Department of Pathology, Haidian Maternal and Children Health Hospital were analyzed retrospectively. Results: There were 130 singleton placentas with abnormal shape in this cohort, including 48 succenturiate placentas, 12 bilobed placentas, 50 marginate placentas, 13 circumvallate placentas, 3 annular placentas, 2 membranous placentas and 2 fenestrated placentas. Gestational age ranged from 29+5 to 40+4 weeks. There were 51 cases of premature rupture of membranes, 11 cases of placenta previa, 5 cases of placental abruption, 15 cases of placental adhesion/implantation and 27 cases of postpartum hemorrhage. There were 46 preterm fetuses,28 fetuses with fetal growth restriction, 22 fetuses with intrauterine distress, and 1 fetus with intrauterine death. Grossly, the placental lobules of succenturiate placentas had apparent size difference, while two lobules of bilobate placenta were more consistent. The chorionic plate size was smaller than the bottom plate of circumvallate placenta, the folded fetal membrane in the rim of placenta was thickened (termed marginate placenta if there was no thickening). The membranous placenta was characterized by a thin, large membrane-like shape. Annular placenta showed characteristic hollow cylinder, ring or horseshoe-shape. Fenestrated placenta was characterized by tissue defects near central area. Microscopically, functional/morphologic changes were the main manifestations of inadequate maternal-fetal perfusion, including villous infarction, distal villous dysplasia and excessive villous maturation. Conclusions: The abnormal shaped singleton placentas showed variable extent of inadequate maternal-fetal perfusion, which may lead to adverse pregnancy outcomes such as premature delivery, fetal growth restriction, intrauterine distress or fetal death.

The association between nocturia, hormonal symptoms and bladder parameters in women: an observational study.

OBJECTIVE: Postmenopausal nocturia is poorly understood. This study aimed to identify hormonal and lifestyle factors associated with nocturia and to understand the relative contribution of altered urine production and bladder storage dysfunction in women. DESIGN, SETTING, POPULATION AND METHODS: Women ≥40 years presenting to public continence services were enrolled in a cross-sectional study. A total of 153 participants completed a hormone status questionnaire, a validated nocturia causality screening tool and a 3-day bladder diary. Descriptive statistics and logistic regression models for nocturia severity and bladder diary parameters were computed. RESULTS: Overall, 91.5% reported nocturia, 55% ≥2 /night. There was a difference of 167.5 ml (P < 0.001) in nocturnal urine volume between women with nocturia ≥2 (median 736 ml) versus less often (517 ml). Significant predictors of self-reported disruptive nocturia were age (odds ratio [OR] 1.04, 95% CI 1.002-1.073) and vitamin D supplementation (OR 2.33, 95% CI 1.11-4.91). Nocturnal polyuria was significantly more common with nocturia ≥2 compared with less frequent nocturia (P < 0.002). Exercise for 150 minutes a week was protective for nocturnal polyuria (OR 0.22, P = 0.001). Nocturia index >1.3 was significantly predicted by age (OR 1.07, P < 0.001), regular exercise (OR 0.41, P = 0.036), day flushes (OR 4.00, P = 0.013) and use of vitamin D (OR 2.34, P = 0.043). Maximum voided volumes were significantly lower with nocturia ≥2 versus less often (night: 268 ml versus 350 ml; day: 200 ml versus 290 ml). CONCLUSIONS: Bothersome nocturia in postmenopausal women is associated with changes to both nocturnal diuresis and bladder storage. Regular physical activity, prolapse reduction and oestrogen replacement may be adjunctive in managing bothersome nocturia in women.

[Artificial intelligence aided measurement of cervical squamous epithelial thickness and its correlation with cervical precancerous lesions].

Objective: To study the thickness of cervical squamous epithelia and its correlation with cervical precancerous lesions. Methods: We selected 495 HE slides of 209 cervical biopsies from January 2020 to June 2020 in the Department of Pathology, the First and Seventh Medical Center of the PLA General Hospital, including 173 slides with low grade squamous intraepithelial lesion (LSIL) and 214 slides with high grade squamous intraepithelial lesion (HSIL). Artificial intelligence labeling software was used to assist in measuring the epithelial thickness of normal cervical squamous epithelium, LSIL and HSIL of each slide. The thickest, thinnest, and middle widths of epithelial thickness were measured, respectively. Average epithelial thickness was defined as the sum of the above three widths divided by 3. The correlation statistical analysis was performed by combining the data of age and pathological diagnosis. Results: The average thickness of normal cervical squamous mucosa was (245.83±91.40) µm, which was (222.42±81.22) µm and was (195.95±66.59) µm in LSIL and HISL epithelial respectively (F=27.09, P<0.01). The average cell layers of normal cervical squamous epithelium was (15.5±4.2) layers, which of LSIL was (14.8±4.8) layers, and that of HSIL was (15.8±4.8) layers. The differences among normal, LSIL and HSIL were not statistically significant (P>0.05). Further statistical analysis was stratified by age (≤30 years, 31-40 years, 41-50 years, 51-60 years, and >60 years), the results of Pearson correlation analysis showed that the thickness of normal cervical squamous epithelial gradually thinned with age (correlation coefficient r=-0.141 9, P<0.05), while LSIL and HSIL epithelial thickness had significant correlation with age (P>0.05). In the subgroup of ≤50 years old, the epithelial thickness of normal squamous epithelium was the thickest, followed by LSIL, and HSIL epithelial thickness was the thinnest. The differences were statistically significant (P<0.05). While in the subgroup of >50 years, the differences were not statistically significant (P>0.05). Conclusions: The cervical squamous epithelium gradually becomes thinner with the degree of precancerous lesions increasing among patients of ≤50 years old. However, after age of 50 years, with the onset of menopause, the normal mucosal epithelium is becoming atrophy, so that mucosal thickness is no longer correlated with the extent of the lesion. In addition, it is suggested that the cervical vinegar white test performance during colposcopy is related to the protein changes in the mucosal epithelial cells, but not directly related to the thickness of the epithelial layer.

Interactive effects of age and estrogen on cortical neurons: implications for cognitive aging.

In the past few decades it has become clear that estrogen signaling plays a much larger role in modulating the cognitive centers of the brain than previously thought possible. We have developed a nonhuman primate (NHP) model to investigate the relationships between estradiol (E) and cognitive aging. Our studies of cyclical E treatment in ovariectomized (OVX) young and aged rhesus monkeys have revealed compelling cognitive and synaptic effects of E in the context of aging. Delayed response (DR), a task that is particularly dependent on integrity of dorsolateral prefrontal cortex (dlPFC) area 46 revealed the following: (1) that young OVX rhesus monkeys perform equally well whether treated with E or vehicle (V), and (2) that aged OVX animals given E perform as well as young adults with or without E, whereas OVX V-treated aged animals display significant DR impairment. We have analyzed the structure of layer III pyramidal cells in area 46 in these same monkeys. We found both age and treatment effects on these neurons that are consistent with behavioral data. Briefly, reconstructions of pyramidal neurons in area 46 from these monkeys showed that cyclical E increased the density of small, thin spines in both young and aged monkeys. However, this effect of E was against a background of age-related loss of small, thin spines, leaving aged V-treated monkeys with a particularly low density of these highly plastic spines, and vulnerable to cognitive decline. Our current interpretation is that E not only plays a critically important role in maintaining spine number, but also enables synaptic plasticity through a cyclical increase in small highly plastic spines that may be stabilized in the context of learning. Interestingly, recent studies demonstrate that chronic E is less effective at inducing spinogenesis than cyclical E. We have begun to link certain molecular attributes of excitatory synapses in area 46 to E effects and cognitive performance in these monkeys. Given the importance of synaptic estrogen receptor α (ER-α) in rat hippocampus, we focused our initial studies on synaptic ER-α in area 46. Three key findings have emerged from these studies: (1) synaptic ER-α is present in axospinous synapses in area 46; (2) it is stable across treatment and age groups (which is not the case in rat hippocampus); and (3) the abundance and distribution of synaptic ER-α is a key correlate of individual variation in cognitive performance in certain age and treatment groups. These findings have important implications for the design of hormone treatment strategies for both surgically and naturally menopausal women. This article is part of a Special Issue entitled: Neuroactive Steroids: Focus on Human Brain.

Long-term Safety and Tolerability of Colesevelam HCl in Subjects with Type 2 Diabetes.

The bile acid sequestrant, colesevelam hydrochloride, is approved for glycemic control in adults with type 2 diabetes. In three double-masked, placebo-controlled studies, colesevelam hydrochloride 3.75 g/day demonstrated its glycemic-lowering properties when added to existing metformin-, insulin-, or sulfonylurea-based therapy in adults with inadequately controlled type 2 diabetes. This was a 52-week open-label extension study conducted at 63 sites in the United States and one site in Mexico to further evaluate the safety and tolerability of colesevelam hydrochloride in subjects with type 2 diabetes. All subjects who completed the three double-masked, placebo-controlled studies were eligible to enroll in this open-label extension. In total, 509 subjects enrolled and received open-label colesevelam hydrochloride 3.75 g/day for 52 weeks. Safety and tolerability of colesevelam hydrochloride was evaluated by the incidence and severity of adverse events. In total, 360 subjects (70.7%) completed the extension. Of the safety population, 361 subjects (70.9%) experienced an adverse event, most (88.1%) being mild or moderate in severity. Fifty-six adverse events (11.0%) were drug-related; the most frequent drug-related adverse events were constipation and dyspepsia. Thirty-five subjects (6.9%) discontinued due to an adverse event. Fifty-four subjects (10.6%) experienced a serious adverse event; only one was considered drug-related (diverticulitis). Seventeen subjects (3.3%) experienced hypoglycemia; most episodes were mild or moderate in severity. Glycemic improvements with colesevelam hydrochloride were seen without change in weight over 52 weeks (0.2 kg mean reduction from baseline). Colesevelam hydrochloride was safe and well-tolerated as long-term therapy for patients with type 2 diabetes.

Role of TLR4 for paclitaxel chemotherapy in human epithelial ovarian cancer cells.

BACKGROUND: Paclitaxel has been reported to be a ligand to Toll like receptor 4 (TLR4). Myeloid differentiation factor 88(MyD88) was described as a myeloid differentiation primary response gene. TLR4 signalling owns two pathways: MyD88-dependent and MyD88-independent pathways. XIAP is a key member of the inhibitor of apoptosis protein family. Akt is a major downstream target of growth factor receptor tyrosine kinases, which negatively regulates apoptotic pathways through phosphorylation (pAkt). The aim of the present study is to investigate the role of TLR4 in paclitaxel resistance of ovarian cancer cells. MATERIALS AND METHODS: We reconstructed the RNA interference expression vector, pGenesil-1-U6 specifically targeting TLR4 mRNA, which was stable transfected into the human ovarian cancer cell line SKOV3 (MyD88-positive expression) and A2780 (MyD88-negative expression). Cell proliferation, cell cycle distribution and cell apoptosis were assessed in the cells transfected with scramble control shRNA (SKOV3/shControl, A2780/shControl) and TLR4 shRNA (SKOV3/shTLR4, A2780/shTLR4) to explore the possible functions of TLR4 in ovarian cancer cells growth. The expression of TLR4, MyD88, XIAP, Akt and pAkt was analysed by Western blot analysis. RESULTS: A knockdown of TLR4 levels down-regulated the expression of XIAP and pAkt. And it restored the inhibitory effect of paclitaxel on cell proliferation and impeding cell cycle progression in SKOV3 cells. CONCLUSIONS: It suggests that TLR4 negatively regulates paclitaxel chemotherapy and MyD88 is an essential downstream factor to TLR4 signalling for this resistance. Knockdown of TLR4 induces paclitaxel chemosensitivity which might depress the Akt pathway. The TLR4-MyD88 signalling represents an important source to promote tumour growth.

Postoperative management of incidental durotomy in minimally invasive lumbar spinal surgery.

Unintended durotomy is a relatively common complication in spine surgery, with a reported incidence up to 14%. Traditional management has been mandatory bed rest for at least 48 h following repair, with or without placement of a drain. With the muscle-splitting approach and decreased potential (dead) space created during minimally invasive spinal surgery (MISS), there is less potential likelihood of symptoms such as spinal headaches or cerebrospinal fluid fistulas. We reviewed the cases of 5 patients undergoing lumbar MISS complicated by an incidental dural tear. Surgical treatment consisted of primary repair and/or use of DuraGen followed by application of either DuraSeal or Tisseel. Although the duration of bed rest varied, postoperative management involved early mobilization less than 48 h after surgery without the use of a drain. One patient was mobilized early on the second postoperative day, 2 patients were mobilized the morning after surgery, and 2 patients were mobilized immediately upon recovery from anesthesia. None of the patients developed symptoms related to durotomy. Although this represents a small series, early postoperative mobilization appears to be a reasonable option and results in shorter hospitalization.

The correlation between preoperative voiding mechanism and surgical outcome of the tension-free vaginal tape procedure, with reference to quality of life.

OBJECTIVES: To determine whether the surgical outcome of the tension-free vaginal tape (TVT) procedure differs in patients with dysfunctional voiding (DV) or normal voiding. PATIENTS AND METHODS: The voiding mechanism and surgical efficacy of the TVT procedure were analysed retrospectively by reviewing the charts of 79 consecutive women treated over 2 years. Based on their initial voiding mechanism, the patients were divided into two groups, with or without DV. The King's Health Questionnaire was used to evaluate the women's quality of life both before and 1 year after surgery. RESULTS: The change in free maximum urinary flow rate (Qmax) after surgery differed significantly between the groups (P = 0.001). Moreover, both before and after surgery, the free Qmax was significantly lower (P = 0.019 and 0.001, respectively), and the detrusor pressure at Qmax (both P < 0.001) and urethral resistance (P = 0.036 and 0.027, respectively) significantly higher in the group with DV. The subjective outcome measure showed that the cure rates were not significantly different in the two groups (P = 0.173), but the objective outcome measure showed a significant difference (P = 0.025). Analysis of the total scores for all domains showed that significantly more women improved by> 25% in the group without than in those with DV (P = 0.016). CONCLUSIONS: The objective cure rate of the group without DV undergoing the TVT procedure was significantly higher than in those with DV. In addition, subjective measures assessed by the disease-specific quality-of-life questionnaire indicated that the group without DV had a better quality of life than those with DV.

Peroxisome proliferator-activated receptor-gamma regulates airway epithelial cell activation.

The peroxisome proliferator-activated receptors (PPARs) are nuclear hormone transcription factors that regulate genes associated with lipid and glucose metabolism. Recent evidence suggests that PPAR-gamma may also act as a negative immunomodulator. To investigate the potential role of PPAR-gamma in regulating airway inflammation, we characterized the expression and function of PPAR-gamma in airway epithelial cells. Airway epithelial cells constitutively express PPAR-gamma-specific messenger RNA and protein. Further, airway epithelial PPAR-gamma is inducible by interleukin (IL)-4 in NIH-A549 cells. Two PPAR-gamma agonists, the prostaglandin D2 metabolite 15-deoxy-(Delta)(12,14) prostaglandin J2 (15d-PGJ2) and a thiazolidinedione, ciglitazone, were used to study the effects of PPAR-gamma activation on airway epithelial cytokine expression. Activation of PPAR-gamma stimulated a PPAR-responsive reporter gene in a ligand-specific manner. In NIH-A549 cells, both ligands also blocked the cytokine-induced expression of the inducible form of nitric oxide synthase in a dose-dependent manner. In contrast, ciglitazone alone had a slight effect on cytokine-induced IL-8 secretion, but markedly inhibited IL-8 secretion from cells pretreated with IL-4. The demonstration of PPAR-gamma expression and function in airway epithelial cells expands the immunoregulatory role of PPARs and suggests a critical role for PPAR-gamma in antagonizing proinflammatory pathways in the airways.

Fibronectin regulates the activation of THP-1 cells by TGF-beta1.

OBJECTIVE AND DESIGN: To determine how fibronectin regulates the immunomodulatory effects of transforming growth factor (TGF)-beta on THP-1 cells. MATERIAL OR SUBJECTS: THP-1 monocytic cell line. TREATMENT: THP-1 cells were primed for 48 h in the presence or absence of 250 pM TGF-beta1. METHODS: Assays or assessments carried out, together with statistical test applied. RESULTS: We found that adherence to fibronectin dramatically modulates the effects of TGF-beta1 on the human monocytic cell line THP-1. TGF-beta did not significantly affect constitutive interleukin (IL)-8 secretion or IL-1beta-induced IL-8 secretion from suspended cells. In contrast, TGF-beta stimulated IL-8 secretion as well as augmented IL-1beta-induced IL-8 secretion from adherent cells. The differential effects of TGF-beta1 on IL-8 secretion from suspended and adherent cells could not be explained by differences in IL-1 receptor antagonist production. The effects of fibronectin on TGF-beta1 induced IL-8 secretion from THP-1 cells were mimicked by adhesion to immobilized anti-a4beta1 integrin antibody and to a fibronectin fragment containing the CS-1 domain. CONCLUSIONS: These results indicate that alpha4beta1-mediated adhesion to fibronectin may play a key role during inflammation by profoundly influencing the effects of TGF-beta1 on monocytes.

Randomized comparison of local versus epidural anesthesia for tension-free vaginal tape operation.

PURPOSE: We determine the difference between local anesthesia and epidural blockade for the tension-free vaginal tape operation. MATERIALS AND METHODS: Between November 1995 and November 1997, 73 women who had genuine stress incontinence in the absence of pelvic prolapse underwent a prospective randomized study. The study was conducted using a standardized protocol for different types of anesthesia for the tension-free vaginal tape procedure. A formal pain scale was used to determine the pain score for the patients during the operation. Additionally an anxiety scale was used to measure the anxiety level of the subjects immediately after admission to the ward and before discharge from the hospital. RESULTS: One woman was excluded from study due to loss at followup. The comparisons of pain score, duration of procedure and anxiety level of the 2 different types of anesthesia were not significantly different in the 72 study subjects. There was no significant difference in the amount of blood loss, while initial spontaneous voiding occurred significantly earlier (3.5 +/- 2.3 versus 5.8 +/- 0.1 hours, p <0.01), the number of patients in whom initial spontaneous voiding occurred more than 6 hours postoperatively was fewer (2 versus 10, p =0.01), amount of post-void residual during hospitalization was significantly less (98 +/- 63 versus 155 +/- 56 ml., p <0.01) and length of hospital stay was significantly shorter (3.4 +/- 1.4 versus 5.5 +/- 1.6 days, p <0.01) in the local anesthesia compared to epidural group. Subjective and objective success rates were not significantly different in these 2 groups. CONCLUSIONS: Both anesthetic methods can be equally effectively used for the tension-free vaginal tape operation. Local may be better than epidural anesthesia but its clinical significance needs to be proved by further study.

Ultrasonographic and urodynamic evaluation after tension free vagina tape procedure (TVT).

BACKGROUND: This study was carried out to evaluate the urodynamic and ultrasonographic findings after tension-free vagina tape (TVT) procedure on stress urinary incontinent women. METHODS: Ninety women suffering from genuine stress incontinence without pelvic relaxation syndrome underwent surgery. Urodynamic measurement, one-hour pad test and introital ultrasonographic evaluation were performed preoperatively and one year after surgery. Additional ultrasonographic surveillance of the urethra was performed immediately after the operation. The position and mobility of the bladder neck was compared pre- and post-operatively in relation to the inferior edge of the pubic symphysis. RESULT: Eight women were excluded for various reasons. Among the 82 women who completed the study, 76 (93%) were cured, four were improved and two failed. No major intra- or post-operative complications occurred. The position and mobility of the bladder neck showed no significant difference before and after surgery. A urethral knee angle was noted ultrasonographically on cured and improved patients during maximum straining. Nine patients with immediate postoperative voiding difficulty were found to have a pronounced mid-urethra angulation. The symptom and sign were resolved by time after urethra depressing. Urodynamic assessment of the urethral pressure profile and other parameter showed no significant difference before and after the surgery except that a positive pressure transmission in the middle portion of the urethra was noted among 70 (87.5%) of cured and improved subjects. CONCLUSION: Tension-free vagina tape operation is an effective surgical procedure for the treatment of female urinary stress incontinence. The procedure seems neither to change hypermobility nor to elevate the position of bladder neck. Urinary continence after surgery is most probably achieved by creating a dynamic mid-urethral knee angulation by which the urethra is closed i.e. kinked at stress. Lifting of the mid-urethra resulted in postoperative voiding difficulty. It is the important that the tape is placed tension free under the urethra. Introital ultrasonographic surveillance is a suitable technique to visualize the result of the operation.

Opportunities within a large metropolitan school district.

As a school district employee, the child psychiatrist can offer valuable school consultations at multiple levels as an "insider." The access to teamwork within the district system is particularly empowering and advantageous. This article outlines the richness and variety of school consultative opportunities within the school district.

Bladder-sphincter biofeedback as treatment of detrusor instability in women who failed to respond to oxybutynin.

BACKGROUND: This study was designed to determine the efficacy of bladder-sphincter-biofeedback as a secondary treatment for those women with detrusor instability who failed to respond to oxybutynin chloride. METHODS: In a prospective non-randomized trial, 31 of 70 women with detrusor instability were assigned to either the study bladder-sphincter-biofeedback training group (n = 16) or to the control pelvic floor exercise group (n = 15) after they had failed to respond to oxybutynin chloride. RESULTS: Thirty (43%) of the 70 women were cured by oxybutynin chloride, and 9 (13%) withdrew due to various side effects. A comparison of cure rates between biofeedback training and pelvic floor exercise groups demonstrated that there were significant differences in objective changes: detrusor pressure (68.75% vs. 0%, p < 0.001), compliance (75.0% vs. 6.67%, p < 0.001), and resting maximal urethral closure pressure (43.75% vs. 6.67%, p < 0.037). Neither the cure rate nor improvement rate of subjective changes (urgency, and frequency and episodes of urge incontinence), significantly differed. CONCLUSION: Oxybutynin chloride was not well tolerated while bladder-sphincter-biofeedback was well accepted. As a secondary treatment, it appears better than pelvic floor exercise alone and may be the choice of non-surgical treatment in those women who failed to respond to oxybutynin chloride for detrusor instability.

An assessment of the early surgical outcome and urodynamic effects of the tension-free vaginal tape (TVT).

Fifty-two women underwent a tension-free vaginal tape (TVT) procedure for genuine stress incontinence (GSI). Preoperative assessment included a detailed medical history, pelvic examination, a 1-hour pad test with a comfortably full bladder, and urinary culture. Thirteen of the 52 women were excluded for various reasons. Both before and 12-24 months postoperatively all patients had a full urodynamic investigation using microtip transducer catheters. The study subjects were instructed to maintain a 1-week baseline urinary diary 1 week before the operation, and postoperative urodynamic assessment as well. The period of follow-up ranged from 12 to 24 months (median 19 months). Another 1-hour pad test with a comfortably full bladder and urinary culture were carried out thereafter. Comparisons of the 39 women pre- and postoperatively found a significantly improved 1-hour pad test (34.9 +/- 34.7 vs 8.3 +/- 24.0, P<0.001). Analyzing the urodynamic effects of surgery revealed no significant postoperative changes except for the maximal urethral closure pressure (MUCP) at rest. An objective assessment using a pad test revealed the success rate (cure plus improved) to be 90% (35/39) and the failure rate 10% (4/ 39). TVT can thus be considered a safe and effective procedure for GSI in women. Moreover, the urodynamic effects of surgery were not found to be critical to success.

Radiologic diagnosis and surgical treatment of urethral diverticulum in women. A reappraisal of voiding cystourethrography and positive pressure urethrography.

OBJECTIVE: To reappraise the optimum radiologic procedure for the diagnosis of urethral diverticula in women and to assess the results of surgery. STUDY DESIGN: From January 1994 to December 1997, 132 urine-continent women with pelvic prolapse and the most characteristic symptoms of urethral diverticulum underwent pelvic repair. In addition to routine urologic evaluations and pelvic examinations, the women underwent voiding cystourethrography (VCUG) and positive pressure urethrography (PPUG) with a double-balloon catheter. The x-ray examination was scheduled as follows. One hundred thirty-two women initially underwent VCUG followed by a PPUG. Another VCUG was subsequently performed on women with a negative PPUG finding. Twelve patients were excluded because they were unable to urinate for the first VCUG; thus, the study group was composed of the remaining 120 patients. Subsequently those patients underwent various pelvic operations, including total abdominal/vaginal hysterectomy, abdominal colposacropexy, Manchester's operation, sacrospinous ligament suspension, diverticulectomy and colporrhaphy. RESULTS: Both VCUG and PPUG were able to demonstrate the diverticula in 20 of the 120 women. Another 13 women showed positive findings on PPUG. Ten of the 87 cases with a negative PPUG had a positive finding in the subsequent VCUG. Forty-two diverticula were detected in 39 patients during pelvic repair. The only complication of urethral diverticulectomy was urethrovaginal fistula, which occurred in 3 of the 39 patients. CONCLUSION: Though VCUG is not as sensitive as PPUG, it still has merits and can be used as a screening test. If VCUG is inconclusive but clinical suspicion persists, particularly when PPUG is doubtful, magnetic resonance imaging should be considered.

Tension-free vaginal tape. A minimally invasive solution to stress urinary incontinence in women.

OBJECTIVE: To determine the efficacy and safety of a new continence procedure, tension-free vaginal tape (TVT) placement for surgical treatment of stress urinary incontinence in women. STUDY DESIGN: Eighty-three women with demonstrable stress urinary incontinence underwent a nonrandomized, prospective study using the TVT procedure. The procedure was previously described by Ulmsten et al. In the present study, instead of local anesthesia, epidural blockade with 20 mL of 2% xylocaine was used. Preoperatively the patients were evaluated with a one-hour pad test, full urodynamic testing using either a double-lumen catheter or microtip transducer catheter and were instructed to maintain an one-week baseline urinary diary one week before and two months after the operation. Another one-hour pad test and complete urodynamic evaluation using microtip transducer catheters were offered to 20 patients postoperatively. The period of follow-up ranged from 3 to 18 months. RESULTS: Thirteen women were excluded for various reasons; thus, 70 subjects were enrolled in the study. The urodynamic diagnosis of the 83 women revealed that 71 had genuine stress incontinence, 11 had mixed incontinence and 1 was normal. Mean operation time was 29 minutes (range, 20-51) and mean hospital stay 3 days (range, 2-8). Three bladder perforations occurred intraoperatively. No patients had intraoperative bleeding > 300 mL, but 11 (16%) had blood loss > 200 mL, necessitating an indwelling catheter and vaginal tamponade. No evidence of defect healing or rejection of the tape occurred. Urine leakage observed on the pad test was significantly reduced from a mean of 63 g (range, 10-213) before to a mean of 5 g (range, 0-42) after surgery. The objective cure rate was 83%, and the subjective rate was 87%. CONCLUSION: Although the follow-up period was short, the TVT procedure seemed to be a safe and effective method for the treatment of stress urinary incontinence.