[INFLUENCE OF DIANATALO OBSTETRIC GEL ON THE LENGTH OF SECOND STAGE OF LABOR.]

One of the risk factors for the occurrence of occult anal sphincter injuries (OASIS) and pelvic floordamage is the increased duration of the second stage of labor; leading to a relatively high incidence of perineal trauma, which in the majority of cases remains unrecognized. If we can decrease the duration of second stage of labor we could also expect a statistically significant decrease the incidence of OASIS in clinical practice. Purpose and Goals To identify changes in the length of the second slage of labor fater adminidtration of Dianatal® obstetric gel. Material and methods The study enrolled 33 primiparous women after vaginal delivery in General Hospital Trbovlje, Slovenia between January and June 2012. We also included 19 more patients, delivered between May and July 2011 in the Department of Obstetrics, University Hospital - Pleven, and 8 patients, delivered between February and October 2013 in Women's Health Hospital "Nadezhda" - Sofia Results We were able to observe a significant decrease in second slage of labor in relation with administration of Dianatal® obstetric gel. Discussion Shortening the period of expulsion of the fetus through the use of obstetric gel can significantly reduce the incidence of birth trauma and minimize complications related to delivery trauma - anal and urinary incontinence, changes in the statics of pelvic organs, sexual dysfunction and as a result poor quality of life.

[EVALUATION OF INCIDENCE OF POSTPARTUM OCCULT ANAL SPHINCTER INJURIES BY ENDOANAL ULTRASONOGRAPHY.]

The estimated overall risk of intrapartum damage of the anal sphincter (IUAS) is 1% of all vaginal births. The so called "occult" anal sphincter injuries (defects of the anal sphincter established by endoanal ultrasonography - OASIS) occur in 33% of primiparous women after vaginal birth. The most logical explanation for OASIS is that they are either completely missed or detected, but not mentioned in the patient's documentation, or erroneously classified as a low grade tear. Objectives To es7ablish the actual values of OASIS in the study population using endoanal ultrasonography. Material and methods The study included 29 vaginal deliveries in Porodnisnica Ljubljana in the January to June 2009 period, and 34 patients from July 2009 to May 2010, who gave birth in ObsTetric Clinic of the University Hospital - Pleven. Results The identified UAS frequency in our dtudy (25.4%) confirms the results of the incidence of such damage, cited in the literature. Discussion The results vary extensively from reported frequency of anal sphincter injuries among researched population, reflecting underesTimation of the problem, diagnostic gaps and inadequate clinical management behavior and tracking patients.

[RISK FACTORS FOR POSTPARTUM OCCULT INJURIES OF THE ANAL SPHINCTER.]

introduction The overall risk of intrapartum damage the anal sphincter (IUAS) is 1% of all vaginal births. In contrast, the so-called "occult" anal sphincter injuries (OASIS) (defects esablished by endoanal ultrasonography) occur in 33% of primiparous women after vaginal birth. Identifying the most common risk factors for OASIS can be the basis for selecting high-risk patients. These women should be targeted by early pospartum diagnosis and treatment, which could reduce the incidence of anal incontinence developed later in life. Objectives To determine the role of common risk factors for the occurrence of OASIS in selected population. Material and methods The study included 42 patients after vaginal birth, born in Maternity Ljubljana in the period January to June 2009, and 38 patients from July 2009 to November 2011, born in Obstetric Clinic of the University Hospital - Pleven, diagnosed with OASIS using endoanal ultrasonography. Results We demonstrated that all of the independent variables studied in our research (primiparity, gestational age over 41gw and fetal weight over 3500 g.) are risk factors for the occurrence of OASIS. Discussion This sudy shows that the sudied risk factors for the occurrence of OASIS may be included in a clinical practice guideline for eady diagnosis and proper treatment of posTpartal injuries affecting the pelvic floor.

First assessment of short-term efficacy of Er:YAG laser treatment on stress urinary incontinence in women: prospective cohort study.

OBJECTIVES: This is the first assessment of efficacy and safety of the Er:YAG laser in the treatment of stress urinary incontinence. The aim of this study was to assess the short-term outcome of a non-invasive laser treatment for mild-to-severe stages of this condition and to check its applicability in different body mass index and age groups. METHODS: A prospective cohort, single-center study at the Ob/Gyn Clinic, Zagreb, Croatia recruited a consecutive sample of 73 female patients suffering from stress urinary incontinence. The procedure was performed with a 2940-nm Er:YAG laser (XS Dynamis, Fotona, Slovenia) designed to achieve heating up of vaginal mucosa to around 60°C, 500-700 µm in depth. RESULTS: The score in the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form was reduced to a median of 46% (95% confidence interval 33-67%; p < 0.001). The reduction was significantly higher in women with normal body mass index (67%) than in overweight women (25%), as well as in women younger than 39 years (100%) compared with those older than 60 years (8%) (p < 0.001). No serious adverse events were noticed. CONCLUSION: This study of Er:YAG laser therapy in women has demonstrated a clinically relevant, short-term improvement of stress urinary incontinence, with minimal adverse events of a transient nature.

Validation of ultrasound scan in the diagnosis of female stress urinary incontinence.

OBJECTIVE: To validate transperineal ultrasound (US) in the assessment of urethrovesical junction hypermobility. METHODS: In this prospective study carried out between 1999 and 2003 at a university medical centre we enrolled 100 women with genuine stress urinary incontinence (study group) and 50 continent women (control group). All women underwent the diagnostic protocol including urodynamic measurement and transperineal US scan using an abdominal semicircular 3.5 MHz linear array transducer. The position of the urethrovesical junction was described in relation to the inferior edge of the symphysis pubis by two parameters: the cephalocaudal and the ventrodorsal distance. The position and degree of urethrovesical junction descent during stress (3 consecutive coughs) were measured and the results compared between the groups. Classification performance was evaluated by sensitivity and specificity. RESULTS: There was no significant difference in the horizontal plane of the urethrovesical junction at rest and in the backward displacement during stress between the groups. The downward displacement of the urethrovesical junction showed an average descent of 16.10 +/- 4.01 mm in the study group vs 7.92 +/- 2.85 mm in the control group; the difference between the groups was statistically significant (p = 0.001). Considering the 12 mm cut-off value of the descent, US evaluation had an 88% specificity, and a 92% sensitivity; the PPV and NPV were 96 % and 79 %, respectively. CONCLUSIONS: We found a significantly greater downward displacement of the urethrovesical junction during stress in women with stress urinary incontinence compared to healthy controls. We may conclude that transperineal US can accurately visualise a hypermobile urethrovesical junction.

Correlation between fetal movement revealed in actography and fetal-neonatal well-being: observational study on 3,805 pregnancies followed in a Northern Italy tertiary care hospital.

PURPOSE OF INVESTIGATION: To evaluate the correlation between fetal movement revealed in cardiotocography and fetal-neonatal well-being as well as to assess the value of cardiotocography in our clinical practice. METHODS: Retrospective analysis of 3,805 pregnancies followed at Parma General Hospital. Exclusion criteria were cesarean section, preterm delivery, and stillbirth. We analyzed the predictive power of actography during the dilating and expulsive phases of labor by establishing a correlation between number of fetal movements and our neonatal indexes of well being, i.e., cardiotocographic score, Apgar index and neonatal pH value. Statistical tests used were Fisher's test, chi-square test (X2), Pearson correlation and Spearman Rho; p value was considered significant if it was less than 0.05. RESULTS: We considered 2,389 vaginal deliveries. Analyzing the correlation between fetal movement and cardiotocographic score in the two different phases of labor, the comparison among subpopulations identified by different cardiotocograph scores revealed no statistical difference. CONCLUSION: Cardiotocography is reconfirmed as a good instrument to evaluate neonatal outcome, while actigraphy cannot be used alone to define fetal well-being, mainly due to the inability to standardize assessment of the actographic study.

Retroperitoneal mass with ischiorectal fossa extension: diagnosis, clinical features and surgical approach. A literature review starting from a rare clinical case of primary retroperitoneal dermoid cyst.

BACKGROUND: Primary retroperitoneal teratomas are rare and occur mostly in the sacrococcygeal area of children. They constitute less than 4% of all extragonadal teratomas with less than 120 cases having been reported, and only partly described in the retroperitoneum of adults. We describe an unusual case of a paravescical teratoma with ischio-rectal extension and its successful surgical management. CLINICAL CASE: A 24-year-old female was referred to our hospital with a history of pelvic pain, pressure and evidence of a pelvic-perineal tumor. Serial work-up disclosed a mass in the left paravesical fossa that bulged out through the levator-ani muscle, in the left ischial-rectal fossa, altering the symmetry of the gluteal/perineal region. At surgery a cystic tumor, consistent with a dermoid, was completely excised from the left paravesical fossa by means of a laparotomic approach. Pathological examination revealed a mature cystic teratoma. The postoperative course was smooth and the patient was doing well at two-year followup. CONCLUSION: This is the second reported case of paravesical dermoid cyst with ischio-rectal extension through the levator-ani muscle. Retroperitoneal teratomas are rare and difficult to early diagnose because of non specific signs and symptoms and should be considered in the differential diagnosis of a pelvic mass in adults. Solid and cystic morphology, fat signal and areas of calcification are some of the helpful features in diagnosing this neoplasia. Once the diagnosis is made, surgical removal is indispensable because of the indeterminate course of the disease. Prognosis depends on the histologic nature of teratoma. Patients with complete resection of benign teratoma have an excellent prognosis. Malignant teratomas, either with germ cell elements or with somatic elements, have a poor outcome.

[Stress urinary incontinence: an overview on actual surgical trends]. / Incontinenza urinaria da sforzo. Una panoramica su gli attuali trend chirurgici.

Stress urinary female incontinence (IUS) is an unpleasant symptom describing a loss of urine during physical exertion; genuine stress incontinence (GSI) is a socially unacceptable, involuntary loss of urine in absence of detrusor activity from the urethra associated with sudden cough or strain. The incidence of IUS is less than 10% in reproductive-age women but may approach 10-20% in postmenopausal women. The IUS pathophysiology is connected with two specific mechanisms: the urethral-bladder sliding out of anatomical area involves the normal system of endobladder/intraabdominal pressures, with a loss of urine; the second mechanism involves the damaged urethral sphincteric function, with a reduction of the urethral closure pressure and a urinary loss after minimal physical stimulation. The IUS medical therapy is troublesome and often inefficient, and the only approved effective measures are the surgical procedures, actually reserved for cases of unsuccessful medical therapy; surgical treatments can be classified according to the access as: vaginal, abdominal, associated and complex. They intend to reposition the urethral-bladder sliding in its normal intra-abdominal position, to allow equal transmission of increased intraabdominal pressure to the bladder and the proximal urethra. In the scientific literature there are more than one hundred surgical procedures for IUS correction, but the IUS surgical approach is anyway the actual gold standard therapy.

Standardization of anal sphincter EMG: technique of needle examination.

The external anal sphincter (EAS) anatomy is complex, and no exact technique of needle electrode insertion into it for electromyography (EMG) has been described. To define optimal positions for needle electrode insertions, EAS muscle topography was studied by concentric needle EMG. Fifteen women without uroneurological disorders were examined. Perpendicular insertions were made superficially (just under the mucosa) at the mucocutaneous junction, 5 and 10 mm more proximally (toward the anus), and at the anal orifice. In addition, at the anal orifice, deeper insertions were made. Superficially, EMG activity was detected at the mucocutaneous junction in 9 (60%) subjects. In the remaining 6, the muscle was found either 5 mm (in 5) or 10 mm (in 1) more centrally. At the anal orifice, superficial EMG activity was present in 67% of women. On deep insertion (15-25 mm) at the anal orifice, muscle was always present. It is suggested that, in further studies, the portions of the EAS muscle examined should be specified.

Prognostic factors in ovarian cancer.

The improvement in the treatment of ovarian cancer is based on the recognition of the prognostic factors. The 5-year survival rate of 174 patients with epithelial ovarian malignancies after primary operation at the University Department of Obstetrics and Gynecology in Ljubljana and treated with adjuvant therapy at the Institute of Oncology in Ljubljana in the period 1970-1980 was 29.3% (56% for stage I, 36% for stage II, 23% for stage III and 4.5% for stage IV). The amount of residual tumor after the primary operation was prognostically very important (5-year survival in stage III in cases of residual tumor less than 2 cm is 46.6%, in tumor greater than 2 cm only 18.6%). The histological type of tumor, considering the stage, was not important prognostically. On the contrary the grade of differentiation was prognostically very important even in advanced cases: 5 year survival for stage III in cases of well differentiated serous tumors was 61%, in moderately and poorly differentiated cases it was only 7%. Younger patients have better prognosis than older ones, because the tumors are better differentiated, too. Since ovarian cancers are diagnosed too late in 65% of cases in advanced stages, today all efforts should be focussed on early diagnosis, which is probably the only factors that can lead to the dramatic fall of the mortality rate.

[Urologic complications after radical hysterectomy]. / Uroloske komplikacije posle radikalne histerektomije.

From 1981-1984, in cases of the carcinoma of the cervix uteri, 174 radical abdominal and 29 radical vaginal hysterectomies were performed. Prior the surgery, there were 6.4% of pathologic urograms in the patients. After it, applying the Wertheim method, temporary hydronephrosis was recorded in 32.5%, lasting hydronephrosis in 9.8%, and fistulas in 2.5% of patients. Lasting complications developed also several year following the treatment. Subsequent surgery due to urologic complications included 19 patients having been treated by a combined therapy, surgery and radiation. More complications were observed after combined therapy applied in 58.6% of cases.