Twin pregnancy with gastroschisis in both twins.

OBJECTIVE: Gastroschisis is a congenital malformation characterized by an abdominal wall defect located laterally to a normal umbilicus. The cause of gastroschisis is unknown, but most authors consider it exogenous. We describe the case of a woman with a twin pregnancy in which both twins had gastroschisis. CASE REPORT: A 17-year-old primiparous female was referred to our institution because of a twin pregnancy, with one twin diagnosed with gastroschisis at 34 weeks of gestation. Unfortunately, gastroschisis was noted in both twins, but no other anomalies were observed under level II sonographic evaluation. The twins were delivered by cesarean section at 36+ weeks of gestation because of preterm labor and breech presentation of one fetus. Both twins presented with a 3-cm abdominal wall defect located to the right side of the umbilicus and a large portion of the bowel protruding that was not covered by membrane. Histopathology of the placenta revealed that the twins were diamniotic monochorionic. Chromosomal analysis of cord blood showed normal karyotype (46,XX) in both newborns. CONCLUSION: The cause of gastroschisis is unknown, although possible exogenous causes have been studied. The diagnosis of gastroschisis in twin pregnancy is always in late gestation. Therefore, maternal serum alpha fetoprotein screening and a detailed prenatal ultrasound evaluation are recommended in multifetal pregnancies.

Concomitant pelvic organ prolapse surgery with TVT procedure.

The aim of this study is to evaluate the efficacy and feasibility of concomitant pelvic reconstructive surgery with tension-free vaginal tape (TVT) procedure to treat pelvic organ prolapse women with urodynamic stress incontinence (USI) or occult USI. Seventy-five women with pelvic organ prolapse and diagnosed as USI or occult USI were enrolled in this study. All patients with USI or occult USI underwent TVT treatment under general anesthesia, combined with transvaginal total hysterectomy (VTH), anterior-posterior colporrhaphy (APC), and/or right sacrospinous ligament suspension (SSS) reconstructive surgeries. The subjective assessment was evaluated by using a visual analog scale (VAS) score and a urinary symptomatic questionnaire. The objective assessment was carried out with a 1-h pad test, cough stress test, and urodynamic examination. Of the 75 patients, 35 patients with grade III uterine prolapse underwent VTH and APC, 30 patients with grade IV uterine prolapse underwent VTH, SSS, and APC, and the other 10 patients who had previous hysterectomy with total vaginal vault prolapse underwent SSS and APC. The mean follow-up interval was 25 months (12-42 months). The mean hospitalization was 5.9 days and the mean catheterization time was 3.8 days. The subjective success rate for the treatment of urine incontinence was 88%, and the objective complete cure rate was 84%. The rate of postoperative complications with persistent urinary urgency, de novo detrusor overactivity, dysfunctional voiding, and tape erosion were 50, 8, 12, and 1.3%, respectively. There were no bladder perforations during the TVT procedure and no perioperative complications requiring conversion to laparotomy. Pelvic organ prolapse women with USI or occult USI can be treated by reconstructive surgeries combined with a TVT procedure to treat and prevent postoperative USI.

Combination of a tension-free vaginal tape procedure and laparoscopic-assisted vaginal hysterectomy for the treatment of benign uterine disease associated with stress urinary incontinence.

BACKGROUND: Women undergoing hysterectomy for benign uterine disease (BUD) may experience stress urinary incontinence (SUI). We performed tension-free vaginal tape (TVT) procedure and laparoscopic-assisted vaginal hysterectomy (LAVH) simultaneously and assessed the feasibility and efficacy of TVT performed under general anesthesia and the resultant anti-incontinence effects following the combined procedures. METHODS: Between March, 2000 and March, 2002 inclusively, 63 patients, who suffered from both BUD and SUI, underwent LAVH and TVT. Preoperative evaluation included history-taking, physical examination and ultrasonography. One-hour pad test, multichannel urodynamics and urinary questionnaire were conducted preoperatively and postoperatively. Details about surgical procedures undertaken, hospitalization and urinary problems in the follow-up period were recorded. RESULTS: 50 patients completed the study with a mean follow-up period of 34 (25-48) months. The mean age was 49 (39-67) years and mean parity 3 (2-6). The mean surgical duration was 163 (95-240) minutes and blood loss 284 (100-1,500) milliliters. Mean duration of hospital stay was 5.5 days and bladder drainage 1.9 days. Three patients suffered bladder perforation and one patient was complicated with excess blood loss. Postoperative urinary problems included transient urine retention, de novo frequency/urgency symptoms and voiding difficultly. CONCLUSIONS: The efficacy of concomitant TVT in LAVH procedure remained satisfactory in treatment of SUI associated with BUD. Both procedures reflect the benefits of less-invasive surgery. So the combination of LAVH and TVT is probably a good alternative for the patient who needs to undergo hysterectomy and anti-incontinence surgery simultaneously.

Management of polypropylene mesh erosion after intravaginal midurethral sling operation for female stress urinary incontinence.

The intravaginal midurethral sling operations have become a trend to treat female stress urinary incontinence. Cases of complications requiring surgical revision are rarely reported. We report on seven patients with complications necessitating surgery. Six patients with vaginal erosion were treated with transvaginal excision of migrated tape and fibrotic tissues around the vaginal wall, and one patient with bladder erosion was treated with suprapubic minimal laparotomy and transvaginal partial excision of the tension-free vaginal tape (TVT). The incidence of polypropylene mesh erosion was 1.1% in this study. All patients recovered well from our surgical intervention, except the bladder erosion patient who needed anticholinergic medication to treat postoperative urgency and urge incontinence.

A comparison of urodynamic parameters and lower urinary tract symptoms in urodynamic genuine stress incontinence women with or without stress urinary incontinence.

BACKGROUND: The aim of this study was to investigate the urodynamic parameters and lower urinary tract symptoms (LUTS) of women with urodynamic genuine stress incontinence (GSI). METHODS: A cross-sectional study involving 3323 women with LUTS was conducted. We recruited 1261 women with urodynamic GSI and were further grouped as with or without symptomatic stress urinary incontinence (SUI). The LUTS and urodynamic measurements between the two groups were analyzed and compared. RESULTS: Women with symptomatic SUI had a greater maximal flow rate, larger voided volume, larger maximal cystometric capacity, and smaller maximal urethral closure pressure (MUCP) during both rest and stress. The amount of urine leakage during the 1-hour pad test of GSI women with symptomatic SUI was much greater than women without symptomatic SUI (26.0 g vs 7.2 g, p < 0.001). The significant differences in other lower urinary tract symptoms including nocturia, diurnal frequency, incomplete emptying, poor stream, urgency, urge incontinence, and post-void dribbling in women without symptomatic SUI were all less than women with symptomatic SUI. CONCLUSIONS: The urodynamic parameters and LUTS between the GSI women with or without symptomatic SUI are different. Approximate 15% of the GSI women do not complain of symptomatic SUI. The lower urinary tract symptoms of women with GSI without symptomatic SUI were less prominent than for the GSI women with symptomatic SUI.

Quantified short-term outcome of uterine artery embolization with gelatin sponge particles and lipiodol for symptomatic myoma.

OBJECTIVE: To investigate and quantify clinical outcomes and spectral Doppler analyses of uterine arteries in patients with myoma undergoing uterine artery embolization (UAE) with gelatin sponge particles and lipiodol. DESIGN: Prospective observational study. SETTING: Tertiary medical center. PATIENT(S): Forty premenopausal women with symptomatic myoma. INTERVENTION(S): Uterine artery embolization with gelatin sponge particles and lipiodol. MAIN OUTCOMES MEASURE(S): Hemoglobin, hematocrit, CA-125, pictorial blood loss assessment, visual analogue pain scale, questionnaire for symptoms, tumor volume, and spectral Doppler analyses of uterine arteries. RESULT(S): The mean follow-up period was 8.1 months (range, 6-12). Menstrual flow improved in 29 of 35 patients (83%) and decreased significantly by 78.4%. Menstrual pain improved in 27 of 35 patients (77%) and decreased significantly by 70%. Hematocrit and CA-125 improved significantly. The mean percentage reductions of uterine and myomal volumes were 40.2% and 54.9%, respectively. The mean peak systolic velocity of the uterine arteries decreased by 52%. The major complication rate was 2.56%. There was no correlation between tumor volume reduction and clinical outcome. CONCLUSION(S): Uterine artery embolization with gelatin sponge particles and lipiodol had satisfactory short-term outcomes, comparable to those associated with polyvinyl alcohol particles. Quantified and semiquantified measurements provided objective assessment of clinical outcomes. Serum CA-125 might play a role in clinical follow-up. Reduction of tumor volume is not predictive of UAE efficacy.

Concomitant surgery with tension-free vaginal tape.

BACKGROUND: To evaluate the efficacy and feasibility of tension-free vaginal tape (TVT) surgery combined with gynecologic surgery using general anesthesia. METHODS: One hundred and six women with genuine stress incontinence (GSI) diagnosed with a traditional urodynamic examination were prospectively enrolled into this study. All of the 106 women underwent TVT surgery for the treatment of GSI, along with a concomitant hysterectomy procedure, under general anesthesia. We estimated the severity of incontinence symptoms on a visual analog scale (VAS), and used a questionnaire for subjective assessment before and after TVT surgery. The objective assessment of urinary incontinence was carried out with a 1-h pad test and traditional urodynamic examination. Of the 106 patients, 50 had uterine prolapse and underwent transvaginal hysterectomy and anteroposterior colporrhaphy (APC), and another 50 had uterine myoma and underwent laparoscopic-assisted vaginal hysterectomy (LAVH). RESULTS: The follow-up mean interval was 18 months (range 12-36 months). The 50 women undergoing LAVH and TVT surgery had a mean hospitalization of 3.5 days. The subjective success rate was 90.5% and the objective success rate was 86.8%. The other group of 50 women undergoing vaginal total hysterectomy (VTH), APC and TVT surgery had a mean hospitalization of 4.8 days. The subjective success rate was 88.6% and the objective success rate was 84.9%. There were six patients lost to follow-up for several reasons. The rates of complications of bladder perforation, postoperative voiding difficulty and postoperative urinary urgency were 2%, 11% and 10%, respectively; neither pelvic hematoma requiring blood transfusion nor conversion to laparotomy occurred. CONCLUSION: The results of this study prove that the TVT procedure, performed under general anesthesia without the need for the intraoperative cough provocation test to treat GSI, and carried out concomitantly with other gynecologic surgeries, is safe and effective.