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PubMed1992

[A case of vaginal delivery--11 months after a primary cesarean section].

The state of the uterine cicatrix and more specifically its sufficiency are extremely important for the obstetrician when he has to choose between a second caesarean operation and a vaginal delivery. This decision determines the post partum and postoperative techniques and behaviour. The author reports a case of a woman who has vaginally delivered a child 11 months after a caesarean operation. This case demonstrates that approaching personally the obstetrician can decide in favour of a vaginal delivery after a previous caesarean operation even in the cases of pregnancy which has begun before the 6 month period after the caesarean operation has elapsed.

Adult↗
PubMed2000

Pelvic organ prolapse: a review.

Pelvic organ prolapse is a common medical problem in parous women. This condition usually refers to a combination of deficiencies of the pelvic organs as they relate to support mechanisms of the vaginal wall. Symptoms vary--an accurate diagnosis requires a careful and complete physical examination with attention directed toward the pelvis and perineum. Although many patients will not require surgical treatment for pelvic organ prolapse, a comprehensive approach to repair in which all of the anatomic defects affecting support are addressed is necessary for successful treatment. Patients presenting with pelvic organ prolapse often provide some of the most complex, challenging, and rewarding cases in reconstructive pelvic surgery. This article addresses the definitions and classifications, prevalence and risk factors, and anatomy and pathophysiology relevant to pelvic organ prolapse. Discussion also includes diagnosis and approaches to management (surgical and nonsurgical) of anterior vaginal wall prolapse, cystourethrocele, apical vaginal prolapse, uterine prolapse and enterocele, posterior vaginal wall prolapse, rectocele, and pelvic floor relaxation and perineal laxity, with indications for and approaches to surgery, along with possible complications.

Female↗
PubMed2003

Validation of diagnostic algorithms for syndromic management of sexually transmitted diseases.

OBJECTIVES: To validate our revised syndromic algorithms of the management of sexually transmitted diseases and determine their sensitivity, specificity, positive predictive value and cost-effectiveness. METHODS: Patients with either urethral discharge, vaginal discharge or genital ulcer, were selected during their first visits to three urban sexually transmitted disease clinics in Fujian Province, China. They were managed syndromically according to our revised flowcharts. The etiology of the syndromes was detected by laboratory testing. The data were analyzed using EPI INFO V6.0 software. RESULTS: A total of 736 patients were enrolled into the study. In male patients with urethral discharge, the sensitivities for gonococcal and chlamydial infections were 96.7% and 100%, respectively, using the syndromic approach. The total positive predictive value was 73%. In female patients with vaginal discharge, the sensitivity was 90.8%, specificity 46.9%, positive predictive value 50.9%, and negative predictive value 89.3% for the diagnosis of gonorrhea and/or chlamydial infection by syndromic approach. In patients with genital ulcer, the sensitivities were 78.3% and 75.8%, specificities of 83.6% and 42.9%, and positive predictive values of 60.0% and 41.0% for the diagnosis of syphilis and genital herpes, respectively, using the syndromic approach. Cost-effectiveness analysis indicated that the average cost of treatment for a patient with urethral discharge was RMB 46.03 yuan using syndromic management, in comparison with RMB 149.19 yuan by etiological management. CONCLUSIONS: The syndromic management of urethral discharge was relatively effective and suited clinical application. The specificity and positive predictive value for syndromic management of vaginal discharge are not satisfactory. The revised flowchart of genital ulcer syndrome could be suitable for use in clinical settings. Further validation and revision are needed for syndromic approaches of vaginal discharge and genital ulcer.

Adolescent↗
PubMed2005

Effects of candidate vaginally-applied microbicide compounds on innate immune cells.

Ideally, a vaginally-applied microbicide would be effective against a broad range of pathogens but would have minimal effects on the female genital tract. The aim of this study was to determine if representative candidate detergent-type and sulfated/sulfonated polymer-type microbicides altered the composition or function of innate immune cells normally found in the vaginal mucosa. The effect of microbicide on the composition of vaginal leukocytes was tested using a flow cytometric approach. Application of the detergent cholic acid, but not the sulfated polysaccharide lambda carrageenan, resulted in a significant increase in macrophages at the vaginal epithelial surface compared to control treatment (19.3% macrophages compared to 2.8%; p<0.0004). Phagocytosis of fluorochrome-labeled bacteria by macrophages was inhibited greater than 50% in the presence of 1.0mg/ml of the sulfonated polymer PRO 2000 but was not inhibited by the same concentration of lambda carrageenan. PRO 2000-pulsed macrophages regained phagocytic function after being washed free of the compound. Culture of macrophages with PRO 2000 also resulted in diminished detection of the surface proteins CD11b and CD18. After treated cells were washed free of PRO 2000, these proteins were detected at levels similar to control treated cells. In conclusion, application of a detergent-type microbicide, but not a sulfated polymer, resulted in the infiltration of inflammatory cells at the vaginal epithelial surface. Phagocytic function of macrophages was lost in the presence of 1mg/ml PRO 2000 which may have reflected masking of important cell surface proteins by the microbicide; however, there was no evidence of permanent loss of function upon removal of the compound.

Administration, Intravaginal↗
PubMed2003

Transurethral resection of tension-free vaginal tape penetrating the urethra.

BACKGROUND: The penetration of a tension-free vaginal tape into the urethra is a rarely described complication. It might occur much more often, given the common clinical practice of tension-free vaginal tape implantation. We describe a less invasive approach to resection than the transvaginal urethral resection method previously reported in the literature. CASE: A 68-year-old woman with stress urinary incontinence underwent a tension-free vaginal tape procedure. After surgery, the woman complained about pain and voiding disorders. A urodynamic investigation performed 14 months later revealed an infravesical obstruction caused by parts of the tension-free vaginal tape penetrating the urethra. After transurethral resection of the mesh, voiding returned to normal, and the patient remained subjectively and objectively continent. CONCLUSION: The transurethral approach described is a minimally invasive and successful technique that should be tried before embarking on major destructive and reconstructive surgery on the urethra.

Aged↗
PubMed1986

[Subjective and objective improvement of urinary incontinence in females following vaginal and abdominal incontinence operations].

236 patients were reevaluated one year after vaginal or suprapubic continence surgery. Personal history, clinico-gynaecological status, morphology and urodynamics were considered. 70.6% respectively 82% of all patients considered themselves cured. These numbers correlate well with objective control parameters. The clinical examination shows that a suprapubic approach is better for an urethrocele whereas vaginal surgery is more successful for a cystocele or rectocele. The correction of an urethrocele has however a greater influence on the chance of cure. Obesity is a risk factor especially for vaginal surgery and in both groups oestrogen application improved the healing process. The morphological examination demonstrates the importance of urethro-vesical suspension giving better results after suprapubic than after vaginal operation. The urodynamic results depend on the choice of measurement parameters. Suprapubic surgery generally brings about a greater improvement in pressure conditions than vaginal surgery. The best parameter seems to be the Dep Q. Vaginal continence surgery needs a good indication with a best possible urethro-vesical suspension. This is not an operation for beginners.

Abdomen↗
PubMed2002

Minilaparotomy-assisted vaginal hysterectomy.

OBJECTIVES: To determine the feasibility and acceptability of minilaparotomy-assisted vaginal hysterectomy. METHODS: A prospective pilot study in a general hospital was conducted. Twenty patients who were on the waiting list for abdominal hysterectomy were included in the study. All these patients had one or more relative contraindications to vaginal hysterectomy. The hysterectomy procedure was started vaginally in all cases. A minilaparotomy incision was performed to complete the procedure if vaginal hysterectomy was not feasible. Results were analyzed on the intention to treat basis. RESULTS: The procedure was successfully completed as intended in 19/20 patients (95%). Six patients had the procedure completed vaginally (30%). Thirteen patients had the procedure completed with minilaparotomy assistance (65%). The mean operative time was 63+/-24.8 min (+/-S.D.). The median estimated blood loss was 155 ml (range: 20-800). One bladder injury occurred. The overall post-operative complication rate was 35% (7/20). This included urinary retention necessitating catheterization for 24 h (n=3), urinary infection (n=2), vaginal infection (n=1) and wound hematoma (n=1). The mean post-operative pain score on a scale from 1 to 10 was 3.1. The overall patient satisfaction based on a scale from 1 to 10 was 9.23 (range: 8-10). CONCLUSIONS: Minilaparotomy-assisted vaginal hysterectomy is a feasible and safe procedure. Our results suggest that this approach is potentially useful in increasing the proportion of hysterectomies performed vaginally.

Adult↗
PubMed1997

The UCLA surgical approach to sphincteric incontinence in women.

Stress urinary incontinence (SUI) in the female may be treated by a variety of non-surgical and surgical therapies. However, once the patient has chosen to undergo operative repair the ideal procedure is based on three considerations: the degree of anterior vaginal wall prolapse, the degree of incontinence and associated anatomic abnormalities requiring surgical repair. In the vast majority of cases vaginal wall sling is our procedure of choice for the surgical treatment of SUI in the female. Vaginal wall sling is based on sound anatomic principles, may be performed as an outpatient procedure and is equally efficacious for the treatment of SUI due to anatomic incontinence (urethral hypermobility) and intrinsic sphincter deficiency. Since vaginal wall sling is performed through a transvaginal approach, other associated manifestations of pelvic floor prolapse such as rectocele can be addressed and repaired simultaneously. When necessary the vaginal wall sling can be easily modified to repair large grade cystoceles.

Female↗
PubMed2002

Radical vaginal trachelectomy after supracervical hysterectomy.

BACKGROUND: Radical vaginal trachelectomy (RVT) is an acceptable approach when applied toward a select group of patients with early stage cervical carcinoma. It is less invasive, can maintain fertility, and can be ideal in patients with significant comorbid factors compared to abdominal approaches. A small subset of patients with a previous supracervical hysterectomy can pose a surgical dilemma. CASE: An 81-year-old woman with a history of severe cardiac disease on routine gynecological examination was found to have adenocarcinoma in situ with a focus suspicious for invasion of the cervical stump diagnosed by cone biopsy. She previously had a supracervical hysterectomy for benign disease of the uterus. A RVT was performed as definitive treatment and the patient recovered without complications. CONCLUSION: In the rare case that presents with a history of supracervical hysterectomy, RVT with some technical modifications can still be considered as a therapeutic option for early stage cervical carcinoma.

Aged↗
PubMedDate not supplied

Transanal advancement of the anterior rectal wall for vaginal fistulas involving the lower rectum.

Experience from a personal series of nine patients with anovaginal or low rectovaginal fistula, operated upon by what is known as the Noble-Elting-Laird technique, is presented and added to the literature concerning the subject. Extensive preoperative mechanical bowel preparation including antibiotics was unnecessary as was a diverting colostomy. There were no operative deaths. Fistula did not recur in any of the nine patients followed six months, nor in any of eight of the nine patients followed over a period of two to 20 years. On comparing patients with anovaginal and rectovaginal fistula treated by transanal advancement of the anterior rectal wall with those patients treated by local layer closure, vaginally or anally, transanal advancement of the anterior rectal wall seems to be the better choice, particularly for the patient with a recurrent fistula. The data support the thesis that, since the anorectum is the primary source of such vaginal fistulas, the condition is best approached and treated accordingly.

Adult↗
PubMed2004

Laparoscopically assisted radical vaginal hysterectomy vs. radical abdominal hysterectomy for cervical cancer: a match controlled study.

OBJECTIVES: The technical feasibility of laparoscopically assisted radical vaginal hysterectomy has been well described, but its advantages over the open technique remain largely unproven. We reviewed and compared our experiences with both approaches. METHODS: All patients undergoing laparoscopically assisted radical vaginal hysterectomy (LARVH) between 1996 and 2003 were identified and matched for age, FIGO stage, histological subtype and nodal metastases using a control group of women who underwent radical abdominal hysterectomy (RAH) during the same time period. RESULTS: Fifty-seven women were listed for LARVH, resulting in five conversions. Fifty cases were matched successfully using the criteria above. The majority of cases were FIGO stage 1B1. Statistically significant differences (P < 0.05) were present when the following were compared for LARVH vs. RAH: duration of surgery (median 180 vs. 120 min), blood loss (median 350 vs. 875 ml), hospital stay (median 5 days vs. 8 days) and duration of continuous bladder catheterisation (median 3 days vs. 7 days). There were no statistically significant differences with regard to nodal yield, completeness of surgical margins or perioperative complication rate. Four major complications (8%, three cystotomies and one enterotomy) occurred in the LARVH group and three in the RAH group (6%, one pulmonary embolism, one ureteric injury and one major haemorrhage). Three women in LARVH group had seen a specialist regarding postoperative bladder dysfunction, versus 12 in the RAH group (P = 0.04). No patients in the LARVH group reported constipation requiring regular laxatives, versus six in the RAH group (P = 0.03). Median follow-up was 52 months for LARVH and 49 months for RAH. There was no significant difference between recurrence rates or overall survival (94% for LARVH vs. 96% for RAH). CONCLUSIONS: Despite the inherent limitations of LARVH and its associated learning curve, the procedure conveys many advantages over the open technique in terms of blood loss, transfusion requirement and hospital stay. In addition, the incidence of postoperative bladder and bowel dysfunction appears low-suggesting improved quality of life-without compromising survival.

Adult↗
PubMed1982

Vaginal immunization against urinary tract infection.

In an attempt to lessen susceptibility to induced urinary tract infections, rats were immunized by a non-traumatic, non-parenteral, intra-vaginal route. Up to 8 weeks following vaginal immunization against Escherichia coli O6, there was decreased adherence of viable E. coli O6 to the rats' bladder epithelium. Scanning electron microscopy of the urothelium revealed that immunized rats had less epithelial swelling, exfoliation, and surface mucin disruption than non-immunized control animals. Immunized animals also cleared an induced E. coli O6 infection from the kidneys and bladder faster than control animals. Vaginal immunization may offer a new approach to prophylaxis and treatment of ascending urinary tract infections.

Animals↗
PubMed2005

[Update on contraception].

Since the introduction of hormonal contraceptives in the 1960s, great advances have been achieved in contraception. Biological effects of sexual steroids as well as risks and benefits of oral contraception are better estimated. After the development of a new hormone-containing intra-uterine system, new hormone delivery systems offer women safe and effective contraceptive options. These new options that combine high efficacy and ease of use should allow better acceptance and compliance than daily pill ingestion and should then reduce the high rate of unintended pregnancies terminated by elective abortion. Transdermal contraceptive system and vaginal ring offer a promising innovative approach in pregnancy prevention. Subdermal implants give women the choice of a highly effective contraceptive system in spite of significant side effects. New hormonal delivery systems such as injectables are under development. Hysteroscopic tubal sterilization is now also available and is a very effective procedure. This wide variety of new contraceptive methods offers a marked improvement from previous medications for users by providing better efficacy and tolerability.

Adolescent↗
PubMed1993

Endometriosis: radical surgery.

Radical ablative surgery for endometriosis is indicated chiefly for symptoms of pain that fail to respond to conservative treatment. The sites of involvement must be carefully assessed and surgery planned taking account of the wishes of the patient concerning her fertility. Procedures include oophorectomy, salpingo-oophorectomy, hysterectomy, appendicectomy, and the excision of deeply infiltrating endometriosis possibly involving bowel resection. The most important arbiter of therapeutic success is the removal of the ovaries, hysterectomy and bilateral salpingo-oophorectomy offering the ultimate cure for this chronic condition. Whereas laparotomy has been the traditional approach for most of these procedures, vaginal and laparoscopic surgery are modern alternatives for many of these cases offering important advantages in terms of reduced postoperative discomfort, shorter hospitalization, faster recovery and a superior cosmetic result. Preoperative and postoperative medical therapy has a limited role in surgery, whereas postoperative hormone replacement therapy after bilateral oophorectomy is generally recommended.

Appendectomy↗
PubMed1997

Comparison of hysterectomy techniques and cost-benefit analysis.

There are an increasing number of approaches to the surgical removal of the uterus; each of these has clinical advantages and disadvantages. This paper outlines the various forms of laparoscopic hysterectomy currently undertaken and attempts to compare outcome measures and complications with these new approaches. In general laparoscopically-assisted vaginal hysterectomy appears to be associated with longer operating time but less post-operative pain and a shorter convalescent period than both abdominal and vaginal hysterectomy. Economic evaluation is dependent on local factors and upon the type of technique adopted. The use of disposable instrumentation profoundly influences the costs. Laparoscopically-assisted vaginal hysterectomy can be performed for similar or less total costs than conventional surgery providing techniques using re-usable equipment are employed. The place of the laparoscope in facilitating hysterectomy is not yet defined. Techniques are continuing to evolve. The debate now appears to be how laparoscopic and vaginal surgical skills can be best combined to ensure the best possible patient outcome.

Cost-Benefit Analysis↗
PubMed2001

Urological management of cloacal anomalies.

BACKGROUND: A cloacal anomaly results from incomplete urorectal division and is frequently associated with genitourinary abnormalities. Experience of the urological reconstruction of this entity is reported. METHODS: Nine girls with cloacal malformation have been treated at the Osaka Medical Center in the past 9 years. Seven patients were detected by prenatal ultrasonography as having: megacystis (two patients); hydronephrosis (two patients); or hydrometrocolpos (three patients). Two patients underwent prenatal shunt placement between the enlarged bladder and the amniotic space. RESULTS: For neonatal urinary diversion, four patients received cystostomy. Six of seven patients with associated hydrocolpos required intermittent catheterization to decompress an enlarged vagina. Vesicoureteral reflux was detected in 12 ureters of seven patients. Antireflux surgery was indicated in four patients before definitive repair. Definitive reconstruction was performed on eight patients. The posterior sagittal approach was used in all patients. Vaginal reconstruction was done utilizing a perineal skin flap (one patient), a tubularized vaginal flap (three patients), distal rectum (three patients) and total urogenital mobilization (one patient). Postoperatively, urethrovaginal fistula was created in one patient and complete occlusion was seen in one patient. CONCLUSION: The anatomical variety of this entity determines the management options from in utero. It involves not only the creation of three perineal orifices, but also a continent, catheterizable urethra under the stabilization of renal function. Accomplishment of the definitive repair requires the combined expertise of experienced pediatric surgeons and pediatric urologists.

Clitoris↗