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PubMed1975

Obstetricians and nurse-midwives: The team approach in private practice.

Much has been written about the need for help for the overworked obstetrician. Two obstetricians delivering over 500 babies annuallay had insufficient time for their gynecology practice. Two nurse-midwives were employed and in the first year they delivered 61 per cent of those patients who delivered vaginally. All normal patients had the privilege of choosing their accoucheur; patients, nurse-midwives, and obstetricians were very well pleased with the team approach.

California↗
PubMed2003

What's new in prolapse surgery?

PURPOSE OF REVIEW: There are very many types of operation for the correction of symptomatic pelvic floor relaxation, and the pelvic surgeon is faced with a difficult task when selecting the most appropriate procedure(s) for an individual patient. Currently, the lifetime risk of undergoing prolapse or continence surgery in France is one in 11; up to 30% of patients will require repeat prolapse surgery, and 10% will require repeat continence surgery. Reconstructive pelvic surgery for the treatment of vaginal prolapse continues to evolve as surgeons continue their quest for a definitive surgical cure. This review looks at the etiology, presentation and current surgical management of genital prolapse in females. RECENT FINDINGS: There are three primary routes of access in reconstructive pelvic surgery (abdominal, vaginal and laparoscopic) for the repair of anterior, superior and posterior defects; the choice often depends on the surgeon's experience. Of the abdominal repairs, abdominal sacrocolpopexy with mesh remains the 'gold standard'; the retropubic paravaginal repair and laparoscopic techniques have not gained widespread acceptance. The laparoscopic approach appears to be the least utilized, because of the great degree of technical difficulty associated with laparoscopic suturing. Of the vaginal restorative procedures, uterosacral ligament vault suspension and iliococcygeous and sacrospinous fixation have their proponents. However, there is increasing interest in the use of biological prostheses (allografts/xenografts) and synthetic absorbable meshes. SUMMARY: Randomized controlled trials are required to evaluate the role of surgical procedures in reconstructive surgery, to determine which type of prosthesis is most suitable.

Female↗
PubMedDate not supplied

Effect of neonatal exposure to DES in Fas and Bcl-2 expression in the adult mouse vagina and approach to the DES syndrome.

Neonatal exposure to a synthetic estrogen, diethylstilbestrol (DES), induces the ovary-independent persistent proliferation of vaginal epithelium in mice. Mouse vagina at the estrous stage in the normal estrous cycle shows 10 to 15 layers of epithelium with superficial keratinized layers, and ovariectomy induces a decrease of these epithelial cell layers and lymphocyte infiltration. Thus, cell proliferation and regression of vaginal epithelium are ovary dependent. Neonatally DES-treated mouse vagina showed the same phenotype as normal mouse vagina at the estrous stage, but ovariectomy did not induce a decrease of epithelial cell layers or a lymphocyte infiltration, and there was persistent proliferation of vaginal epithelium even after ovariectomy. In addition, apoptotic cell death characterized by oligonucleosomal DNA fragmentation, Fas expression, and Bcl-2 downregulation were induced after ovariectomy in normal mouse vagina, but not in DES-treated mouse vagina. These results suggest that neonatal DES-exposure in mice prevents vaginal Fas-mediated apoptosis following the downregulation of Bcl-2, and these abnormalities in expression are involved in persistent proliferation of the vaginal epithelium.

Animals↗
PubMed1984

Vaginal scent marking: effects on ultrasonic calling and attraction of male golden hamsters.

Male hamsters were tested for their responses to areas that had been scent marked by intact or vaginectomized females to determine the effects of naturally deposited vaginal secretions on male behavior. In the first experiment males produced more ultrasonic courtship calls when investigating areas marked by intact females than areas scented by vaginectomized females, demonstrating that vaginal marks facilitate such calling. In a wind-tunnel preference test situation in which scent-marked alleys and clean alleys served as sources of odor, males approached the scented alley first if it had been freshly marked by intact females but not if it had been scented by vaginectomized females or other males. Thus, the odors of vaginal marks are sufficient to attract males over short distances. After males entered these alleys they showed a preference for odors of both intact and vaginectomized females over no odors, but still spent significantly more time investigating the odors of intact females than those of vaginectomized females. These experiments indicate that vaginal secretions are one of the primary cues that elicit male courtship calling, and the small quantities of vaginal secretions deposited by females in vaginal marks are sufficient to elicit ultrasonic calling and attract males over short distances. Thus it is likely that vaginal scent marking and ultrasonic calling by females interact to facilitate attraction and location of mates during courtship.

Animals↗
PubMed1997

Complications of hysterectomy.

The complications of hysterectomy are discussed, generally speaking their definition is poorly standardized and direct comparisons are extremely difficult. Furthermore, there is uncertainty as to what is meant by laparoscopic hysterectomy. The complications are discussed as post-operative fever, haemorrhage, injury to adjacent organs, other complications and life-threatening events. The incidence of post-operative infection and haemorrhage is least with the laparoscopic approach, but injury to surrounding organs is probably greater. In 1982, the Collaborative Review of Sterilization study data suggested an average woman of reproductive age with no pre-existing medical condition, no previous abdominal surgery, and who received prophylactic antibiotics, was best served by vaginal hysterectomy without colpororrhaphy rather than an abdominal procedure. This does not seem to have changed. The incidence of abdominal hysterectomy may be reduced by adding laparoscopy to vaginal hysterectomy to deal with adhesive disease, endometriosis or adnexal disease. Laparoscopic hysterectomy is feasible and safe but the indications for this approach have not yet been established.

Blood Loss, Surgical↗
PubMed2006

Conservative treatment of reproductive and sexual function in young woman with squamous carcinoma of the vagina.

OBJECTIVE: Primary squamous carcinoma of the vagina in young woman is extremely rare. Conservative management of both sexual and reproductive function poses challenging problems to gynecologic oncologists. METHODS: Between January 2001 and December 2004, four women under 40, nulliparous, with squamous cell carcinoma of the upper third of the vagina, at FIGO Stage I were submitted to conservative surgery of the reproductive/sexual function at our Institution. After written informed consent was obtained, conservative surgical treatment consisting of radical tumorectomy with pelvic lymphadenectomy, in three patients, and partial hemi-vaginectomy plus homolateral paracolpectomy/parametrectomy with pelvic lymphadenectomy, in the forth patient, was carried out. RESULTS: Mean operative time of conservative surgical treatment was 161 min. No intraoperative or postoperative complications were observed. In one patient, definitive pathologic examination revealed microscopic involvement of the paracolpium. Thus, after carrying out laparoscopic ovarian transposition, adjuvant radiotherapy (RT), consisting of pulsed-dose rate brachytherapy and external RT, was delivered in this woman. After a follow-up time of 51, 45, 21 and 9 months, respectively, all patients are regularly menstruating, sexually active and clinically free of disease. CONCLUSION: To our knowledge, this is the first report showing the feasibility and the efficacy of conservative surgery of reproductive and sexual function in young woman with vaginal carcinoma. A larger number of patients and a longer follow-up are needed to validate the safety of this approach.

Adult↗
PubMed2002

Urinary incontinence and menopause: an evidence-based treatment approach.

OBJECTIVE: To review the evidence on risk factors, evaluation, diagnosis, and treatments in postmenopausal women with incontinence. DATA SOURCES: Articles on urinary incontinence were located by searching Medline and the Cochrane Database of Systematic Reviews in March 2000. RESULTS: Urinary incontinence is common with aging. The relationship between urinary incontinence and menopause is not well understood. There are 3 major types of urinary incontinence: stress, urge, and mixed. The diagnosis can often be established with a good history. For a long time estrogen was thought to be of benefit in the treatment of incontinence, however, there is now evidence it may exacerbate urinary incontinence. There are multiple new agents shown to be effective in the treatment of incontinence. Surgical approaches for the treatment of stress incontinence have not been studied in large clinical trials, however, open abdominal retropubic suspension seems to be better than anterior vaginal repair. CONCLUSIONS: As the aging population grows, urinary incontinence will become an increasing public health problem. Increasing awareness is needed by women and their providers to identify, evaluate, and apply evidence-based treatment approaches to urinary incontinence.

Evidence-Based Medicine↗
PubMed1998

Double pessary use in grade 4 uterine and vaginal prolapse.

BACKGROUND: Certain situations dictate conservative management of grade 4 uterine or vaginal vault prolapse in women. The reduction of a prolapse may not be possible if the vagina cannot retain a single pessary. We have used double pessaries in the management of this condition. TECHNIQUE: With the patient in the dorsal lithotomy position, either a Donut or Inflatoball (Milex Products Inc., Chicago, IL) pessary is inserted and pushed into the vagina as far as is comfortable. A second pessary, either a flexible Gellhorn or Shaatz (Milex Products Inc.), then is placed caudad to the first. EXPERIENCE: We have used this approach in five women who have been followed for 7-15 months. There have been no erosions or vaginitis and all the women experienced symptomatic relief. CONCLUSION: In women who want or require conservative management of grade 4 prolapse and are unable to retain a single pessary, the placement of two pessaries often will be successful.

Aged↗
PubMed2006

Acceptability of self-taken vaginal swabs and first-catch urine samples for the diagnosis of urogenital Chlamydia trachomatis and Neisseria gonorrhoeae with an amplified DNA assay in young women attending a public health sexually transmitted disease clinic.

OBJECTIVES: Public health efforts are needed to encourage young women to get tested for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC). GOAL: To assess the acceptability and feasibility of 2 noninvasive diagnostic approaches. STUDY DESIGN: Participants of this cross-sectional survey were 413 young women (age 16-35) who underwent STD testing by self-taken vaginal swab (SVS) and a first-catch urine sample (FCU) by nucleic acid amplification test (BDProbTec) and filled out a questionnaire. RESULTS: CT and GC were diagnosed in 10.9% (45/413) and 1.5% (6/413). Eleven percent of the participants who never previously had an STD examination (68%) tested STD positive. SVS and FCU were almost uniformly reported as easy to perform and preferred above gynecologic examination. CONCLUSIONS: Using SVS combined with FCU can be an important enhancing tool in public health approaches. Acceptability among potential patients is high, enabling the noninvasive detection of STDs that would otherwise remain undetected and untreated.

Adolescent↗
PubMed1997

Reconstruction of the high urogenital sinus: early perineal prone approach without division of the rectum.

PURPOSE: Reconstruction of the vagina and external genitalia in the infant is quite challenging, particularly when a urogenital sinus is associated with high confluence of the vagina and urethra. Many surgeons believe that children with such a malformation should undergo staged or delayed reconstruction, so that vaginoplasty is done when the child is older and larger. Vaginoplasty early in life is thought to be difficult due to patient size and poor visualization. The posterior sagittal approach has been beneficial for acquiring exposure to high urogenital sinus anomalies but it has been thought to require splitting of the rectum and temporary colostomy. We report a modification of this technique. MATERIALS AND METHODS: In the last 5 years all patients with urogenital sinus anomalies underwent reconstruction using a single stage approach regardless of the level of confluence. In 8 patients with a high level of confluence reconstruction was performed using a perineal prone approach. Exposure was achieved without division of the rectum. The operative technique is presented in detail. RESULTS: This midline perineal prone approach has allowed excellent exposure of the high vagina even in infants. In all 8 patients reconstruction was done without difficulty and no patient required incision of the rectum or colostomy. This procedure did not preclude the use of a posteriorly based flap for vaginal reconstruction. CONCLUSIONS: While patients with low confluence can be treated with single posteriorly based flap vaginoplasty, those with higher confluence may benefit from a perineal prone approach to achieve adequate exposure for pull-through vaginoplasty. This prone approach to the high urogenital sinus anomaly can be performed without division of the rectum, provides excellent exposure of the high confluence even in small children and does not preclude the use of posterior flaps for vaginal reconstruction.

Abnormalities, Multiple↗
PubMedDate not supplied

Cervical ripening: randomized comparison of intravaginal prostaglandin E2 gel with prostaglandin E2 gel plus laminaria tents.

The purpose of this study was to evaluate the efficacy of adding laminaria tents to sequential intravaginal prostaglandin E2 (PGE2) gel for cervical ripening. A prospective, randomized study was conducted from October 1994 to May 1995. Pregnant women with maternal or fetal indications for induction of labor at > or = 37 weeks gestation and a Bishop score of < or = 4 were eligible. Nineteen patients received laminaria tents in addition to 4 mg PGE2 gel, while 25 patients received PGE2 gel alone. After 4 hr, the laminaria tents were removed and the gel was continued in both groups at 4-hr intervals. Induction with oxytocin was initiated after a Bishop score of > or = 5 was achieved. The groups were comparable with respect to maternal age, parity, gestational age, reason for induction, and initial Bishop score. The addition of laminaria tents to sequential PGE2 gel did not statistically improve the time to a favorable cervix (control group 12.7 +/- 8.5 hr (95% CI, 9.1-16.3) and study group 10.9 +/- 7.1 hr (95% CI, 7.5-14.3) (P = 0.59). The 6-hr difference from the time of the initial PGE2 gel placement to delivery was not detected (control group 22.4 +/- 11.2 hr, 95% CI 17-27 and study group 23.4 +/- 13.1 hr, 95% CI 17-29.6 (P = 0.79). The combination approach of laminaria tents and PGE2 gel did not have a significant impact on the vaginal delivery rate, with 28.0% of patients in the control group and 26.3% of patients in the study group undergoing cesarean section (P = 0.90). Maternal and neonatal complications were rare in both groups. We had insufficient evidence to show that the addition of laminaria tents to PGE2 gel improved cervical ripening, the induction to delivery interval, or the cesarean section rate in patients at term undergoing induction of labor.

Administration, Intravaginal↗
PubMed1990

The role of transvaginal sonography in chorionic villi sampling.

Vaginosonography has the potential of improving not only accurate diagnosis preceeding chorionic villus sampling but also the sampling procedure itself. The vaginosonographic diagnostic landmarks of early pregnancies are the contact area between the amnion and the chorion, the insertion of the umbilical cord, the yolk sac and the decidua-trophoblast complex. The occurrence of a "Swiss-cheese-pattern" in the latter structure is a strong hint for an unfavourable outcome of early pregnancy. Vaginosonographically guided puncture is a promising approach for chorionic villus biopsy. The punturing facilities are firmly attached to the high resolution vaginal ultrasound probe. Thus, precise ultrasound-guided puncture penetrating the vaginal skin and the uterine wall in the shortest possible distance has become possible.

Adolescent↗
PubMed1996

A pelvic retroperitoneal schwannoma arising in the right paracolpium.

Nerve sheath tumors of the retroperitoneum are infrequently reported. In this paper, a rare case of a benign pelvic retroperitoneal schwannoma arising in the right paracolpium is presented. Preoperatively, magnetic resonance imaging revealed a solid tumor beside the vaginal canal with a clear margin. The tumor could be completely resected by the transvaginal approach and was diagnosed to be a benign schwannoma of the Antoni A type with palisade arrangement. The patient had no symptoms of motor or sensory disturbances after surgery.

Adult↗
PubMed2006

TVT vs Monarc: a comparative study.

Following the success of the tension-free vaginal tape (TVT), there has been considerable interest in technique modifications such as the transobturator approach for implant placement. We attempted to elucidate possible anatomical and clinical differences between the two methods in a retrospective cohort study. One hundred and fourteen women who had undergone TVT or Monarc implantation were assessed by or under the supervision of the senior author, with identical tensioning technique. They were followed up by an interview, uroflowmetry, and translabial 3D ultrasound. There were significant differences for patient satisfaction (P=0.013), subjective overall cure/improvement (P=0.0018), and the symptom of poor stream (P=0.03), all favoring the Monarc group. On imaging Monarc tapes appeared more proximal at rest (P=0.006) and Valsalva (P=0.002) and remained further from the symphysis pubis on Valsalva (P=0.01). At 9 months follow-up, there was no significant difference as regards to cure rates for stress incontinence between the two suburethral slings. Monarc tapes are located more proximally and may be less obstructive, judging from a lower incidence of symptoms of voiding dysfunction. Patient satisfaction and overall subjective cure/improvement were higher after Monarc. In summary, the Monarc is an effective TVT alternative, achieving cure of stress incontinence by similar means. It may be less obstructive, resulting in improved patient satisfaction.

Female↗
PubMed2005

Peri-operative complications and pain after the suburethral sling procedure for urinary stress incontinence: a French prospective randomised multicentre study comparing the retropubic and transobturator routes.

OBJECTIVE: To compare peri-operative complications, pain, and the immediate functional results of the sub-urethral sling procedure for urinary stress incontinence by the retropublic and transobturator routes, using a non-elastic polypropylene sub-urethral sling. PATIENTS AND METHODS: This prospective, multicentre study involved 88 women undergoing the sub-urethral sling procedure for stress urinary incontinence (SUI). The retropubic route (RPR) and the transobturator route (TOR) were used in respectively 42 and 46 cases. The characteristics of the women in the RPR and TOR groups were as follows: mean age (+/-standard deviation) 56.8+/-12 years and 53.4+/-10 years, respectively; mean BMI: 25+/-4 and 26+/-4; mean parity: 2.1+/-0.9 and 2+/-1 children; post-menopausal status: 66.7% and 58.7%; prior surgery for SUI: 7.1% and 6.5%; and prior hysterectomy: 21.4% and 26.1%. None of these characteristics differed significantly between the groups. Likewise, pre-operative urinary functional status (SUI stage, and pollakiuria, nocturia and urgency rates) was similar in the two groups. RESULTS: Mean hospital stay and overall morbidity rate were not significantly different between the RPR and TOR groups. Mean operating time was longer in the RPR group. Bladder injury was significantly more frequent in the RPR group and vaginal injury was significantly more frequent in the TOR group. Pain scores were significantly lower in the TOR group. The objective functional results at one month did not differ between the groups. Quality of life, evaluated with questionnaires and numerical rating scales, was similarly improved in the two groups. DISCUSSION: The suburethral sling procedure was less painful by the TOR route than by the RPR route. Bladder injury, haematomas and abscesses were only observed in the RPR group, while vaginal injury only occurred in the TOR group. The immediate functional results of the two approaches were similar.

Adult↗
PubMed1999

Treatment of the Mayer-Rokitansky-Küster-Hauser syndrome in Bangladesh: results of 10 total vaginal replacements with sigmoid colon at a missionary hospital.

PURPOSE: We report our experience with treating the Mayer-Rokitansky-Kuster-Hauser syndrome in a developing country. The operations were performed by a pediatric surgical team at a missionary hospital in Khulna, Bangladesh. MATERIALS AND METHODS: From 1995 to 1998, 10 young women with the Mayer-Rokitansky-Kuster-Hauser syndrome underwent complete vaginal replacement. In 4 patients the abnormality was discovered after marriage at the initial sexual approach and, thus, the husband abandoned 3. In 4 of the 10 cases the diagnosis was suspected because of absent menstruation. A physician made the diagnosis in only 2 cases. Preoperatively abdominal ultrasound in 3 patients showed a hypoplastic uterus in all and a right solitary pelvic kidney in 1. In all 10 women a neovagina was created using a 14 cm. segment of sigmoid colon. Two weeks postoperatively patients were taught to dilate and irrigate the neovagina. RESULTS: A minimum of 1 year of followup is available in 7 of the 10 patients. The vagina had a good appearing introitus. Mucous production significantly decreased 3 to 4 months after the operation. Two patients already had an active sexual life. The remaining 3 patients underwent surgery during the last mission and they had no complications 6 months postoperatively. CONCLUSIONS: Our experience shows the feasibility of treating patients with a severe abnormality in a hospital with basic facilities in one of the poorest countries in the world.

Adolescent↗
PubMed2000

Update on the medical treatment of endometriosis.

The treatment of women with endometriosis can be a challenge. Therapeutic strategies must be tailored to the individual symptoms, age, and desire for fertility. Medical therapy continues to be based on endocrine treatment, such as oral contraceptives, progestins, danazol, and GnRH agonists. Unfortunately, recurrence rates are high after discontinuation of therapy. Recent clinical research on GnRH analogues plus add-back therapy has produced favorable results. Long-term treatment of patients using this approach has successfully reduced pain while minimizing symptoms of hypoestrogenism and adverse metabolic effects, such as loss of bone mineral density. Currently, GnRH analogues given with add-back therapy seems to be the most effective long-term approach to the treatment of symptomatic endometriosis. In the future, other modalities, such as medicated vaginal rings, inhibitors of steroidogenic enzymes, and GnRH antagonists, will most likely be options.

Contraceptives, Oral↗
PubMed1996

Laparoscopy versus Laparotomy for Radical Hysterectomy

From July 1993 to March 1996 we performed 62 radical hysterectomies, 15 (24.2%) by laparoscopy and 47 (75.8%) by laparotomy. All patients had cervical carcinoma FIGO stages Ia2 and Ib1. We compared the duration of surgery, blood loss, number of pelvic nodes obtained, surgical margins, and complications. The average duration of laparoscopic surgery was 4.5 hours versus 3 hours for laparotomy. Blood loss at laparoscopy was 250 ml, and 600 ml at laparotomy. The number of pelvic nodes obtained by laparotomy was 24.74 and by laparoscopy an average of 25. In all cases the surgical margins were free of tumors. Two complications in the laparoscopy group were a vaginal hematoma and a ureteral injury. At laparotomy one ureteral fistula occurred. No difference between approaches in pathology specimens were seen. Blood loss was lower at laparoscopy but the duration of surgery was longer. Radical hysterectomy by laparoscopy seems safe and effective.

Journal Article↗