A randomized, prospective study comparing the use of the missile trocar and the pyramidal trocar for laparoscopy access.

BACKGROUND: The missile trocar was developed for smooth abdominal penetration of the primary port. It contains a longitudinal tunnel connecting the abdominal cavity with the outside. OBJECTIVE: To evaluate the efficacy of the missile trocar compared with the traditional method using the Veress needle. MATERIAL AND METHOD: The times required to enter the abdominal cavity and the difficulty of the procedure were compared with the traditional Veress needle. A blind technique was used on 100 consecutive patients in a randomized fashion. RESULTS: The missile trocar technique took 2.7 +/- 1.6 minutes to perform compared with 3.9 +/- 1.3 min in the Veress needle group (p = 0.001), and the difficulty of the procedure was 2.1 +/- 1.9 cm (p = 0.433) rated from 10-cm scale. No carbon dioxide leakage or serious complications occurred in any patient. CONCLUSION: The results of the present study indicate that a long-tip missile trocar technique may be used safely when the technique is fully understood. This procedure is a relatively quick alternative approach for laparoscopy.

Can pre-operative urodynamic study predict the successful outcome of tension free vaginal tape (TVT) operation in Thai women with stress urinary incontinence?

OBJECTIVE: To study the preoperative urodryramic parameters whether it can predict the outcome of TVT operation in Thai women with stress urinary incontinence (SUI). STUDY DESIGN: Cohort study. MATERIAL AND METHOD: Twenty five Thai women undergone TVT from January to December 2004 at Bumrungrad Hospital were included in the present study. Urodyramic studies were done pre-operatively. The TVT operations were carried out with spinal anesthesia. The follow-ups at one, three, and six months were scheduled. RESULTS: At six months after the operation, the subjective cure rate was 72% (18/25) and 28% (7/25) had the improved symptoms. Multivariate regression analysis showed the valsava leak point pressure (VLPP) of less than 60 cm H2O to be associated with the 0.6-fold (0.3-0.9) risk of having successful outcome (being cured). Anyhow 7 cases of women not being cured still had improved symptoms and were satisfied with the operation. CONCLUSION: The present results confirmed the usefulness of pre-operative urodynamic study in prediction of the outcome of TVT. Low VLPP (<60 cm. H2O) was associated with poorer outcome of TVT operation in Thai women.

Urinary symptoms and quality of life changes in Thai women with overactive bladder after tolterodine treatment.

OBJECTIVES: To study the urinary symptoms and quality of life changes in Thai women with overactive bladder (OAB) after tolterodine treatment. MATERIAL AND METHOD: Thirty women (aged 30-77 years) diagnosed as having OAB at the Gynecology Clinic, King Chulalongkorn Memorial Hospital from January to April 2004 were included in the present study. Tolterodine 2 mg, twice daily was given. After 8 weeks treatment, changes in micturition diary variables and tolerability were determined. Short form 36 (SF36) questionaires (Thai version) were given before and after 8 weeks of treatment. RESULTS: At 8 weeks, all micturition per day decreased from 16. 7 +/- 5. 3 to 6. 7 +/- 2.4 times per day. The number of nocturia episodes decreased from 5.4 +/- 4.2 to 1.1 +/- 1.0 times per night. The most common side effect was dry month in 5 cases (16.7%) with 2 cases reporting a moderate degree and 1 case with severe degree. Only one case (3.3%) withdrew from the present study due to a severe dry mouth. The SF-36 scores changed significantly in the domains of physical functioning, role function emotional, social function and mental heath. CONCLUSION: Tolterodine was well tolerated and its effects improved the quality of life in Thai women with OAB.

Risk factors of female urinary incontinence and overactive bladder in Thai postmenopausal women.

OBJECTIVES: To assess the risk factors of stress incontinence (SUI), Urge incontinence (UI), mixed type incontinence (MUI) and overactive bladder (OAB) in Thai postmenopausal women. MATERIAL AND METHOD: A total of 360 Thai post menopausal women (60 had SUI, 60 had UI, 60 had MUI, 60 had OAB, and 120 were controls). All women attended the gynecologic clinic at King Chulalongkorn Memorial Hospital during January-June 2004. All cases and controls were given questionaires on the risk factors of age, body mass index (BMI), years since menopause, alcohol intake, routes and number of deliveries, history of chronic cough and constipation, and current hormonal therapy use. The multivariate logistic model was used to identified the independent risk factors and female urinary incontinence and OAB. RESULTS: In multivariate analysis, no factor was associated in UI or OAB group. In the SUI and MUI group, only the history of chronic cough [in SUI gr: OR 1.6 (1.1-2.3) in MUI gr: OR 3.5 (1.2-10.4)] and history of chronic functional constipation [in SUI group or 4.7 (1.5-14.7), in MUI or 3.0 (1.1-7.9)]. CONCLUSION: Chronic cough and chronic functional constipation were the associated risk factors in stress and mixed type incontinence in Thai postmenopausal women.

Five years follow up of laparoscopic burch colposuspension for stress urinary incontinence in Thai women.

OBJECTIVES: To study the cure rate and 5 year results of laparoscopic burch colposuspension for stress urinary incontinence in Thai women. MATERIAL AND METHOD: Twenty one Thai women with stress urinary incontinence attending the gynecology clinic at King Chulalongkorn Memorial hospital were recruited. Pre operative clinical and urodynamic evaluation were done. They underwent Laparoscopic burch colposuspension between January - December 1998. The cure rate was evaluated by clinical and urodynamic examination. RESULTS: The mean +/- SD of operative time, blood loss and hospital stay were 70 +/- 20 min, 140 +/- 30 ml and 1.6 +/- 0.5 days respectively. The complication rate was 19.1% (Bladder injuries 2 cases, voiding difficulties 1 case and de novo detrusor overactivity 1 case). The objective cure rate at 5 years was 76.2%. CONCLUSION: The authors found that the cure rate was rather low in laparoscopic burch colposuspension. Due to the long operative time, the requirement of complicated instruments and well trained physicians, the authors suggested that this technique should be selected only in cases of women with concomitant gynecologic disease that required lapascopic surgery.

Case report of voiding difficulty after intravaginal slingplasty (IVS) procedure: the emphasize of pre-service training.

BACKGROUND: The Intravaginal slingplasty procedure (IVS) is a minimally invasive surgery for the treatment of stress urinary incontinence (SUI). Too much tension during pulling the tape and the incorrect placing of the tape can cause urinary retention that may require release of the tape. CASE REPORT: A fifty one years old women with SUI had undergone IVS procedure in a private hospital. After the surgery, urinary retention occurred with prolonged catheterization for 20 days. The patient came to King Chulalongkorn Memorial Hospital on the 21st day after the operation. Surgical release of the tape which was located at the urethrovesical junction rather than the midurethera was done. The patient remained stress continent after the tape was released confirmed by the videourodynamic study one month later. CONCLUSION: Too much tension, insertion of the tape too close to the urethrovesical junction or the tape migration may be the causes of prolonged urinary retention after IVS procedure. The authors found the surgical release of the tape to be the effective management for this complication. Pre-service training in models and practice under the supervision of an experienced surgeon are needed before attempting any on their own. From the authors extensive review, this is the first case report of urinary retention after IVS procedure that required tape incision.

Quality of life assessment in Thai postmenopausal women with an overactive bladder.

OBJECTIVE: To compare the quality of life (QoL) among 3 groups of Thai postmenopausal women with an overactive bladder (OAB), diabetes, and without these conditions. MATERIAL AND METHOD: A total cross-sectional cohort of 180 postmenopausal women aged 48-60 years (60 had OAB, 60 diabetes and 60 controls) were recruited from the menopause clinic and diabetes clinic of Hatyai regional hospital between June and December 2003. Information on QoL were collected by the SF-36 questionnaire, validated for Thai women. RESULTS: There was no significant difference in the patient's demographic characteristics. All dimensions of QoL score of women with OAB and diabetes were lower than the scores of the controls. When compared with diabetes, OAB had significantly lower scores in the general health, social function and role-function emotional dimensions. CONCLUSION: QoL was significantly impaired in Thai postmenopausal women with OAB and diabetes compared to those women without these conditions. General health, social function and role-function emotional dimensions were particularly affected.

Prevalence of genital prolapse in Thai menopausal women (using new standardization classification).

BACKGROUND: There is an increasing number of menopausal women in Thailand (estimation of 5 million women). There is no published data on the prevalence of genital prolapse among Thai menopausal woman. So the authors created this hospital based study to identify the magnitude of this problem in Thai menopausal women. OBJECTIVE: To study the prevalence and symptoms of genital prolapse in Thai menopausal women attending the menopausal clinic in King Chulalongkorn Memorial Hospital. STUDY DESIGN: Descriptive study (Cross-sectional study). MATERIAL AND METHOD: Two hundred and fifteen Thai menopausal women attending the menopause clinic at King Chulalongkorn Memorial Hospital from the 1st of January to the 28th of February 2004 were recruited. Urinary symptoms history taking and pelvic examination were done. The severity of any prolapse was classified using International Continence Society classification. RESULTS: Prevalance of Thai menopausal women having any type of genital prolapse was 43.3%. Anterior vaginal wall prolapse and superior vaginal prolapse were the two highest prevalences of genital prolapse (29.3% and 14.9%). The prevalence of genital prolapse increased by the menopausal age. The two leading symptoms were stress incontinence and vaginal outlet relaxation (89.3% and 51.6%). CONCLUSION: From the present study, the authors found the prevalence of any genital prolapse (43.3%) and stress incontinence(89.3%) among Thai women attending menopausal clinic in King Chulalongkorn Memorial Hospital. The authors strongly recommend pelvic examination and urinary-symptoms history taking to evaluate the severity of genital prolapse.

The three years results of tension free vaginal tape (TVT) for the treatment of stress urinary incontinence in Thai women.

OBJECTIVE: To evaluate the three years result of TVT procedure in Thai women with genuine stress urinary incontinence (SUI). MATERIAL AND METHOD: Sixty three women, aged 35 - 71 years attending the gynecology clinic at King Chulalongkorn Hospital from February 2000 to May 2001 were recruited in the present study. Pre-operative evaluation included history taking and physical examination. All had stress urinary incontinence urodynamically confirmed genuine stress urinary incontinence and were treated with TVT Follow up at 3, 6, 12, 18, 24, 30 and 36 months were scheduled after surgery. RESULTS: The mean +/- SD of operative time for TVT was 32.3 +/- 10.0 min the mean +/- SD of hospitalization was 1.8 +/- 2.0 days. Two patients had bladder perforations by the trocar without severe bleeding and needed no reparation. No healing defect or rejection of the prolene mesh was found. The cure rate and improved rate were 95.2% and 4.8% respectively (60 from 63 cases) at 3 years follow up. CONCLUSION: The three years results revealed that TVT was effective and safe in the treatment of SUI in Thai women.

Serum estradiol level in Thai surgical menopausal women receiving oral micronized 17 beta-estradiol 1mg.

OBJECTIVE: To compare serum estradiol (E2) level in Thai surgical menopausal women before and after receiving a daily dose of 1 mg oral micronized 17 beta-estradiol. DESIGN: Experimental study (before and after treatment). SETTING: Gynecological ward, Hatyai regional hospital. PATIENTS: 40 premenopausal Thai women who had undergone total abdominal hysterectomy with bilateral salpingoooporectomy (Surgical menopause) for 1 week previously due to benign gynecologic conditions were recruited in the present study. These women had no contraindications for receiving hormonal replacement therapy and no history of any hormonal intake in the past. INTERVENTION : All women were assigned to receive a 1 mg micronized 17 beta-estradiol (Estrofem, Novo Nordisk A/S, Denmark) orally applied at bedtime (08.00 p.m.) each day. MEASUREMENTS: Serum estradiol (E2) levels were measured before and after treatment at 4, 8 and 12 weeks. The hormonal measurement was performed using the ELFA-technique (Enzyme Linked Fluorescent Assay). RESULTS: Four cases were excluded due to loss to follow up. Of the remaining 36 cases, the mean age (+/- SD) and the body mass index were 46.27 +/- 5. 74 years and 23.72 +/- 2.92 kg/m2, respectively. Serum E2 level significantly increased from baseline value at 4, 8 and 12 weeks (mean (+/- SD) of E2 level at 0, 4, 8 and 12 weeks: 3.82 +/- 6.30 pg/ml, 117.11 +/- 92.86 pg/ml, 135.28 +/- 91.38 pg/ml and 164.48 +/- 78.94 pg/ml, p < 0.05) respectively. CONCLUSION: A daily dose of 1 mg oral micronized 17 beta-estradiolfor 12 weeks increased the serum E2 level to the follicular phase level of the normal menstrual cycle.

Long term results of anterior colporrhaphy with Kelly plication for the treatment of stress urinary incontinence.

OBJECTIVE: To study the five years' outcome of anterior colporrhaphy with Kelly plication for the treatment of stress urinary incontinence MATERIAL AND METHOD: Fifty two patients who underwent anterior colporrhaphy with Kelly plication with or without posterior colpoperineorrhapy for the treatment of stress urinary incontinence between January 1997 and February 1998 in King Chulalongkorn Memorial hospital were included in the study. All patients were contacted by phone, forty seven patients (90.38%) responded and were willing to participate in the present study. The patients' characteristics, operative data and outcome were reviewed. Questionnaires designed to assess the outcomes of the procedure and incontinence symptoms were given to each patient at the appointment date. Pelvic examination was performed using the Baden halfway classification for genital prolapse grading. Cough test was performed during pelvic examination for the objective demonstration of stress incontinence. RESULTS: The mean +/- SD of age was 46.68 +/- 8.78 yrs. The authors found that the incidence of post operative urinary retention was 43.3%. Incontinence rates at 1, 2, 3, 4 and 5 years were 0, 8.51%, 21.28%, 29.79% and 46.81% respectively. CONCLUSION: The present results show the high recurrence rate at the five-year follow up. The authors emphasized the need of long term follow up and pre-operative counseling about the high chance of having recurrence by this operative technique.

Laparoscopic finding in Thai women with chronic pelvic pain.

OBJECTIVE: To study the laparoscopic findings in Thai women with chronic pelvic pain. SETTING: The Gynecology Endoscopy unit, Department of Obstetrics and Gynecology, Faculty of Medicine, King Chulalongkorn Memorial hospital. DESIGN: Descriptive study. MATERIAL AND METHOD: The medical records of Thai women with chronic pelvic pain undergoing laparoscopic diagnosis from January 1996 to December 2001 at King Chulalongkorn Hospital were reviewed. Patients' characteristics and laparoscopic findings were reviewed and analyzed. RESULTS: One hundred and ten eligible women were enrolled in this study. The mean age was 33.9 +/- 7.2 years old (16-54 years old). Sixty-seven (60.90%) women had endometriosis, 14 (12.73%) women had pelvic adhesion, 4 (3.64%) women had myoma uteri, 4 (3.64%) women had tubal occlusion and 13 (11.81%) women had normal findings. The majority (38.15%) of endometriosis findings were in minimal stage of American Fertility Society (AFS) scores. CONCLUSIONS: The vast majority of causes of chronic pelvic pain in women in this study was pelvic endometriosis. Laparoscopic diagnosis was an important tool for identifying the causes in Thai patients.

Location of quinacrine pellets in different positions of non-surgical female sterilization.

OBJECTIVE: To compare quinacrine pellets distribution in the uterine cavity between women standing up promptly after insertion and those lying down for a further 30-minutes. DESIGNS: Randomized controlled trial MATERIAL AND METHOD: Twenty women who, desired interval female sterilization, were equally randomized into 2 groups. Quinacrine pellets were inserted twice, one month apart in both groups. Transvaginal ultrasonography (TVS) was performed after insertion in order to locate the position of the quinacrine pellets. In group I, the TVS was performed after the women stood up promptly. In group II, the TVS was performed after the women lay down for 30-minute. The distribution of quinacrine pellets, measured from the uterine fundus to the lowest pellet, were compared. RESULTS: There was no difference at the baseline and 30 minutes measurement of both groups. In the first insertion, there was statistical difference of the distance of the quinacrine pellets when compared in the same group immediately and the 30-minute measurement (Gr 1: 19.10+/-3.28 mm vs 22.30+/-3.50 mm); (Gr 2: 18.70+/-3.40 mm vs 24.40+/-5.95 mm). In the same manner, the authors found statistical difference in the same group of the second insertion (Gr 1: 21.80+/-5.39 mm vs 24.70+/-7.24 mm); (Gr 2 : 20.89+/-4.78 mm vs 28.30+/-7.59 mm) CONCLUSIONS: There was statistical difference of quinacrine pellet distribution in uterine cavity after time. However, body movement did not effect the position of the pellets. The failure rate of quinacrine pellet insertion for non-surgical female sterilization may not be explained by the changes of position after insertion.

Dilating missile trocar for primary port establishment: a cadaver study.

The missile trocar was developed for controllable entry force, smaller fascial defects and post-operative pain improvement. The trocar was composed of a fascial-dilating long-conical head and a handle. Accompanied with this trocar, the authors designed a rectus sheath-hooking instrument to promote negative intra-abdominal pressure during the trocar puncture. The hooking procedure allowed room air to pass through the central canal of the trocar and fill the space between the intestinal loops and the trocar tip. The abdominal access procedure succeeded in forty-five attempts in fresh cadavers. No second attempt was done. The trocar accessed into the peritoneal cavity at every attempt without intestinal penetration. The missile trocar may be an alternative device for establishment of the primary port. Its efficacy and safety still has to be proved.

Serum beta-hCG regression after laparoscopic salpingostomy in the treatment of ectopic pregnancy in Thai women.

This is a descriptive study which reviewed the regression pattern of serum beta hCG in Thai women with ectopic pregnancy after laparoscopic salpingostomy. The study group included the medical records of 21 patients who underwent laparoscopic salpingostomy between January 1991 and August 2001. The results revealed that the regression of serum beta hCG in patients with ectopic pregnancy after laparoscopic salpingostomy was about 10, 100, 1,000 times at day 6, 20 and 35 after operation. The correlation between days after operation and serum beta hCG was in the equation of log (beta hCG difference) = -0.0671 (days after operation) - 0.6187. This estimation curve can probably be used to predict the normal serum beta-hCG regression after laparoscopic salpingostomy.

Rectus sheath hooking: alternative method of abdominal wall lifting and fixing for laparoscopy: a pilot cadaver bio-mechanical study.

Four bio-mechanical tests were used to study properties of the rectus sheath for laparoscopic abdominal access procedure and to provide surgical exposure by the ChulaLift gasless retractor. The profile of forces and displacement showed how some patients were good candidates for the gasless operation. The lifting weight should not excess 10 kg for minimal harm and optimal exposure. The rectus hooking could be an alternative choice for abdominal wall fixing during the first trocar entry. One-cm width hooking, the rectus sheath could withstand 18-20 kg lifting force. The exposure provided by the gasless technique was narrow between the lateral ports compared to the conventional technique. The rectus sheath could be hooked to provide effective fixing of the area to be penetrated by the first trocar, and this fascial layer could be lifted to produce exposure in the gasless technique.

Serum estradiol and follicle-stimulating hormone levels in Thai women post total abdominal hysterectomy and bilateral oophorectomy using oral 17 beta-estradiol.

OBJECTIVE: To assess the difference of serum estradiol (E2) and follicle stimulating hormone (FSH) levels in Thai women post total abdominal hysterectomy and bilateral oophorectomy, before and after using a daily dose of 2 mg oral 17 beta-estradiol. STUDY DESIGN: Experimental study (before and after treatment). SETTING: Menopause Clinic, Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University. SUBJECTS: Thirty-five women who had undergone total abdominal hysterectomy and bilateral oophorectomy at Chulalongkorn Hospital 1 week previously due to benign gynecologic conditions were recruited in the study. Body mass index was 20-25 kg/m2. These women had no contraindication for using hormonal replacement therapy and no history of any hormonal intake in the past. INTERVENTION: All subjects were assigned to receive a daily dose of 2 mg oral 17 beta-estradiol applied at bedtime (8.00 p.m.). MAIN OUTCOME MEASURES: Serum E2 and FSH were measured before and after the study at weeks 4, 8 and 12, 12-14 hours after oral application. The hormonal measurement was performed using the time-resolved fluoroimmunoassay (FIA) method. RESULTS: Five cases were excluded, three cases due to poor compliance which was less than 85 per cent and two cases due to loss to follow-up. Of the remaining 30 cases, the mean age and body mass index were 43.03 +/- 4.58 years and 22.72 + 1.86 kg/m2, respectively. Serum E2 level significantly increased from baseline value at 4, 8 and 12 weeks (median of E2 value at 0, 4, 8 and 12 weeks: 20.00, 22.50, 324.65 and 355.35 pmol/L, p<0.001). On the other hand, there was no significant difference in the FSH serum level (median of FSH value at 0, 4, 8 and 12 weeks: 18.65, 18.40, 18.60 and 20.35 IU/L, p=0.517). CONCLUSION: A daily dose of 2 mg oral 17 beta-estradiol taken at bedtime (8.00 p.m.) for 12 weeks increased the serum E2 to the follicular phase level of the normal menstrual cycle. On the other hand, there was no significant difference in the FSH serum level.