Anterior colporrhaphy: a randomized trial of three surgical techniques.

OBJECTIVE: The purpose of this study was to compare outcomes after anterior colporrhaphy with the use of 3 different surgical techniques. STUDY DESIGN: One hundred fourteen women with anterior vaginal prolapse were randomly assigned to undergo anterior repair by one of 3 techniques: standard, standard plus polyglactin 910 mesh, or ultralateral anterior colporrhaphy. Before and after operation, patients underwent physical examination staging of prolapse; the International Continence Society system was used. Symptoms were assessed by questionnaire and visual analog scales. We defined "cure" as satisfactory (stage I) or optimal (stage 0) outcome at points Aa and Ba. RESULTS: Of 114 patients who were originally enrolled, 109 patients underwent operation, and 83 patients (76%) returned for follow-up. Mean age (+/- SD) was 64.7 +/- 11.1 years. At entry, 7 patients (7%) had stage I anterior vaginal prolapse; 35 patients (37%) had stage II anterior vaginal prolapse; 51 patients (54%) had stage III anterior vaginal prolapse; and 2 patients (2%) had stage IV anterior vaginal prolapse. At a median length of follow-up of 23.3 months, 10 of 33 patients (30%) who were randomly assigned to the standard anterior colporrhaphy group experienced satisfactory or optimal anatomic results, compared with 11 of 26 patients (42%) with standard plus mesh and with 11 of 24 patients (46%) with ultralateral anterior colporrhaphy. The severity of symptoms that were related to prolapse improved markedly (preoperative score, 6.9 +/- 2.7; postoperative score, 1.1 +/- 0.8). Twenty-three of 24 patients (96%) no longer required manual pressure to void after operation. CONCLUSION: These 3 techniques of anterior colporrhaphy provided similar anatomic cure rates and symptom resolution for anterior vaginal prolapse repair. The addition of polyglactin 910 mesh did not improve the cure rate compared with standard anterior colporrhaphy.

Posterior vaginal prolapse and bowel function.

OBJECTIVE: This study's objectives were to describe symptoms related to bowel dysfunction in women with uterovaginal prolapse and to compare these symptoms according to extent of posterior vaginal prolapse. STUDY DESIGN: One hundred forty-three women completed a questionnaire assessment of bowel function and underwent standardized physical examination according to the International Continence Society's system for grading uterovaginal prolapse. RESULTS: The mean age was 59.2 years (SD 11.8 years); 78% of the women were postmenopausal. According to the furthest extent of posterior vaginal prolapse at point Bp, 22 (15.5%) were in stage 0, 46 (32.4%) were in stage I, 50 (35.2%) were in stage II, 23 (16.2%) were in stage III, and 1 (0.7%) was in stage IV. Ninety-two percent of women reported having bowel movements at least every other day. When asked whether straining was required for them to have a bowel movement, 38 (26.6%) reported never or rarely, 71 (49.6%) reported sometimes, 20 (14.0%) reported usually, and 14 (9.8%) reported always. When asked whether they ever needed to help stool come out by pushing with a finger in the vagina or rectum, 98 (69.0%) reported never or rarely, 30 (21.1%) reported sometimes, 8 (5.6%) reported usually, and 6 (4.2%) reported always. Twenty-three women (16.1%) had fecal incontinence, with 11 having loss of control of stool less often than once a month and 12 having it more often than once a month. When asked whether to rate how much they were bothered by their bowel function on a scale of 1 to 10, with 1 being not at all and 10 being extremely, 51.7% of women chose 1 to 4, 20.3% chose 5 to 7, and 28% chose >/=8. There were no clinically significant associations between any of the questions related to bowel function and severity of posterior vaginal prolapse. CONCLUSION: Women with uterovaginal prolapse frequently have symptoms related to bowel dysfunction, but this is not associated with the severity of posterior vaginal prolapse.

Prevalence of hydronephrosis in patients undergoing surgery for pelvic organ prolapse.

OBJECTIVE: To determine the prevalence of hydronephrosis in patients undergoing surgery for pelvic organ prolapse and to determine whether hydronephrosis is associated with the type and severity of prolapse. METHODS: The charts of 375 consecutive patients undergoing surgery for pelvic organ prolapse at the Cleveland Clinic Foundation between January 1, 1990, and December 31, 1993 were reviewed. Preoperative renal ultrasounds and intravenous pyelograms (IVP) were evaluated for hydronephrosis based on the final diagnosis established by the radiologists. The severity of prolapse was determined from the preoperative office examination or from the examination under anesthesia at the time of surgery. RESULTS: Of 375 patients, 323 had either a preoperative renal ultrasound or IVP. The mean age was 66.0 +/- 10.2 years (range 35-93) and median parity was 3.0 (range 0-10). Of the 323 patients, 25 (7.7%, 95% confidence interval 5, 11) had hydronephrosis. Thirteen patients (4.0%) had mild hydronephrosis, nine (2.8%) had moderate hydronephrosis, and three (0.9%) had severe hydronephrosis. The prevalence of hydronephrosis increased with increasing severity of prolapse. Two patients with hydronephrosis had evidence of renal insufficiency (creatinine > or = 1.6), and both had severe bilateral hydronephrosis and complete procidentia. The prevalence of hydronephrosis was lower in patients with vaginal vault prolapse versus uterine prolapse (3.9% compared with 12.6%, P < .01), CONCLUSION: The prevalence of hydronephrosis in patients undergoing surgery primarily for pelvic organ prolapse is low, increases with worsening pelvic organ prolapse, and is lower in patients with vaginal vault prolapse that in those with uterine prolapse.

Pelvic support defects and visceral and sexual function in women treated with sacrospinous ligament suspension and pelvic reconstruction.

OBJECTIVE: Our purpose was to evaluate the efficacy and consequences of sacrospinous ligament suspension and pelvic reconstruction. STUDY DESIGN: Patients who underwent sacrospinous ligament suspension between 1978 and 1991 were evaluated from follow-up visits, telephone interviews, questionnaires, and chart reviews. Before and after operation, vaginal support was graded in three segments. Postoperative visceral and sexual function was evaluated. RESULTS: Mean length of follow-up for 243 patients was 73.6 months. Of these, 102 (42.0%) had a support defect in at least one segment; anterior, posterior, and apical defects were found in 91 (37.4%), 33 (13.6%), and 20 (8.2%) patients, respectively. A clinically significant defect was defined as a symptomatic first-degree or any second-or third-degree prolapse. Defect-free survival rates at 1, 5, and 10 years were 88.3%, 79.7%, and 51.9%, respectively. Eleven patients (4.5%) underwent subsequent pelvic reconstruction. CONCLUSION: Sacrospinous ligament suspension and pelvic reconstruction are effective for vaginal apex support, but vaginal prolapse recurs with time, most commonly in the anterior segment.

Transvaginal mobilization and removal of ovaries and fallopian tubes after vaginal hysterectomy.

OBJECTIVE: To describe a technique of transvaginal mobilization and removal of ovaries and tubes, and to assess its use in older women undergoing vaginal hysterectomy. METHODS: Charts of 151 women age 50 and older who underwent vaginal hysterectomy by one senior gynecologic surgeon during 1991-1993 were reviewed. RESULTS: Ninety of 138 women (65%) who chose ovarian removal had their ovaries successfully removed vaginally. In 48 women, one or both ovaries were examined and noted to be normal, and they were not removed or could not be removed vaginally. Operating time, estimated blood loss, length of hospital stay, and rates of intraoperative complications and postoperative morbidity did not differ significantly in the bilateral salpingo-oophorectomy and ovarian conservation groups. CONCLUSION: Transvaginal removal of ovaries and tubes can be achieved in about two-thirds of women undergoing vaginal hysterectomy with minimal or no increases in operating time and surgical morbidity.

Endosalpingiosis.

The origin of psammoma bodies in cul-de-sac fluid must always be explained. Multiple, histologically benign, predominantly peritoneal foci of tubal-like epithelium are described in a woman with endometriosis and psammoma bodies in the cul-de-sac fluid. Because no primary ovarian neoplasm was present, the diagnosis of endosalpingiosis was made. The pathogenesis and significance of endosalpingiosis are discussed.

Turner's syndrome: results of estrogen therapy.

PIP: Annual endometrial biopsy had been advocated for patients with Turner's syndrome. The practicality of using this procedure on patients with no symptoms of abnormal bleeding has been questioned; this study attempts to answer this issue. Charts of patients with Turner's syndrome from the Cleveland Clinic for the period 1951-75 were reviewed. A criteria was established for inclusion of patients in the study. 34 of 43 women who met the criteria returned for the follow-up and were given pelvic exam, Pap smear, and endometrial biopsy by Vabra aspiration. Of the 43 patients given substitution therapy, 13 were taking estrogen alone; 24 were on estrogen-progesterone therapy, and 6 had stopped taking estrogen (Table 1). The presenting symptom in all cases of endometrial adenocarcinoma was abnormal bleeding (menorrhagia or menometrorrhagia), suggesting a change from previous menstrual patterns. At high risk for developing endometrial carcinoma at an early age was patients with dysgenesis who were receiving estrogen replacement therapy. The results of this study suggest that annual endometrial sampling is not necessary for patients with Turner's syndrome. It is recommended, however, that an annual examination and a Pap smear of an endocervical specimen be performed. Should there be any sign of menstrual aberration, endometrial biopsy or dilatation and curettage should be done. The importance of careful follow-up should also be impressed on patients who are on estrogen therapy; not more than 1 year's supply of estrogen should be given to such patients.^ieng

Seed dormancy: breaking by uncouplers and inhibitios of oxidative phosphorylation.

When 2,4-dinitrophenol and carbon dioxide were applied together to dormant seeds of Trifolium subterraneum L. (subterranean clover), 2,4-dinitrophenol did not disturb the breaking of dormancy which carbon dioxide usually induces in legume seeds. On the contrary, on its own, it promoted germination in a substantial proportion of seeds; a similar effect was produced by other uncouplers or inhibitors of oxidative phosphorylation.