Cervical screening strategies in resourced and resource-constrained countries.

Screening for cervical cancer is well established in resourced countries, but in resource-constrained countries, it is almost non-existent at national level. In resourced countries, the Pap test forms the hallmark of screening, with the human papillomavirus DNA test a recent adjunct. In many resourced countries, however, screening for cervical cancer is still far from ideal. A coverage around 50% prevails in some countries, and few have reached the target of 80% or more. Furthermore, the human papillomavirus test and newly developed biomarkers may lead to the development of a 'super test', which could be applied less frequently compared with present-day cytological screening. In resource-constrained countries, the movement is towards a 'screen and treat' approach. The main screening methods under investigation are the visual inspection after diluted acetic acid application test and the human papillomavirus test. Cryotherapy and large loop excision of the transformation zone have been used most often as treatment methods. The ideal seems to be the human papillomavirus test with large loop excision of the transformation zone, provided a low-cost human papillomavirus test becomes available. Coverage is even a greater problem in resource-constrained countries, a problem in need of urgent attention. Resource-constrained countries, however, must curtail the high incidence of cervical cancer, which is often a lower priority than other pressing healthcare needs.

Culdocele repair in female pelvic organ prolapse.

OBJECTIVES: To review patients with a culdocele, a wide and deep cul-de-sac, and to report the results of treatment by sacrocolpopexy. METHODS: A retrospective review of 117 patients with a culdocele identified by clinical examination and intraoperatively. RESULTS: The mean age and parity of the patients were 61.4 years and 3.1, respectively. Bladder complaints occurred in 46% of patients and bowel problems in 74% (mainly obstructed defecation). Something protruded through the vaginal introitus in 84% of patients. All patients were treated with a sacrocolpopexy: 96% with mobilization and elevation of the rectum (rectopexy), and 79% with Burch colposuspension. Follow-up results were obtained for 98% of the patients (mean, 14.7 months). Recurrent prolapse occurred in 10% of patients. CONCLUSIONS: A culdocele differs from an enterocele because it a distended and deep cul-de-sac without a true hernia between the distal vagina and rectum. Sacrocolpopexy resulted in a 10% recurrence rate of prolapse.

Screening for cervical cancer in an African setting.

OBJECTIVE: To estimate the proportion of women who were screened for cervical neoplasia with Papanicolaou (Pap) smears in 2002 in the Free State province of South Africa, and determine whether progress had been made since 1985. METHODS: A cross-sectional survey was done using 1887 smears, which represented 5% of the 37,749 smears examined at the 7 laboratories serving the province in 2002. RESULTS: Extrapolating the results to the census data for 2002, Pap smears were taken in 4.1% of the female population aged 15 to 65 years during that year. The rates were 18.8% for white women, most of whom use private medical services, and 2.6% for black women, almost all of whom use public medical services. In 1985, in a similar study found that 7.1% of the female population was screened with Pap smears, which means that cervical screening decreased by 42% over the 17 years (P< or =0.0001; 95% confidence interval, -3.1% to -2.9%). CONCLUSION: In view of the deterioration of cervical screening services documented in this study, it seems unlikely that Pap smear screening will succeed in Africa.

Vault Prolapse Treated by Sacrocolpopexy

Objective. To evaluate the success rate of sacrocolpopexy in 153 patients with stage 3 and 4 vault prolapse. Methods. A retrospective review was done on 153 patient records from a database in a urogynaecological unit. For the sacrocolpopexy procedure; semi-absorbable mesh was placed along the anterior and posterior vaginal walls; and attached to the anterior longitudinal ligament of the sacrum. Results. The median age was 65 years and parity 3.0; 94of the patients were white. Previous surgery for prolapse was reported by 48of the patients and 25were on thyroid hormone treatment. The vault prolapse was stage 3 in 81 patients (52.9) and stage 4 in 72 (47.1). At surgery; the mesh extended from the vaginal vault to the sacrum in 7 patients (4.6). In the remaining 146 patients (95.4) the mesh was attached to the posterior vaginal wall and in 133 (86.9) a second strip of mesh was fixed to the anterior vaginal wall. Follow-up was possiblein 149 patients (97.4); with a median of 29 months. Recurrent prolapse (any type) occurred in 22 patients (14.4)and 12 had repeat surgery for recurrent prolapse (7.8). In total; 25 patients (16.3) had repeat surgery for anyindication. Conclusions. Vault prolapse is difficult to treat owing to absence of support of the upper vagina; but sacrocolpopexy delivered acceptable results

Combined Abdominal Sacrocolpopexy and Burch Colposuspension for the Treatment of Stage 3 and 4 Anterior Compartment Prolapse

Objective. To review our experience with sacrocolpopexy and Burch colposuspension for stage 3 and 4 anterior compartment prolapse. Methods. Review of 154 patient records drawn from a urogynaecological database; with stage 3 and 4 anterior compartment prolapse treated by sacrocolpopexy and Burch colposuspension. Results. The median age of the patients was 60 years and a third of them had had previous prolapse surgery. Patients presented with bladder (41) and bowel (55) symptoms; and most complained of prolapse protruding through the vaginal introitus (86). Recurrent prolapse; stage 2 - 4; occurred in 24 patients (15.6); 9.7were anterior compartment prolapses. Where mesh was omitted from the anterior vaginal wall but placed on the posterior vaginal wall; significantly more recurrent anterior compartment prolapses occurred (95confidence interval (CI) 0.2; 34.8) compared with cases where mesh was placed both anteriorly and posteriorly to the vagina. Perioperative complications occurred in 13of patients. A tension-free vaginal tape (TVT) procedure for urinary stress incontinence was done at a later stage in 8of the patients. Conclusion. Sacrocolpopexy effectively treated anterior compartment prolapse where mesh was attached to the anterior vaginal wall as well. A Burch colposuspension probably did not make a difference

Moxifloxacin versus ofloxacin plus metronidazole in uncomplicated pelvic inflammatory disease: results of a multicentre, double blind, randomised trial.

OBJECTIVE: This multinational, multicentre, prospective, randomised, double blind, parallel group, non-inferiority study compared the efficacy and safety of moxifloxacin monotherapy with ofloxacin plus metronidazole in women with uncomplicated pelvic inflammatory disease. METHODS: Women from hospitals throughout 13 countries received a 14 day course of either oral moxifloxacin, 400 mg once daily (n = 384), or oral ofloxacin, 400 mg twice daily plus oral metronidazole, 500 mg twice daily (n = 365). RESULTS: Of the 741 patients in the intent to treat (ITT) population, 564 (74.2%) were valid for the per protocol (PP) analyses; 112 (19.9%) of these were included in the microbiologically valid population (MBV). Clinical resolution rates in the PP population at the test of cure visit (TOC, 5-24 days post-therapy, primary efficacy end point) were 90.2% (248/275) for moxifloxacin and 90.7% (262/289) for ofloxacin plus metronidazole (95% CI: -5.7% to 4.0%). At follow up (28-42 days post-therapy), resolution rates in the PP population were 85.8% (236/275) and 87.9% (254/289) for moxifloxacin and comparator, respectively (95% CI: -8.0% to 3.1%). Bacteriological success rates in the MBV population at TOC were 87.5% (49/56) for moxifloxacin and 82.1% (46/56) for comparator (95% CI: -8.3% to 18.8%). Against Chlamydia trachomatis and Neisseria gonorrhoeae, bacteriological success rates with moxifloxacin were 88.5% (23/26) and 100% (13/13) and for comparator 85.7% (18/21) and 81.8% (18/22), respectively. Drug related adverse events occurred less frequently with moxifloxacin (22.5% (85/378)) versus the comparator (30.9% (112/363)) (p = 0.01). CONCLUSION: In uncomplicated PID, once daily moxifloxacin monotherapy was clinically and bacteriologically as efficacious as twice daily ofloxacin plus metronidazole therapy and was associated with fewer drug related adverse events.

Posterior intravaginal slingplasty for vaginal prolapse.

OBJECTIVE: To evaluate the results of the posterior intravaginal slingplasty (IVS). PATIENTS AND METHODS: From a urogynecology database, 42 patients who had undergone posterior IVS procedures were analyzed. All the selected patients had also had a posterior colporrhaphy (88% with mesh inserted into the rectovaginal space). RESULTS: Intraoperatively, there was one complication, a rectum perforation. All patients were followed-up, with a median of 13 months. Recurrent prolapse, grade 3 or 4, developed in 12 patients (29%) which included ten cystoenteroceles (24%), four rectoenteroceles (10%), and three cases of utero/vault prolapse (7%). Repeat surgery was performed in six patients (14%). For utero/vault prolapse, eight patients presented preoperatively with grades 3 and 4 prolapse. On follow-up, three patients had utero/vault prolapse, one of whom did not have utero/vault prolapse on presentation. Therefore, of the eight patients presenting with utero/vault prolapse, only two had repeat prolapse on follow-up, which reflected an improvement of 75%. CONCLUSION: The posterior IVS delivered satisfactory results for vault and posterior compartment prolapse, with a 75% improvement in vault prolapse. It was not possible, however, to separate the effect of posterior IVS and posterior colporrhaphy on the prevention of recurrent prolapse nor on the improvement of difficulty in defecation. Due to the utilization of the now-abandoned vaginal anterior colposuspension procedure for the treatment of anterior compartment prolapse, no conclusions regarding the impact of the posterior IVS on the anterior compartment can be made.

Electrosurgical bipolar vessel sealing during vaginal hysterectomy.

OBJECTIVE: To compare electrosurgical bipolar vessel sealing (EBVS) with traditional suturing during vaginal hysterectomy. METHODS: In a randomized controlled trial involving 68 women undergoing vaginal hysterectomy for benign disease, 37 procedures were performed using EBVS and 31 using traditional suturing. The end points were procedure time, blood loss, number of ligatures used, postoperative pain score, and number of days in hospital. RESULTS: The procedure duration was shorter using EBVS (median duration, 32 vs. 40 min; P=.0003), with fewer ligatures (1 vs. 7; P<.0001) and less pain (median score, 4 vs. 6; P<.0001). There were no significant differences regarding blood loss (median, 100 vs. 160 mL; P=.36) and days in hospital (median, 2 vs. 2; P=.03). CONCLUSION: The EBVS system provided advantages over traditional suturing with regard to procedure time, number of ligatures used, and postoperative pain score.

Screening for cervical cancer in the developing world.

Cervical cancer remains the most common malignancy amongst females in countries of low income, mainly due to a lack of screening. Responsible factors are centred around inadequacies of the Pap smear: high cost; low sensitivity; the need of a laboratory with high human expertise; and a demanding logistic system for mass screening. No alternative screening method seems to be clearly advantageous. Although combinations of tests have higher sensitivities, they are complex, costly and associated with low specificities. Adding the problem of effective treatment, it seems that mass screening with adequate coverage of the population is an unreachable goal for many developing countries. The most promising development in the control of cervical cancer seems to be vaccination against the human papillomavirus, either as a preventative measure or for stimulating immunity in infected women.

Abdominal hysterectomy and Burch colposuspension for uterovaginal prolapse.

The recurrence rate for prolapse in patients who underwent abdominal hysterectomy and sacrocolposuspension for genital prolapse were determined. Patient records were reviewed and 58 patients who had undergone abdominal hysterectomy for genital prolapse and sacrocolposuspension with mesh were included. The patients' median age was 47.0 years and parity 3. Preoperatively, 25 patients (43%) presented with bladder symptoms, 17 (29%) with bowel symptoms and 45 (78%) with something protruding through the vagina. All patients underwent hysterectomy, of which 51 (88%) were subtotal. Colposuspension was performed by inserting a mesh from the mid-vagina to the sacrum (S1). A Burch colposuspension was performed in 50 patients (87%). The median follow-up was 20 months. Six patients (10%) developed recurrent prolapse, of which five (9%) underwent repeat surgery. There were no mesh erosions. The recurrence rate for prolapse was low, indicating that abdominal hysterectomy with sacrocolposuspension is an excellent option for uterovaginal prolapse.

The pathophysiology of an enterocele and its management.

This paper describes 130 patients with enteroceles and their treatment. It includes analysis of all cases with enterocele over a 17-month period in a pelvic floor dysfunction database. Procedures performed included the Moschcowitz procedure with suspension of the vaginal vault to the sacrum in 13 patients (10%), colposacrosuspension (CSS) (mesh from the upper posterior half of the vagina to the sacrum with mobilisation and fixation of the rectum to the mesh) in 39 patients (30%), perineocolposacrosuspension (PCSS) (similar to CSS, but the mesh is inserted further down to the perineum) in 48 patients (37%) and perineopubo-colposacrosuspension (PPCSS) (as PCSS, but with a second mesh between the bladder and vagina extending to the sacrum) in 30 patients (23%). An additional modified Burch colposuspension was performed in 87 patients (67%). A failure was defined as a recurrent vaginal prolapse of Grade II or more, or urinary incontinence requiring surgical correction. The patients' mean age was 60.5 years, their mean parity 3.3 and 92.3% were white. Preoperatively, 33.8% of the patients complained of constipation, 33.1% of difficulty in defaecation and 77% had bladder symptoms, suggesting urinary stress incontinence or detrusor instability. In 74.6% of the patients part of the vagina protruded through the vaginal introitus. The mean period of follow-up was 7.4 months (range 1-26) with only 13 patients (10%) not followed. Only two patients (1.5%) developed Grade II vaginal prolapse (both cystoceles and both from the PCSS group). Urinary stress incontinence in need of further treatment developed in 13 patients (10%). The failure rate, therefore, was 11.5%. In six patients (4.6%) the mesh had to be removed due to mesh reaction. In all cases the mesh was unabsorbable. Vaginal suspension procedures with mobilisation of the rectum provided satisfactory results for severe enterocele over the short term.

Colposacrosuspension for severe genital prolapse.

OBJECTIVE: A descriptive study of 140 patients with severe genital prolapse managed by colposacrosuspension with mesh interposition and a modified Burch colposuspension. METHODS: A laparotomy was performed with mobilization of the rectum and exploration of the rectovaginal septum. Vaginally, a longitudinal incision was made in the posterior vaginal wall which was completely separated from the rectum. A perineal repair was done, whereafter a strip of Vypro (Johnson & Johnson, Brussels, Belgium) mesh was inserted from the perineum to the sacrum at S1. It was fixated to the perineum and vagina while the rectum was elevated and attached to the mesh. Where a perineal repair was deemed not necessary, the mesh extended from the mid-vagina to the sacrum. A second mesh strip was placed anteriorly of the vagina, covering the upper third of the vagina and extending to the sacrum. After closure of the pelvic peritoneum, covering the mesh, a modified Burch colposuspension was performed. Follow-up was done at 6 weeks, 6 months and yearly thereafter. RESULTS: The median age was 61 years with a median parity of 3. All patients presented with grade 2 (extending to the vaginal introitus) or 3 (outside the vaginal introitus) prolapse. Approximately one-third had urinary incontinence and a similar proportion complained of difficulty in defecation. All the patients underwent colposacrosuspension with the mesh extending to the perineum in 67% of the patients. A Burch colposuspension was performed in 79% of the women. Postoperatively, 97% of the patients were followed for 1-29 months with a median of 8.5 months (mean 10.2 months). Recurrent prolapse, grade 2 or 3, developed in 11 patients (8%) and 17 patients (12%) developed urinary incontinence, needing a transvaginal tape procedure. Removal of the mesh was necessary in one patient (0.7%). CONCLUSION: Colposacrosuspension for severe genital prolapse delivered satisfactory short-term results. It is, however, a major surgical procedure and elderly or compromised patients may require less invasive procedures.

Screening for cervical cancer in developing countries.

Cervical cancer is the most common malignancy amongst females in developing countries, mainly due to a lack of precursor screening. This absence of screening is the result of inherent disadvantages of the Pap smear: high cost, low sensitivity, the need for a laboratory with high human expertise and a complex screening program logistic system. The prerequisites for screening in a developing country include a screening method that is affordable, which can be effectively applied once in a lifetime at the age of 30-35 years, provide an immediate result and thereby allowing for on-site treatment of positive cases. None of the current screening methods comply with these prerequisites. More research is necessary into different combinations of tests, which improve sensitivity. On-site human papillomavirus (HPV) identification, alone or in combination with other tests, is promising. Another promising development is immunization against HPV infection, either as a preventative measure or for stimulating immunity in infected women.