Correlation Between Apical, Anterior, and Posterior Vaginal Wall Prolapse With Voiding Dysfunction: A Single Center Retrospective Cohort Study.

Objective: Voiding Dysfunction (VD) is one of the most common disorders among women, which is characterized by a disorder in urination. Pelvic organ prolapse is one of the factors that can affect VD. In this study, the relationship between prolapse in the anterior, posterior, and apical areas and VD has been evaluated. Materials and methods: This is a cohort retrospective study. The participants in this study were women with VD, who referred to the pelvic floor disorders clinic of Imam Khomeini Hospital in Tehran in 2018-2020. Clinical information was obtained retrospectively from the hospital's electronic data system, also symptoms (intermittent stream, incomplete voiding, poor flow, post void dribble, straining to void, stage anterior, posterior and apical) and urodynamic parameters (including EMG, PVR100, Qmax12, and pdet20) were evaluated, which included detailed questionnaires (Urinary Distress Inventory 6 (UDI-6) and Incontinence Impact Questionnaire-7 (IIQ-7)), pelvic examination, and complete urodynamic evaluation. Results: There was a direct relationship between the age of the patients and the stage of prolapse (p<0.001). So that, the stage increased with age. In addition, it was found that the severity of urinary symptoms is related to the stage of prolapse in the apical area (p=0.001). Also, the results showed that intermittent stream symptoms and the symptoms of staining to void had a significant relationship with the stage of prolapse (III and IV) in the apical and anterior areas. Also, it was shown that only PVR > 100 had a significant relationship with the stage of prolapse in the apical area (p=0.001). Conclusion: Intermittent stream and straining to void were related to the stages of prolapse in the apical and anterior regions. It was also concluded that the greater the prolapse, the higher the value of PVR > 100.

Prediction of bleeding in placenta accrete spectrum with lacunar surface: a novel aspect.

PURPOSE: Diagnosing the placenta accreta spectrum is crucial to prevent morbidities and mortalities among women with the suspicion of this pathology. We aim to evaluate novel ultrasonography markers for these patients in diagnosing and predicting prognosis. METHODS: This cross-sectional study was performed in a referral academic hospital. The population was composed of 51 pregnant women with a suspect of placenta accreta spectrum who had scheduled C-sections. Their primary information and past medical histories were documented. Then the ultrasonography markers, including the most bulging volume behind the bladder (area, perimeter, and volume), the Lacune (diameter, length, number, and surface of the largest lacuna obtained by multiplying the length by the width), the most considerable thickness of placenta on the cervix in patients with placenta previa, the most considerable thickness of the placenta behind the bladder, the Jellyfish sign, and sponge cervix were evaluated. Their comparison to the severity of the bleeding, the rate of the hysterectomy, and the following pathology of the placenta accreta spectrum were analyzed. RESULTS: The results showed that 17 (33.3%) of patients had severe bleeding (more than 2500 cc). The diameter, length, and surface of the largest lacunae limited to women with severe bleeding were 13.50 (5.5-21) mm, 20.50 (11-56) mm, 273.00 (60-1176) mm2, and they were 11.00 (5-24) mm, 16.25 (10-39) mm, and 176.25 (50-744) mm2 for women without severe bleeding (P value = 0.039, 0.027, 0.021). 13 (76.5%) women with severe bleeding had Jellyfish signs,16 (94.2%) had bulging on the cervix, and 10(58.8%) had a sponge cervix (P value = 0.046, 0.036, 0.006). Also, 34 (66.66%) patients needed hysterectomy. The diameter, length, and surface of the largest lacunae limited to women with hysterectomy were 12.00 (5-24) mm, 18.00 (11-56) mm, 231.00 (60-1176) mm2, and they were 9.00 (5-18) mm, 15.00 (10-28) mm, and 136.00(50-504) mm2 for women without hysterectomy (P value = 0.012, 0.070, 0.021). 24(70.6%) women with hysterectomy had Jellyfish signs, 29 (85.3%) of them had bulging on the cervix, and 15 (44.1%) had sponge cervix (P value = 0.05, 0.036, 0.028). The cut-off associated with the Lacunar surface was 163.5 mm2. Its sensitivity was 80%, and its specificity was 48% (P value = 0.021). CONCLUSION: The presence of single large lacunae could be a suitable predictive factor for bleeding in the placenta accreta spectrum; Moreover, there are some other US criteria, including the presence of a sponge cervix or the Jellyfish sign that are valuable predictive factors for negative outcomes for this spectrum, including hysterectomy.

Concomitant pericervical reconstruction with sacrospinous hysteropexy: Anatomical and functional results.

OBJECTIVE: Pericervical ring reconstruction through restoration of pubocervical and rectovaginal fascia is performed concomitantly with sacrospinous hysteropexy as a transvaginal native tissue procedure for vaginal apical prolapse. The main goal of this study was to assess subjective and objective outcomes of sacrospinous hysteropexy and additional pericervical ring reconstruction. MATERIALS AND METHODS: We conducted a prospective and observational study. All participants underwent sacrospinous hysteropexy and pericervical ring reconstruction and perineorrhaphy. Surgical complications, anatomical and functional efficacy were assessed. RESULTS: 108 cases were included in this study. The mean follow-up timeframe was 18.62 ± 1.22 months (minimum 12 and maximum 26 months). All parameters of subjective outcomes were improved significantly. The overall anatomic success rate was 92.59%. Mean operation time was 50.64 ± 20.8 min. No major intraoperative or postoperative complications were found. There was no statistically significant difference in demographic characteristics including age, BMI, gravidity, medical comorbidities, menopausal status, sexual activity, pretreatment prolapse severity scores between subjects with failure, and good anatomical outcome. Recurrence was mostly observed in patients with higher prolapse stages of anterior and apical compartments. Baseline POP-Q parameters Ba, C, D were significantly higher in cases with failure. CONCLUSION: Our study disclosed sustainable anatomic and subjective outcomes of modified sacrospinous hysteropexy by means of additional pericervical ring reconstruction.

Rate and Causes of Suicide in Ilam: A Report of the Suicide Registry.

Objective: Suicide is one of the most important health problems in the world. Financial, academic, social, and environmental difficulties along with genetic, physical, and mental disorders affect suicide attempts. This study aimed to find risk factors for completed suicide in Ilam province according to the suicide registry in Ilam province. Method : This was a prospective study and was performed based on suicide case registration data, pre-determined checklist data, and death registration data in Ilam province from March 2019 to September 2020. Logistic regression models and the Chi-square test were used to determine the relationship between completed suicide and its risk factors. Results: Among 1,410 attempted suicides, 66 (4.7 %) were executed. Rate of completed suicides was higher in men (6.5%) compared to women (4.5%), (p = 0.005), age groups over 65 years (P < 0.001), retirees and farmers (P = 0.009), illiterate people (P < 0.001), villagers (P = 0.02), people motivated due to physical problems (P = 0.016), suicide by physical methods (P < 0.001) and self-immolation (P < 0.001). Logistic regression showed that incidence of completed suicide was significantly higher in the age group over 65 years, illiterate people, people using physical methods, villagers, and men. Multivariate logistic regression also showed that men and individuals using physical methods of suicide were significantly more successful in suicide. Conclusion: Men, the elderly, illiterates, villagers, and people who used physical suicide methods were in high-risk groups. Despite lower prevalence of suicide, a higher rate of completed suicide was demonstrated. To decrease completed suicide rates, we must pay attention to these groups.

Resumption of Elective Surgery Following COVID-19 Outbreak, Guideline for Female Pelvic Medicine and Surgery.

Division of Female Pelvic Medicine and Surgery, Department of Obstetrics and Gynecology, Emam Khomeini Hospital, Tehran University of medical sciences proposed a clinically relevant algorithm to guide appropriate decision making based on underlying risk stratification and resource utilization in order to resume elective surgeries, following COVID-19 pandemic crisis. The consequence of standardized decision-making factors and transparency of the principles will provide more assurance, consistency, and reliability on both sides, care providers and the patient. It also will decrease ethical dilemmas and moral criticism for surgeons. Eventually, this approach is applicable in any other disaster preparedness as a logical stratification of surgical indications for the female pelvic floor surgical procedures.

Outcomes of Surgery with Vaginal Native Tissue for Posterior Vaginal Wall Prolapse Using a Special Technique.

There are several techniques for repairing prolapse in the posterior vaginal compartment, yet there is no general agreement on the best surgical procedure. This study was performed to investigate the outcomes of the common vaginal route technique for posterior vaginal wall prolapse repair in the first Iranian fellowship teaching center for female pelvic floor disorders. This prospective cohort study was performed on women with posterior vaginal wall prolapse with or without prolapse of other vaginal compartments who underwent surgery between 2014 and 2018 in a referral center for female pelvic floor disorders. A follow-up period of 12 months was considered. Patients subjected to the transvaginal technique by attachment of the rectovaginal fascia to the pericervical ring using vaginal native tissue were included. Among the 107 patients, the Pelvic Floor Distress Inventory-20 (PFDI-20) scores were 141.87 ± 34.48 and 100.87 ± 26.48 before and after surgery, respectively, showing the significant improvement of patient's symptoms after surgery in the 12-month follow-up. Comparing Pelvic Organ Prolapse Quantification (POP-Q) results before and after surgery, a significant improvement in patients' conditions was seen at the 12-month follow-up. Based on the results of the present study, the surgical procedure of the rectovaginal fascia attachment to the pericervical ring in posterior vaginal wall prolapse repair seems an effective surgical intervention without significant morbidity in the short-term follow-up.

Patient Satisfaction and Symptoms Improvement in Women Using a Vginal Pessary for The Treatment of Pelvic Organ Prolapse.

Pelvic organ prolapse is a common complaint among older women. Vaginal pessary insertion is an appropriate treatment as a non-surgical method with few complications. This paper is a prospective observational study of 68 patients with pelvic organ prolapse that was carried out at the Imam Khomeini Hospital's Pelvic Floor clinic. The degree of pelvic organ prolapse was graded according to the Pelvic Organ Prolapse Quantification (POP-Q) System. For all patients, the Pelvic Floor Distress Inventory-20 (PFDI-20) questionnaire was completed before vaginal pessary insertion, and after approximately 6 months of treatment. After 6-8 months, we found out that vaginal discharge was significantly increased and the feeling of fullness in the vagina was significantly decreased. However, sexual dissatisfaction, the feeling of incomplete evacuation, fecal and urinary incontinence, frequent urination, and pain or discomfort in the genital region were not significantly different after using a pessary. Approximately half a year later, 96.7% of the women with a successful pessary fitting trial were satisfied and reported a significant improvement in symptoms. Further studies with larger sample size, a different type of pessary, and a longer follow-up duration are recommended to evaluate all the symptoms associated with pelvic organ prolapse and its treatment.

Luteal phase estradiol versus luteal phase GnRH antagonist administration: their effects on antral follicular size coordination and basal hormonal levels.

BACKGROUND: The differential efficacy between long GnRH agonist with antagonist can partly be due to the preexisting differences in the early antral follicles before ovarian stimulation. OBJECTIVE: To compare the effect of pretreatment by estradiol with GnRH antagonist on antral follicular size coordination and basal hormone levels in GNRH antagonist protocol. MATERIALS AND METHODS: On cycle day 3 (control/day 3), women underwent measurements of early antral follicles by ultrasound and serum FSH and ovarian hormones then were randomized to receive oral estradiol 4mg/day (n=15) or 3mg cetrorelix acetate (n=15) in luteal phase before subsequent antagonist protocol. Participants were re-evaluated as on control/day 3. RESULTS: There was a significant reduction of mean follicular sizes in each group after medical intervention (7.63±2.11 Vs. 4.30±0.92 in group A and 8.73±1.96 Vs. 4.13±1.11 in group B) (p=0.0001). The magnitude of follicular size reduction was significantly higher in group B (-4.60±2.04 Vs. -3.33±2.28) (0.027). There was a non significant attenuation of follicular size discrepancies in two groups. FSH and inhibin B levels in the day 3 of the next cycle in both groups were significantly decreased but did not have significant difference between two groups. CONCLUSION: Both luteal E2 and premenstrual GnRH antagonist administration reduces the follicular sizes significantly and GnRH antagonist acts more potently than E2 in this way but attenuation of follicular size discrepancies in both treatment is not significant.

Preoperative prognostic factors and effects of adjuvant therapy on outcomes of early stage cervical cancer in Iran.

BACKGROUND: The aim of this study was to investigate the clinical and histopathological characteristics and the pretreatment that might predict prognosis and to evaluate the impact of postoperative adjuvant therapy on the outcomes of patients with early stage cervical carcinoma. METHODS: A total of 203 patients with stage IB and stage II cervical cancers treated with radical hysterectomy and systematic retroperitoneal lymphadenectomy were reviewed at the Vali-Asr University Hospital from 1995 to 2002. The median follow-up period was 42 months. RESULTS: The depth of cervical stromal invasion, clinical stage, histology of pure adenocarcinoma and lymph node (LN) status were important histopathological prognostic factors of cervical carcinoma. Patients' prognosis could be stratified into three groups (low, intermediate and high risk), with five-year relapse free survival (RFS) rates of 93.5%, 80.6% and 64.7%, respectively (p=0.002), and overall survival (OS) was 95.3%, 83.1% and 67.2% (p=0.001). Among the patients with pelvic lymph node metastases who were free of parametrial extension, those who received postoperative chemo-radiotherapy had significantly better RFS (p=0.021) and OS (p=0.030) than those who received no adjuvant therapy. Also of the patients without pelvic LN metastases but at a high risk of recurrence, the individuals who received adjuvant radiotherapy had a significantly more favorable RFS (p=0.038 ) and a marginally improved OS (p=0.064). CONCLUSION: Depth of cervical stromal invasion, clinical stage and histology are independent predictors of outcome on multivariate analysis using a Cox regression model. RFS is significantly improved with radiotherapy in patients who are without pelvic lymph node metastases but who are in a high risk group for recurrence.