Updated recommendations on ultrasonography in urogynecology.

Ultrasound is a supplementary, indispensable diagnostic procedure in urogynecology; perineal, introital, and endoanal ultrasound are the most recommended techniques. The position and mobility of the bladder neck can be demonstrated. In patients undergoing diagnostic work-up for urge symptoms, ultrasound occasionally demonstrates urethral diverticula, leiomyomas, and cysts in the vaginal wall. These findings will lead to further diagnostic assessment. The same applies to the demonstration of bladder diverticula, foreign bodies in the bladder, and bullous edema. With endoanal ultrasound, different parts of the sphincter ani muscle can be evaluated. Recommendations for the standardized use of urogenital ultrasound are given.

Prevalence of female sexual dysfunction in gynecologic and urogynecologic patients according to the international consensus classification.

OBJECTIVES: To evaluate the prevalence of female sexual dysfunction (FSD) in an outpatient gynecologic and urogynecologic clinic using the current International Consensus Classification. METHODS: One hundred fifty-nine patients were asked to answer an anonymous survey about FSD. Patients in the gynecologic (group 1) and urogynecologic (group 2) clinics were compared. RESULTS: The mean age in group 1 was 37.8 years (range 20 to 76) and in group 2 was 55.7 years (range 18 to 82). The prevalence of FSD was 50% in group 1 and 48% in group 2; 86% of group 1 and 66% of group 2 patients had been sexually active within the past 2 years. The differences found in FSD according to the consensus panel classification achieved no significance. Of the 159 patients, 96% were not embarrassed by filling out this questionnaire about their sexual function. CONCLUSIONS: No statistically significant difference in FSD was found between the younger and older patients seeking help in a gynecologic or urogynecologic outpatient clinic. Because of the high incidence of FSD, we recommend integrating the inquiry about female sexual health concerns into routine gynecologic care. The simple survey based on the International Consensus Conference Classification of FSD gives reliable results, and this systematic framework facilitates methodologic examination.

Tension-free vaginal tape operation: results of the Austrian registry.

OBJECTIVE: To assess the use of and perioperative complications associated with the tension-free vaginal tape operation with a central registry. METHODS: Fifty-five gynecology units completed questionnaires on patients undergoing the tension-free vaginal tape operation. Information was collected on patient, surgical, and postoperative data. RESULTS: A total of 2795 patients were entered. Overall, 773 patients (28%) had undergone previous surgery for incontinence or prolapse; 1640 (59%) tension-free vaginal tapes were performed as isolated operations, and 1155 (41%) were done in combination with other procedures. The median operating time for tension-free vaginal tapes alone was 30 minutes (range 10-120). Of the isolated tension-free vaginal tapes, 727 (44%) were performed with local, 711 (43%) with regional, and 193 (12%) with general anesthesia. In patients undergoing tension-free vaginal tape only, postoperative bladder drainage was obtained with intermittent catheterization in 389 (24%) patients, an indwelling urethral catheter in 1032 (63%), and a suprapubic catheter in 143 (9%). The bladder perforation rate was 2.7% overall (n = 75) and higher in patients with than in those without previous surgery (4.4% compared with 2.0%, P =.01). There were four bladder perforations (3.3%) among the 120 patients with previous colposuspension. Most patients undergoing tension-free vaginal tape only were able to void the next day (range 0 to over 64). A total of 68 patients (2.4%) required reoperation for reasons related to the tape (39 to loosen, remove, or cut the tape, or to place a suprapubic catheter, 19 for hematoma, one for bowel injury). CONCLUSION: The tension-free vaginal tape has become a frequently performed operation in Austria. There are considerable variations in clinical practice. The risk of bladder perforation was increased in patients with previous surgery. Severe complications were rare.

The Austrian tension-free vaginal tape registry.

In Austria a central registry for all TVT operations has been established in which more than 800 cases have so far been registered. The registry contains information on pertinent data on the operated patients and intra- and postoperative outcomes of the TVT surgery. No serious complications and no mortality have been registered until now.

Three-dimensional ultrasound of the female urethra: comparing transvaginal and transrectal scanning.

OBJECTIVES: To compare transvaginal and transrectal three-dimensional ultrasound in determining the morphology and measurements of the female urethra. DESIGN: Sixty-five women who had not had surgery for incontinence or pelvic floor descent had transvaginal and transrectal sonography using a 7.5-MHz mechanical sector endoprobe with three-dimensional facilities. The multiplanar display of the scanned volumes allowed detailed morphologic assessment of the urethra and the measurement of distances and volumes. Statistical endpoints were: sagittal urethral diameter, maximum rhabdosphincter length and thickness, maximum thickness of the smooth muscle complex, and the volumes of the rhabdosphincter and the smooth muscle complex. Values were compared between the two approaches using Student's t-test and Bland-Altman analysis. RESULTS: Both vaginal and rectal scans were feasible. However, significant differences between the two approaches were found for the sagittal diameter of the urethra (8.4 +/- 1.9 mm on vaginal vs. 11.5 +/- 2.2 mm on rectal scans, P < 0.01) and the transverse diameter of the urethra's smooth muscle complex (11.2 +/- 0.3 mm on vaginal vs. 8.6 +/- 0.2 mm on rectal scans, P < 0.001). No other variables showed significant differences. Compression of the urethra and displacement under the symphysis pubis were observed when the ultrasound probe was applied vaginally. Bland-Altman analysis showed acceptable variability for differences of distances but considerable variability for the differences of volumes. CONCLUSION: The female urethra can be examined both vaginally and rectally by three-dimensional ultrasound. A transvaginally applied probe seems to have a compression effect on the urethra.

Could we treat more unruptured ectopic pregnancies with intramuscular methotrexate?

The main reason for the restricted use of methotrexate in the treatment of ectopic pregnancy (EP) obviously is the fear of tubal rupture in patients with lower abdominal pain after the administration of methotrexate. Therefore, we wanted to find out if patient characteristics at first presentation, such as age, pretreatment beta-hCG level, adnexal mass as visualized by transvaginal ultrasonography, or history of prior EP, would identify patients at risk for tubal rupture if they were hemodynamically stable and showed no signs of peritoneal irritation. We examined whether more patients could have been treated medically with methotrexate, because tubal rupture was unforeseeable at first presentation and inclusion criteria for methotrexate treatment were fulfilled. From January 1996 to August 1998, 122 patients diagnosed as having EP were treated at the Gynecologic Department of the University Hospital of Vienna. Inclusion criteria for medical treatment with intramuscular methotrexate (50 mg/ m(2) body surface area) were (1) hemodynamic stability, (2) an unruptured ectopic mass < or = 5 cm at the greatest dimension demonstrated at transvaginal ultrasonography; (3) beta-hCG level < or = 5,000 mIU/ml; (4) no cardiac activity of the extrauterine embryo; (5) wish of future fertility, and (6) informed consent. Patients with hemodynamic instability, severe abdominal pain, an ectopic mass > or = 5 cm at the greatest dimension, beta-hCG levels > or = 5,000 mIU/ml, cardiac activity of the extrauterine embryo, and no wish of future fertility, or disagreement with methotrexate treatment, primarily underwent surgery. Despite the fact that none of the above patient characteristics at first presentation identified patients at risk for tubal rupture, only 60/122 patients (49%) actually underwent medical treatment whereas our inclusion criteria would have granted medical treatment in 101/122 patients (83%). We determined the actual and maximal possible percentages of patients with unruptured EP eligible for medical treatment of EP with intramuscular single-dose methotrexate 50 mg/m(2) body surface area. Our data show that tubal rupture in hemodynamically stable patients is not foreseeable and should not lead to a restricted use of medical treatment in patients preferring methotrexate.

Value of urethral pressure profilometry in the female incontinent patient: a prospective trial with an 8-channel urethral catheter.

OBJECTIVES: To measure the pressure profiles at different positions of the urethral circumference simultaneously. METHODS: Twenty-two women with symptoms of genuine stress incontinence underwent urogynecologic assessment and multichannel urethral pressure profilometry (UPP) at rest with a specially designed 8-channel urethral catheter with radial openings. RESULTS: The distribution pattern of maximum urethral closure pressure (MUCP) and functional urethral length (FUL) values were significantly different (P=0.004 and P=0.0004, respectively). Most of the highest MUCP values per patient were found between channels 2 and 4 (P=0.015); most of the greatest FUL values per patient were found between channels 3 and 4 (P=0.15). CONCLUSIONS: The data of our study substantiate asymmetric radial pressure distribution within the urethra and underline the necessity of cautious interpretation of results of conventional single-channel UPP, which might vary because of transducer orientation.

Transurethral injection of silicone microimplants for intrinsic urethral sphincter deficiency.

OBJECTIVE: To assess the short-term efficacy of transurethral injection of silicone microimplants in women with intrinsic sphincter deficiency. METHODS: During January 1995 and December 1996, 32 women (mean age 64.3 years, range 39-85 years) with type III stress incontinence (intrinsic sphincter deficiency) underwent transurethral injection of silicone microimplants under general anesthesia. Twenty-eight had undergone previous continence surgery. Subjective and urodynamic assessments were made at 6 and 12 months after injection to evaluate success and short-term effects. RESULTS: Objective and subjective success rates were 75% and 59% at 6 and 12 months, respectively. Injections of silicone microimplants significantly increased maximum urethral closure pressure (maximum urethral pressure at rest: 34.40+/-16.46 cm H2O, 95% confidence interval [CI] 28.55, 40.25 versus 25.35+/-10.78 cm H2O, 95% CI 21.52, 29.18; P = .027). There were no complications after surgery up to 1 year. CONCLUSION: Transurethral silicone injections were effective in 60% of cases of intrinsic sphincter deficiency, although there was a time-dependent decrease.

The prognostic value of CD44 isoform expression in endometrial cancer.

Isoforms of the transmembrane glycoprotein CD44 have been implicated in tumour cell adhesion, tumour differentiation and metastatic spread in various human malignancies. We investigated the expression of CD44 isoforms containing variant exons v3, v5, v6 and v7-8 in 156 human endometrium cancer specimens by means of immunohistochemistry. CD44 isoforms CD44v3, CD44v5, CD44v6 and CD44v7-8 were detected in 26% (41 out of 156), 31% (48 out of 156), 22% (35 out of 156) and 15% (23 out of 156) of the tumour samples respectively. The expression of CD44 isoforms CD44v3, CD44v5 and CD44v7-8 showed no prognostic impact. In the univariate analysis, the expression of CD44v6 showed an association with shortened overall survival (log-rank test, P = 0.06). Multivariate analysis correcting for the confounding variable histological grading revealed CD44v6 not to be a prognostic factor in endometrial cancer (log-rank test, P = 0.06). Comparing the expression of CD44 isoforms CD44v3, CD44v5, CD44v6 and CD44v7-8 in 45 specimens of normal endometrial tissue, we found an up-regulation of all investigated CD44 isoforms in the secretory phase compared with the proliferative phase of the menstrual cycle. Our data indicate that the expression of CD44 isoforms, while obviously playing a role in the functional changes of normal endometrium, is not an adverse predictive factor in endometrial cancer.

Present state of diagnostics and therapy in female urinary incontinence.

OBJECTIVE: To determine the present state of urogynecological diagnostics, therapy and follow-up in the Departments of Gynecology and Obstetrics in Austria. DESIGN: We sent questionnaires to all Departments of Gynecology and Obstetrics in Austria. The anonymous questionnaire consisted of 25 multiple choice questions. It was possible to choose one ore more answers by ticking applicable boxes with the casual option to give some additional information in form of free text. RESULTS: Fifty-eight departments (58%) returned their questionnaires completely answered indicating interest in quality management in medicine. The most remarkable discrepancy was found between the interrogated people's estimation of the expressiveness of examination techniques and the actual use of such techniques. CONCLUSION: We regard the results of this survey as a basis for further quality management strategies in the field of urogynecology in Austria.

Omental evisceration after laparoscopic treatment of a tubal pregnancy. A case report and review of the literature.

The increasing use of the laparoscopic surgery in the management of gynecologic diseases resulted in an increasing incidence of complications and the development of new complications. Postoperative complications are uncommon after laparoscopy. The most common complication is incisional herniation. A rare form of port-associated complications is omental evisceration. Since herniation through trocar incision sites might implicate severe complications, the use of safety techniques should be applied on a routine basis to reduce laparoscopy-associated morbidity.

Effect of spinal anaesthesia on the lower urinary tract in continent women.

OBJECTIVE: To evaluate the effect of spinal anaesthesia on the bladder neck position and the urethral closure function in the resting state and during clinical stress test in healthy, continent women. DESIGN: Controlled clinical trial. SETTING: Department of Gynaecology and Obstetrics, Vienna University Medical School. PARTICIPANTS: Fourteen continent women, of which seven were nulliparous and seven parous, underwent minor gynaecological procedures under spinal anaesthesia. Urodynamics and ultrasound investigations were performed before and during spinal anaesthesia. MAIN OUTCOME MEASURES: Changes in the bladder neck position and the urethral closure function before and during spinal anaesthesia. RESULTS: Bladder neck position was found to be lower and more posterior during spinal anaesthesia as compared with pre-operative assessment. The posterior urethrovesical angle increased significantly both at rest and during maximum straining. We observed a significant increase in bladder compliance, and all parameters of the urethral pressure profile decreased significantly. While none of the nulliparous women had a positive clinical stress test during spinal anaesthesia, 4/7 parous women demonstrated leakage (Fisher's exact test, P = 0.003). CONCLUSIONS: Blockage of nerve supply to the pelvic floor muscles in continent women is associated with a significant loss of support of the bladder neck region confirming the theory of an active mechanism of muscular elements providing continence.

Serum evaluation of interleukin 6 in ovarian cancer patients.

BACKGROUND: Cytokines are intercellular hormones, believed to play a functional role in the natural history of various malignant diseases. In vitro and in vivo studies have indicated that interleukin 6 (IL-6) may provide autocrine and paracrine growth stimulation in ovarian cancer cells. METHODS: In the present study we measured IL-6 in the serum of 73 patients with FIGO stage I to IV ovarian cancer. Enzyme-linked immunosorbent assay (ELISA) was used to determine IL-6 serum levels. Results were correlated to clinical data. Serum levels of IL-6 were additionally evaluated in a panel of 50 normal controls. RESULTS: Median serum levels of IL-6 in patients with ovarian cancer and normal controls were 55.6 (minimum 0, maximum 2869.0) pg/ml and 0.5 (minimum 0, maximum 2.14) pg/ml, respectively (Mann-Whitney U test, P = 0.0001). When serum levels of IL-6, taken prior to therapy, were grouped by FIGO stage, lymph node involvement, and grading of tumor cells, we found a statistically significant correlation with FIGO stage (Mann-Whitney U test, P = 0.04). Lymph node involvement and grading of tumor cells were not correlated with IL-6 levels. Elevated IL-6 serum levels prior to therapy were significantly correlated with poorer disease-free (log-rank test, P = 0.003) and overall survival (log-rank test, P = 0.01). CONCLUSION: Elevated IL-6 serum levels prior to therapy are correlated with a poor relapse-free and overall survival in ovarian cancer patients.

Prophylactic cerclage in pregnancy. Effect in women with a history of conization.

OBJECTIVE: To evaluate the effect of prophylactic cerclage on the course of pregnancy in women with prior conization. STUDY DESIGN: In a retrospective, observational study, the outcome of pregnancies in 69 women with (n = 30) and without (n = 39) cerclage who previously underwent conization was evaluated regarding hospitalization due to threatened preterm labor and delivery before 37 weeks of gestation. RESULTS: The occurrence of preterm delivery was 23.3% in the cerclage group and 20.5% in the control group (P = .78). Women with prophylactic cerclage were hospitalized significantly more often due to threatened premature labor: with cerclage, 66.7%; without cerclage, 33.3% (P = .006). CONCLUSION: Prophylactic cerclage should be used more sparingly in women with a history of conization because it does not prevent premature delivery and tends to induce preterm uterine contractions.

Serum M3/M21 in cervical cancer patients.

Cytokeratins are polypeptides which constitute a subclass of intermediate filaments in epithelial cells. The serum tumour marker M3/M21 is based on monoclonal antibodies against the epitopes M3 and M21 of cytokeratin 18. In the present study, we measured M3/M21 serum levels in 50 patients with FIGO stage IB-IIB cervical cancer and in 50 control subjects using a two-site radiometric immunoassay directed against soluble fragments of cytokeratin 18. Median serum levels of M3/M21 in patients with cervical cancer and in normal controls were 70.6 U/ml (range 0-397.7) and 6.5 U/ml (range 0-205.2), respectively (Mann-Whitney U-test, P = 0.0001). Median serum levels of M3/M21 prior to therapy and 4 weeks after therapy were 104.2 U/ml (range 24.6-397.7) and 39.3 U/ml (range 0-234.7), respectively (Mann-Whitney U-test, P = 0.004). We found a significant correlation between elevated M3/M21 serum levels and metastatic disease in pelvic lymph nodes (Mann-Whitney U-test, P = 0.002). 24 patients relapsed after complete remission. In these patients, elevated M3/M21 serum levels before the detection of relapse by computed tomography was observed in 13 cases. Considering these preliminary results, further studies with an increased number of patients are justified to clarify the prognostic value and the monitoring abilities of M3/M21 in cervical cancer patients.

CD44 is an independent prognostic factor in early-stage cervical cancer.

The expression of specific cell-adhesion molecule CD44 isoforms (splice variants) is associated with metastatic spread and poor prognosis in human malignancies. The aim of this study was to evaluate whether CD44 isoform expression is a prognostic factor in early-stage cervical cancer. We used 4 different variant exon sequence-specific murine monoclonal antibodies to the CD44 isoforms CD44v3, CD44v5, CD44v6 and CD44v7-8 to study the prognostic value of CD44 splice variants in 200 cases of International Federation of Gynecology and Obstetrics (FIGO) stage-IB cervical cancer by immunohistochemistry. In the univariate analysis, the expression of CD44v3 (log-rank test, p = 0.03) and CD44v6 (log-rank test, p = 0.03) was correlated with poor overall survival. In the subgroup of patients without metastatic disease in the pelvic lymph nodes, expression of CD44v6 was correlated with poor disease-free and overall survival (log-rank test, p = 0.04 and p = 0.01, respectively). Multivariate analysis, correcting for the confounding variables pelvic lymph-node involvement, depth of invasion and histologic grading, revealed CD44v6 to be an independent prognostic factor for overall survival of patients with early-stage cervical cancer. The results of this study indicate that CD44v6 is an additional prognostic marker in surgically treated cervical cancer. The assessment of CD44 isoform expression could be of clinical value in deciding upon adjuvant therapy, resulting in a more individualized management of therapy.

Serum M3/M21 in ovarian cancer patients.

Cytokeratins are polypeptides that constitute a subclass of intermediate filaments in epithelial cells. The aim of the present study was to evaluate the clinical usefulness of the serum evaluation of M3/M21 in patients with ovarian cancer. This retrospective study comprises 75 patients suffering from ovarian cancer FIGO stages Ia-III. M3/M21 reached a sensitivity of 78%, a specificity of 85%, a PPV of 89% and a NPV of 83% using a cut-off level of 45 U 1(-1). Forty-four women developed recurrent disease after complete remission during the observation period. M3/M21 showed lead time effects in 19 patients, ranging from 2 to 8 months (median 3.2 months). Elevated M3/M21 serum levels before therapy were associated with a poor overall survival (log-rank test, P = 0.02). Considering these preliminary results, the value of M3/M21 as a serum tumour marker, i.e. to evaluate the tumour burden, seems promising.

Menstrual phase and breast cancer surgery: influence on clinical outcome or pitfall of statistical analysis?

The influence of menstrual status at the time of surgery on the prognosis of women suffering from breast cancer is still discussed controversially. In our patient collective, including 149 patients, we obtained statistically significant results for six different time intervals, indicating that patients who underwent surgery between 11 and 22 days after the last menstrual period (LMP) have a poorer outcome. Focusing on the effect of statistical data evaluation strategy we designed a simulation study to evaluate the amount of type I error (error of a false positive test result) in a multiple testing situation involving a cyclical covariate. Accordingly, we corrected the minimum P-values for the occurring type I error rates. After that correction all six previously significant P-values failed to achieve statistical significance. The impact of different statistical data evaluation strategies in a multiple testing situation is discussed.

Prognostic value of immunohistochemically detected CD44 isoforms CD44v5, CD44v6 and CD44v7-8 in human breast cancer.

We investigated the expression of CD44 isoforms containing variant exons v5, v6 and v7-8 in 115 human breast cancer specimens by means of immunohistochemistry. CD44 isoforms CD44v5, CD44v6 and CD44v7-8 were detected in 56% (n = 64), 24% (n = 28) and 15% (n = 17), respectively. In 36 specimens of axillary lymph node metastasis, expression of CD44v5, CD44v6 and CD44v7-8 was found in 94% (n = 34), 92% (n = 33) and 89% (n = 32), respectively. Five year survival rates with or without CD44v5 and CD44v6 expression were 71% versus 86% (log-rank test, P = 0.02) and 62% versus 81% (log-rank test, P = 0.001), respectively. For disease-free survival, expression of CD44v5, CD44v6 and CD44v7-8 showed a prognostic impact (log-rank test, P = 0.004, P = 0.0001 and P = 0.0001, respectively). However, multivariate analysis revealed that all investigated CD44 isoforms failed to be independent predictors of the patient's outcome.