[Operative therapy of female stress incontinence]. / Operative Therapie der weiblichen Belastungsinkontinenz.

Description of the fateful change of the differing operation methods for the treatment of female stress incontinence between 1979-2005. For the reason of scientific cognitions and many years of applying experience there are two logical and anatomical well-founded possibilities for the treatment of stress incontinence: 1. Elevation of the bladder neck to it's original position by a shortarm sling plasty. In doing that vaginally the ligg. urethrotendinea and the ligg. pubourethralia posteriora are connected suburethrally by a shortarm sling plasty or a double sling plasty and in this way the bladderneck is elevated to the height of the arcus tendineus fasciae pelvis. So a horizontal bladder base plate able to contract results with a retrovesical angle of about 90 %. The anatomic proof for continence. 2. Producing of the urethrovesical reflex by UST (Urethra Surrounding Tape). A polypropylene mesh with a circumference of 1,5 x 2,6 cm is fixed to the inner surface of the right and left os pubis and paraurethrally right and left too. This stable hammock causes a physiological impression of the dorsal urethra of about 2 mm. Because of that the urethrovesical reflex is set off leading to the contraction of the bladder neck and the relaxation of the detrusor vesicae muscle. This minimal invasive stress incontinence operation method brings about a subjective incontinence healing rate of 83.7 % and a clinical healing rate of 97.7 %. That means the same results like after TVT (Tension Free Vaginal Tape) or TOT (Transobturatorial Tape). In contrast to TVT or TOT there are no complications with UST.

Cathepsin D in ovarian cancer: prognostic value and correlation with p53 expression and microvessel density.

OBJECTIVE: Overexpression of ubiquitous lysosomal aspartyl protease cathepsin D (CD) is involved in the progression of cancer. This study investigates the prognostic value and the association of cathepsin D expression with clinicopathological parameters, p53 expression, and angiogenesis in ovarian cancer. METHODS: Cathepsin D was determined immunohistochemically in 43 ovarian tumors of low malignant potential (LMP) and 80 invasive tumors FIGO stage I-IV. Results were correlated with clinicopathological characteristics, p53, and microvessel density (MVD). Survival analysis of cathepsin D expression and MVD was performed in invasive tumors. RESULTS: Epithelial tumor cathepsin D expression was more common in LMP tumors (65.1%) compared to invasive tumors (43.7%; P = 0.02). In LMP tumors, stromal cathepsin D was associated with mucinous tumors (P = 0.01), whereas in invasive tumors, epithelial cathepsin D expression was associated with clear cell tumors (P = 0.003). Invasive tumor cathepsin D had a negative relation to p53 expression. In LMP tumors, stromal cathepsin D correlated with microvessel density (P = 0.03). Stromal cathepsin D expression was an independent prognostic factor for disease-free survival (DFS) in patients with invasive cancer (P = 0.03, Cox regression), while cathepsin D expression missed to be of prognostic value for overall survival (OS) in invasive ovarian cancer. MVD had no influence on survival in invasive ovarian cancer (P > 0.05). CONCLUSION: Our study demonstrates a prognostic value of cathepsin D expression in invasive ovarian cancer, while cathepsin D expression in LMP tumors seems to be linked to angiogenesis. The relation among cathepsin D, p53 expression, and angiogenesis demonstrates biological differences between invasive ovarian cancer and LMP tumors.

Leiomyosarcoma of the vulva. A case report.

BACKGROUND: Leiomyosarcoma of the vulva is a rare mesenchymal tumor. Biologic features of a low grade tumor were investigated by an immunohistochemical workup. CASE: A 38-year-old woman presented with a slowly growing vulvar mass. Surgical treatment was performed, and a low grade leiomyosarcoma of the vulva was diagnosed. Immunohistochemical reactions were performed with monoclonal antibodies against desmin, vimentin, smooth muscle actin, cytokeratin, S-100 protein, estrogen, progesterone and androgen receptor, p53 protein, Ki-67 antigen, leukocyte common antigen and polyclonal antibodies to factor VIII-related antigen. Expression of estrogen, progesterone and androgen receptor was present in addition to a moderate number of Ki-67-positive cells and absence of p53 protein overexpression and lymphatic cell infiltration besides adequate microvessel density for smooth muscle tumors. Since the immunohistochemical markers indicated a less aggressive tumor, any further adjuvant therapy was rejected. The patient was without recurrence 24 months later. CONCLUSION: The immunohistologic profile proved the low histologic grade of vulvar leiomyosarcoma. The findings helped to estimate prognosis and plan therapy.

Interferon-gamma in the first-line therapy of ovarian cancer: a randomized phase III trial.

Intraperitoneal treatment with interferon-gamma (IFN-gamma) has been shown to achieve surgically documented responses in the second-line therapy of ovarian cancer. To assess its efficacy in the first-line therapy, we conducted a randomized controlled trial with 148 patients who had undergone primary surgery for FIGO stage Ic-Illc ovarian cancer. In the control arm women received 100 mg/m(-2) cisplatin and 600 mg/m(-2) cyclophosphamide, the experimental arm included the above regimen with IFN-gamma 0.1 mg subcutaneously on days 1, 3, 5, 15, 17 and 19 of each 28-day cycle. Progression-free survival at 3 years was improved from 38% in controls to 51% in the treatment group corresponding to median times to progression of 17 and 48 months (P= 0.031, relative risk of progression 0.48, confidence interval 0.28-0.82). Three-year overall survival was 58% and 74% accordingly (n.s., median not yet reached). Complete clinical responses were observed in 68% with IFN-gamma versus 56% in controls (n.s.). Toxicity was comparable in both groups except for a mild flu-like syndrome, experienced by most patients after administration of IFN-gamma. Thus, with acceptable toxicity, the inclusion of IFN-gamm in the first-line chemotherapy of ovarian cancer yielded a benefit in prolonging progression-free survival.

Leiomyoma of the round ligament in a postmenopausal woman.

OBJECTIVE: Leiomyoma of the round ligament of the uterus is a rare condition. We present the first case of a postmenopausal, previously hysterectomised, woman who received combined hormonal replacement therapy and developed a leiomyoma of the right round ligament. METHOD: In sections of the tumor, immunohistochemical reaction with monoclonal antibodies against smooth muscle actin, desmin, vimentin, estrogen receptor and progesterone receptor was performed. RESULTS: The leiomyoma showed bizarre histologic appearance in absence of mitotic figures and degenerative changes. Leiomyocytes presented a positive immunohistochemical reaction with monoclonal antibodies against smooth muscle actin, desmin vimentin and progesterone receptor in absence of estrogen receptor. CONCLUSION: Progestin as part of a combined hormonal replacement therapy may play an important role in promoting the development of leiomyoma in hormonal responsive tissue of the round ligament in postmenopausal women.

[Massive edema of the ovary]. / Das massive Odem des Ovars.

Massive edema of the ovary is a rare condition found in young women as a result of partial or intermittent torsion of the ovary. Differentiation of this entity from tumors of the ovary is important to prevent overtreatment. Organ-preserving surgical treatment is indicated as the correct approach to management. We present a case of massive edema of the ovary associated with post partum involution of the female genital tract and discuss the clinical features in the light of the known literature.

[Topographic-anatomic considerations in vaginal surgical therapy of stress incontinence]. / Topographisch-anatomische Uberlegungen zur vaginalchirurgischen Stressinkontinenztherapie.

The medial pubourethral ligament and the posterior pubourethral ligaments have the important task (for continence) of fixing the neck of the bladder. If the neck of the bladder is placed in relationship to height of the posterior wall of the symphisis, viscerographic examinations show that the neck of the bladder is high in 9% of cases, medium-high in 26%, and low in 65%. When performing reconstructive surgery following detachment of the neck of the bladder as a result of abdominal pressure, these topographic-anatomic features can only be taken into consideration if the primary, original site of the neck of the bladder is known. Intraoperative exposure of the ligament insertion and of the posterior pubourethral ligaments will always permit the primary location of the neck of the bladder to be determined. This is situated 2.3 cm beneath the insertion, and joining the medial ligament to the dorsal urethra will guarantee normal repositioning of the neck of the bladder. If the primary location of the neck of the bladder is unknown in the individual case being treated, the deep tissue pad which develops subsequent to anterior colporraphy corresponds to a nonspecific tissue accumulation with incalculable outcome.

[Cingulum vesicae--bladder anchoring in the pelvis]. / Das Cingulum vesicae--die Blasenverankerung im Becken.

The fascia endopelvina, extending into the bladder along the entire circumference between the corpus and fundus vesicae, represents the cingulum vesicae. Dense connective tissue forms a permanent link, adjacent to the cingulum vesicae, between the bladder on the one hand and the lateral pelvic wall and anterior surface of the uterus on the other; in this way the bladder is held in the pelvis at a particular point. The ventral portion of the cingulum (ligamenta pubourethralia posteriora and ligamentum pubourethrale intermedium) is especially important, as it provides an anchor of the vesical cervix as a mark of continence. Laterodorsally the anchor circle is completed via the ligamenta vesicouterina and the septum supravaginale. From a functional anatomic standpoint every precise surgical technique for incontinence must take the cingulum vesicae and the adjacent structures into consideration. Therefore, elevation of the cingulum vesicae and the vesical cervix should be taken into account in the therapeutic plan for incontinence.

[Corporofundal partial peripheral bladder denervation as surgical therapy of urge incontinence]. / Corporofundale partielle periphere Blasendenervation als chirurgische Therapie der Dranginkontinenz.

Urge incontinence places a considerable burden on incontinence treatment. The autonomous nerve supply of the bladder is effected via two anatomically clearly separate ways. On the one hand, we have the accessory innervation via the fascia endopelvina, whereas on the other hand fibres from the plexus pelvicus as the classical site of innervation penetrate into the bladder. Transection of the fascia endopelvina followed by detachment of the plexus pelvicus from the lateral bladder wall in the course of separation of the bladder and levator enables corporofundal partial peripheral bladder denervation. By this procedure both afferent and efferent nerve fibres are transected. As a result, excess autonomous impulses are reduced, thus effecting favourable reduction of the urge incontinence pattern. This method is quite fascinating not only because it is easily translated into practice, offers ideal vaginal access, and is reproducible at all times, but also because it can be utilised as a therapeutic tool in the treatment of urge incontinence, and because it can be integrated in an optimal manner into the standard incontinence and descensus programme. A failure rate of 3% is hardly ever exceeded. Compared with the other methods described so far, which are mostly very severe in their effect and highly specialised, the advantages of corporofundal partial peripheral bladder denervation point towards considerable chances to translate the method into practical reality.

[Urethrovesical suspension with autologous fascia tissue by the purely vaginal approach--the short-arm sling operation]. / Urethrovesikalsuspension mit autologem Fasziengewebe auf rein vaginalem Weg--Kurzarmschlingenoperation.

Sling operations are a last result following failures of routine vaginal surgery for stress incontinence. The present paper describes a new operative treatment of stress incontinence by using pre-existing urethral fixing ligaments. The complex reunion of these ligaments after their preparation results in a sling formation with autologous tissue. The ligaments are 1-2 cm long from their origin. The urethra is directly under the insertion of the ligaments. Their presence in all cases permits the treatment of incontinence of all types and degrees with a reliable fixation of the urethra to the symphysis. The regional anatomy must be well observed in all cases. Plication of the remaining vesico-vaginal septum eliminates the always present vaginal descent. The numerous advantages over all other sling operations of this short arm sling operation are described in detail. Only the incorporation of endopelvic fascia into the carrying structures is a reliable indication for postoperative continence. The ideal nutrition of the fixating ligaments permits full activity four weeks after the operation and integration into the working life. Among the 332 cases of stress incontinence which were cured by this method no true recurrence was observed. A few patients had stress incontinence under extreme stress and were considered as failures. The short arm sling operation shows its advantages by reliable long term results, the pure vaginal approach without costly foreign materials and the lack of infection are other advantages.

[Ventral plasty of the levators a neglected method for the operative treatment of stress incontinence (author's transl)]. / Ventrale Levatorplastik--eine verlässliche Methode zur operativen Behandlung der Belastungsinkontinenz.

A method for the operative treatment of stress incontinence in the female is described. The anatomical importance of the levator sling behind the urethra is stressed. The pubococcygeal muscles which have been lateralized by trauma are prepared. The levator ani muscle with its fascia is mobilized and the two muscle components of the perineal muscles are joined in the midline. The muscular adaptation starts behind the symphysis and is carried on dorsally as far as necessary. In this way a strong sub-urethral and subvesical muscular plate is created. In 673 patients who were treated by this method recurrence was rare. A concomitant six weeks. Urodynamic studies and physical measurements showed the pivotal importance of the levator ani muscle for the maintenance of continence.