Consensus on safe implementation of vaginal natural orifice transluminal endoscopic surgery (vNOTES).

STUDY OBJECTIVE: The first ever report of vaginal natural orifice transluminal endoscopic surgery (vNOTES) for benign gynaecological was reported in 2012. There has been an exponential uptake of the number of surgeons performing such procedures worldwide with no official guidance to ensure the safe implementation of this technique into gynaecological practice due its recency. The objective of this study is to report an international consensus-based statement to help guide a basis for adopting vNOTES into clinical practice. STUDY DESIGN: The consensus-based statement was developed amongst 39 international experts using the Delphi methodology over three successive rounds. Consensus was pre-defined as an agreement of 80% or more by the experts. Consensus sought over eight key concepts pertaining to vNOTES including patient selection, perioperative management, surgical technique, instruments, anatomy, training, registries and trials and definition of the surgical technique. Recommendations from an expert anaesthetist and urogynaecologist were also sought to give a broader perspective with respect to the implementation of vNOTES. RESULTS: Fifty nine international surgeons were invited to participate and 39 (66%) agreed to participate based on being involved in a minimum of 20 vNOTES procedures. They were from 13 countries across 5 continents (Europe, North America, South America, Australia and Asia). Participation was 100% on all three rounds. Overall, consensus was reached in 50 of the 56 questions (89%) with the remaining 6 questions where consensus was not reached pertaining to the domain of patient selection. CONCLUSION: An international expert based vNOTES statement is presented here to help guide adoption of vNOTES based on the experience of early adopters. Consensus was achieved on most components of this consensus statement. Given the recency of this technique, until high-level evidence becomes available, this statement provides an appropriate guidance to the safe implementation of vNOTES into gynaecological practice.

The impact of a nationwide hands-on workshop on the diagnostic rates and management of obstetrical anal sphincter Injuries in Israel.

AIM: The aim was to evaluate the influence of a half day, hands-on, workshop on the detection and repair of obstetric anal sphincter injuries (OASIs). METHOD: Starting in February 2011, hands-on workshops for the diagnosis and repair of OASIs were delivered by trained urogynaecologists in departments of tertiary medical centres in Israel. The structure of the hands-on workshop resembles the workshop organized at the International Urogynecological Association annual conferences. Participants included medical staff, midwives and surgical residents from each medical centre. We collected data regarding the rate of OASIs, 1 year before and 1 year following the workshop, in 11 medical centres. The study population was composed of parturients with the following inclusion criteria: singleton pregnancy, vertex presentation and vaginal delivery. Pre-viable preterm gestations (< 24 weeks), birth weight < 500 g, stillborn, and those with major congenital anomalies, multifoetal pregnancies, breech presentations and caesarean deliveries were excluded from the analysis. RESULTS: In the reviewed centres, 70 663 (49.3%) women delivered prior to the workshop (pre-workshop group) and 72 616 (50.7%) women delivered following the workshop (post-workshop group). Third- or fourth-degree perineal tears occurred in 248 women (0.35%) before the workshop, and in 328 (0.45%) following the workshop, a significant increase of 28.7% (P = 0.002). The increase in diagnosis was significant also in women with third-degree tears alone, 226 women (0.32%) before the workshop and 298 (0.41%) following the workshop, an increase of 28.3% (P = 0.005). CONCLUSION: The detection rate of OASIs has significantly increased following the hands-on workshop. The implementation of such programmes is crucial for increasing awareness and detection rates of OASI following vaginal deliveries.

Long-term follow-up of sacrocolpopexy mesh implants at two time intervals at least 1 year apart using 4D transperineal ultrasound.

OBJECTIVE: To determine, using four-dimensional (4D) transperineal ultrasound, whether the appearance, position or dimensions of sacrocolpopexy mesh implants or the degree of tissue support change in the long term. METHODS: Women who had undergone minimally invasive abdominal sacrocolpopexy for pelvic organ prolapse were invited for follow-up assessment at two consecutive visits at least 1 year apart. All participants completed a Pelvic Floor Distress Inventory questionnaire (PFDI-20) and underwent a pelvic examination by one examiner and had 4D ultrasound volumes obtained by a different examiner. Volumes were analyzed offline for mesh position with the woman at rest and on maximal Valsalva maneuver, and for mesh dimensions and characteristics on three-dimensional orthogonal planes and rendered views, with the operator blinded to the clinical data. Findings were compared between the two examinations. RESULTS: Thirty women attended follow-up assessment at two time points, a median of 22 (range, 12-37) months apart. The median age at the latter visit was 60 (range, 46-72) years, median body mass index was 25.9 (range, 20.8-31.9) kg/m2 , median parity was 3 (range, 1-7) and median time from surgery to first and second visit, respectively, was 11.2 (range, 6-26) months and 33.5 (range, 14-56) months. There were no significant differences between the two time points in symptom scores, reported satisfaction from surgery, pelvic examination findings or pelvic organ descent in any compartment according to ultrasound. While mesh dimensions of anterior and posterior arms did not change significantly over time, both arms descended less on Valsalva at the second follow-up compared with at the first (13.2 ± 6.7 mm vs 21.9 ± 10.0 mm and 9.1 ± 5.3 mm vs 16.1 ± 8.1 mm, respectively, both P < 0.001). There were no mesh erosions, but folding remained a consistent finding, occurring in 80% of women in each assessment. CONCLUSIONS: Characteristics of tissue support and dimensions of sacrocolpopexy mesh implants remained constant over long-term follow-up, with no mesh shrinkage or erosion. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Physicians' attitudes towards androgen replacement therapy for male and female sexual dysfunction.

Androgen deficiency syndrome is a commonly diagnosed condition. The aim of this study was to investigate common clinical practices of specialists in the field of sexual medicine regarding androgen replacement treatment for men and women. Attendees of the 16th Annual Congress of the European Society of Sexual Medicine held in January 2014 in Istanbul, Turkey, were asked to participate in a survey during the congress days. A 24-item self-report, closed-question questionnaire was distributed. Three sections were accessed: sociodemographic data, professional background and personal practice patterns regarding androgen substitution in men and women. A total of 133 physicians (mean age 47 years; range 25-79) completed the survey. Responses were inconsistent regarding the lab tests used for primary evaluation of male androgen deficiency. The majority of participants (62%) recommended testosterone replacement therapy for symptomatic men with testosterone levels <8 nmol l(-1) (231 ng dl(-1)). Similarly, most physicians (88%) recognized a correlation between libido and testosterone levels in women. Only 42% and 53% reported they would prescribe testosterone to women with low libido, premenopausal and postmenopausal, respectively. This survey showed discrepancies among physicians regarding testosterone replacement therapy for men and women.

Urethral sensation following reconstructive pelvic surgery.

INTRODUCTION AND HYPOTHESIS: Most urethral neuromuscular function data focus on efferent rather than afferent innervation. We aimed to determine if changes exist in urethral afferent nerve function before and after reconstructive pelvic surgery (RPS). Secondarily, we compared afferent urethral innervation in women with and without stress urinary incontinence undergoing RPS. METHODS: Participants underwent current perception threshold (CPT) and urethral anal reflex (UAR) testing prior to surgery and again post-operatively. Wilcoxon signed ranked test and Spearman's correlations were used and all tests were two-sided. p = 0.05 was considered to indicate statistical significance. RESULTS: Urethral CPT thresholds increased significantly after RPS, consistent with decreased urethral afferent function. Pre-operative urethral CPT thresholds at 5 and 250 Hz were lower in SUI women (10 [IQR 5-29], 40 [32-750]) compared with continent women (63 [14-99], 73 [51-109]; p = 0.45, p = 0.020), signifying increased urethral sensation or easier activation of urethral afferents in SUI women. CONCLUSIONS: Reconstructive pelvic surgery is associated with a short-term deleterious impact on urethral afferent function, as demonstrated by the higher levels of stimuli required to activate urethral afferent nerves (decreased urethral sensation) immediately after RPS. Women with SUI required lower levels of stimuli to activate urethral afferent nerves prior to RPS, although UAR latencies were similar regardless of concomitant SUI.

Three-dimensional transperineal ultrasound for imaging mesh implants following sacrocolpopexy.

OBJECTIVE: To characterize, using three-dimensional (3D) transperineal ultrasound, the appearance, position and dimensions of mesh implants following minimally invasive abdominal sacrocolpopexy. METHODS: In women who underwent sacrocolpopexy, mesh was evaluated at rest and on maximal Valsalva, on all 3D orthogonal planes and rendered views. Mesh dimensions were obtained by 3D processing in the midsagittal and coronal planes (anterior, posterior and sacral arm) and were analyzed offline, the operator blinded to clinical data. RESULTS: Overall, 62 women, mean age 58.4 (range, 42-79) years were evaluated at a median of 9 (range, 1-26) months following surgery. The anterior arm of the mesh was caudal to the lowermost point of descent of the anterior compartment in 56 (90.3%) women, was equally positioned in five (8.1%) and was cranial in one. The posterior arm was caudal in 44 (71%) women, was equally positioned in 16 (25.8%) and was cranial in two (3.2%). The Y connection and the sacral arm of the mesh could not be adequately seen because of physical limitations of ultrasound (lower resolution at greater depth), large recurrent rectoceles, echogenic stools or folding of mesh remnants. Folding of the mesh was seen in 46 (74.2%) women, folding of the anterior arm in five (8.1%) and folding of the posterior arm in 23 (37.1%). Folding occurred caudally in 26 (41.9%) women, proximally in 11 (17.7%) and in both areas in nine (14.5%). There were no erosions. CONCLUSION: Mesh visualization following minimally invasive abdominal sacrocolpopexy procedures using transperineal 3D/four-dimensional (4D) ultrasound is feasible. Studies are needed to evaluate the correlation between ultrasound measures and prolapse recurrence or mesh erosion.

Use of ultrasound in the clinical evaluation of women following colpocleisis.

OBJECTIVE: To assess the role of transperineal ultrasound in the postoperative evaluation of patients undergoing colpocleisis. METHODS: Patients who underwent colpocleisis between July 2009 and January 2011 completed the pelvic floor distress inventory questionnaire (PFDI-20) and underwent pelvic organ prolapse quantification (POP-Q) examination and four-dimensional (4D) transperineal ultrasound. Volumes were analyzed offline for assessment of pelvic organ descent, levator hiatal dimensions, levator avulsion trauma and the location of the colpocleisis scar. RESULTS: The study included 16 women, of mean ± SD age 75.7 ± 2.9 years, median body mass index 28 (range, 21-32) kg/m2 and median parity 2 (range, 0-5); one woman was nulliparous. Nine (56.2%) women were posthysterectomy. The median interval from surgery to ultrasound examination was 6.5 (range, 2-19) months. Most patients did not have symptoms of prolapse. The median pelvic organ prolapse distress inventory (POPDI-6) score was 37.5 (range, 0-75) and the median postoperative clinical POP-Q stage was 1 (range, 0-2). Ultrasound demonstrated clear visualization in all patients. Ten had avulsion defects (six were bilateral). Ultrasound estimated greater prolapse descent for all compartments when compared with the clinical examination. However, this difference was significant for anterior and posterior descent, but not for apical descent. In two women urethral diverticulum was detected on ultrasound; it was neither symptomatic nor clinically apparent. CONCLUSIONS: 4D transperineal ultrasound seems to be a potentially effective tool for the evaluation of vaginal anatomic and functional changes following colpocleisis surgery. Future investigation of the association between ultrasound findings and patients' subjective symptoms in a larger cohort is warranted.

Female sexual function and gynecological disorders.

Female sexual dysfunction is a common problem among the general population. Indifferent from males is not dependent solely on the physiological function of the genital organs. Partnership, body image perception and other physiological factors play a crucial role in the evaluation and treatment of female sexual dysfunction (FSD). The following article revise the most current literature regarding common gynecological disease and its association with sexual function.

Urinary hesitancy and retention during treatment with sertraline.

We report the cases of two women who began to experience urinary hesitancy and retention after starting treatment with sertraline for depression. Discontinuation of the drug resulted in complete symptom relief. Serotonergic neurons are involved at several levels in control of the lower urinary tract. Retention is apparently an uncommon complication of sertraline. Discontinuation should be considered for patients presenting with voiding difficulties.

Pre-eclampsia is associated with sleep-disordered breathing and endothelial dysfunction.

Pre-eclamptic toxaemia (PET) may be associated with both endothelial dysfunction (ED) and sleep-disordered breathing (SDB). It was hypothesised that females with PET would demonstrate both SDB and ED, and that a correlation between these two would suggest a potential causative association. A total of 17 females with PET and 25 matched females with uncomplicated pregnancy were studied. They underwent a nocturnal ambulatory sleep study (using Watch_PAT100) and noninvasive evaluation of endothelial function utilising the reactive hyperaemia test (using Endo_PAT 2000). A higher ratio of post- to pre-occlusion pulse-wave amplitude (endothelial function index (EFI)) indicated better endothelial function. Females with PET had a significantly higher respiratory disturbance index (RDI) and lower EFI than controls (18.4+/-8.4 versus 8.3+/-1.3.h(-1), and 1.5+/-0.1 versus 1.8+/-0.1, respectively). Blood pressure significantly correlated with RDI and with EFI. EFI tended to correlate with RDI. In conclusion, these results suggest that both sleep-disordered breathing and endothelial dysfunction are more likely to occur in females with pre-eclamptic toxaemia than in females with uncomplicated pregnancies. The current authors speculate that respiratory disturbances contribute to the functional abnormality of the blood vessels seen in females with pre-eclamptic toxaemia, although causality cannot be determined based on this study.

Recent research and views on shaking baby syndrome.

Primary care physicians and psychiatrists should be aware of the incidence, causes, diagnosis, and prognosis of the conditions of Shaking Baby Syndrome (SBS). This article discusses both accidental and non-accidental head injury, and also addresses the legal aspects of SBS. Incidence, potential causes, explanations, prevention, and treatment of the condition, both for the perpetrators and the unfortunate victims, are considered. Of special importance is the fact that SBS is difficult to diagnose with absolute certainty. Hence the identification of a potential perpetrator can be difficult and injustices can occur.

[Transient ischemic ECG changes in a patient with acute cholecystitis without a history of ischemic heart disease].

That abdominal distention, nausea, and chest pain may be accompanied by ischemic ECG changes is well known and has been described in the literature. However, very few cases have been reported with acute cholecystitis and ECG changes not due to cardiac ischemia. We present a previously healthy 20-year-old woman admitted with acute cholecystitis. Prior to surgery routine ECG showed ST-depression and T-wave inversion. The day following cholecystectomy the ECG returned to normal. 1 month later, ergometry and echocardiography were both negative. Based on the literature and our personal experience, although ECG changes may occur in acute cholecystitis, the possibility of cardiac ischemia must be excluded. However, when no cardiac basis is found, ultrasound of the biliary system might reveal the cause of these ECG changes. Thus, in acute cholecystitis with ischemic ECG changes but no other laboratory or clinical evidence of cardiac ischemia, ECG changes alone are not a contraindication to cholecystectomy. Furthermore, delay in treatment could be harmful.

The possible impact of a myomatous uterus on the accuracy of fetal biometric measurements.

OBJECTIVE: The propagation speed of ultrasound beams changes in different media. The aim of the study was to assess the possible measurement error of fetal biometry performed in cases of a myomatous uterus. DESIGN: Three iron phantoms of 30 mm, 50 mm and 70 mm were measured by ultrasound. Each phantom was measured by three different transducers of 3.5 MHz, 6.5 MHz and 7.5 MHz. Measurements were performed in a water bath and the intraobserver variability was assessed. Thereafter phantoms were measured with one of their edges covered by a specimen of a myomatous uterus while their other edge was covered with water. RESULTS: Artifactual lengthening of the phantoms' size was observed in measurements performed with the uterine myoma. The measurement errors were inversely related to the length of the phantoms and became statistically significant in the phantoms of 30 mm (13.15 +/- 3.16% without the myoma vs. 17.38 +/- 4.39% with the myoma; p < 0.0001). Measurement errors were independent of the transducer type (p = 0.001, p = 0.01 and p = 0.014 for the 3.5-MHz, 6.5-MHz and 7.5-MHz transducers, respectively). CONCLUSIONS: Ultrasound measurement errors are expected while examining small fetal organs which are partially overshadowed by a myoma.

Rapid estimation of the accuracy of automatic blood pressure measuring devices (READ).

We propose a rapid method for the evaluation of automatic blood pressure measurement devices (READ) in response to the claim to simplify the validation of those devices. The READ is based on numerous blood pressure (BP) measurements at rest and during a standardised postural challenge in a small number of subjects who exhibit a wide range of BPs. Automatic (AU) and mercury sphygmomanometric (MS) brachial BP were measured simultaneously in a blinded manner. An average of 30 measurements per patient were done in 10-min while in a supine position, followed by 30 min in head-up tilt and again supine for 10 min. Two Collin-8800 automated oscillometric devices were tested with the aid of the READ in 15 adults. The consistency of the MS standard was demonstrated by duplicate MS measurements showing minimal inter-observer differences consistent with class A of the British Hypertension Society (BHS) grading system. AU-to-MS differences of 447 measurements were mean systolic deltaBP = 1.1 +/- 11.4 mm Hg and mean diastolic deltaBP = -13.36 +/- 8.9 mm Hg, classifying into category D of the BHS. Both tested instruments, each subject, each phase of the tilt test (supine I, tilt, supine II) and each mode of measurement (at 5-min intervals or continuously) equally qualified as 'D'. We conclude that the READ permitted us to identify quickly and at low expense a grossly inaccurate automatic BP measuring device. Further studies will show whether the READ can be efficient as a pre-validation test, post-validation test, and for assessment of ambulatory BP measuring devices.