Surgical treatment of ovarian cancer in different hospital categories--a prospective nation-wide study in Finland.

This prospective nation-wide study was performed to evaluate the effect of hospital category and subspeciality training on surgical treatment of ovarian cancer. Data were obtained from a questionnaire filled in by the operating unit, and from the surgical and histopathology reports. The survey included 307 patients. Half of them were operated in the university hospitals where gynaecologic oncologists performed 72% of the operations. This was the case in only 4% and 19% in the central and district hospitals, respectively. In university hospitals, pelvic lymphadenectomy was performed in 88%, and para-aortic lymphadenectomy in 73%, of the patients with stage I disease. The corresponding figures ranged from 11% to 21% in central and district hospitals. For stage III patients operated by gynaecologic oncologists, the estimated odds ratio for no macroscopic tumour was 3.0 times higher (95% CI 1.2-7.5) than for those operated by general gynaecologists. These results favour centralisation of surgical treatment of ovarian cancer.

The effect of home biofeedback training on stress incontinence.

BACKGROUND: To compare the effectiveness of pelvic floor training (PFT) with the aid of a home biofeedback device to PFT alone for urodynamic stress urinary incontinence (SUI) in women after a 1-year follow-up. METHODS: A randomized study comparing two conservative interventions was conducted in an outpatient clinic of a university hospital. Thirty-five consecutive women were randomized to either the PFT with home biofeedback group or the PFT alone group. The intensive training period lasted 12 weeks. After 1 year, 33 women could be evaluated according to the protocol. At the 1-year visit pelvic floor muscle activity was measured and the need for surgical intervention was evaluated. Logistic multivariate analysis was used to predict response to the PFT. RESULTS: In the home biofeedback training group 11/16 (68.8%) avoided surgery vs. 10/19 (52.6%) in the PFT alone group. The difference was not statistically significant. In the nonoperated home biofeedback group the increase in pelvic floor muscle activity (p = 0.005 in supine, p = 0.005 in standing) and the decrease in leakage index (p = 0.05) was significant after 12 weeks and pelvic floor activity remained constant. By contrast, in the nonoperated PFT group the increase in pelvic floor muscle activity after 12 weeks predicted a good result for conservative treatment. CONCLUSIONS: This randomized controlled trial suggests that the home biofeedback method in PFT has a good success rate of 68.8%. The change achieved in leakage index after 12 weeks of training predicted an effective outcome for conservative treatment.

Tension-free vaginal tape and laparoscopic mesh colposuspension for stress urinary incontinence.

OBJECTIVE: To compare objective and subjective outcomes after the tension-free vaginal tape procedure (TVT) with laparoscopic mesh colposuspension as a primary treatment for female stress urinary incontinence. Objective outcome measures were stress test and 48-hour pad test. METHODS: In 6 departments of gynecology in Finland, including 4 university teaching hospitals and 2 central hospitals, 128 women with urodynamic stress incontinence were randomly allocated to 2 treatment groups. Seventy were treated with TVT and 51 by means of laparoscopic mesh colposuspension. There were 7 dropouts. Inclusion criteria were history of stress incontinence, positive stress test, and urodynamic conformation of stress incontinence. Exclusion criteria were age older than 70 years, previous incontinence surgery, more than 3 episodes of urinary tract infection within the last 2 years, coincident other gynecological surgery, body mass index more than 32 kg/m(2), urethral closure pressure less than 20 cm H(2)O, and residual volume more than 100 mL in preoperative urodynamic evaluation. Assessment took place before treatment and at 12 months postoperatively with the cough stress test, Urge Score, 48-hour pad test, King's College Health Questionnaire, Visual Analog Scale, and Urinary Incontinence Severity Score. RESULTS: When negative stress test was used as criteria for cure, 85.7% of women in the TVT group and 56.9% in the laparoscopic mesh colposuspension group were objectively cured. Subject satisfaction was significantly better after the TVT procedure than after laparoscopic mesh colposuspension. CONCLUSION: Treatment with TVT results in higher objective and subjective cure rates at 1 year than treatment by means of laparoscopic mesh colposuspension.

Tension-free vaginal tape and laparoscopic mesh colposuspension in the treatment of stress urinary incontinence: immediate outcome and complications--a randomized clinical trial.

BACKGROUND: The purpose of the study was to evaluate the immediate outcome and complications of the tension-free vaginal tape (TVT) and laparoscopic mesh colposuspension (LC) procedures in the treatment of female stress urinary incontinence (SUI). METHODS: One hundred and twenty-eight patients suffering from urodynamically confirmed SUI were recruited to this multicenter, randomized clinical trial. After randomization there were seven drop-outs--121 patients were operated upon: 70 patients in the TVT group and 51 in the LC group. The patients were evaluated according to the study protocol before operation and 6 weeks after it. The independent sample t-test and the Mann-Whitney U-test were used to calculate statistical differences between the study groups. RESULTS: Immediate cure rates, defined as negative stress test with 300 mL saline in the bladder, were similar (92.9% in the TVT group and 88.2% in the LC group; p = ns). Return to normal voiding was faster in the TVT group (9.2 h in the TVT group vs. 24.4 h in the LC group; p = 0.004). Fewer analgesics were used in the TVT group and hospital stay was shorter in this group. Complication rates associated with the procedures were similar and the number of complications was small. CONCLUSIONS: The immediate outcome of both procedures is the same. The rates of complications were similar. However, the TVT procedure seems to be less invasive and requires fewer hospital resources than LC.

The effect of aging on the electromyographic activity of pelvic floor muscles. A comparative study among stress incontinent patients and asymptomatic women.

OBJECTIVES: Pelvic floor muscle training (PFMT) is commonly used in combination with biofeedback devices for stress urinary incontinence. A new electromyography (EMG)-based home-use device for PFMT is tested for healthy and stress incontinent patients. SUBJECTS AND METHODS: Altogether 31 women with genuine stress incontinence (GSI) and 35 controls without urinary symptoms were measured with a vaginal surface EMG probe. EMG activity during three rapid contractions (5 s) in supine and standing positions were observed. RESULTS: Mean values of three rapid contractions were 17.0 microV (range 6.5-59.0, S.D. 10.5) in the supine position and 12.9 microV (range 5.0-33.0, S.D. 5.9) in the standing position among incontinent patients and 19.5 microV (range 9.0-43.5, S.D. 8.4) and 18.2 microV (range 8.0-43.5, S.D. 8.7) among the controls, respectively. A significant difference (P=0.006) was found in the mean values of three rapid contractions in the standing position between GSI patients and asymptomatic women. In regression analysis, EMG values were dependent on age (P=0.004 in the supine, P=0.009 in the standing) in both groups, but not on parity, body mass index (BMI) or episiotomies. CONCLUSIONS: In the study groups, the EMG activity of pelvic floor muscles (PFMs) decreased during aging. Although the tested surface EMG device showed a tendency that incontinent patients have lower PFM activities especially in the standing position, the value of surface EMG method as a diagnostic tool is not well established. However, the tested EMG-based device for PFMT will be helpful as guidance for incontinent patients.

Increase in pelvic floor muscle activity after 12 weeks' training: a randomized prospective pilot study.

OBJECTIVES: To compare electromyography-assisted biofeedback training to pelvic floor muscle training (PFMT) alone in patients with female stress urinary incontinence. METHODS: A prospective randomized pilot study was conducted between March 1998 and February 2000 at the university hospital for outpatient care. Participants were women with urodynamically tested stress incontinence aged 31 to 69 years without previous incontinence operations, 30 volunteers altogether. The biofeedback group received an electromyography-guided biofeedback device for home training and the PFMT-alone group trained without any device at home. All patients were advised to practice for 20 minutes per day five times a week for 12 weeks. RESULTS: According to the data analysis, muscle forces increased significantly in both supine (P <0.001) and standing (P <0.001) positions. In the supine position, the increase was significantly higher in the biofeedback group (P = 0.024). The results showed close to a significant decrease in the leakage index in the biofeedback group (P = 0.068), but in the PFMT-alone group, no change occurred. With respect to the pad test, the decrease was significant, but it was the same for both groups (P = 0.907). CONCLUSIONS: The findings of this study show that pelvic floor muscle activity is increased and the amount of leaked urine is decreased after 3 months of PFMT. These preliminary results show a significant improvement compared with the PFMT-alone group in PFMT outcome measures in patients using electromyography-assisted biofeedback training.

Elevated hyaluronan concentration without hyaluronidase activation in malignant epithelial ovarian tumors.

The concentration and histological distribution of hyaluronan, a tumor promoting extracellular matrix polysaccharide, and the activity of hyaluronidase, a potential source of angiogenic hyaluronan oligosaccharides, were analyzed in malignant epithelial (n = 24), borderline (n = 8), benign epithelial (n = 20), functional cyst (n = 21), and normal (n = 5) tissue samples of human ovary. Hyaluronan concentration increased specifically in cancers (P = 0.001), particularly in grade 3 tumors (>49-fold) and in metastases (>89-fold). Hyaluronan staining in the tissues correlated with hyaluronan concentration (P = 0.002). Hyaluronidase activity slightly decreased from semimalignant through low grade to high grade tumors (P = 0.041). Therefore, hyaluronan accumulation, but not hyaluronidase activation, is associated with the aggressiveness of ovarian epithelial cancer.

Need for critical care in gynaecology: a population-based analysis.

INTRODUCTION: The purpose of this study was to note potential gynaecological risk factors leading to intensive care and to estimate the frequency, costs and outcome of management. MATERIALS AND METHODS: In a cross-sectional study of intensive care admissions in Kuopio from March 1993 to December 2000, 23 consecutive gynaecological patients admitted to a mixed medical-surgical intensive care unit (ICU) were followed. We recorded demographics, admitting diagnoses, scores on the Acute Physiological and Chronic Health Evaluation (APACHE) II, clinical outcome and treatment costs. RESULTS: The overall need for intensive care was 2.3 per 1000 women undergoing major surgery during the study period. Patients were 55.4 +/- 16.9 (mean +/- SD) years old, with a mean APACHE II score of 14.07 (+/- 5.57). The most common diagnoses at admission were postoperative haemorrhage (43%), infection (39%) and cardiovascular disease (30%). The duration of stay in the ICU was 4.97 (+/- 9.28) (range 1-42) days and the mortality within 6 months was 26%, although the mortality in the ICU was 0%. The total cost of intensive care was approximately 7044 US dollars per patient. CONCLUSIONS: Very few gynaecological patients develop complications requiring intensive care. The presence of gynaecological malignancy and pre-existing medical disorders are clinically useful predictors of eventual outcome, but many cases occur in women with a low risk and this implies that the risk is relevant to all procedures. Further research is needed to determine effective preventive approaches.