Minimally invasive synthetic suburethral sling operations for stress urinary incontinence in women: a short version Cochrane review.

BACKGROUND: Stress urinary incontinence (SUI) is a common condition affecting up to 30% of women. Minimally invasive synthetic suburethral sling operations are among the latest forms of procedures introduced to treat SUI. OBJECTIVES: To assess the effects of minimally invasive synthetic suburethral sling operations for treatment of SUI, urodynamic stress incontinence (USI), or mixed urinary incontinence (MUI) in women. SEARCH METHODS: We searched the Cochrane Incontinence Group Specialised Register (searched March 20, 2008), MEDLINE (January 1950-April 2008), EMBASE (January 1988-April 2008), CINAHL (January 1982-April 2008), AMED (January 1985-April 2008), the UK National Research Register, ClinicalTrials.gov, and reference lists of relevant articles. SELECTION CRITERIA: Randomized or quasi-randomized controlled trials amongst women with SUI, USI, or symptoms of stress or MUI, in which at least one trial arm involved a minimally invasive synthetic suburethral sling operation. DATA COLLECTION AND ANALYSIS: Two review authors assessed the methodological quality of potentially eligible studies and independently extracted data from the included trials. RESULTS: Sixty-two trials involving 7,101 women were included. The quality of evidence was moderate for most trials. Minimally invasive synthetic suburethral sling operations appeared to be as effective as traditional suburethral slings [8 trials, n=599, risk ratio (RR) 1.03, 95% confidence interval (CI) 0.94-1.13] but with shorter operating time and less postoperative voiding dysfunction and de novo urgency symptoms. Minimally invasive synthetic suburethral sling operations appeared to be as effective as open retropubic colposuspension (subjective cure rate at 12 months RR 0.96, 95% CI: 0.90-1.03; at 5 years RR 0.91, 95% CI: 0.74-1.12) with fewer perioperative complications, less postoperative voiding dysfunction, shorter operative time, and hospital stay but significantly more bladder perforations (6% vs. 1%, RR 4.24, 95% CI: 1.71-10.52). There was conflicting evidence about the effectiveness of minimally invasive synthetic suburethral sling operations compared to laparoscopic colposuspension in the short term (objective cure, RR 1.15, 95% CI: 1.06-1.24; subjective cure RR 1.11, 95% CI: 0.99-1.24). Minimally invasive synthetic suburethral sling operations had significantly less de novo urgency and urgency incontinence, shorter operating time, hospital stay, and time to return to daily activities. A retropubic bottom-to-top route was more effective than top-to-bottom route (RR 1.10, 95% CI: 1.01-1.20; RR 1.06, 95% CI: 1.01-1.11) and incurred significantly less voiding dysfunction, bladder perforations, and tape erosions. Monofilament tapes had significantly higher objective cure rates (RR 1.15, 95% CI: 1.02-1.30) compared to multifilament tapes and fewer tape erosions (1.3% vs. 6% RR 0.25, 95% CI: 0.06-1.00). The obturator route was less favorable than the retropubic route in objective cure (84% vs. 88%; RR 0.96, 95% CI: 0.93-0.99; 17 trials, n=2,434), although there was no difference in subjective cure rates. However, there was less voiding dysfunction, blood loss, bladder perforation (0.3% vs. 5.5%, RR 0.14, 95% CI: 0.07-0.26), and shorter operating time with the obturator route. CONCLUSIONS: The current evidence base suggests that minimally invasive synthetic suburethral sling operations are as effective as traditional suburethral slings, open retropubic colposuspension and laparoscopic colposuspension in the short-term but with less postoperative complications. Objective cure rates are higher with retropubic tapes than with obturator tapes but retropubic tapes attract more complications. Most of the trials had short-term follow-up and the quality of the evidence was variable.

A randomised controlled trial comparing outpatient versus daycase endometrial polypectomy.

OBJECTIVE: To evaluate outpatient versus daycase endometrial polypectomy by comparing success rate, complications, patient tolerance, pain score, analgesia requirement and recovery. DESIGN: A randomised controlled trial. SETTING: A large UK Teaching hospital. POPULATION: Forty consecutive women diagnosed with an endometrial polyp at outpatient hysteroscopy were randomly assigned in equal proportions to outpatient or daycase polyp removal. METHODS: The outpatient cohort underwent endometrial polypectomy either using grasping forceps or a bipolar electrode (Versapoint; Gynecare Inc., Menlo Park, CA, USA) introduced down the operating channel of a rigid hysteroscope (Versascope; Gynecare Inc.). The daycase cohort underwent traditional endometrial polyp resection using a hysteroscopic, monopolar, electrosurgical resecting loop, performed under general anaesthetic. MAIN OUTCOME MEASURES: The main outcome measures were as follows: success rates and intra or postoperative complications, time away from home, analgesia requirements, pain scores on the day of and one day after endometrial polypectomy, return to work and preoperative fitness and preference for the location of a future endometrial polypectomy. RESULTS: The majority of women from both cohorts were premenopausal (62.5%), parous (85%) and in paid employment (62.5%). One woman allocated to outpatient polypectomy had cervical stenosis and dilatation was unsuccessful in the outpatient setting. There were no other intra or postoperative complications in either arm of the study. The mean intraoperative visual analogue style (0-100 mm) pain score during outpatient polypectomy was 23.7 mm (1-62). A proportion of women (20%) described no intraoperative discomfort; however, the majority (75%) described mild or moderate intraoperative discomfort. More women in the outpatient cohort (58%) described themselves as pain free for the remainder of the day than in the daycase cohort (28%) (P= 0.09). The day after the procedure, all women from the outpatient group described slight or no discomfort compared with only 41% of women from the daycase group (P= 0.02). All women undergoing outpatient polypectomy had a significantly shorter mean time away from home (3.24 [1.5-5] hours) than women undergoing daycase polypectomy (7.42 [6-10.5] hours), P < 0.0005. Similarly, women from the outpatient cohort had a significantly faster mean return to preoperative fitness (1 [0-4] day versus 3.2 [1-13] days; P= 0.001) and required less postoperative analgesia than the daycase cohort. Ninety-five percent of women from the outpatient cohort and 82% of women from the daycase cohort stated they would prefer to undergo an endometrial polypectomy in the outpatient setting should they require a further polyp removal. CONCLUSION: Endometrial polypectomy can be successfully performed in the outpatient setting with minimal intraoperative discomfort, a significantly shorter time away from home and faster recovery and is preferred by women when compared with daycase polypectomy. Resources need to be made rapidly available to undertake larger scale research and develop this service across the UK.

Hysteroscopic sterilisation: a study of women's attitudes to a novel procedure.

Laparoscopy is the most common mode of surgery for female tubal sterilisation. Hysteroscopic sterilisation is a new method which can be performed in the outpatient setting under local anaesthetic. We carried out a prospective cohort trial to determine whether women would actually favour hysteroscopic sterilisation over laparoscopic sterilisation. Data analysis in a cohort of 96 women showed that 77% would prefer laparoscopic sterilisation over the hysteroscopic procedure (23%), despite the advantages of an outpatient setting. Age, obstetric history, employment and marital status, access to transport and previous anaesthetic did not significantly influence the choice made.

A randomised controlled pilot study of the management of gestational impaired glucose tolerance.

OBJECTIVE: To determine whether a study of a less intensive form of management for impaired glucose tolerance in pregnancy is feasible and whether women would accept randomisation. DESIGN: Prospective randomised controlled study. SETTING: A large district general hospital and a large teaching hospital in West Yorkshire. SAMPLE: Seventy women with impaired glucose tolerance in pregnancy. METHODS: One group monitored plasma glucose up to four times daily. The other group did not monitor plasma glucose at all. MAIN OUTCOME MEASURES: The number of women recruited of those approached and neonatal admissions to special care baby units in each group. RESULTS: Sixty-eight of 70 women approached entered the study. There were no statistically significant differences between the groups in neonatal outcome measures. The median number of plasma glucose measurements in the monitored group was 118 (range 0-500), and 19% of women in the monitored group were treated with insulin. CONCLUSIONS: This study fails to demonstrate any benefit from intensive management of impaired glucose tolerance in pregnancy with additional maternal inconvenience. This pilot study has shown that a large randomised controlled study of the management of impaired glucose tolerance in pregnancy is not only feasible but necessary.

Modern approaches to management of menorrhagia.

Menorrhagia and its management is a common problem in both the primary health-care setting and in hospitals. There is an increasing number of options for management of menorrhagia and these will be discussed in this article.

Preliminary experience with twenty perineal repairs using Indermil tissue adhesive.

OBJECTIVE: To assess the use of Indermil tissue adhesive for perineal repair. SETTING: Leeds General Infirmary, a teaching hospital with 4500 deliveries annually. METHOD: Over a period of five months, 20 women who sustained either a second degree tear or who had an episiotomy at vaginal delivery had their perineal skin repaired with Indermil tissue adhesive. They were followed up prior to discharge and then by telephone once discharged. RESULTS: Ten repairs followed normal vaginal deliveries, six were after ventouse deliveries, three after midcavity forceps delivery and one after a rotational forceps delivery. Three women noticed a burning sensation during application of adhesive. At follow up, 13 women were completely without problems, two complained of a sharp sensation from excess adhesive, one had silver nitrate applied at the six week check, two had small defects in the skin which healed well and in two women the skin edges broke down completely but did not need resuturing. CONCLUSION: Indermil tissue adhesive appears to be a safe and effective method of skin closure for episiotomies and second degree tears. The skin closure is quick and painless.

How do UK gynaecologists manage endometrial carcinoma? A national survey.

OBJECTIVE: The objective of this study was to examine the management of endometrial carcinoma in the United Kingdom (UK). METHODS: Consultant gynaecologists were sent an anonymous postal questionnaire requesting information on investigation and management of endometrial carcinoma. RESULTS: Completed questionnaires were received from 701 respondents (51% response). Most responders were general gynaecologists who saw less than five new cases of endometrial cancer annually; 98% of respondents preferred surgical procedure for endometrial carcinoma was total abdominal hysterectomy and bilateral salpingo-oophorectomy. There was a wide variation in diagnostic investigations and radiotherapy practice.

Odontogenic ghost cell carcinoma: a case report with immunohistochemical and ultrastructural characterization.

The odontogenic ghost cell tumor (OGCT) is the rare, neoplastic variant of the calcifying odontogenic cyst (COC). To date, there have been only four reports of malignant OGCTs, in five patients. We report an additional case of a malignant odontogenic ghost cell tumor that involved the right maxilla of a 20-year-old man. Our report includes its immunocytochemical and ultrastructural characterization.