Exploring the rationale of performing vaginal hysterectomy under local anaesthesia: A single-centre experience.

INTRODUCTION: Vaginal hysterectomy (VH) is usually performed under general (GA) or regional anaesthesia. In recent years, the possibility of performing vaginal hysterectomy under local anaesthesia (LA) has also been explored. Our aim was to compare intraoperative and early postoperative outcomes in women who underwent VH under LA with intravenous sedation or GA. METHODS: In this retrospective study, we collected data of patients who underwent VH at our department from June 2021 to December 2022. For every patient, the following data was obtained: hospitalisation duration, type of anaesthesia (LA or GA), accompanying procedures, the dosage of used local anaesthetic in the LA group, maximal pain score for each day of hospitalisation after the procedure, procedure duration, intraoperative blood loss, and postoperative complication rate. Data was analysed using the SPSS Statistics programme. Statistical significance was set at p < 0.05. RESULTS: Seventy patients were included in the study. The mean age was significantly higher in the LA group compared to GA group (73.8 ± 8.0 years vs. 67.1 ± 9.3 respectively, p-value = 0.003). LA was associated with statistically lower pain scores in the first two days after the procedure (p = 0.003), and shorter procedure duration (p-value <0.001) as well as hospitalisation duration (p < 0.001). Furthermore, the cumulative dosage of different analgesics used during hospitalisation was higher in the GA group. CONCLUSIONS: Our results show that LA is a feasible option for patients undergoing VH. Vaginal surgical procedures under LA could be especially beneficial for older patients with medical comorbidities in whom GA would be particularly hazardous.

The Impact of Extracorporeal Magnetic Stimulation as Addition to Mirabegron in Overactive Bladder Treatment in Women: A Single-Centre Randomized Sham-Controlled Study.

(1) Background: The purpose of our prospective, single-blinded, randomized, sham-controlled study was to investigate the effect of the additional extracorporeal magnetic stimulation (ExMI) to pharmacological treatment in overactive bladder syndrome (OAB) in women. (2) Methods: We recruited 56 women with OAB, who were allocated into two study groups: the active group received mirabegron 50 mg daily and a total of 16 sessions of ExMI in 8 weeks, whereas the sham group received mirabegron 50 mg daily and sham stimulation following the same treatment protocol. Treatment success was evaluated after 4 and 8 weeks. (3) Results: Both groups experienced significant reduction in daytime urinary frequency, nocturia, and number of weekly incontinence episodes after 8 weeks. There were no statistically significant differences in end-point daytime urinary frequency and nocturia between groups. However, the overall average reduction rate in weekly number of incontinence episodes was 43.7% in treatment group and 24.2% in the control group. The number of urinary incontinence episodes in the treatment and control group was reduced for 3.8 ± 11.8 vs. 2.5 ± 4.3 episodes at week 4 and additional 3.3 ± 6 vs. 0.4 ± 3.2 episodes at week 8, respectively (p = 0.013). Moreover, IIQ-7 score showed a significantly greater score reduction and patients' evaluated improvement of symptoms was higher in the active group. (4) Conclusions: The addition of ExMI to mirabegron in OAB treatment further improves the weekly incontinence episode reduction rate and also leads to grater improvement in symptoms.

Measurement of extraction forces of non-absorbable suture and different anchoring systems used for pelvic organ prolapse surgery using soft-embalmed cadavers: A feasibility study.

OBJECTIVE: Success of pelvic organ prolapse (POP) mesh procedures also depends on reliable anchoring systems (AS). Our primary aim was to assess the use of soft-embalmed cadavers in testing of different AS and our secondary aim was to compare extraction forces (EF) of different AS and non-absorbable suture (NAS). STUDY DESIGN: IRB approval was obtained. NAS (Ti-cron®) and different AS were attached to force-measuring instrument (Dynamometer SS25LA) and anchored to anterior longitudinal (ALL) and pectineal ligament (PL) (Protack®, Uplift®, NAS), and sacrospinous ligament (SSL) (Surelift®, Elevate PC®, NAS) of Thiel soft-embalmed cadavers. EF were measured 2-4 times in each cadaver. Data were compared using non-parametric tests. Statistical significance was set at p < 0.05. RESULTS: Three female cadavers (age 59, 77 and 87) were used. NAS EF were significantly higher than AS EF for ALL and SSL, but not PL. Thiel soft-embalmed cadavers proved to be useful in testing of different AS. CONCLUSIONS: Use of soft-embalmed cadavers in testing of different AS is feasible. According to our results, the NAS provides most reliable intra-corporeal fixation. However, significant inter- and intra-subject variability indicates that results may also be dependent on the tissue properties and anchoring procedure. Further testing using soft-embalmed cadavers could help optimise mesh procedures and establish a threshold EF necessary for reliable fixation.

Long-term patient satisfaction and removal rate after essure sterilization: a follow-up study.

BACKGROUND: The objective of our study was to assess the rate and causes for Essure® micro-insert system removal and patients' long term satisfaction rate with the procedure. METHODS: All patients who underwent Essure® hysteroscopic sterilization at our tertiary centre between years 2007 and 2018 were included in this follow-up study. A questionnaire was sent to all patients per standard mail. Patients who did not respond to questionnaires per mail, were called by phone. The satisfaction with the Essure® sterilization, as well as any additional procedures after the insertion or insertion-related complications were analysed. RESULTS: From the year 2007 to 2018, we performed 427 Essure® hysteroscopic sterilizations and of these, 329 patients responded to the questionnaire (response rate 77%). Ten patients (3%) had Essure® removal, two of them due to pain (0.6%). Patients were very satisfied with the procedure (9.5 on scale 0-10). Most patients (95.3%) would recommend the procedure to their friend. CONCLUSIONS: Essure® hysteroscopic sterilization is a procedure with a very high satisfaction rate and a very low removal rate due to sterilization-related complications. Trial registration Institutional review board of University medical centre Maribor approved the study, approval number UKC-MB-KME-73/19.

Comparison of Conservative Treatment of Cervical Intraepithelial Lesions with Imiquimod with Standard Excisional Technique Using LLETZ: A Randomized Controlled Trial.

(1) Background: There are limited data on the success of conservative treatment of high-grade cervical squamous intraepithelial lesions (HSIL) with imiquimod directly compared to standard of treatment with LLETZ. (2) Methods: Patients aged 18-40 with histological HSIL (with high-grade cervical intraepithelial neoplasia, CIN2p16+ and CIN3), were randomly assigned to treatment with imiquimod or LLETZ. The primary outcome was defined as the absence of HSIL after either treatment modality. The secondary outcomes were the occurrence of side effects. (3) Results: 52 patients were allocated in each group and were similar regarding baseline characteristics. In the imiquimod group, 82.7% of patients completed treatment, which was successful in 51.9%. All patients in the LLETZ group completed treatment, which was successful in 92.3% (p < 0.001). In the subgroup of CIN2p16+ patients, treatment with imiquimod was not inferior to LLETZ (73.9% vs. 84.2%, p = 0.477). During and after treatment, no cases of progression to cancer were observed. Side effects and severe side effects (local and systemic) were more prevalent in the imiquimod than in the LLETZ group (88.5% vs. 44.2% (p-value < 0.001) and 51.9% vs. 13.5% (p-value < 0.001), respectively). (4) Conclusion: Generally, in patients with HSIL, LLETZ remains the gold standard of treatment. However, in a subgroup analysis of patients with CIN2p16+, the success rate was comparable between the two treatment modalities. Due to the prevalence of side effects, the treatment compliance with imiquimod use may, however, present a clinically important issue.

Lower urinary tract symptoms in adolescent girls: a questionnaire-based study.

OBJECTIVE: To determine the prevalence of lower urinary tract symptoms (LUTS) in female adolescent population. STUDY DESIGN: We performed a questionnaire-based study in nine randomly selected high schools in our country. Our primary aim was to evaluate the prevalence of certain LUTS in adolescent girls: frequency, urgency, nocturia, feeling of incomplete bladder emptying, dysuria, and urinary incontinence. The secondary aim was to investigate the effect of some possible risk factors on LUTS prevalence. Statistical analysis was performed using SPSS Statistics Programme. Descriptive statistics were calculated. Non-parametric test was used for comparison of numerical and Pearson's Chi-square test for categorical data. Logistic regression was performed to identify the independent prognosticators for LUTS presence. Statistical significance was set at p < 0.05. RESULTS: We included 2745 adolescent girls. Their average age was 16.8 ± 1.2 years and 17.8 % of them regularly experienced at least one LUTS. The frequency of occasional LUTS was even higher. The most common symptom was urinary incontinence (5.9 %), followed by frequency (5.1 %), feeling of incomplete bladder emptying (4.8 %), urgency (3.1 %), and nocturia (2.6 %). Risk factors for LUTS presence were girls' school success, frequent pelvic pain, previous cystitis, history of night enuresis in childhood, and sexual intercourses in the last three months. CONCLUSIONS: According to our results, the prevalence of LUTS amongst female adolescents is high and can be associated with certain risk factors. In our opinion, further research should be directed into determining the effect of LUTS on adolescents' quality of life.

Diagnosis and management of rudimentary horn pregnancy rupture, misinterpreted as bicornuate uterus in the 14th week of pregnancy.

We present a 26-year-old primigravida with rudimentary horn pregnancy rupture at 14 weeks of pregnancy. Uterine anomaly was first diagnosed at the time of nuchal translucency scan and was presumed to be a bicornuate uterus with normal intrauterine pregnancy in the right horn. One day later, she was admitted to our department with abdominal pain, shortly leading to massive hemoperitoneum and hypovolemic shock. Uterine rupture was confirmed ultrasonically, followed by immediate laparotomy. Ruptured rudimentary horn with already expulsed pregnancy was encountered during surgery. Despite significant advances in ultrasonography, diagnosis of prerupture stage remains controversial. However, high mortality of the condition should ensure low threshold for surgical exploration.

Is the fixation of single incision TVT-S tape as good as that of transobturator tape? An ultrasound study of randomized trial results.

INTRODUCTION: TVT-Secur (TVT-S) was the first single-incision sling available on the market and was soon found to have less efficacy than mid-urethral slings. Our aim was to assess the position and tape descent following TVT-O and TVT-S H in a U procedure and, based on this evaluation, to find the possible reason for lower TVT-S surgery efficacy. METHODS: We conducted an ultrasound study of a randomised trial with a 3-year follow-up that took place between 2007 and 2009 and included 197 women with urodynamic stress urinary incontinence. Of these, 67 were allocated to receive the TVT-O procedure, 64 to TVT-S in the H position, and 65 in the U position. Patients underwent a complete urogynaecological and ultrasound examination. The positions of the bladder neck and the tape after surgery were assessed and the data obtained compared between groups. RESULTS: Our primary study showed a significantly higher rate of positive stress tests in the TVT-S groups compared to the TVT-O group. After surgery, there was no difference between the position of the tape at rest and at maximal Valsalva between the groups. In TVT-O patients, the mean length of the upper tape margin descent increased from 6 mm on the 1st day after surgery to 9 mm 3 months after surgery and remained stable afterwards. For TVT-S patients, there was a further increase of up to 15 mm in tape descent after 3 months. CONCLUSIONS: Our results show that the lower efficacy of TVT-S might be due to inadequate fixation and increasing tape descent.

Long-term follow-up of native tissue anterior vaginal wall repair: does the POP-Q stage really reflect patients' satisfaction rate?

INTRODUCTION: Anterior colporrhaphy (AC) is one of the most commonly performed surgical procedures for pelvic organ prolapse treatment; however, there are only few data in the literature regarding its long-term outcomes. Our aim was to assess the long-term efficacy and satisfaction rate after AC. METHODS: Patients who underwent AC at our institution from 2011 to 2014 were invited to this follow-up study, which took place in January-February 2019. Medical history and gynaecological examination with POP-Q assessment were performed. Patients filled out validated questionnaires UIQ-7, CRAIQ-7, POPIQ-7, PFIQ-7, POPDI-6, CRADI-8, and UDI-6 and evaluated their satisfaction with the procedure. Objective success was defined as anterior wall prolapse stage 0 or 1 assessed by the POP-Q system. Subjective success was defined as the absence of bulging sensation or a sense of falling out that can be felt or seen in the vaginal area. Data were analysed using descriptive statistics and non-parametric tests. RESULTS: Seventy out of 137 (51.1%) patients attended the follow-up. Mean follow-up period up was 74.1 ± 12.6 months. Two patients were excluded from the analysis because they had another surgical procedure due to central compartment prolapse. Of the remaining patients, 50 had AC and 18 had AC and posterior colporrhaphy (PC). Objective success rate was 13.2% and subjective success rate was 68.7%. Almost all patients (98.5%) were satisfied with the procedure. In the group of patients with objective recurrence, 66.1% had no prolapse symptoms. CONCLUSION: Despite having a low objective success rate, patients' satisfaction with AC is very high.

A Novel in situ Approach to Studying Detrusor Smooth Muscle Cells in Mice.

The aim of our study was to develop a novel approach to investigating mouse detrusor smooth muscle cell (SMC) physiological activity, utilizing an acute tissue dissection technique and confocal calcium imaging. The bladder of a sacrificed adult female NMRI mouse was dissected. We used light and transmission electron microscopy to assess morphology of SMCs within the tissue. Calcium imaging in individual SMCs was performed using confocal microscopy during stimulation with increasing concentrations of carbamylcholine (CCh). SMCs were identified according to their morphology and calcium activity. We determined several parameters describing the SMC responses: delays to response, recruitment, relative activity, and contraction of the tissue. CCh stimulation revealed three different SMC phenotypes: spontaneously active SMCs with and without CCh-enhanced activity and SMCs with CCh-induced activity only. SMCs were recruited into an active state in response to CCh-stimulation within a narrow range (1-25 µM); causing activation of virtually all SMCs. Maximum calcium activity of SMCs was at about 25 µM, which coincided with a visible tissue contraction. Finally, we observed shorter time lags before response onsets with higher CCh concentrations. In conclusion, our novel in situ approach proved to be a robust and reproducible method to study detrusor SMC morphology and physiology.

Planned home birth in Slovenia-Are we ready?

Nowadays, women want a more intimate and familiar atmosphere during labour, which results in increased planned home birth rates. Every woman has the autonomy to decide where she will give birth; however, it is important that she is informed of risks and advantages beforehand. Home births can be distinguished between planned and unplanned home births. Planned home births can be conducted by professional birth attendants (licensed midwives) or birth assistants (doulas, etc). The rates of Slovenian women who decided to deliver at home are increasing year by year. Researches on home births still present discordant data about home birth safety. Their findings have shown that the main advantage of home birth is a spontaneous birth without medical interventions, especially in multiparous low-risk women. The main disadvantage, however, is a higher risk for neonatal death, in particular on occurrence of complications requiring a transfer to hospital and surgical intervention. Global guidelines emphasize careful selection of candidates suitable for home birth, well-informed pregnant women, education of birth attendants, and strict formation of transfer indications.

Medical management of first trimester missed miscarriage: the efficacy and complication rate.

Our aim of the study was to evaluate the efficacy and complication rate of our inpatient medical management protocol for missed miscarriages. Three-hundred and ninety women hospitalised at our tertiary centre because of a missed miscarriage/anembryonic pregnancy in 2012-2013 were included in this retrospective study. The women underwent either a low (until 9 + 0 weeks of gestation) or high gestational age (from 9 + 1 until 15 + 6 weeks of gestation) management protocol. The success rate, curettage in the first 48 hours after the procedure, the complication rate and the factors that might influence these outcomes were evaluated. The overall success rate was 83.3%. The curettage in the first 48 hours after the procedure was performed in 7.4% of the patients and was more often in the high gestational age protocol. Complications that required another outpatient visit or hospitalisation occurred in 9% of the patients. Higher beta-hCG values 14 days after the procedure and the absence of evacuation of products of conception during hospitalisation were associated with a higher complication rate. IMPACT STATEMENT What is already known on this subject? As much as 10-20% of clinically recognised pregnancies end in a spontaneous abortion. A missed miscarriage and a blighted ovum represent a form of spontaneous abortion, which has long been treated with surgical evacuation. However, nowadays, medical management represents a well-established alternative with very high success rates and is considered as an equivalent and safe method that is also very well accepted by patients. What do the results of this study add? According to our results, a medical management of a first trimester missed miscarriage and a blighted ovum is very effective with an overall success rate of 83.3% and a very low percentage of curettage in the first 48 hours after the procedure (7.4%). Our study was also able to identify higher beta-hCG values 14 days after procedure and absence of evacuation of products of conception during hospitalisation as risk factors for complication occurrence. What are the implications of these findings for clinical practice and/or further research? Our study helps to identify patients who are at greater risk for developing complications after the medical management of a first trimester missed miscarriage.

Long-term results of two different trans-obturator techniques for surgical treatment of women with stress and mixed urinary incontinence: a 10-year randomised controlled study follow-up.

INTRODUCTION: Our aim was to compare the long-term results and complications of the outside-in (Monarc®) versus inside-out (TVT-O®) trans-obturator approaches. METHODS: We performed a 10-year follow-up of our randomised study from 2007 in which we compared short-term outcomes of both procedures in 120 women. Patients were examined at our department in a tertiary centre between March and December 2016. The primary aim of the study was to compare the cure and satisfaction rates of both procedures. The secondary aim was to determine the incidence of vaginal tape exposures, dyspareunia and LUTS. Statistical analysis was performed using SPSS Statistics Programme 21.0. Descriptive statistics were calculated based on basic patient characteristics. Non-parametric tests were used for comparisons of numerical and Pearson's chi-square for categorical data. Statistical significance was set at p < 0.05. RESULTS: Of 114 living patients, 82.5% responded. Average follow-up time was 10.2 years. There were no statistically significant differences between the objective (84.6% for Monarc vs. 94.6% for TVT-O) and subjective cure rates (67.9% vs. 68.3%) or satisfaction rates (83.9% vs. 78.7%). We found no cases of vaginal tape exposure; 6.4% of all (10.3% of sexually active) patients reported dyspareunia and 34% reported LUTS with no significant differences between groups. DISCUSSION: According to our study, both the inside-out and outside-in procedures showed comparable long-term efficacy with low complication rates. To our knowledge, this is the longest randomised study follow-up comparing the cure and satisfaction rates of these two techniques.

A new affordable and easy-to-make pelvic model for training in complex urogynecological laparoscopic procedures.

INTRODUCTION AND HYPOTHESIS: Our aim was to introduce a new affordable and easy-to-make pelvic model for training in complex urogynecological laparoscopic procedures. METHODS: We modified a commercial female pelvic model consisting of sacrum, coccyx, two hip bones, the pubic symphysis, the fifth lumbar vertebra with intervertebral disc, and certain pelvic ligaments. We used sponge foam paper, felt fabric pieces, chenille stems, foam, plastic ties, fabric glue, and a thick, coated wire to create pelvic floor, uterus/vaginal cuff, bladder, both ureters, and anterior longitudinal and pectineal ligaments. RESULTS: We created two different pelvic models: one with the uterus and one with the vaginal cuff. They enable training for laparoscopic pectopexy and hysteropexy/sacrocolpopexy. Trainees can practice proper mesh placement and suture the mesh to the corresponding anatomical structures. Because of the wire inserted in the uterus/vaginal cuff, it is possible to move the uterus/vaginal cuff in the anterior-posterior direction, thus mimicking the use of the manipulator during surgery. Besides the basic pelvis, all other parts of the model can be easily replaced when necessary. CONCLUSIONS: We believe that our pelvic model could provide a valuable tool for training complex urogynecological laparoscopic procedures and help to reduce the long learning curve of these procedures.

Students as partners: Our experience of setting up and working in a student engagement friendly framework.

BACKGROUND: Student engagement (SE) in the curriculum is a positive indicator in the development of students deeply involved in their learning. It also has several benefits for the schools' level of educational innovation and quality assurance. METHOD: In order to identify the most important pearls from the last decade of educational developments within the field of SE at the Faculty of Medicine University of Maribor, we searched through our school's archives, publications and research in the field of medical education. RESULTS: Three areas were identified as the most important SE complements: (i) peer teaching, (ii) school governance, and (iii) extracurricular activities. The paper highlights how many student-driven initiatives move from informal frameworks toward a formal structure, elective courses, and, in the end, compulsory components of the curriculum. DISCUSSION: As demonstrated by the three educational achievements at our school, fostering a high level of SE can lead to innovative curricular changes, benefit the whole school and enable students to deliver highly impactful extracurricular projects.

Anterior compartment descent: A new measure in the assessment of urethral hypermobility in women with urinary incontinence.

OBJECTIVES: To introduce a new, simple, non-invasive test to quantify urethral hypermobility. METHODS: We reviewed data of women with urinary incontinence who were examined at the Department for General Gynaecology and Urogynaecology, Clinic for Gynaecology and Perinatology, Maribor, Slovenia, between October 2010 and March 2014. Patients' age, diagnosis, results of the Q-tip test and Pelvic Organ Prolapse Quantification measurements were collected. In addition, a new parameter was defined as anterior compartment descent, a midline distance between the external urethral meatus and maximum descent of the anterior vaginal wall when performed the Valsalva maneuver. Statistical analysis was performed with spss software using the Mann-Whitney test, correlation, regression and receiver operating characteristic curve analysis. The analysis was also carried out separately for patients with anterior compartment prolapse stage 0 or I. RESULTS: A total of 472 women were included, 323 of them with anterior compartment prolapse stage 0 or I. Women with urethral hypermobility had significantly higher anterior compartment descent values than patients without urethral hypermobility (3.7 cm vs 2.6 cm, P < 0.001). A moderate correlation was found between anterior compartment descent and the Q-tip test (Spearman's rho = 0.55, P < 0.001). Age and anterior compartment descent were identified as independent variables for the presence of urethral hypermobility. When the cut-off value is set at 3.5 cm, anterior compartment descent represents a test for urethral hypermobility assessment with sensitivity of 65.2%, specificity of 88.6%, positive predictive value of 97.0% and negative predictive value of 30.7%. Anterior compartment descent values were also significantly higher in patients with anterior compartment prolapse stage 0 or I (3.4 ± 0.7 cm vs 2.6 ± 0.7 cm, P < 0.001). CONCLUSIONS: The anterior compartment descent could be a valuable tool for the assessment of urethral hypermobility. Further effort should be directed into the standardization of the technique, determination of the normal range of anterior compartment descent, and its intra- and interobserver reliability.