Long-term follow-up of uterine artery embolization for symptomatic adenomyosis.

INTRODUCTION: Long-term results of uterine artery embolization (UAE) for adenomyosis are largely unknown. We assess long-term outcome of UAE in 40 women with adenomyosis. MATERIALS AND METHODS: Between March 1999 and October 2006, 40 consecutive women with adenomyosis (22 in combination with fibroids) were treated with UAE. Changes in junction zone thickness were assessed with magnetic resonance imaging (MRI) at baseline and again at 3 months. After a mean clinical follow-up of 65 months (median 58 [range 38-129]), women filled out the uterine fibroid symptom and quality of life (UFS-QoL) questionnaire, which had additional questions on the long-term evolution of baseline symptoms and adverse events. RESULTS: During follow-up, 7 of 40 women (18%) underwent hysterectomy. Among these 7 women, the junction zones were significantly thicker, both at baseline (mean 23 vs. 16 mm, P = 0.028) and at 3-month follow-up (mean 15 vs. 9 mm, P = 0.034). Of 33 women with preserved uterus, 29 were asymptomatic. Four patients had symptom severity scores of 50 to 85 and overall QoL scores of 60 to 66, indicating substantial clinical symptoms. There was no relation between clinical outcome and the initial presence of fibroids in addition to adenomyosis. CONCLUSION: In women with therapy-resistant adenomyosis, UAE resulted in long-term preservation of the uterus in the majority. Most patients with preserved uterus were asymptomatic. The only predictor for hysterectomy during follow-up was initial thickness of the junction zone. The presence or absence of fibroids in addition to adenomyosis had no relation with the need for hysterectomy or clinical outcome.

[Outcomes of disciplinary proceedings against gynaecologists: comparison between the periods 1980-1991 and 1992-2003]. / Uitkomsten van de tuchtrechtspraak over gynaecologen: vergelijkingen tussen 1980-1991 en 1992-2003.

In a study of the archives of the Chief Inspector for Healthcare in The Netherlands during the period 1992-2003, the number of complaints against gynaecologists submitted to disciplinary boards (n = 371) was found to be higher than during the period of 1980-1991 (n = 240). On the other hand, the number of complaints per gynaecologist had decreased from 6.3 complaints per 100 gynaecologists in 1992 to 2.6/100 in 2003. The number ofcomplaints declared legitimate relative to the number of submitted complaints remained the same in both periods (55/240 (23%) in 1980-1991 and 84/371 (23%) in 1992-2003), although the percentage ofcomplaints ruled as legitimate did increase during the course of the second period from 14 between 1992-1997 to 28 during the 1998-2003 period. Interesting points included the number of rulings regarding the death of an infant (40%), the interpretation of the cardiotocography recording, the need to keep medical records up to date (in particular the informed consent) and the fact that almost 50% of complaints ruled to be legitimate related to how the locum position was arranged, the role of the duty gynaecologist and that of the house officer.

Removal of a missed polypropylene tape by a combined transurethral and transabdominal endoscopic approach.

Surgical intervention for bladder perforation caused by application of a transvaginally placed polypropylene tape is rare. Open as well as endoscopic procedures for removal from the bladder have been described earlier. In this case report we describe the removal of an intravesical polypropylene tape by a combined transurethral and transabdominal endoscopic approach 3 months after the initial surgical procedure.

Anorectal symptoms after various modes of vaginal delivery.

The aim of this study was to determine the prevalence of, and the changes in, anorectal symptoms following different modes of vaginal delivery in primiparous women. Six hundred and seventeen questionnaires were distributed to primiparous women 3-4 years after delivery. The questionnaires were designed to obtain information regarding the development of anorectal symptoms, including the type of symptoms experienced, their severity and their impact on lifestyle. A total of 479 questionnaires were returned, representing a response rate of 77.6%. Women included in the study were divided into three groups on the basis of the mode of delivery (normal vaginal, vacuum extraction and forceps). Any episode of fecal incontinence was considered to be abnormal. Following delivery, de novo incontinence developed in 22%. There was no significant difference between the three modes of vaginal delivery in terms of the development of fecal incontinence (normal vaginal delivery 22%, vacuum extraction 20%, forceps delivery 26%). Furthermore, analysis of obstetric variables could not identify one significant independent risk factor for anorectal incontinence. The results of this study suggest that instrumental vaginal deliveries are as safe as a normal vaginal delivery in terms of the development of anorectal symptoms.

Declining trend in major gynaecological surgery in The Netherlands during 1991-1998. Is there an impact on surgical skills and innovative ability?

OBJECTIVES: To assess the number of major surgical procedures in gynaecology over a period of eight years in The Netherlands and to detect possible trends. Relevance of the trends and the possible impact on surgical skills and on innovative ability are discussed. DESIGN: Observational study. SETTING: Hospital care in The Netherlands. SAMPLE: Data from a national hospital discharge database, from all 119 hospitals in The Netherlands. METHODS: When a patient is discharged from the hospital. data on the diagnosis and treatment are registered by local medical officers and administrators. Registration of surgical procedures is based on the International Classification of Procedures in Medicine (ICPM, WHO 1978), the so-called WCC-standard. All hospitals but one (a cancer centre) in The Netherlands participate in this registration, resulting in 99.3% of all admissions. Data on gynaccological manpower were obtained from the Dutch College of Obstetricians and Gynaecologists. In order to standardise the frequency numbers per 1,000 women, yearly data of the female population according to age were obtained from the Central Office for Population Statistics. RESULTS: The female population aged 20 years of age and older increased 3% between 1991 and 1998, from 5.8 million to 6.0 million. In the same period the number of gynaecologists grew from 604 to 625, also an increase of 3%. The total number of hysterectomies dropped from 21,433 in 1991 to 16,320 (-24 %) in 1998 (chi2 for trend 1,245.1. P < 0.001) Surgery of the uterine cavity, either performed hysteroscopically or blind, increased from 311 to 1,958 (+ 625%) cases per year (chi2 for trend 2,459.2, P < 0.001). No trend has been detected in the numbers of adnexal operations, including surgical treatment of tubal pregnancy (tubotomy or tubectomy). In 1998, 12% of all ovarian surgery and 28% of all surgery for ectopic pregnancies was performed laparoscopically. Surgery for female urinary incontinence experienced a strong decline of 46% in the studied period. The frequency of vaginal repair decreased with 1354 (-16%) cases. The abdominal prolapse surgery (abdominal sacral colpopexy, obliteration of the Douglas pouch) is steadily increasing, although the absolute numbers are small. In 1998 seven hundred and forty-three women underwent an abdominal approach of their prolapse repair, compared with 7239 that had the vaginal repair. CONCLUSIONS: The declining trend of major gynaecological surgery in combination with the increasing number of gynaecologists will result in more difficulty for gynaecologists to acquire and maintain surgical skills and may therefore affect their ability to innovate within the surgical profession.

[Embolization as treatment for symptomatic uterus myomata]. / Embolisatie als behandeling bij symptomatische uterus myomatosus.

Selective percutaneous embolisation of the uterine arteries was carried out on three women with hypermenorrhea caused by uterine myomata. Two of the patients experienced resumption of the normal menstrual pattern. In the first case the myoma became 30% smaller and in the second case, the fibroid was expelled into the vagina six months later. The third patient suffered a fever one week after the treatment due to an infected necrotic myoma, after which a hysterectomy was carried out. The embolisation of myomata can offer an alternative to medicinal treatment, myomectomy or hysterectomy. The advantages of embolisation compared to a hysterectomy are a shorter hospital admission time, quick recovery after the procedure and retention of the uterus.

[The value of ultrasonography consultation by second-line gynecological caregivers to midwives and family practitioners]. / De waarde van een echoscopiespreekuur door verloskundige hulpverleners uit de tweede lijn voor verloskundigen en huisartsen.

OBJECTIVE: Evaluation of a consulting hour for ultrasound examination for general practitioners and midwives, performed by gynaecologists. STUDY DESIGN: Prospective. METHOD: Indications for ultrasound examination, as determined by general practitioners and midwives, were compared with the ultrasound findings. The consequences of the ultrasound examination were analysed. RESULTS: An abnormal finding was obtained in 23.5% of 1801 women examined by ultrasound. Correction of estimated gestational age took place in 47%. Abnormal findings were present in 64% of women with first trimester bleeding. In 5.6% a further consultation of a gynaecologist was necessary. CONCLUSION: A consulting hour for ultrasound examination is a useful supplementary diagnostic tool for general practitioners and midwives.

The performance of a simple scoring system screening for low birthweight infants for gestation in an unselected pregnant population.

Identification of poor fetal growth is an important objective of antenatal care. We evaluated the validity of the Wennergren score to predict small for gestational age and/or underweight for length infants (low ponderal index). To 405 randomly chosen pregnant women from our university hospital population, this numerical scoring system was applied at 28 and 34 weeks of gestation. Birthweights below the 2.3rd and 10th centile and ponderal indexes below the 3rd and 10th centile were used as outcome standards. The sensitivity of predicting SGA infants ranged from 28.4% for infants below the 10th birthweight centile at 28 weeks, to 66.7% for infants below the 2.3rd centile at 34 weeks. Figures for low ponderal indices ranged from 25.0% to 50.0%. In contrast to the promising performance of the Wennergren score as described in the Scandinavian literature, this score was not useful as a screening test for SGA or underweight for length infants in a Dutch hospital population.

Non-radical hysterectomy and the function of the lower urinary tract. I: Urodynamic quantification of changes in storage function.

The intermediate sequelae of non-radical abdominal and vaginal hysterectomies on the storage function of the lower urinary tract were studied by comparison of pre- and postoperative urodynamic parameters. A statistically significant reduction in maximum cystometric capacity after abdominal extrafascial and vaginal hysterectomies was found, together with a decline in bladder compliance. Both findings are attributed to a decrease in the musculoelastic properties of the detrusor muscle caused by edema and surgical injury. This reduction in capacity and compliance, however, appeared to have no clinical importance. Sensory innervation remained unaltered. In general no evidence was found that hysterectomy contributed to the development of involuntary detrusor contractions and motor urge incontinence. Urethral competence, assessed by urethral pressure profilometry and urethral leakage pressure measurement, remained unaffected. No increase in stress incontinence was seen after hysterectomy. Vaginal hysterectomy appeared to influence storage function slightly more than abdominal hysterectomy did. Postoperative lower urinary tract dysfunction is for the most part determined by the preoperative urological status.

Non-radical hysterectomy and the function of the lower urinary tract. II: Urodynamic quantification of changes in evacuation function.

The intermediate sequelae of non-radical abdominal and vaginal hysterectomies on the evacuation function of the lower urinary tract were studied by comparison of pre- and postoperative urodynamic parameters. No significant changes were observed in detrusor contractility or the contribution of abdominal straining after hysterectomy. Pressure-flow studies revealed no development towards obstructive patterns. Uroflowmetry did not demonstrate any changes in flow rates or in flow patterns. Except in one woman, no major variations were seen in residual urine volumes. There were no differences between abdominal and vaginal hysterectomies. It is concluded that lower urinary tract evacuation function remains unaltered by total hysterectomy.

Radical hysterectomy and the function of the lower urinary tract. Urodynamic quantification of changes in storage and evacuation function.

The intermediate sequelae of radical hysterectomy on the storage and evacuation function of the lower urinary tract were studied by comparison of pre- and postoperative urodynamic parameters. A modified surgical technique was employed in order to remove only the necessary part of the upper part of the vagina and paravaginal tissues. A non-significant reduction in bladder capacity and compliance was found. Urethral function remained unaltered. The most prominent finding was a significant reduction in detrusor contractility and the development of abdominal straining in order to empty the bladder. The pathophysiologic mechanisms by which lower urinary tract is changed after radical hysterectomy are a decrease in the musculo-elastic properties of the bladder wall caused by surgical injury, and partial damage to the neural innervation of the bladder.

Micturition symptoms and urinary incontinence after non-radical hysterectomy.

The effects of 554 non-radical vaginal and abdominal hysterectomies on micturition symptoms and urinary incontinence were studied. From the urological point of view, two groups of women may be distinguished prior to hysterectomy: one without urological symptoms and the second with urological complaints (present in no less than 57% of all women and differing significantly from the distribution of urological symptoms in the normal population). In the first group, frequency developed significantly more often than nocturia, dysuria, stress incontinence and nocturnal and diurnal urge incontinence. The type of hysterectomy was not related to this development, except that urgency more often followed vaginal hysterectomy. In the second group, highly significant improvement and disappearance of symptoms was observed. Age, parity, menopausal status, the presence of myomas, height, weight and body mass index had no influence.

Preliminary results with the antiprogestational compound RU-486 (mifepristone) for interruption of early pregnancy.

RU-486 (mifepristone) (Roussel-Uclaf, Paris, France) is an antiprogesterone that acts through a competitive binding at the site of the progesterone and cortisol receptor. It induced a complete expulsion in 29 (83%) of 35 patients with an unwanted pregnancy with up to 55 days of amenorrhea. A complete expulsion occurred in 17 (89%) of the 19 nulliparous women, and no serious side effects were seen. However, our results were less successful in ine patients with a more advanced pregnancy (between 8 and 10 weeks). In this group, only three complete expulsions were seen.