The views of patients with brain cancer about palliative care: a qualitative study.

BACKGROUND: Palliative care, a specialty aimed at providing optimal care to patients with life-limiting and chronic conditions, has several benefits. Although palliative care is appropriate for neurosurgical conditions, including brain cancer, few studies have examined the views of brain cancer patients about palliative care. We aimed to explore the thoughts of brain cancer patients about palliative care, their opinions about early palliative care, and their preferred care setting. METHODS: Semi-structured interviews and the qualitative research methodologies of grounded theory were used to explore perceptions of palliative care on the part of 39 brain cancer outpatients. RESULTS: Seven overarching actions emerged: ■Patients would prefer to receive palliative care in the home.■Increased time with caregivers and family are the main appeals of home care.■Patients express dissatisfaction with brief and superficial interactions with health care providers.■Patients believe that palliative care can contribute to their emotional well-being.■Patients are open to palliative care if they believe that it will not diminish optimism.■There is a preconceived idea that palliative care is directly linked to active dying, and that supposed link generates fear in some patients.■Patients prefer to be educated about palliative care as an option early in their illness, even if they are fearful of it. CONCLUSIONS: Overall, when educated about the true meaning of palliative care, most patients express interest in accessing palliative care services. Although the level of fear concerning palliative care varies in patients, most recognize the associated benefits.

Comparison of two trocar-guided trans-vaginal mesh systems for repair of pelvic organ prolapse: a retrospective cohort study.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to compare failure and complication rates in patients who underwent a trocar-guided vaginal mesh repair with either a non-absorbable or a partially absorbable mesh. METHODS: Retrospective analysis of prospectively collected data from consecutive women undergoing either non-absorbable or partially absorbable mesh for symptomatic stage 2 prolapse or higher were evaluated at 12 months. Outcome measures included objective and subjective failure rates, patient's satisfaction, complications and perioperative outcomes. RESULTS: Five hundred and sixty-nine women (347 with non-absorbable mesh, 222 with partially absorbable mesh) were included. Failure rates were similar in the two groups; the re-operation rate in the untreated compartments was higher in the non-absorbable mesh group compared with the partially absorbable mesh group (5% vs 1%). Mesh exposure rate in the non-absorbable mesh group was 12% and in the partially absorbable mesh group it was 5%. Other complication and patient satisfaction rates were similar. CONCLUSIONS: Non-absorbable and partially absorbable mesh demonstrated similar outcome rates at 12 months. The risk of reoperation was lower for partially absorbable mesh. The mesh exposure rate was significantly lower for the partially absorbable mesh group compared with the non-absorbable mesh group.

Surgical treatment of pelvic organ prolapse: a historical review with emphasis on the anterior compartment.

INTRODUCTION AND HYPOTHESIS: The objective of this work was to collect and summarize a detailed historical review of the surgical treatment of pelvic organ prolapse (POP) in which we specifically focused on the anterior compartment. METHODS: A literature search in English, Dutch, and German was carried out using the keywords pelvic organ prolapse, anterior colporrhaphy, cystocele, and interposition operations in several databases (e.g., PubMed and HathiTrust Digital Library). Other relevant journal and textbook articles were found by retrieving references cited in previous articles and textbooks. RESULTS: Probably the first explanation of the treatment of POP dates from 1500 B.C. The Egyptians gave a description to "falling of the womb" in the Kahun Papyrus. More than a millennium later, Euryphon, a contemporary of Hippocrates (400 B.C.) described some interesting therapeutic options, from succussion (turning a women upside down for several minutes) to irrigating the displaced uterus with wine. A wide range of techniques has been attempted to repair the prolapsing anterior vaginal wall. By 1866, Sim had already performed a series of operations very similar to a modern anterior repair. The first reviews about the abdominal approach to correcting a cystocele were in 1890. The first description of using mesh to cystoceles was the use of tantalum mesh in 1955. In 1970, the first report of collagen mesh in urogynecology was described. Nowadays, robot-assisted surgery and cell-based tissue engineering are the latest interventions. CONCLUSION: Many surgeons have tried to find the ideal surgical therapy for anterior compartment prolapse, but to date, this has not been achieved.

Inter- and intraobserver reliability for diagnosing levator ani changes on magnetic resonance imaging.

OBJECTIVES: To assess the inter- and intraobserver reliability of the diagnosis of pubovisceral muscle avulsions and measurements of the levator hiatus on magnetic resonance imaging (MRI). METHODS: Women with recurrent pelvic organ prolapse or in whom there was a discrepancy between clinical signs and symptoms of pelvic floor dysfunction underwent MRI and were eligible for inclusion. MRI datasets of the pelvic floor of 262 women were obtained and evaluated by two observers, who scored the presence and extent of pubovisceral muscle avulsions on each side using a scale from 0 to 3 and obtained measurements of the anteroposterior and transverse diameters and area of the levator hiatus. A random sample of 100 patients was reviewed a second time by one of the observers. Intraclass correlation coefficients (ICCs) with their 95% CI were calculated for all measurements. Mean differences with accompanying limits of agreement were calculated to estimate agreement between pairs of measurements and to detect possible systematic bias. RESULTS: Good interobserver reliability was found for the assessment of pubovisceral muscle avulsions (ICC = 0.76-0.79) and excellent agreement for measurements of the levator hiatus (ICC = 0.85-0.89). The intraobserver reliability for pubovisceral muscle avulsions and other levator hiatus measurements was also excellent (ICC = 0.80-0.97). A significant interobserver systematic bias was observed in the measurement of levator hiatus transverse diameter; however, narrow limits of agreement were observed. CONCLUSIONS: Pubovisceral muscle avulsions and levator hiatus measurements can be assessed with good to excellent reliability on MRI.

Does the method of dissecting in anterior colporraphy lead to a difference in thickness of removed vaginal tissue?

OBJECTIVE: To evaluate the difference in thickness of the anterior vaginal wall removed after different surgical dissecting techniques of anterior colporrhaphy. STUDY DESIGN: In patients undergoing primary anterior colporrhaphy, trimmed vaginal tissue was taken following different surgical techniques of vaginal wall dissection. Tissues were preserved in formalin and stained with hematoxylin-eosin and elastica-van Giesen stains. The examiner was an experienced pathologist blinded to the surgical technique. The specimens were examined for the epithelial thickness (ET), lamina propria thickness (LPT), muscular layer thickness (MT) and total thickness (TT). RESULTS: Tissue was analysed in 93 women who underwent anterior compartment pelvic organ prolapse surgery. There was no difference between the different surgical techniques in thickness measured in the three histological layers and for the total thickness. The use of hydrodissection was the only independent factor leading to thicker removed vaginal tissue. CONCLUSIONS: Dissecting the vaginal wall as thin as possible does not result in a thinner vaginal layer than dissecting in the most optimal surgical plane. The use of hydrodissection provides a thicker trimmed tissue.

Surgical management of pelvic organ prolapse and uterine descent in the Netherlands.

INTRODUCTION AND HYPOTHESIS: To evaluate current practice in the surgical treatment of uterine descent among members of the Dutch Urogynecological Society and to analyze possible trends in the surgical treatment of pelvic organ prolapse in the Netherlands during the last decade. METHODS: A questionnaire, including case scenarios, was sent to the members of the Dutch Urogynecological Society. Using a nationwide registry from the Netherlands, we assessed the number and type of surgical procedures performed for pelvic organ prolapse between 1997 and 2009. RESULTS: The response rate was 73%, with 161 questionnaires completed. Vaginal hysterectomy, sacrospinous hysteropexy, and the Manchester Fothergill procedure were the most frequently performed surgical interventions for uterine descent. In the case of lower stage uterine descent, uterus preservation was preferred, but in the case of higher stage there was wide variation. Two thirds of the respondents stated that in recent years they tended to save the uterus more often. The registered number of hospital admissions for uterine descent increased by 30% between 1997 and 2009 and the number of surgical procedures almost doubled. The number of vaginal hysterectomies performed because of uterine descent increased by only 15% in this period. CONCLUSIONS: In the Netherlands, surgical policy in the case of uterine descent is very variable, with no clear preference for either hysterectomy or uterus preservation. There was a high increase in hospital admissions and pelvic organ prolapse procedures in the last decade. The number of vaginal hysterectomies performed because of uterine descent did not follow this change, which reflects a trend toward preserving the uterus.

Can preoperative urodynamic investigation be omitted in women with stress urinary incontinence? A non-inferiority randomized controlled trial.

AIMS: To assess in women with stress urinary incontinence (SUI) the value of urodynamics prior to treatment. METHODS: We performed a multicenter non-inferiority randomized controlled trial. Women with SUI were randomly allocated to management based on a workup with or without urodynamics. The primary outcome was clinical reduction of complaints as measured with the Urogenital Distress Inventory urinary incontinence subscale (UDI-UI) at 12 months after the onset of treatment. A mean difference in improvement of less than 8 was considered non-inferior. The study was analyzed according to intention-to-treat. RESULTS: The trial was stopped prematurely because of slow recruitment. We randomly allocated 59 women to a strategy with (N = 31) or without (N = 28) urodynamics. The mean difference in improvement on the UDI-UI was 14 in favor of the group without urodynamics (48 SD ± 22 vs. 34 SD ± 22, 95% CI: -28 to -0.26), confirming non-inferiority. Addition of urodynamics did not result in a lower occurrence of de novo overactive bladder complaints compared to a workup without urodynamics (6/31 vs. 1/28; RR 5.4, 95% CI: 0.70-42). In the group allocated to urodynamics, initial surgical management was more often abandoned compared to the group not allocated to urodynamics (5/31 vs. 1/28; RR 4.5, 95% CI: 0.56-36). CONCLUSIONS: In this relatively small study, the omission of urodynamics was not inferior to the use of urodynamics in the preoperative workup of women with SUI. Women with SUI undergoing urodynamics had the risk of a choice for more prudent treatment, which seemed to result in a delay until effective treatment.

The use of synthetic mesh in vaginal prolapse surgery: a survey of Dutch urogynaecologists.

OBJECTIVE: To evaluate the use of mesh in vaginal prolapse surgery amongst members of the Dutch Urogynaecologic Society. STUDY DESIGN: A questionnaire evaluating the use of mesh vs. native tissue repair in vaginal prolapse surgery was sent out by email to all members. Some specific questions on standard measures of infection prevention were included. RESULTS: One hundred and thirty-three completed questionnaires were received. The response rate was 65%. Seventy-one percent of respondents stated that they apply use synthetic meshes in their patients. The mean percentage of mesh use in overall vaginal pelvic organ prolapse surgery was 14%. Most responders use mesh in recurrent surgery only. Prolift is the most commonly used brand. All women received prophylactic antibiotics. Although only half of the respondents changed gloves. CONCLUSIONS: Meshes are commonly used in the Netherlands. The major indication is repair of a recurrent prolapse.

Development of de novo prolapse in untreated vaginal compartments after prolapse repair with and without mesh: a secondary analysis of a randomised controlled trial.

OBJECTIVE: To compare the de novo prolapse rate in the untreated vaginal compartments following conventional vaginal prolapse repair and tension-free vaginal mesh repair. DESIGN: Secondary analysis of a randomised controlled trial. SETTING: Thirteen centres in the Netherlands. POPULATION: Women with recurrent pelvic organ prolapse stage II or higher. METHODS: Random assignment to either conventional vaginal native tissue repair or vaginal mesh insertion. PRIMARY OUTCOME: de novo pelvic organ prolapse stage II or higher in the untreated vaginal compartments at 12 months after surgery. SECONDARY OUTCOMES: de novo pelvic organ prolapse at and beyond the hymen, de novo prolapse beyond the hymen and prolapse domain scores of the Urogenital Distress Inventory. RESULTS: At 12 months ten of 59 women (17%) in the conventional group versus 29 of 62 women (47%) in the mesh group were diagnosed with a de novo pelvic organ prolapse stage II or higher in the untreated compartment (P < 0.001, odds ratio 4.3, 95% confidence interval 1.9-10.0). Additional apical support to a mesh-augmented anterior repair significantly reduced the de novo prolapse rate. Women with a de novo prolapse in the mesh-treated group demonstrated significantly higher mean bother scores on the domain genital prolapse of the Urogenital Distress Inventory score (13.1 ± 24.2) compared with those without de novo prolapse (2.9 ± 13.9) (P = 0.03). CONCLUSION: Mesh-augmented prolapse repair in only one vaginal compartment is associated with a higher de novo prolapse rate in the untreated compartments compared with conventional vaginal native tissue repair in women with recurrent pelvic organ prolapse.

The prevalence and factors associated with previous surgery for pelvic organ prolapse and/or urinary incontinence in a cross-sectional study in The Netherlands.

OBJECTIVE: To estimate the prevalence and identify the factors associated with previous pelvic organ prolapse (POP) and/or incontinence surgery. STUDY DESIGN: In a cross-sectional study, all women who were aged 45-85 years and registered in eight general practices were invited to participate. They completed standardised questionnaires (the urinary distress inventory (UDI) and the defaecatory distress inventory (DDI)) and answered questions on previous pelvic floor surgery. RESULTS: Out of 2979 women eligible for this study, 1380 women were included. Previous surgery had been performed in 119 women. The prevalence of surgery increased with age, with a prevalence of 20.3% in the age group 76-85 years. Pelvic floor symptoms were more prevalent in women who had undergone previous surgery, with higher UDI and DDI scores. Factors associated with previous surgery were age, higher BMI, POP symptoms during pregnancy and previous hernia surgery. CONCLUSION: In The Netherlands, approximately one in five women will undergo surgery for POP and/or incontinence during her lifetime. The women who underwent surgery were more likely to have symptoms of pelvic floor dysfunction than those who did not undergo surgery.

Factors influencing success of pelvic organ prolapse repair using porcine dermal implant Pelvicol.

OBJECTIVE: To evaluate factors influencing pelvic organ prolapse (POP) recurrence after repair surgery with a porcine dermal collagen implant (Pelvicol). STUDY DESIGN: From December 2003 to August 2005, 78 patients with mainly stage 3 pelvic organ prolapse by the Pelvic Organ Prolapse Quantification (POP-Q) system underwent vaginal repair using porcine dermal implant. Assessments were made preoperatively and at 6 weeks and one year follow-up. These included physical examination with POP-Q, Incontinence Impact Questionnaire, Urogenital Distress Inventory and the Defaecatory Distress Inventory and questions from the Patient Global Impression of Improvement. Data were recorded on changes in functional status, mesh erosion and adverse events. Procedural success was defined as POP-Q stage 0/1. RESULTS: 71 patients returned for one year follow-up. The overall cure rate was 74.6%. The chance of a successful operation in the younger group was significantly higher than in the older group (OR: 7.5; 95% CI 1.38, 40.69), but this effect is lower and no longer significant after adjusting for compartment (post, anterior, post+anterior) (adjusted OR: 5.5; 95% CI 0.92, 32.6). CONCLUSIONS: A low complication rate and satisfactory overall results were observed in a group of women after POP repair surgery with Pelvicol. Whether these results are better or worse than with conventional surgery or non-resorbable mesh implantation is unclear and can only be determined in a randomized controlled trial. There was a strong tendency towards better results in the younger women than in the older women, but the reason for this phenomenon is unclear.

Pelvic organ prolapse and overactive bladder.

AIMS: In this review we try to shed light on the following questions: *How frequently are symptoms of overactive bladder (OAB) and is detrusor overactivity (DO) present in patients with pelvic organ prolapse (POP) and is there a difference from women without POP? *Does the presence of OAB symptoms depend on the prolapsed compartment and/or stage of the prolapse? *What is the possible pathophysiology of OAB in POP? *Do OAB symptoms and DO change after conservative or surgical treatment of POP? METHODS: We searched on Medline and Embase for relevant studies. We only included studies in which actual data about OAB symptoms were available. All data for prolapse surgery were without the results of concomitant stress urinary incontinence (SUI) surgery. RESULTS: Community- and hospital-based studies showed that the prevalence of OAB symptoms was greater in patients with POP than without POP. No evidence was found for a relationship between the compartment or stage of the prolapse and the presence of OAB symptoms. All treatments for POP (surgery, pessaries) resulted in an improvement in OAB symptoms. It is unclear what predicts whether OAB symptoms disappear or not. When there is concomitant DO and POP, following POP surgery DO disappear in a proportion of the patients. Bladder outlet obstruction is likely to be the most important mechanism by which POP induces OAB symptoms and DO signs. However, several other mechanisms might also play a role. CONCLUSIONS: There are strong indications that there is a causal relationship between OAB and POP.

Face validity and reliability of the first digital assessment scheme of pelvic floor muscle function conform the new standardized terminology of the International Continence Society.

AIMS: To test the face validity and reliability of a new digital pelvic floor muscle function (PFMF) assessment scheme that was designed on the basis of the recently standardized terminology of the International Continence Society. METHODS: Study participants comprised 41 women, age 18-85 years. Data on age and parity were obtained. Face validity of the new assessment scheme was tested by three senior and one junior pelvic physiotherapists, using the Delphi technique. PFMF of each woman was assessed four times by three specially trained pelvic physiotherapists. Examiners were blinded to parity and other findings. To test reliability, Kappa (K) was used for the dichotomous variables and Weighted Kappa (K(w)) for the items with more than two categories. RESULTS: Mean age of the women was 41 years (SD 10.5); 14 were nulliparous (34.1%), 6 primiparous (14.6%), and 21 multiparous (51.2%). The new assessment scheme showed satisfactory face validity and intra-observer reliability but low inter-observer reliability. CONCLUSIONS: The new assessment scheme based on the terminology of the ICS showed satisfactory face validity and intra-observer reliability. It can therefore be considered suitable for use in clinical practice. More detailed redefinition of the described outcome measures is necessary to improve the inter-observer reliability.

Overactive Bladder and Continence Guidelines: implementation, inaction or frustration?

Guidelines for the management of continence and overactive bladder are generally available across Europe. For a majority of countries, these have been adopted by professional societies in either urology or gynaecology for local use. There has, however, been little monitoring of formal implementation of these guidelines and seldom any attempt to audit their operation. The state of continence care therefore remains largely unknown. This article reviews current guidelines and their status across Europe and examines what might be relevant from other disease areas to promote successful implementation.

Discrepancies between physician interview and a patient self-assessment questionnaire after surgery for pelvic organ prolapse.

The objective of this article was to investigate whether there were discrepancies between the physician interview and a patient's self-assessment questionnaire on the functional results after surgery for pelvic organ prolapse. Before their follow-up appointment, 79 patients were sent a validated urogynaecological questionnaire. At the follow-up visit, the physician interviewed the patients using a checklist with ten symptoms and scored the items as present or absent. Seventy-two patients (91.1%) attended the follow-up visit and had completed the questionnaire. There was poor to slight agreement between the interview score and the self-reported responses to the questionnaire on all items. This was illustrated by low kappa coefficients. The physician was more optimistic about the outcome of the operation than was justified according to the answers to a patient self-assessment questionnaire. We therefore recommend the use of validated questionnaires to evaluate surgical outcome because they provide a more realistic (objective) view of the functional results.

[Diagnostic image (344). A woman with progressive abdominal pain]. / Diagnose in beeld (344). Een vrouw met toenemende buikpijn.

A 28-year-old woman, three months post partum, presented with abdominal pain due to uterine perforation by a levonorgestrel releasing intrauterine device.

[Some complications of tension-free midurethral tapes for the treatment of stress incontinence in women]. / Enkele complicaties van spanningsvrije midurethrale tapes voor de behandeling van stressincontinentie bij vrouwen.

Complications occurred in two women of 45 and 54 years of age who were treated with tension-free midurethral sling procedures. The first woman was treated with transobturator tape due to stress incontinence and an overactive bladder. The procedure resulted in a worsening of the overactive bladder. The second woman was treated with tension-free vaginal tape (TVT) due to stress incontinence and subsequently suffered from pain on urinating. In the first patient, the tape was found to be too tight and following adjustment of the tape tension, the overactive bladder symptoms and the stress incontinence disappeared. The second woman experienced bladder erosion on the right side. After removal of the tape, the symptoms disappeared but the stress incontinence returned. During the last few years, the surgical treatment of stress urinary incontinence has shifted towards the positioning of tension-free tapes. Because this minimally invasive technique is fairly simple to perform, the number of anti-incontinence surgical procedures has increased threefold in the last 4 years in the Netherlands. The literature states high success rates and low complication percentages. However, in everyday practice, these results cannot always be achieved. Doctors should therefore show caution when selecting patients for tension-free midurethral tape procedures. Furthermore, patient information should clearly indicate the actual results. Initial treatment for stress incontinence should consist of intensive pelvic floor muscle training.