A Systematic Review and Network Meta-Analysis to Evaluate the Comparative Efficacy of Interventions for Unfit Patients with Chronic Lymphocytic Leukemia.

INTRODUCTION: Rituximab plus fludarabine and cyclophosphamide (RFC) is the standard of care for fit patients with untreated chronic lymphocytic leukemia (CLL); however, its use is limited in 'unfit' (co-morbid and/or full-dose F-ineligible) patients due to its toxicity profile. We conducted a systematic review and Bayesian network meta-analysis (NMA) to determine the relative efficacy of commercially available interventions for the first-line treatment of unfit CLL patients. METHODS: For inclusion in the NMA, studies had to be linked via common treatment comparators, report progression-free survival (PFS), and/or overall survival (OS), and meet at least one of the five inclusion criteria: median cumulative illness score >6, median creatinine clearance ≤70 mL/min, existing co-morbidities, median age ≥70 years, and no full-dose F in the comparator arm. A manual review, validated by external experts, of all studies that met at least one of these criteria was also performed to confirm that they evaluated first-line therapeutic options for unfit patients with CLL. RESULTS: In unfit patients, the main NMA (five studies for PFS and four for OS) demonstrated clear preference in terms of PFS for obinutuzumab + chlorambucil (G-Clb) versus rituximab + chlorambucil (R-Clb), ofatumumab + chlorambucil (O-Clb), fludarabine and chlorambucil (median hazard ratios [HRs] 0.43, 0.33, 0.20, and 0.19, respectively), and a trend for better efficacy versus rituximab + bendamustine (R-Benda) and RFC-Lite (median HR 0.81 and 0.88, respectively). OS results were generally consistent with PFS data, (median HR 0.48, 0.53, and 0.81, respectively) for G-Clb versus Clb, O-Clb, and R-Clb 0.35 and 0.81 versus F and R-Benda, respectively); however, the OS findings were associated with higher uncertainty. Treatment ranking reflected improved PFS and OS with G-Clb over other treatment strategies (median rank of one for both endpoints). CONCLUSION: G-Clb is likely to show superior efficacy to other treatment options selected in our NMA for unfit treatment-naïve patients with CLL. FUNDING: F. Hoffmann-La Roche Ltd.

Female sexual function following surgery for stress urinary incontinence: tension-free vaginal versus transobturator tape procedure.

The aim of this study was to compare sexual function outcome following tension-free vaginal (TVT) versus transobturator tape (TOT) for stress urinary incontinence (SUI). All women who underwent TVT or TOT procedures for SUI with no concomitant prolapse repair between January 2002 and July 2007 were sent a retrospective pre-post questionnaire. Eighty-one and 64 women were sexually active before and after TVT and TOT procedures, respectively. Sexual function outcome did not differ pre- and postoperatively for the TVT and TOT groups, and postoperatively between the two groups. Responders reported an improvement of intercourse satisfaction in 23 (29.5%) and 21 (32.9%) cases, whereas 14 (17.3%) and eight (12.5%) complained of sexual function deterioration after TVT and TOT procedure, respectively (p = 0.43). This study suggests that anti-incontinence surgery can have a positive and negative outcome on sexual function, with no significant differences between the TVT and TOT procedures.

Sexual function in women following the transvaginal tension-free tape procedure for incontinence.

OBJECTIVE: To assess the impact of the tension-free vaginal tape (TVT) procedure on the sexual function of women who underwent this treatment for stress urinary incontinence (SUI). METHOD: The Lemack questionnaire was mailed to 135 women treated for SUI only, with no concomitant pelvic organ prolapse repair. RESULTS: Of the 82 returned questionnaires (60.7%), 66 (80.5%) could be included in the analysis. Compared with preoperative responses, there were no significant postoperative changes regarding frequency of sexual intercourse, satisfaction with sexual intercourse, or personal importance of having an active sexual life. Although there was a significant postsurgical decrease in urinary coital incontinence (P=0.02) and 12 women (25.5%) reported improved satisfaction from intercourse, 11 women (23.4%) complained of a worsening. CONCLUSION: These results suggest that TVT for SUI does not significantly affect sexual function in women. Additional prospective studies are warranted to verify these preliminary findings and compare the impact of the TVT with that of other anti-incontinence procedures.

Sexual function after transobturator tape procedure for stress urinary incontinence.

OBJECTIVES: To assess the effect of the transobturator tape (TOT) procedure for stress urinary incontinence (SUI) on female sexual function. METHODS: All women who underwent a TOT outside-in or inside-out procedure for SUI with no concomitant prolapse repair from January 2002 to November 2005 were sent a questionnaire by mail. RESULTS: A total of 105 women fulfilled the inclusion criteria, 69 (65.7%) of whom returned the questionnaire. Of these 69 women, 66 (95.6%) agreed to participate in the study, although 4 did not complete the pre or postoperative questionnaire, for a follow-up of 62 women (59.0%). Of the 62 women, 48 were sexually active before and after surgery. No significant differences were found after surgery in the frequency and appreciation of intercourse, extent of sexuality, or the frequency of leakage during intercourse. A nonsignificant decrease of leakage was found after surgery (P = 0.06). Of the 48 women, 15 (31.2%) reported an improvement in intercourse satisfaction and 5 (10.4%) complained of sexual function deterioration after the anti-incontinence procedure. Partner discomfort remained unchanged. Of the 62 patients, 10 (16.1%) were unsatisfied with the surgical outcome because of persistent or recurrence of SUI in 6 and a deterioration of intercourse satisfaction after surgery in 4. CONCLUSIONS: These results suggest that TOT procedures for SUI can have a positive, but also a negative, outcome on female sexual function. Additional and larger prospective studies are warranted to support these preliminary findings and to compare sexual function outcomes after transvaginal tape versus TOT procedures for SUI.

Sexual function in women before and after transvaginal mesh repair for pelvic organ prolapse.

The aim of the study was to assess sexual function in women before and after surgery with transvaginal mesh for pelvic organ prolapse. Women were invited to complete a sexual function questionnaire including the Lemack and the Pelvic Organ Prolapse Urinary Incontinence Sexual Questionnaires (PISQ-12) before undergoing surgery and 1 year after surgery. Eighty-three complete pre and postoperative questionnaires were analyzed. Mean age was 65.1 years. Forty-six were sexually inactive and 37 were sexually active women. Two sexually active women completed the preoperative PISQ-12 questionnaire retrospectively after surgery. There were no significant differences after surgery in the answers to the Lemack questionnaire and PISQ-12 scores. These results suggest that nonabsorbable transvaginal mesh repair of genital prolapse does not impair sexual function 1 year after surgery. Nevertheless, patients should not necessarily expect a significant improvement in sexual function outcome following transvaginal mesh repair for genital prolapse.

Amniotic band syndrome with limb amputation after exposure to mifepristone in early pregnancy.

To date, the number of cases reported after exposure to mifepristone alone in early pregnancy is limited. In 24 cases, only 1 observation of fetal malformation associated with mifepristone has previously been reported. We report a case of amniotic band syndrome with limb amputation after exposure to mifepristone in early pregnancy. This association raises the question of a possible causal relationship.

[Nested variant urothelial carcinoma: diagnostic difficulties]. / Carcinome urothélial a type de nid: difficultés diagnostiques.

Nested variant urothelial carcinoma is a recently identified variant of urothelial carcinoma which is difficult to diagnose due to its resemblance to other benign bladder lesions, such as hyperplasia of Von Brünn nests. The authors present three clinical cases of this variant of urothelial carcinoma and emphasize the importance of clinical, cytological, histological and immunohistochemical criteria for the diagnosis and the need for early and adapted therapeutic management, as this type of bladder tumour, wrongly considered to be benign up until the early 1990s, is just as invasive as high-grade urothelial carcinoma.