Impact of Laparoscopic Prolapse Repair in the Levator Hiatus Area.

STUDY OBJECTIVE: To determine whether laparoscopic surgery by sacrocolpopexy or sacrocervicopexy with posterior mesh attachment to levator ani to treat pelvic organ prolapse reduces the levator hiatus area, as measured by transperineal 3- and 4-dimensional ultrasound. The secondary objective was to assess the risk factors for prolapse recurrence. DESIGN: This is a prospective cohort study. SETTING: A university tertiary hospital. PATIENTS: Women with symptomatic apical prolapse at a high risk of recurrence were included. High risk of recurrence was defined as age <60 years and levator injury (avulsion and/or ballooning) or stage III-IV prolapse Pelvic Organ Prolapse Quantification. INTERVENTIONS: Women were treated with laparoscopic sacrocolpopexy or sacrocervicopexy. MEASUREMENTS AND MAIN RESULTS: Women underwent clinical examination according to assessment by the Pelvic Organ Prolapse Quantification system and transperineal ultrasound for the levator hiatus area at Valsalva. We collected demographic, clinical, and ultrasound data before surgery from clinical records and performed a comparative analysis of the levator hiatus areas before and after surgery and univariate and multivariate analyses of the risk factors for recurrence. Among the 30 women who enrolled, the levator hiatus area at Valsalva decreased significantly after surgery by an average of 4.68 cm2 (p = .028). However, despite a recurrence rate of 13.3%, we found no risk factors associated with recurrence in either the univariate or the multivariate analyses. CONCLUSION: Laparoscopic surgery by sacrocolpopexy or sacrocervicopexy for pelvic organ prolapse with mesh posterior attachment to levator ani significantly reduces the levator hiatus area measured by transperineal ultrasound. Further large-scale studies will be needed to confirm our results and identify risk factors for recurrence.

Prevalence of levator ani avulsion in a multicenter study (PAMELA study).

PURPOSE: The objective is to determine the prevalence of levator ani muscle (LAM) avulsion using four-dimensional ultrasound in primiparous women after vaginal delivery and according to delivery mode. METHODS: This prospective, multicenter study included 322 women evaluated at 6-12 months postpartum by four-dimensional transperineal ultrasound to identify levator ani muscle avulsion. The researcher who performed the ultrasound was blinded to all clinical data. Meaningful data about the birth were also recorded: mode of delivery, mother's age and body mass index, duration of second stage, episiotomy, perineal tearing, anesthesia, assistant, head circumference and fetal weight. RESULTS: 303 volumes were valid for evaluation. The overall prevalence of levator ani muscle avulsion was 18.8% (95% CI 14.4-23.2%). In our multivariate analysis, only mode of delivery reached statistical significance as a risk factor for levator ani muscle avulsion (p < 0.001). The prevalence according to the different modes of delivery was 7.8% in spontaneous delivery, 28.8% in vacuum-assisted and 51.1% in forceps-assisted delivery. Compared with spontaneous delivery, the OR for LAM avulsion was 12.31 with forceps (CI 95% 5.65-26.80) and 4.78 with vacuum-assisted delivery (CI 95% 2.15-10.63). CONCLUSIONS: Levator ani avulsion during vaginal delivery in primiparous women occurs in nearly one in every five deliveries. Delivery mode is a significant and modifiable intrapartum risk factor for this lesion. The incidence is lower in spontaneous delivery and significantly increases when an instrument is used to assist delivery, especially forceps.

Comparison of Screened and Nonscreened Breast Cancer Patients in Relation to Age: A 2-Institution Study.

INTRODUCTION: Screening programs for breast cancer aim to allow early diagnosis, and thus reduce mortality. The aim of this study was to assess the effect of a population screening program in a sample of women aged between 50 and 69 years in terms of recurrence, metastasis, biological profiles, and survival, and to compare their results with those of women of a wider age range who did not participate on the screening program. PATIENTS AND METHODS: A prospective multicenter study in which 1821 patients with 1873 breast tumors who received surgery between 1999 and 2014 at MútuaTerrassa University Hospital and the Hospital of Terrassa in Barcelona were analyzed. A comparison was performed in the 50- to 69-year-old age group between those who participated on the screening program and those who did not. RESULTS: The mean age of patients was 58 years. The mean follow-up was 72 months, and median follow-up 59 months. The screened group showed significantly better results in all prognostic factors and in specific mortality than all nonscreened groups. The specific mortality rate in the screened patients was 2.4% (12/496), local recurrence 2.8% (14/496), and metastasis at 10 years 3.6% (18/496). In the nonscreened group, younger women presented a higher rate of metastasis (16.4% [81/493]) and a shorter disease-free period (77.1% [380/493]). The age group older than 70 years had the highest number of T4 tumors (7.5% [30/403]) and the highest proportion of radical surgery (50.4% [203/403]). CONCLUSION: Patients in the screening program presented improved survival. We speculate that extending breast cancer screening programs to women younger than 50 and older than 70 years could bring about mortality benefits.

Does episiotomy protect against injury of the levator ani muscle in normal vaginal delivery?

AIMS: To investigate whether episiotomy is associated with avulsion of the levator ani in its pubic insertion after normal vaginal delivery. METHODS: This is an observational study at a tertiary obstetric unit recruited 194 primiparous women who had normal vaginal delivery with or without episiotomy. All women underwent translabial 4D ultrasound scanning after delivery. Tomographic ultrasound imaging was used to diagnose levator avulsion. Lesions were recorded as unilateral or bilateral. The investigators were blinded to all clinical data. The influence of other variables associated with delivery such as maternal age, body mass index, gestational age, birth weight, fetal head circumference, and use of epidural anesthesia was recorded and their relation with avulsion was also studied. RESULTS: Avulsion was identified in eleven (10.9%) of the 101 women with episiotomy and in fourteen (15.1%) of the 93 women without. The difference was not statistically significant (P = 0.401). Other variables showed no influence on the prevalence of avulsion. CONCLUSIONS: Episiotomy does not appear to be associated with injury to the levator ani muscle in its pubic insertion in normal vaginal delivery.

[Treatment of uterine fibroids using high-intensity ultrasound]. / Tratamiento de los miomas uterinos mediante ultrasonidos de alta intensidad.

High-intensity ultrasound surgery is being actively introduced as an alternative treatment to conventional surgery for uterine fibroids. Numerous studies have shown that high-intensity ultrasound surgery is a safe and effective treatment, with fewer side effects than fibroidectomy and hysterectomy, and is cost-effective. It is now possible to offer this alternative therapy to patients with symptomatic uterine fibroids. We describe the technical basis of ultrasound surgery, the pretherapy selection of patients, the limiting factors and the risks of high-intensity ultrasound therapy. We describe our unit's clinical experience with 319 patients treated in an outpatient regimen, which resulted in a high rate of success (81%) and an acceptable rate of mild complications, as well as a virtually immediate return to daily activities. We comment on the follow-up of pregnancies that occurred after treatment with high-intensity focused ultrasound (HIFU) with no side effects attributable to the therapy.

Tratamiento de los miomas uterinos mediante ultrasonidos de alta intensidad / Treatment of uterine fibroids using high-intensity ultrasound

La cirugía mediante ultrasonidos de alta intensidad (HIFU, high intensity focused ultrasound) se esta introduciendo con fuerza como tratamiento alternativo a la cirugía convencional de los miomas uterinos. Múltiples estudios han demostrado que es un tratamiento efectivo y seguro, con efectos secundarios mucho menores que la miomectomía y la histerectomía, siendo además coste-efectivo. Hoy es posible ofrecer esta alternativa terapéutica a las pacientes con miomas uterinos sintomáticos. Describiremos las bases técnicas de la cirugía por ultrasonidos, la selección preterapéutica de las pacientes, los factores limitantes y los riesgos de la terapia con ultrasonidos de alta intensidad. Describimos la experiencia clínica de nuestra unidad con 319 pacientes tratadas en régimen ambulatorio con una elevada tasa de éxito, 81%, y con una tasa de complicaciones leves aceptable, además de una reincorporación a las actividades habituales prácticamente inmediata. Comentamos el seguimiento de las gestaciones que se han producido después del tratamiento con HIFU sin efectos secundarios atribuibles a la terapia (AU)

High-intensity ultrasound surgery is being actively introduced as an alternative treatment to conventional surgery for uterine fibroids. Numerous studies have shown that high-intensity ultrasound surgery is a safe and effective treatment, with fewer side effects than fibroidectomy and hysterectomy, and is cost-effective. It is now possible to offer this alternative therapy to patients with symptomatic uterine fibroids. We describe the technical basis of ultrasound surgery, the pretherapy selection of patients, the limiting factors and the risks of high-intensity ultrasound therapy. We describe our unit's clinical experience with 319 patients treated in an outpatient regimen, which resulted in a high rate of success (81%) and an acceptable rate of mild complications, as well as a virtually immediate return to daily activities. We comment on the follow-up of pregnancies that occurred after treatment with high-intensity focused ultrasound (HIFU) with no side effects attributable to the therapy (AU)

Introital ultrasonography: a comparison of women with stress incontinence due to urethral hypermobility and continent women.

OBJECTIVE: To determine if there is a variable on introital ultrasonography (IUS) that can be used to distinguish between women with stress urinary incontinence (SUI) due to urethral hypermobility (UH) and continent women. PATIENTS AND METHODS: This single-centre, prospective, blind, cohort, observational study comprised 383 women (245 continent and 138 incontinent) who were all appropriately informed volunteers selected according to the inclusion criteria. IUS with a convex probe was performed on all women; the measurement plane was standardized and coordinates were obtained at rest and on straining. Several distances were measured to determine if any provided an objective distinction between continent and incontinent women. RESULTS: Among all the IUS variables assessed, sliding (calculated as the difference between the distance urethra-bladder neck, U-BN, at rest and under stress) was the best for distinguishing continent and incontinent women. The receiver operating characteristic curves showed that with a threshold of 8 mm, sliding had a sensitivity of 92% and a specificity of 79.6% for detecting SUI due to UH. The distances symphysis-urethra (S-U) and U-BN at rest could also discriminate, but with lower significance. CONCLUSIONS: IUS is an important tool for diagnosing SUI; there are three independent variables, one dynamic (sliding) and two static (distances S-U and U-BN), that can be used to distinguish between continent women and those with SUI due to UH. Sliding is the most reliable, as it has the highest sensitivity and specificity. We think that the simplicity, low financial cost and reliability of IUS could allow it to be a routine procedure for physicians working in incontinence units.