Comparison of the Efficiency of Posterior Intravaginal Sling (PIVS) Procedure in Older and Younger Groups.

INTRODUCTION: Vaginal vault prolapsus is a challenging problem for the patients and physicians. There may be differences between young and elderly patients in terms of efficiency and safety of surgical procedures. AIM: The aim of our study was to compare the efficiency of the Posterior Intravaginal Sling (PIVS) procedure in older versus younger patient groups. MATERIALS AND METHODS: A total of 40 patients who underwent the PIVS procedure were chosen. Twenty of these patients were younger than 60 years of age (Group I) while the other 20 patients were 60 years of age or older (Group II). Preoperative Pelvic Organ Prolapsed Quantification (POP-Q) reference points were compared with postoperative data at the first year following surgery. Student's t-test was used to analyse continuous variables and the χ(2) test was used to analyse categorical data. The Mann-Whitney test was used for data that were not normally distributed. RESULTS: Anatomical cure rates were 90 percent in both groups (p=1.00). There were significantly greater improvements in POP-Q points in group I than group II. CONCLUSION: It could be concluded that PIVS as minimally invasive procedure for vaginal vault prolapsed and is effective in all age groups.

The value of ultrasonographic tubo-ovarian abscess morphology in predicting whether patients will require surgical treatment.

OBJECTIVE: To determine if the ultrasonographic morphology of a tubo-ovarian abscess (TOA) could be used to predict if a patient will require surgical treatment. METHOD: A retrospective cohort study reviewed medical records from patients diagnosed with TOA via ultrasonography between January 2009 and January 2014 at a tertiary referral center in Turkey. Patients with pelvic inflammatory disease and an inflammatory adnexal mass, identified during sonographic examination, were included in the study. Ultrasonographic morphology, demographic characteristics, and clinical and laboratory findings were compared between patients who required surgical treatment and those who did not. RESULTS: Records were included from 164 patients; medical therapy was successful in 121 (73.8%) patients and 43 (26.2%) required surgical treatment. TOA morphology was identified, using ultrasonography, as unilocular cystic, complex multicystic mass, or pyosalpinx in 56 (34.1%), 73 (44.5%), and 35 (21.3%) patients, respectively. No correlation was present between ultrasonographic TOA morphology and patients requiring surgical treatment (all P>0.05). Multivariate analyses demonstrated that an abscess larger than 6.5 cm in size (P=0.027), fever at admission (P<0.001), and parity greater than two (P=0.026) were independent predictors of patients requiring surgical treatment for TOA. CONCLUSION: Although increased TOA size, fever at admission, and parity were associated with increased odds of patients with TOA requiring surgical treatment, ultrasonographic TOA morphology was not.

An overlooked effect of systemic anticholinergics: alteration on accommodation amplitude.

AIM: To investigate the effect of oral solifenacin succinate, tolterodine-L-tartarate and oxybutinin hydrochloride (HCl) on accommodation amplitude. METHODS: Female overactive bladder syndrome (OAB) patients who were planned to use oral anticholinergics, patients that uses solifenacin succinate 5 mg (Group I, n=25), tolterodine-L-tartarate 4 mg (Group II, n=25), and oxybutinin HCl 5 mg b.i.d (Group III, n=25) and age matched healthy female subjects (Group IV, n=25) were recruited and complete ophthalmological examination and accommodation amplitude assessment were done at baseline and 4wk after initiation of treatment. RESULTS: The mean age of 100 consecutive female subjects was 51.6±5.7 (40-60)y and there were no statistically significant difference with regard to the mean age (P=0.107) and baseline accommodation amplitude (P=0.148) between study groups. All treatment groups showed a significant decrease in accommodation amplitude following a 4-week course of anticholinergic treatment (P=0.008 in Group I, P=0.002 in Group II, P=0.001 in Group III), but there was no statistically significant difference in Group IV (P=0.065). CONCLUSION: A 4-week course of oral anticholinergic treatment have statistically significant effect on accommodation amplitude. Clinicians should avoid both overestimating this result, as this would unnecessarily restrict therapeutic possibilities, and also underestimating it which may lead to drug intolerance.

Ocular surface changes following oral anticholinergic use for overactive bladder.

OBJECTIVE: To investigate the effect of oral solifenacin succinate on Schirmer I test results, tear break-up time (TBUT) and Ocular Surface Disease Index (OSDI) scores in overactive bladder (OAB) patients and to compare these results with those of healthy control subjects. MATERIALS AND METHODS: The female OAB patients who were prescribed oral solifenacin succinate 5 mg/day (Group I, N = 80) and age-matched healthy female subjects (Group II, N = 40) were recruited for the study and underwent ophthalmological examination prior to oral treatment and after 4 weeks. They completed the OSDI questionnaire and underwent ocular surface tests including Schirmer I test and TBUT. RESULTS: The statistical analysis of the Schirmer I test and TBUT revealed no significant difference between the baseline and 4th week values in both groups (Group I, p = 0.506 and p = 0.070 consecutively) (Group II, p = 0.810 and p = 0.823 consecutively). OSDI scores were found to be significantly increased in group I (21.8 ± 4.2 vs 23.1 ± 4.6, p = 0.020) and remained unchanged in group II (20.5 ± 7.0 vs 20.7 ± 7.0, p = 0.805). CONCLUSIONS: Short-term solifenacin succinate treatment has no effect on the Schirmer I test results and TBUT, but ocular surface symptoms appeared to be exacerbated in respect with increased OSDI scores. However, the clinical significance needs to be further evaluated with larger studies.

The effect of oral solifenacin succinate treatment on intraocular pressure: glaucoma paradox during overactive bladder treatment.

INTRODUCTION AND HYPOTHESIS: Anticholinergic medication is the mainstay of pharmacotherapy for overactive bladder (OAB). The aim of the study is to investigate the effect of oral solifenacin succinate on intraocular pressure (IOP) in female OAB patients and to discuss the ocular drawbacks during treatment. METHODS: The female patients with a clinical diagnosis of OAB in whom use of oral solifenacin succinate 5 mg/day (group I) and age-matched healthy female subjects (group II) underwent complete ophthalmological examination, including IOP measurement at the beginning of the oral treatment and after 4 weeks. The patients with a history of previous ocular surgery and those with ocular diseases besides refraction disorders and presbyopia were excluded. RESULTS: The data from the right eyes of 60 consecutive patients in group I and 30 consecutive patients in group II were used for analysis. No statistically significant change was detected in the IOP (from 16.05 ± 2.30 mmHg to 16.30 ± 2.25 mmHg at the 4th week in group I, p = 0.160; from 15.60 ± 2.14 mmHg to 15.60 ± 2.09 mmHg at the 4th week in group II, p = 0.864) of the eyes in both groups. CONCLUSIONS: Since the power of the study is not enough to draw a clear conclusion, a 4-week course of solifenacin succinate treatment in women with OAB seemed to have no clinically significant effect on IOP values. Further larger studies are needed to determine the effect of anticholinergics on anterior chamber parameters and to evaluate their safety in glaucoma patients.

Anatomical and functional assessment of anterior colporrhaphy versus polypropylene mesh surgery in cystocele treatment.

OBJECTIVE: To compare the anatomical and functional results of traditional anterior colporrhaphy and polypropylene mesh surgery in cystocele treatment. STUDY DESIGN: Prospective study conducted in the Urogynecology Clinic of Etlik Zubeyde Hanim Maternity and Women's Health Teaching and Research Hospital between June 2006 and February 2007. Forty patients with stage II and III cystocele according to the Pelvic Organ Prolapse Quantification system were allocated by a computer programme to conventional or mesh surgery. Twenty patients each underwent anterior colporrhaphy (group I) or polypropylene mesh (Sofradim(®), Parieten) surgery (group II). Both groups were followed for 12 months. RESULTS: At the end of the 12th month, anatomical cure rates were 15/20 (75%) and 19/20 (95%) in groups I and II, respectively, and the difference between the two groups was statistically significant (p<0.05). De novo stress urinary incontinence developed in one patient in group I. Mesh erosion developed postoperatively in three cases (15%). CONCLUSION: In terms of anatomical cure rates, polypropylene mesh surgery was the more successful treatment option when compared with anterior colporrhaphy at the end of 1 year follow-up.

Is the simple closure technique effective in the treatment of genital fistulas?

Aim. Genitourinary fistulas are bothersome clinical entities not only for the patient but also for the treating surgeon as well. A lot of surgical procedures have been proposed; however, most of the fistulas can be easily treated with plain surgical techniques, such as the simple surgical closure of the fistula tract. Material and Method. The study was carried out in the urogynecology department of Ankara Etlik Zübeyde Hanim Maternity Training and Research Hospital. The study included 12 cases with vesicovaginal fistulas and 15 cases with rectovaginal fistulas. Twenty-six patients underwent simple surgical closure technique. The age, the referral time to the hospital, the longest diameter of the fistula opening, the hospitalization time, the follow-up period and identifiable risk factors of the patients were evaluated. Results. Caeserean section was detected as primary risk factor for vesicovaginal fistulas and prolonged labor was detected as the most important risk factor for rectovaginal fistulas. In our study, we found that the simple closure technique cured 91% of vesicovaginal fistulas and 93% of rectovaginal fistulas. Conclusion. The simple closure technique has very high cure rates for both vesicovaginal and rectovaginal fistulas when the longest diameter of the fistula openings is ≤5 mm.

What is the success of drug treatment in urge urinary incontinence? What should be measured?

PURPOSE: The aim of this study is to evaluate the efficacy and the tolerability of three classic antimuscarinic drugs used in the treatment of over active bladder syndrome using clinical data and quality of life tests, and to evaluate the parameters affecting the success of these drugs. METHODS: A total of 90 patients with urge urinary incontinence were randomly allocated into three groups either to receive tolterodine (group A), trospium chloride (group B) or oxybutynin (group C). Urogenital distress inventory short form (UDI-6) and Incontinence impact questionnaire short form (IIQ-7) of the Turkish Urogynecology and Pelvic Reconstructive Surgery Association were performed to each patient before and after treatment to evaluate the effectiveness and tolerability of the antimuscarinic drugs. Adverse events were also recorded during treatment. RESULTS: Improved urodynamic test values were recorded after 6 weeks of treatment in each group. Similarly, statistically significant differences were observed in UDI-6 and IIQ-7 test scores before and after treatment. Complete cure was achieved in 86 % of patients in group A; however, complete cure rates were 67 and 80 % in group B and C, respectively. Although, patients reported comparable tolerability against trospium chloride (77 %) and tolterodine (80 %), only 23 % of patients using oxybutynin considered the drug as tolerable. The most common side effect was dry mouth, followed by insomnia. Both dry mouth and insomnia was highest in group C (50 %). One patient (0.3 %) in group B and two patients (0.7 %) in group C reported that they did not want to continue to use the drug. CONCLUSION: Antimuscarinic medications are very successful in the treatment of urge urinary incontinence; however, the success of treatment is not only limited to clinical improvement. Patients do not regard a drug as successful unless it is tolerable, easy to adapt to the daily life and improve the quality of life even it has very successful clinical outcomes.

A prospective randomized controlled trial of the transobturator tape and tissue fixation mini-sling in patients with stress urinary incontinence: 5-year results.

PURPOSE: We present the 5-year results of a randomized controlled trial comparing the efficacy of a transobturator tape operation with an adjustable mini-sling (tissue fixation system) for the treatment of stress urinary incontinence. MATERIALS AND METHODS: This prospective randomized controlled trial comprised 80 female patients with only urodynamically proven stress urinary incontinence. The participants were randomly allocated to the transobturator tape group or the tissue fixation system group according to a computer program at a maternity research hospital. The patients were reassessed 5 years after surgery. Primary outcome measures were objective and subjective cure rates as well as total failure rate. RESULTS: Total followup was 64 months (range 58 to 70). The objective cure, subjective cure and failure rates in the tissue fixation system group were 83% (30 cases), 6% (2) and 11% (4), respectively. The objective cure, subjective cure and failure rates in the transobturator tape group were 75% (27 cases), 3% (1) and 22% (8), respectively. The difference in objective cure rates was statistically significant in favor of the tissue fixation system (p = 0.029). The difference in decreased cure rates between 5 and 3 years was 7% (90% to 83%) for the tissue fixation system vs 9% (84% to 75%) for the transobturator tape. The relative decrease in cure rates between the 2 groups was not statistically significant (p = 0.16). CONCLUSIONS: Contrary to reports in the literature of poor results with mini-slings, the tissue fixation system mini-sling demonstrated a higher cure rate and lower complication rate than the transobturator tape.

The comparison of the anatomical and symptomatic outcomes of sacrocolpopexy and posterior intravaginal slingoplasty.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to compare abdominal sacrocolpopexy (ASCP) with posterior intravaginal slingoplasty (PIVS) in terms of lower urinary tract symptoms and anatomical restoration. METHODS: Ninety-two patients underwent PIVS and 98 patients underwent ASCP. RESULTS: Regarding ASCP, the blood loss, operation time, and hospitalization length were 537 ml, 94.5 min, and 3.07 days, respectively. Eight (8) patients required blood transfusion; urinary retention was diagnosed in four cases, surgical side infection was seen in three cases; constipation was a problem in nine cases; retroperitoneal haematoma was observed in one case; and bladder injury happened in two cases. Regarding PIVS, the blood loss, operation time, and hospitalization length were 275 ml, 53 min, and 2.08 days, respectively. Intramuscular haematoma was diagnosed in one patient, and constipation was a problem in one patient. CONCLUSIONS: ASCP and PIVS had same efficiency for the treatment of vault prolapse during the study follow-up. Both operations had good anatomical restoration for rectocele and cystocele. Moreover, PIVS also cured enterocele as an additional advantageous over ASCP. Besides, PIVS has significantly improved stress urinary incontinence, nocturia, and pelvic pain in terms of lower urinary tract symptoms compared to ASCP.

The management of recurrent cases after the Burch colposuspension: 7 years experience.

PURPOSE: We aimed to discuss our approach to the failure cases whose primary surgery was Burch colposuspension. METHODS: Total cases who underwent Burch colposuspension was 298, however, 36 cases lost follow-up therefore the study population was 262 cases. Forty-two patients having recurrent stress urinary incontinence (16.0%) after Burch procedure enrolled for the study. Twenty-nine of the recurrent cases were treated with mid-urethral slings tension-free vaginal tape or transobturator tape (TOT) as a secondary procedure, whereas thirteen of the recurrent cases preferred to take medical therapy. Seven of the failed patients after the repeat surgery accepted TOT as a tertiary procedure. RESULTS: The cumulative cure rates after the secondary and tertiary interventions were 62.1 and 57.1%, respectively. No complications were noticed during the secondary and tertiary surgical interventions. CONCLUSION: Our study showed that suburethral sling surgery can be an effective choice for the treatment of recurrent cases after Burch colposuspension.

The multifilament polypropylene tape erosion trouble: tape structure vs surgical technique. Which one is the cause?

This study was designed to clarify whether the structure of multifilament tape or the surgical technique is associated with vaginal erosions. Patients were randomized into two groups: in group 1, formed from the patients who were operated with the technique "setting the tape loosely leaving a scissor tip gap between the tape and the urethra," and in group 2, formed from the patients who were operated with the technique "setting the tape actually touched the urethra and covering the tape by the adjacent pubocervicovaginal fascia with the aid of a suture." After 4-year follow-up, it was found that the erosion rate was very high in group 1 (13.6%). We conclude that the high erosion rate seen in multifilament tapes is associated with the surgical technique that is used, not the structure of the multifilament tape.

How does a concomitant surgery effect the outcomes of Burch colposuspension?

AIM: To evaluate the outcomes of 90 Burch colposuspension procedures with or without concomitant surgery after a 6-year follow-up period. METHODS: The study was carried out in the urogynecology department of Ankara Etlik Women's and Maternity Teaching Hospital, Turkey. Ninety women who were diagnosed as having genuine stress urinary incontinence (GSI) were enrolled in this study. The Burch colposuspension procedure was performed for the treatment of genuine stress urinary incontinence with or without a concomitant surgery RESULTS: After a 6-year follow-up, it has been noted that concomitant surgeries have no effect on the outcome of continence (P>0.05). Pelvic prolapse incidence was 7%. No voiding difficulty was observed. CONCLUSION: The study shows that concomitant surgeries have no effect on the outcome of continence. However, concomitant surgery can increase operational morbidity. Modified McCall culdoplasty does not seem to be a preventive measure for pelvic organ prolapse.

Extremely skewed X-chromosome inactivation is increased in pre-eclampsia.

Pre-eclampsia is a disorder that affects approximately 5% of pregnancies. We tested the hypothesis that skewed X-chromosome inactivation (XCI) could be involved in the pathogenesis of pre-eclampsia. Peripheral blood DNA was obtained from 67 pre-eclampsia patients and 130 control women. Androgen receptor (AR) was analyzed by the HpaII/polymerase chain reaction assay to assess XCI patterns in DNA extracted from peripheral-blood cells. In addition, buccal cells were obtained from seven patients, and the analysis repeated. Extremely skewed XCI was observed in 10 of 46 informative patients (21.74%), and in 2 of 86 informative controls (2.33%, P = 0.0005; chi(2) test). Our findings support a role for the X-chromosome in the pathogenesis of pre-eclampsia in a subgroup of patients.

A randomized comparison of transobturator tape and Burch colposuspension in the treatment of female stress urinary incontinence.

This study was performed to compare the efficacy of transobturator tape (TOT) and Burch colposuspension in the treatment of female stress urinary incontinence (SUI). This is a prospective randomized single blind study of 100 women diagnosed as with urodynamic SUI who were randomized either to TOT procedure (n = 49) or Burch procedure (n = 51). The outcome was evaluated at 1 and 2 years. The mean operation time and hospital stay were significantly shorter in the TOT group compared to Burch group (p < 0.001). Procedure-related complications and postoperative voiding problems including postoperative urinary retention, de novo voiding difficulties and de novo urge incontinence were similar in the two groups. Both the subjective and objective cure rates of SUI at 1 year were 85.7 and 87.5%, respectively, in the TOT group. This was similar to subjective and objective cure rates at one year of 84.3% (p = 0.8) and 80.3% (p = 0.4) in the Burch group, respectively. At the end of 2 years, 32 patients were available in the TOT group and 31 patients were available in the Burch group for analysis. Both the subjective and objective cure rates of SUI at 2 years were 87.5 and 87.5% in the TOT group which was similar to the 87% (p = 0.9) and 83.8% (p = 0.6) in the Burch group, respectively. TOT procedure results in similar cure rates of SUI at 1 and 2 years compared to Burch procedure. The TOT procedure has a shorter operative time and length of hospital stay.

Posterior sling (infracoccygeal sacropexy): an alternative procedure for vaginal vault prolapse.

This study of 30 patients evaluated the effectiveness and safety of the posterior sling (infracoccygeal sacropexy) in the surgical treatment of vaginal vault prolapse. The patients were reevaluated 3 months, 6 months and yearly postoperatively. Coexisting preoperative symptoms of pelvic pain, urgency, nocturia and 'obstructed' micturition feeling were followed-up. There was remarkable improvement in vault prolapse and in coexisting symptoms.

Random urine protein-creatinine ratio to predict proteinuria in new-onset mild hypertension in late pregnancy.

OBJECTIVE: The aim of this study was to evaluate the diagnostic accuracy of random urine protein-creatinine ratio for prediction of significant proteinuria (> or = 300 mg/24 h) in patients with new-onset mild hypertension in late pregnancy. METHODS: Medical records of 185 consecutive pregnant patients with new onset of mild hypertension in late pregnancy were reviewed. Random urine samples were taken before 24-hour urine collection. The predictive values of the random urine protein-creatinine ratio for diagnosis of significant proteinuria were estimated by using at least a 300-mg protein level within the collected 24-hour urine as the gold standard. RESULTS: Thirty-nine patients (21%) had significant proteinuria. There was a significant association between 24-hour protein excretion and the random urine protein-creatinine ratio (rs = 0.56, P <.01). With a cutoff protein-creatinine ratio greater than 0.19 as a predictor of significant proteinuria, sensitivity and specificity were 85% and 73%, respectively. Positive and negative predictive values of the test were 46% and 95%, respectively. CONCLUSION: The random urine protein-creatinine ratio was a poor predictor for significant proteinuria in patients with new-onset mild hypertension in late pregnancy.

Multinodular hydropic leiomyoma of the uterus with perinodular hydropic degeneration and extrauterine extension.

Multinodular hydropic leiomyoma (MHL) of the uterus is one of the rarest variants of uterine leiomyomas and can create some diagnostic problems. Only five cases have been reported previously. We describe an MHL with perinodular hydropic degeneration in a 48-year-old woman. Gross examination revealed a large and predominantly intramural, edematous multinodular uterine tumor and extrauterine, small grape-like nodules overlying the lateral surface of the uterine serosa. Histologically, the tumor was composed of extra-intrauterine benign, small smooth muscle nodules with perinodular hydropic degeneration, prominent intramural dissecting growth pattern, and satellite nodules closely resembling vascular invasion. Immunohistochemically, these cells stained for desmin, smooth muscle actin and vimentin. The patient had no evidence of disease for 18 months after hysterectomy. Multinodular hydropic leiomyoma is a clinically benign tumor and should not be confused with intravenous leiomyomatosis and some other unusual leiomyoma variants.