Influence of contraceptive choice on vaginal bacterial and fungal microflora.

The influence of contraception on vaginal microflora can have a major impact on the risk of developing acute or recurrent vaginal infections, but also may influence the risk of acquiring sexually transmissible infections (STI) such as HIV. A cohort of 248 women presenting for levonorgestrel-releasing intrauterine system (LNG-IUS) insertion or reinsertion were stratified according to their current contraceptive method. Information concerning their menstrual pattern and data about the medical history were collected. The composition of their vaginal microflora was studied by detailed phase contrast microscopy of fresh vaginal fluid, and aerobic cultures were taken to detect enteric bacterial growth and fungal colonisation. LNG-IUS and progesterone-only-pill (POP) users had significantly lower blood loss (p < 0.001) than other women. Regardless of the type of contraception used, all women reported similar rates of symptomatic lower genital tract infection during the preceding year. Women using combined oral contraception (COC) and long-term LNG-IUS had the same bacterial composition of vaginal microflora as non-contraceptive users, even when infections were combined. Both hormonal and non-hormonal intrauterine device users had an increased tendency to have more vaginal colonisation with Candida. Women on POPs or subcutaneous implants had a tendency towards increased vaginal atrophy, but had a lower Candida carriage rate compared to IUCD users (LNG-IUS and Copper-IUCD, p = 0.037). Women with an increased risk of acquiring STIs or recurrent BV could benefit from LNG-IUS or COC due to a well-preserved vaginal bacterial flora. Women with a susceptibility for RVVC should prefer POPs, and avoid intrauterine contraception.

Strategies to optimize the performance of Robotic-assisted laparoscopic hysterectomy.

A hybrid technique of robot-assisted, laparoscopic hysterectomy using the ENSEAL(®) Tissue Sealing Device is described in a retrospective, consecutive, observational case series. Over a 45 month period, 590 robot-assisted total laparoscopic hysterectomies +/- oophorectomy for benign and malignant indications were performed by a single surgeon with a bedside assistant at a tertiary healthcare center. Patient demographics, indications for surgery, comorbidities, primary and secondary surgical procedures, total operative and surgical time, estimated blood loss (EBL), length of stay (LOS), complications, transfusions and subsequent readmissions were analyzed. The overall complication rate was 5.9% with 35 patients experiencing 69 complications. Mean (SD) surgery time, operating room (OR) time, EBL, and LOS for the entire cohort were 75.5 (39.42) minutes, 123.8 (41.15) minutes, 83.1 (71.29) millilitres, and 1.2 (0.93) days, respectively. Mean surgery time in the first year (2009) was 91.6 minutes, which declined significantly each year by 18.0, 19.0, and 24.3 minutes, respectively. EBL and LOS did not vary -significantly across the entire series. Using the cumulative sum method, an optimization curve for surgery time was evaluated, with three distinct optimization phases observed. In summary, the use of an advanced laparoscopic tissue-sealing device by a bedside surgical assistant provided an improved operative efficiency and reliable vessel sealing during robotic hysterectomy.

Total transvaginal mesh (TVM) technique for treatment of pelvic organ prolapse: a 5-year prospective follow-up study.

INTRODUCTION AND HYPOTHESIS: To evaluate clinical effectiveness and complication rates at 5 years following the total Trans Vaginal Mesh (TVM) technique to treat pelvic organ prolapse. METHODS: Prospective, observational, multi-centre study in patients with prolapse of stage II or higher. RESULTS: Of the 90 women enrolled in the study, 82 (91%) were available for the 5-year follow-up period. At the 5-year endpoint, success, defined as no surgical prolapse reintervention and leading edge <-1 (International Continence Society [ICS] criteria) or above the level of the hymen, was 79% and 87% respectively. A composite criterion of success defined as: leading edge above the hymen (<0) and no bulge symptoms and no reintervention for prolapse was met by 90%, 88% and 84% at the 1-, 3-, and 5-year endpoints respectively. Quality of life improvement was sustained over the 5 years. Over the 5-year follow-up period, a total of only 4 patients (5%) required re-intervention for prolapse, while a total of 14 patients (16%) experienced mesh exposure for which 8 resections needed to be performed. Seven exposures were still ongoing at the 5-year endpoint, all asymptomatic. Only 33 out of 61 (54%) sexually active patients at baseline remained so at 5 years. De novo dyspareunia was reported by 10%, but no new cases at the 5-year endpoint. One patient reported de novo unprovoked mild pelvic pain at 5 years, 5 reported pains during pelvic examination only. CONCLUSIONS: Five-year results indicated that TVM provided a stable anatomical repair. Improvements in QOL and associated improvements in prolapse-specific symptoms were sustained. Minimal new morbidity emerged between the 1- and 5-year follow-up.

A novel radiographic technique to asses grafts in the female -pelvis: a comparison of the Inside-Out and the Outside-In trans-obturator mid urethral sling positioning.

UNLABELLED: The three-dimensional configuration of mid-urethral sling tapes is difficult to demonstrate in traditional anatomical dissections or imaging studies. The aim of this study was to test the utility of a novel technique using mesh tapes to assess spatial differences between the in-out and out-in transobturator mid-urethral slings. Two independent surgeons performed their usual transobturator mid-urethral sling placement on 10 fresh thawed cadavers, alternating sides in the consecutive cadavers. Tantalum wires threaded through the polypropylene-tapes rendered them radio-opaque. Following placement, CT scans were obtained to generate 3-D and MIPS images for analysis. Results showed that the mean angle formed by the in-out sling measured 122º (95%CI: 107º-136º); versus 144º (95%CI: 131º-151º) for the out-in sling (p = 0.02). The paired differences between the tapes' inner angles were significantly different; with a mean difference of 20º (median 19.0º), (p = 0.008). There was no significant correlation between either approach and BMI or angle of the pubic arch. The images revealed that the tapes lie as a band posterior/dorsal to the urethra rather than inferior. IN CONCLUSION: marking mesh with -Tantalum wire, in combination with 3-D and MIPS CT-scan reconstruction images, provided a unique method to visualize the entire sling trajectory. The clinical implications of the more horizontal positioning after the out-in approach remain to be determined.

Medium-term clinical outcomes following surgical repair for vaginal prolapse with tension-free mesh and vaginal support device.

INTRODUCTION AND HYPOTHESIS: This study was designed to evaluate clinical outcomes ≥2 years following surgery with polypropylene mesh and vaginal support device (VSD) in women with vaginal prolapse, in a prospective, multi-center setting. METHODS: Patients re-consented for this extended follow-up (n = 110), with anatomic evaluation using Pelvic Organ Prolapse Quantification (POP-Q) and validated questionnaires to assess pelvic symptoms and sexual function. Complications were recorded (safety set; n = 121). RESULTS: Median length of follow-up was 29 months (range 24-34 months). The primary anatomic success, defined as POP-Q 0-I, was 69.1%; however, in 84.5% of the cases, the leading vaginal edge was above the hymen. Pelvic symptoms and sexual function improved significantly from baseline (p < 0.01). Mesh exposure rate was 9.1%. Five percent reported stress urinary incontinence and 3.3% required further prolapse surgery. CONCLUSION: These results indicate this non-anchored mesh repair is a safe and effective treatment for women with symptomatic vaginal prolapse in the medium term.

The effect of antifungal treatment on the vaginal flora of women with vulvo-vaginal yeast infection with or without bacterial vaginosis.

Antibacterial therapy may enhance the risk of symptomatic vulvo-vaginal candidosis in susceptible women. We addressed the question whether oral antifungal treatment for vulvo-vaginal candidosis also influences the bacterial vaginal microflora. One hundred and forty-two patients with a culture-proven acute episode of recurrent vulvo-vaginal candidosis (RVC) were treated with fuconazole according to the ReCiDiF regimen (induction dose of 600 mg orally per week followed by 200 mg per week) or with a single dose of 200 mg pramiconazole, a new potent oral triazole. At inclusion, 1 week and 1 month after the end of antifungal treatment, the bacterial microflora was assessed by microscopy of vaginal fluid to detect lactobacillary grades and bacterial vaginosis (BV). The presence of BV was studied in these patients with vulvo-vaginal candidosis after treatment with antifungal medication. At the start of oral antifungal treatment, 6.3% of women with Candida were co-infected with BV. Of the BV-negative women, 10 out of 133 (8%) developed BV after 1 week and after 1 month 8 of them (7%) were still BV-positive. Although no patients received antibacterial treatment at any moment of the study, 6 out of 9 (66%) of the women with Candida and BV at inclusion no longer had BV 1 week after antifungal treatment and 6 out of 7 (86%) lacked BV after 1 month. Treatment with antifungals may have a beneficial effect on women with concurrent BV, but does not prevent BV from occurring in BV-negative women with Candida vaginitis.

The Posterior Intravaginal Slingplasty treatment for apical prolapse: 3 years experience in a single centre setting.

AIM: To assess the anatomic effectiveness and complications of the Posterior IVS technique for the treatment of pelvic organ prolapse over a period of 3 years. METHODS: A retrospective, single-arm, non-comparative study involving routine, standardised, pre-operative assessment, surgery and follow-up care using the Pelvic Organ Prolapse Quantifications score at 1, 2 and 3 years was performed. The Posterior IVS technique was performed in patients with a symptomatic grade 2 or greater prolapse of the apical compartment (i.e. point C and/or D ≥ -1). Concomitant prolapse procedures were allowed. RESULTS: Twenty-nine consecutive patients underwent a Posterior IVS suspension over a period of 2 years. Ninety -percent (26/29) of patients required a concomitant prolapse procedure (79% an anterior and 55% a posterior vaginal wall repair). No serious peroperative complications, bladder injuries or rectal perforations were encountered. Overall anatomical success rates (

Undescended ovary and unicornuate uterus: simplified diagnosis by the use of clomiphene citrate ovarian stimulation and magnetic resonance imaging (MRI).

BACKGROUND: Although the association between unicornuate uterus and undescended ovaries is well established, little information is available on this entity, suggesting the possibility that many cases are not recognized at all. Consequently, important clinical information is missed in many patients worldwide. METHODS: During a period of 5 years, eight cases of unicornuate uterus were observed in our infertility clinic. The first three patients received magnetic resonance imaging (MRI) after mild clomiphene citrate (CC) stimulation due to a discrepancy between estradiol levels and follicular growth and because a suspected ectopic ovary could not be visualized on ultrasound. Based on this experience, five consecutive patients were offered MRI after CC stimulation as part of this study. RESULTS: In five out of eight patients with unicornuate uterus (62.5%) an undescended ovary could be visualized in the upper abdomen. Abdominal ultrasound revealed the ectopic ovary in only two cases. The use of CC stimulation undoubtedly facilitated the diagnosis of the undescended ovary on MRI. CONCLUSION: It is suggested that MRI after CC stimulation is an excellent non-invasive method to diagnose undescended ovaries in women with a unicornate uterus.

Endometrial ossification and infertility: the diagnostic value of different imaging techniques.

We present a case of longstanding secondary subfertility caused by endometrial ossification. Of all diagnostic techniques performed, magnetic resonance imaging and hysterosalpingography did not detect the abnormality. Transvaginal ultrasound and computed tomography clearly showed the endometrial pathology. After successful operative hysteroscopy with removal of the osseous tissue, the patient became pregnant spontaneously within 2 months.