Protective effect of suburethral slings on postoperative cystocele recurrence after reconstructive pelvic operation.

OBJECTIVE: The purpose of this study was to evaluate the independent effect of suburethral sling placement on the risk of cystocele recurrence after pelvic reconstructive operation. STUDY DESIGN: One hundred forty-eight women with cystoceles to or beyond the hymenal ring underwent pelvic reconstructive operation, with or without incontinence procedures, and were evaluated at 12 and 52 weeks after operation with a standardized pelvic examination. Rates of recurrent prolapse, at all sites, were statistically compared between subjects with and without suburethral slings. A multiple regression analysis was used to determine the independent effect of sling placement on the risk of recurrent cystoceles. RESULTS: Suburethral sling placement was associated with a 54.8% reduction in the mean rate of postoperative cystocele recurrence (P =.004). This protective effect was observed as early as 12 weeks and remained significant at 1-year follow up (42% vs 19%). A markedly reduced risk of cystocele recurrence was observed when women with sling procedures were compared with all other women, with those women who underwent other incontinence operations, and even with those women who had undergone prolapse repair with no incontinence procedure. The protective effect of the sling procedure remained highly significant (odds ratio, 0.29; P =.0003), even after controlling for potentially confounding variables in a multiple logistic regression model. CONCLUSION: Suburethral sling procedures appear to significantly reduce the risk of cystocele recurrence after pelvic reconstructive operation, in contrast with the effect of retropubic urethropexy and needle suspensions. These findings should be considered when the surgical treatment of stress incontinence that accompanies pelvic organ prolapse is being planned.

Protective effect of vitamin E on the response of the rabbit bladder to partial outlet obstruction.

PURPOSE: There is increasing evidence that ischemia/reperfusion is a major etiological factor in the progression of bladder dysfunction after partial outlet obstruction. If this evidence is correct, treatment with an antioxidant should be beneficial in rabbits subjected to partial outlet obstruction. We designed the current study to determine if diets high in alpha-tocopherol protected the rabbit bladder against dysfunction induced by partial outlet obstruction. MATERIALS AND METHODS: A total of 32 rabbits were separated into 4 groups of 8. Groups 1 and 2 were placed on a diet enriched with 1,000 IU/kg. alpha-tocopherol, and groups 3 and 4 were fed a regular diet containing 44 IU/kg. alpha-tocopherol. After 4 weeks partial outlet obstruction was created in groups 1 and 3, while groups 2 and 4 underwent sham operation. After 4 weeks of obstruction the rabbits were anesthetized and the bladders were rapidly excised. Four longitudinal strips obtained from the bladder body were used for contractility studies. The balance of the bladder body was separated between muscle and mucosa. Each section was frozen and stored at -70C for analysis of malondialdehyde as a measure of peroxidation and for alpha-tocopherol concentrations. RESULTS: Feeding rabbits a diet high in alpha-tocopherol resulted in significant protection against the development of contractile dysfunction after partial outlet obstruction. The protective effect of alpha-tocopherol was related to significantly decreased malondialdehyde and significantly increased tissue concentrations of alpha-tocopherol. CONCLUSIONS: These data indicate that a major etiology of bladder dysfunction secondary to partial outlet obstruction is related to free radical generation and resultant membrane lipid peroxidation.

Prospective randomized trial of polyglactin 910 mesh to prevent recurrence of cystoceles and rectoceles.

OBJECTIVE: Our aim was to evaluate the efficacy of polyglactin 910 mesh in preventing recurrent cystoceles and rectoceles. STUDY DESIGN: In a prospective, randomized, controlled trial, patients undergoing vaginal reconstructive surgery with cystoceles to the hymenal ring and beyond were randomly selected to undergo anterior and posterior colporrhaphy with or without polyglactin 910 mesh reinforcement. Results were evaluated preoperatively and at 2, 6, 12, and 52 weeks postoperatively. RESULTS: A total of 161 women were randomly selected for this study. One woman was excluded at the time of surgery, and 17 women were lost to follow-up. Eighty women received mesh, and 80 did not. Both groups were found to be equivalent with respect to age, parity, concomitant surgery, and menopausal and hormone replacement status. Preoperatively 49 women had a central cystocele to the hymenal ring and 111 women had cystoceles beyond the introitus; 91 women had a rectocele to the mid-vaginal plane, 31 to the hymenal ring, and 22 beyond the introitus. After 1 year, 30 (43%) of 70 subjects without mesh and 18 (25%) of 73 subjects with mesh had recurrent cystoceles beyond the mid-vaginal plane (P =.02). Eight women without mesh and 2 women with mesh had recurrent cystoceles to the hymenal ring (P =.04). No recurrent cystoceles beyond the hymenal ring occurred in either group. Multivariate logistic regression analysis showed concurrent slings to be associated with significantly fewer recurrent cystoceles (odds ratio, 0.32; P =.005), whereas the presence of mesh remained significantly predictive of fewer cystocele recurrences in this analysis. Thirteen recurrent rectoceles were noted 1 year postoperatively, with no differences between groups. CONCLUSION: Polyglactin 910 mesh was found to be useful in the prevention of recurrent cystoceles.

Incisional hernia after suprapubic catheterization.

BACKGROUND: Suprapubic catheterization is a popular method of bladder drainage after gynecologic surgery. We report two cases of incisional hernia that developed after suprapubic catheterization. CASES: The first case involved a 64-year-old woman who underwent Burch urethropexy. Her suprapubic catheter was not removed until postoperative day 55 because of prolonged retention. She presented 1 month later with abdominal pain. In the second case, a 65-year-old woman had vesicovaginal fistula repair with suprapubic catheterization for 2 weeks after surgery. Five months later, she presented with abdominal pain. In both cases, examination revealed a hernia at the catheter exit site. CONCLUSION: Incisional hernia is a rare complication of suprapubic catheterization that should be considered in patients who present with abdominal discomfort some time after catheterization.

Long-term results of laparoscopic Burch urethropexy.

STUDY OBJECTIVE: To evaluate the long-term efficacy of laparoscopic Burch urethropexy. DESIGN: Pilot study. SETTING: Private practice. PATIENTS: Thirty-five consecutive women (average age 45.5 yrs, average parity 2.3, average weight 67.7 kg) treated for genuine stress incontinence between May 1992 and July 1994. INTERVENTIONS: Urethropexy was performed with curved needle suturing in 7 women, straight needle suturing in 5, and Stamey needle suturing in 23. Twenty-five (71.4%) patients had concomitant pelvic surgery. MEASUREMENTS AND MAIN RESULTS: Wilcoxon two-sample, chi2, and Fisher's exact tests were performed to determine which variables were significantly associated with surgical success. Average operating time was 190 minutes, hospitalization 24 hours, and catheterization 5 days. The cure rate of stress incontinence was 89% 3 months and 86% 1 year after surgery. At average follow-up of 34 months, only 68.6% of patients reported complete or almost complete cure, 11.4% were improved, and 20% were complete failures. The only operative variable approaching statistical significance for predicting surgical success was type of suture needle (p = 0.07), with the Stamey needle group having the highest cure rate. Women who were cured or almost cured had a significantly shorter follow-up than those who were improved or failures (p = 0.001). CONCLUSION: The success rate of laparoscopic Burch urethropexy compares with that of open Burch procedure at 1 year, but drops considerably thereafter.

The PIE-1 protein and germline specification in C. elegans embryos.

Totipotent germline blastomeres in Caenorhabditis elegans contain, but do not respond to, factors that promote somatic differentiation in other embryonic cells. Mutations in the maternal gene pie-1 result in the germline blastomeres adopting somatic cell fates. Here we show that pie-1 encodes a nuclear protein, PIE-1, that is localized to the germline blastomeres throughout early development. During division of each germline blastomere, PIE-1 initially associates with both centrosomes of the mitotic spindle. However, PIE-1 rapidly disappears from the centrosome destined for the somatic daughter, and persists in the centrosome of the daughter that becomes the next germline blastomere. The PIE-1 protein contains potential zinc-finger motifs also found in the mammalian growth-factor response protein TIS-11/NUP475 (refs 4-7). The localization and genetic properties of pie-1 provide an example of a repressor-based mechanism for preserving pluripotency within a stem cell lineage.

The empty supine stress test as a predictor of intrinsic urethral sphincter dysfunction.

OBJECTIVE: To assess the usefulness of a proposed test for intrinsic urethral sphincter dysfunction. METHODS: Subjects were included in the study if they had complaints of incontinence, did not have substantial pelvic prolapse, and had undergone multichannel urodynamic testing. The initial evaluation involved uroflowmetry, catheterized residual urine, history, urogenital examination, and a cough stress test within 20 minutes after catheterization. Standardized multichannel urodynamic testing was performed at a follow-up appointment. Test indices were calculated based on the result of the empty supine stress test, the presence of genuine stress incontinence, and maximum urethral closure pressures. RESULTS: Three hundred four women met the inclusion criteria; 124 had a positive empty supine stress test and 180 had a negative test. Genuine stress incontinence was diagnosed in 238 subjects. A positive empty supine stress test was found to have 70% sensitivity and 90% negative predictive value for detecting very low urethral closure pressures, and 98% positive predictive value for genuine stress incontinence; in low-risk populations, the test had 95% negative predictive value for excluding urethral dysfunction. CONCLUSION: The empty supine stress test is easy to perform, inexpensive, and without significant risk. By itself, a positive empty supine stress test is essentially diagnostic for genuine stress incontinence, and in combination with a fixed urethra, it is diagnostic for intrinsic urethral sphincter dysfunction. In low-prevalence populations, a negative test reliably excludes the presence of intrinsic urethral sphincter dysfunction. However, for high-prevalence and referral populations, the low predictive values of the test limit its usefulness.

Measles during the Gulf War: a public health threat in Israel, the West Bank, and Gaza.

A measles outbreak began in Ramallah District in the West Bank in the period just before the outbreak of the Gulf War in 1991. After a local control program, the outbreak was contained to a total of 236 reported cases, including one death, but sporadic cases appeared over the ensuing months. An epidemic of measles followed 2-3 weeks later in Beer Sheva district in Israel, initially among the Bedouin population just prior to the outbreak of the war, then spreading to the Jewish population. The epidemic reached its peak during the war in February, continuing into March. There were a total of over 433 reported cases, with 203 hospitalizations and 7 deaths. The epidemic was slowed by curtailment of school and other civilian activities, and a mass vaccination campaign reaching 60,000 children, but was spread by crowded conditions in hospital, and was spread to other parts of the country by internal population migration. An epidemic of a preventable disease occurring during a national emergency adds to the burdens of the health system. The public health system must be prepared to contain epidemics and other public health threats in wartime, employing standard control methods developed and practiced during peacetime. Routine immunization policies should take into account the possibility of a civilian epidemic during national emergencies, and the need to assure protection of both the civilian and military population in preparation for such contingencies.

Citation analysis of the field of medical decision making: update, 1959-1985.

This article updates a prior citation analysis of medical decision making, published in this journal in 1984. Building on the original core list, decision making papers were added based on any of three criteria: citation of three papers already on the list, identification by a MEDLINE search (CATLINE for books) as relevant to the topic, or mention in a recent review article on decision analysis. The revised core list contains 105 articles and five books. The changes in the field of medical decision making from 1978 to 1981 are reviewed, and key areas of development are identified by co-citation clustering.