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Uterine Prolapse [keywords]
- [Etiological study of pelvic organ prolapse and stress urinary incontinence with collagen status and metabolism]. [English Abstract, Journal Article]
- Zhonghua Yi Xue Za Zhi 2013 Feb 19; 93(7):500-3.
To explore the alteration of collagen ultrastructure and content in uterine ligaments and paraurethral tissue and explore whether the alteration may contribute to stress urinary incontinence (SUI) and pelvic organ prolapse (POP).The cardinal ligament, uterosacral ligament and paraurethral tissue samples were obtained from 90 subjects undergoing hysterectomy. Collagen ultrastructure was examined with transmission electron microscopy. And collagen content and expression of vasoactive intestinal peptide (VIP) were examined with immunohistochemisty.The smooth muscle fascicles were thinner in the patients of SUI and POP. Arrangement of smooth muscle fascicles was disorderly. Fiberoblast was metabolically active. The mean collagen fibril diameters in the SUI and POP groups were larger than that in the control group (P < 0.01). The mean contents of collagen I and III in the SUI and POP groups were lower than that in the control group (P < 0.01). The expression of VIP was lower (P < 0.05).Predominance of collagen degradation during tissue repair may contribute to and promote POP and SUI. The decrease of VIP might be related with nerve damage or degeneration to cause or accelerate the progress of pelvic organ prolapse.
- Surgical management of pelvic organ prolapse in women. [Journal Article]
- Cochrane Database Syst Rev 2013.:CD004014.
Pelvic organ prolapse may occur in up to 50% of parous women. A variety of urinary, bowel and sexual symptoms may be associated with the prolapse.To determine the effects of the many different surgeries used in the management of pelvic organ prolapse.We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In Process and handsearching of journals and conference proceedings, healthcare-related bibliographic databases, handsearched conference proceedings (searched 20 August 2012), and reference lists of relevant articles. We also contacted researchers in the field.Randomised or quasi-randomised controlled trials that included surgical operations for pelvic organ prolapse.Trials were assessed and data extracted independently by two review authors. Six investigators were contacted for additional information with five responding.Fifty-six randomised controlled trials were identified evaluating 5954 women. For upper vaginal prolapse (uterine or vault) abdominal sacral colpopexy was associated with a lower rate of recurrent vault prolapse on examination and painful intercourse than with vaginal sacrospinous colpopexy. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living and increased cost of the abdominal approach. In single studies the sacral colpopexy had a higher success rate on examination and lower reoperation rate than high vaginal uterosacral suspension and transvaginal polypropylene mesh.Twenty-one trials compared a variety of surgical procedures for anterior compartment prolapse (cystocele). Ten compared native tissue repair with graft (absorbable and permanent mesh, biological grafts) repair for anterior compartment prolapse. Native tissue anterior repair was associated with more recurrent anterior compartment prolapse than when supplemented with a polyglactin (absorbable) mesh inlay (RR 1.39, 95% CI 1.02 to 1.90) or porcine dermis mesh inlay (RR 2.08, 95% CI 1.08 to 4.01), however there was no difference in post-operative awareness of prolapse after absorbable mesh (RR 0.96, 95% CI 0.33 to 2.81) or a biological graft (RR 1.21, 95% CI 0.64 to 2.30). Data on morbidity and other clinical outcomes were lacking. Standard anterior repair was associated with more anterior compartment prolapse on examination than for any polypropylene (permanent) mesh repair (RR 3.15, 95% CI 2.50 to 3.96). Awareness of prolapse was also higher after the anterior repair as compared to polypropylene mesh repair (28% versus 18%, RR 1.57, 95% CI 1.18 to 2.07). However, the reoperation rate for prolapse was similar at 14/459 (3%) after the native tissue repair compared to 6/470 (1.3%) (RR 2.18, 95% CI 0.93 to 5.10) after the anterior polypropylene mesh repair and no differences in quality of life data or de novo dyspareunia were identified. Blood loss (MD 64 ml, 95% CI 48 to 81), operating time (MD 19 min, 95% CI 16 to 21), recurrences in apical or posterior compartment (RR 1.9, 95% CI 1.0 to 3.4) and de novo stress urinary incontinence (RR 1.8, 95% CI 1.0 to 3.1) were significantly higher with transobturator meshes than for native tissue anterior repair. Mesh erosions were reported in 11.4% (64/563), with surgical interventions being performed in 6.8% (32/470).Data from three trials compared native tissue repairs with a variety of total, anterior, or posterior polypropylene kit meshes for vaginal prolapse in multiple compartments. While no difference in awareness of prolapse was able to be identified between the groups (RR 1.3, 95% CI 0.6 to 1.7) the recurrence rate on examination was higher in the native tissue repair group compared to the transvaginal polypropylene mesh group (RR 2.0, 95% CI 1.3 to 3.1). The mesh erosion rate was 35/194 (18%), and 18/194 (9%) underwent surgical correction for mesh erosion. The reoperation rate after transvaginal polypropylene mesh repair of 22/194 (11%) was higher than after the native tissue repair (7/189, 3.7%) (RR 3.1, 95% CI 1.3 to 7.3).Data from three trials compared posterior vaginal repair and transanal repair for the treatment of posterior compartment prolapse (rectocele). The posterior vaginal repair had fewer recurrent prolapse symptoms (RR 0.4, 95% CI 0.2 to 1.0) and lower recurrence on examination (RR 0.2, 95% CI 0.1 to 0.6) and on defecography (MD -1.2 cm, 95% CI -2.0 to -0.3).Sixteen trials included significant data on bladder outcomes following a variety of prolapse surgeries. Women undergoing prolapse surgery may have benefited from having continence surgery performed concomitantly, especially if they had stress urinary incontinence (RR 7.4, 95% CI 4.0 to 14) or if they were continent and had occult stress urinary incontinence demonstrated pre-operatively (RR 3.5, 95% CI 1.9 to 6.6). Following prolapse surgery, 12% of women developed de novo symptoms of bladder overactivity and 9% de novo voiding dysfunction.Sacral colpopexy has superior outcomes to a variety of vaginal procedures including sacrospinous colpopexy, uterosacral colpopexy and transvaginal mesh. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living, and increased cost of the abdominal approach.The use of mesh or graft inlays at the time of anterior vaginal wall repair reduces the risk of recurrent anterior wall prolapse on examination. Anterior vaginal polypropylene mesh also reduces awareness of prolapse, however these benefits must be weighted against increased operating time, blood loss, rate of apical or posterior compartment prolapse, de novo stress urinary incontinence, and reoperation rate for mesh exposures associated with the use of polypropylene mesh.Posterior vaginal wall repair may be better than transanal repair in the management of rectocele in terms of recurrence of prolapse. The evidence is not supportive of any grafts at the time of posterior vaginal repair. Adequately powered randomised, controlled clinical trials with blinding of assessors are urgently needed on a wide variety of issues, and they particularly need to include women's perceptions of prolapse symptoms. Following the withdrawal of some commercial transvaginal mesh kits from the market, the generalisability of the findings, especially relating to anterior compartment transvaginal mesh, should be interpreted with caution.
- LigaSure vessel sealing system in vaginal hysterectomy: safety, efficacy and limitations. [JOURNAL ARTICLE]
- Arch Gynecol Obstet 2013 Apr 27.
PURPOSE:The aim of this study is to compare vaginal hysterectomy performed with standard technique versus the one performed with LigaSure.
METHODS:Observational-longitudinal-cohort study on 42 women candidates to vaginal hysterectomy because of benign uterine pathology. Outcome variables, methods of analysis, inclusion and exclusion criteria were determined prospectively. Eligible patients were subdivided in Group-A (LigaSure-21 patients), or in Group-B (classical-21 patients). Group-A was divided into Subgroup-A1 (10 patients) and Subgroup-A2 (11 patients), depending on the point where the stump of the uterosacral-ligament was transfixed: Subgroup-A1 at cervical portion, Subgroup-A2 at intermediate portion. For all patients were reported: pre-post surgery haemoglobin and hematocrit, number of sutures, duration of intervention and blood loss, NRS-score on first/third post-operative days. All patients underwent gynaecological examination 30 and 180 days after surgery.
RESULTS:General characteristics did not show significant differences between the two groups. Statistically significant differences emerged from the comparison between Group-A versus Group-B in terms of: intraoperative bleeding, post-operative value of haemoglobin, Δ-Hb, number of sutures, surgical time, pain at first and third post-operative day. The 180 days follow-up demonstrated four cases of vaginal vault prolapse, only in the Subgroup-A1 related to thermal damage of the uterosacral ligament.
CONCLUSION:LigaSure vessel sealing system is a safe alternative for securing pedicles in vaginal hysterectomy with significant improvement in patients outcome. Following vaginal vault prolapse, we determined the optimal fixation-site to perform the colposuspension in the intermediate portion of the uterosacral-ligament, especially if the cervical portion received a thermal damage, as occurs during the LigaSure use.
- Sexually transmitted infections and reproductive health morbidity in a cohort of female sex workers screened for a microbicide feasibility study in Nellore, India. [Journal Article]
- Glob J Health Sci 2013 May; 5(3):139-49.
Women constitute 38% of India's 2.4 million HIV-infected persons. Microbicides are potential HIV-prevention products currently undergoing clinical trials for efficacy. A four-month placebo vaginal gel trial was conducted in Nellore, India to determine the feasibility of recruiting a suitable cohort of female sex workers (FSWs) for a future vaginal microbicide efficacy trial. We report on the HIV and STI prevalence and reproductive health (RH) morbidity of FSWs screened for the trial.
RESULTS:529 FSWs completed screening procedures; of those 33.6% were found ineligible. The mean age was 30.9 years; 68.6% women were married and 57.5% were home-based FSWs. Self-reported symptoms included abnormal vaginal discharge (31.6%), genital itching (3.4%), uterine mass/prolapse (3%) and painful intercourse (2.6%). Gynecological surgery was reported by 73.2% of participants; of those 10.5% had undergone a hysterectomy. Female sterilization was the most commonly reported contraceptive method. Pelvic examination showed vaginal discharge (50.7%), cervical discharge (5.3%), uterine/vaginal wall prolapse (2.6%), and cervical mass/nodule/vesicles/genital warts (4.2%). Common epithelial findings included erythema (79.1%) and vesicles/bullae (6%); 46% of participants had Papanicolaou tests graded as inflammatory and 1.1% as malignant. HSV-2 was the mostly commonly detected STI (60.7%) followed by HIV (5.3%), syphilis (2.8%), chlamydia (2.2%), gonorrhoea (0.7%) and trichomoniasis (15.5%). RTIs were more common: bacterial vaginosis (27.8%) and candidiasis (18.9%).
CONCLUSIONS:The low HIV prevalence and high RH morbidity in the population makes this site unsuitable for a future phase 2 or 3 microbicide efficacy trial. HIV prevention programs targeting this population should include access to RH services.
- Vaginal hysterectomies in patients without uterine prolapse: ten-year experience. [JOURNAL ARTICLE]
- Hong Kong Med J 2013 Apr 22.
OBJECTIVE.To review the results of vaginal hysterectomies in patients without uterine prolapse.
DESIGN.Retrospective chart review.
SETTING.University affiliated hospital, Hong Kong.
PATIENTS.All patients who had vaginal hysterectomies in the absence of uterine prolapse from 1999 to 2005 inclusive (first period) and 2006 to 2009 inclusive (second period). MAIN OUTCOME MEASURES. The number of such hysterectomies, indications, operative procedures, complications, use of preoperative gonadotropin-releasing hormone agonist, and concomitant vaginal salpingo-oophorectomies performed.
RESULTS.In all, 94 and 98 patients fulfilling the necessary inclusion criteria within the two respective periods underwent vaginal hysterectomy. The indications for hysterectomy in the respective groups were similar, and 89 (95%) and 90 (92%) of the patients were Chinese. The respective proportions having additional procedures were 11% versus 23% (P=0.018) and the respective vaginal bilateral salpingo-oophorectomy rates were 1% versus 15% (P<0.001). The vault haematoma rate decreased significantly in the second period (from 12% to 1%; P=0.002). There were no significant differences between the periods with respect to mean operative blood losses, uterine weights, and operating times. The use of gonadotropin-releasing hormone agonist resulted in reduced mean uterine sizes (12 weeks vs 10 weeks; P=0.041). A decreasing trend in mean operating times and blood losses was also observed after such use. Vaginal hysterectomy and bilateral salpingo-oophorectomies were successfully performed in 12 (80%) patients without laparoscopic assistance. For this procedure, a learning curve was also evident.
CONCLUSIONS.Surgeons' experience can influence the complication rate and the chance of successful vaginal salpingo-oophorectomy. More liberal use of gonadotropin-releasing hormone agonist may further reduce the complication rate and allow more vaginal hysterectomies.
- Current status of uterus transplantation in primates and issues for clinical application. [JOURNAL ARTICLE]
- Fertil Steril 2013 Apr 1.
OBJECTIVE:To clarify the current status of uterus transplantation (UT) and the medical, ethical, and social problems surrounding UT.
PATIENT(S):Mainly nonhuman primates and humans.
MAIN OUTCOME MEASURE(S):A systematic search of Pubmed with the terms "uterus/uterine transplantation" was performed for English-language articles to review the current status of UT and issues associated with its clinical application, with a focus on nonhuman primate and human studies on UT.
RESULT(S):The first UT procedure in humans was conducted for a patient with absolute uterine infertility in Saudi Arabia in 2000. The transplanted uterus was removed after 99 days owing to prolapse and necrosis. That attempt led to a greater focus on basic UT experiments in animal models, including nonhuman primates. The subsequent accumulation of basic data has led to performance of UT in humans by groups in Turkey and Sweden. However, there has yet to be a pregnancy or delivery after allo-UT in primates. Moreover, there are many medical, ethical, and social problems that require examination before clinical application.
CONCLUSION(S):Clinical application of UT has just begun, but more basic data are needed and medical, ethical, and social problems require thorough discussion before clinical application.
- Lichen sclerosus occurring on vaginal mucosa secondary to uterine prolapse. [Journal Article]
- J Obstet Gynaecol 2013 Apr; 33(3):319-20.
- Purse string suturing in a neonatal prolapsed uterus. [Journal Article]
- Indian J Surg 2012 Apr; 74(2):143-5.
Prolapsed uterus in a newborn is a rare condition. We present our purse-string suturing as a new technique to restore it to its normal position to avoid complications. Prolapse is usually associated with congenital spinal defects, and is often resistant to simple reduction.
- Recurring and generalized visceroptosis in ehlers-danlos syndrome hypermobility type. [Journal Article]
- Am J Med Genet A 2013 May; 161(5):1143-7.
Visceroptosis is described in several heritable connective tissue disorders, including the hypermobility type of Ehlers-Danlos syndrome (hEDS), a.k.a. joint hypermobility syndrome (JHS). Clinical features of hEDS comprise joint hypermobility, mild skin hyperextensibility, joint instability complications, chronic joint/limb pain, and positive family history. Uterine and rectal prolapse has been reported in nulliparous women. We report on a family with two patients with hEDS. The proposita, a 38-year-old woman, present bilateral kidney prolapse requiring three nephropexies, gastric ptosis treated with gastropexy and Billroth I gastrectomy, and liver prolapse treated with a non-codified hepatopexy procedure. Radiological evaluation also showed ovarian and heart prolapse. To our knowledge this is the first case of multiple visceral ptoses in hEDS. Visceral prolapse may lead to severe morbidity, affecting quality of life and a high rate of relapses after surgical procedures. Further investigations are needed to understand the molecular basis of the disease and retrospective studies on surgical outcomes, presentation of case series can be effective in order to offer a better treatment and prevention for hEDS patients. © 2013 Wiley Periodicals, Inc.
- Cow attributes, herd management, and reproductive history events associated with the risk of nonpregnancy in cow-calf herds in Western Canada. [Journal Article, Research Support, Non-U.S. Gov't]
- Theriogenology 2013 Apr 15; 79(7):1083-94.
To identify herd management and cow characteristics associated with the reproductive success of cow-calf herds in Western Canada, 33,391 beef cows were followed from the beginning of the breeding season in 2001 through pregnancy testing in 2002. Breeding management and cow-level risk factors such as age, body condition score (BCS), and previous reproductive history, were measured through a series of herd visits by project personnel and records maintained by the herd owner. Pregnancy status was measured in 205 herds in the fall of 2001 and again in 200 herds in the fall of 2002. Cows least likely to be pregnant in the fall of the year were 10 years old or older, exposed to a bull less than 84 days, had a BCS ≤5 of 9 at pregnancy testing, <5 of 9 before calving, and lost condition between calving and the start of the breeding season, or had a prebreeding BCS <5 of 9 with a loss of condition between breeding and pregnancy testing. Other factors identified that decreased the likelihood of pregnancy in at least one of the 2 years included being a heifer or being a cow exposed to breeding after her first calf, and using a single bull on breeding pasture. Cows vaccinated for bovine viral diarrhea virus and infectious bovine rhinotracheitis and bred on community pastures were more likely to be pregnant than cows that were not vaccinated and bred on community pastures. Cows bred on community pastures that were not vaccinated were also less likely to be pregnant than cows that were not on community pastures regardless of vaccination status. Calving-associated events such as twin birth, Cesarean section or malpresentation, problems such as uterine prolapse or retained placentas, abortion or calf death within 1 hour after birth, or calving late after the start of the breeding season, were also associated with fewer pregnancies after accounting for all other factors.