David Pauzner

Combined genitourinary prolapse repair and prophylactic tension-free vaginal tape in women with severe prolapse and occult stress urinary incontinence : Preliminary results

OBJECTIVESnContinent patients with a positive stress test demonstrated on repositioning of severe genitourinary prolapse are considered to be at high risk of developing postoperative symptomatic stress urinary incontinence (SUI). Our aim was to evaluate in a prospective study whether a prophylactic, tension-free vaginal tape (TVT) procedure, performed during prolapse repair, may prevent the development of postoperative SUI in these women.nnnMETHODSnThirty consecutive, clinically continent women (mean age 64.5 +/- 9.04 years) with severe genitourinary prolapse and occult SUI were prospectively enrolled. Occult SUI was defined as a positive stress test with repositioning of the prolapse during the preoperative urodynamic studies. All patients had urethral hypermobility; none had intrinsic sphincter deficiency. In addition to genitourinary prolapse repair, these patients underwent concomitant TVT to prevent postoperative SUI. Patients were followed up for at least 1 year. Repeated urodynamic studies were performed at 3 to 6 months postoperatively. The main outcome measures were postoperative SUI, persistent or de novo detrusor instability, and recurrence of prolapse.nnnRESULTSnThe mean duration of follow-up was 14.25 +/- 3.08 months (range 12 to 24). None of the patients developed postoperative symptomatic SUI. However, three asymptomatic patients (10%) had a positive stress test during their postoperative urodynamic evaluation. Nine patients (30%) had detrusor instability before surgery, which persisted in six (66%) postoperatively. Postoperative de novo detrusor instability was diagnosed in four other patients (13.33%). None of the patients had recurrent urogenital prolapse, nor did they have clinical evidence of bladder outlet obstruction.nnnCONCLUSIONSnThe preliminary results of TVT as a prophylactic procedure in clinically continent women with severe prolapse and occult SUI are encouraging. Long-term follow-up is required to confirm the durability of these results.

Ovarian stimulation and emergency in vitro fertilization for fertility preservation in cancer patients

OBJECTIVEnTo evaluate the outcome of ovarian stimulation and in vitro fertilization (IVF) in women undergoing fertility preservation prior to chemotherapy compared with healthy patients with infertility due to tubal factor.nnnSTUDY DESIGNnCase control, retrospective study in an academic IVF unit. The study participants were 21 cancer patients and 1 patient with focal proliferative glomerulosclerosis, undergoing emergency IVF or intracytoplasmic sperm injection (ICSI; Group A) and 22 patients undergoing IVF for tubal factor (Group B). All patients underwent controlled ovarian stimulation, ovum pick-up, and embryo freezing or transfer. The outcome measures included: dose of gonadotropins, mean estradiol and progesterone levels, length of stimulation, number of retrieved oocytes, number of 2 pronuclei zygotes, fertilization rate, and clinical pregnancy rate. Students t-test was used for assessment of group comparisons.nnnRESULTSnPatients in Group A (mean age 32.8+/-5.7 years) underwent 22 emergency IVF cycles for fertility preservation prior to chemotherapy. The mean number of days until human chorionic gonadotropin administration was 10.4+/-4.8. Eleven cycles involved normal insemination while nine involved ICSI. In one cycle three arrested immature oocytes were retrieved, and in one cycle no oocytes were retrieved. Donor sperm was used in 9 cycles. Tamoxifen was part of the treatment protocol in 6 IVF cycles of breast cancer patients. The mean age of the women in Group B was 34+/-4.2 years. There were no significant differences in any of the main outcome measures between the two groups. Thawed embryos were transferred in four cancer patients: two patients had colon cancer, one had breast cancer and one had pseudomyxoma peritonei. Two of these four women conceived and gave birth to healthy newborns.nnnCONCLUSIONSnEmergency IVF is a promising approach for preserving fertility in cancer patients. Current treatment protocols offer a minimal time delay until chemotherapy is commenced, and the ovarian stimulation outcomes are comparable to those of women with tubal factor.

Effects of cancer on ovarian response in controlled ovarian stimulation for fertility preservation

OBJECTIVEnTo evaluate the effects of cancer on ovarian response in controlled ovarian hyperstimulation (COH).nnnDESIGNnRetrospective analysis study.nnnSETTINGnUniversity-based tertiary medical center.nnnPATIENT(S)n81 cancer patients undergoing controlled ovarian stimulation cycles for fertility preservation, and age- and date-matched controls undergoing COH for in vitro fertilization (IVF) for male factor infertility.nnnINTERVENTION(S)nControlled ovarian hyperstimulation and oocytes retrieval.nnnMAIN OUTCOME MEASURE(S)nMaximal estradiol levels at day of human chorionic gonadotropin administration, duration of stimulation, total amount of gonadotropins administered, number of dominant follicles, number of oocytes retrieved, and rate of metaphase 2 oocytes.nnnRESULT(S)nThe overall number of dominant follicles and the number of oocytes aspirated of the study group and control were comparable (8.8 ± 5.3 vs. 9.7 ± 4.9, and 11.93 ± 8.3 vs. 12.3 ± 7.9, respectively). The total dose of gonadotropins used and number of stimulation days of the study group (2,250 IU [1,800-3,000 IU] and 9.5 [8-11]) were also similar to the controls (2,100 IU [1,700-2,900] and 10 [9-13]). Comparison between four subgroups of cancer-breast cancer, soft tissue sarcoma, hematologic malignancies, and gastrointestinal tract cancers-showed no difference in their ovarian response indexes. Regression analysis to assess the effect of cancer on ovarian response showed no effect on the main outcome measured.nnnCONCLUSION(S)nCancer does not influence ovarian response in COH for fertility preservation.

The Safety and Efficacy of the "Inside-Out" Trans-Obturator TVT in Elderly Versus Younger Stress-Incontinent Women: A Prospective Study of 353 Consecutive Patients

To analyze the safety and efficacy of the trans‐obturator tension‐free vaginal tape (TVT‐O) in elderly versus younger stress‐incontinent women.

Protracted postpartum urinary retention: The importance of early diagnosis and timely intervention

To evaluate the prevalence and obstetric risk factors of protracted postpartum urinary retention, beyond the third postpartum day.

“Inside-out” Transobturator Tension-free Vaginal Tape for Management of Occult Stress Urinary Incontinence in Women Undergoing Pelvic Organ Prolapse Repair

OBJECTIVESnTo assess the safety and effectiveness of the inside-out transobturator tension-free vaginal tape procedure for the management of occult stress urinary incontinence (SUI) in clinically continent women undergoing prolapse repair.nnnMETHODSnA total of 117 consecutive continent women (mean age and parity 66.8 ± 9.9 years and 3.2 ± 1.5, respectively) with significant pelvic organ prolapse and urodynamically confirmed occult SUI were enrolled in the present study. Surgical intervention included transvaginal prolapse repair and concomitant prophylactic transobturator tension-free vaginal tape. The main outcome measures were procedure-related complications, early and late postoperative morbidity, postoperative urodynamic SUI, persistent or de novo overactive bladder, and bladder outlet obstruction.nnnRESULTSnNo cases of significant blood loss, hematoma formation, or bladder injury occurred. Of the 117 patients, 6 (5.1%) had immediate postoperative voiding difficulties necessitating catheterization for >2 days. Late postoperative morbidity was assessed in 110 patients with ≥3 months of follow-up (mean 27.2 ± 17.7). Of these 110 patients, 7 (6.4%) had protracted postoperative thigh pain with spontaneous resolution within 1-3 months, and 7 (6.4%) had developed recurrent urinary tract infections. No cases of vaginal erosion developed. The functional outcome analysis was restricted to 92 patients with ≥12 months of follow-up (mean 31 ± 16). Of the 92 patients, 13 (14%) were found to have urodynamic SUI. However only 2 patients (2.2%) were symptomatic for a subjective and objective cure rate of 97.8% and 86%, respectively. Of the 34 patients who had had overactive bladder preoperatively, 22 (64.7%) had persisting symptoms postoperatively. An additional 4 patients (6.9%) had developed de novo overactive bladder symptoms, and 1 patient had bladder outlet obstruction.nnnCONCLUSIONSnThe prophylactic transobturator tension-free vaginal tape procedure is both effective and safe in patients with occult SUI undergoing prolapse repair.

Elevated levels of CRP in ovarian hyperstimulation syndrome: an unrecognised potential hazard?

Objectiveu2003 Elevated levels of C‐reactive protein (CRP) were found recently to be a crucial marker for cardiovascular disease. This protein might have a role in endothelial cell activation, vascular damage and a thrombotic tendency. We sought to determine whether concentrations of CRP are altered in women with controlled ovarian hyperstimulation (COH) or hyperstimulation syndrome (OHSS).

Role of urethrocystoscopy in the evaluation of refractory idiopathic detrusor instability

OBJECTIVESnTo assess the role of diagnostic urethrocystoscopy in the evaluation of women with idiopathic detrusor instability (DI) refractory to conventional pharmacologic management.nnnMETHODSnOne hundred consecutive women (mean age 62.1 +/- 15.1 years) with idiopathic DI refractory to conventional pharmacologic management were prospectively enrolled. All patients underwent a meticulous evaluation, including a detailed history, urogynecologic questionnaire, micturition diary and pad test, urinalysis and culture, physical examination, and urodynamic studies. Refractory DI was defined as the lack of clinical improvement after at least 6 months of conventional drug therapy. These patients underwent additional evaluation with diagnostic urethrocystoscopy.nnnRESULTSnAll patients had a normal urinalysis and negative cytologic findings. Diagnostic urethrocystoscopy revealed isolated bladder tuberculosis in one and transitional cell carcinoma in another. Seven other patients had bladder diverticula (only one of which was also diagnosed by sonographic examination) and 22 had mild-to-moderate bladder trabeculations.nnnCONCLUSIONSnThe absence of other alarming signs (ie, recurrent urinary tract infection, hematuria, significant residual urinary volume, positive cytologic findings, or suspicious sonographic findings) cannot confirm the lack of significant lower urinary tract abnormalities among patients with refractory DI. Diagnostic urethrocystoscopy, a simple and safe office procedure, facilitates timely diagnosis and appropriate treatment for these patients.

Intrafollicular and serum levels of leptin during in vitro fertilization cycles: comparison between the effects of recombinant follicle-stimulating hormones and human menopausal gonadotrophin

Objectives.u2003To compare the effect of recombinant follicle-stimulating hormones (r-FSH) and human menopausal gonadotrophin (hMG) on leptin levels in serum and follicular fluid (FF) during in vitro fertilization IVF/ET treatment, and to investigate whether leptin levels in the follicular fluid and/or serum are correlated with IVF success. Methods.u2003Sixty-three patients undergoing IVF cycle were subdivided into two groups. r-FSH was used to for controlled ovarian hyperstimulation in 29 patients (Group A) while, hMG was used in 34 patients (Group B). Our main outcomes were serum and FF leptin on the day of oocyte collection. Result(s).u2003The two groups were comparable in age, body mass index (BMI), indications for IVF/ET, E2 level on human chorionic gonadotrophin day, number of retrieved oocytes, fertilization rate, number of transferred embryos and pregnancy rate. Serum and FF leptin levels were similar between the two study groups. Additionally, no correlation was found between levels of leptin in either serum or FF and cycle results such as: number of retrieved oocytes, fertilization rate and pregnancy rate. Conclusions.u2003r-FSH and hMG have been found to have comparable effects on leptin levels in the serum and the FF of patients undergoing IVF/ET. Additionally, leptin levels in both serum and FF on day of retrieval have no correlation to IVF/ET outcome.

Spontaneous splenic rupture in pregnancy after heparin treatment

A 32-year-old woman presented in the 34th week of her fourth pregnancy with sudden diffuse abdominal pain. She had previously undergone a preterm delivery of twins at 24 weeks of gestation and an early miscarriage at seven weeks of gestation. After her first two pregnancies, she underwent evaluation for thrombophilia and was diagnosed as being homozygous for methyl-tetra-hydro-folatereductase (MTHFR) deficiency. During her third pregnancy, she had been treated with folic acid 5 mg daily and prophylactic subcutaneous low molecular weight heparin (enoxaparin) 40 mg daily. She carried that pregnancy to full-term (38 weeks) without complications. In the present pregnancy, she had received enoxaparin 40 mg and folic acid 5 mg daily until she presented with abdominal pain. She described the pain as sudden in onset, sharp and continuous. She denied any past or recent abdominal trauma. She had taken her last dose of enoxaparin at 19:00 and arrived at the hospital at 23:30 of the same evening. On admission, blood pressure was 100/70 mmHg and pulse 70 bpm. Physical examination revealed a diffusely tender and distended abdomen, with signs of peritoneal irritation. The uterine tone was normal, and there was no vaginal bleeding. Non-reactive stress testing and her biophysical profile were normal. She was transferred to our delivery room for further observation because of her unrelenting pain. A severe prolonged fetal bradycardia was identified 10 minutes later and an emergency caesarean was performed under the assumption of a placental abruption. The peritoneum was opened, revealing a large amount of fresh blood and blood clots in the abdominal cavity. A live baby was delivered. The amniotic fluid was clear and no evidence of abruption was seen on the placenta. After suturing the uterus, persistent bleeding was noted to appear from the upper abdominal cavity and a general surgeon was called in order to locate the source of bleeding. He performed a vertical abdominal incision and an exploratory laparotomy revealed a tear in the splenic hilum, whereupon he performed a splenectomy. There appeared to be no other source of bleeding. The patient received blood products during and after the operation. Her recovery was uneventful and she was discharged with a healthy baby 10 days after her admission. The pathology report confirmed a rupture of the splenic capsule.