Emmanuel Karantanis

Vaginal hysterectomy versus total laparoscopic hysterectomy for benign disease: a metaanalysis of randomized controlled trials.

OBJECTIVE Recent randomized trials comparing total laparoscopic hysterectomy (TLH) and vaginal hysterectomy (VH) have produced conflicting results. The role of TLH in women suitable for VH remains uncertain. STUDY DESIGN This study was a metaanalysis of randomized studies comparing TLH and VH for benign disease. Pooled outcome measures (odds ratio [OR] and weighted mean difference [WMD]) were calculated using random-effects models. RESULTS No differences in perioperative complications, either total (pooled odds ratio, 0.87; P = .74) or by grade of severity, were demonstrated. TLH was associated with reduced postoperative pain scores (WMD -2.1; P = .03) and reduced hospital stay (WMD -0.62 days; P < .0001) but took longer to perform (WMD 29.3 minutes; P = .003). No differences in blood loss, rate of conversion to laparotomy, or urinary tract injury were identified. CONCLUSION TLH may offer benefits compared with VH for benign disease, although this analysis is likely underpowered for rare complications. Further studies of long-term outcomes, including prolapse, urinary incontinence, and sexual function, are required.

The 24-hour pad test in continent women and men: normal values and cyclical alterations.

Objective To obtain control values for the 24‐hour pad test in a wide age range of continent women using accurate weighing scales and to compare the results obtained from pantyliners and pads in women and men.

The tension-free vaginal tape in older women

Objective  To evaluate peri‐operative morbidity, continence outcome and patient satisfaction in older women (≥65 years) compared with younger women undergoing tension‐free vaginal tape.

Risk factors for obstetric anal sphincter injuries and postpartum anal and urinary incontinence: a case–control trial

Introduction and hypothesisObstetric anal sphincter injuries (OASIS) cause serious maternal morbidity for mothers. A clearer understanding of aetiological factors is needed. We aimed to determine the risk factors for OASIS .MethodsBirth details of 222 primiparous women sustaining OASIS were compared with 174 women who did not sustain OASIS (controls) to determine the relevant risk factors. The data underwent univariate analysis and logistic regression analysis.ResultsAsian or Indian ethnicity, operative vaginal birth (p = 0.00), persistent occipito-posterior position (p = 0.038) and rapid uncontrolled delivery of the head were identified as risk factors for OASIS. Pushing time, use of epidural, episiotomy and head circumference were not predictors of OASIS.ConclusionsWomen with Asian or Indian ethnicity, operative vaginal birth, persistent occipito-posterior position and rapid uncontrolled delivery of the fetal head were likely to sustain OASIS. Awareness of these factors may help to minimise the incidence of OASIS.

Does patient activity level affect 24-hr pad test results in stress-incontinent women?†‡

Standardization of the 24‐hr pad test procedure would increase its validity as an objective measure of urinary incontinence. Our aim was to establish whether patient activity levels affect pad test results in stress‐incontinent women, and if so, to develop a standard activity level during the testing period.

Symphyseal diastasis and vestibular rupture during spontaneous vaginal delivery

The woman was a 25 year old primipara. Her labour was induced at 41þ weeks of gestation because of a post-date pregnancy. There were no antepartum complications. Her body mass index was 26. She did not have gestational diabetes. The estimated fetal weight by an ultrasound scan at 36 weeks of gestation was 3.7 kg. However, at the time of induction, her symphysis–fundal height was 44 cm. Induction of labour was performed using a single intravaginal dose of 1 mg of prostaglandin E2 gel. Full dilatation of the cervix was reached within 13 hours. She did not have an epidural block. The active second stage lasted 45 minutes and she delivered spontaneously a boy weighing 5.2 kg. The baby cried at birth. Her placenta was delivered 20 minutes later. After the birth of her baby, a disruption of the anterior vestibule measuring 3.5 cm in diameter was identified, extending from the clitoris to the external urethral meatus. The cave of Retzius and the anterior surface of the bladder were visible through this defect (Fig. 1). Complete disruption of the pubourethral supports was evident. A wide pubic symphyseal diastasis was present on palpation and the separated bone ends were visible on retraction of the vestibular tear (Fig. 1). In addition, complete disruption of the external anal sphincter was noted. Repair was performed in theatre under general anaesthesia. The external urethral meatus was identified and the bladder was catheterised, yielding clear urine. The vestibule was repaired in two layers using interrupted 2/0 polyglactin braided absorbable sutures (Vicryl, Johnson & Johnson, USA) and the external anal sphincter was repaired in an overlapping manner using 2/0 polydioxanone monofilament absorbable sutures (PDSII, Johnson & Johnson, USA). The estimated blood loss was 1.5 L, and the woman was transfused with four units of packed red cells. A Foley catheter was left in situ for 10 days. The orthopaedic surgeon was notified at the time of the injury, and conservative treatment was recommended. Low molecular weight heparin and graduated stockings were prescribed until the woman was mobile. Prophylactic antibiotics in the form of intravenous cephradine and metronidazole were also administered and continued for three days, together with stool softeners for one week. The woman was seen by the pelvic orthopaedic specialist team (MB) on her first postnatal day. An X-ray of the pelvis revealed symphyseal diastasis measuring 6.0 cm in width (Fig. 2). A pelvic brace was applied to stabilise the pelvis and facilitate mobilisation. A repeat X-ray performed the

Outcome Measures in Pelvic Floor Rehabilitation

Throughout this textbook, many different measures are used to evaluate the pelvic floor and urinary or fecal incontinence. In this chapter, those measures that are also suitable for evaluating posttreatment response, or “outcome”, are considered. In the past 3–4 decades, numerous tests, scoring systems, and quality-of-life instruments have been created. Unfortunately many of these tests have not been formally validated as outcome measures. Therefore they may not give an accurate picture of the “quantity” of a patient’s response to treatment. Also, when many different outcome measures are used to gauge response to any treatment (by different authors), it is almost impossible to compare results.

Cardiac arrhythmias and gynaecological laparoscopy: A reminder

A 62-year-old woman underwent a laparoscopic right salpingooophorectomy (RSO) for a 6 cm simple ovarian cyst. Her preoperative electrocardiogram (ECG) showed normal sinus rhythm. The surgery was complicated by dense infraumbilical adhesions from a previous transverse laparotomy. A standard CO2 pneumoperitoneum was introduced, with the intra-abdominal pressure kept at 15 mmHg for the duration of surgery. Adhesiolysis and RSO were performed in steep Trendelenburg position, with minimal use of suction-irrigation. The total operating time was 90 min and she remained haemodynamically stable throughout the procedure. Eight hours postoperatively, the patient complained of mild chest pain. An irregular pulse, 135 b.p.m. was found with O2 saturations 92% on room air and BP 92/55 mmHg. ECG confirmed fast atrial fibrillation (AF) without ST changes. Arterial blood gas and serum electrolytes, magnesium and calcium were normal. Given the high suspicion for a thromboembolic event, she was heparinised and transferred to the High Dependency Unit. An urgent CT pulmonary angiogram was negative for pulmonary embolism and pneumothorax, but showed evidence of surgical emphysema. In consultation with the cardiology department, rate control with intravenous metoprolol was unsuccessful and she was cardioverted with digoxin with good effect. Trans-thoracic echocardiography (TTE) and a dipyridamole myocardial perfusion scan were both normal. She was discharged home on postoperative day 2 on digoxin and aspirin.