Esther Shih-Chu Ho

Factors that affect recurrence after anterior colporrhaphy procedure reinforced with four-corner anchored polypropylene mesh

The purpose of this study was to evaluate the effectiveness of the anterior colporrhaphy procedure reinforced with four-corner anchored polypropylene mesh in patients with severe (stage III or IV) anterior vaginal prolapse. Thirty-eight consecutive women were enlisted for this prospective study. The procedure consisted of an extensive vaginal dissection to join the vesicovaginal and retropubic space and an anchoring of a polypropylene mesh patch between the two Arcus Tendineus Fasciae Pelvis in a tension-free manner. The mean age of the study group was 63 (33–80) years. The success rate was 87% (33/38) at a mean follow-up interval of 21 (12–29) months. A total of eight (100%) patients were also cured of concomitant stress incontinence (five overt and three occult type) with an additional tension-free vaginal tape (TVT) operation. During follow-up, there were five de-novo stress incontinence cases (16.7%) and four vaginal erosions of mesh (10.5%). Four clinical variables—diabetes mellitus, recurrent anterior vaginal prolapse, chronic cough and vaginal erosions of mesh—were found to have a significant correlation with an unsatisfactory surgical result with large values of hazard ratios found by survival analysis. We concluded that the anterior colporrhaphy procedure reinforced with four-corner anchored polypropylene mesh was effective for most, but failed in some patients who had specific risk factors within short convalescence periods. Concomitant stress incontinence can be successfully treated by a TVT operation in combination with the anterior colporrhaphy procedure reinforced with four-corner anchored polypropylene mesh. However, the anterior colporrhaphy procedure may itself have adverse effects on urethral sphincter function.

KAI1 Metastasis Suppressor Gene Is Frequently Down-Regulated in Cervical Carcinoma

KAI1 is a metastasis suppressor gene located on human chromosome 11p11.2. It belongs to a structurally distinct family of cell surface glycoproteins. Decreased KAI1 expression has been observed in several common solid epithelial tumors, including prostatic, pancreatic, lung, hepatic, colorectal, ovarian, and esophageal cancers. A recent study also observed frequent loss of KAI1 expression in a number of squamous cell carcinomas of the cervix by immunohistochemical technique. To further confirm whether this gene is altered in this malignancy, we analyzed KAI1 expression in various stages of cervical carcinoma by a molecular method. Total cellular RNA was extracted from 84 primary invasive cervical carcinomas and 6 metastatic or recurrent lesions. cDNA was synthesized and was used for real-time quantitative polymerase chain reaction analysis. The level of KAI1 expression was obtained as the value of threshold cycle (Ct) and was quantitated with a comparative Ct method. In addition, paraffin blocks of the tumors were selected and prepared for immunohistochemical study with an anti-KAI1 polyclonal antibody, C-16. Both the real-time quantitative polymerase chain reaction method and immunohistochemical study revealed a frequent decrease in KAI1 expression in invasive cervical cancers and metastatic or recurrent lesions. However, the reduction in KAI1 was not related to progression of the disease. When tumor cell differentiation was analyzed, poorly differentiated tumors showed a greater decrease in KAI1 expression than well or moderately differentiated tumors (P < 0.001). Histologically, KAI1 loss was observed equally in both squamous cell carcinoma and adeno-/adenosquamous carcinoma. Since down-regulation of KAI1 occurs in both early and late stages of cervical cancer, we suggest that its involvement in the progression of this malignancy is an early event.

Prediction of persistence or recurrence after conization for cervical intraepithelial neoplasia III.

OBJECTIVE: To estimate the predictive factors for persistent/recurrent disease before and after conization for cervical intraepithelial neoplasia III. METHODS: Patients who received conization due to histologic diagnosis of cervical intraepithelial neoplasia III from 1998 to 2000 and who had at least one cytologic/histologic follow-up within one year of conization (n = 449) were enrolled in our study. All available demographic and pathologic parameters were analyzed. RESULTS: We performed multivariable logistic regression analysis to identify predictive factors for cervical intraepithelial neoplasia III persistence/recurrence. Age (greater than 50 years) was the only preoperative predictor and had an odds ratio equaling 3.070 (95% confidence interval [CI] 1.421–6.630, P = .004). Post–cone endocervical curettage was found to be the most statistically significant factor for predicting persistent disease (odds ratio 7.940, 95% CI 3.428–18.390, P < .001). Positive endocervical curettage was associated with 65.5% (36/55) of persistent disease, whereas negative endocervical curettage was associated with only 7.6% (26/342). Positive endocervical resection margins and multiple-quadrant disease also had predictive values with odds ratios equaling 2.972 (95% CI 1.401–6.281, P = .004) and 2.180 (95% CI 1.014–4.689, P = .046), respectively. The positive predictive values for age (> 50 years), positive endocervical curettage, positive endocervical resection margin, and multiple quadrant disease were 31.7%, 65.5%, 40.0%, and 21.9%, respectively. CONCLUSION: We found that age is the only preoperative predictive factor. Pathologic parameters, including endocervical curettage, endocervical resection margins, and multiple-quadrant disease are the only postoperative predictive factors for cervical intraepithelial neoplasia persistence or recurrence found in our study. These factors should be considered in patient management before and after therapeutic conization for cervical intraepithelial neoplasia III. LEVEL OF EVIDENCE: II-3

Detection of Chromosome Aberrations in the Second Trimester Using Genetic Amniocentesis: Experience during 1995-2004

OBJECTIVE To retrospectively investigate the 10-year experience of prenatal diagnosis of fetal chromosome aberrations by second-trimester amniocentesis. METHODS Data were collected at Taichung Veterans General Hospital between 1995 and 2004 from cytogenetic analyses of cultured amniocytes from second-trimester amniocentesis. The main indications for amniocentesis included advanced maternal age, abnormal maternal serum screening results, and abnormal ultrasound findings. Chromosome aberrations included autosomal aneuploidies, sex chromosome aneuploidies, polyploidies, and rearrangements. Variant chromosomes were considered to be normal and excluded. RESULTS A total of 7,028 amniocenteses were performed and analyzed for chromosome aberrations. Among these, 4,026 (57.29%) were for advanced maternal age, 1,500 (21.34%) for abnormal maternal serum screening results, 553 (7.87%) for abnormal ultrasound findings, and 949 (13.50%) for other reasons. The highest detection rate of chromosome aberrations was in cases undergoing amniocentesis for abnormal ultrasound findings (8.86%), followed by other reasons (2.74%), abnormal maternal serum screening results (2.60%), and advanced maternal age (2.31%). Chromosome aberrations were detected in 207 cases (2.90%), including fetuses of 93 older mothers, 39 mothers with abnormal serum screening results, 49 mothers with abnormal ultrasound findings, and 26 mothers with other reasons for amniocentesis. Of fetuses with chromosome aberrations, 144 (69.56%) had trisomy 13, trisomy 18, trisomy 21, or sex chromosome disorder. The other 63 cases (30.44%) included balanced translocation, unbalanced abnormality, inversion, and marker chromosome. CONCLUSION For daily practice, our data could offer a database for proper genetic counseling, such as termination issues and future pregnancies.

Transitional cell carcinoma of the ovary.

OBJECTIVE Transitional cell carcinoma (TCC) of the ovary is a rare, recently recognized, subtype of ovarian surface epithelial cancer. We present a case of TCC of the ovary, managed by staging operation and followed by postoperative chemotherapy with carboplatin and cyclophosphamide. CASE REPORT A 67-year-old postmenopausal woman presented with a 2-year history of progressive enlargement of an abdominal mass. Pelvic sonography and abdominal computed tomography showed a pelvic mass measuring 210 x 165 x 203 mm. The serum CA-125 titer was also elevated (65.01 U/mL). A staging operation with total abdominal hysterectomy, bilateral salpingo-oophorectomy, infracolic omentectomy and pelvic lymph node dissection was performed. After surgery, the pathologic report of the left ovarian tumor was TCC, grade 2-3, stage IA. The patient then underwent four cycles of postoperative chemotherapy with carboplatin and cyclophosphamide. CA-125 levels declined to within the normal range after the first cycle of chemotherapy. CONCLUSION TCC of the ovary is a rare subtype of epithelial ovarian cancer. It differs from malignant Brenner tumor by the absence of a benign or borderline Brenner component. Surgical resection is the primary therapeutic approach, and patient outcomes after chemotherapy are better than for other types of common epithelial ovarian cancers.

Prenatal Detection of Bladder Wall Involvement in Invasive Placentation with Sequential Two-dimensional and Adjunctive Three-dimensional Ultrasonography

OBJECTIVE The purpose of this study was to determine the diagnostic capability of sequential two-dimensional (2D) and adjunctive three-dimensional (3D) ultrasonography (US) in identifying the location and extent of placental invasion of the bladder. MATERIALS AND METHODS Forty-five patients at risk of placenta previa were examined sequentially with 2D US and then with a targeted scan of the region of interest with adjunctive 3D US to determine whether those patients suspected of having advanced invasive placentation by conventional ultrasonographic evidence had placental invasion of the bladder. The images were coded as positive, negative or indeterminate (equivocal) for bladder invasion. Follow-up postoperative outcomes were obtained. RESULTS Seven of the 45 patients exhibited characteristic ultrasonographic findings for placenta increta/percreta. Among these seven patients with advanced invasive placentation, a targeted scan with adjunctive 3D US correctly provided additional corroborative information to the 2D US indeterminate diagnosis in patients who were found with variable degrees of bladder wall involvement at surgery. CONCLUSION 3D US may be a useful adjunctive tool in refining 2D ultrasonographic techniques to identify the extent and degree of placental invasion of the bladder. The advantages of 3D US are: (1) a multiplanar image display allows viewing of sections from sagittal, coronal and axial planes at the same time, thereby more accurately determining the location and extent of placental invasion; (2) the viewing planes of the spatial angioarchitecture network can be arbitrarily manipulated to better delineate the aberrant vessels protruding into the bladder; (3) 3D reconstruction images can be clearly displayed by live 3D in a rotation mode for a better illustrative effect.

Risk factors that affect the treatment of interstitial cystitis using intravesical therapy with a dimethyl sulfoxide cocktail

Introduction and hypothesisDimethyl sulfoxide (DMSO) bladder instillation is a standard therapy for interstitial cystitis (IC); however, there are varying degrees of success. We hypothesize that first-line intravesical therapy with a DMSO cocktail will optimize treatment outcome.MethodsNinety women with newly diagnosed IC were enrolled consecutively for the treatment. The IC symptom and problem index was used as an outcome measure.ResultsSix (6.7%) patients dropped out of the treatment due to intolerable bladder irritation. Fifty-five (65.5%) of the remaining 84 patients, who completed the treatment, experienced ≧50% symptomatic improvement. After a regression analysis, three clinical variables were found to affect treatment adversely, i.e., the presence of advanced cystoscopic glomerulations, microscopic hematuria, and urodynamic detrusor underactivity, respectively.ConclusionsOur results suggest bladder instillation with a DMSO cocktail may well be considered as first-line therapy for IC patients. However, there exists a subgroup of nonresponders who may have severe disease.

The effect of preincubation period of oocytes on nuclear maturity, fertilization rate, embryo quality, and pregnancy outcome in IVF and ICSI.

AbstractPurpose: To clarify the effect of preincubation of oocytes on the results of IVF and ICSI. Methods: A total of 176 IVF and 64 ICSI cycles received long protocol ovarian stimulation. The oocytes were incubated for 1–8 h before insemination or sperm injection. Metaphase II (MII) percentage was evaluated in the ICSI arm; fertilization rates, embryo quality, and pregnancy outcomes were analyzed in both IVF and ICSI arms according to the preincubation period duration of oocytes. Results: The MII percentage of the ICSI arm was significantly lower (P < 0.05) in the group with preincubation period of <2.5 h. The fertilization rates in groups with preincubation for 2.5–5.5 h were significantly higher (P < 0.001) for IVF. Embryo quality and pregnancy outcomes were not significantly different between the IVF or ICSI arm. Conclusions: The preincubation of oocytes for at least 2.5 h is beneficial to both IVF and ICSI outcomes by increasing the nuclear maturity of oocytes.

Analysis of two sling procedures using polypropylene mesh for treatment of stress urinary incontinence.

Objectives: To evaluate and compare the surgical outcome between the innovative tension‐free vaginal tape (TVT) and conventional pubovaginal sling (PVS) procedures using polypropylene mesh. Methods: Eighty consecutive women with urodynamic stress urinary incontinence (SUI), who chose to undergo either a TVT (n=23) or a PVS (n=57) procedure using polypropylene mesh based on financial consideration, were recruited for this study. The surgical results were analyzed and compared subjectively and objectively. Results: The mean follow‐up interval was 23 months for the TVT and 20 months for the PVS procedure (P=0.062). Postoperatively, SUI (91.3% vs. 93.0%), concomitant urge symptoms (85.0% vs. 85.3%) and the negative impact of incontinence and urogenital distress on patients’ quality of life (79.8% vs. 77.8%) (77.4% vs. 68.8%) had improved markedly. After a multivariable logistic regression analysis, the treatment outcome of SUI was found to be independent of the main effects of patient age, parity, concurrent gynecological surgeries, intrinsic sphincter deficiency, previous failed incontinence surgeries, and concomitant urge symptoms. However, it was significantly related to treatment procedures (TVT vs. PVS) and their interaction with patient body mass index (BMI). Based on the fitted logistic model, we see that TVT performs better than PVS when BMI is less than 27.27 kg/m2, and the advantage of TVT decreases as BMI increases. Conclusion: Both TVT and PVS procedures using polypropylene mesh are effective treatment modalities for female SUI. However, TVT was not as effective in treating overweight or obese women as PVS.

Experience with Conservative Strategy of Uterine Artery Embolization in the Treatment of Placenta Percreta in the First Trimester of Pregnancy

OBJECTIVE There is little prospective experience in the conservative treatment of placenta percreta during the first trimester in order to preserve uterine fertility. We describe herein our experience with uterine artery embolization (UAE) in the management of placenta percreta at 9 weeks of gestation. CASE REPORT A 36-year-old woman, gravida 3, para 1, was referred for ultrasonographic evaluation because of suspected molar pregnancy due to persistent vaginal spotting at 9 weeks of gestation. A Grade 3+ lacunar flow pattern with multiple bizarre and large irregular sonolucent spaces were observed. Color Doppler imaging revealed extensive turbulent lacunar blood flow perfusing throughout the whole surrounding uteroplacental tissues and fetus. The patient was informed of the situation and she had a strong desire to avoid surgery. Conservative management with bilateral UAE was performed using polyvinyl alcohol particles to promote involution and shedding of the abnormally adherent placenta. However, an unsatisfactory vessel-occluding effect caused by extensive collateral supply was still detected after repeated UAE. We, therefore, performed hysterectomy, and the patient had an uneventful postoperative course. CONCLUSION The efficacy and complications of UAE as a therapeutic modality for the conservative management of invasive placentation in the first trimester of pregnancy are not clear, as this is the first report of its kind. However, although UAE had failed in this case, it may still be a useful procedure as a prophylactic measure before surgical intervention, and hysterectomy can also be performed for better control of operative hemorrhage.