G. Creatsas

Burch Colposuspension and Tension-Free Vaginal Tape in the Management of Stress Urinary Incontinence in Women

OBJECTIVE Objective of the study was to compare the efficacy and the complications of tension-free vaginal tape (TVT) and Burch colposuspension in the treatment of female genuine stress incontinence (GSI). METHODS In this controlled, prospective, randomized study, participated 35 patients who underwent Burch colposuspension and 36 patients that underwent TVT procedure. Patients with prolapse more than first degree, previous surgical treatment of stress urinary incontinence (SUI) and detrusor instability were excluded from the study. RESULTS The operative time for TVT was significantly shorter compared to BC. The severity and duration of postoperative pain for TVT was significantly less compared to BC. The necessary time for return to normal activity was 10 days for TVT and 21 days for BC. The cure rate after 24 months of follow-up was as follows: TVT: 84% and BC: 86%, while the improvement was 7% for TVT and 6% for BC. CONCLUSIONS TVT and Burch colposuspension are equally effective in the management of female GSI at two years follow-up. TVT procedure requires much less operative time, has much shorter hospitalization time, with significantly less postoperative pain and faster return to normal daily activities than Burch colposuspension.

Tension-Free Vaginal Tape versus Tension-Free Vaginal Tape Obturator in Women with Stress Urinary Incontinence

Background: To assess the efficacy and complications of tension-free vaginal tape (TVT) versus tension-free vaginal tape obturator in women with urodynamic stress incontinence. Methods: Prospective, randomized study. Initially, 91 patients were included in the study and 89 of them were available at 12 months follow-up. Forty-six patients were subjected to classic TVT procedure and 43 to transobturator vaginal tape from inside to outside (TVT-O) operation. There was no significant difference between the groups for age, BMI, menopausal status and prolapse. No patients had cystocele greater than stage I. Subjective and objective cure and improvement rate, mean operative time, hospital stay and complications incidence were assessed. Results: Mean operative time was significant shorter in the TVT-O group (17.4 ± 6.9 min) compared to the TVT group (26.7 ± 8.6 min). There was no significant difference in the duration of hospital stay between two groups. The objective cure rate for TVT group was 89%, the improvement rate was 6.5%, the failure rate was 4.3% and the subjective cure rate 73.9%. The objective cure rate for TVT-O group was 90%, the improvement rate was 7.6%, the failure rate was 2.5% and the subjective cure rate 76.7%. The hemoglobin loss ranged between 1.0 ± 0.5 g/dl for TVT group and 0.9 ± 0.4 g/dl for TVT-O group. Conclusion: The TVT-O technique presents success rates comparable to the classic TVT method in the short term.

Long-term efficacy of tension-free vaginal tape in the management of stress urinary incontinence in women: efficacy at 5- and 7-year follow-up

The objective of the study was to obtain a prospective assessment of the efficacy and the complications associated with the use of tension-free vaginal tape (TVT) for the management of urodynamic stress incontinence at 5- and 7-year follow-up. Sixty-five female patients with stage I cystocele or less who have been operated with TVT procedure for management of urodynamic stress incontinence have been included in the study. At 5-year follow-up, the objective cure rate was 83% and failure rate 9.4%. At 7-year follow-up, the objective cure rate was 80% and the failure rate 13.5%. De novo detrusor overactivity was seen in 9.4% and 11.4% of patients at 5- and 7-year follow-up, respectively. TVT operation is an effective and safe minimally invasive procedure for the management of urodynamic stress incontinence in women without significant cystocele in the long-term follow-up. The 10- and 20-year results are awaited.

Changes of collagen type III in female patients with genuine stress incontinence and pelvic floor prolapse.

PURPOSE Objective of this study was to determine possible changes in the quantity of type III collagen in women with genuine stress incontinence (GSI) and with pelvic relaxation or not. MATERIAL AND METHODS Ninety-four women participated in the study and they were divided in to three groups as follow: 34 patients with GSI and pelvic relaxation (group 1), 32 patients with pelvic relaxation but without GSI (group 2) and 28 patients with neither pelvic relaxation nor GSI (group 3). All the women underwent a complete pre-operative urodynamic evaluation. The presence of collagen type III was determined by immunohistochemical technique. The X-test was used for statistical analysis. A P<0.05 was considered statistically significant. RESULTS Collagen type III was significantly reduced (p<0.05) in patients with GSI and pelvic relaxation in both sites of biopsy (group 1), compared to patients in groups 2 and 3. Specimens from women without GSI (group 2 and group 3) had a similar density of collagen type III in both sites of biopsy. CONCLUSION In this study, we found that women with GSI had less collagen type III around the urethra regardless of the degree of pelvic relaxation. It appears that collagen has a significant role in the maintenance of urinary continence but the mechanism by which collagen metabolism is altered remains unknown.

Ureteral injuries during gynecological surgery.

The purpose of this study was to review the cases of ureteric injuries during major pelvic surgery that occurred in our department over the last 15 years, in relation to possible predisposing factors and patient management according to the type of injury. From 5122 major gynecologic operations we found 18 cases of ureteric injury, including 4 cases of urinoma. Parameters that were examined included the indication for surgery and the type of operation, coexisting pathological conditions, the position of and the delay in recognition of the ureteric damage. The incidence of ureteric injury was 0.35%. The time of recognition of injury in 9 cases was during primary surgery and end-to-end anastomosis was performed, whereas in the other 9 cases the injury was recognized after surgery and repair of the ureter was performed, with reimplantation into the bladder in 4 cases and end-to-end anastomosis in 5. Action to prevent the development of iatrogenic ureteral injury must be taken in advance, and the management of ureteric injuries could be improved with prompt recognition and repair by a skilled surgeon.

Intrauterine inflammation and preterm delivery

Spontaneous preterm delivery, prematurity, and low birth weight due to prematurity account for a great part of neonatal morbidity and mortality. Specifically, chronic amniotic fluid inflammation may cause preterm labor, with the involvement of different mediators that produce diverse aspects of the inflammatory response. Although bacteria are considered to be the main trigger for intrauterine infection/inflammation, viral infections also appear to be involved. Recently, molecular genetic techniques have helped us better understand the underlying pathophysiologic processes. This is especially important because epidemiological and experimental studies indicate that intrauterine infection and inflammation constitute a risk factor for adverse neurological outcome in preterm infants. Chronic subclinical chorioamnionitis associated with preterm birth can also modify lung development. Although no current clinical strategy is aimed at adapting the maternofetal inflammatory response, immunomodulators may serve as a future intervention in preterm embryos.

Ovarian masses during adolescence: clinical, ultrasonographic and pathologic findings, serum tumor markers and endocrinological profile.

This retrospective study was undertaken to assess the epidemiological and clinical features, laboratory findings, preoperative work-up, surgical treatment and pathologic findings in adolescents with ovarian cysts. All adolescents who were referred to our institution and had been operated on because of a diagnosed ovarian mass, from January 1997 to June 2003, were included in this study. Forty-four cases of women with an ovarian mass were retrospectively analyzed. These patients, aged between 12 and 21 years, had 47 ovarian masses (three patients had bilateral lesions), of which 49% were non-neoplastic and 51% were neoplastic. Of the neoplastic lesions, 62.5% were germ cell tumors, 20.8% were epithelial and 16.7% were sex cord–stromal tumors. Of the neoplastic tumors, 95.8% were benign while 4.2% were malignant. Procedures included 30 operative laparoscopies (68.2%) and 14 exploratory laparotomies (31.8%). Simple excision of the ovarian cyst was performed in 39 cases (88.6%). According to our study, most of the adolescents with an ovarian cyst underwent an operation because of a neoplastic lesion. The majority of ovarian tumors occurring in adolescents are non-epithelial in origin, and germ cell tumors are the most common histological type. Ultrasound examination is one of the most important diagnostic tools. Preoperative diagnostic approach of these patients should always include careful history taking, physical examination, imaging and evaluation of serum assays. Gynecologists who care for young girls must be familiar with the differential diagnosis of ovarian masses whose surgical treatment should be conservative when appropriate, so that hormonal status and future fertility are not compromised in this group of patients.

Adhesions: Laparoscopic Surgery versus Laparotomy

Abstract: This study was undertaken to assess the effectiveness in pregnancy rates of microsurgery and operative laparoscopy in adhesiolysis. Adhesions were found to be the sole infertility factor in 15% of our patients. One hundred and ninety infertile patients with periadnexal adhesions as the only cause of their infertility were treated by microsurgery (86) or operative laparoscopy (104) and were followed up for 24 months. Our results indicate that advanced laparoscopic surgery in general is as effective as microsurgery in healthy infertile patients with adhesions but offers some advantages in comparison to laparotomy. Factors that adversely affect the postoperative success rates are the age of the women, the duration of infertility, and the severity of the adhesions.

Thyroid autoimmunity in patients with recurrent spontaneous miscarriages

Recurrent spontaneous miscarriage (RSM) is a multifactorial problem. Auto- and alloimmune parameters have been implicated. Antithyroid antibodies (ATA) were tested in a group of women with RSM. The presence of antipatemal antibodies (APCA) was evaluated as an index of alloimmune contribution. Thirty euthyroid women with RSM (three or more consecutive miscarriages) aged 25–37 years were compared with 15 matched controls. Thyroid peroxidase (TPO) and thyroglobulin antibodies were tested with a chemiluminescence immunoassay and APCA were tested with a cross-match reaction. Results were compared using the chi-squared test. There was a higher frequency of ATA in women with RSM compared to controls (37% versus 13%, p < 0.05). Twenty of the women (67%) with RSM were tested negative for APCA, indicating an alloimmune contribution to their infertility. In this subgroup of women, the frequency of ATA continued to be higher than controls (40% versus 13%, p < 0.05). In conclusion, women with RSM, independent of APCA status, have a higher frequency of ATA. This may represent an additional marker for impaired regulation of the maternal immune system.

The renin-aldosterone system during normal and hypertensive pregnancy

Abstract Gestational hypertension complicates approximately 5%–7% of pregnancies and it may be deleterious to both maternal and fetal health. Gestational hypertension is a multisystem disorder which always resolves itself after delivery; its primary pathology still remains incompletely clarified. The renin-aldosterone system is a major determinant of sodium balance in pregnancy. To evaluate the changes in renin and aldosterone levels during normal and hypertensive pregnancy we undertook this study. Plasma renin activity and aldosterone levels were measured in 71 pregnant (43 normotensive, 28 hypertensive) and 24 non-pregnant (12 normotensive, 12 hypertensive) women, aged 19–43 years (mean±SD 28±2.8). Women were allocated into the following five groups: Groups 1 and 2 consisted of 12 normotensive and 12 hypertensive non-pregnant women, respectively; group 3 consisted of 20 women (14 normotensive and 6 hypertensive) at 11–19 weeks of gestation; group 4 consisted of 24 women (14 normotensive and 10 hypertensive) at 20–29 weeks of gestation, and group 5 consisted of 27 women (15 normotensive and 12 hypertensive) at 30–37 weeks of gestation. Both plasma renin activity and aldosterone levels progressively increased during normotensive pregnancy and were higher compared to normotensive non-pregnant women. Among hypertensive pregnant women, plasma renin activity levels remained unchanged during the three trimesters of pregnancy and were higher compared to hypertensive non-pregnant women. Only during the third trimester did aldosterone levels significantly increase in hypertensive pregnant women, compared to hypertensive non-pregnant women. Despite stable renin levels, aldosterone levels increased significantly during the third trimester of hypertensive pregnancy. Thus, we conclude that aldosterone biology seems to be directly or indirectly involved in the etiology of gestational hypertension independently of renin levels.