Guang-Perng Yeh

Complications of synthetic graft materials used in suburethral sling procedures

Problems relating to the erosion of sling material, through either the vagina or the urethra, have been encountered with almost all kinds of synthetic sling materials. We present four unusual cases of women using different synthetic materials and the complications that occurred. The biopsies were examined histologically and analyzed for collagen and inflammatory reactions. Four patients who underwent suburethral slingplasty previously with different sling materials required surgical management for complications, including one intravesical Ethibond migration, vaginal mucosal mesh erosion in two patients, and one proximal urethral overcorrection with intravesical erosion. We reviewed the literature regarding the amount of mesh erosion and connective tissue reaction with synthetic materials. The efficiency of mesh removal was assessed. The four patients maintained urinary continence after urethrolysis and removal of the mesh. Fibrosis and severe inflammatory reactions were found in the connective tissue adjacent to the mesh as well as the Prolene mesh. Technically, it would be easier to remove the graft of patch sling if rejection or erosion occurs.

Using color Doppler sonography to identify the perivesical umbilical arteries: a useful method in the prenatal diagnosis of omphalocele-exstrophy-imperforate anus-spinal defects complex.

Objective. To describe the different prenatal sonographic findings in 3 cases of omphalocele‐exstrophy‐imperforate anus‐spinal defects (OEIS) complex, or cloacal exstrophy. Methods. Three patients with OEIS complex were examined by sonography. In 2 (cases 2 and 3) of the 3 cases, color Doppler sonography was applied to the area of cord insertion and the abdominal mass to determine the origin of the abdominal mass. Results. Three cases of OEIS complex with different sonographic appearances are included in this series. An absent bladder without an abdominal mass but with bowel floating in the amniotic cavity was revealed in case 1; an absent bladder with a lower anterior abdominal mass was found in the second trimester in case 2; and a large cystlike mass located in the anterior abdominal wall was found in case 3. Color Doppler imaging showed that the abdominal mass originated from the urinary bladder in cases 2 and 3; therefore, OEIS complex was presumptively diagnosed antenatally in these cases. In all cases, OEIS complex was confirmed postnatally. Conclusions. Omphalocele‐exstrophy‐imperforate anus‐spinal defects complex should be considered in patients with an absent bladder combined with either an anterior abdominal wall mass or defects. Special attention should be given to search for other combined anomalies. We suggest that color Doppler sonography for identifying the perivesical umbilical arteries is a very useful method in establishing of the diagnosis of OEIS complex.

Prenatal Diagnosis of Persistent Right Umbilical Vein Using Three-dimensional Sonography with Power Doppler

OBJECTIVE To investigate the incidence and the importance of isolated persistent right umbilical vein (PRUV) in our obstetric population and to determine the role of three-dimensional (3D) ultrasound in prenatal diagnosis of isolated PRUV. MATERIAL AND METHODS A total of 1,302 women who received regular antenatal care by a sole obstetrician at our hospital were prospectively evaluated between July 2003 and April 2005. Detailed anatomical evaluation of the fetus was performed by one sonographer. When the diagnosis of PRUV was made, it was confirmed by a senior obstetrician. 3D ultrasound with power Doppler was applied to delineate local anatomy. Echocardiography was performed in all the newborns by pediatric cardiologists to confirm the prenatal diagnosis and to evaluate for the presence of associated anomalies. RESULTS Six fetuses with PRUV were detected among the 1,302 study subjects. The incidence of PRUV in our population was 0.46% (1:217 live births). Vascular anatomy was easy to demonstrate using 3D power Doppler. The ductus venous (DV) was present in all six fetuses. An atrial septal defect was shown to exist in four newborns by neonatal echocardiography, but spontaneous closure had occurred in the follow-up scan. CONCLUSION PRUV is a common vascular anomaly that is easy to be overlooked. Reconstruction of the portal system in the affected fetuses using 3D ultrasound facilitated the identification of the DV. If the DV is present, and other anomalies are excluded, the fetus with PRUV has a good outcome.

Prenatal Diagnosis of Congenital Cystic Adenomatoid Malformations: Evolution and Outcome

OBJECTIVE The aim of this study was to describe the natural history and outcomes of fetal congenital cystic adenomatoid malformation (CCAM) of the lung in three antenatally diagnosed cases. CASE REPORT Three women whose fetuses had CCAM of the lung between 2004 and 2006 chose to continue their pregnancies. We followed up these fetuses every 2 weeks and observed whether there were CCAM-related complications, such as polyhydramnios, mediastinal shifting, and even hydrops fetalis. We also used three-dimensional ultrasound using the VOCAL (Virtual Organ Computer-aided Analysis) rotational technique to calculate CCAM volume serially until delivery. At presentation, the three cases of fetal CCAM were all unilateral and microcystic. Two were complicated by mediastinal shift, but none had hydrops fetalis. Serial ultrasound volumetry demonstrated a trend toward a decreasing CCAM volume, despite an initial increase in volume. Complete resolution was noted in two cases by antenatal sonography. However, persistent lung lesions were found in two cases by postnatal chest radiography and in all cases by postnatal computed tomography scans. CONCLUSION The outcomes of the prenatally detected CCAMs were good in our cases. If the CCAM is not complicated by hydrops fetalis, maintaining the pregnancy with continuing management seems to be a reasonable recommendation. Despite antenatal resolution of CCAM on ultrasound, postnatal examination with chest radiography and computed tomography scan is necessary.

Fulminant Sepsis after Second-Trimester Amniocentesis in Pregnant Women by in vitro Fertilization and Embryo Transfer

Second-trimester amniocentesis is a common procedure for prenatal diagnosis. Sepsis is a rare complication after amniocentesis and may rapidly deteriorate if prompt treatment, including broad-spectrum antibiotics and removal of the infected abortus, is delayed. In vitro fertilization and embryo transfer (IVF-ET) is a standard final treatment for infertile women. Transvaginal oocyte retrieval is necessary for such women; this procedure potentially causes Escherichia coli attaching and effacing in the abdominal cavity. Here we report that two pregnant women by IVF-ET developed sepsis after second-trimester amniocentesis. The cause of sepsis after amniocentesis is still unknown. We provided the possibility of the causation of the E. coli infection associated with the previous intra-abdominal procedure, but it needs more evidence to prove it.

Prenatal Diagnosis of a Fetus Affected with Down Syndrome and Deletion 1p36 Syndrome by Fluorescence in situ Hybridization and Spectral Karyotyping

Objective: A fetus having partial trisomy of the distal part of chromosome 21q due to a de novo translocation is reported here. Method: A 29-year-old woman received amniocentesis at 18 weeks of gestation because of abnormal ultrasound findings including bilateral choroid plexus cysts, atrioventricular septal defects, rocker-bottom feet, and possible hydrocephalus. Results: Cytogenetic analysis revealed 46,XY, add(1)(p36.3), in which an additional material of unknown origin was attached to one of the terminal short arms of chromosome 1. Parental blood studies showed normal karyotypes in both parents. Spectral karyotyping was then performed and the origin of the additional material locating at chromosome 1p was found to be from chromosome 21. Conventional fluorescence in situ hybridization analysis was also used and confirmed the spectral karyotyping findings by use of a chromosome 21 specific painting probe, a locus specific probe localized within bands 21q22.13–q22.2 and a 21q subtelomeric probe. A hidden Down syndrome caused by a de novo translocation in this fetus was therefore diagnosed and the karyotype was designated as 46,XY, der(1)t(1;21)(p36.3;q22.1).ish der(1)(WCP21+, LSI 21+, 1pTEL–, 21q TEL+) de novo. Clinical features of the 1p36 deletion syndrome are also reviewed and may contribute to some features of this fetus. Termination of pregnancy was performed at 20 weeks of gestation. Conclusion: To our knowledge, our case appears to be the first to have partial monosomy 1p and partial trisomy 21q caused by de novo translocation being diagnosed prenatally.

Outcomes of autologous fascial slingplasty procedure for treating female urinary incontinence

The aims of this study were to compare the pre- and postoperative urodynamic findings of the suburethral autologous rectus fascial sling procedure and to determine patient satisfaction with the procedure by telephone interviews. Eight-four female patients with urodynamic stress incontinence completed a multi-channel urodynamic study and pad test before and after the operation. Subjective and objective satisfaction were also recorded. Significant changes were noted in the stress maximal urethral closure pressure, pad test, voided volume, and peak flow rate (P < 0.05). The success rate was about 94%, and subjective satisfaction was about 72%. The most common complication was transient urinary tract infections. The suburethral sling resolved 50% of detrusor overactivity (DO), but de novo DO was 24%. The procedure combined with anterior colporrhaphy corrected or improved 97% of anterior vaginal wall prolapses (≥stage II). This retrospective study demonstrates that suburethral autologous facial slingplasty has a high cure rate, high patient satisfaction, and is a less complicated procedure. It can also correct and prevent a recurrence of anterior vaginal wall prolapse when combined with anterior colporrhaphy.

Sonographic Features of Uterine Arteriovenous Malformations: Two and Three dimensional Findings

Uterine arteriovenous malformations (AVMs) are uncommon but occasionally serious and even life-threatening vascular lesions within the myometrium. They are detectable with traditional two-dimensional (2D) ultrasonography and color Doppler mapping. The diagnosis is made by visualizing a hypervascular region or mass within the myometrium. We report a case of uterine AVMs that was diagnosed with 2D and three-dimensional (3D) ultrasonography and confirmed by post-hysterectomy histology. When women have abnormal uterine bleeding with a heterogeneous myometrial mass, even in pregnancy, uterine AVMs should be considered.

Prenatal diagnosis of parapagus diprosopus dibrachius dipus twins with spina bifida in the first trimester using two- and three-dimensional ultrasound

OBJECTIVE Here, we report a case of parapagus diprosopus twins with spina bifida diagnosed in the first trimester of pregnancy using two-dimensional (2D) and three-dimensional (3D) ultrasound. CASE REPORT A 28-year-old Taiwanese woman, gravid 1, para 0, visited our hospital due to an abnormal fetal head shape discovered by 2D ultrasound at 11-weeks gestation. Parapagus diprosopus twins with spina bifida were diagnosed after ultrasound examination. The characteristics of parapagus diprosopus twins are more illustrative in 3D ultrasound than in 2D ultrasound. After counseling, termination of pregnancy was chosen by the couple. Although necropsy was declined, the gross appearance and radiograph of the abortus confirmed our diagnosis. CONCLUSION With the help of 3D ultrasound, we made an early and definitive diagnosis of conjoined twins.

CHANGES OF URETHRAL PRESSURE PROFILOMETRY IN PUBOVAGINAL SLING AND MODIFIED BURCH COLPOSUSPENSION PROCEDURES

OBJECTIVE To evaluate the different effects on urethral pressure profilometry (UPP) in pubovaginal slingplasty (PVS) and modified Burch colposuspension (MBC) procedures. MATERIALS AND METHODS This was a descriptive study of urodynamic parameters and urethral pressure profilometry. A total of 63 patients with successful anti-incontinence surgery were recruited for this study. Thirty-eight women had received MBC before 1998, to stabilize the bladder neck and the anterior vaginal wall. Twenty-five women had undergone autologous PVS to elevate the backstop effect on the proximal urethra between 1998 and 2000. All patients were followed-up for at least 24 months after surgery. RESULTS The mean age of patients in the PVS group was 52.5 years (range, 32-70 years), and 45.5 years (range, 31-61 years) in the MBC group. Age and parity were not significantly different between the two groups. The pressure transmission ratio (PTR) of the urethra increased significantly in both groups during the postoperative evaluation. Patients who had the MBC procedure showed an increased PTR at quarter (Q) Q1, Q2, and Q3 of the urethra. However, in the PVS group, the PTR increased only at Q3. The urethral closure pressure elevated significantly after MBC, but there were no significant changes after PVS. CONCLUSION Our results indicate that different effects on UPP are evident in the PVS and MBC procedures. These two procedures should be considered in different anti-incontinence effect.