Hazem Al-Mandeel

Incidence of stress urinary incontinence following vaginal repair of pelvic organ prolapse in objectively continent women

Objective To estimate the incidence of stress urinary incontinence (SUI) following vaginal repair of pelvic organ prolapse (POP) in preoperatively continent women and to evaluate the impact of the problem.

Monopolar Electrosurgery through Single-Port Laparoscopy: A Potential Hidden Hazard for Bowel Burns

BACKGROUND Surveys indicate that up to 90% of general surgeons and gynecologists use monopolar radiofrequency during laparoscopy and 18% have experienced visceral burns. Monopolar electrosurgery compared with other energy sources is associated with unique characteristics and inherent risks and complications caused by inadvertent direct or capacitive coupling or insulation failure of instruments. These dangers become particularly important with the reemergence of single-port laparoscopy, which requires close proximity and crossing of multiple intraabdominal instruments outside the surgeons field of view. STUDY OBJECTIVES To determine the effects of monopolar electrosurgery on various tissues/organs during simulated single-port laparoscopic surgery in vitro and in vivo. DESIGN Simulation in a dry laboratory with fresh sheep liver, pig bowel and bowel in an anesthetized dog (Canadian Classification II-3). SETTING University-affiliated teaching hospital and animal facilities. MEASUREMENTS AND MAIN RESULTS We used Valleylab Force 2 and FX electrosurgical generators at clinically used power outputs of 40 to 60 watts, and both high- and low-voltage (coagulation and cut) waveforms and commercially-available single-port devices. The effect on tissue was recorded by pictures and video camera and graded visually and histologically with hematoxylin and eosin stains. During activation of any standard monopolar laparoscopic instrument (scissors, coagulating electrode, etc), capacitive coupled currents resulting in visible tissue burn (blanching) caused by other adjacent cold instrument (graspers, etc) including metallic suction-irrigation cannulas and the laparoscope itself were noted. Histopathologic study confirmed transmural thermal damage extending to the mucosa of small bowel, even in the presence of mild serosa blanching. With prolonged activation of the electrosurgical generator, the capacitive coupled corona discharge burned the insulation and caused rapid insulation breakdown of the electrode instrument resulting in direct coupling (sparking, arcing) to adjacent cold instruments and more severe burning to the contacted tissue/organ. CONCLUSIONS During single-port laparoscopy and use of monopolar radiofrequency, the proximity and crossing of multiple instruments generate capacitive or direct coupled currents, which may cause visceral burns.

De novo stress urinary incontinence after vaginal repair for pelvic organ prolapse: one-year follow-up

OBJECTIVE A few studies have reported a wide range (2-43%) in incidence of de novo stress urinary incontinence (SUI) following surgical repair of pelvic organ prolapse (POP) in previously continent women. The aim of this study was to re-examine this incidence up to one year following vaginal repair of prolapse. STUDY DESIGN Retrospective review of a cohort of women who underwent reconstructive vaginal repair of POP without a concomitant anti-incontinence procedure between 2003 and 2007 at two tertiary referral centers. Women were considered eligible if they were stress continent by symptoms and objective assessment (including urodynamics testing) prior to surgical repair. All women who had had any anti-incontinence procedure previously were excluded. The endpoint was subjective SUI that prompted the patient to undergo any treatment within one year from their prolapse surgery. RESULTS 64 women, with a mean age of 61 (±11) years, were eligible for the study: 26 (41%) had preoperative symptoms of overactive bladder. Fifty-four patients were available for analysis at the one-year visit. Seven women (13.5%) had symptoms of SUI but only one (2%) was found to have SUI objectively. Another patient underwent anti-incontinence surgery following her prolapse surgery. CONCLUSION The incidence of de novo SUI requiring treatment in previously continent women who underwent vaginal repairs for POP without concomitant anti-incontinence surgery is low (4%). A large-scale prospective study is necessary to further evaluate this finding.

Effects of intentional delivery on maternal and neonatal outcomes in pregnancies with preterm prelabour rupture of membranes between 28 and 34 weeks of gestation: a systematic review and meta-analysis

Objective: To assess the effects of intentional delivery (ID) over expectant management (EM) in pregnancies complicated by preterm prelabour rupture of membranes (PPROM) between 28 and 34 weeks of gestation on maternal and neonatal outcomes. Methods: We searched Ovid MEDLINE, EMBASE, CINAHL, CENTRAL and Science Citation Index; contacted experts and checked reference lists of relevant studies. Studies were included if they were randomized controlled trials in all languages. Results: Five randomized trials were included and 488 subjects were analyzed. Overall, the results showed significant heterogeneity. Maternal infection as well as respiratory distress syndrome (RDS) & neonatal sepsis (NS) were not different between the two groups. Neonatal death, however, was significantly higher (risk ratio: 5.81; 95% CI: 1.35–25.08; p = 0.03) in the ID group after excluding studies that gave antenatal steroids. Incidence of cesarean section was significantly higher in the intentional delivery group, as well (risk ratio: 1.35; 95% CI: 1.02–1.80; p = 0.03). Conclusion: Based on the available evidence, ID in pregnancies complicated with PPROM between 28 and 34 weeks carries some maternal and neonatal risks with no added benefits. Thus, this treatment should not be considered as an option for women with PPROM before 34 weeks of gestation in the absence of other indications for early delivery.

Recurrent pelvic organ prolapse: International Urogynecological Association Research and Development Committee opinion

Introduction and hypothesisThis committee opinion paper summarizes available evidence about recurrent pelvic organ prolapse (POP) to provide guidance on management.MethodA working subcommittee from the International Urogynecological Association (IUGA) Research and Development Committee was formed. The literature regarding recurrent POP was reviewed and summarized by individual members of the subcommittee. Recommendations were graded according to the 2009 Oxford Levels of Evidence. The summary was reviewed by the Committee.ResultsThere is no agreed definition for recurrent POP and evidence in relation to its evaluation and management is limited.ConclusionThe assessment of recurrent POP should entail looking for possible reason(s) for failure, including persistent and/or new risk factors, detection of all pelvic floor defects and checking for complications of previous surgery. The management requires individual evaluation of the risks and benefits of different options and appropriate patient counseling. There is an urgent need for an agreed definition and further research into all aspects of recurrent POP.

Reliability of Arabic ICIQ-UI short form in Saudi Arabia

Context: The International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) provides a brief measure of symptoms and impact of urinary incontinence on quality of life. It is suitable for use in clinical practice and research. An Arabic version of the ICIQ-UI SF was translated and validated in Egypt and Syria. Aims: The objective was to assess the reliability of the Arabic version of the ICIQ-UI SF in women from Saudi Arabia. Settings and Design: A study at the Urogynecology Clinic was conducted from November 2010 until August 2011. Materials and Methods: Thirty-seven consecutive Saudi women attending urogynecologic clinic were recruited. Questionnaires were distributed for self-completion and then redistributed to the same set of respondents two to four weeks later as part of a test-retest analysis for assessing questionnaires stability. Statistical Analysis Used: Agreement between two measurements was determined by weighted Kappa. Internal consistency was assessed using Cronbachs alpha coefficient. Results: Participants had a mean (SD) age of 39 (9.9), median parity of 4, and mean BMI (SD) of 30.9 kg/m2 (4.6). There were no differences in the frequency and amount of urine leaks or the impact of UI on quality of life observed between the two visits. Assessment of internal consistency was excellent with the Cronbachs alpha coefficient of 0.97 (95% CI: 0.88-0.98). Participants agreed that the questionnaire was clear, appropriate, and easy to understand. Conclusions: The Arabic ICIQ-UI SF is a stable and clear questionnaire that can be used for UI assessment in clinical practice and research among Saudi women.

Effectiveness and outcomes of thermablate endometrial ablation system in women with heavy menstrual bleeding

Abstract Heavy menstrual bleeding (HMB) is a common problem in women of reproductive age group with major impact on their quality of life (QoL). The aim was to study the short-term effectiveness of Thermablate Endometrial Ablation System (EAS) and its impact on QoL in women with HMB. This was a prospective cohort study conducted on consecutive 72 women suffering from HMB. The success rate was estimated and patients’ QoL was compared before and after the procedure using the Aberdeen menorrhagia severity scale. The mean follow-up period was 18 months (6–24 months). The mean age and body mass index were 48 (±5.2) years 33.2 (±7.4) kg/m2 respectively. Among treated participants, 58 (80.6%) reported the absence of bleeding. A significant decrease was observed in the rate of missed social activity and increase in the leisure time activities. The overall patient satisfaction was 95.7%. Thermablate EAS is an effective minimally invasive treatment with marked improvement in QoL in women with HMB. Impact statement Heavy menstrual bleeding (HMB) is a common problem that affects 11–13% of reproductive age women with major impact on their quality of life (QoL). A variety of methods for endometrial ablation has been used for the destruction of the endometrial lining to treat HMB. The short-term results of this study shows amenorrhoea rate of (80.6%) after the procedure and a significant decrease in the rate of missed social activity and increase in the leisure time activities with marked improvement in QoL. The overall patient satisfaction was 95.7%. Thermablate Endometrial Ablation System is an effective minimally invasive treatment for HMB with advantages of shorter operating time, shorter hospital stay and high-level patient satisfaction. However, further clinical research with large-scale studies and possible comparison with other treatment options are recommended.

Ovulation induction by metformin among obese versus non-obese women with polycystic ovary syndrome

Objectives There is some evidence that the efficacy of metformin as an ovulation stimulation agent depends on the body mass index (BMI) of the treated anovulatory women with polycystic ovary syndrome (PCOS). The aim of this study was to examine the likelihood of successful ovulation among obese (BMI ⩾30 kg/m2) versus non-obese (BMI <30 kg/m2) women with PCOS. Methods A total of 243 medical charts of women with PCOS who visited King Khaled University Hospital (KKUH) in Riyadh, Saudi Arabia, between 2006 and 2012 were reviewed. Patients’ sociodemographic, laboratory, and medical data were collected. Descriptive statistics and multiple logistic regression analyses were performed to compare the patients’ baseline data and successful ovulation among the obese and non-obese anovulatory women with PCOS, respectively. Results One hundred and nine women with PCOS who were prescribed metformin for ⩾3 months were included in the study. Almost 60% of the women who were included in the study were obese. The likelihood of ovulation among obese women with PCOS was 77.9% (odds ratio = 0.221, 95% CI 0.052–0.947, P = 0.042) less than that in their non-obese counterparts. Conclusion The findings of this study suggest that metformin is more effective as an ovulation stimulation agent when administered to non-obese women with PCOS. Lifestyle modifications such as diet and exercise should be emphasized upon as an integral part of any treatment plan for PCOS.

The effect of metformin use on pregnancy rates among polycystic ovary syndrome patients undergoing in vitro fertilization: A retrospective-cohort study

Background Metformin is widely used with gonadotropins by women with polycystic ovary syndrome (PCOS) during in vitro fertilization (IVF) to increase their chances of pregnancy. The aim of this study was to evaluate the efficacy of metformin in improving the rates of clinical pregnancy among women with PCOS undergoing IVF. Methods This was a retrospective cohort study of women with PCOS, aged 18–40 years, undergoing IVF during 2006–2012 at a University Hospital in Riyadh, Saudi Arabia. Baseline patient data including menstrual frequency, biochemical parameters such as fasting serum insulin (FSI) concentration, comorbidities, and the rates of ovulation and pregnancy were collected. Pregnancy rates were compared between the metformin and non-metformin groups. Results A total of 210 women with PCOS met the inclusion criteria and were included in the study. Of the 210 women with PCOS, 109 of them received metformin in addition to gonadotropins. Patients who received metformin were 16% less likely to be pregnant in comparison with those who did not receive metformin (OR = 0.840; 95% CI = 0.710–0.993; P = 0.0415), when controlled for baseline prolactin level, testosterone level, lipid panel, FSI concentration, fasting plasma glucose (FPG) concentration, comorbidities, duration of infertility, daily metformin dosage, and the previous use of clomiphene and/or leuprolide. Conclusions Metformin co-treatment during IVF may negatively affect pregnancy rates. Further well-designed, randomized, double-blind placebo-control clinical trials are needed to confirm the findings of this study.

Incidence of Early Postpartum Voiding Dysfunction in Primiparae: Comparison Between Vaginal Delivery and Cesarean Section

To compare the incidence of early postpartum voiding dysfunction (PPVD) in primiparae women delivered vaginally (VD) to those delivered by elective Caesarean section (CS).