Man-Jung Hung

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.

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.

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.

Expression Analysis of Apoptosis-related Markers TP53, BCL-2, BAX and c-MYC in Female Genital Tract Sarcomas

Background: Most female genital tract sarcomas are highly malignant and fatal. Their aggressive growth pattern and poor response to chemotherapy are the major causes of death. Deregulation of the apoptosis pathway is related to tumorigenesis and chemodrug resistance. The purpose of this study was to investigate the expression status and relationship of the apoptosis‐related markers TP53, BCL‐2, BAX and c‐MYC in this group of tumors. In addition, correlations of these markers with clinicopathologic findings and their prognostic significance were also examined. Methods: Paraffin blocks of female genital tract sarcoma tissue from 54 patients were obtained after pathology review. Protein expression of TP53, BCL‐2, BAX and c‐MYC was examined using immunohistochemical staining with standard procedures. A semiquantitative method was used to assess the staining result where scoring 1–3 was negative and 4–9 was positive for expression. The mutual relationships between TP53, BCL‐2, BAX and c‐MYC were examined. Associations between expression of the apoptotic markers and tumor stage as well as outcome were also analyzed. Results: We found that all 4 of the apoptosis‐related markers were frequently expressed in female genital tract sarcomas. Of the 54 cases, 24 (44%) were positive for TP53, 23 (43%) for BCL‐2, 25 (46%) for BAX, and 30 (56%) for c‐MYC. A significant positive association was observed between BAX and c‐MYC (p < 0.001). There was no significant difference for the expression status of the 4 markers in early and late stage tumors. In prognostic analysis, overexpression of TP53, late stage, and age were significant prognostic factors in both univariate and multivariate analyses. Conclusion: Since changes in TP53, BCL‐2, BAX and c‐MYC frequently occur in female genital tract sarcomas, deregulation of apoptosis appears to be involved in the pathogenesis of this group of tumors. This mechanism may occur early in tumorigenesis and include the c‐MYC/BAX apoptotic pathway or BCL‐2. However, TP53 mutation may play a crucial role in this process, and clinically, it could be used as a prognostic indicator.

Loss of Smad4 protein expression occurs infrequently in endometrial carcinomas

Smad4 is a member of the Smad proteins, which are needed for mediating signals of transforming growth factor &bgr; from the cell surface to the nucleus. Smad4 is also a tumor suppressor gene for cancers of the pancreas, colon, and lung. The aim of this study was to investigate the expression and prognostic significance of this gene product in endometrial cancer. Immunohistochemical staining for Smad4 was performed on formalin-fixed, paraffin-embedded specimens of endometrial tumors with an anti-Smad4 monoclonal antibody (clone B8): 97 primary endometrial carcinomas, 20 cases of endometrial hyperplasia, and 26 cases of metastases from endometrial carcinoma. The immunoreactivity of each tumor was correlated with the clinical and histopathologic parameters of the patients. Diffusely positive expression of Smad4 protein was detected in all 20 cases of endometrial hyperplasia and in most of the primary and metastatic endometrial cancers. The frequency of positive expression decreased progressively with tumor grade. Clinically, however, it was not associated with tumor progression, nor did it predict patient outcome. Although loss of heterozygosity at chromosome 18q21 (the location of the Smad4 gene) is frequent in endometrial carcinomas, the authors show in this immunohistochemical study that inactivation of this gene occurs infrequently in this tumor.

Management of Pelvic Lymphocysts by Ultrasound-Guided Aspiration and Minocycline Sclerotherapy

Objective: The purpose of this study was to describe our experience with ultrasound-guided aspiration of postoperative pelvic lymphocysts followed by intracavitary minocycline injection as sclerotherapy. Patients and Methods: From 1997 to 2003, patients who developed either symptomatic or persistent lymphocyst after pelvic lymphadenectomy for gynecological malignancy were recruited in this study. All of the lymphocysts were palpable and were further examined by ultrasonography. Percutaneous ultrasound-guided needle aspiration of the lymphocyst was performed and then immediately followed by a single-dose injection of minocycline into the collapsed cavity. Follow-up was conducted every 4 weeks with pelvic examination and ultrasonography. Results: Nineteen patients with a total of 21 pelvic lymphocysts underwent this procedure. The median size of the lymphocysts was 6 cm in diameter (range, 4–9 cm). Fifteen patients received 1 treatment, 3 received 2, and 1 patient with bilateral lymphocysts received 3 treatments. Complete resolution occurred in 14 patients (74%), and the other 5 patients (26%) had partial resolution with the volume of the lymphocyst decreasing at least 50%. For the 14 patients with complete resolution, the median time from treatment to disappearance of the lymphocyst was 3 months (range, 1–10 months), and none of them developed recurrence during the average follow-up period of 40 months (range, 2–62 months). No significant complication occurred with this procedure except for transient mild to moderate pelvic pain. Discussion: Minocycline sclerotherapy seems to be a simple and safe method with a satisfactory success rate in treating lymphocysts which develop after pelvic lymphadenectomy. It can be performed in an outpatient setting and can be repeated if necessary. This procedure may be considered as the initial treatment modality for patients suffering from symptomatic or persistent lymphocysts after radical gynecological surgery.

The coexistence of interstitial cystitis and overactive bladder in a patient with lower urinary tract symptoms.

The definition of interstitial cystitis (IC) has evolved to include painful bladder syndrome (PBS) in the past few years. IC is a syndrome characterized by “the complaint of suprapubic pain related to bladder filling, accompanied by other symptoms such as increased dayand nighttime frequency, in the absence of proven urinary infection or other obvious pathology” [1]. However, the signs and symptoms of IC/PBS early in the course of disease may be intermittent and variable, making IC/PBS difficult to recognize [2]. Overactive bladder (OAB), which was recently defined by the International Continence Society as “urinary urgency, usually accompanied by frequency and nocturia, with or without urinary urgency incontinence, in the absence of urinary tract infection or other obvious pathology” [3], is one of several disorders that have the same cluster of symptoms as IC/PBS. Therefore, it is sometimes not easy to differentiate IC and OAB on the basis of clinical presentation alone. However, the conventional therapies used for each diagnosis address different pathophysiological mechanisms [4,5]. It is crucial to establish the correct diagnosis prior to embarking on any extended treatment protocol. Many clinicians have used the presence of urodynamic detrusor overactivity (DO) as a criterion to exclude the diagnosis of IC [6]. However, recent studies and surveys suggest the possibility that two conditions may exist concurrently [7]. Investigators have suggested that some patients diagnosed with OAB, particularly those refractory to treatment with antimuscarinics, may have IC [8e11].

Low compliance bladder

In the current issue of the Taiwanese Journal of Obstetrics and Gynecology (Volume 54, Issue 6), Liao et al [1] presented an interesting article entitled “Monitoring bladder compliance using end filling detrusor pressure: Clinical results and related factors.”We congratulate the success of this publication and are happy to read this article. However, we are uncertain about some of the data presented in this article, and we hope that the study authors can provide additional information about their results. First, because there is no gold-standard reference to evaluate the compliance of urinary bladder, caution should be exercised when using the investigated tools; besides, these tools might not be accepted by the majority of the experts to define those who might have low compliance bladder. We believe that the investigated tools should be carefully compared with the well-accepted procedures, to analyze the sensitivity and specificity between the investigated tools and wellaccepted procedures. Furthermore, the authors claimed that target women (n1⁄4 1490) in their study who had received videourodynamic studies had lower urinary tract symptoms, including voiding dysfunction (n1⁄4 385), urinary incontinence (n1⁄4 374), pelvic organ prolapse (n1⁄4 275), recurrent urinary tract infection (n1⁄4 171), and neurogenic bladder (n1⁄4 285) [1]. The authors reported that 136 women (9.1%) had low compliance bladder based on their original definition (i.e., >20 cmH2O of end filling detrusor pressure) [1]. However, the authors failed to mention how they obtained this definition. In addition, the cutoff point (end filling detrusor pressure 17.5 cmH2O) in the area under a receiver operating characteristic curve suggested by the study authors may be questionable. Finally, it is uncertain whether those women who were diagnosed with low compliance bladder showed any clinical significance in the study. The data presented by the authors showed that there was a statistically significant difference in the end filling detrusor pressure between all patients and the patients diagnosed with low compliance bladder (15.02± 7.54 cmH2O vs. 48.67± 95.58 cmH2O). However, we found that the standard deviation of the data was too big, thus resulting in the high possibility of no use. The standard deviation in women with low compliance bladder was so big and reached up to 95.58, which is two times as that of the mean (48.67), suggesting that that data presented should be interpreted with caution. Furthermore, it is interesting to find that patients with low compliance bladder even had a much higher urinary capacity than all patients studied, because the first desire to voiding in this group occurred when the bladder capacity reached a mean value of 409.98 mL; by contrast, for all other patients studied, the first desire to voiding was much smaller