Paul P. Koonings

A comparison of propylthiouracil versus methimazole in the treatment of hyperthyroidism in pregnancy

OBJECTIVE Our purpose was to demonstrate that propylthiouracil and methimazole are equally effective and safe in the treatment of hyperthyroidism during pregnancy. STUDY DESIGN Between 1974 and 1990 records were available on 185 pregnant patients with a history or diagnosis of hyperthyroidism. Ninety-nine patients were treated with propylthiouracil and 36 with methimazole. The response to therapy was compared with respect to the time to normalization of the free thyroxine index and the incidences of congenital anomalies and hypothyroidism. RESULTS The time to normalization of the free thyroxine index was compared in the two groups by means of survival analysis. The median time to normalization of the free thyroxine index on propylthiouracil and methimazole was 7 and 8 weeks, respectively (p = 0.34, log-rank test). The incidence of major congenital malformations in mothers treated with propylthiouracil and methimazole was 3.0% and 2.7%, respectively. No neonatal scalp defects were seen. One infant was overtly hypothyroid at delivery. CONCLUSION Propylthiouracil and methimazole are equally effective and safe in the treatment of hyperthyroidism in pregnancy.

Predicting postoperative urinary incontinence development in women undergoing operation for genitourinary prolapse

A total of 67 female patients with pelvic relaxation (cystocele beyond the vaginal orifice) and with no urinary incontinence were clinically and urodynamically evaluated before and after a reconstructive surgical procedure. Of these, 24 patients had a significant decrease in abdominal pressure transmission to the urethra once the cystocele was reduced by vaginal pessary (abdominal pressure transmission ratio to urethra: bladder of less than 1.0). All 24 had a revised Pereyra procedure in addition to the cystocele repair. The other 43 patients had adequate abdominal pressure transmission to the urethra once the cystocele was reduced by vaginal pessary (abdominal pressure transmission ratio to urethra: bladder of greater than or equal to 1.0). These 43 patients underwent cystocele repair only with no surgical repair to the urethra or urethrovesical junction. Evaluation was repeated at 3 to 6 months after the operation. No patient developed urinary incontinence after operation. All 67 patients had urodynamically good abdominal pressure transmission to the urethra while coughing. Women with significant genitourinary prolapse may be continent in spite of a weak urethral sphincter because of kinking of the poorly supported urethra. Urodynamic testing can identify those women at risk of developing postoperative urinary incontinence so that prophylactic measures can be undertaken.

Comparison of three different surgical procedures for genuine stress incontinence: Prospective randomized study

One hundred seven consecutive patients with clinical and urodynamic findings of genuine stress incontinence not previously treated were prospectively allocated in a randomized manner to one of three surgical procedures: anterior colporrhaphy, revised Pereyra procedure, or Burch retropubic urethropexy. Randomization included the surgical procedure and choice of surgeon (one of the three authors). Clinical and urodynamic evaluations were repeated at 3 months and 1 year after surgery. Differences in cure rates among the three procedures at the 3-month postoperative evaluation were insignificant (82%, 84%, and 92% for the anterior colporrhaphy, Pereyra, and Burch respectively) but became statistically significant at the 1 year postoperative evaluation (cure rates of 65%, 72%, and 91% for the anterior colporrhaphy, Pereyra, and Burch respectively, p less than 0.05). In our hands the Burch procedure stabilized the urethrovesical junction and prevented its descent during straining (evaluated by a postoperative Q-tip test) more effectively than either the Pereyra or anterior colporrhaphy. No procedure resulted in severe postoperative voiding difficulties. The present prospective randomized study demonstrates that in our hands the abdominal retropubic operation for genuine stress incontinence in patients not previously operated on results in a higher cure rate when compared with anterior colporrhaphy or Pereyra procedure.

Primary stress urinary incontinence and pelvic relaxation: Prospective randomized comparison of three different operations

There were 289 women with clinical and urodynamic diagnosis of primary stress urinary incontinence, stable bladder, and pelvic relaxation who underwent a single-stage surgical procedure because of incontinence and pelvic relaxation. Patients underwent one of three surgical procedures because of stress incontinence—anterior colporrhaphy, revised Pereyra procedure, or Burch retropubic urethropexy. Decisions with regard to the type of bladder neck suspension and the surgeon were made randomly with a randomization table. Each patient had a complete clinical and urodynamic evaluation before surgery and at 3 and 12 months after surgery. Cure rate as defined by strict clinical and urodynamic criteria was not significantly different among the three groups at the 3-month postsurgical evaluations; however, at the 12-month postsurgical evaluations, the cure rate among women who underwent Burch urethropexy ( n = 101) was significantly higher than that of either Pereyra or anterior colporrhaphy (cure rates were 87%, 70%, and 69%, respectively; p

Proposed Management of Low Urethral Pressure Type of Genuine Stress Urinary Incontinence

One hundred and twenty-one patients with genuine stress urinary incontinence underwent urodynamic examination before and after Burch colposuspension. They were divided into two groups, one with preoperative urethral pressure of 20 cm water or less (n = 17), and the other with urethral pressure greater than 20 cm water (n = 104). Success rates at 12 months were significantly lower in women with low urethral pressure as compared with those with normal urethral pressure (65 vs. 88%; p less than 0.01). Starting in January 1987, all patients with low urethral pressure preoperatively underwent a surgical procedure which combined the techniques of the Ball and Burch procedures. Short-term cure rate (at 3 months postoperative follow-up) in women with low urethral pressure was 83% as opposed to 70% with the Burch urethropexy (p less than 0.05).

Preservation of ovarian tissue in adnexal torsion with fluorescein

OBJECTIVE Our purpose was to assess the ability of fluorescein to intraoperatively detect viable fallopian and ovarian tissues involved in adnexal torsion. STUDY DESIGN This prospective study was performed at Los Angeles County+University of Southern California Womens Hospital. Participants were female patients 18 to 45 years old with adnexal torsion confirmed at exploratory celiotomy. Five milliliters of 10% fluorescein were injected intravenously, and the involved untwisted adnexa was observed under ultraviolet light. Nonfluorescent tissue was resected and histologically evaluated. RESULTS Eleven patients were entered into the study. Mean age was 25 years (range 15 to 42). Eight patients (72%) had preservation of involved ovarian tissue. No complications were associated with this procedure. Only three patients (28%) underwent oophorectomy. CONCLUSION The use of intravenous fluorescein appears to be a valuable adjunct in the management of adnexal torsion. Application of this technique in reproductive-aged patients resulted in a three-quarter reduction in oophorectomy procedures.

Urethral pressure changes in women with detrusor instability. Bladder or urethral pathologic process

Abstract One hundred and fourteen female patients had clinical and urodynamic diagnosis of detrusor instability. They all received oxybutynin chloride (Ditropan) 5 mg t.i.d. for four weeks and evaluation repeated. Sixty-six of the 114 patients (58%) responded favorably to antieholinergic treatment while 48 patients (42%) did not. Based on urethrocystometry, two groups of patients were identified: Group I consisted of 73 women with bladder contraction that preceded any change in urethral pressure. Group II consisted of 41 patients with urethral pressure drop that preceded the detrusor contraction by a few seconds. Sixty-one of the 73 women (84%) in Group I responded favorably to four weeks of anticholinergic therapy while 88 percent (36 of 41) of women in Group II did not (P

Bilateral ovarian neoplasms and the risk of malignancy

Bilateral ovarian neoplasms are believed more likely to be malignant than are unilateral neoplasms. To our knowledge, this clinical tenet has not been evaluated or quantified. To test this hypothesis, we conducted a 10-year review of ovarian neoplasms found at the time of celiotomy at the Womens Hospital, Los Angeles County-University of Southern California Medical Center. Overall, women with bilateral neoplasms had a 2.6-fold increased risk of malignancy when compared with women who had unilateral neoplasms (95% confidence interval, 2.0 to 3.4; p less than 0.001). The age-standardized relative risk was 1.8 (95% confidence interval 1.4 to 2.3). When standardized for the effect of menopausal status, the relative risk was 2.0 (95% confidence interval, 1.6 to 2.5). Bilaterality is associated with a doubling in the risk of cancer, a highly significant difference.

CA-125: a marker for persistent gestational trophoblastic disease?

The objective was to determine whether CA-125 levels have any clinical utility in gestational trophoblastic disease. Fifty-one patients with a pathologically confirmed diagnosis of complete hydatidiform mole had a CA-125 level obtained prior to suction molar evacuation. Data were analyzed using chi 2 and Mann-Whitney U test. CA-125 levels were twice as high in persistent gestational trophoblastic disease than those in complete hydatidiform molar patients (85.9 vs 48.3 U/ml; P = 0.004). CA-125 levels were independent of age, gravidity, weeks of amenorrhea, or presence of thecal-luteal cysts. CA-125 levels appear to be of value in predicting which molar patients will develop persistent disease.

A clinical-pathology review of cervical intraepithelial neoplasia following cryotherapy failure

Cervical intraepithelial neoplasia (CIN) after cryotherapy can pose both diagnostic and therapeutic problems. To clarify these issues, 27 consecutive patients who underwent cone biopsy for CIN after cryotherapy over a 10-year period at Womens Hospital LAC + USC Medical Center were reviewed. Although the initial features of the cervical intraepithelial neoplasia allowed for outpatient cryotherapy, the features of these failures did not (unsatisfactory colposcopy or CIN in the endocervical curettings). Eleven percent of these patients had stromal invasion on cone biopsy that was not suspected clinically. Patients presenting with cervical intraepithelial neoplasia following cryotherapy may, in fact, have progressive disease (i.e., stromal invasion) that is inapparent clinically. Hence, surgical excision should be considered in these circumstances.