Pentti K. Heinonen

Low-weight polypropylene mesh for anterior vaginal wall prolapse: a randomized controlled trial.

OBJECTIVE: To compare anterior colporrhaphy with and without a tailored mesh. METHODS: Postmenopausal women with anterior vaginal prolapse to the hymen or beyond were randomly assigned to undergo traditional anterior colporrhaphy alone or reinforced with mesh. The low-weight monofilament polypropylene mesh was self-tailored, having four arms and being placed over the plicated fascia. Before and 2 and 12 months after surgery, participants were evaluated by physical examination, postvoidal residual urine measurement and standard questions covering prolapse-related symptoms. The primary outcome was recurrence of anterior vaginal prolapse at 12 months. Secondary outcomes included operative complications, symptom resolution, and postvoidal urine residual volume. RESULTS: Of the 202 women randomly assigned, 201 were operated on (97 without, 104 with mesh). Thirty-seven women (38.5%) in the no-mesh and seven (6.7%) in the mesh group experienced a recurrence of anterior wall prolapse (P<.001) at 12 months; as a result, the number needed to treat for benefit was four. The mean (standard deviation) postvoidal residual urine volume was lower in patients with mesh than in those undergoing the traditional operation: 25 (26) mL and 41 (57) mL (P=.01). Twenty-three women (23%) with mesh and 9 (10%) with no mesh reported stress urinary incontinence (P=.02). In 18 (17.3%), exposure of the mesh was noted, mainly asymptomatic. CONCLUSION: Anterior colporrhaphy, reinforced with, tailored mesh significantly reduced the rate of recurrence of anterior vaginal wall prolapse compared with the traditional operation, but was associated more often with stress urinary incontinence. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00420225 LEVEL OF EVIDENCE: I

Reproductive Performance of Women with Uterine Anomalies: An evaluation of 182 cases

Abstract. A total of 182 women with uterine anomalies were observed over a period of 18 years. In all, 126 women had 265 pregnancies, fetal survival rate was 66%, perinatal mortality 8% and premature labors occurred in 23%. When the uterine anomalies were grouped according to degree of failure of normal uterine development, the complete septate uteri had the best fetal survival rate (86%), complete bicornuate uteri (50%) and unicornuate (40%) poorest. Cervical cerclage was applied most in the partial bicornuate uteri (17%), where fetal survival in operated cases was: before operation, 53% and after, 100%. The frequency of breech presentation was 40–50% in all groups except complete septate uteri (25%) and complete bicornuate (0%). The highest cesarean section rate (82%) was in deliveries of patients with uterus didelphys. The frequency of cesarean section among total deliveries was 53%. Metroplasty was carried out on 19 patients. The obstetric outcome improved from 10% successful pregnancies before surgery to 88% postoperatively.

Unicornuate uterus and rudimentary horn

OBJECTIVE To evaluate clinical implications of the unicornuate uterus and rudimentary horn. DESIGN A retrospective study. SETTING A university hospital. PATIENT(S) Forty-two women who had a unicornuate uterus with or without rudimentary horn. INTERVENTION(S) The rudimentary horn was removed in 21 cases. MAIN OUTCOME MEASURE(S) Presence of other anomalies, fertility, and outcome of pregnancies were studied. RESULT(S) A right unicornuate uterus with noncommunicating rudimentary horn was the most common type of uterine anomaly. Unilateral renal agenesis was found in 13 (38%) of 34 cases. Six (14%) of the 42 patients had primary infertility. Thirty-four women produced 93 pregnancies; ectopic pregnancy (EP; rudimentary horn, tubal) occurred in 20 of these cases (22%). The pregnant uterine horn ruptured in 3 of 7 cases. Eight (57%) of the 14 women with infertility underwent treatment by IVF-ET; 4 of them conceived, and 2 had term delivery. The fetal survival rate was 61%, prematurity 17%, fetal growth retardation 5%, and the spontaneous intrauterine (IU) abortion rate was 16%. Pregnancy-induced hypertension (PIH) was more common in women lacking a kidney than in those with two kidneys. CONCLUSION(S) The high number of EPs indicates removal of rudimentary horn and its tube when diagnosed. The prognosis of IU pregnancy is not impaired in the unicornuate uterus although prematurity threatens. Unilateral renal agenesis is associated with PIH.

Outcomes after anterior vaginal wall repair with mesh: a randomized, controlled trial with a 3 year follow-up

OBJECTIVE The objective of the study was to compare anterior colporrhaphy with and without a mesh. STUDY DESIGN Two hundred two women with anterior prolapse were assigned to undergo colporrhaphy alone or reinforced with a tailored polypropylene mesh. Before and 2, 12, 24, and 36 months after surgery, the outcome was assessed by examination and standard questions. The primary endpoint was anatomic recurrence of anterior vaginal prolapse. Secondary outcomes were symptom resolution, reoperation, and mesh exposure. RESULTS Recurrences of anterior vaginal prolapse were noted in 40 of the 97 (41%) in the colporrhaphy group and 14 of 105 (13%) in the mesh group (P < .0001). The number needed to treat was thus 4. The proportion of symptomatic patients, including those with dyspareunia, did not differ between the groups. The mesh erosion rate was 19%. CONCLUSION At 3 year follow-up, anterior colporrhaphy with mesh reinforcement significantly reduced anatomic recurrences of anterior vaginal prolapse, but no difference in symptomatic recurrence were noted and the mesh erosion rate was high. The use of mesh was not associated with an increase in dyspareunia.

Microbiological and histopathological findings in acute pelvic inflammatory disease

Upper genital tract infection was investigated in 45 women admitted to hospital for suspected acute pelvic inflammatory disease (PID). Salpingitis was diagnosed by laparoscopy in 30 (67%) women. Histopathological evidence of endometritis was found significantly more often in the 30 women with salpingitis (87%) than in the other 15 women without salpingitis (33%). C. trachomatis or N. gonorrhoeas, or both, were isolated from the upper genital tract in 14 of the 31 women who had both salpingitis and endometritis or endometritis only but in none of the four women who had salpingitis alone and in none of the 10 women who had no evidence of PID. Bacterial vaginosis was associated with histopathological evidence of upper tract infection. Non‐chlamydial nongonococcal organisms were frequently isolated from the upper genital tract. No organisms were isolated from the upper genital tract from 9 of 35 women with laparoscopic or histopathological evidence of PID compared with 7 of 10 women without evidence of PID. C, trachomatis or N. gonorrhoeae in the endometrium was associated with lymphoid follicles comprising transformed lymphocytes, and correlated with the density of plasma cells on biopsy. The microbiological results support the recommendations of broad spectrum antimicrobial therapy for PID.

Transanal or Vaginal Approach to Rectocele Repair: A Prospective, Randomized Pilot Study

PURPOSEThis study was designed to compare outcomes of transanal and vaginal techniques for rectocele repair.METHODSThirty females with symptomatic rectocele were enrolled in a prospective, randomized study. Fifteen underwent transanal rectoceleplasty, the other 15 underwent vaginal posterior colporrhaphy. Patients were assessed by clinical interview and examination, defecography, colon transit study, and anorectal manometry before randomization and 12 months postoperatively. Patients with compromised anal sphincter function or other symptomatic prolapse were excluded.RESULTSThe study groups were comparable in terms of demographic factors and rectocele-related symptoms and signs. Eleven (73 percent) patients in the vaginal group and 10 (66 percent) in the transanal group digitally assisted rectal emptying preoperatively. The mean depth of the rectocele was 6.0 ± 1.6 cm vs. 5.6 ± 1.8 cm (P = 0.53) in the respective groups. At follow-up, 14 (93 percent) patients in the vaginal group and 11 (73 percent) in the transanal group reported improvement in symptoms (P = 0.08). Need to digitally assist rectal emptying decreased significantly in both groups, to one (7 percent) for the vaginal group and four (27 percent) for the transanal group (P = 0.17 between groups). The respective recurrence rates of rectocele were one (7 percent) vs. six (40 percent) (P = 0.04), and enterocele rates were zero vs. four (P = 0.05). In the vaginal group defecography showed a significant decrease in rectocele depth whereas in the transanal group the difference did not reach statistical significance. None of the patients reported de novo dyspareunia, but 27 percent reported improvement.CONCLUSIONPatients’ symptoms were significantly alleviated by both operative techniques. The transanal technique was associated with more clinically diagnosed recurrences of rectocele and/or enterocele. Adverse effects on sexual life were avoided by use of both techniques.

Finnish national register of laparoscopic hysterectomies: A review and complications of 1165 operations

OBJECTIVE We evaluated the advantages and disadvantages of laparoscopic hysterectomy over a 2-year period when this new technique was introduced to several hospitals in Finland. STUDY DESIGN A nationwide register was founded and a prospective multicenter survey of 1165 laparoscopic hysterectomies was carried out from January 1993 to December 1994. The operations were performed because of uterine fibroids (54%), menorrhagia (27%), dysmenorrhea (8%), endometriosis (2%), and other reasons (9%) by 68 gynecologists at 30 hospitals. RESULTS The mean operation time was 132 minutes. The patients stayed in hospital for an average of 3.3 days, and the mean convalescence period was 17.9 days, half that after abdominal hysterectomy. Complications occurred in 10.2% of the procedures: infections in 5.6%, vascular complications in 1.2%, urinary tract complications in 2.7%, and bowel complications in 0.4%. CONCLUSIONS Laparoscopic hysterectomy offers a short hospital stay and convalescence time to the patient, but effective teaching is imperative to minimize, in particular, the risk of urinary tract injuries.

Clinical implications of the didelphic uterus: long-term follow-up of 49 cases

OBJECTIVE The aim of the study was to evaluate reproductive performance of women with didelphic uterus and to consider possible long-term consequences associated with this uterine anomaly. STUDY DESIGN Forty-nine women were diagnosed as having a didelphic uterus with a longitudinal vaginal septum at Tampere University Hospital, Finland between 1962 and 1998. The presence of other anomalies, gynecologic disorders, fertility and outcome of pregnancies were reviewed. The long-term clinical implications associated with a didelphic uterus were evaluated during the mean (S.D.) follow-up period of 9.1 (6.3) years. RESULTS An obstructed hemivagina was found in nine (18%) out of forty-nine cases; eight of these had ipsilateral renal agenesis. A longitudinal vaginal septum was excised in twenty-six (53%) cases, but metroplasty in none. Five (13%) patients had primary infertility. Thirty-four (94%) out of thirty-six women who wanted to conceive had at least one pregnancy, and they produced seventy-one pregnancies; 21% miscarried, and ectopic pregnancy occurred in 2%. The fetal survival rate was 75%, prematurity 24%, fetal growth retardation 11%, perinatal mortality 5. 3%, and cesarean section rate 84%. Pregnancy located more commonly (76%) in the right uterus than in the left. During the follow-up period endometriosis was observed in seven (16%) out of forty-five cases. Ovarian neoplasm was found in four (9%) cases, one of them had ovarian cancer. CONCLUSIONS Fertility in women with didelphic uterus is not notably impaired. The prognosis of pregnancy is comparatively good, while prematurity and fetal growth retardation indicate meticulous prenatal care. Long-term follow-up did not reveal that didelphic uterus is associated with increased frequency of endometriosis or genital neoplasm.

Anatomic and functional assessment and risk factors of recurrent prolapse after vaginal sacrospinous fixation

Background.  To identify risk factors in recurrence and to evaluate anatomic and functional results of vaginal sacrospinous ligament fixation and pelvic floor reconstruction for genital prolapse.

Comparison of endometrial biopsy and peritoneal fluid cytologic testing with laparoscopy in the diagnosis of acute pelvic inflammatory disease

Twenty-seven women with suspected acute pelvic inflammatory disease were studied by laparoscopy and endometrial biopsy. Overall, 67% (18 of 27) of the women had acute salpingitis at laparoscopy, 70% (19 of 27) had plasma cell endometritis, and 67% (10 of 15) had an inflammatory cytologic pattern of the peritoneal fluid. In comparison to laparoscopically detected salpingitis, endometritis detected with biopsy had a sensitivity of 89%, a specificity of 67%, a positive predictive value of 84%, and a false negative rate of 22% in the diagnosis of pelvic inflammatory disease. The corresponding figures for inflammation of the peritoneal fluid were 75%, 67%, 90%, and 25%. This study demonstrates that nonpuerperal endometritis is an entity associated with pelvic inflammatory disease, most likely representing an intermediate stage between cervicitis and salpingitis. Endometrial biopsy as an office procedure is a good alternative to laparoscopy in the diagnosis of acute pelvic inflammatory disease and may in fact detect early cases not yet visible at laparoscopy.