Abdominal sacrospinous ligament colposuspension

BACKGROUND: When an abdominal approach is chosen for repair of pelvic prolapse, a paravaginal repair is often used to correct lateral cystoceles and a retropubic urethropexy to correct genuine stress incontinence. If concomitant vaginal vault prolapse exists, an approach for vaginal vault support, which can be done through the space of Retzius, would be beneficial. We describe an abdominal approach to the sacrospinous ligament. TECHNIQUE: The space of Retzius is accessed and important anatomic landmarks, including the obturator canal and neurovascular bundle, paravaginal veins, bladder, and ischial spine, are identified. The sacrospinous ligament complex is palpated and exposed. The superior posterolateral vaginal wall is then fixed to the complex. Often a bilateral repair is possible. EXPERIENCE: Fifty-five women at two centers had abdominal sacrospinous ligament colpopexies for vaginal vault prolapse. All had other repairs for pelvic organ prolapse. No follow-up operations were needed for recurrent vault prolapse, over an average of 23 months follow-up. CONCLUSION: An abdominal approach to the sacrospinous ligament complex can be used, providing pelvic reconstruction surgeons with an alternative technique for vaginal vault support when other space-of-Retzius procedures are required.     

Breast irradiation with brachytherapy: approved techniques and new concepts

Among surgery and chemotherapy, radiotherapy has an important role in the treatment of breast cancer patients. But not only external beam radiotherapy (EBRT) treatment is an established method for treatment of breast cancer, also brachytherapy (BT) is an approved method. BT is well known for boost irradiation in combination with EBRT, but new indications as re-irradiation for local recurrences or partial breast irradiation offer new aspects in the field of BT for breast cancer treatment. Because of modern CT based 3-D treatment planning systems and the possibility of intensity modulated brachytherapy (IMBT) has getting more potential. In the future for selected patient's re-irradiation of the breast using IMBT after local relapse and second breast conserving surgery might be an alternative instead of mastectomy. Even partial breast BT following breast conservative operation as a new treatment option is getting more and more interesting and is widely investigated in several studies. Due to the approved techniques and the new indications BT is and will be an attractive alternative and extension in the field of breast cancer treatment. But we need five better ten years results for definite conclusions at least.     

Normal pregnancy following resection of ovary for primary ovarian pregnancy; case report

The literature is reviewed and a case is reported in which an ovary, the site of an ovarian pregnancy, was treated by partial resection.The case is of interest since, although the opposite ovary had been completely removed for an endometrial cyst, an intrauterine pregnancy ensued.     

Severe chemical peritonitis caused by spontaneous rupture of an ovarian mature cystic teratoma: a case report

BACKGROUND: Rupture of an ovarian cyst may cause chemical peritonitis. When an ovarian cyst ruptures spontaneously, an emergency operation is usually performed, and the chemical peritonitis is alleviated by irrigating the abdominal cavity. This appears to be the only report of prolonged chemical peritonitis. CASE: A spontaneously ruptured ovarian mature cystic teratoma was left untreated for >2 weeks, and chemical peritonitis lasted for 1 year. The peritonitis required administration of a synthetic adrenal corticosteroid and an immunosuppressive antimetabolite. CONCLUSION: It is important to perform an operation immediately when spontaneous rupture of an ovarian cyst is suspected. For therapeutic purposes, spilled ovarian cyst fluid should be eliminated as soon as possible to prevent prolonged chemical peritonitis.     

Anaesthesia for obstetricians

Anaesthesia and the anaesthetist have an important contribution to make to the provision of safe and effective maternity care. This is particularly relevant for current obstetric practice which is providing care to an older obstetric population with an increasing incidence of co-morbidities. In this review, the role of the anaesthetist in maternity care is described and the issues for providing anaesthesia and analgesia to pregnant women are discussed.     

Vulvar surgery for neurofibromatosis

Von Recklinghausen's neurofibromatosis is an unusual disorder with a wide variety of manifestations. The initial findings may at times involve the female genitalia. When the vulva is affected, the obstetrician-gynecologist has an opportunity for the establishment of an accurate diagnosis as well as for cosmetic correction. Two cases are presented which illustrate these concepts.     

Avoiding misdiagnosing an early intrauterine pregnancy as an ectopic pregnancy

In women at risk for an ectopic pregnancy, every effort should be made to exclude the presence of an intrauterine pregnancy before embarking on an irreversible treatment for ectopic pregnancy. The diagnosis of ectopic pregnancy, unless directly visualized with transvaginal ultrasound, is made with the exclusion of an intrauterine pregnancy. Measurement of human chorionic gonadotrophin and progesterone levels, and transvaginal ultrasound are the tools used to evaluate early pregnancy. In women at risk for an ectopic pregnancy, every effort should be made to exclude the presence of an intrauterine pregnancy before embarking on an irreversible treatment course. Methotrexate is an antimetabolite that inhibits DNA synthesis and repair and cell replication. It is administered to ostensible destroy a pregnancy, especially ectopic pregnancies. When administered to an intrauterine pregnancy, embryonic death and missed abortion is the most common result, but early embryos that survive this exposure are likely to have multiple anomalies. The mistaken administration of methotrexate to an intrauterine pregnancy is made because of misinterpretation of the discriminatory zone of human chorionic gonadotropin(h CG), misinterpretation of early h CG serum levels, misinterpretation of early transvaginal ultrasound images, and failure to clinically correlate h CG levels and ultrasound findings.     

Peri- and post-menopausal incidental adnexal masses and the risk of sporadic ovarian malignancy: new insights and clinical management

Adnexal masses are common among peri- and post-menopausal women. Although ovarian cancer is a significant cause of mortality in menopausal women, large population-based studies demonstrate that the majority of adnexal masses are benign. Despite this, the appearance of an adnexal mass is a concern for the patient and an insight exercise for physicians. In most cases, an adnexal enlargement is an incidental finding, generally corresponding to a benign cyst and easily diagnosed by conventional ultrasound. Exceptionally an ovarian tumour may be malignant and should be treated as early as possible. When conventional ultrasound renders complex morphology other diagnostic tools must be used such as: colour Doppler and functional tumour vessel properties, serum CA 125 levels, nuclear magnetic resonance imaging and in some cases laparoscopy. Several new tumour markers are being studied for clinical application, although there are presently no clear recommendations. Adnexal masses with benign morphological and functional properties must be periodically monitored as an alternative to surgery since malignant transformation is exceptional.     

A patient presenting with a pelvic mass, elevated CA-125, and fever

BACKGROUND: Tuberculous peritonitis is a rare event which can mimic advanced stage ovarian cancer. A pelvic mass and an elevated CA-125 is suggestive of an ovarian malignancy; however, benign conditions may be discovered, especially in the premenopausal patient. CASE: A patient with a pelvic mass, ascites, and an elevated CA-125 underwent an exploratory laparotomy for presumed ovarian cancer. Final pathology revealed pelvic tuberculosis without any pulmonary involvement. Acid-fast bacilli were confirmed with polymerase chain reaction in the surgical specimen. DISCUSSION: Pelvic tuberculosis is an uncommon gynecologic condition that presents with ascites, a pelvic mass, and fever. An elevated CA-125 is not specific for ovarian malignancy.     

The performance of Pipelle endometrial sampling in a dedicated postmenopausal bleeding clinic.

Endometrial sampling using the Pipelle device is widely used in the UK especially in the investigation of postmenopausal bleeding. This study was aimed at evaluating the clinical benefit and diagnostic accuracy of the procedure in the setting of a dedicated one-stop clinic for women with postmenopausal bleeding. The study also examined the factors that would affect the adequacy of endometrial samples in terms of their suitability for histopathalogical examination. Data from 97 consecutive patients attending the clinic were collected and analysed. All the patients had a transvaginal ultrasound scan and an endometrial Pipelle sample was attempted unless refused by the patient. The analysis revealed that the procedure avoided the need for hysteroscopy in 61.5% of cases with an endometrial thickness of > 4mm. No cases of endometrial cancer were missed after successful Pipelle sampling. The ability to obtain an adequate endometrial sample was primarily affected by the endometrial thickness. There is only a 27% probability of getting an adequate endometrial sample in the group of women with an endometrial thickness of < 5 mm. The study recommends this procedure for the group of women with an endometrial thickness of > 4 mm. However, when the endometrial thickness is < or = 4 mm, little can be gained from endometrial sampling as malignancy is rare and the chance of getting an adequate sample is small.     

Term stillbirth in older women

Increasing numbers of women are choosing to delay pregnancy. Pregnancy in older women is associated with increased risks, of which stillbirth is one of the most devastating. This retrospective cohort study reviewed the obstetric outcomes in women aged 40 and above over an 11-year period to determine whether maternal age is an independent risk factor for term stillbirth. The study shows that advanced maternal age is an independent risk factor for term stillbirth (odds ratio 2.42, 95% confidence interval 1.04-5.62).     

The Dynamics of Leaving and Recovering from an Abusive Relationship

The process of leaving an abusive relationship involves repeated attempts at leaving and returning and is influenced by a number of individual characteristics and contextual factors. Leaving is an initial step in recovering from an abusive relationship, a process that also includes struggling for survival, grieving, and searching for the meaning of the experience. Nurses must recognize that recovering from an abusive relationship can be a lifelong process, and health care providers have unique opportunities to support a woman's recovery.     

Die ��beraktive Blase

The continence function is one of the first social and control abilities expected within the framework of child development and is generally seen as an indicator for further social and control abilities. The high grey area of patients with an overactive bladder is for those affected always coupled with an avoidable limitation in the quality of life which can be reduced by timely intervention. Within the framework of the AWMF (Working Group of Scientific Medical Specialist Disciplines) guidelines an overactive bladder is defined by the symptoms pollakiuria, imperative micturition and nocturia with or without incontinence. First line medicinal treatment is based on anticholinergics. Operative therapies are possible but only in off-label use.     

Surgical treatment for endometrial adenocarcinoma: first approaches. Review of the literature

Three surgical approaches have been described for the treatment of women presenting an endometrial cancer. The aim of this study was to appreciate the current criteria that would offer guidelines for this choice. We reviewed the data available in the literature (search Medline). Only laparotomy and laparoscopy permit the carrying out of all the routine surgical staging according to the FIGO's criteria (classification 1988). Only one randomised study compares the results obtained by laparotomy and laparoscopy. Laparoscopy patients had significantly less morbidity. Overall survival did not differ in both groups with a limited follow-up. The other not randomised studies show that laparoscopy is usually proposed to patients having a lower IMC and presenting limited stages. No randomized study had compared laparotomy with the only vaginal surgery. The latter is generally proposed for patients having an associated comorbidity and presenting limited stages. In such cases, no difference in survival is highlighted. Obesity does not represent an absolute contra indication for any way. It makes the surgery generally more complex. A suspicious ovarian lesion, a large uterus are, currently, an indication for laparotomy. Laparoscopy can be accepted only if the uterine volume is lower than 500 g and without deep myometrial infiltration. Laparotomy surgery is the standard. The main indication of vaginal surgery is to permit treatment to high operatory risk patients. Laparoscopy is an option for the early stages. It is not recommended if an ovarian lesion or a deep uterine parietal infiltration are suspected. Whatever the route used, the surgeon must be trained.     

Novel developments on cervical length screening and progesterone for preventing preterm birth

Cervical length (CL) measured by transvaginal ultrasound is an effective screening test for the prevention of preterm birth (PTB). The criteria for an effective screening test are all met by CL. It studies an important condition (PTB); it is safe and acceptable by >99% of women; it recognises an early asymptomatic phase that precedes PTB by many weeks; it has a well-described technique, is reproducible, is predictive of PTB in all populations studies so far; and, perhaps most importantly, it has been shown that 'early' treatment is effective in prevention. These two interventions, effective only in specific populations, are ultrasound-indicated cerclage and vaginal progesterone.     

Stem cell research, personhood and sentience

In this paper the permissibility of stem cell research on early human embryos is defended. It is argued that, in order to have moral status, an individual must have an interest in its own wellbeing. Sentience is a prerequisite for having an interest in avoiding pain, and personhood is a prerequisite for having an interest in the continuation of one's own existence. Early human embryos are not sentient and therefore they are not recipients of direct moral consideration. Early human embryos do not satisfy the requirements for personhood, but there are arguments to the effect that they should be treated as persons nonetheless. These are the arguments from potentiality, symbolic value and the principle of human dignity. These arguments are challenged in this paper and it is claimed that they offer us no good reason to believe that early human embryos should be treated as persons.     

Metrorrhagia during the third trimester disclosing Munchausen syndrome

Metrorrhagia during the third trimester of pregnancy similar to that observed in placenta praevia may be a signal to the physician that the patient is calling for help. This clinical situation is one where the patient mimics an illness, playing the role of a patient. The risk is that an unnecessary surgical procedure may be triggered, in this case cesarean section. The main difficulty in caring for these patients is to make the diagnosis. Treatment relies on psychotherapy which can contribute to an improved mother-infant relationship and perhaps prevent acts of self-mutilsation.     

Ovarian tumour: ovarian pregnancy. Diagnosis and management

An ovarian mass in a premenopausal patient has many differential diagnoses. In young patients the mass is most likely to be benign. Sometimes patients with an abdominal mass will present as acute abdomen. If the patients have an IUD and a positive test for serum HCG, an ectopic ovarian pregnancy has to be suspected. However one also has to take into consideration the possibility of an ovarian germ cell tumour. The latter occurs in young patients, presents as an ovarian mass and can produce HCG. The preoperative and even intraoperative diagnosis are difficult. In these cases where there is a suspected ovarian mass and no clear diagnosis a laparoscopic approach should be considered. Patients with an ovarian pregnancy have a good prognosis for future fertility and therefore conservative surgical management is advocated. The approach and treatment modalities of an ovarian pregnancy are discussed.     

Psychosexual changes associated with the perimenopausal period

The perimenopausal period is often a frustrating time for the woman who is experiencing it and for the health care professional who provides care for her. Although menopause is a universal experience for women, how it is experienced is not universal. Physiology, anatomy, social support systems, culture, expectations, and the woman's attitudes (especially her self-image) all have an influence on how easy or difficult the perimenopausal transition period is for an individual. This paper discusses psychosexual aspects of the perimenopausal period and suggests how nurse-midwives or other health professionals can make this often difficult period easier.     

Tolerance of synthetic tissues in touch with vaginal scars: review to the point of 287 cases

With an experience of 287 vaginal way operations using synthetic material, the authors make a review about the tolerance of the tissues. Three tissues were used (polytetrafluoroethylene, Dacron and Lyodura). The procedures are: Mouchel, big and small slings, Stamey and para vaginal refect procedures. At 30 months, the tolerance is 70% for Mouchel and 90% for sling procedures. The rejection rate with Dacron is globally 19.3% vs. 30.3% for Gore Tex . The authors describe materials' history, clinical symptoms and histopathologic signs of the intolerance. They think that the synthetic tissue tolerance is proportional to the exhibit surface and to the distance which separates it from the scar. The substratum of the intolerance process answers with two explanations: infection and foreign body reaction. Different theories are explained. Infection can be an ethiologic factor in early rejection. With rigid material, a small ulcer is formed and serves as a nidus for an ascending infection. Foreign material acts as an adjuvant by decreasing the number of bacteria necessary to produce an infection.The tissue reaction may be an immune response to Dacron, a delayed hypersensitivity reaction, or a graft vs. host antigen-antibody reaction. The ideal synthetic mesh material for pelvic surgery has yet to be developed.