An Unusual Complication of Vesical Stones

The author reports a complicated recurrence of genital tract fistula. The initial vesicovaginal fistula resulted from obstructed labor, which was subsequently surgically managed without success. The patient had a recurrent vesicovaginal fistula that was formed by the erosion of vesical stones through the anterior endopelvic fascia into the vagina. The stones eventually eroded into the rectum, resulting in the formation of a complex vesicovaginal and rectovaginal fistula.     

Assessment of the durability of robot-assisted laparoscopic sacrocolpopexy for treatment of vaginal vault prolapse

Transabdominal sacrocolpopexy has been shown, in multiple long-term studies of its success and durability, to be the definitive treatment option for post-hysterectomy vaginal vault prolapse. It is, however, associated with greater morbidity than vaginal repair. We describe a minimally invasive technique for vaginal vault prolapse repair and present our experience with a minimum of one-year follow-up. The surgical technique involves five laparoscopic ports—three for the da Vinci robot and two for the assistant. After appropriate dissection a polypropylene mesh is attached to the sacral promontory and to the vaginal apex by use of Gore-Tex sutures. The mesh material is then covered by the peritoneum. Patient analysis focused on complications, urinary continence, patient satisfaction, and morbidity, with a minimum of 12 months follow-up. Forty-two patients with post-hysterectomy vaginal vault prolapse underwent robot-assisted laparoscopic sacrocolpopexy at our institute and 35 have a minimum of 12 months follow-up, with a mean follow-up of 36 months (range 12–48) in the group. Mean age was 67 (47–83) years and mean operating time was 3.1 (2.15–4.75) h for the entire cohort. All but one patient were discharged home on postoperative day one; one patient left on postoperative day two. One developed recurrent grade three rectocele, one had recurrent vault prolapse, and two suffered from vaginal extrusion of mesh. All patients were satisfied with their outcome. The robot-assisted laparoscopic sacrocolpopexy is a minimally invasive technique for vaginal vault prolapse repair, combining the advantages of open sacrocolpopexy with the reduced morbidity of laparoscopy. We observed reduced hospital stay, low occurrence of complications, and high patient satisfaction, with a minimum of 1-year follow-up. Most importantly, the long-term results of the robotic repair are similar to those of open repair, but with significantly less morbidity.     

宫颈癌放疗后家庭阴道冲洗效果观察

目的:为寻找一种院外阴道冲洗的有效方法,从而帮助一些由于各种原因不能来医院行阴道冲洗术的患者继续完成治疗。方法:对204例宫颈癌放疗结束后的患者随机分实验组与对照组,实验组实施家庭阴道冲洗,对照组未行阴道冲洗,通过放疗结束后1个月、3个月、6个月门诊随访,观察阴道粘膜急性放射反应治疗后消退情况,对家庭阴道冲洗患者和未行阴道冲洗者进行对照研究。结果:行家庭阴道冲洗者在阴道粘膜急性放射反应方面与未冲洗者差异有显著性(P<0.05)。结论:家庭阴道冲洗是对因各种原因出院后不能来医院行阴道冲洗的患者可以采取的一种行之有效的方法。     

"Endoview" project of intrapartum endoscopy.

INTRODUCTION: The change in obstetrical practices over the last decade in favor of trials of labor in patients with uterine scars has resulted in increased incidences of uterine ruptures. Although neither repeat cesarean delivery nor a trial of labor is risk free, evidence from a large multicenter study shows vaginal birth after the cesarean (VBAC) is associated with shorter hospital stays, fewer postpartum blood transfusions, and a decreased incidence of postpartum maternal fever. The uterine rupture remains the most serious complication associated with VBAC. Factors associated with uterine rupture include excessive exposure to oxytocin, dysfunctional labor, and a history of more than 1 cesarean delivery.2 Because uterine rupture may be a life-threatening event, intrapartum surveillance and the ability to perform an emergency surgery are both necessary when trial of labor is allowed. Until now, no early symptoms pathognomonic to uterine rupture had been described. We share our experiences with the novel approach to the problem - an intrapartum endoscopy. MATERIALS AND METHODS: Endoscopic examination was accomplished by using the intraoperational fiberscope (Olympus and Endoview system (Costa Mesa, CA, USA). A gas-sterilized 25-cm long fiberscope is introduced into the amniotic cavity through the cervical canal after rupture of the membranes. The distance between the fiberscope and the object varies from 3 to 50 mm. The fiberscope has a separate channel for the fluid infusion (normal saline) throughout the procedure; the surgeon looks through the eyepiece directly and exhibits control over the flexible scope. The duration of endoscopy is less than 15 minutes. The inserting of the endoscopic device is very similar to that of insertion of an intrauterine pressure catheter. The IRB Committees of both participating institutions approved the study protocol. Twenty-eight patients with an unknown or poorly documented site of the uterine scar were included in the study. An ultrasound examination had been performed on all patients prior to endoscopy to assess fetal wellbeing and placental location. The ages of the patients ranged from 21 to 38 years. Eighteen women had 1 previous cesarean delivery, and 10 had 2. The performance of intrapartum endoscopy did not interfere with fetal monitoring; 21 fetuses were monitored externally, 7 internally. Indications for previous cesarean deliveries were as follows: fetal distress in 11 cases, failure to progress in labor in 8, placenta previa in 2, and unknown in 7. Twenty-one patients delivered vaginally; 7 had had repeat cesarean deliveries. All neonates were born in satisfactory condition. The Apgar scores at 1 minute varied from 7 to 9 and at 5 minutes from 8 to 10. The integrity of the uterine wall was assessed by manual postpartum uterine exploration in each case of vaginal delivery and by visualization and palpation of the scar site in each abdominal delivery. RESULTS: The lower uterine segment and contractile portion of the anterior uterine wall were visualized successfully in all patients. In 25 patients, the presumed scar site looked totally indistinguishable from the rest of the lower uterine segment and anterior uterine wall. Two scars were identified as vertical in 2 patients who were delivered by a repeat abdominal operation. A vertical scar appears as a groove running in a cephalad-caudad direction from the lower uterine segment into the contractile portion of the anterior uterine wall. The usefulness of the intrapartum endoscopy is best demonstrated by the following case reports (2 of 28 study cases).     

Isthmotectal axons make ectopic synapses in monocular regions of the tectum in developing Xenopus laevis frogs.

During the development of binocular maps in the tectum of Xenopus laevis, axons that relay input from the ipsilateral eye via the nucleus isthmi undergo a prolonged period of shifting connections. This shifting accompanies the dramatic change in eye position that takes place as the laterally placed eyes of the tadpole move dorsofrontally. There is a concomitant expansion of the proportion of tectum that receives contralateral retinotectal input corresponding to the binocular portion of the visual field. Electrophysiological recording demonstrates that ipsilateral units are present in those rostral tectal zones, and anatomical methods show that the isthmotectal axons arborize densely in the rostral region but also extend sparser branches into the caudal zone, which is occupied by contralateral inputs with receptive fields in the monocular zone of the visual field. A mechanism that aligns the ipsilateral and contralateral maps is activity-dependent stabilization of isthmotectal axons that exhibit firing patterns correlated with those of nearby retinotectal axons. In order for activity patterns to function in stabilizing correct connections and promoting the withdrawal of incorrect connections, synaptic communication of some sort is hypothesized to be essential. We have investigated whether isthmotectal axons make morphologically identifiable synapses during development and where such synapses are located. We find evidence for morphologically identifiable synapses in all regions of the tectum, along with many growth cones and structures that are probably immature synapses. As in the adult, the synapses contain round, clear vesicles, have asymmetric specializations, and terminate on structures that appear to be dendrites. In both adult and tadpole, the rarity of serial synapses involving isthmotectal terminals suggests that the interactions between retinotectal and isthmotectal inputs are mediated by postsynaptic dendrites.     

The importance of vaginal mucosal folds at the urethral external meatus

We report on the vaginal mucosal folds (VMF) at the urethral external meatus. Resection of the VMF reduces the dispersed micturition and other urinary symptoms. EDITORIAL COMMENT: The investigators describe the presence of a vaginal mucosal fold (VMF) just dorsal to the urethral meatus and its relationship to voiding abnormalities. VMF were found on physical examination in 8.9% of the clinic population, all of whom complained of dispersed micturition, and 79% also experienced other voiding abnormalities. The complaint of dispersed micturition was successfully treated with excision of the VMF, and the other associated symptoms were improved. This structure should be routinely looked for on physical examination, especially in patients with voiding symptoms. Only further investigation of this newly described entity at other centers around the world will determine the incidence of the anatomic finding and the prevalence of associated voiding disturbances across different populations.     

Development of specificity in corticospinal connections by axon collaterals branching selectively into appropriate spinal targets

Corticospinal projections in adult rodents arise exlusively from layer V neurons in the sensorimotor cortex. These neurons are topographically organized in their connections to spinal cord targets. Previous studies in rodents have shown that the mature distribution pattern of corticospinal neurons develops during the first 2 weeks postnatal from an initial widespread pattern that includes the visual cortex to a distribution restricted to the sensorimotor cortex. To determine whether specificity in corticospinal connections also emerges from an intially diffuse set of projections, we have studied the outgrowth of corticospinal axons and the formation of terminal arbors in developing hamsters. The sensitive fluorescent tracer 1, 1′, dioctadecyl-3, 3, 3′, 3′-tetramethylindocarbocyanine perchlorat (DiI) was used to label corticospinal axons from the visual cortex or from small regions of the forelimb or hindlimb sensorimotor cortex in living animals at 4–17 days postnatal. Initially axon outgrowth was imprecise. Some visual cortical axons extended transiently beyond their permanent targets in the pontine nuclei, by growing through the pyramidal decussation and in some cases extending as far caudally as the lumbar enlargement. Forelimb sensorimotor axons also extended past their targets in the cervical enlargement, in many cases growing in the corticospinal tract to lumbar levels of the cord. By about 17 days postnatal these misdirected axons or axon segments were withdrawn from the tract. Despite these errors in axon trajectories within the corticospinal tract, terminal arbors branching into targets in the spinal gray matter were topographically appropriate from the earliest stages of innervation. Thus visula cortical axons never formed connections in the spinal cord, forelimb sensorimotor axons arborized only in the cervical enlargement, and hindlimb cortical axons terminated only in the lumbar cord at all stages of development examined. Corticospinal arbors formed from collaterals that extended at right angles from the shafts of primary axons, most likely by the process of interstitial branching after the primary growth cone had extended past the target. Once collaterals extended into the spinal gray matter, highly branched terminal arbors formed within 2–4 days, beginning at about 4 and 8 days postnatal for the cervical and lumbar enlargements, respectively. These results show that specificity in connectivity is achieved by selectivty growth of axon collaterals in to appropriate spinal targets from the beginning and not by the later remodeling of intially diffuse connections. In contrast, errors occur in the initial outgrowth of axons in the corticospinal tract, which are subsequently corrected. Copyright © 1994 Wiley-Liss, Inc.