Laparoscopic versus open Burch colposuspension: a randomised controlled trial

OBJECTIVE

To compare perioperative characteristics, short-term, and long-term outcomes for laparoscopic Burch colposuspension (LBC) and open Burch colposuspension (OBC) for the treatment of urinary stress incontinence.

DESIGN

Randomised surgical trial with single blinding.

SETTING

Three tertiary level teaching hospitals involving seven surgeons of varying skill levels.

POPULATION

Two hundred women with urodynamic stress incontinence (USI).

METHODS

The two groups were treated in identical fashion, except for the laparoscopic or open approach to surgery. Attempts were made to blind the subjects and the observers obtaining outcome data to treatment group. Analyses were adjusted for surgeon experience.

MAIN OUTCOME MEASURES

Absence of USI 6 months following surgery, postoperative pain, time spent in hospital, and time to return to activities of normal daily living.

RESULTS

There were no significant differences in objective and subjective measures of cure and in patient satisfaction at 6 months, 24 months, or 3-5 years of follow up between laparoscopic and open colposuspension groups. Laparoscopic colposuspension took longer time to perform (87 versus 42 minutes, P< 0.0001) but was associated with less blood loss (P = 0.03), less pain (P = 0.02), and quicker return to normal activities (P = 0.01).

CONCLUSION

LBC has significant advantages over traditional OBC, without any apparent compromise in short-term and long-term outcomes. To compare perioperative characteristics, short-term, and long-term outcomes for laparoscopic Burch colposuspension (LBC) and open Burch colposuspension (OBC) for the treatment of urinary stress incontinence. Randomised surgical trial with single blinding. Three tertiary level teaching hospitals involving seven surgeons of varying skill levels. Two hundred women with urodynamic stress incontinence (USI). The two groups were treated in identical fashion, except for the laparoscopic or open approach to surgery. Attempts were made to blind the subjects and the observers obtaining outcome data to treatment group. Analyses were adjusted for surgeon experience. Absence of USI 6 months following surgery, postoperative pain, time spent in hospital, and time to return to activities of normal daily living. There were no significant differences in objective and subjective measures of cure and in patient satisfaction at 6 months, 24 months, or 3-5 years of follow up between laparoscopic and open colposuspension groups. Laparoscopic colposuspension took longer time to perform (87 versus 42 minutes, P < 0.0001) but was associated with less blood loss (P= 0.03), less pain (P= 0.02), and quicker return to normal activities (P= 0.01). LBC has significant advantages over traditional OBC, without any apparent compromise in short-term and long-term outcomes.

A new method to measure elastic properties of plastic-viscoelastic connective tissue

An experimental protocol was tested to measure elastic properties of connective tissue displaying viscoelastic as well as plastic properties. The protocol consisted of a slow rate, linear elongation (0.88 mms(-1), 8 mm) in combination with a superimposed sinusoidal vibration of small amplitude (50 Hz, 0.1 mm). Using digital filters and mathematical algorithms, the force responses to linear elongation and to vibration were obtained. The method was tested on excised fibromuscular tissue of the vaginal wall obtained from women who suffered a vaginal prolapse. The force-stiffness and force-elongation relationships based on the vibration response were unaffected by any long-term deformation of the specimens. The directly measured force-elongation curves were strongly affected by these deformations. It was therefore concluded that with the new method, it is possible to determine the elastic properties accurately. Furthermore, this method seems more sensitive to small changes in elastic properties than the classic tensile test.

Genital tract fistula repair on 116 women

A personal series of 130 genital tract fistula repairs in 116 women is presented. All fistulas were repaired vaginally. The majority of the fistulas were due to obstetric injuries, especially prolonged obstructed labour. Obstetric fistula continue to be a cause of personal and social morbidity to sufferers.

Positive Kleihauer result following an ectopic pregnancy

The case presented highlights the risk of fetomaternal haemorrhage in ectopic pregnancy. With the current shortages of anti-D, it may be necessary to reduce administration of anti-D, but this may result in an increase in rhesus isoimmunization. As Kleihauer testing may be of limited value (1), recommendations by deCrespigny and Davison (2) for the use of a reduced dose of 30 mcg anti-D in all rhesus negative women with early pregnancy complications including ectopic pregnancy, would seem appropriate.

Transcervical endometrial resection

STUDY OBJECTIVES

To determine the safety and efficacy of endometrial resection, and to provide an indicator of the operative problems and treatment outcomes.

DESIGN

Prospective study.

SETTING

Academic practice tertiary care setting.

PATIENTS

One hundred twenty-six consecutive women undergoing endometrial resection because of menorrhagia, who wished to retain their uterus.

INTERVENTION

Hysteroscopic endometrial resection performed as a day procedure.

MEASUREMENTS AND MAIN RESULTS

In 126 women, 2 cases of uterine perforation were readily identified on the operating monitor screen; they had no serious sequelae. Three patients had heavy uterine bleeding, which was controlled by intrauterine tamponade. No women had other serious complications.

CONCLUSION

Hysteroscopic endometrial resection is a safe, successful, and cost-effective treatment of menorrhagia.

Female circumcision

Three cases of female circumcision are presented together with a literature review. Unfortunately, this procedure frequently results in genital mutilation. Treatment with deinfibulation enables restoration of the external genitalia and vagina. Obstetric and gynaecological complications have been documented, but emotional and psychological effects may be difficult to assess. These women should be treated without bias and with sensitivity.

A new laparoscopic aspiration technique for ovarian dermoid cysts

A new method for aspirating benign dermoid cysts enables removal of the collapsed cyst wall without the need for extending laparoscopic incisions or opening the pouch of Douglas. The technique has been used by one of the authors in 10 patients with good effect and minimal or no spillage of dermoid cyst contents into the peritoneal cavity.

External cephalic version at term

The case notes of women with singleton term (37 weeks' gestation and beyond) breech presentation and delivery were retrospectively reviewed. Thirty-two of the 72 women in the study group had attempted external cephalic version at term, with a success rate of 53% (17 women). The Caesarean section rate was significantly lower in the group which had attempted ECV compared to the group which did not.

Active chronic peptic ulcer disease complicated by gastric outlet obstruction in pregnancy

A case of active peptic ulcer disease in a primigravida at 29 weeks' gestation is presented, with a literature review. This particular case was complicated by gastric outlet obstruction, a complication which has not been previously reported in the obstetric literature. Although an uncommon diagnosis in pregnancy, the investigations for peptic ulcer disease should be actively pursued. Treatment can prevent serious complications.

Postmenopausal endometrioma and hormonal replacement therapy

This case of postmenopausal endometrioma following hormonal replacement therapy (HRT) demonstrates the often forgotten possibility of reactivation of endometriosis with HRT. The diagnosis of endometriosis should be considered in a postmenopausal woman who presents with pelvic pain and mass whilst on HRT.

First antenatal visit haematocrit and pregnancy induced hypertension

First antenatal visit haematocrit values during the first and second trimesters were retrospectively collected from 546 nulliparas with singleton pregnancies. The results were analysed for correlation with development of pregnancy induced hypertension (PIH) later in pregnancy. It was found that women with higher haematocrit values, especially over 0.40, had an increased risk of developing PIH. However, there appeared to be no absolute level of haematocrit which had sufficient discriminative value to be useful in clinical practice.