Outcome of arterial embolization of uterine leiomyoma: case report

OBJECTIVE

To describe the outcomes after uterine artery embolization treatment of leiomyoma.

DESIGN

Case report.

SETTING

Department of Gynecology - Federal University of São Paulo.

PATIENT

a 34-year-old woman with a diagnosis of leiomyoma for two years.

INTERVENTION

embolization of uterine arteries with 500 to 700-microm diameter polyvinyl alcohol particles.

MAIN OUTCOME MEASURE

pregnancy and delivery.

RESULTS

After embolization, the follow-up revealed a good clinical response with significant reduction in uterus and leiomyoma volume. Also, the patient became spontaneously pregnant, but the delivery was cesarean section due to placenta accreta..

CONCLUSION

Regardless of arterial embolization results for controlling uterine bleeding, this procedure might have some consequences on pregnancy outcome.

Sexual steroids in urogynecology

The decline in sex hormone levels that accompanies the menopause has substantial effects on the tissues of the urogenital system, leading to atrophic changes. These changes can have negative effects on sexual and urinary function. The authors evaluate the repercussion of hypoestrogenism and sexual steroids on some elements of the pelvic floor and lower urinary tract. They summarize their research work and review significant published papers. They emphasize the changes in urinary mucosae, periurethral vessels, muscular layer, connective tissue, gene expression, autonomic nervous system receptors, as well as the main clinical aspects involved.

Fas/CD95 promoter polymorphism gene and its relationship with cervical carcinoma

OBJECTIVE

Apoptosis is an important fail-safe control in human papillomavirus (HPV)-associated carcinogenesis. We tested the hypothesis that the A/G polymorphism at -670 of Fas promoter is associated with an increased risk for cervical cancer, using a matched case-control setting.

METHODS

The material in this case-control study consisted of 91 patients with cervical carcinoma and 176 population-based control subjects, recruited between 2002 and 2004; all the ethnic Brazilian women had histologically confirmed cervical carcinoma. Control subjects were age-matched; healthy women who were selected following a negative cervical cytology and normal colposcopy. Fas genotyping was performed using a PCR-RFLP technique.

RESULTS

No significant difference existed in the distribution of the Fas polymorphisms (wild, heterozygous, mutant) between the cases and controls. The heterozygous (OR: 4.85, 95% CI: 1.1-22.6) genotypes among the younger (< 48 yrs) cancer patients were almost 5-fold increased, as compared with the wild type. No such increase was observed among the patients older than 48 years.

CONCLUSIONS

Our data suggest that 670A/G polymorphism in the promoter region of the death receptor Fas is associated with an increased risk of cervical cancer among Brazilian women under 48 years. The mechanisms would be the inhibition of apoptosis by Fas -670G allele-mediated down-regulation of Fas transcription.

Impact of pregnancy and childbirth on female rats’ urethral nerve fibers

This study aims to evaluate the urethral nerve fibers of adult female rats during pregnancy and after vaginal birth, cesarean section or simulated birth trauma. For immunohistochemical analysis of nerve fibers, 70 female rats were distributed in seven groups of ten female rats: group 1, control; group 2, pregnant; group 3, cesarean section; group 4, vaginal birth; group 5, virgin female rats with simulated birth trauma; group 6, cesarean section followed by simulation of birth trauma; and group 7, vaginal birth followed by simulation of birth trauma. The number of nerve fibers in groups 1, 2, and 3 were significantly higher than the other groups. Pregnancy and cesarean section did not cause alterations in the nerve fibers number. Vaginal birth and simulated birth trauma significantly decreased the number of nerve fibers in the female rats' middle urethra.

Hormonal influence on periurethral vessels in postmenopausal incontinent women using Doppler velocimetry analysis

The lack of estrogen affects the urinary tract mainly by diminishing vascular, muscular and epithelial trophism, resulting in negative effects on continence in postmenopausal women.

OBJECTIVE

Study the effect of hormone therapy (estrogen and progesterone) in periurethral vessels detected by Doppler velocimetric analysis using, as parameters, the number of vessels, resistance and pulsatility indexes, as well as the minimum diastolic value.

METHODS

Thirty-eight postmenopausal women with stress urinary incontinence were randomized into two groups. The first consisted of women receiving 3 months of estrogen therapy previous to 3 months of continuous estrogen and progesterone combined therapy. The second comprised of women receiving 3 months of continuous estrogen and progesterone therapy. Periurethral Doppler velocimetric analysis was done before hormone administration and during treatment in both groups.

RESULTS

We observed a statistically significant increased number of periurethral vessels during treatment in both groups. There was an increase in value of the mean minimum diastolic value during estrogen and progesterone therapy in Group 2. The resistance indexes diminished in both groups. However, they were not statistically significant.

CONCLUSION

Hormonal therapy of short duration (3-6 months) had a positive effect on the urethral continence mechanism increasing the number of periurethral vessels either with estrogen alone or combined therapy (estrogen and progesterone).

The impact of pregnancy and childbirth in the urethra of female rats

The aim of this study was to evaluate the modifications in the amount of collagen, muscular, and elastic fibers in the mid-urethra of adult female rats during the pregnancy and after the natural childbirth, cesarean, and after simulated trauma of childbirth. The authors evaluated the histomorphometric aspects (collagen, muscular, and elastic fibers) in the mid-urethra of 70 animals distributed in seven groups: group 1 (n = 10)--control, group 2 (n = 10)--pregnant female rats, group 3 (n = 10)--female rats submitted to cesarean, group 4 (n = 10)--female rats with natural childbirth, group 5 (n = 10)--virgin female rats with simulated trauma of childbirth, group 6 (n = 10)--female rats submitted to cesarean followed by simulation of childbirth trauma, and group 7 (n = 10)--female rats with natural childbirth followed by simulation of childbirth trauma. The average concentration of collagen and elastic fibers and the collagen/muscular fiber correlation in groups 1, 2, and 3 were similar and significantly inferior to groups 4, 5, 6, and 7. The average of muscular fibers was similar in groups 1, 2, and 3 and significantly superior to groups 4, 5, 6, and 7. Pregnancy and cesarean did not induce alterations in collagen, muscular, and elastic fibers. However, the vaginal delivery and simulation of childbirth trauma determined the decrease in muscular fibers and the increase in collagen and elastic fibers and the correlation collagen/muscular fiber.

Effect of tibolone on cytochrome c oxidase I, beta-2-microglobulin and vascular endothelial growth factor gene expression in the lower urinary tract of castrated rats

INTRODUCTION

The objective of this study was to evaluate the effect of tibolone on cytochrome oxidase I (COX I), beta-2-microglobulin (B2M) and vascular endothelial growth factor (VEGF) gene expression in the lower urinary tract of castrated rats. These genes are related to cell energy, cellular immunity and vascularization processes.

METHODS

Fifty adult castrated rats remained at rest for 28 days. Thereafter they were randomly divided into two groups of 25 animals each. The lower urinary tract (bladder and urethra) was extracted in animals of one group and the other group received tibolone at a dose of 0.25 microg/animal/day for another 28 days followed by removal of the lower urinary tract. Total RNA was extracted from animals of both groups, forming two pools. After RT-PCR (reverse transcriptase polymerase chain reaction), expression of COX I, B2M and VEGF genes was evaluated by agarose gel electrophoresis, visualized by UV illumination.

RESULTS

Expression of the three genes (COX I, B2M and VEGF) was greater in the group treated with tibolone.

CONCLUSION

The use of tibolone increases the expression of COX, B2M and VEGF genes in the lower urinary tract as compared with that in castrated rats.

Bladder neck mobility and functional evaluation of the pelvic floor in primiparae according to the type of delivery

In this study, 91 primiparous women were selected, with a period of post-delivery variable from 45 to 60 days. These patients were divided according to the type of delivery into three groups: I--consisting of 32 patients who had vaginal delivery; II--comprised 29 patients who were subjected to forceps; III--formed by 30 women who were subjected to cesarean section. Patients with a previous pregnancy were not included, so that the possible previous alterations of the pelvic floor did not interfere with the present evaluation. Patients with a pre-term pregnancy, fetus below 2,500 g or above 4,000 g, anomalous presentations, twin pregnancy, diabetes mellitus, systhemic arterial hypertension, hypertensive disease specific of pregnancy, endocrinopathies and neuropathies were also excluded. After 45 to 60 days from delivery the patients were subjected to anamnesis, gynecological examination, functional evaluation of the pelvic floor (FEAF), Q-Tip test and ultrasound of the bladder neck. As for the functional evaluation of the pelvic floor, it was observed that the patients with cesarean section presented better indexes compared to those who were subjected to forceps. The Q-Tip test showed that in both the patients from group I and group II bladder neck mobility was greater than in those from group III. Concerning bladder neck topography in relation to public symphysis and its mobility, which were evaluated by ultrasound, it was observed that at rest all the groups had the neck in a supra-pubic position, with no differences among them. Yet, during the required strain, the bladder neck stayed in the infra-pubic position with major frequency in group I. Bladder neck mobility was greater in the vaginal delivery group in relation to the other groups. It was also noticed that the group undergoing cesarean section showed less mobility. The obtained results lead us to conclude that despite the fact that vaginal delivery may cause displacement of the urethro-vesical junction during strain, and consequently greater bladder neck mobility, it is the attending physician's role to minimize the damage to the pelvic floor, thus avoiding the emergence of a predisposing factor to future stress urinary incontinence.

Does electrical stimulation of the pelvic floor make any change in urodynamic parameters? When to expect a cure and improvement in women with stress urinary incontinence?

OBJECTIVE

Our study aimed at determining the effects of pelvic floor electrical stimulation assessed by the number of leakages per day recorded in a voiding diary over 90 days of treatment and urodynamic parameters.

STUDY DESIGN

This prospective study was carried out with 34 patients presenting stress urinary incontinence who were treated and evaluated by voiding diaries and urodynamic tests. The primary outcome measure was the number of leakages during the 90 days of treatment. Urodynamic tests were performed before and after treatment.

RESULTS

In our series, average and maximum flow rates and residual urine volume were within normal range in all subjects before and after treatment. Maximum urethral closure pressure and functional profile length on urethral pressure profiles did not change after treatment. In the cystometry, bladder capacities at the first (p < 0.0082) and maximum sensations (p < 0.01) improved significantly after treatment. During the 90 days of treatment, we observed a gradual drop in the number of leakages. This decrease began around day 22. It dropped in half around day 45, tending to zero close to day 90 of treatment (p < 0.01).

CONCLUSIONS

The number of incontinent leakage dropped to half around the 8th week, and on average, there was a tendency of the patients to be cured after the 12th week of treatment. At urodynamic studies we observed a significant increase in bladder capacity at the first desire to void and in the maximum cystometric capacity.

Urodynamic alterations after pelvic floor exercises for treatment of stress urinary incontinence in women

The following study improves the effectiveness of pelvic floor exercise in women with stress urinary incontinence. A group of 27 women with stress urinary incontinence performed specific pelvic floor exercises twice a week for 45 minutes under a therapist's supervision for a period of 12 weeks. This group had urodynamic and urethral pressure profile studies and filled in a daily diary. The patients self-evaluated their symptoms. After the therapy, the urodynamic and urethreal pressure profile studies were repeated and the results were: 66.7% patients were self-evaluated as cured; 14.8% improved and 18.5% unchanged. The urodynamic results showed that 48.2 % of the patients did not have urinary loss, however, 51,8% of the patients that had a loss showed an increase in vesicle volume, and only 7.3% remained unchanged. The results show that pelvic floor exercises are an effective and low cost treatment for stress urinary incontinence rehabilitation.

Urodynamic and clinical evaluation of postmenopausal women with stress urinary incontinence before and after cyclic estrogen therapy

OBJECTIVE

The purpose [corrected] of this study was to evaluate the effects of isolated cyclic estrogen therapy in menopausal women with stress urinary incontinence, and thus without the effects of progesterone.

METHODS

Nineteen menopausal patients with stress urinary incontinence were selected and submitted to anamnesis and physical, gynecological and urodynamic examinations. The group was homogeneous in relation to parity, body mass index and degree of urogenital prolapse. All the patients received conjugated equine estrogens orally, at a dose of 0.625 mg, for 21 days each month. After three months the clinical and urodynamic evaluations in relation to urine loss, were performed again.

RESULTS

Of the patients 57.9% were satisfied with the treatment. The urodynamic parameters remained unaltered in 36.85% of the patients.

CONCLUSION

Our results show that estrogen is important for stress urinary incontinence in postmenopause, specially in patients without cystocele or with cystocele of degree I or II.

Histomorphometric study of the inferior urinary tract of adult female rats during the interval between castration and hormonal replacement

OBJECTIVE

To evaluate the epithelial thickness, number of vessels, amount of collagen and muscular fibers of the bladder and urethra of castrated adult female rats during the time between castration and the beginning of the administration of synthetic conjugated estrogen.

METHOD

118 adult female rats were divided into four groups: Group I (n = 30): noncastrated female rats; group II (n = 30): female rats treated with synthetic conjugated estrogen in the dose of 50 microg/animal/day for 28 days, beginning immediately after castration; group III (n = 28): female rats treated with synthetic conjugated estrogen, 50 microg/animal/day for 28 days, beginning 30 days after castration: group IV (n = 30): female rats sacrificed after 30 days of castration. The histology of the bladder wall and the medium-third of the urethra wall were evaluated after flushing with hematoxylin-eosin and picrosirius for morphometric analysis.

RESULTS

It was verified that the epithelial thickness in groups II and III were similar whereas in groups I, II and III the thickness of the bladder and also the urethra were larger than in group IV. Concerning the bladder groups I and II were similar. In group I the urethra was superior than in groups II and III. In relation to the number of vessels and muscular fibers, groups I, II and III were similar to each other and superior to group IV in the bladder and urethra. The amount of collagen was similar in groups I, II and III and inferior in group IV in the bladder and in the urethra.

CONCLUSION

Independent of the time of estrogen administration (immediate or within 30 days) after castration, the thickness of the epithelium, the number of vessels, amount of collagen and muscular fibers were similar. The female rats with estrogen replacement presented significantly larger thickness of the epithelium, number of vessels and muscular fibers, and a smaller amount of collagen in the bladder and urethra in relation to the castrated group. Finally, estrogen therapy (immediate and 30 days after castration) reverted the effects of the estrogen deficiency in the vessels, collagen and muscular fibers, the bladder and of the urethra when compared to the group of castrated female rats, thus becoming similar to noncastrated animals.

Clinical and urodynamic evaluation of women with detrusor instability before and after functional pelvic floor electrostimulation

Detrusor instability is the second most frequent cause of female urinary incontinence. There are many therapeutic options, including non-invasive and surgical procedures. In this study, we evaluated the effects of pelvic floor vaginal electrostimulation using equipment designed in our institution, over three consecutive months, for treatment of 29 women with detrusor instability. After treatment 22 patients (76%) considered themselves cured or symptomatically improved; seven patients (24%) had no change in symptoms after therapy. There was objective cure and improvement in ten (34.5%) and in eight (27.5%) patients, respectively, and the urodynamic parameters did not change in 11 patients (38%). Electrical stimulation resulted in a gradual decrease in the number of urinary leakage episodes and increase in maximum cystometric capacity in first desire to void and in urinary volume.

Vaginal hysterectomy allied with Kelly-Kennedy surgery and perineal repair for the treatment of patients with a prolapsed uterus and urinary stress incontinence

PURPOSE

To evaluate patients with uterine prolapse, before and after surgical treatment, using urodynamic and bladder neck ultrasound.

MATERIAL AND METHODS

33 postmenopausal patients with uterine prolapse were submitted to vaginal hysterectomy (Mayo-Ward technique) allied with Kelly-Kennedy surgery and perineal repair. The women were divided into three groups depending on the degree of prolapse. A urodynamic examination was performed before, after 30 days and in the third month after the operation. A bladder neck ultrasound was performed before and in the third month after the operation.

RESULTS

In 23 women who lost urine preoperatively, 14 continued to show objective loss 90 days after the surgery. Ultrasound identified a significant elevation in the bladder neck during rest in groups I and II, but not in group III. There was a significant reduction in its mobility in all three groups.

CONCLUSION

Kelly-Kennedy surgery does not have any indication, even in patients with urinary stress incontinence and a prolapsed uterus who are submitted to vaginal hysterectomy.

Analysis of collagen in parametrium and vaginal apex of women with and without uterine prolapse

Our objective was to compare the amount of collagen in parametrium and vaginal apex between women with uterine prolapse at pre- and postmenopause, and in women without prolapse. The study included 22 premenopausal women without prolapse (group A), 10 premenopausal women with prolapse (group B), and 23 postmenopausal women with prolapse (group C) (total 55). Patients in group A underwent abdominal hysterectomy for uterine leiomyoma, and patients in groups B and C underwent vaginal hysterectomy. During the surgical procedure we obtained biopsies from the lateral parametrium and vaginal apex. The tissue was stained for histological analysis with picrosirius. We observed a lower amount of collagen in the parametrium of women with uterine prolapse, both in menacme and in postmenopause, than in the parametrium of women without prolapse. We observed no statistically significant difference in vaginal apex between the groups.