Minimally Invasive Sacrohysteropexy Versus Vaginal Hysterectomy With Uterosacral Ligament Suspension for Pelvic Organ Prolapse: A Prospective Randomized Non-Inferiority Trial

STUDY OBJECTIVE

To investigate whether minimally invasive Sacrohysteropexy (SH) is non-inferior to vaginal hysterectomy (VH) with uterosacral ligament suspension (USLS) in women with symptomatic uterovaginal prolapse.

DESIGN

Prospective, randomized, non-inferiority study.

SETTING

Tertiary university-based hospital.

PATIENTS

A total of 146 patients with uterovaginal prolapse between July 2016 and August 2019.

INTERVENTIONS

Patients were randomly assigned in a 1:1 ratio to either laparoscopic or robotic SH surgery or VH with USLS surgery.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was prolapse recurrence at 1 year after surgery, defined as prolapse ≥ stage 2 evaluated using the pelvic organ prolapse quantification system, bothersome vaginal bulge symptoms, or retreatment for prolapse. The secondary outcomes included operation time, estimated blood loss, hospital stay, operation-related complications, pain intensity, quality of life, and activities of daily living. Of 146 women who underwent randomization, 73 in the SH group and 73 in the VH with USLS group were analyzed. SH was non-inferior for recurrence compared with VH with USLS (16.4% vs 15.8%, 95% confidence interval: -13.0% to 14.2%). Operating duration and transvaginal length were significantly longer in the SH group, while there were no significant differences in the estimated blood loss, length of hospital stay, or postoperative complication rates. Although perioperative pain intensity was greater from 1 week to 1 month in the SH group, the quality of life and activities of daily living did not differ between the groups throughout postoperative year 1.

CONCLUSION

Laparoscopic or robotic SH was non-inferior to VH with USLS for the recurrence of pelvic organ prolapse at the 1-year follow-up.

Optimized treatment parameter by computer simulation for high-intensity focused ultrasound treatment of uterine adenomyosis: Short-term and long-term results

This study aimed to investigate the efficacy and safety of using optimized parameters obtained by computer simulation for ultrasound-guided high-intensity focused ultrasound (HIFU) treatment of uterine adenomyosis in comparison with conventional parameters. We retrospectively assessed a single-institution, prospective study that was registered at Clinical Research Information Service (CRiS) of Republic of Korea (KCT0003586). Sixty-six female participants (median age: 44 years) with focal uterine adenomyosis were prospectively enrolled. All participants were treated with a HIFU system by using treatment parameters either for treating uterine fibroids (Group A, first 20 participants) or obtained via computer simulation (Group B, later 46 participants). To assess the treatment efficacy of HIFU, qualitative indices, including the clinically effective dysmenorrhea improvement index (DII), were evaluated up to 3 years after treatment, whereas quantitative indices, such as the nonperfused volume ratio and adenomyosis volume shrinkage ratio (AVSR), on MRI were evaluated up to 3 months after treatment. Quantitative/qualitative indices were compared between Groups A and B by using generalized linear mixed effect model. A safety assessment was also performed. Results showed that clinically effective DII was more frequently observed in Group B than in Group A (odds ratio, 3.69; P = 0.025), and AVSR were higher in Group B than in Group A (least-squares means, 21.61; P = 0.001). However, two participants in Group B developed skin burns at the buttock and sciatic nerve pain and required treatment. In conclusion, parameters obtained by computer simulation were more effective than the conventional parameters for treating uterine adenomyosis by using HIFU in terms of clinically effective DII and AVSR. However, care should be taken because of the risk of adverse events.

External validation of the de novo stress urinary incontinence prediction model after pelvic organ prolapse surgery in Korean women: a retrospective cohort study

BACKGROUND

De novo stress urinary incontinence (SUI) may develop following pelvic organ prolapse surgery. Performing prophylactic continence surgery may reduce the risk of de novo SUI and subsequent continence surgery; however, it may increase the risk of complications. Therefore, many surgeons try to identify women at high risk for de novo SUI and perform continence surgery selectively. Recently, a model for predicting the risk of de novo SUI after prolapse surgery was developed using data from the Outcomes following vaginal Prolapse repair and midUrethral Sling (OPUS) trial; its prediction accuracy was significantly better than that of the stress test alone. However, few studies have verified its prediction accuracy in discrete populations. The aim of this study was to externally validate the prediction model for de novo SUI after prolapse surgery in Korean women.

METHODS

This retrospective cohort study included 320 stress-continent women who underwent prolapse surgery for pelvic organ prolapse quantification stage 2-4 anterior or apical prolapse and who completed a 1-year follow-up. Predicted probabilities by the de novo SUI online risk calculator were compared with observed outcomes and quantitated using the model's area under the curve and calibration plot. Subgroup analyses were also performed by the type of prolapse surgery.

RESULTS

The de novo SUI prediction model showed moderate discrimination in our study cohort; area under the curve (95% confidence interval) = 0.73 (0.67-0.78) in the whole cohort, 0.69 (0.61-0.78) in women who underwent native tissue repair or colpocleisis, and 0.74 (0.65-0.82) in those who underwent sacrocolpopexy. Calibration curves demonstrated that the model accurately predicted the observed outcomes of de novo SUI in women who underwent native tissue repair or colpocleisis but underestimated outcomes in those who underwent sacrocolpopexy. The predicted probability cutoff points corresponding to an actual risk of 50% were 40% in women who underwent native tissue repair or colpocleisis and 30% in those who underwent sacrocolpopexy.

CONCLUSIONS

The de novo SUI prediction model is acceptable for use in Korean women and may aid in shared decision-making regarding prophylactic continence procedure at the time of prolapse surgery.

The Diagnostic Accuracy of a Retrograde Voiding Trial for Restoration of Spontaneous Voiding Function after Prolapse and Urinary Incontinence Surgery

STUDY OBJECTIVE

To assess the diagnostic accuracy of a retrograde voiding trial for the restoration of spontaneous voiding function after prolapse and urinary incontinence surgery and thereby determine whether the retrograde method can be a reliable alternative to the spontaneous voiding trial.

DESIGN

A retrospective cohort study.

SETTING

A single tertiary hospital in South Korea.

PATIENTS

Women who underwent operations for prolapse, urinary incontinence, or both.

INTERVENTION

Sequential voiding trials on postoperative day 1 or 2-retrograde voiding trial followed by spontaneous voiding trial.

MEASUREMENTS AND MAIN RESULTS

Of the 408 women analyzed, 278 (68.1%) passed the spontaneous voiding trial on the first day of assessment and none experienced urinary retention after a successful voiding trial. Receiver operating characteristic analyses of retrograde voiding trials evaluating voided volume (VV), postvoid residual (PVR), and voiding efficiency (VE) all demonstrated high diagnostic accuracy for restoration of spontaneous voiding function, whereas measuring PVR and VE had better discriminative ability than VV (area under the curve [95% confidence interval] = 0.93 [0.90-0.95] for PVR, 0.94 [0.91-0.96] for VE, and 0.88 [0.85-0.91] for VV; DeLong's test between PVR/VE and VV p < .01). The optimal cutoffs determined by the Youden index were 200 mL for VV (sensitivity 85.0%, specificity 78.0%), 100 mL for PVR (sensitivity 84.0%, specificity 87.0%), and 66.7% for VE (sensitivity 86.0%, specificity 88.0%).

CONCLUSIONS

The retrograde voiding trial is an accurate predictor for restoration of spontaneous voiding function after prolapse and incontinence surgery and can be a useful alternative to the spontaneous voiding trial.

Anatomic Criterion for Clinically Relevant Apical Prolapse in Urogynecology Populations

IMPORTANCE

Despite recognition of the critical role of the apex in vaginal support, there is no consensus on the anatomic criteria for clinically relevant apical prolapse.

OBJECTIVE

The aim of this study was to define an optimal anatomic criterion for clinically relevant apical prolapse.

STUDY DESIGN

This retrospective cohort study included 3,690 patients who had visited a tertiary hospital for ambulatory urogynecologic care. Vaginal bulge symptom was defined as a response of "somewhat," "moderately," or "quite a bit" to Question 3 on the Pelvic Floor Distress Inventory-20. Receiver operating characteristic curves were generated for a vaginal bulge symptom and apical support (Pelvic Organ Prolapse Quantification point C and C/total vaginal length [TVL]).

RESULTS

Both point C and the C-to-TVL ratio (C/TVL) had excellent performance for predicting vaginal bulge symptoms (area under the curve, 0.917 and 0.927, respectively). The optimal cutoffs were -3.0 for C and -0.50 for C/TVL. When we analyzed the data set according to the TVL, there was a significant difference in the cutoffs for C, whereas those for C/TVL had little difference. There was no difference in the cutoffs of C and C/TVL according to hysterectomy status.

CONCLUSIONS

The C/TVL is more appropriate than point C as a measure to define an anatomic criterion for clinically relevant apical prolapse. Descent of the vaginal apex beyond the halfway point of the vagina could be considered as an anatomic threshold for clinically relevant apical prolapse. This finding needs to be validated in nonurogynecology populations.

Development and validation of a prediction model for bothersome stress urinary incontinence after prolapse surgery: a retrospective cohort study

OBJECTIVE

To develop and validate a prediction model for bothersome stress urinary incontinence after prolapse surgery and to compare it with an existing clinical prediction model (CUPIDO model).

DESIGN

Retrospective cohort study.

SETTING

Two tertiary hospitals in South Korea.

POPULATION

A total of 1142 patients who underwent prolapse surgery with or without a concomitant midurethral sling.

METHODS

To construct a prediction model, we performed logistic regression using both exhaustive and stepwise variable selection, validating the model both internally and externally.

MAIN OUTCOME MEASURES

Bothersome stress urinary incontinence defined as the presence of bothersome symptoms of stress urinary incontinence and/or subsequent continence procedure one year after surgery.

RESULTS

Postoperative bothersome stress urinary incontinence occurred in 10% of patients. A model containing six predictors (age, diabetes mellitus, subjective urinary incontinence, prolapse reduction stress test result, type of prolapse surgery, and a concomitant midurethral sling) showed excellent performance for predicting bothersome stress urinary incontinence (area under the curve 0.74, 95% confidence interval 0.62-0.86) and outperformed the CUPIDO model (area under the curve 0.63, 95% confidence interval 0.49-0.76; DeLong's test P = 0.014).

CONCLUSIONS

This prediction model might be a useful tool to guide patient decision making regarding a concomitant continence procedure at the time of prolapse surgery. The predictive value of this model needs to be validated further in cohorts with different characteristics.

TWEETABLE ABSTRACT

The proposed prediction model for bothersome stress urinary incontinence after prolapse surgery outperforms an existing model.

Hormone autocrination by vascularized hydrogel delivery of ovary spheroids to rescue ovarian dysfunctions

The regeneration potential of implantable organ model hydrogels is applied to treat a loss of ovarian endocrine function in women experiencing menopause and/or cancer therapy. A rat ovariectomy model is used to harvest autologous ovary cells while subsequently producing a layer-by-layer form of follicle spheroids. Implantation of a microchannel network hydrogel with cell spheroids [vascularized hydrogel with ovarian spheroids (VHOS)] into an ischemic hindlimb of ovariectomized rats significantly aids the recovery of endocrine function with hormone release, leading to full endometrium regeneration. The VHOS implantation effectively suppresses the side effects observed with synthetic hormone treatment (i.e., tissue overgrowth, hyperplasia, cancer progression, deep vein thrombosis) to the normal levels, while effectively preventing the representative aftereffects of menopause (i.e., gaining fatty weight, inducing osteoporosis). These results highlight the unprecedented therapeutic potential of an implantable VHOS against menopause and suggest that it may be used as an alternative approach to standard hormone therapy.

Aberrant Expression of Sodium-Potassium-Chloride Cotransporter in Endometriosis

Cell membrane ion channels have important roles in cell migration during cancer development and metastasis. Although endometriosis is a benign gynecological disease, some migration and invasion characteristics of endometriosis are similar to those of cancer. However, only a few studies have examined cell membrane ion channels and their associations with endometriosis. This study aimed to investigate the effects of these ion channels on development of endometriosis. A total of 39 women who underwent laparoscopic ovarian cyst enucleation were included in the study population. Eutopic endometrium or ectopic endometrium tissues were obtained from each patient based on allocation to an endometriosis group (n=21) or a control group (n=18). Quantitative real-time PCR (qRT-PCR) and western blot analyses were performed to quantify NKCC1, NKCC2, and CLCN3 mRNA expression and protein concentrations. SiRNA transfection and migration assays of the endometrial stromal cells were performed to test the effects of the ion channels on the migration ability. The qRT-PCR and western blot analyses revealed significantly elevated mRNA expression and protein expression of NKCC1, NKCC2, and CLCN3 in the ectopic endometrial tissue from the patients with endometriosis (p < 0.05). Migration assay of siRNA transfected cells suggested a decreased migratory potential of the endometrial stromal cells (p < 0.001). The magnitudes of expression of NKCC1, NKCC2, and CLCN3 were positively correlated with endometrioma size. The increased expression of NKCC1, NKCC2, and CLCN3 in endometriosis offers opportunities to understand mechanisms of endometriosis and develop novel therapeutic approaches.

Pelvic floor muscle function recovery using biofabricated tissue constructs with neuromuscular junctions

Damages in pelvic floor muscles often cause dysfunction of the entire pelvic urogenital system, which is clinically challenging. A bioengineered skeletal muscle construct that mimics structural and functional characteristics of native skeletal muscle could provide a therapeutic option to restore normal muscle function. However, most of the current bioengineered muscle constructs are unable to provide timely innervation necessary for successful grafting and functional recovery. We previously have demonstrated that post-synaptic acetylcholine receptors (AChR) clusters can be pre-formed on cultured skeletal muscle myofibers with agrin treatment and suggested that implantation of AChR clusters containing myofibers could accelerate innervation and recovery of muscle function. In this study, we develop a 3-dimensional (3D) bioprinted human skeletal muscle construct, consisting of multi-layers bundles with aligned and AChR clusters pre-formed human myofibers, and investigate the effect of pre-formed AChR clusters in bioprinted skeletal muscle constructs and innervation efficiency in vivo. Agrin treatment successfully pre-formed functional AChR clusters on the bioprinted muscle constructs in vitro that increased neuromuscular junction (NMJ) formation in vivo in a transposed nerve implantation model in rats. In a rat model of pelvic floor muscle injury, implantation of skeletal muscle constructs containing the pre-formed AChR clusters resulted in functional muscle reconstruction with accelerated construct innervation. This approach may provide a therapeutic solution to the many challenges associated with pelvic floor reconstruction resulting from the lack of suitable bioengineered tissue for efficient innervation and muscle function restoration.

Engineering Functional Rat Ovarian Spheroids Using Granulosa and Theca Cells

Although menopausal hormone therapy (MHT) is the most effective approach to managing the loss of ovarian activity, serious side effects have been reported. Cell-based therapy is a promising alternative for MHT. This study constructed engineered ovarian cell spheroids and investigated their endocrine function. Theca and granulosa cells were isolated from ovaries of 10-week-old rats. Two types of engineered ovarian cell spheroids were fabricated through forced aggregation in microwells, multilayered spheroids with centralized granulosa aggregates surrounded by an outer layer of theca cells and mixed ovarian spheroids lacking spatial rearrangement. The ovarian cell spheroids were encapsulated into a collagen gel. Non-aggregated ovarian cells served as controls. The endocrine function of the engineered ovarian spheroids was assessed over 30 days. The structure of the spheroids was well maintained during culture. The secretion of 17β-estradiol from both types of engineered ovarian cell spheroids was higher than in the control group and increased continuously in a time-dependent manner. Secretion of 17β-estradiol in the multi-layered ovarian cell spheroids was higher than in the non-layered constructs. Increased secretion of progesterone was detected in the multi-layered ovarian cell spheroids at day 5 of culture and was sustained during the culture period. The initial secretion level of progesterone in the non-layered ovarian cell spheroids was similar to those from the controls and increased significantly from days 21 to 30. An in vitro rat model of engineered ovarian cell spheroids was developed that was capable of secreting sex steroid hormones, indicating that the hormone secreting function of ovaries can be recapitulated ex vivo and potentially adapted for MHT.

Suture Complication Rates and Surgical Outcomes According to the Nonabsorbable Suture Materials Used in Vaginal Uterosacral Ligament Suspension: Polyester versus Polypropylene

STUDY OBJECTIVE

To evaluate suture complication rates and surgical outcomes according to the nonabsorbable suture materials used in vaginal uterosacral ligament suspension (USLS) surgery. Multifilament polyester (polyethylene terephthalate [PET]) and monofilament polypropylene (PP) sutures were compared.

DESIGN

Retrospective cohort study.

SETTING

Single teaching hospital.

PATIENTS

Total of 229 patients who underwent transvaginal USLS and completed a 1-year follow-up.

INTERVENTIONS

Use of PET and PP sutures for transvaginal USLS procedures.

MEASUREMENTS AND MAIN RESULTS

PP sutures were used in 149 patients, and PET sutures were used in 80 patients. The suture-related complication rates, including granulation tissue and suture erosion at the vaginal apex, were significantly higher in the PET suture group than in the PP suture group (46.3% vs 20.1%, p <.01). However, there was no significant difference in the rates of surgical failure (defined as the presence of vaginal bulging symptoms, apical descent ≥ half of the total vaginal length, anterior or posterior vaginal wall descent beyond the hymen, or retreatment for prolapse) between the 2 groups (p = .84).

CONCLUSION

Compared with the use of multifilament PET sutures, the use of monofilament PP sutures in transvaginal USLS may reduce suture-related complications without increasing surgical failure rates.

Non-absorbable versus absorbable sutures for anterior colporrhaphy: study protocol for a randomised controlled trial in South Korea

INTRODUCTION

The anterior vaginal wall is the segment most commonly affected by prolapse. Traditionally, anterior vaginal wall prolapse is repaired via anterior colporrhaphy, which is known to have a high recurrence rate. Several factors might affect the outcome of anterior colporrhaphy, and the use of absorbable sutures might also be associated with the high recurrence rate because the sutures might not be able to retain adequate strength until the plicated pubocervical fascia remodels and regains maximum tensile strength. Nonetheless, no comparative data exist about the relative efficacy and safety of anterior colporrhaphy using non-absorbable versus absorbable sutures. The objective of this study is to compare the surgical outcomes of anterior colporrhaphy using non-absorbable sutures with those of anterior colporrhaphy using absorbable sutures.

METHODS AND ANALYSIS

This is a randomised, multicentre, superiority trial. Anterior colporrhaphy will be performed in a traditional manner with midline plication of the fibromuscular layer using either non-absorbable or absorbable sutures. The primary outcome is composite surgical success 1 year after surgery defined as the absence of all of the following: (1) anterior vaginal descent beyond the hymen, (2) the presence of vaginal bulge symptoms and (3) retreatment for recurrent anterior vaginal wall prolapse with either surgery or pessary. The secondary outcomes include the individual components of the composite primary end point, anatomical outcomes, condition-specific quality of life and adverse events related to anterior colporrhaphy. The planned number of participants is 192.

ETHICS AND DISSEMINATION

This study was approved by the Institutional Review Board of Seoul National University Hospital (H-1810-037-977). The results of the study will be published in peer-reviewed journals, and the findings will be presented at scientific meetings.

TRIAL REGISTRATION NUMBER

NCT03736811.

Risk Factors Associated with Endometrial Pathology in Premenopausal Breast Cancer Patients Treated with Tamoxifen

PURPOSE

To evaluate factors associated with endometrial pathology during tamoxifen use in premenopausal breast cancer (BC) patients.

MATERIALS AND METHODS

We reviewed the medical records of premenopausal BC patients treated with tamoxifen who underwent endometrial biopsy with or without hysteroscopy. Clinical characteristics were compared between women with endometrial pathology (endometrial hyperplasia or cancer) and those with normal histology or endometrial polyps.

RESULTS

Among 284 endometrial biopsies, endometrial hyperplasia was diagnosed in 7 patients (2.5%), endometrial cancer was diagnosed in 5 patients (1.8%), normal histology was noted in 146 patients (51.4%), and endometrial polyp was present in 114 patients (40.1%). When comparing women with endometrial cancer (n=5) to women with normal histology, abnormal uterine bleeding was more common (p=0.007), and endometrial thickness was greater (p=0.007) in women with endometrial cancer. Chemotherapy for BC was also more common in patients with endometrial cancer (p=0.037). When comparing women with endometrial polyps and those with endometrial hyperplasia or cancer, the presence of abnormal uterine bleeding was more common in patients with endometrial hyperplasia or cancer (p<0.001); however, tamoxifen duration and endometrial thickness did not differ significantly between the two groups.

CONCLUSION

In premenopausal BC patients treated with tamoxifen, abnormal uterine bleeding, increased endometrial thickness, and chemotherapy for BC were associated with the occurrence of endometrial cancer. These findings may provide useful information for gynecologic surveillance and counseling during tamoxifen treatment in premenopausal BC patients.

Risk factors for vaginal mesh erosion after sacrocolpopexy in Korean women

Objective

Although sacrocolpopexy (SCP) can provide durable apical support, the use of mesh may give rise to various complications, including vaginal mesh erosion. The aim of this study was to identify the risk factors for vaginal mesh erosion after SCP in Korean women.

Methods

This retrospective cohort study included 363 women who underwent SCP with type 1 polypropylene mesh. They were evaluated at 1, 4, and 12 months after surgery and then annually thereafter with respect to anatomy and complications. Univariate and multivariate analyses using the Cox proportional hazard model were performed to identify the risk factors for mesh erosion.

Results

During the median 2-year follow-up period, vaginal mesh erosion was found in 29 women (8.0%). Among them, 19 (65.5%) required surgical correction. Estrogenic status was the only independent risk factor for mesh erosion. The risk for mesh erosion was 4.5 times higher in premenopausal women than in menopausal women not on estrogen replacement therapy (ERT) (95% confidence intervals [CI] 1.9–10.9, p<0.01). Menopausal women on ERT also had an increased risk, with a statistically marginal significance (hazard ratio 2.5, 95% CI 0.9–6.6; p = 0.07).

Conclusions

Premenopausal or menopausal women on ERT are at high risk for mesh erosion after SCP with type 1 polypropylene mesh, and two-thirds of mesh erosion cases require reoperation. This information should be incorporated into patient counseling and treatment decisions.

Preoperative POPQ versus Simulated Apical Support as a Guideline for Anterior or Posterior Repair at the Time of Transvaginal Apical Suspension (PREPARE trial): study protocol for a randomised controlled trial

INTRODUCTION

Transvaginal reconstructive surgery is the mainstay of treatment for symptomatic pelvic organ prolapse. Although adequate support for the vaginal apex is considered essential for durable surgical repair, the optimal management of anterior and posterior vaginal wall prolapse in women undergoing transvaginal apical suspension remains unclear. The objective of this trial is to compare surgical outcomes of pelvic organ prolapse quantification (POPQ)-based surgery with outcomes of simulated apical support-based surgery for anterior or posterior vaginal wall prolapse at the time of transvaginal apical suspension.

METHODS AND ANALYSIS

This is a randomised, multicentre, non-inferiority trial. While women who are assigned to the POPQ-based surgery group will undergo anterior or posterior colporrhaphy for all stage 2 or greater anterior or posterior vaginal prolapse, those assigned to simulated apical support-based surgery will receive anterior or posterior colporrhaphy only for the prolapse unresolved under simulated apical support. The primary outcome measure is the composite surgical success, defined as the absence of anatomical (anterior or posterior vaginal descent beyond the hymen or descent of the vaginal apex beyond the half-way point of vagina) or symptomatic (the presence of vaginal bulge symptoms) recurrence or retreatment for prolapse by either surgery or pessary, at 2 years after surgery. Secondary outcomes include the rates of anterior or posterior colporrhaphy, the changes in anatomical outcomes, condition-specific quality of life and sexual function, perioperative outcomes and adverse events.

ETHICS AND DISSEMINATION

This study was approved by the institutional review board of each participating centre (Seoul National University College of Medicine/Seoul National University Hospital, Chonnam National University Hospital, Seoul St. Mary's Hospital, International St. Mary's Hospital). The results of the study will be published in peer-reviewed journals, and the findings will be presented at scientific meetings.

TRIAL REGISTRATION NUMBER

NCT03187054.

The effect of diagnosis-related group payment system on the quality of medical care for pelvic organ prolapse in Korean tertiary hospitals

PURPOSE

To assess changes in clinical practice patterns after implementing diagnosis-related group (DRG) payment system in July 2013 and its effect on the quality of care for pelvic organ prolapse (POP).

MATERIALS AND METHODS

Using the 2011-2016 administrative database from National Health Insurance claim data, we reviewed medical information of 7362 patients who underwent hysterectomies for POP in Korean tertiary hospitals. We compared changes in several variables including length of stay, concomitant procedures, outpatient visits and readmission within 30 days after discharge, and retreatment for POP or stress urinary incontinence within postoperative 1 year before and after DRG system.

RESULTS

After the introduction of DRG system, the average length of stay decreased (7.74 ± 2.88 to 6.63 ± 2.18 days, p<0.001) without increasing readmission rates. However, the number of outpatient visits increased (2.78±2.33 to 2.98±2.47, p<0.001). Regarding concomitant procedures, the rates of colpopexy and midurethral slings significantly decreased (7.87% and 9.84% to 4.93% and 2.93%, respectively, all p<0.001). Even though there was no difference in the reoperation rates, pessary insertion for recurrent POP significantly increased after the introduction of DRG system (0.10% to 0.38%, p = 0.015).

CONCLUSION

The implementation of DRG in Korean tertiary hospitals has led to increase of outpatient visits and reduced surgical management for POP, which indicates that the uniform application of DRG influences the quality of care for POP patients.

Uterine Leiomyoma Is Associated with Female Sexual Dysfunction in Postmenopausal Women

PURPOSE

To determine the relationship between uterine leiomyoma and female sexual dysfunction (FSD) among premenopausal and postmenopausal women.

MATERIALS AND METHODS

The study population consisted of consecutive women who underwent gynecologic screening tests, including transvaginal ultrasound, and completed the questionnaires on FSD. A total of 841 women were included from January 2010 to December 2011. FSD was defined as Female Sexual Function Index (FSFI) ≤26.55. The relationship between uterine leiomyoma and FSD were compared according to menopausal status.

RESULTS

In premenopausal group (n=564), there were no differences in the frequency of FSD (55.0% vs. 58.8%, p=0.387) and total FSFI score. However, in postmenopausal group (n=277), women with uterine leiomyoma had a lower frequency of FSD than those without uterine leiomyoma (71.3% vs. 86.4%, p=0.003). This relationship between uterine leiomyoma and lower frequency of FSD in postmenopausal women remained significant after adjusting for confounding variables.

CONCLUSION

The relationship between uterine leiomyoma and FSD is different depending on the menopausal status.

Risk factors for the failure of iliococcygeus suspension for uterine prolapse

OBJECTIVES

The objective of this study was to evaluate the risk factors for the failure of iliococcygeus suspension (ICG) for uterine prolapse and estimate its long-term success rates using a clinically relevant criterion.

STUDY DESIGN

This retrospective cohort study included 144 women who underwent transvaginal reconstructive surgery including ICG for symptomatic pelvic organ prolapse. Surgical failure was defined as anatomic recurrence (descent of the vaginal apex beyond the halfway point of the vagina or descent of the anterior or posterior vaginal wall beyond the hymen), symptomatic recurrence (vaginal bulge symptoms), or retreatment for prolapse.

RESULTS

During the median 4-year follow-up period, surgical failure was observed in 20 women (13.9%). Multivariate analysis with the Cox proportional hazard model showed that advanced prolapse (preoperative pelvic organ prolapse quantification [POP-Q] stage >II and point C >0) and uterus-saving techniques were independent risk factors for failure. When the ICG was performed as a vault suspension procedure together with hysterectomy, the estimated 4-year success rates were 100% for mild prolapse (POP-Q stage II or point C ≤0) and 91.2% for advanced prolapse. When the procedure was done as a hysteropexy, the corresponding success rates decreased to 75.3% and 48.0%, respectively.

CONCLUSIONS

This study indicates that the severity of prolapse and the uterus-saving technique affect the prognosis after ICG. The ICG provides a durable apical vaginal support when performed together with hysterectomy, irrespective of the severity of the prolapse. In addition, it appears to be an acceptable hysteropexy option for mild uterine prolapse.

MicroRNAs 125a and 125b inhibit ovarian cancer cells through post-transcriptional inactivation of EIF4EBP1

The aim of the present study was to identify the specific miRNAs involved in regulation of EIF4EBP1 expression in ovarian cancer and to define their biological function. miRNA mimics and miRNA inhibitors were used in quantitative PCR, western blotting, and luciferase reporter assays to assess cell migration, invasiveness, and viability. miR-125a and miR-125b were downregulated in ovarian cancer tissue and cell lines relative to healthy controls. Increased expression of miR-125a and miR-125b inhibited invasion and migration of SKOV3 and OVCAR-429 ovarian cancer cells and was associated with a decrease in EIF4EBP1 expression. The inverse relationship between miR-125a and miR-125b was corroborated by cotransfection of a luciferase reporter plasmid. Furthermore, miR-125a and miR-125b caused apoptosis and decreased cell viability and migration in an apparently EIF4EBP1-directed manner. Collectively, these results indicate that miR-125a and miR-125b are important posttranscriptional regulators of EIF4EBP1 expression, providing rationale for new therapeutic approaches to suppress tumour invasion and migration using miR-125a, miR-125b, or their mimics for the treatment of ovarian cancer.

Prognostic Effects of Adjuvant Chemotherapy-Induced Amenorrhea and Subsequent Resumption of Menstruation for Premenopausal Breast Cancer Patients

Chemotherapy-induced amenorrhea (CIA) is a side effect that occurs in patients with breast cancer (BC) as a result of chemotherapy. These patients require special treatments to avoid infertility and menopause. However, the factors controlling CIA, resumption of menstruation (RM), and persistence of menstruation after chemotherapy are unknown. The long-term prognosis for premenopausal patients with BC and the prognostic factors associated with CIA and RM are subject to debate. We performed a retrospective study by reviewing the medical records of 249 patients with BC (stage I to stage III) who were treated with cytotoxic chemotherapy. The median patient age was 43 (range, 26-55 years) and the median duration of follow-up was 64 months (range, 28-100 months). The medical records indicated that 219 patients (88.0%) scored as positive for the hormone receptor (HR); the majority of these patients completed chemotherapy and then received additional therapy of tamoxifen. Our analyses revealed that 88.0% (n = 219) of patients experienced CIA, and the percentage of RM during follow-up was 48.6% (n = 121). A total of 30 patients (12.0%) did not experience CIA. Disease-free survival (DFS) was affected by several factors, including tumour size ≥2 cm, node positivity, HR negative status, and body mass index ≥23 kg/m. Multivariate analysis indicated that tumour size ≥2 cm remained as a significant factor for DFS (hazard ratio = 3.3, P = 0.034). In summary, this study finds that the majority of premenopausal patients with BC (stage I to stage III) who receive chemotherapy experience CIA and subsequent RM. Although tumour size ≥2 cm is negatively associated with DFS, RM after CIA is not associated with poor prognosis.

MicroRNA-30d and microRNA-181a regulate HOXA11 expression in the uterosacral ligaments and are overexpressed in pelvic organ prolapse

The balanced turnover of collagen is necessary to maintain the mechanical strength of pelvic supportive connective tissues. Homeobox (HOX) A11 is a key transcriptional factor that controls collagen metabolism and homoeostasis in the uterosacral ligaments (USLs), and the deficient HOXA11 signalling may contribute to alterations in the biochemical strength of the USLs, leading to pelvic organ prolapse (POP). However, it is unknown how HOXA11 transcripts are regulated in the USLs. In this study, we found that microRNA (miRNA)-30d and 181a were overexpressed in women with POP, and their expression was inversely correlated with HOXA11 mRNA levels. The overexpression of miR-30d or 181a suppressed HOXA11 mRNA and protein levels in 293T cells, whereas the knockdown of these miRNAs enhanced HOXA11 levels and collagen production. Cotransfection of a luciferase reporter plasmid containing the 3′-untranslated region of HOXA11 with miR-30d or 181a mimic resulted in decreased relative luciferase activity. Conversely, cotransfection with anti-miR-30d or 181a increased luciferase activity. Taken together, these results indicate that both miR-30d and 181a are important posttranscriptional regulators of HOXA11 in the USLs and could be a potential therapeutic target for POP.

Subclinical Hypothyroidism is not a Risk Factor for Female Sexual Dysfunction in Korean Middle-Aged Women

BACKGROUND

Previous studies have suggested that subclinical hypothyroidism is associated with the risk of anxiety or depression and can affect quality of life. However, there is a paucity of information regarding the relationship between subclinical hypothyroidism and female sexual dysfunction.

METHODS

The study population consisted of sexually active middle-aged women (≥40 years old) who visited the center for health promotion and optimal aging at Seoul National University Hospital for a health check-up between 2010 and 2011. Sexual function was evaluated by the female sexual function index (FSFI) questionnaire, and female sexual dysfunction was defined as a FSFI score of ≤26.55. FSFI scores and female sexual dysfunction frequencies were compared between cases with subclinical hypothyroidism and healthy controls. Nonparametric methods were used for statistical analysis.

RESULTS

A total of 1086 women were included, and the frequency of subclinical hypothyroidism and female sexual dysfunction was 138 (12.7%) and 741 (68.2%), respectively. The total FSFI score and the scores in each domain were not different between the two groups (median total FSFI score (interquartile range): 23.8 (20.2-27.5) for normal thyroid status vs. 24.4 (20.6-27.6) for subclinical hypothyroidism, p=n.s.). The frequency of female sexual dysfunction was not different between the two groups, either (68.4% for normal thyroid status vs. 67.4% for subclinical hypothyroidism, p=n.s.). These findings were consistent even after adjustment for confounding variables.

CONCLUSIONS

Subclinical hypothyroidism is not a risk factor for sexual dysfunction in middle-aged women.

Association between susceptibility to advanced pelvic organ prolapse and glutathione S-transferase P1 Ile105Val polymorphism

OBJECTIVE

Oxidative stress is associated with the pathogenesis of pelvic organ prolapse (POP). Because glutathione S-transferases (GSTs) are the major detoxification enzymes which protect cells against oxidative stress, genetic variations in the GST gene may modulate the risk of POP. This study aimed to determine the association between advanced POP and the polymorphisms of GSTM1, GSTT1 and GSTP1 (rs1695).

STUDY DESIGN

This is a hospital-based case-control study. The POP group consisted of 189 women diagnosed with POP stage III or IV, and the control group consisted of 156 postmenopausal women with POP stage 0 or I. The GSTM1 and GSTT1 null mutations were detected by multiplex PCR, and the GSTP1 Ile105Val polymorphism was genotyped by real-time PCR analysis using a TaqMan assay.

RESULTS

There was no significant association between the GSTM1 and GSTT1 null mutations and advanced POP (p>0.05). The distribution of the GSTP1 Ile105Val genotypes, however, was significantly different between the POP and control groups (AA/AG/GG rates=74.1%/25.9%/0% vs. 64.1%/32.1%/3.8%, p=0.008), and the G allele frequency was significantly lower in the POP group than in the control group (13.0% vs. 19.9%, p=0.014). Women with the non-AA genotype had a 0.63-fold lower risk of developing advanced POP than women with the AA genotype (95% CI, 0.39-0.99), and women with the G allele had a 0.60-fold lower risk of advanced POP than women with the A allele (95% CI, 0.40-0.90).

CONCLUSIONS

The GSTP1 Ile105Val polymorphism is a protective factor against advanced POP.

Alteration of elastin metabolism in women with pelvic organ prolapse

PURPOSE

Although there are many studies about the effects of vaginal birth, the effects of menopause on pelvic floor support have not been identified. We compared elastin metabolism in the uterosacral ligament of women with and without pelvic organ prolapse, and defined the menopausal regulation of this process.

MATERIALS AND METHODS

The study group consisted of 35 women who underwent hysterectomy for pelvic organ prolapse. The control group consisted of 39 women without pelvic organ prolapse. A questionnaire was administered to assess age, parity, body mass index, and menopausal status. Expression levels of mRNA, and protein for neutrophil elastase, matrix metalloproteinase-2, and matrix metalloproteinase-9 were determined by real-time quantitative polymerase chain reaction and ELISA, respectively, using uterosacral ligament samples from each patient. Expression of alpha-1-antitrypsin, an inhibitor of neutrophil elastase, was also determined. ANOVA, the Kruskal-Wallis test and multivariate linear regression were used for statistical analysis.

RESULTS

Expression of neutrophil elastase and matrix metalloproteinase-2 mRNA was higher in women with pelvic organ prolapse than in those without pelvic organ prolapse. Compared to before menopause, neutrophil elastase and matrix metalloproteinase-2 showed a significant decrease in postmenopausal women without pelvic organ prolapse, although these remained increased in postmenopausal women with pelvic organ prolapse. Alpha-1-antitrypsin was significantly less in postmenopausal women with pelvic organ prolapse than in postmenopausal women without pelvic organ prolapse. The activities of neutrophil elastase, matrix metalloproteinase-2 and matrix metalloproteinase-9 were increased in women with pelvic organ prolapse, and these trends were similar to neutrophil elastase and matrix metalloproteinase-2 expression even after adjustment for age, parity and menopausal status.

CONCLUSIONS

After menopause increased elastolytic protease has a significant role in the development of pelvic organ prolapse.

A long-term treatment outcome of abdominal sacrocolpopexy

PURPOSE

The aim of this study was to evaluate the long-term treatment outcome and major complication rates of abdominal sacrocolpopexy (ASC).

MATERIALS AND METHODS

This retrospective study included 57 Korean women who underwent ASC with mesh for symptomatic uterine or vault prolapse and attended follow-up visits for at least 5 years. Forty-seven women with urodynamic stress incontinence concomitantly received a modified Burch colposuspension. The long-term anatomical and functional outcomes and complication rates were assessed.

RESULTS

The median follow-up was 66 months (range 60-108). Overall anatomical success rates (no recurrence of any prolapse >or= stage II according to the pelvic organ prolapse-quantification system) were 86.0%. Urinary urgency and voiding dysfunction were significantly improved after surgery, however, recurrent stress urinary incontinence developed in 44.7% (21/47) of cases and half of them developed within 1-3 months post-op. Bowel function (constipation and fecal incontinence) and sexual function (sexual activity and dyspareunia) did not significantly change after surgery. Major complication requiring reoperation or intensive care developed in 12 (21.0%) cases.

CONCLUSIONS

ASC provides durable pelvic support, however, it may be ineffective for alleviating pelvic floor dysfunction except for urinary urgency and voiding dysfunction, and it contains major complication risk that cannot be overlooked.

No association between the GSTP1 exon 5 polymorphism and susceptibility to advanced stage endometriosis in the Korean population

PROBLEM

To investigate whether the glutathione-S-transferase P1 (GSTP1) exon 5 polymorphism is associated with susceptibility to advanced stage endometriosis in Korean women.

METHOD OF STUDY

Case-control study in a collective of 260 patients and 164 controls. Genotyping of the GSTP1 exon 5 polymorphism was performed by using real-time TaqMan PCR assay.

RESULTS

The genotype distribution of the GSTP1 exon 5 polymorphism in the endometriosis group was not significantly different from that of the control group (AA/AG/GG rates were 64.2%/32.7%/3.1% and 65.2%/31.7%/3.0% for the endometriosis and control groups, respectively, P = 0.977). Further subgroup analysis according to either stage or bilaterality of ovarian endometrioma also found no significant difference in the genotype distribution between any of the endometriosis subgroups and the control group.

CONCLUSION

These findings suggest that the GSTP1 exon 5 polymorphism is not a major determinant of the development of advanced stage endometriosis in the Korean population.

Preoperative maximum urethral closure pressure and valsalva leak point pressure as predictive parameters for midurethral sling

OBJECTIVE

To evaluate the efficacy of tension-free vaginal tape (TVT) and transobturator tape (TOT) according to urethral function based on a preoperative urodynamic study (UDS).

STUDY DESIGN

Preoperative Valsalva leak point pressure (VLPP) and maximum urethral closure pressure (MUCP) were compared with the actual surgical outcome, and patients were followed for > 1 year. Student's t test, chi2 test, multiple regression analysis and receiver operating character curve analysis were used for statistical analysis. Of the 437 patients, 225 received TVT and 212 patients received TOT.

RESULTS

Age, parity, body mass index, menopausal status, hormone replacement therapy and previous surgical history showed no significant difference between the groups. Advanced pelvic organ prolapse, concomitant hysterectomy and vault suspension were more common in the TOT group, whereas concomitant anterior colporrhaphy was more common in the TVT group. The treatment outcome of TVT was not associated with VLPP and MUCP. However, cutoff values of VLPP > or = 72.5 cm H2O and MUPC > or = 42 cm H2O were most predictive of successful surgical outcomes in TOT group, revealing a sensitivity of 95.7% and a positive predictive value of 98.4%.

CONCLUSION

Preoperative MUCP and VLPP can predict the treatment outcome of TOT but not TVT.

Changes in expression of fibulin-5 and lysyl oxidase-like 1 associated with pelvic organ prolapse

OBJECTIVES

Pelvic organ prolapse is associated with defects in connective tissue including elastic fibers. The purpose of this study was to investigate expression of fibulin-5 and lysyl oxidase-like 1, which play an essential role in synthesis and assembly of elastic fibers in the uterosacral ligament, in samples taken from women with advanced pelvic organ prolapse compared with controls.

STUDY DESIGN

Specimens were obtained prospectively during abdominal hysterectomy from 30 women with advanced pelvic organ prolapse and 30 controls matched to the study group for age and parity among postmenopausal women with benign gynecologic pathology. Expression levels of protein and mRNA of fibulin-5 and lysyl oxidase-like 1 in uterosacral ligaments were measured by Western blot analysis and real-time quantitative polymerase chain reactions. For statistical analyses, Student's t-test, chi-square test, Mann-Whitney U test, Fisher's exact test and Spearman's correlation were used.

RESULTS

Significant decrease in the expression of mRNA of fibulin-5 was found in patients with prolapse (P-value=0.042; 0.743+/-0.229 and 1.061+/-0.537). The expression of mRNA of lysyl oxidase-like 1 was increased in the patient group (P-value=0.017; 4.099+/-2.832 and 1.816+/-1.602). Similar results were shown in Western blot analysis. Differences in expression of fibulin-5 and lysyl oxidase-like 1 were noted according to stage of prolapse (P-value=0.037 and 0.009).

CONCLUSIONS

There was decreased expression of fibulin-5 and increased expression of lysyl oxidase-like 1 in uterosacral ligaments in patients with pelvic organ prolapse, which suggests the possibility of defects in elastin synthesis.

The relationship between COL3A1 exon 31 polymorphism and pelvic organ prolapse

PURPOSE

We investigated the role of COL3A1 exon 31 polymorphism (a single base substitution from guanine to adenine at +2092), resulting in the replacement of alanine with threonine at the 698th amino acid of COL3A1, in the pathogenesis of pelvic organ prolapse.

MATERIALS AND METHODS

A total of 72 postmenopausal Korean women who were not on hormonal replacement therapy and who had a history of vaginal childbirth were enrolled in this study. The patient group consisted of 36 women diagnosed with stage II or greater pelvic organ prolapse irrespective of urodynamic stress incontinence. The control group consisted of 36 healthy volunteers with pelvic organ prolapse quantification system stage 0 or I disease without urodynamic stress incontinence. After extracting the genomic DNA from peripheral blood leukocytes the polymorphism of exon 31 of COL3A1 was typed by restriction fragment length polymorphism (Alu I restriction fragment length polymorphism) and confirmed by direct sequencing.

RESULTS

Frequency of the G allele was significantly higher in patients with pelvic organ prolapse than in controls (0.8 vs 0.6, p = 0.002). In women with the G allele the OR for pelvic organ prolapse was 3.2 (95% CI 1.4-7.3).

CONCLUSIONS

COL3A1 exon 31 polymorphism may have a role in determining the risk of pelvic organ prolapse in women with risk factors such as aging, vaginal childbirth and hypoestrogenism.

Hormone-dependent aging problems in women

One of the major social issues nowadays is the aging society. Korea is already an aging society, and 63 cities and districts are ultra-aged societies where the rate of people older than 65 yr exceeds 20%. Among them, more than 67% are women. These statistics reveal the importance of healthcare for older women. Disease and disability of older women are very closely related to the loss of female sex hormones after menopause. Major hormone-dependent aging problems in women such as osteoporosis, Alzheimer's disease (AD), urinary incontinence, and coronary atherosclerosis were surveyed in this review, and the key role of hormones in those diseases and hormone replacement therapy (HRT) were summarized. We expect that this review would provide some understanding of factors that must be considered to give optimal care to older women for healthy lives.

Surgical therapeutic index of tension-free vaginal tape and transobturator tape for stress urinary incontinence

BACKGROUND/AIMS

The aim of this study was to obtain the surgical therapeutic index (STI) of tension-free vaginal tape (TVT) and transobturator tape (TOT) and compare it with the previously obtained result of Burch colposuspension.

METHODS

The study population consisted of 121 patients who were diagnosed as having stress urinary incontinence, underwent TVT or TOT between January 1, 2000 and June 30, 2005 and were followed up for at least 1 year. Patients with detrusor overactivity, urinary tract infection, intrinsic sphincter deficiency and pelvic organ prolapse more than stage II according to the POP-Q system were excluded. The cure and complication rates were investigated, and the STI (median percent cure rate/median percent complication rate) of each operation was calculated.

RESULTS

Of the 121 patients, 61 underwent TVT and 60 received TOT. Patient characteristics and the results of preoperative urodynamic studies showed no significant difference between the two groups. The STI of TOT (2.72, 4.08, 4.23, 5.29) was higher than that of Burch colposuspension (1.19, 2.27, 2.89, 3.53) and TVT (2.77, 3.69, 3.23, 3.17) irrespective of follow-up months (at 1, 3, 6, 12 months).

CONCLUSION

TOT seems to be a more suitable surgical procedure for stress urinary incontinence with urethral hypermobility.

Surgical repair of anterior wall vaginal defects

OBJECTIVE

To compare the clinical efficacy of 3 surgical procedures for central types of anterior vaginal wall defect.

METHODS

A total of 138 patients diagnosed with central types of anterior vaginal wall defect who underwent classic transvaginal repair (n=72), transvaginal repair with polypropylene mesh (n=28), and internal repair (n=38) were followed up for at least 1 year.

RESULTS

There were no differences in development of fever, vaginal erosion, detrusor overactivity, and voiding difficulty among the 3 groups, but the incidence of postoperative urinary tract infections was significantly higher in the polypropylene mesh repair group. The difference in preoperative and postoperative hemoglobin levels and wound infection incidence were significantly higher in the internal repair group. Moreover, the recurrence rate of the anterior vaginal wall defect was significantly higher at 1 year in the internal repair group.

CONCLUSION

Transvaginal surgical repair seems to be more efficacious than internal surgical repair for central types of anterior vaginal wall defects.

Treatment outcome of tension-free vaginal tape in stress urinary incontinence: comparison of intrinsic sphincter deficiency and nonintrinsic sphincter deficiency patients

The object of this study was to compare the treatment outcomes of tension-free vaginal tape (TVT) for intrinsic sphincter deficiency (ISD) and nonintrinsic sphincter deficiency (NISD) patients in stress urinary incontinence (SUI) and to evaluate whether TVT can be effectively used in both groups of patients. 111 women with SUI treated by TVT procedure from June 2003 to June 2005 with follow-ups for at least 1 year postoperatively were included in this study. The patients were divided into two groups: 31 patients with ISD and 80 patients with NISD. ISD was defined as the cases with low Valsalva leak-point pressure (VLPP) or Maximal urethral closure pressure (MUCP). Patients were followed up at 1, 3, 6, and 12 months postoperatively. There were no significant differences found in demographics between ISD and NISD groups: mean age, parity, body mass index, menopausal status, and hormone replacement therapy (p > 0.05). All urodynamic parameters except for VLPP and MUCP showed no significant differences. The cure rates of the two groups at 1 month follow-up (87.0 vs 100%; p = 0.0053) showed a significant difference, but no significant differences were found at 3, 6, and 12 months. There were no differences in postoperative complication rates (voiding difficulty, de novo urgency, urinary tract infection, retropubic hematoma, and vaginal mesh erosion) between the two groups irrelevant of follow-up months. TVT is effective for SUI in both ISD and NISD patients.

Use of grafts in pelvic reconstructive surgery

There has been growing interest in the use of grafts in pelvic reconstructive surgery. This article will address available graft materials and assess their clinical efficacy and safety. We conducted a Pubmed MEDLINE literature search for full-length English text studies with follow-up periods of at least one year. There are many reports on synthetic and biological graft materials; the majority are not well-designed, have short-term follow-up, small sample sizes, and poor outcome assessment. The use of non-absorbable synthetic grafts may offer excellent anatomical cure rates. However, it is associated with a high incidence of graft-related complications, including healing abnormalities and adverse bladder, bowel, and sexual function effects. These complications can be decreased with absorbable synthetic meshes, but efficacy is lower compared to non-absorbable ones. There is insufficient evidence in favor of biological grafts. In conclusion, based on current knowledge, routine application of grafts in pelvic reconstruction is not recommended. It is preferred that graft utilization be individualized, with close monitoring for complications.

Risk factors for pelvic organ prolapse

OBJECTIVES

To evaluate the risk factors for pelvic organ prolapse (POP) and to determine the relationship between these risk factors and stage or other components of POP.

METHODS

244 patients with primary POP and 314 women without POP were included. Age, parity, smoking, body mass index (BMI), menopause, and hormone replacement therapy (HRT) were investigated.

RESULT

Independent risk factors for POP included age over 70, parity higher than 3, and menopause. Age, parity, menopause, and HRT were significantly associated with stage of POP. Genital hiatus (GH) and perineal body (PB) showed a significant positive and negative correlation with age and parity, respectively. Menopause and HRT were also associated with them.

CONCLUSION

Age, parity and menopause are possible risk factors of POP and associated with the lengths of GH and PB in POP women. Further, these risk factors and HRT are significantly correlated with the severity of the disease.

Leiomyomas of the female urethra and bladder: a report of five cases and review of the literature

Through the experience of five cases of leiomyoma developed in the female bladder and urethra with a review of the literature, we have made an effort to characterize the association of symptom with the size and location of the tumor and demonstrate an appropriate treatment. The study population was composed of patients who underwent surgery for bladder or urethral leiomyoma in our hospital from March 1990 to April 2005. Their medical records were reviewed retrospectively concerning the symptom, size and location of leiomyoma, the result of cystoscope and radiological examination, surgical method, pathologic report, complications, and recurrence. Four cases were diagnosed as urethral leiomyoma and one case as bladder leiomyoma. All patients with urethral leiomyoma were admitted for the chief complaint of a palpable tumor. When the tumor size was small, if it was located on the lateral side of the urethra, it was asymptomatic, but if located in the midline, it presented irritative or obstructive symptom. When it was big, if located on the lateral side, it presented irritative rather than obstructive symptom, and if located in the midline, it presented obstructive symptom. One case of bladder leiomyoma was discovered incidentally during ultrasonic exam. In all five cases, surgical removal was performed and complications or recurrence were not detected afterwards. Bladder and urethral leiomyomas are very rare and cause diverse manifestations from asymptomatic to irritative or obstructive symptom. It is presumed that the location and size of the tumor are associated with symptom. Unless it is the case with severe hemorrhage or obstructive acute renal failure, immediate surgery is not required. However, it is desirable to distinguish leiomyoma from malignant or other benign tumors by surgical biopsy or removal.

Chimerism and mosaicism are important causes of ABO phenotype and genotype discrepancies

Discrepancies between blood group genotype and RBC phenotype are important to recognize when implementing DNA-based blood grouping techniques. This report describes two such cases involving the ABO blood group in the Korean population. Propositus #1 was a 22-year-old healthy man undergoing pretransfusion testing for minor surgery. Propositus #2 was a 23- year-old male blood donor. RBCs from both propositi were determined to be group AB and demonstrated unusual agglutination patterns on forward typing, which were inconsistent with their ABO genotype determined by allele-specific (AS) PCR. RBCs from propositus #1 demonstrated mixed field agglutination with both anti-A and -B, while RBCs from propositus #2 demonstrated mixed field only with anti-A reagents. Both had B/O genotypes by AS-PCR. Cloning and sequencing of ABO exons 6 and 7 revealed three alleles in both propositi: propositus #1: A102/B101/O04; propositus #2: A102/B101/O01. A panel of nine short-tandem repeat (STR) loci was tested on DNA extracted from blood, buccal mucosal cells, and hair from the propositi and on DNA isolated from their parents' blood. In all tissues tested from propositus #1, three loci demonstrated a double paternal and a single maternal DNA contribution, indicating that he was a chimera or a mosaic; in those from propositus # 2, one STR locus demonstrated a double paternal DNA contribution, indicating that he was a tetragametic chimera. Chimerism and mosaicism are uncommon but important causes of ABO genotype and phenotype discrepancies. The evaluation of patients and donors with unusual or unexpected serology in pretransfusion testing and consensus ABO alleles may include the evaluation of STR loci to detect these phenomena.

The genetic and phenotypic basis of blood group A subtypes in Koreans

A serological and genetic study of Korean blood donors with phenotypic group A subtypes was performed. There were 176 donors with phenotypic A subtypes identified. Exons 6 and 7 from 57 representative donors were sequenced. The A(var) allele (784 G > A) was cloned and sequenced, and a family study demonstrating its inheritance and unusual serological characteristics was performed. The A102 allele was the most frequently identified allele in phenotypically A2 (58%, 11/19) and A2B (68%, 17/25) donors. Anti-A1 was rarely present amongst A2 and A2B donors. The family study revealed that the A(var) allele was expressed as phenotype A(weak)B in A(var)/B heterozygote members, but as phenotype O in A(var)/O heterozygotes. The most frequent allele in Korean donors with the A2 phenotype differs from its Caucasian counterpart, as does the frequency of anti-A1. The A(var) allele demonstrates allelic enhancement in A(var)/B heterozygotes.

Pelvic leiomyomatosis with intracaval and intracardiac extension: a case report and review of the literature

BACKGROUND

Intravenous leiomyomatosis with intracaval and intracardiac extension has been rarely described in surgical, gynecological, and radiological literatures. Complete excision of the tumor is essential for a favorable outcome. Because of the uniqueness of this tumor having an absent or localized attachment site, its removal is feasible when assisted, prior to surgery, with appropriate imaging and planning.

CASE

The case was a 46-year-old woman, with intravenous leiomyomatosis originating from the uterus and extending to the inferior vena cava and right atrium, with extensive intracaval attachment, diagnosed from the various preoperative studies and operated successfully through the single-stage approach using cardiopulmonary bypass.

CONCLUSION

We present an unusual case of intravenous leiomyomatosis originating from the uterus and extending to the inferior vena cava and right atrium with extensive intracaval attachment. We include a brief review of the literatures.

Relationship between stress urinary incontinence and pelvic organ prolapse

We investigated the objective coexisting rate of stress urinary incontinence and pelvic organ prolapse, and also compared the treatment outcomes in patients who had both conditions, treated by a corrective operation on the basis of a precise preoperative evaluation. We reviewed 97 cases who underwent urodynamic studies and evaluation of the prolapse according to the Pelvic Organ Prolapse Quantification (POP-Q) system from among patients who were admitted for treatment of either stress urinary incontinence or pelvic organ prolapse. A Burch urethropexy, either alone or with a parvaginal repair, was done to correct the stress urinary incontinence, as well as additional operations to correct prolapse of stage II or more. The patients were evaluated postoperatively for the stress urinary incontinence and the degree of prolapse at every visit. Nineteen of 30 (63.3%) patients who were admitted with stress urinary incontinence had a coexisting pelvic organ prolapse, most often of the anterior wall. In 42 of 67 (62.7%) cases admitted with pelvic organ prolapse there was a coexisting stress urinary incontinence. A total of 61 patients who had both conditions were followed for 12 months postoperatively. The recurrence rate of stress urinary incontinence and prolapse (all of which were stage II) was 3.3% and 18.0%, respectively. It was noted that the greater the preoperative stage, the higher the recurrence rate (stage II 4.35%; stage III 25.0%; stage IV 33.6%). The coexisting rates of pelvic organ prolapse in patients having stress urinary incontinence, and stress urinary incontinence in patients having a pelvic organ prolapse, were both high. Therefore, when a preoperative evaluation that simultaneously considers both conditions and the correcting surgery is based on this evaluation, the recurrence rates of both conditions could be lowered.

Efficient intracellular delivery of an exogenous protein GFP with genetically fused basic oligopeptides

Several oligopeptides, derived from certain proteins, translocate as a form fused to small molecules or exogenous proteins across the plasma membrane into cells. Some of these oligopeptides, the so-called protein-transduction domains (PTDs), contain a high proportion of basic residues. The translocation of some of these basic PTDs, such as oligoarginines, has been studied as chemically fused forms to other organic compounds. In this study, we also tested to determine whether or not oligoarginines, when fused genetically to an exogenous protein such as GFP, are also able to translocate efficiently across the plasma membrane. The oligoarginine Rn (n = 5,6,7,8,9)-GFP fusion proteins were translocated quite efficiently, and the transduction efficiency increased in proportion to the number of arginine residues. However, the cellular uptake of the oligolysine-GFP fusion proteins was less efficient than that of the corresponding oligoarginine-GFP fusion proteins. When fused to GFP, the translocation efficiency of R5 was similar to that of Tat(49-57)(RKKRRQRRR). This finding suggests that the arginine homo-oligopeptide is more efficient than other PTDs which contain a mixture of basic residues. On the other hand, both the K9- and Tat(49-57)-GFP fusion proteins were transduced with similar efficiencies. It appears that basic oligopeptides may be useful for the efficient translocation of diverse exogenous proteins as genetically fused forms.

Efficient intracellular delivery of GFP by homeodomains of Drosophila Fushi-tarazu and Engrailed proteins

The 60 amino acid long homeodomain of Antennapedia (Antp), either alone or as a fusion protein with 30-40 amino acid long foreign polypeptides, has been reported to cross biological membranes by an energy- and receptor-protein-independent mechanism. Moreover, the 16 amino acid long third helix of the Antp homeodomain, so-called penetratin, possesses translocation properties when fused to fewer than 100 amino acids as well. These findings led us to study whether such a protein tansduction property is shared by other homeodomains. We report here that homeodomains of two homeoproteins, Fushi-tarazu and Engrailed, are able to transduce a 238 amino acid long green fluorescent protein into cultured cells as efficiently as other well-known protein transduction domains, such as an internal oligopeptide of Tat and penetratin. These findings suggest that such transduction activity of homeodomains might have some physiological roles and that it can be exploited for development of efficient transduction vectors for research use and protein therapy.