European experience with the Afirma Gene Expression Classifier for indeterminate thyroid nodules: A clinical utility study in the Netherlands

BACKGROUND

The Gene Expression Classifier (GEC) and Genomic Sequencing Classifier (GSC) were developed to improve risk stratification of indeterminate nodules. Our aim was to assess the clinical utility in a European population with restrictive diagnostic workup.

METHODS

Clinical utility of the GEC was assessed in a prospective multicenter cohort of 68 indeterminate nodules. Diagnostic surgical rates for Bethesda III and IV nodules were compared to a historical cohort of 171 indeterminate nodules. Samples were post hoc tested with the GSC.

RESULTS

The GEC classified 26% as benign. Surgical rates between the prospective and historical cohort did not differ (72.1% vs. 76.6%). The GSC classified 59% as benign, but misclassified six malignant lesions as benign.

CONCLUSION

Implementation of GEC in management of indeterminate nodules in a European country with restrictive diagnostic workup is currently not supported, especially in oncocytic nodules. Prospective studies with the GSC in European countries are needed to determine the clinical utility.

Establishing a Multicenter Network for Patients With Thyroid Nodules and Cancer: Effects on Referral Patterns

OBJECTIVE

To perform a qualitative evaluation of the Thyroid Network, with a quantitative analysis of second opinion referrals for patients in the southwestern part of the Netherlands who have thyroid nodules and cancer.

METHODS

This prospective observational study registered all patients with thyroid nodules and cancer who were referred to the academic hospital from 2 years before and 4 years after the foundation of the Thyroid Network. We implemented biweekly regional multidisciplinary tumor boards using video conference and a regional patient care pathway for patients with thyroid nodules and cancer. For qualitative evaluation, interviews were conducted with a broad selection of stakeholders via maximum variation sampling. The primary outcome was the change in second opinions after the foundation of the Thyroid Network.

RESULTS

Second opinions from Thyroid Network hospitals to the academic hospital decreased from 10 (30%) to 2 (7%) two years after the start of the Thyroid Network (P = .001), while patient referrals remained stable (n = 108 to 106). Qualitative evaluation indicated that the uniform care pathway and the regional multidisciplinary tumor board were valued high.

DISCUSSION

Establishing a regional network, including multidisciplinary tumor boards and a care pathway for patients with thyroid nodules and cancer, resulted in a decrease in second opinions of in-network hospitals and high satisfaction of participating specialists.

IMPLICATIONS FOR PRACTICE

The concept of the Thyroid Network could spread to other regions as well as to other specialties in health care. Future steps would be to assess the effect of regional collaboration on quality of care and patient satisfaction.

Change in Thyroid Hormone Metabolite Concentrations Across Different Thyroid States

Background: In contrast to the thyroid hormones (TH) 3,3',5-triiodothyronine (T3) and thyroxine (T4), current literature on thyroid hormone metabolite concentrations in the hypothyroid and hyperthyroid states is inconclusive. It is unknown how thyroidectomy affects thyroid hormone metabolite concentrations and if levothyroxine (LT4) replacement therapy after thyroidectomy restores thyroid hormone metabolite concentrations in those without a thyroid gland. The treatment of patients with differentiated thyroid cancer (DTC) covers the euthyroid, hypothyroid, and (subclinical) hyperthyroid states and therefore provides a unique model to answer this. Here, we prospectively studied nine TH and its metabolites (THM) across different thyroid states in a cohort of patients treated for DTC. Also, three potentially important determinants for THM concentrations were studied. Methods: We prospectively included patients aged 18 to 80 years who were scheduled for DTC treatment at the Erasmus MC. Peripheral blood samples were obtained before surgery (euthyroid, endogenous TH production), after surgery just before radioactive iodine therapy (hypothyroid), and six months later on LT4 therapy ([subclinically] hyperthyroid, exogenous T4 supplementation). Nine THMs were quantified in serum with an established liquid chromatography/tandem mass spectrometry method. Repeated measurement analysis was used to compare the three different thyroid states with each other for each THM, while linear regression was used to determine the association between THM concentrations and age, sex, and kidney function. Results: In total, 77 patients (mean age 49 years; 65% women) were eligible for the study. 3,5-diiodothyronine and 3,3',5-triiodothyroacetic acids were below the lower limit of detection. Compared with the euthyroid state, all THMs were significantly decreased in the hypothyroid state and significantly increased in the (subclinically) hyperthyroid state, with T3 concentrations remaining within the reference interval. Higher age was associated with higher 3-monoiodothyronine (3-T1) concentrations (p < 0.001). Women had higher L-thyronine concentrations than men (p = 0.003). A better kidney function was associated with lower 3-T1 concentrations (p < 0.001). Conclusions: All THMs decrease after a thyroidectomy and increase under thyrotropin (TSH)-suppressive LT4-therapy, suggesting that formation of thyroid hormone metabolites is dependent on peripheral extrathyroidal metabolism of T4. This is also reflected by T3 concentrations that remained within the reference interval in patients receiving TSH-suppressive LT4-therapy as T3 has some thyroidal origin.

Spontaneous remission of unidentified Cushing's disease revealed by hair cortisol analysis

Pituitary apoplexy is an infrequent but life-threatening complication of pituitary adenomas. When apoplexy occurs in a hormonally active adenoma, this may induce spontaneous remission of the clinical syndrome. In these cases, clinical suspicion of Cushing's disease or acromegaly may arise at presentation, but due to spontaneous remission of active hormone production, it is not possible to biochemically confirm this diagnosis in retrospect. Resolution of clinical symptoms during follow up retrospectively suggests the diagnosis. However, we describe a patient with Cushing's disease presenting with pituitary apoplexy, who was biochemically in remission at presentation. The diagnosis could be confirmed in retrospect using hair cortisol analysis, thereby enabling clinicians to adequately anticipate remission of Cushing's disease.

Postoperative parathyroid hormone levels as a predictor for persistent hypoparathyroidism

OBJECTIVE

Hypoparathyroidism is a common complication after thyroidectomy. It is not yet possible to predict in which patients hypoparathyroidism will persist. We aim to determine whether a decrease in PTH levels, measured at the first postoperative day, can identify patients with a high risk for persistent hypoparathyroidism one year after thyroidectomy.

DESIGN

Prospective multi-center cohort study.

METHODS

Patients undergoing total or completion thyroidectomy were included. We measured PTH levels preoperatively and on the first postoperative day. Primary outcome is the proportion of patients with persistent hypoparathyroidism, defined as the need for calcium supplementation one year after surgery.

RESULTS

We included 110 patients of which 81 were used for analysis of the primary outcome. At discharge 72.8% of patients were treated with calcium supplementation. Persistent hypoparathyroidism was present in 14 patients (17.3%) at one-year follow-up, all of them had a decrease in PTH >70% at the first postoperative day. These 14 were 43.8% of the 32 patients who had such a decrease. In the group of 49 patients (59.8%) without a PTH >70% decrease, none had persistent hypoparathyroidism one year after surgery (P-value <0.001). A decrease of >70% in PTH levels had a sensitivity of 100.0% (95% CI: 85.8-100.0%), a specificity of 73.1% (95% CI: 62.5-83.7%) and an area under the curve of 0.87 (95% CI: 0.79-0.94) to predict the risk for persistent hypoparathyroidism.

CONCLUSION

In our study a decrease in PTH levels of >70% after total or completion thyroidectomy is a reliable predictor for persistent hypoparathyroidism, and this should be confirmed in larger cohorts.

Longitudinal Analysis of the Effect of Radioiodine Therapy on Ovarian Reserve in Females with Differentiated Thyroid Cancer

Background: Although international guidelines have become more conservative on the use of radioactive iodine (RAI) therapy, it is still one of the cornerstones of the treatment of patients with advanced differentiated thyroid cancer (DTC). As a large proportion of females diagnosed with DTC is in their reproductive years, knowledge about the effect of RAI on their gonadal and reproductive function is important. Earlier studies evaluating Anti-Müllerian hormone (AMH) as a representative of ovarian reserve were either cross-sectional, had relatively low numbers, had no patients with multiple RAI therapies, or had a relatively short follow-up. The primary aim of our study was, therefore, to prospectively evaluate the effect of RAI on AMH in women undergoing treatment for DTC. Methods: We included females, aged 16 years until menopause, who were scheduled to undergo their first RAI treatment for DTC at our hospital. Serum AMH was measured before initial therapy and regularly thereafter. Repeated measurement analysis was used to assess the changes of AMH concentrations over time, and how this is influenced by age and cumulative RAI dose. Results: Longitudinal AMH assessments were available in 65 patients (mean age 32 years, median of five measurements during median follow-up of 34 months). AMH concentrations changed nonlinear over time, decreased until 12 months in the single RAI group (-55%), and stabilized thereafter. In the multiple RAI group, after stabilization, a further decrease occurred (-85% after 48 months). Age in both RAI groups significantly influenced AMH change over time, with younger patients (<35 years of age) showing a less steep decrease. Conclusions: In a population of female DTC patients treated with total thyroidectomy and a single RAI therapy, AMH concentrations significantly dropped during the first year after initial therapy, and thereafter they remained stable. In patients receiving multiple RAI therapies, a further decrease was seen. Age at baseline significantly influenced AMH change over time. These results support a less aggressive treatment with RAI in low-risk patients as is advocated in the current American Thyroid Association (ATA) guidelines, especially in females older than 35 years of age with the desire to have a child.

Longitudinal analysis of quality of life in patients treated for differentiated thyroid cancer

OBJECTIVE

Earlier cross-sectional studies showed that patients with differentiated thyroid cancer (DTC) have a significant reduction of quality of life (QoL) compared to controls. However, recent longitudinal studies showed mixed results and had relative short follow-up or lacked knowledge about QoL before initial surgery. Therefore, we initiated a longitudinal study to assess changes of QoL in patients undergoing treatment for DTC.

METHODS

We prospectively included patients, aged 18-80 years, who were treated for DTC at a Dutch university hospital. Using questionnaires, QoL was assessed before surgery, just before radioiodine (RAI) therapy, and regularly during follow-up. Repeated measurement analysis was used to assess changes of QoL over time, and we explored the influence of different characteristics on QoL.

RESULTS

Longitudinal QoL assessments were available in 185 patients (mean age 47 years; 71% women). All patients were treated according to the Dutch guidelines with total thyroidectomy followed by RAI (83% after thyroid hormone withdrawal). Median time between baseline and final questionnaire was 31 months, and patients completed a median of three questionnaires. QoL at baseline was lower than that in the general population, developed non-linear over time, was lowest around RAI therapy, and recovered over time. Females, younger patients, and patients with persistent hypoparathyroidism had lower QoL scores.

CONCLUSIONS

In a population of DTC patients, QoL before initial therapy is already lower than that in the general population. Thereafter, QoL develops non-linearly over time in general, with the lowest QoL around RAI therapy, while 2 to 3 years later, it approximates baseline values.

Pressure-volume analysis in athyroid patients off and on thyroxine supplementation: a pilot study

Thyroid hormone importantly affects the cardiovascular system. However, evaluation of stroke volume (SV) and its determinants is confounded by variations in volume status that occur along different thyroid states. This study applied the pressure-volume (PV) framework to obtain relatively load-independent estimates of cardiac function in hypothyroidism as compared to euthyroidism. Ten athyroid patients were assessed echocardiographically after 4 weeks in deep hypothyroid state, and again after supplementation with oral Levothyroxine (LT4) for 3 months. Thyroid hormone levels were assessed and noninvasive pressure-volume (PV) analysis based on dedicated repeated echocardiograms was performed. Changes were assessed using paired tests. Results are presented as medians and interquartile ranges. Hypothyroidism was associated with reduced stroke volume (SV: 67.6 ± 17 vs. 75.7 ± 20.6 mL, P = 0.024), preload (end-diastolic volume, EDV: 122.6 ± 32.5 vs. 135.7 ± 33.6 mL, P = 0.004), and contractility (end-systolic elastance, Ees : 1.7 ± 0.33 vs. 2.58 ± 1.33 mmHg/mL, P = 0.01). Afterload was constant (effective arterial elastance, Ea : 1.66 ± 0.32 vs. 1.79 ± 0.52 mmHg/mL, P = 0.43) and the total energy spent was lower (PVA∙HR: 86.7 ± 28 vs. 110.9 ± 32.1 J, P = 0.04). Hemodynamic manifestations of frank hypothyroidism in humans are characterized by reduced preload and contractility, and unchanged total afterload. LT4 therapy increased work efficiency and heart rate, but not the net energy expenditure. Noninvasive PV analysis may be useful to follow-up different thyroid states.

Effects of Thyrotropin on Peripheral Thyroid Hormone Metabolism and Serum Lipids

BACKGROUND

Subclinical hypothyroidism is associated with dyslipidemia and atherosclerosis. Whether these effects are in part mediated via direct effects of thyrotropin (TSH) on peripheral thyroid hormone (TH) metabolism and/or concentrations of serum lipids is not clear.

OBJECTIVE

This study examined whether TSH has direct effects on peripheral TH metabolism and serum lipids.

METHODS

Eighty-two patients with differentiated thyroid cancer were retrospectively analyzed. All patients had undergone total thyroidectomy and ¹³¹I remnant ablation. During follow-up, two successive injections of recombinant human TSH (rhTSH) were administered to patients on a stable dose of levothyroxine. In all patients, TSH, thyroxine (T4), free T4 (fT4), triiodothyronine (T3), reverse T3 (rT3), total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, apolipoprotein B, lipoprotein(a), and triglyceride levels were measured immediately before the first and approximately 72 hours after the second injection of rhTSH.

RESULTS

After rhTSH stimulation, T3 values decreased (from 1.91 to 1.81 nmol/L; p < 0.001). T4, fT4, and rT3 did not change. After rhTSH, median apolipoprotein B increased from 0.90 to 0.92 g/L (p = 0.03), lipoprotein(a) from 0.21 to 0.24 g/L (p < 0.001), and triglycerides from 1.98 to 2.50 mmol/L (p < 0.001). Serum high-density lipoprotein cholesterol decreased from 0.98 to 0.81 mmol/L (p < 0.001). Multiple regression analysis showed that the changes in lipids were most closely associated with the decrease in T3 levels.

CONCLUSIONS

TSH has direct effects on peripheral TH metabolism by decreasing T3 levels in levothyroxine-treated thyroidectomized patients. This decrease in T3 levels is accompanied by unfavorable changes in serum lipids.

Thyroid State Regulates Gene Expression in Human Whole Blood

CONTEXT

Despite the well-recognized clinical features resulting from insufficient or excessive thyroid hormone (TH) levels in humans, it is largely unknown which genes are regulated by TH in human tissues.

OBJECTIVE

To study the effect of TH on human gene expression profiles in whole blood, mainly consisting of T3 receptor (TR) α-expressing cells.

METHODS

We performed next-generation RNA sequencing on whole blood samples from eight athyroid patients (four females) on and after 4 weeks off levothyroxine replacement. Gene expression changes were analyzed through paired differential expression analysis and confirmed in a validation cohort. Weighted gene coexpression network analysis (WGCNA) was applied to identify thyroid state-related networks.

RESULTS

We detected 486 differentially expressed genes (fold-change >1.5; multiple testing corrected P value < 0.05), of which 76% were positively and 24% were negatively regulated. Gene ontology (GO) enrichment analysis revealed that three biological processes were significantly overrepresented, of which the process translational elongation showed the highest fold enrichment (7.3-fold, P = 1.8 × 10-6). WGCNA analysis independently identified various gene clusters that correlated with thyroid state. Further GO analysis suggested that thyroid state affects platelet function.

CONCLUSIONS

Changes in thyroid state regulate numerous genes in human whole blood, predominantly TRα-expressing leukocytes. In addition, TH may regulate gene transcripts in platelets.

Maternal and obstetrical outcome in 35 cases of well-differentiated thyroid carcinoma during pregnancy

OBJECTIVES/HYPOTHESIS

Thyroid cancer, with 6% to 10% of cancer diagnoses, is one of the most common malignancies during pregnancy. Its treatment poses a risk for the pregnancy, as the thyroid gland plays a crucial role in the evolution of pregnancy. The aim of this study is to evaluate treatment of primary well-differentiated thyroid carcinoma during pregnancy and fetal and maternal outcomes.

STUDY DESIGN

This is an international cohort study.

METHODS

Primary thyroid cancer patients were identified from the database of the International Network on Cancer, Infertility, and Pregnancy registration study. Data on histopathological characteristics, diagnostic and therapeutic interventions, outcome (obstetrical, neonatal, and maternal) and maternal follow-up were analyzed.

RESULTS

Thirty-five patients with well-differentiated thyroid carcinoma were eligible. All 35 patients underwent surgery, 29 (83%) of which during pregnancy. Procedures during pregnancy were mainly total thyroidectomies (n = 24). The median number of days between diagnosis and surgical treatment was different between the groups with surgery during and after pregnancy (27 vs. 139 days, P < .001). Both maternal and neonatal outcomes were uncomplicated, regardless of gestational age during surgery.

CONCLUSIONS

Well-differentiated thyroid carcinoma diagnosed during pregnancy has a favorable outcome for both mother and child. Surgical management during pregnancy has no negative impact on the pregnancy regardless of the trimester at the time of surgery. However, the potential negative effects of thyroid surgery early in pregnancy demand management of these patients in an experienced multidisciplinary team to provide the best possible care for these patients and their unborn babies.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:1493-1500, 2018.

Effects of Thyroid Hormone on Urinary Concentrating Ability

BACKGROUND

Hypothyroidism has been associated with impaired urinary concentrating ability. However, previous reports on thyroid hormone and urinary concentrating ability in humans only studied a limited number of patients with autoimmune thyroid disease or used healthy controls instead of paired analysis within the same patients.

OBJECTIVE

To study the urinary concentrating ability in athyreotic patients with differentiated thyroid cancer on and off levothyroxine treatment as they are exposed to different thyroid states as part of their treatment in the absence of an autoimmune disease.

DESIGN AND METHODS

We studied 9 patients (mean age of 42.7 years) during severe hypothyroid state (withdrawal of levothyroxine before radioactive iodine therapy) and TSH-suppressed state (on levothyroxine therapy). At these two points, serum and urine samples were collected after 14 h of overnight fasting without any food or drink.

RESULTS

Serum and urine osmolality were not significantly different between on and off levothyroxine treatment. Serum creatinine levels were significantly higher in patients off versus on levothyroxine treatment (87.0 vs. 71.0 µmol/L, respectively; p = 0.044) and, correspondingly, the estimated glomerular filtration rate was significantly lower (89.6 vs. 93.1 mL/min, respectively; p = 0.038).

CONCLUSION

Short-term, severe hypothyroidism has no effect on urinary concentrating ability. Our study confirms the well-known effects of thyroid hormone on serum creatinine concentrations.

Thyroid hormone and its metabolites in relation to quality of life in patients treated for differentiated thyroid cancer

BACKGROUND

Levothyroxine (LT4) is the standard of care in patients with hypothyroidism. Despite this replacement therapy, quality of life (QoL) remains impaired in a substantial amount of patients. The reasons for this are still a matter of debate. Suggested causes include lack of endogenous T3 secretion by the thyroid, changes in other thyroid hormone metabolites and interference by autoimmune processes.

OBJECTIVE

To investigate the association between thyroid function tests (TFTs) and QoL in patients with a history of differentiated thyroid cancer on LT4 monotherapy. These patients lack endogenous thyroidal T3 secretion in the absence of autoimmune disease.

MATERIALS AND METHODS

This is a cross-sectional study in 143 patients (69·2% female). Initial therapy consisted of total thyroidectomy followed by radioiodine ablation minimally one year before inclusion. We assessed health-related QoL (RAND-36), thyroid-specific QoL (ThyPRO) and fatigue with the Multidimensional Fatigue Inventory. Extensive TFTs were assessed, including 3,5-diiodo-L-thyronine (3,5-T2).

RESULTS

Mean age was 50·2 years and mean time since diagnosis was 8·4 years. Median TSH was 0·042 mU/l, total T4 145·0 nmol/l, free T4 25·6 pmol/l, total T3 1·93 nmol/l, reverse T3 0·53 nmol/l and 3,5-T2 0·86 nmol/l. Multiple linear regression analyses did not show any association between QoL and the different TFTs, including T4/T3 and 3,5-T2/T3 ratios reflecting peripheral metabolism.

CONCLUSION

We did not find any association between TFTs and QoL in athyreotic patients on LT4 monotherapy. Our data do not provide evidence that a slight increase in dose improves fatigue or well-being in hypothyroid patients on LT4 therapy.

Aberrant Levels of Hematopoietic/Neuronal Growth and Differentiation Factors in Euthyroid Women at Risk for Autoimmune Thyroid Disease

Background

Subjects at risk for major mood disorders have a higher risk to develop autoimmune thyroid disease (AITD) and vice-versa, implying a shared pathogenesis. In mood disorder patients, an abnormal profile of hematopoietic/neuronal growth factors is observed, suggesting that growth/differentiation abnormalities of these cell lineages may predispose to mood disorders. The first objective of our study was to investigate whether an aberrant profile of these hematopoietic/neuronal growth factors is also detectable in subjects at risk for AITD. A second objective was to study the inter relationship of these factors with previously determined and published growth factors/cytokines in the same subjects.

Methods

We studied 64 TPO-Ab-negative females with at least 1 first- or second-degree relative with AITD, 32 of whom did and 32 who did not seroconvert to TPO-Ab positivity in 5-year follow-up. Subjects were compared with 32 healthy controls (HCs). We measured serum levels of brain-derived neurotrophic factor (BDNF), Stem Cell Factor (SCF), Insulin-like Growth Factor-Binding Protein 2 (IGFBP-2), Epidermal Growth Factor (EGF) and IL-7 at baseline.

Results

BDNF was significantly lower (8.2 vs 18.9 ng/ml, P<0.001), while EGF (506.9 vs 307.6 pg/ml, P = 0.003) and IGFBP-2 (388.3 vs 188.5 ng/ml, P = 0.028) were significantly higher in relatives than in HCs. Relatives who seroconverted in the next 5 years had significantly higher levels of SCF than non-seroconverters (26.5 vs 16.7 pg/ml, P = 0.017). In a cluster analysis with the previously published growth factors/cytokines SCF clustered together with IL-1β, IL-6 and CCL-3, of which high levels also preceded seroconversion.

Conclusion

Relatives of AITD patients show aberrant serum levels of 4 hematopoietic/neuronal growth factors similar to the aberrancies found in mood disorder patients, suggesting that shared growth and differentiation defects in both the hematopoietic and neuronal system may underlie thyroid autoimmunity and mood disorders. A distinct pattern of four inter correlating immune factors in the relatives preceded TPO-Ab seroconversion in the next 5 years.

[Radiofrequency ablation of a symptomatic benign thyroid nodule]

Radiofrequency ablation (RFA) enables the ablation of selected tissue by means of heat. For the first time in the Netherlands, RFA is being used to treat patients with benign thyroid nodules. RFA is able to reduce the volume of a nodule that may be causing cosmetic complaints or problems due to mass effect. This avoids the need for surgery or treatment with radioactive iodine in this benign condition. The average reduction in size is 80% in the first year, leading to a considerable decrease in both symptomatic and cosmetic complaints. At Erasmus Medical Centre, Rotterdam, the Netherlands, this technique has been introduced in accordance with current guidelines, and it is expected that other centres of excellence will follow in implementing it. It is important that the initial experiences with this technique in the Netherlands in terms of effectiveness, risks and patient satisfaction should be monitored before RFA becomes routine treatment.

Pituitary hyperplasia: an uncommon presentation of a common disease

A 21-year-old woman presented with amenorrhea, bilateral galactorrhea and fatigue. Visual acuity and visual fields were normal. Laboratory examination demonstrated hyperprolactinemia. Magnetic resonance imaging (MRI) of the pituitary showed a 19×17×12-mm sellar mass with supra- and parasellar extension, causing compression of the pituitary stalk and optic chiasm. Further examinations confirmed mild hyperprolactinemia, strongly elevated TSH (>500 mU/l), low free thyroxine (FT₄), hypogonadotropic hypogonadism and secondary adrenal insufficiency. Hydrocortisone and l-T₄ replacement therapy was started. Three months later, the galactorrhea had disappeared, thyroid function was normalized and MRI revealed regression of the pituitary enlargement, confirming the diagnosis of pituitary hyperplasia (PH) due to primary hypothyroidism. Subsequently, the menstrual cycle returned and the hypocortisolism normalized. This case demonstrates that severe primary hypothyroidism may have an unusual presentation and should be considered in the differential diagnosis of pituitary enlargement associated with moderate hyperprolactinemia.

Does vaginal reconstructive surgery with or without vaginal hysterectomy or trachelectomy improve sexual well being? A prospective follow-up study

OBJECTIVE

To compare sexual well being in women with pelvic organ prolapse before and after vaginal reconstructive surgery.

METHODS

Sixty-seven women, mean age 61 (36-85) years, who underwent vaginal reconstructive surgery, were asked to complete detailed questionnaires before and after surgery. In addition, they underwent a physical examination using the Pelvic Organ Prolapse Quantification (POPQ), before surgery and at follow-up.

RESULTS

Mean duration of follow-up was 14.4 months (6.6-27.6 months). The overall satisfaction with the operation was high with a mean of 7.5 on a visual analogue scale from 0 to 10. There was a significant improvement of dyspareunia after vaginal reconstructive surgery. The ability to have intercourse, the satisfaction with intercourse as well as the frequency of intercourse also improved although not significantly. Urine loss during intercourse improved significantly.

CONCLUSION

Vaginal reconstructive surgery for pelvic organ prolapse has a positive effect on the sexual well being of the afflicted women.

Application of the Blaivas-Groutz bladder outlet obstruction nomogram in women with urinary incontinence

AIMS

To test the applicability of the Blaivas-Groutz nomogram for female bladder outlet obstruction in urinary incontinent women presenting in a general gynecologic practice and to determine how the nomogram results related to the presence of obstructive symptoms according to a standardized questionnaire.

METHODS

All women with complaints of urinary incontinence underwent multichannel urodynamic testing, free uroflowmetry and were asked to complete a standardized quality of life questionnaire consisting of the urogenital distress inventory (UDI). The patients were classified according to the Blaivas-Groutz nomogram.

RESULTS

One hundred and nine patients were classified according to the nomogram. Thirty-three patients (30.3%) were classified as unobstructed, 63 patients (57.8%) as mildly, 12 patients (11%) as moderately, and 1 patient (0.9%) was classified as severely obstructed. Fifty patients correctly completed the UDI. There was no significant difference (P = 0.61) in the score on the domain UDI obstruction between, according to the nomogram, obstructed and unobstructed patients. Only 18% of the obstructed patients had isolated voiding symptoms suggestive of obstruction. Forty-nine percent of the obstructed patients had urgency-frequency symptoms as well as voiding symptoms suggestive of obstruction. There was no correlation (Pearson, r = -0.06, P = 0.61) between the severity of the symptoms (assessed by the UDI scale) and the degree of obstruction (the four nomogram zones).

CONCLUSIONS

Application of the Blaivas-Groutz nomogram gave an unlikely high prevalence of obstruction in our patient group, which showed no correlation with symptoms when measured with the UDI.

Prevalence, impact on the quality of life and pathophysiological determinants of nocturia in urinary incontinent women

The objective of this study was to estimate the prevalence of nocturia in incontinent women in a urogynaecologic practice and its association with the quality of life and to estimate the prevalences of the pathophysiological categories among nocturics. From 1 January 2002, all patients with complaints of urinary incontinence were analysed according to a specific protocol: multichannel urodynamic testing, a 1-h International Incontinence Society (ICS) pad test and a 3-day frequency-volume (FV) chart. From 1 June 2002, subjects had to fill in a standardised quality of life questionnaire as well. Nocturia was defined as two or more micturitions per night calculated from the FV chart. Evaluable FV charts were received from 111 patients, and 72 patients completed the questionnaires correctly. The overall prevalence of nocturia was 48.6% (confidence interval: 43.9-53.3%). Nocturia had a negative impact on several aspects of the quality of life. The maximum voided volume was significantly (p=0.005) less in nocturics. The 24-h frequency was higher in nocturics (p=0.001). Nocturics lost more urine during the pad test (p=0.039). The multivariate logistic regression analysis showed that the greater the proportion of 24-h urine excreted at night, the greater the odds of having nocturia and that the lesser the maximum voided volume, the greater the odds of having nocturia. The majority (92.7%) of the nocturics can be classified into one of the responsible pathophysiologic categories: nocturnal polyuria in 51.2%, a low functional bladder capacity in 14.6%, a combination of both in 9.8%, polyuria in 4.9% and a combination of polyuria and nocturnal polyuria in 12.2% of the cases. Nocturia is a frequent symptom among urinary incontinent patients, with a negative impact on several aspects of the quality of life. With a FV chart, nocturics can be classified into one of the responsible pathophysiologic categories in the majority (92.7%) of the cases.