Effects of topical dehydroepiandrosterone therapy in women after pelvic organ prolapse surgery

OBJECTIVE

Pelvic organ prolapse (POP) occurs predominantly in postmenopausal women. Restoration of the proper estrogenization of vaginal mucosa is important in preoperative and postoperative treatment, increasing the effectiveness of this approach. The objective of this study was the development of intravaginal vaginal suppositories containing DHEA and comparison of the clinical effects of vaginal topical therapy with DHEA, estradiol, or antibiotic after POP surgery.

METHOD

Nine types of vaginal suppositories containing 6.5 mg DHEA in different bases were prepared to find optimal formulation for the vaginal conditions. Ninety women referred for POP surgery were randomly assigned to one of three groups receiving topical treatment in the postoperative period (estradiol, DHEA, or antibiotic). On admission to hospital and during follow-up vaginal pH, vaginal maturation index and vaginal symptoms were assessed.

RESULTS

Vaginal suppositories with the base made from polyethylene glycol 1,000 without surfactants characterized the highest percentage of the released DHEA. In women treated with topical estradiol or DHEA a significant decrease in the number of parabasal cells, increase in superficial and intermediate cells in the vaginal smears, decrease in vaginal pH, and reduction of vaginal symptoms were observed.

CONCLUSIONS

The use of topical therapy with DHEA or the use of topical therapy with estradiol in the postoperative period were both shown to improve maturation index, vaginal pH, and vaginal symptoms. The benefits of topical therapy with DHEA after pelvic organ prolapse repair brings similar results as estradiol, without potential systemic exposure to increased concentrations of sex steroids above levels observed in postmenopausal women.

A new family with spastic paraplegia type 51 and novel mutations in AP4E1

Background

Autosomal recessive mutations in the AP-4 (adaptor protein complex 4) complex subunit ϵ − 1 (AP-4E1) gene on chromosome 15q21.2 are known to cause spastic paraplegia 51 (SPG51). The exact phenotype of SPG51 remains poorly characterized, because only a few families have been reported as carriers of the mutation. In addition, a previous study identified an autosomal dominant mutation in the AP4E1 gene as being associated with persistent stuttering. The aim of the current study was to characterize the phenotype of a paediatric patient with an identified novel AP4E1 mutation presenting with significant psychomotor retardation, intellectual disability and paraplegia.

Methods

Magnetic resonance imaging was used to identify hypoplasia of the corpus callosum. The DNA sample was tested using multiplex ligation-dependent probe amplification (MLPA) and array comparative genomic hybridization (aCGH). In addition, next-generation sequencing (NGS) was performed using the patient’s DNA, and Sanger sequencing was performed using that of his family members.

Results

The phenotype was identified to be associated with a novel pathogenic variant c.942_943 + 3delinsCC in the AP4E1 gene. The patient manifested severely delayed psychomotor development, impaired global physical development and general illness. Movement disorders were evident during the neonatal period.

Conclusions

The present study identifies a previously unknown disease-inducing AP4E1 gene mutation.

An association of circulating Tregs and Th17 cells producing IL-21 and IL-22 with the ROMA in ovarian cancer patients

The purpose of the present study was to assess the association of regulatory T cells (Tregs; CD4+ FOXP3+) and helper T lymphocytes (Th17) releasing interleukin (IL)-21 and IL-22, with the Risk of Ovarian Malignancy Algorithm (ROMA). Similar association was made with two additional tumour markers, human epididymis protein 4 (HE4) and carbohydrate antigen 125 (CA125) from patients serum. The presence of Tregs and Th17 was determined both in the peripheral blood and in the tissue of epithelial ovarian tumors. Mononuclear cells obtained from patient's peripheral blood (PBMCs) and from ovarian tissue were isolated by density gradient centrifugation. As a control group patients who had undergone surgery for infertility without ovarian pathology were selected. The percentage of Tregs and Th17 releasing IL-21 or IL-22 cells from both peripheral blood and tumor tissue was measured by flow cytometry. No differences in demographic parameters like body mass index, age, or gravidity were observed among the studied groups. However, an increased concentration of marker HE4 and value of ROMA was identified in individuals with ovarian cancer when compared with women with cystadenomas. Furthermore, a negative correlation between the ROMA value in the serum and Tregs from the peripheral blood of patients with cystadenoma ovarian tumors was detected. The presented work documents, for the first time, the negative association between peripheral blood Tregs and ROMA evaluation based on the tumour markers present in the serum of women with ovarian cystadenoma. Such an effect might result from the negative impact of Tregs on the inflammation process and on tumorigenesis caused by the persistent inflammation.

The Influence of Vaginal Native Tissue Repair (VNTR) on Various Aspects of Quality of Life in Women with Symptomatic Pelvic Organ Prolapse-A Prospective Cohort Study

Pelvic organ prolapse (POP) and the associated functional disorders are a major epidemiological problem that compromises the quality of life (QoL). The aim of this study was to assess the impact of lower urinary tract symptoms (LUTS) related to POP and vaginal native tissue repair (VNTR) on QoL. Two hundred patients with symptomatic POP were stratified into four groups according to the dominant storage phase function disorders: Urgency; stress urinary incontinence (SUI); mixed urinary incontinence (MUI), and without clinically significant symptoms from lower urinary tract (LUT). They underwent VNTR from January 2018 to February 2019. After 12 months, the QoL was assessed by the Prolapse Quality of Life (P-QoL) and visual analogue scale (VAS) questionnaires. The data were analyzed with Statistica package version 12.0 (StatSoft, Krakow, Poland), using the Kalmogorow–Smirnoff, Shapiro–Wilk W and the one-way analysis of variance with post hoc Tukey tests. The results of P-QoL showed significant improvement (p < 0.05) in all the study groups in most domains assessed before surgery and 12 months after surgery. Significant improvements in all the symptoms assessed by the VAS scale results were found in groups Urgency and MUI. The LUTS questionnaire revealed significant improvement in all voiding and post voiding symptoms in these groups. VNTR effectively eliminated LUTS and significantly improved the patients’ QoL associated with POP.

The Influence of Vaginal Native Tissues Pelvic Floor Reconstructive Surgery in Patients with Symptomatic Pelvic Organ Prolapse on Preexisting Storage Lower Urinary Tract Symptoms (LUTS)

The aim of this study was to assess the effectiveness of vaginal native tissue repair (VNTR) on preexisting Lower Urinary Tract Symptoms (LUTS) in women with symptomatic pelvic organ prolapse (POP). Two hundred patients who underwent VNTR for symptomatic POP from January 2018 to February 2019 were followed up for 6 months. All patients underwent VNTR, but in the posterior compartment, the rectovaginal fascia was reconnected to the uterosacral ligaments and additionally sutured to the iliococcygeus fascia and muscle. To assess the severity and change in storage phase LUTS before and after surgery, all participants were asked to complete 3 questionnaires: the International Consultation on Incontinence Questionnaire- Short Form (ICIQ-SF), Urogenital Distress Inventory-6 (UDI-6), and Incontinence Impact Questionnaire-7 (IIQ-7). The data were assessed with Statistica package version 12.0, using Kalmogorow–Smirnoff, W Shapiro–Wilk tests. Furthermore, one-way analysis of variance was applied with post-hoc Tukey test. The study results indicate that the majority of patients with advanced POP suffered from various LUTS. Among storage symptoms, the occurrence of urinary incontinence (UI) and urgency decreased significantly after surgery. Moreover, ICIQ-SF, UDI-6, and IIQ-7 results showed statistically significant improvement in the impact of UI on the quality of life (QoL) in the vast majority of patients after surgery. VNTR is an effective way to treat not only anatomical, but also functional problems in such patients.

Current trends in urogynecological surgeries in Poland

INTRODUCTION AND HYPOTHESIS

Pelvic organ prolapse (POP) treatment has become more common in the world's health care systems, and the demand for pelvic floor disorder rehabilitation has been projected to increase by 35% between 2010 and 2030. Restitution procedures vary, but after the US Food and Drug Administration (FDA) notifications, the global use of mesh in vaginal surgeries has significantly decreased. The aim of this study is to show trends in urogynecological surgeries in Poland.

METHODS

Retrospective analysis was performed of data obtained between 2009 and 2017 from the National Health Fund Information Centre website. Vaginal hysterectomies (VH), POP and urinary incontinence (UI) surgeries were considered.

RESULTS

In the study, 327,294 hospitalizations between 2009 and 2017 were considered: 29,821 VH, 265,147 POP and 53,328 UI procedures. Between 2009 and 2015, a rapid increase in the number of POP procedures was observed (r² = 0.94, b = 1711, p < 0.001). The following years, however, were characterized by a marked decline in the number of POP surgeries. In addition, the number of vaginal suspensions with mesh dropped by 24.7%, posterior and anterior repair by 8.5%, and posterior repair by 7.5%, but the number of anterior repair procedures increased slightly by 1.5%. Moreover, between 2015 and 2017, the number of vaginal hysterectomies decreased by 9%. The number of UI surgeries had increased between 2011 and 2015 and then remained at a relatively stable level. A similar trend was observed for tape procedures, whereas the popularity of colposuspension has declined noticeably.

CONCLUSIONS

The impact of FDA notifications has been observed in Poland as a decrease in TVM surgeries.

Diagnostic and therapeutic recommendations for patients with nocturia

Introduction

Nocturia is defined as the urge to urinate at night when the micturition was directly preceded and followed by sleep. Due to its negative impact on the quality of life of patients, an effective treatment for this disease has become a significant therapeutic challenge. The aim of this article was to explain the main risk factors for the occurrence of nocturia and to present diagnostic and therapeutic schemes in the case of nocturnal polyuria (idiopathic night time polyuria).

Material and methods

A review of the literature was carried out and the available guidelines of international science societies, which provided the basis for the above recommendations, were analyzed.

Results

Detailed medical history should include information concerning: lower urinary tract symptoms (including nocturia), underlying illnesses, urogenital disorders, previous surgeries and medications administered. Keeping a bladder diary is recommended. The physical examination, depending on the patient's gender, should include gynecological examination with pelvic organ prolapse assessment or prostate evaluation. In laboratory tests, a urinalysis may be used, in particular cases a cytological analysis of urine sediment may be carried out. In addition, a possible ultrasound and/or cystoscopy may be conducted. Nocturia therapy should begin with modifying dietary habits, including compliance with the fluid regimen, avoiding alcohol, coffee and tea. Moderate physical exercise is also recommended. The pharmacological treatment of nocturia caused by nocturnal polyuria is based on the use of desmopressin at a daily single dose of 25 µg for women and 50 µg for men. The use of desmopressin allows for the reduction in the number of nocturia episodes, as well as improves the overall quality of life and sleep. Treatment with desmopressin can also be considered as a form of therapy added in people with an overactive bladder or benign prostatic hyperplasia, in which nocturia is a significant clinical problem.

Conclusions

Desmopressin is an effective and safe first-line treatment option in pharmacological therapy of nocturia caused by nocturnal polyuria.

Perspectives for the pharmacological treatment of overactive bladder syndrome

It has been found that antimuscarinic drugs, viewed as the "gold standard" in overactive bladder syndrome (OAB) treatment, have an unsatisfactory tolerance profile and limited clinical effectiveness. This fact has given a clear impetus to search for new options in OAB pharmacotherapy. The conducted pre-clinical trials have led to the development of new solutions for the treatment of OAB, which stand a good chance of being applied in clinical practice. The said compounds are characterised by higher receptor and organ specificity than currently used medications.

Hysterectomy trends for benign indications over a 15-year period in an academic teaching center in Poland: a retrospective cohort study

OBJECTIVES

The aim of the study was to evaluate changes in the operative trends for various types of hysterectomy due to benign indications, between 2001 and 2015, at the 2nd Department of Gynecology, Medical University of Lublin, as compared to the National Health Service (NHS) registry in Poland.

MATERIAL AND METHODS

A retrospective cohort study was conducted. Data from the Internal Hospital Discharge Registry and Pathological Results Registry have been compared to the NHS database, which has been available nationwide since 2009.

RESULTS

The study group included 5629 women who underwent hysterectomy due to benign indications. During the study period, the following number of procedures were performed: total abdominal hysterectomy - 344 (6.11%), total abdominal hysterectomy with bilateral salpingo-oophorectomy - 1760 (31.27%), total vaginal hysterectomy - 563 (10.00%), subtotal abdominal hysterectomy - 2536 (45.05%), and laparoscopically-assisted subtotal hysterectomy (LASH) - 426 (7.57%). The abdominal route, with the preference for subtotal abdominal hysterectomy, was the main approach to hysterectomy. Symptomatic fibroids were the most common indication for the procedure. Comparison of data collected over the last five years revealed a significant difference in the approach to hysterectomy in favor of subtotal abdominal hysterectomy (SAH) and LASH.

CONCLUSIONS

Less invasive techniques of hysterectomy (LASH, SAH), which are the preferred choice at the 2nd Department of Gynecology (Lublin), are safe and effective options of treating benign conditions. We are of the opinion that these ap-proaches should be offered to patients instead of more radical techniques. Proper training of physicians may influence the decision-making process in favor of minimally invasive techniques.

Urinary incontinence after hysterectomy- does type of surgery matter?

Objectives

The aim of the study was to assess the effect of different types of hysterectomy on the development of postoperative urinary incontinence (UI).

Materials and Methods

The study group consisted of 392 women who underwent supracervical laparoscopic hysterectomy (SLH), total abdominal hysterectomy (TAH), supervical abdominal hysterectomy (SH), or vaginal hysterectomy (VH) for benign indications 2010 and 2013. The patients reported no UI-related complaints before surgery. UI status was assessed 12 months postoperatively using the cough test and the 24-hour pad test.

Results

UI developed within 12 months after surgery in 149 (38%) out of 392 women. No statistically significant correlation between the type of treatment and UI incidence was detected. The percentage of patients affected by UI did not differ between the study groups.

Conclusions

Hysterectomy constitutes a risk factor for the development of urinary incontinence but the occurrence of postoperative UI does not depend on the type of surgery.

Prevalence of common comorbidities among urogynaecological patients

OBJECTIVES

Due to prolonged life expectancy, regardless of the fact that elderly women are more likely to suffer from comorbidities, urogynaecologists worldwide should expect a growing demand for counseling and effective treatment for patients with pelvic floor defects. The aim of the study was to investigate the incidence of popular comorbidities among urogynaecological patients.

MATERIAL AND METHODS

The retrospective analysis included clinical data of 4,065 consecutive female patients who under-went surgical treatment in the 2nd Department of Gynaecology at the Medical University of Lublin due to urogynaecological disorders between January 2005 and December 2014. Patients were divided into two groups (< 65 years and ≥ 65 years). The vast majority of patients affected by stress urinary incontinence were treated with mid-urethral slings. Most of patients affected by pelvic organ prolapse underwent reconstructive vaginal surgery with reinforcement using anterior and/or pos-terior meshes. Statistical analysis was performed using STATISTICA 10.0 PL (unpaired Student t-test, U Mann Whitney, χ2 test).

RESULTS

In both study groups, overweight and obesity were the most common disorders affecting urogynaecological patients (72.6% overall). Furthermore, the elderly patients suffered more often from the most common comorbidities, such as hypertension (p < 0.01), coronary artery disease (p < 0.001) and diabetes mellitus (p < 0.005).

CONCLUSIONS

Common comorbidities such as overweight and obesity, followed by hypertension and coronary heart diseases, are usual among urogynaecological patients. Changes in lifestyle leading to a decrease in obesity should be considered as an important line treatment when counselling urogynaecological patients.

Expression of genes encoding extracellular matrix proteins: a macroarray study

Endometrial cancer (EC) is one of the most common gynecological malignancies in Poland, with well-established risk factors. Genetic instability and molecular alterations responsible for endometrial carcinogenesis have been systematically investigated. The aim of the present study was to investigate, by means of cDNA macroarrays, the expression profiles of genes encoding extracellular matrix (ECM) proteins in ECs. Tissue specimens were collected during surgical procedures from 40 patients with EC, and control tissue was collected from 9 patients with uterine leiomyomas. RNA was isolated and RT-PCR with radioisotope-labeled cDNA was performed. The levels of ECM protein gene expression in normal endometrial tissues were compared to the expression of these genes in EC specimens. Statistically significant differences in gene expression, stratified by clinical stage of the ECs, were detected for aggrecan, vitronectin, tenascin R, nidogen and two collagen proteins: type VIII chain α1 and type XI chain α2. All of these proteins were overexpressed in stage III endometrial carcinomas compared to levels in stage I and II uterine neoplasms. In conclusion, increased expression of genes encoding ECM proteins may play an important role in facilitating accelerated disease progression of human ECs.

[Carcinoma of the cervical stump--multicenter study]

OBJECTIVES

Cervix-sparing hysterectomy due to benign conditions remains controversial, especially when the presumed risk of cervical cancer in the retained cervical stump is concerned. On the other hand, supracervical hysterectomy is associated with shorter operative time, decreased blood loss and decreased intraoperative complications. Moreover, beneficial effects of retaining the cervix on the pelvic statics and female psychosexual functioning have been suggested, although not yet proven.

THE AIM

The aim of the study was to determine the frequency and types of cervical cancers in the retained cervical stump after supracervical hysterectomy performed due to benign diseases of the uterine corpus in four academic settings.

MATERIAL AND METHODS

Retrospective review of medical records of 903 women who underwent treatment due to cervical carcinoma in four departments participating in the study: Centre 1- 2nd Department of Gynecology, Medical University Lublin (years: 2001- 2011); Centre 2- Department of Gynecology and Gynecologic Oncology, Military Institute of Medicine, Warsaw (years: 2002-2012); Centre 3- Katedra i Kliniki Poloźnictwa, Chorób Kobiecych i Ginekologii Onkologicznej II Wydziału Lekarskiego WUM, Warsaw (years: 2008-2013) and Centre 4- Department of Gynecologic Oncology, Poznań University of Medical Sciences, (years: 2000-2012). The occurrence rate of cervical stump carcinoma was reported in relation to patient age, time elapsed between supracervical hysterectomy and diagnosis stump cancer and histological type of cancer.

RESULTS

Only 3 cases of cervical stump carcinoma (0.33%) were identified among the 903 investigated women. In all these cases, cervical stump cancers were diagnosed several years after supracervical hysterectomy. In one case the only treatment was radiotherapy in one case only trachelectomy was performed, whereas in one case surgery followed by radiotherapy was used.

CONCLUSIONS

It should be remembered that subtotal hysterectomy carries a risk, albeit relatively low, of developing stump cancer. Therefore, patients should be informed that after such operation further cervical cancer screening is mandatory. Moreover subtotal hysterectomy should not be offered in populations at risk of developing cancer of the uterine cervix.

Does a midurethral sling inserted at the time of pelvic organ prolapse mesh surgery increase the rate of de novo OAB? A prospective longitudinal study

OBJECTIVES

Approximately 20% of women suffer from pelvic organ prolapse (POP) and stress urinary incontinence (SUI). Furthermore, POP and overactive bladder (OAB) symptoms often coexist. Midurethral slings and mesh surgeries are both considered to be risk factors for de novo OAB symptoms. The aim of our study was to determine whether simultaneous midurethral sling insertion at the time of pelvic organ prolapse mesh surgery further increases the risk of de novo OAB.

MATERIALS AND METHODS

The study group consisted of 234 women who underwent surgery in our department between August 2007 and October 2009 (114 patients underwent surgery because of coexisting POP and SUI, and 120 underwent surgery because POP alone). The patients were evaluated at follow-up visits scheduled after 6-8 weeks and after 12 months. All women underwent surgery using the Gynecare Prolift Pelvic Floor Repair System, whereas in women with additional overt or occult SUI after restoration of the pelvic anatomy monofilament midurethral slings were simultaneously inserted. The chi-squared test was used to compare the study groups.

RESULTS

De novo OAB symptoms were significantly more pronounced among women in the Prolift only surgery group (23.3%) compared to the Prolift with IVS04M group (10.5%; p = 0.0093).

CONCLUSIONS

Midurethral sling insertion at the time of pelvic organ prolapse surgery significantly decreases the rate of postoperative de novo OAB symptoms. The lack of anatomical success of the mesh-based reconstructive surgery is a risk factor for the development of de novo OAB symptoms.

[The new era in the pharmacological treatment of overactive bladder (OAB): mirabegron--a new selective beta3agonist]

Overactive bladder is defined by ICS as urgency frequency and nocturia, with or without urgency urinary incontinence in the absence of urinary tract infection, or other obvious causative pathology Lower urinary tract symptoms (LUTS) are highly prevalent, especially in aging populations. Epidemiological studies reported LUTS in 62% of men and 67% of women, rising to 81% and 79%, respectively in adults over 60 years old. However the actual burden of LUTS remains relatively unrecognized. LUTS, mainly due to considerable distress including almost all aspects of social functioning, impact on sleep and mental health, may significantly affect quality of life. Management of LUTS including OAB has undergone dramatic changes since 1972, when the first antimuscarinic drug-oxybutynin, was introduced into clinical practice. In the last two decades, six new antimuscarinic drugs entered OAB field and this was accompanied by introduction of botulinum toxin into clinical practice in patients resistant to or not compliant with antimuscarinics. Nowadays, it is recognized that OAB is progressive, age-related and non sex-specific condition with most patients experiencing a combination of storage, voiding and post-micturition symptoms. In 2013, the next step was taken, with new therapeutic options for OAB, enabling an even more patient-tailored approach. This was possible for both, male and female OAB sufferers with new class of oral 3 adrenoreceptor agonist (mirabegron). This drug, by stimulation of 3-adrenoceptors, couples via Gs proteins to adenylyl cyclase, what results in an increase of intracellular cAMP levels and a subsequent activation of cAMP-dependent protein kinase A, which then phosphorylates myosin light chain kinase responsible for inhibition of calcium-calmodulin dependent interaction of myosin with actin. Moreover the cAMP increase also leads to the reduction of cytoplasmic Ca2+ concentration by removal of calcium ions from cytoplasm. These both actions result in a significant increase in the storage bladder capacity and by this interval between micturitions is prolonged. Mirabegron was evaluated in three 12-week, double blind, randomized, placebo controlled, parallel-group, multicenter clinical trials in OAB patients with symptoms of urge urinary incontinence, urgency and frequency - study 046, 047 and 074. It should be pointed out that efficacy of mirabegron was maintained through the entire 12-month period in phase Ill long-term study Discoveries on the physiology of the normal bladder and on the pathophysiology underlying OAB have led to the development of new treatment options for OAB. Pharmacological management of OAB should be tailored to patient's characteristics. New and recent options of pharmacological treatment have undoubtedly expanded treatment possibilities, what should allow physicians to select the optimal treatment for each patient.

[Therapeutic and prognostic value of lymphadenectomy in gynecological oncology]

Lymphadenectomy is an integral part of gynecological cancer surgery however there is still lack of standardization in the terminology used. In the current literature several types of surgical procedures for pelvic lymph nodes dissection are recognized. Complete pelvic lymphadenectomy is defined as the removal of all fatty lymphatic tissue from the predicted areas of high incidence of lymph nodes with possible metastatic involvement. Para-aortic lymphadenectomy is defined as the removal of all lymphatic tissue from the aortic region. The latter is divided into two levels: the lower--up to the inferior mesenteric artery and the upper--up to the left renal vein. Another classification divided pelvic and aortic lymphadenectomy into three classes. Class I is defined as the removal of the chosen lymph nodes, class II as the removal of lymph nodes located ventrally and laterally to the large retroperitoneal pelvic vessels, obturator nerves and laterally to the aorta and the inferior vena cava, whereas class III as the complete removal of lymphatic tissue surrounding the iliac vessels, obturator pits, dorsally to the obturator nerve and the presacral lymph tissue around the aorta and the inferior vena cava. In each gynecological cancer depending on the severity of the disease different procedures are applied concerning lymphadenectomy. In patients with advanced ovarian cancer systematic lymphadenectomy prolongs the survival rate. Omission of systematic lymphadenectomy can be considered only for patients with mucinous carcinoma G1 level. In the case of vulvar cancer removal of pelvic, iliac and obturator lymph nodes is inappropriate as it has not been proven to result in an increased survival rate. Inguinal lymphadenectomy in this cancer depends on the stage and location of the primary tumor--at an early stage vulvar cancer located laterally a superficial, unilateral inguinal lymphadenectomy can be performed, if the primary lesion is located centrally an inguinal lymphadenectomy should be performed on both sides. Deep inguinal lymphadenectomy should be performed only in cases where: primary tumor is located centrally in case of cancer in the early stages, in advanced stage and in patients with metastases in the superficial nodes. Sentinel lymph node biopsy is an alternative method that can be offered to patients with early-stage vulvar cancer located laterally. Lymphadenectomy in endometrial cancer is beneficial in stages I G3, II and III. In stages I G1 and G2 an increase in the survival time has not been shown. The cervical cancer stage IB-IIA removal of para-aortic lymph nodes (to the mesenteric artery) is indicated in patients with large tumors and suspected or known disease in the pelvic nodes. In patients in whom diagnostic imaging studies have not shown metastasis in para-aortic and pelvic lymph nodes or distant metastasis, para-aortic lymphadenectomy can be omitted. Further randomized studies are needed to elucidate the necessity and extent of lymphadenectomy in given gynecological cancers.

The polymorphisms of the MMP-1 and the MMP-3 genes and the risk of pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

To investigate the associations between single nucleotide polymorphism (SNP) type 1G/2G at position -1607/-1608 of the matrix metalloproteinase (MMP)-1 gene and SNP type 5A/6A at position -1612/-1617 of the MMP-3 gene and the development of pelvic organ prolapse (POP) in women.

METHODS

133 patients with symptomatic POP were included in the study group. The control group consisted of 132 women with a normal pelvic floor. 1G/2G MMP-1 and 5A/6A MMP-3 SNPs were determined by polymerase chain reaction (PCR) and restriction fragments length polymorphism analysis.

RESULTS

When estimated individually none of the investigated SNPs were associated with POP. The combined MMP-1/MMP-3 SNP analysis showed that the following polymorphic pairs were overrepresented in women with POP: 1G/2G -5A/6A, 2G/2G -5A/6A, 2G/2G -5A/5A, 1G/1G -6A/6A, p=0.005.

CONCLUSIONS

The combined effect of -1607/-1608 MMP-1 and -1612/-1617 MMP-3 SNPs may contribute to the development of POP in some women.

[Sacral nerve stimulation in the treatment of the lower urinary tract function disorders]

Functional disorders of the female lower urinary tract like urge incontinence, idiopathic urinary retention and symptoms of urgency-frequency occasionally do not respond properly to classical behavioral and pharmacological therapy Therefore, additional alternative therapies are needed to alleviate these bothersome symptoms. Sacral neuromodulation (SNS) utilize mild electrical pulses which activate or suppress neural reflexes responsible for voiding by stimulating the sacral nerves that innervate the bladder, external urethral sphincter and pelvic floor muscles. The exact mechanism of SNS action is not yet fully understood but it is assumed that it influences the neuroaxis at different levels of the central nervous system and restores the balance between inhibitory and activatory control over the voiding reflex. There is numerous evidence on the success of SNS not only in the treatment of refractory urge incontinence in adult and children but also in idiopathic urinary retention and symptoms of urgency-frequency

Botulinum toxin--a new therapeutic agent in girls with non-neurogenic overactive bladder--a case report and review of the literature

The aim of this article is to present the safety and efficacy of intradetrusor botulinum toxin injections in the treatment of non-neurogenic overactive bladder in pediatric patients. The electronic database MEDLINE (1966-2009) was searched including the following entries: non-neurogenic overactive bladder and botulinum overactive bladder. Data on the investigation topic are scarce. Most of the papers concern neurogenic overactive bladder in adults, with only a few dealing with children with neurological disturbances. Therefore, the following paper presents a case of botulin toxin treatment in girl with overactive bladder. The patient did not tolerate the standard anticholinergic therapy and did not present neurollogical disturbances. Successful outcome allows us to state that intradetrusor botulinum toxin type A injection is a promising new treatment method in the refractory cases of non-neurogenic pediatric overactive bladder.

[Risk factors of pelvic organ prolapsed in women qualified to reconstructive surgery--the Polish multicenter study]

AIM OF STUDY

To evaluate the prevalence rate of various pelvic floor disorders among patients treated in 8 academic centers in Poland due to pelvic organ prolapse (POP).

MATERIAL AND METHODS

The study group consisted of 717 women scheduled for reconstructive surgery due to POP. Risk factors, functional abnormalities along with symptoms affecting quality of life, were assessed by means of disease specific questionnaire. The stage of the disease was assessed after gynecological examination using POP-Q score.

RESULTS

The mean age of affected women with POP was 61,25 years (median 61), and mean BMI--27.62 (median--27.29). 80% of women were menopausal. Mean time of symptoms related to disease was 65,6 months; whereas the time relapsed from first doctor diagnosis of POP to hospital admission was 50.6 months. 97.4% affected women were multiparous. Only 1.21% women with POP were nulliparous. Family history of prolapse was found in 13.4% of patients, whereas familial positive history of urinary incontinence was 10%. Lower urinary tract symptoms (LUTS) among the analyzed group were as follows: frequency--almost 50%, urgency 32.2%, feeling of improper voiding -29,6% and voiding difficulty -17.7%. Functional disorders of lower bowel were found in 43% of patients and the most prevalent symptom was constipation (31%), followed by empting difficulty (12%), dyschesia (9%), and urge stool empting (7.7%). Cardiovascular diseases were found among 43% of respondents, whereas pulmonary diseases with chronic coughing were present in 20% of the analyzed population. Subjective POP symptoms reported by women were as follows: feeling of heaviness in lower abdomen--378%, perineal pain--27.8%, lumbosacral pain-34.2%, and abdominal pain--28.4%. Female sexual disorders were reported by 9,8% women and dyspareunia was found in 7.6% of responders. POP was the main reason for sexual abstinence only in 1 out of 10 patients. More than 30% of patients from the study group underwent previously pelvic surgery due to various reasons. POP related quality of life measured by VAS (Visual Analogue Scale) was 61.4 points (median--60). The most common finding during gynecological examination was cystocele--96.5%, followed by rectoenterocele--92.7%, and central defect--79%. Mean POP quantification was stage III in POP-Q scale. LUTS symptoms (urinary incontinence, urgency and voiding difficulties) were present among 81% of patients whereas lower gastrointestinal disorders (constipation, fecal incontinence, dyschesia) were found in 43% of women affected by POP.

CONCLUSIONS

Mean delay time from objective POP diagnosis until decision concerning surgical treatment was more than 5 years. The most common risk factors associated with POP were: multiparity with vaginal deliveries, obesity and aging. The most common defect found among patients with POP was cystocele, followed by rectoenterocele and central defect however most patients presented with advanced combined defects.

[MMP-1 and MMP-3 gene encoding polymorphism and the risk of the development of pelvic organ prolapse and stress urinary incontinence]

OBJECTIVES

The estimation of the association between the polymorphism at position -1607/1608 of the gene promoter encoding matrix metalloproteinase type 1 (MMP- 1) and the polymorphism at position -1612/1617 of the gene promoter encoding stromelysin type 1 (MMP-3) and the risk of the occurrence of pelvic organ prolapse (POP) and stress urinary incontinence (SUI).

MATERIAL AND METHODS

347 women were included into the analysis. POP study: the study group consisted of patients with clinically significant POP (POP-Q scale: 2, 3, 4). Women with normal pelvic floor statics (POP-Q scale: 0, 1) and not reporting symptoms of urinary incontinence were included into the control group. SUI study: the study group--patients with symptoms of stress urinary incontinence, the control group--continent women with normal pelvic floor statics (POP-Q scale: 0, 1). Samples of DNA were isolated from whole blood. The type of polymorphism was detected by RFLP method.

RESULTS

Both, in the POP and the SUI study we have observed no statistically significant differences in the occurrences of MMP-1 and MMP-3 promoter polymorphisms between the study and the control groups. Also, the presence of the alleles G/GG (MMP-1) or 5A/6A (MMP-3) did not modify the risk of the POP and SUI development.

CONCLUSIONS

Polymorphism type G/GG of gene promoter encoding MMP-1 and polymorphism type 5A/6A of the gene promoter encoding MMP-3 are not associated with the risk of the development of POP and SUI.

Height at menarche is influenced by estrogen receptor alpha gene polymorphisms

BACKGROUND

It has been suggested that polymorphic variations in estrogen receptors (ERs) genes may have an impact on linear growth of girls during puberty.

AIM

The aim of the study was to investigate whether height at menarche is influenced by PvuII and XbaI polymorphisms of the ERalpha gene.

SUBJECTS AND METHODS

The study population consisted of 127 healthy girls, who were observed from premenarcheal period at six monthly intervals, until menarche occurred in all participants. Anthropometric measurements were taken at each visit and their values at menarche were calculated using centile curves drawn individually for each subject. PvuII and XbaI ERalpha gene polymorphisms were evaluated with RLFP-PCR.

RESULTS

The age at menarche was not related to ERalpha gene polymorphisms. Girls with pp genotype were at menarche on average 3.2 cm shorter than PP homozygotes and in addition xx homozygotes were shorter than subjects with XX and Xx genotypes: 3.0 cm and 3.9 cm respectively. Subjects with px haplotype were, at the onset of the first menstrual period, from 2.3 cm to 3.1 cm shorter than carriers of other haplotypes. The leg length-to-height ratio at menarche was lower in xx homozygotes than in Xx heterozygotes and lower in px haplotype in comparison to Px and pX haplotypes carriers. Corresponding associations were observed at the final visit.

CONCLUSIONS

Height at menarche is influenced by the ERalpha gene polymorphism.

[The quality of life of patients with overactive bladder after local injections of botulinum toxin A--a preliminary report]

OBJECTIVES

The purpose of this work was to evaluate the quality of life of patients suffering from urge urinary incontinence resistant to anticholinergic therapy treated with intradetrusical injections of 200 U botulinum toxin A.

MATERIALS AND METHODS

The study group consisted of 10 female patients who were diagnosed with urge urinary incontinence. Standard King's questionnaire was used for the assessment of the change in the quality of life after treatment. Questionnaires were filled in by all patients before the treatment and during control visits, 3 months after the injection of botulinum toxin A.

RESULTS

Statistically significant improvement in the quality of life for the majority of the domains of King's questionnaire (except the evaluation of urinary incontinence impact on the general health condition and social relations) was observed in 7 out of 10 patients subjected to botulinum toxin therapy (p < 0.05).

CONCLUSIONS

Based on the results of this study we can conclude that treatment of patients with urge urinary incontinence not responding to classical anticholinergic treatment with botulinum toxin causes a significant improvement in the quality of their life.

[Anatomical and functional effect of laparoscopic Vecchietti operation]

OBJECTIVE

To evaluate surgical: anatomical and functional effect of the laparoscopic Vecchietti procedure to treat women with vaginal agenesis.

METHODS

Retrospective analysis of 10 patients operated in the II-nd Department of Gynecology Medical University of Lublin, Poland. The length of vagina and macroscopic evaluation of it structure was assessed in each case. Sexually active women for more than 6 months answered the BISF-W questionnaire (Brief Index of Sexual Functioning for Women). The results were analyzed comparing health age-matched controls.

RESULTS

The mean age of operated women was 22.8-4.5 year whereas in the control group 22.9 +/- 3.3 year. In two operated patients the small areas of granulation were found in the vagina: in one woman on the side wall of vagina in the other in the apex. The mean length of neo-vagina was 8 +/- 2.1 cm, whereas in the control group 10 +/- 1.0 cm. The difference was statistically significant (U Mann-Whitney test, p = 0.013). BISF-W scores were comparable in both groups.

CONCLUSION

The laparoscopic Vecchietti operation allows to create shorter vagina in comparison to health women but the sexual life of this patients is as satisfying as the normal controls.

Changing trends in the surgical treatment of female stress urinary incontinence--twenty two years observation

OBJECTIVES

The aim of this study was to analyze the changing trends in surgical treatment of female urinary incontinence (UI).

MATERIAL AND METHODS

Medical records of all women admitted to II Department of Gynecology from 1985 to 2006 were analyzed in order to find out how the female SUI treatment changed over these years.

RESULTS

During analyzed time 36819 patients were hospitalized in our Department and 77.6% (28568) of them were operated because of various indications. The number of SUI surgeries among all hospitalized women steadily rose from 1.93% in 1985 to 10.96% in 2006 reaching maximum in 2005 (13.73%). Clinical effectiveness of SUI surgeries markedly improved from 35% for anterior colporrhaphy to almost 90 % for suburethral slings.

CONCLUSIONS

Introduction into clinical practice modern suburethral slings improved clinical efficacy of SUI treatment. The percentage of women admitted and treated surgically because of SUI steadily increased over the last years.

[Polymorhism of CYP17 gene and age of menarche]

OBJECTIVES

It is believed that the age of menarche may be related to polymorphisms in the genes involved in estrogen biosynthesis. A candidate gene is CYP 17 encoding cytochrome P450 c17alpha, which mediates activity of steroid 17-hydroxylase and 17,20-lyase. A single base-pair change (T-->C) in the promoter region of CYP 17 creates a polymorphic variant with an additional SP-1 transcription factor binding site. The aim of our study was to evaluate the relationship between CYP 17 gene polymorphism and the age of menarche.

MATERIALS AND METHODS

The study group was composed of 124 healthy Caucasian girls inhabiting the Lublin region (Poland). The observation had began from prepubertal period, thus allowing for the age of menarche to be recorded precisely. CYP 17 polymorphism was assessed with RLFP-PCR using Msp Al restriction endonuclease. An allele with the respective restriction site was designated as A2, whereas one resistant to restriction enzyme as A1.

RESULTS

The following frequency of CYP 17 genotypes has been observed: A1/A1-36 (29.0%), A1/A2-67 (54.0%) and A2/A2-21 (17.0%). The mean age of menarche for these three genotypes did not differ significantly and was: A1/A1-13.14+/-0.92, A1/A2-12.93+/-1.04 and A2/A2-13.40+/-0.91 years, although later age of first menstrual period in carriers of A2/A2 genotype compared with carriers of A1/A2 was nearly statistically significant (p=0.058). The distribution of CYP 17 genotypes in groups of girls with onset of menarche before and after thirteenth year of age did not differ significantly.

CONCLUSION

The age of menarche in population of Polish girls is not associated with the polymorphism of CYP 17 gene.

Polymorphism of the gene encoding alpha-1 chain of collagen type I and a risk of pelvic organ prolapse--a preliminary study

INTRODUCTION

Polymorphism of the gene encoding alpha-1 chain of type I collagen (COL1A1) may influence the mechanical properties of the pelvic floor connective tissue.

AIM OF STUDY

We examined possible role of G-->T substitution in transcription factor Sp1 binding site in the gene encoding alpha-1 chain of type I collagen (COL1A1) in the development of pelvic organ prolapse.

MATERIALS AND METHODS

The study group consisted of 37 women with pelvic floor defects graded according POPQ scale as stage II, III and IV. All study group patients underwent reconstructive surgery of the pelvic floor. We enrolled forty control subjects. All of them were treated for benign gynecological conditions other then stress urinary incontinence or pelvic organ prolapse. DNA was obtained from peripheral blood leukocytes. The fragment of the first intron of COL1A1 gene containing Sp1 binding site was amplified by PCR and analysis of restriction fragment length polymorphism was done.

RESULTS

The GG polymorphism in COL1A1 gene was identified in 26 (70.3%), GT sequence in 10 (27%) and TT in 1 (2.7%) patient. The distribution of the investigated polymorphisms in the control group were: 27 (67.5%), 9 (22.5%) and 4 (10%), respectively. We do not found association between investigated polymorphic variants and pelvic organ prolapse (chi2 test, p=ns).

CONCLUSION

G-->T substitution in transcription factor Sp1 binding site in the COLIA1 gene does not increase the risk of development of pelvic floor defect (POPQ stages II, III, IV).

Relationship between estrogen receptor-alpha polymorphism and serum levels of vascular cell adhesion molecule-1, intercellular adhesion molecule-1, C-reactive protein and homocysteine in postmenopausal women

BACKGROUND AND AIM

Genetic variation in the estrogen receptor-gene (ERalpha) may influence the risk of cardiovascular diseases in postmenopausal women. This effect, at least in part, may be dependent on the decrease in expression of injury and inflammatory markers in the vascular wall. The aim of the present study was to evaluate the relationship between ERalpha PvuII and XbaI polymorphisms and serum levels of soluble vascular cell adhesion molecule-1 (sVCAM-1), soluble intercellular adhesion molecule-1 (sICAM-1), C-reactive protein (CRP) and homocysteine in postmenopausal women.

SUBJECTS AND METHODS

Subjects of the study were 64 postmenopausal women. PvuII and XbaI ERalpha gene polymorphisms were analyzed by polymerase chain reaction-restriction fragment length polymorphism.

RESULTS

Mean sVCAM-1 level was significantly higher in pp homozygotes in comparison with PP homozygotes and Pp heterozygotes, as well as higher in xx homozygotes in comparison with XX homozygotes and Xx heterozygotes. Levels of sVCAM-1 were also significantly higher in women with px haplotype compared with PX and Px haplotypes. There were no relationships between investigated genotypes or haplotypes and levels of sICAM-1, CRP and homocysteine.

CONCLUSION

The results of our study suggest that genetic variation in ER gene may influence blood levels of VCAM-1 in women after the menopause.

[Tape erosion--local process or general reaction of the organism. The erosion rate and localization of implanted polypropylene tape in female pelvis]

OBJECTIVES

Our study was aimed to reveal whether the tape rejection is associated with increase in serum C-reactive protein level and to assess if localization of implanted polypropylene tape predisposes to its rejection.

MATERIAL AND METHODS

Between January 2002 and June 2005, 780 women with SUI or pelvic organ prolapse underwent retropubic sling procedure--IVS 02 (n = 379) or transobturator suburethral tape--IVS 04 (n = 283) or posterior IVS operation (n = 118). IVS multifilament tape (Tyco Healthcare) was used in all surgeries. The same antibiotic prophylaxis and disinfected procedure were applied in all cases. Follow-up visits were performed 4-6 weeks after the operation and next were scheduled every 3 months during first year after surgery and every 6 months in the years to follow. Blood to CRP level analysis (ELISA method) was collected form all patients with mesh erosion without any concomitant inflammatory or immunologic diseases.

RESULTS

Until January 2006 we have observed 28 cases of tape rejection: 5 after posterior IVS operation, 14 after IVS 02 and 9 after IVS 04. The chi-square test revealed no statistically significant differences between these groups. Ten women with mesh rejection were completely asymptomatic, two had fever and abscessi. Also, four women had pyogenic discharge from the skin or the vagina. Ten women complained of dyspareunia, vaginal bleeding and irritating voiding. We have found CRP values normal in all cases beside woman with fever and abscesi two.

CONCLUSIONS

The process of mesh erosion in most cases is limited to local cellular response. The tape rejection rate is not associated with the localization of the implant in female pelvis.

[Women's sexual life quality assessment with use of questionnaires in clinical trials--review of accessible tools, their characteristics and comparison of their properties]

AIM

Aim of the study is a review of women's sexual life quality assessment questionnaires available in literature, analysis of their construction, special properties and usability in clinical trials.

MATERIAL AND METHODS

Medline database and accessible literature has been reviewed. Seven questionnaires have been chosen for analysis. Analysis in scope of potential and usability of those questionnaires in clinical tests has been performed.

CONCLUSIONS

Suitability of The Female Sexual Function Index (FSFI) and The Brief Index of Sexual Functioning for Women (BISF-W) have been shown as universal tools for sexual function assessment in clinical trials. They meet current model of women's sexual reaction and criteria of sexual disfunction classification.