Intrauterine device (IUD) migration in cesarean delivery scar: What to do with the niche?

BACKGROUND

The presence of a niche after cesarean section is a common and mostly asymptomatic finding. However, it can cause symptoms or result in impaired fertility or obstetric complications in following pregnancies. At present there is no uniform consensus on when to treat and which way of repair is most suitable. The aim of this systematic review of literature was to provide an overview of current knowledge about cesarean scar niches and about the modalities of niche repair.

METHODS

On the second of January 2019 Pubmed and Cochrane databases were searched for relevant studies published until December 2018. Search terms were cesarean scar defect, niche, niche repair. As combination key words `hysteroscopy ´, `laparoscopy ´ and `vaginal repair ´ were used.

RESULTS

Eight articles were included in this review. The publications were very heterogeneous. Most of them stated that hysteroscopic niche repair with resection of the lower (and upper) rim is suggested for abnormal uterine bleeding. In symptomatic women who wish to conceive, different authors suggest laparoscopic niche repair with double layer closure to increase myometrial thickness. Also, one report on vaginal repair was included, none of the included patients had child wish. Nothing was reported on residual myometrial thickness after surgery.

CONCLUSION

The current literature is not sufficient to draw strong conclusions on what to do about cesarean scar niches, yet, they justify the role of hysteroscopic as well as laparoscopic niche repair dependent on different pre- operative factors. We conclude that further large randomized controlled trials are necessary.

The rationale of opportunistic bilateral salpingectomies (OBS) during benign gynaecological and obstetric surgery: a consensus text of the Flemish Society of Obstetrics and Gynaecology (VVOG)

Ovarian cancer (OC), is a disease difficult to diagnose in an early stage implicating a poor prognosis. The 5-year overall survival in Belgium has not changed in the last 18 years and remains 44 %. There is no effective screening method (secondary prevention) to detect ovarian cancer at an early stage. Primary prevention of ovarian cancer came in the picture through the paradigm shift that the fallopian tube is often the origin of ovarian cancer and not the ovary itself. Opportunistic bilateral salpingectomy (OBS) during benign gynaecological and obstetric surgery might have the potential to reduce the risk of ovarian cancer by as much as 65 %. Bilateral risk-reducing salpingectomy during a benign procedure is feasible, safe, appears to have no impact on the ovarian function and seems to be cost effective. The key question is whether we should wait for a RCT or implement OBS directly in our daily practice. Guidelines regarding OBS within our societies are therefore urgently needed. Our recommendation is to inform all women without a child wish, undergoing a benign gynaecological or obstetrical surgical procedure about the pro's and the con's of OBS and advise a bilateral salpingectomy. Furthermore, there is an urgent need for a prospective registry of OBS. The present article is the consensus text of the Flemish Society of Obstetrics and Gynaecology (VVOG) regarding OBS.

A re-investigation of the role of utricular asymmetries in Space Motion Sickness

During the first days of spaceflight, about 50-70% of the astronauts experience symptoms of Space Motion Sickness (SMS). It has been proposed that an asymmetry between the left and right otolith organs contributes to an astronaut's individual susceptibility. A recently developed test to measure unilateral utricular function enabled us to re-investigate this so-called otolith asymmetry hypothesis, while using the paradigm of sustained centrifugation as a ground based model for SMS. This latter paradigm has been shown to elicit symptoms similar to those of SMS and is referred to as Sickness Induced by Centrifugation (SIC). In 15 healthy subjects unilateral utricular function was assessed by recording ocular counter rolling during a unilateral centrifugation paradigm. In addition, saccular function was assessed by recording Vestibular Evoked Myogenic Potentials (VEMPs), and horizontal semicircular canal function was assessed using bithermal caloric stimulation. SIC-susceptible subjects showed a marginally higher degree of utricular asymmetry, utricular sensitivity and semicircular canal sensitivity (p < 0.1) than the non-susceptible group. Interestingly, a logistic regression model using both utricular and semicircular canal parameters led to a correct classification of 91% of the subjects. As such, these results suggest that otolith asymmetry is at most one factor - and not present in all susceptible subjects - in defining susceptibility to SMS and SIC. Both the utricular and the canal system might be involved as well.

Reliability of utricular function testing sinusoidal translation profile during unilateral centrifugation

The unilateral centrifugation test is one of the few vestibular tests that evaluate the utricles side by side. During this test, a subject is rotated about an earth vertical axis at high rotation speeds (e.g. 400 degrees/s) and translated sideways along the interaural axis to align the axis of rotation consecutively with the right and the left utricle. The combined rotation and translation induces ocular counter rolling (OCR), which is measured using three-dimensional video-oculography. Recently, a new model has been proposed to analyse the OCR. The model is based on contributions from both the semicircular canals and the utricles. Concomitant with the new model a new stimulation profile using a sinusoidal translation profile during the unilateral centrifugation has been introduced [1]. The current study presents the test-retest reliability as well as the robustness of the new stimulation method, based on data of 67 healthy subjects. Test-retest reliability was based on repeated measurements of a group of subjects. To test the robustness of the new sinusoidal translation paradigm, we investigated the effect of a different amplitude of the sinusoidal translation (6 cm instead of 4 cm) and of an offset in translation (from -3 to +5 cm, instead of from -4 to +4 cm) on the parameters. Several statistical measures were used to reflect the reliability: intraclass correlation coefficient (ICC), the "coefficient of variation of the method error" and the "minimal difference" (MD). All relevant variables from the physiological model for the OCR induced by unilateral centrifugation show a good to excellent reliability during the test-retest study and the relevant parameters remain unaffected by the changes applied to the translation profile (p > 0.05) as predicted by the model. Additionally, all observed differences are smaller than the MD values calculated in the test-retest part of the study.

Vestibular evoked myogenic potentials: Test-retest reliability and normative values obtained with a feedback method for the sternocleidomastoid muscle contraction

Objective: To determine normal limits and to analyse the test-retest reliability of the vestibular evoked myogenic potentials (VEMPs) parameters. Methods: The VEMP procedure was repeated on different test days to analyze test-retest differences. We calculated several reliability parameters: intraclass reliability coefficient (ICC), method error (ME), coefficient of variation of the method error (CV M E ), standard error of measurement (SEM) and minimal difference (MD) for test-retest measurements. Normal values for left-right differences, based on the interaural ratio (IAR), were determined. Results: For each VEMP parameter, the ICC values indicated excellent reliability, except for p13 and corrected amplitude (fair to good reliability). The CV M E values were less than 7% for p13, n23, threshold, MRV f e m a l e s and MRV m a l e s . For the parameters corrected amplitude and raw amplitude, the CV M E values exceeded 15%. The 95% IAR prediction intervals (PIs) were also largest for the parameters raw amplitude and corrected amplitude. Conclusion: In order to evaluate a VEMP outcome in a patient, the VEMP parameters and IAR values can be compared with the 95% PI of the normal values. When successive measurements are performed within the same subjects, the minimal difference (MD) serves as a tool to decide whether these differences are clinically relevant or not.

The Posterior Intravaginal Slingplasty treatment for apical prolapse: 3 years experience in a single centre setting

AIM

To assess the anatomic effectiveness and complications of the Posterior IVS technique for the treatment of pelvic organ prolapse over a period of 3 years.

METHODS

A retrospective, single-arm, non-comparative study involving routine, standardised, pre-operative assessment, surgery and follow-up care using the Pelvic Organ Prolapse Quantifications score at 1, 2 and 3 years was performed. The Posterior IVS technique was performed in patients with a symptomatic grade 2 or greater prolapse of the apical compartment (i.e. point C and/or D ≥ -1). Concomitant prolapse procedures were allowed.

RESULTS

Twenty-nine consecutive patients underwent a Posterior IVS suspension over a period of 2 years. Ninety -percent (26/29) of patients required a concomitant prolapse procedure (79% an anterior and 55% a posterior vaginal wall repair). No serious peroperative complications, bladder injuries or rectal perforations were encountered. Overall anatomical success rates (

CONCLUSION

Three years follow-up of the Posterior IVS yields a high anatomical failure and substantial surgical -reintervention rate.

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Key Words

• Pelvic organ prolapse
• Posterior IVS
• apical prolapse
• infraccocygeal sacropexy
• mesh
• surgery

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MESH Headings Collapse

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Validity of a new feedback method for the VEMP test

CONCLUSIONS

We used a feedback method, based on a blood pressure manometer with inflatable cuff, to control the sternocleidomastoid muscle (SCM) contraction. To obtain comparable left-right VEMP responses, it is necessary (1) to determine which cuff pressures on both sides yield identical mean rectified voltage (MRV) values of the SCM contraction and (2) to apply these cuff pressures during the VEMP test.

OBJECTIVE

To investigate the effect of the SCM muscle contraction variability on the VEMP variables when applying the feedback method.

MATERIALS AND METHODS

Subjects pushed with their jaw against the hand-held inflated cuff to generate cuff pressures of subsequently 30, 40 and 50 mmHg during a MRV and VEMP measurement.

RESULTS

When analyzing the relationship between the applied cuff pressures and the MRV values/VEMP amplitudes, we showed that (1) there was a linear relationship, (2) there was no side effect and (3) there was an interaction effect between 'side' and 'subject'. There was neither a side effect, nor an effect of the applied cuff pressure when considering the p13 latencies. As for the n23 values, there was no side effect but there was a significant difference when comparing the n23 latencies at cuff pressures of 30 vs 40 mmHg/50 mmHg.

Posterior semicircular canal dehiscence: value of VEMP and multidetector CT

OBJECTIVE

To illustrate that posterior semicircular canal dehiscence can present similarly to superior semicircular canal dehiscence.

CASE STUDY

The symptomatology initially presented as probable Menière's disease evolving into a mixed conductive hearing loss with a Carhart notch-type perceptive component suggestive of otosclerosis-type stapes fixation. A small hole stapedotomy resulted in a dead ear and a horizontal semicircular canal hypofunction. Recurrent incapacitating vertigo attacks developed. Vestibular evoked myogenic potential (VEMP) testing demonstrated intact vestibulocollic reflexes. Additional evaluation with high resolution multidetector computed tomography (MDCT) of the temporal bone showed a dehiscence of the left posterior semicircular canal.

CONCLUSIONS

Besides superior semicircular canal dehiscence, posterior semicircular canal dehiscence has to be included in the differential diagnosis of atypical Menière's disease and/or low tone conductive hearing loss. The value of performing MDCT before otosclerosis-type surgery is stressed. VEMP might contribute to establishing the differential diagnosis.

Meniett therapy: rescue treatment in severe drug-resistant Ménière's disease?

CONCLUSION

Our data indicate that Meniett therapy is unlikely to be helpful in the long-term treatment of patients with severe, drug-resistant Ménière's disease (MD) in whom injection of intratympanic gentamicin (ITG) or another destructive procedure would otherwise be performed.

OBJECTIVE

To investigate the value of Meniett therapy in patients with drug-resistant MD referred for injection of ITG.

MATERIAL AND METHODS

Twelve patients referred for ITG treatment were followed during a 2-month period of Meniett therapy. Symptoms, functional level and hearing status were evaluated using a standardized staging system. Disease-specific quality-of-life measures were obtained before and after Meniett therapy. At the end of the study period, patients were followed for a mean of 37 months, thus providing long-term outcome data.

RESULTS

In two patients, Meniett treatment was interrupted after 1 month because of persistent severe vertigo. In the remaining 10 subjects, we found a significant decrease in the median number of vertigo spells from 10.0/month (25th-75th percentile 4.0-19.0) prior to treatment to 3.0/month (25th-75th percentile 1.5-4.5) after treatment (p = 0.02). There was, however, no improvement in hearing status, tinnitus, functional level or self-perceived dizziness handicap. Long-term (>1 year) follow-up data revealed that only 2 subjects preferred to continue Meniett therapy and that ablative surgery had to be performed in 6/12 study patients.