Surgery for endometriosis-associated infertility: do we exaggerate the magnitude of effect?

OBJECTIVE

Surgery remains the mainstay in the diagnosis and management of endometriosis. The number of surgeries performed for endometriosis worldwide is ever increasing, however do we have evidence for improvement of infertility after the surgery and do we exaggerate the magnitude of effect of surgery when we counsel our patients? The management of patients who failed the surgery could be by repeat surgery or assisted reproduction. What evidence do we have for patients who fail assisted reproduction and what is their best chance for achieving pregnancy?

MATERIAL AND METHODS

In this study we reviewed the evidence-based practice pertaining to the outcome of surgery assisted infertility associated with endometriosis. Manuscripts published in PubMed and Science Direct as well as the bibliography cited in these articles were reviewed. Patients with peritoneal endometriosis with mild and severe disease were addressed separately. Patients who failed the primary surgery and managed by repeat or assisted reproduction technology were also evaluated. Patients who failed assisted reproduction and managed by surgery were also studied to determine of the best course of action.

RESULTS

In patients with minimal and mild pelvic endometriosis, excision or ablation of the peritoneal endometriosis increases the pregnancy rate. In women with severe endometriosis, controlled trials suggested an improvement of pregnancy rate. In women with ovarian endometrioma 4 cm or larger ovarian cystectomy increases the pregnancy rate, decreases the recurrence rate, but is associated with decrease in ovarian reserve. In patients who have failed the primary surgery, assisted reproduction appears to be significantly more effective than repeat surgery. In patients who failed assisted reproduction, the management remains to be extremely controversial. Surgery in expert hands might result in significant improvement in pregnancy rate.

CONCLUSION

In women with minimal and mild endometriosis, surgical excision or ablation of endometriosis is recommended as first line with doubling the pregnancy rate. In patients with moderate and severe endometriosis surgical excision also is recommended as first line. In patients who failed to conceive spontaneously after surgery, assisted reproduction is more effective than repeat surgery. Following surgery, the ovarian reserve may be reduced as determined by Anti Mullerian Hormone. The antral follicle count is not significantly reduced. In women with large endometriomas > 4 cm the ovarian endometrioma should be removed. In women who have failed assisted reproduction, further management remains controversial in the present time.

Dispersion of Bioactive Glass using Cetyltrimethylammonium Bromide

The dispersion of bioactive glass, (BG), sample was studied using cetyltrimethylammonium bromide (CTAB). An array of experimental techniques like adsorption, Zeta potential and turbidity were used to achieve this goal. Turbidity was used as a parameter to reflect the degree of dispersion where a higher value of turbidity represents higher dispersion efficiency. Dispersion of the BG particles was largely affected by CTAB concentration and the solution pH. Dispersion of the BG particles was increased with increasing of CTAB concentration till the CMC of CTAB is reached. Above the CMC, the BG particles become hydrophilic causing a decrease in glass dispersion. On the other hand, dispersion of the BG particles was affected with the solution pH. It was increased with increasing pH till pH 9. At higher pH, dispersion was decreased where the formation of micelles is favored.

Urologic complications of genitourinary schistosomiasis

OBJECTIVES

To provide systematic review of the literature on the long-standing complications of genitourinary schistosomiasis.

MATERIALS AND METHODS

The PubMed literature database was searched from inception to December 2010. The following keywords were used: schistosomiasis, bilharziasis, and genitourinary. Only English language publications were utilized.

RESULTS

Variable tissue reactions to bilharzial eggs with subsequent healing or progression and complications in the urinary tract mainly affect the urinary bladder and pelvic segments of the ureters. These lesions may assume an atrophic, proliferative, or neoplastic pattern. Although the pathology is usually extensive in the submucosal, all layers from the mucous membrane through deep to the perivesical or periureteral tissues may be involved. Main fixed bilharzial urologic sequelae include chronic bladder ulcers, leucoplakia, vesical granuloma, contracted bladder, bladder neck contracture, stricture ureters, and bladder carcinoma. These sequelae may lead to marked morphologic and functional changes of the urinary tract, and ultimately, mortality can follow from renal failure or bladder cancer.

CONCLUSIONS

Urinary schistosomiasis is a preventable disease through nationwide snail control and mass therapy with oral antibilharzial drugs. If not properly treated, long-standing urinary complications may result in serious sequelae that may lead to mortality from renal failure or bladder cancer.

Generalized Bessel beams in modified axially symmetric graded index structures

We explore a general type of stable Bessel beams in graded index media. The proposed axially symmetric medium is characterized by an "α" index profile. Explicit solutions for the radial envelope of the field E(r) are derived in terms of generalized Bessel functions. Emphasis is given on illustrating how far the conditions of the proposed modified structure permit only a Bessel function of the first kind to be uniquely retained in the solution. This paper considers both the optical and mathematical aspects. Some numerical examples corroborating our theoretical results are included, showing the stability, propagation, and diffraction of such Bessel beams.

Experience with impacted upper ureteral stones; should we abandon using semirigid ureteroscopes and pneumatic lithoclast?

Introduction

The AUA/EAU Ureteral Stones Guideline Panel reported that the stone free rate for the proximal ureteral stones is around 81% when treated by either SWL or ureteroscopy (URS).

Complication rates, most notably ureteral perforation and long-term complications of URS such as stricture formation rates, have been reduced to < 5%. Moreover, impacted ureteral calculi are more difficult to fragment with SWL because of the lack of natural expansion space for stones, this result in a situation that is better managed by ureteroscopy. The aim of this study is to assess the efficacy, safety, and complications of impacted upper ureteral stone disintegration using semirigid ureteroscopes and pneumatic lithotripsy.

Methods

We retrospectively analyzed the records of 267 consecutive patients with impacted upper ureteral stones (9–20 mm) who were treated by semirigid ureteroscopes and pneumatic disintegration. The efficacy of treatment was estimated using the stone-free rate and all treatment related complications were analyzed.

Results

Except for 24 cases where the stone migrated to the kidney, the stone was successfully treated ureteroscopically, with a low rate of minimal complications such as mild hematuria (18.4%), short term low grade fever (13.5%). Only 3 patients (1.1%) had high grade fever and none had post operative stricture.

Conclusion

The use of semirigid URS and pneumatic lithotripsy in impacted upper ureteral stones in experienced hands has very satisfactory results with minimal complications. When Holmium laser and flexible URS are not available, semirigid URS and pneumatic lithotripsy is a good alternative that shouldn't, yet, be abandoned.

Mainz II and double folded rectosigmoid pouches. Experience with 95 patients

OBJECTIVES

We report a clinical case series for construction of Mainz II or double folded rectosigmoid pouch with suitable antireflux uretero-intestinal anastomosis.

MATERIALS AND METHODS

Ninety-five patients with invasive bladder carcinoma were treated by radical cystectomy and supravesical urinary shunt in form of either Mainz II {56 (58.9%)} or double folded {39 (41.1%)} rectosigmoid pouch. Antireflux techniques for uretero-intestinal anastomosis were subserosal extramural and submucosal tunnels for 122/190 (64.2%) dilated and 68/190 (45.8%) normal caliber ureters. All patients were kept on prophylactic alkalization. Evaluation included clinical, radiological, laboratory, and urodynamic evaluations. Mean follow-up was 40 months.

RESULTS

Early postoperative complications were reported in seven (7.4%) cases that were treated conservatively. All patients were continent day and night. Reflux was reported in 2/122 (1.6%) renal units (RU) with dilated ureters and in 1/68 (1.5%) RU with normal caliber ureter, that was managed conservatively. Stenosis at uretero-intestinal anastomosis was reported in 10 (5.3%) RU. Laboratory investigations were within normal. Pouchometry results were comparable in both Mainz II and double folded rectosigmoid pouches. Both were low-pressure good capacity reservoirs.

CONCLUSIONS

Mainz II pouch is indicated in cases of normal caliber, unilateral dilated, and some cases of bilateral dilated ureters, while double folded rectosigmoid pouch is optional in case of bilateral dilated ureters. Both have comparable low-pressure urodynamic features.

Patellar tendinitis: the significance of magnetic resonance imaging findings

We evaluated the significance of magnetic resonance imaging findings in patients with patellar tendinitis. Midline sagittal magnetic resonance images were taken of 12 knees from 10 patients and of 17 knees from 15 age- and activity-matched subjects who underwent imaging for reasons other than patellar tendinitis. Of the 12 magnetic resonance imaging scans of knees with clinical patellar tendinitis, 3 (25%) exhibited no defect and only 7 (58%) had unequivocal intratendinous lesions. Among the 17 scans of subjects without clinical patellar tendinitis, 5 (34%) showed no defect and 4 (24%) had unequivocal intratendinous lesions. Proximal tendon width was significantly larger for the tendinitis patient group (5.0 +/- 1.7 mm versus 3.9 +/- 1.0 mm), although considerable overlap was present. All subjects with unequivocal intratendinous signal changes had a significantly longer nonarticular inferior patellar pole and were significantly older (38.1 years versus 26.8 years). Only Blazina stage III lesions were associated with abnormal findings on magnetic resonance imaging. As a whole, the sensitivity and specificity of magnetic resonance imaging was 75% and 29%, respectively. In younger patients with relatively mild symptoms, magnetic resonance imaging did not show significant changes; in older, active patients changes may be present in asymptomatic knees.

Simple assay for detection of circulating antigens in children infected with schistosomiasis

The ability of monoclonal based dot-ELISA and a previously described solid-phase ELISA were directly compared to detect circulating schistosomal antigens in sera from 50 Egyptian individuals with parasitologically proven schistosomiasis. The mAb employed, 128C3/3/21, recognized a repeating carbohydrate epitope expressed at all stages of the parasite development. The same mAb and patient serum samples were used i both tests, 17 samples from age-matched individuals infected with other parasites but not with Schistosoma were also tested. In the dot-ELISA, 44 serum samples (88%) were found to contain parasite antigens when screen at a dilution of 1;24, 43 serum samples (86%) were positive in the solid-phase ELISA at 1:8 dilution and only 37 (74%) samples were positive at 1:24 dilution. The specificity of the dot-ELISA was 93% as compared to > 99% for the solid-phase ELISA. The detection limit of dot-ELISA was 0.01 ng/ml, whereas only > 1 ng/ml could be detected by the solid-phase ELISA. As dot-ELISA does not require radioactivity or sophisticated equipment, so it is practically well suited for use in endemic areas in developing countries.

Comparison of polymerase chain reaction and monoclonal antibodies for G-typing of group A bovine rotavirus directly from fecal material

A reverse transcriptase and polymerase chain reaction (RT-PCR)-based assay for G-typing of bovine rotaviruses (BRV) was compared with a monoclonal antibody-based immunoassay (MAbs-ELISA) in the characterization of BRV field strains obtained from calves in different regions of Quebec between 1992 and 1994. The strains were analysed for two G types (G6 and G10) which are the most predominate BRV field strains. Fecal samples positive for BRV by polyacrylamide gel electrophoresis (n = 74) were typed by both methods revealing 77% correlation. RT-PCR detected 10 more G6 and 2 more G10 serotypes than MAbs-ELISA. Nine of the 12 discrepant samples could be cultivated and were confirmed as G6 (8) or G10 (1) by both methods. RT-PCR was able to efficiently detect artificial mixes of G6 and G10 and detected two mixed field infections. Four additional infections considered as mixed by MAbs-ELISA and as only G6 by RT-PCR were possibly MAbs-ELISA cross-reactions. RT-PCR provided a very sensitive method for typing BRV field isolates.

Topical treatment of erectile dysfunction: randomised double blind placebo controlled trial of cream containing aminophylline, isosorbide dinitrate, and co-dergocrine mesylate

OBJECTIVE

To examine the effectiveness in treating impotence to topically applied cream containing three vasodilators--aminophylline, isosorbide dinitrate, and co-dergocrine mesylate--which act by different mechanisms.

DESIGN

Randomised double blinded placebo controlled crossover trial over two weeks.

SUBJECTS

36 men with erectile dysfunction randomly allocated to two equal groups.

INTERVENTIONS

Active cream containing aminophylline 3%, isosorbide dinitrate 0.25%, and co-dergocrine mesylate 0.05% for one week and placebo for another.

MAIN OUTCOME MEASURES

Patients' reported experience of penile responses and side effects of treatment in questionnaires. Penile tumescence and arterial flow in the laboratory.

RESULTS

21 patients reported full erection and satisfactory intercourse with the active cream. Three men reported full erection and satisfactory intercourse with either cream. The active cream was more effective in psychogenic than organic impotence (eight out of nine men with psychogenic impotence achieved a full erection upsilon four out of eight with neurogenic impotence and two out of seven with arterial insufficiency). No major side effects were reported. In the laboratory the active cream increased penile arterial flow (0.19 (SD 0.08) m/s upsilon 0.02 (0.15) m/s with placebo) and induced tumescence in 24 patients.

CONCLUSIONS

Topical treatment with a cream containing three different vasodilators might be considered before intracavernous injection of vasoactive agents, particularly in psychogenic impotence.

Experimental observation of spatial soliton interactions with a pi/2 relative phase difference

We report the experimental observation of the nonlinear interaction between two fundamental spatial solitons with a pi/2 phase difference in carbon disulfide. An energy flow from the phase-advanced soliton to the phasedelayed soliton was observed, which leads to a single self-trapped beam. The position of the output beam can be switched by reversing the sign of the solitons' initial phase difference.

Experimental spatial soliton trapping and switching

We show experimentally the trapping of two spatial solitons of the same wavelength but with slightly different propagation directions, which results from the collision of two initially overlapped solitons beams. This is the spatial analog of soliton pulse trapping in birefringent optical fibers. Adjustment of the phase shift between each beam permits the switching of one soliton to the other without disturbing their trajectory.

Techniques in endoscopic lithotripsy using pulsed dye laser

The pulsed dye laser represents a new tool in the treatment of ureteral calculi. Laser energy channeled through a delicate optical fiber is used to disimpact and fragment calculi. Standard ureteroscopic instruments including graspers, baskets and dilatation balloons can be used with the laser system. Interchangeable optical fibers ranging from 200 to 400 micrometers deliver up to 120 mJ of energy to the stone's surface. For two weeks in 1989 an endourology clinic was held in upper Egypt. Eighty patients ranging in age from nine years to sixty-seven years old were evaluated and treated endoscopically. Endoscopes ranging from 6.9F to 12.5F were used to deliver the optical fiber. All stones visualized endoscopically were fragmented. Greater than 60 percent of the stones fragmented were composed of pure calcium oxalate monohydrate. Schistosoma hematobium was endemic among our study group. Bilharzial strictures of the distal ureter were noted in 30 percent of these patients. Treatment of these strictures using both balloon dilatation and graduated Teflon dilators is reviewed. Techniques in treating different types of ureteral calculi were explored. Large calcium oxalate dihydrate stones were treated most efficiently with the 3-point fragmentation technique. The shear off-center technique was used for the calcium oxalate monohydrate calculi. Variations in total energy delivered and frequency of pulsation allowed for prompt stone disimpaction as well as prevention of retrograde fragment migration. Concurrent use of stone baskets and graspers with the pulsed dye laser was explored.