Surgical excision of paraurethral cyst

Purpose

Patients with paraurethral cyst may be asymptomatic or bothered by sensation of a mass, pain, distorted urinary outflow, dyspareunia, and dysuria (1). Differential diagnosis includes ectopic ureterocele, pelvic organ prolapse, and urethral diverticulum. At present, the management of paraurethral cysts is unclear, but surgical excision appears as the best treatment option (1-3). Alternative methods include waiting for spontaneous rupture, needle aspiration and marsupialization (4). The aim of the video-tutorial is to provide anatomic views and surgical steps necessary to achieve a successful complete excision of a paraurethral cyst.

Materials and methods

A 54-year-old woman with a 2cm paraurethral cyst bothered by intermittent sensation of an introital mass, dyspareunia, and dysuria was admitted to surgical excision according to the described technique. Urethrocystoscopy and ultrasonography were preoperatively performed to confirm the diagnosis and rule out an urethral diverticulum. Surgical steps included: cyst exposure; vaginal mucosa incision; adequate dissection (needle injection of saline solution inside the cyst can be performed to inflate the cyst) with scissors and swab, isolation and excision of paraurethral cyst, layered reconstruction with avoidance of suture layers overlapping.

Results

Surgical procedure was successfully achieved without complications. The postoperative course was uneventful. No recurrence was observed and the patient reported complete resolution of her symptoms.

Conclusions

The featured video showed complete excision of a paraurethral cyst successfully achieved without complications. Surgical excision represents a safe and effective procedure to manage paraurethral cysts. This step-by-step video-tutorial may represent an important tool to improve surgical know-how.

P6315Effects of chronic heart failure unconventional therapies on endothelial function

Introduction

Endothelial Dysfunction (ED) of peripheral arteries in Chronic Heart Failure (CHF) subjects has been demonstrated.

Purpose

We assessed endothelial function in subjects undergoing unconventional treatments for CHF, namely Heart Transplantation (HTX), continuous-flow Left Ventricular Assist Device implantation (LVAD), and repeated levosimendan infusions (r-LEVO).

Methods

Twenty HTX recipients (median time from HTX 21 months), 20 patients supported with LVAD (median time from implant 39 months), and 20 patients receiving monthly Levosimendan infusions (median time on treatment 28 months) were enrolled and compared to a group of 20 healthy subjects. ED was evaluated with ultrasound assessment of the diameter before and after ischemic stress at the brachial artery level. The difference between the two diameters normalized for the baseline value (Flow Mediated Dilation – FMD) has been used for the analysis. All the patients were stable at the time of FMD assessment, with those on r-LEVO being evaluated prior to infusion.

Results

FMD was significantly lower in HTX and LVAD groups with respect to controls (9.8±7.4, 9.3±5.7, and 15.6±6.4% respectively, p=0.01), but not in r-LEVO group (12.5±6.9%).

When patients were analyzed according to time from the operation or on treatment, (< versus > of the median value), no differences were seen in HTX and r-LEVO group, while in LVAD group FMD was borderline significantly higher in patients with longer follow-up (8.4±6.4% versus 10.2±5.2%, p=0.05).

Conclusions

Based on this preliminary data we can inference the following: 1- FMD is abnormal in HTX recipients, despite their good functional status, probably due to factors unrelated to CHF (e.g. hypertension, renal insufficiency, denervation, and drug effects); 2- LVAD patients also show ED, with possible better adaptation in very long-term survivors; 3- Near-normal FMD values in CHF patients who remain stable with r-LEVO suggest that pulsed treatment may obtain favorable effects at peripheral level, persisting after clearance of the drug and its metabolites.

Acknowledgement/Funding

None

2422Outcome of histologically-proven fulminant versus acute non-fulminant myocarditis with left ventricular systolic dysfunction. Evidence from the International Registry on Acute Myocarditis

Background

Fulminant myocarditis (FM) is a form of acute myocarditis characterized by severe left ventricular (LV) dysfunction requiring inotropes and/or mechanical circulatory support. Based on a retrospective single-center study published in 2000, patients with FM were considered to have better outcomes than those affected by acute non-fulminant myocarditis (NFM) presenting with LV systolic dysfunction (LVSD). Recently, this tenet was challenged, though substantial disagreement still exists.

Purpose

Aim of the present study is to provide additional evidence on the outcome of FM and to ascertain if patient stratification based on the main histologic subtypes can provide additional prognostic information.

Methods

Two hundred and twenty patients (median age 42 years, 46.3% female) with histologically proven acute myocarditis (onset of symptoms <30 days) presenting with LVSD were included in a retrospective, international registry comprising 16 tertiary hospitals in the United States, Europe, and Japan. The primary endpoint was the occurrence of cardiac death or heart transplant (HTx) within 60 days from admission and at long-term follow-up.

Results

Patients with FM (N=165) had significantly higher rates of cardiac death and HTx compared with those with NFM (N=55), both at 60 days (28.0% vs. 1.8%, p=0.0001) and at 7-year follow up (47.7% vs. 10.4%, p<0.0001; Figure). At Cox-multivariate analysis, the histologic subtype emerged as a further variable affecting outcome in FM patients, with giant cell myocarditis having a significantly worse prognosis compared with eosinophilic and lymphocytic myocarditis both at 60 days (62.5% vs. 26.3% vs. 21.0%) and at 3 years (81.3% vs. 39.9% vs. 37.3%, overall p<0.0001). In a sub-analysis including only adults with lymphocytic myocarditis, the main endpoints occurred more frequently in FM compared with NFM both at 60 days (19.5% vs. 0%, p=0.005) and up to 7 years (41.4% vs. 3.1%, p=0.0004).

Outcome of FM vs NFM

Conclusions

The results of this international registry confirm that patients with FM have higher rates of cardiac death and HTx both in the short and long-term compared with patients with NFM. Furthermore, we provide evidence that the histologic subtype of FM carries independent prognostic value, highlighting the need for timely endomyocardial biopsy in this condition.

Acknowledgement/Funding

None

P1660Therapy treatment, adherence and persistence in chronic heart failure patients: a populaion study, from 2005 to TO 2012 in Lombardy

Background

The treatment with angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor II blocker (ARB), beta blocker (BB), and aldosterone antagonist (AA), adherence and persistence to therapies, improve clinical status, prevent hospital admission and reduce mortality in patients with chronic heart failure (CHF).

Purpose

To analyze adherence and persistence to indicated therapies.

Methods

We analyzed, from the Lombardy healthcare system administrative database, the discharge forms of patients with HF-related diagnosis, recorded from 2000 to 2012. We evaluated the adherence using the proportion of days covered (PDC≥80%) method, adjusted for hospitalisations. Medication persistence was identified as a duration of time from initiation to discontinuation of therapy. Patient was considered non-persistent if does non-refill medication within a period of 30 days.

Results

We considered 100,784 HF patients, mean (SD) age 74.54 (11.73) years: of them 636 patients were lost from database, 71,166 were alive (71.06%) and 28,982 did not survive (28.94%) at the end of the study. The mean (SD) number of hospitalizations were 2.16 (1.48) per patient (217,422 in total) and drug prescriptions were 12.28 (7.56) per patient (1,237.784 in total). 77% of patients were treated with ACEI/ARB, 64% with BB and 37% with AA. In the table, we reported the results on adherence and persistence measures.

Prescribed Therapy Total pts, No (%) Days covered, mean (SD) Adherent pts, No (%) Persistent pts, No (%) PDC (%), mean (SD) ACEI/ARB+BB+AA 20,831 (21%) 148 (102) 2,649 (13%) 2,068 (10%) 41 (28) ACEI/ARB+BB 33,617 (33%) 237 (110) 14,528 (43%) 11,165 (33%) 65 (30) ACEI/ARB+AA 9,327 (9%) 157 (107) 1,469 (16%) 1,149 (12%) 43 (29) AA+BB 3,070 (3%) 166 (105) 518 (17%) 386 (13%) 45 (29) ACEI/ARB 23,398 (23%) 270 (103) 13,487 (58%) 10,882 (47%) 74 (28) BB 6,806 (7%) 259 (105) 3,567 (52%) 2,782 (41%) 71 (29) AA 3,735 (4%) 204 (113) 1,133 (30%) 922 (25%) 56 (31) pts, patients.

Conclusions

Findings of this database analysis suggests that while treatment with ACEI/ARB and BB is in line of European Guideline, treatment with AA is very low. Despite recommendations, treatment with a combination of two or three HF drug classes decreases further. Adherence and persistence were moderate across all HF therapies of interest, although around 70% for ACEIs, BBs alone and in combination. This analysis evidences the need to understand the reasons for a limited use of the therapeutic guidelines and the need for much more work to improve adherence and persistence to therapy in CHF patients.

Poly[(μ4-phenylphosphonato)zinc(II)]

The title two-dimensional coordination polymer, [Zn(C6H5PO3)] n , was synthesized serendipitously by reacting a tetraphosphonate cavitand Tiiii[C3H7, CH3, C6H5] and Zn(CH3COO)2·2H2O in a DMF/H2O mixture. The basic conditions of the reaction cleaved the phosphonate bridges at the upper rim of the cavitand, making them available for reaction with the zinc ions. The coordination polymer can be described as an inorganic layer in which zinc coordinates the oxygen atoms of the phosphonate groups in a distorted tetrahedral environment, while the phenyl groups, which are statistically disordered over two orientations, point up and down with respect to the layer. The layers interact through van der Waals interactions. The crystal studied was refined as a two-component twin.

Long-term outcomes and five-year recurrence-free survival curves after native-tissue prolapse repair

OBJECTIVE

To evaluate the long-term objective and subjective outcomes to build recurrence-free survival curves after mesh-free uterosacral ligament suspension and to evaluate the long-term impact of prognostic factors on outcome measures.

METHODS

A retrospective study analyzed 5-year follow-up after repair of primary prolapse through high uterosacral ligament suspension. Bulging symptoms and post-operative prolapse stage II or above were considered subjective and objective recurrences, respectively. The cumulative proportion of relapse-free patients in time was analyzed by Kaplan-Meier curves.

RESULTS

A total of 353 women were analyzed. Five-year recurrence rates were 15.0% for objective recurrence, 13.0% for subjective recurrence, and 4.0% for the combined objective and subjective recurrences. Premenopausal status was shown to be a risk factor for anatomic (P=0.022), symptomatic (P=0.001), and combined (P=0.047) recurrence. Conversely, anterior repair was shown to be a protective factor for symptomatic (P=0.012) and combined (P=0.002) recurrence. Most of the recurrences occurred within 2 years after surgery.

CONCLUSION

Long-term outcomes after high uterosacral ligament suspension were satisfactory. Premenopausal status and lack of anterior repair represented risk factors for recurrence in the long term.

Selective IUGR in dichorionic twins: what can Doppler assessment and growth discordancy say about neonatal outcomes?

OBJECTIVE

The aim of the present study was to assess, in a population of dichorionic twin pregnancies with selective growth restriction, the effect of inter-twin differences by use of Doppler velocimetry and fetal growth discordancy on perinatal outcomes.

METHODS

This was a retrospective study including dichorionic twin pregnancies from January 2008 to December 2015 at the Department of Obstetrics and Gynecology of Fondazione MBBM. Only dichorionic twin pregnancies affected by selective intrauterine growth restriction (IUGR) delivering at ≥24 weeks were included in the study.

RESULTS

We found that twin pregnancies with inter-twin estimated fetal weight (EFW) discordance ≥15% were significantly associated with a higher risk of preterm delivery before 32 (P=0.004) and 34 weeks (P=0.04). Similarly, twin pregnancies with inter-twin abdominal circumference (AC) discordance ≥30° centiles were associated with a higher rate of neonatal intensive care unit (NICU) admission (P=0.02), neonatal resuscitation (P=0.02) and adverse neonatal composite outcome (P=0.04). Of interest, when comparing twin pregnancies according to Doppler study, growth restricted twins had a higher rate of composite neonatal outcome and in multivariate analysis, an abnormal Doppler was an independent risk factor for this outcome.

CONCLUSIONS

Our study associated growth discrepancy with specific pregnancy outcomes, according to defined cut-offs. In addition, we demonstrated that an abnormal umbilical artery Doppler is independently associated with a composite neonatal adverse outcome in growth restricted fetuses.

Efficacy of needle retractor device in single-incision slings for treatment of stress urinary incontinence

BACKGROUND

Single-incision slings demonstrated overall similar effectiveness and less pain and recovery time compared to standard tapes. Efficacy rates vary widely among different commercial kits and may be affected by device characteristics. The aim was to evaluate the impact needle removal device of single-incision sling on objective, subjective and functional outcomes.

METHODS

This was a retrospective study. Single-incision sling without needle removal device (Group A) were compared to same single-incision sling with needle removal device (Group B) in terms of complications, objective, subjective and functional outcomes.

RESULTS

A total of 191 patients were analyzed: 51 in group A and 140 in group B. Estimated blood loss, operative time and overall complications were not different. No bladder perforation or other intraoperative complications were observed. At 12-month follow-up visit, objective cure rate was similar irrespective of the presence of the needle retractor lever (Group A: 84.3%, Group B: 87.1%; P=0.61). Subjective outcomes evaluated as International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) score, ICIQ-SF score improvement and Patient Global Impression of Improvement score were similar between groups. De-novo onset of overactive bladder syndrome resulted more frequent in Group A (Group A: 19.6%, Group: B 7.9%; P=0.02) while voiding symptoms were reported without differences between groups.

CONCLUSIONS

The current study showed that the presence of a needle retractor device to avoid unintentional tip displacement for single-incision sling had no impact on objective and subjective postoperative continence. However, a reduced rate of de-novo overactive bladder syndrome was observed after implantation of single-incision sling with needle retractor.

Transvaginal native-tissue repair of vaginal vault prolapse

BACKGROUND

Posthysterectomy vaginal vault prolapse repair is a challenge for pelvic floor surgeons. Native-tissue repair procedures imply lower costs and reduced morbidity. Our study aims to evaluate operative data, complications, objective, subjective and functional outcomes of transvaginal native-tissue repair for posthysterectomy vaginal vault prolapse. We also investigated differences among available techniques.

METHODS

Retrospective study including patients with symptomatic vaginal vault prolapse (≥stage 2), previously treated with transvaginal vault suspension through native-tissue repair. Objective recurrence was defined as the descent of at least one compartment ≥II stage according to Pelvic Organ Prolapse Quantification (POP-Q) system or need of reoperation. Subjective recurrence was defined as the presence of bulging symptoms. Patients satisfaction was evaluated with PGI-I Score.

RESULTS

The study included 111 patients. Apical suspension was achieved either by uterosacral ligament suspension (16), levator myorrhaphy (17), iliococcygeus fascia fixation (65) or sacrospinous ligament fixation (13). No intraoperative complications were observed. Perioperative/postoperative complications occurred in 8 patients (7.2%). Mean follow-up was 24.5±12.1 months. Objective recurrence was observed in 28 patients (25.2%). Reintervention was required by 3 patients (2.7%). Subjective recurrence was referred by 6 patients (5.4%). Mean satisfaction evaluated with PGI-I Score was 1.2±0.6. No differences in terms of operative data, overall complications, objective, subjective cure rate and perceived satisfaction were found among different techniques.

CONCLUSIONS

Transvaginal repair with native-tissue procedures is safe and effective in correcting posthysterectomy vaginal vault prolapse and represents a valid alternative to prosthetic procedures for vaginal vault prolapse treatment.

Transvaginal native-tissue repair of enterocele

INTRODUCTION AND HYPOTHESIS

Enterocele repair represents a challenge for pelvic surgeons. Surgical management implies enterocele sac removal. Subsequently, hernial port closure and adequate suspension may be achieved with Shull uterosacral ligament suspension (ULS).

METHODS

A 55-year-old woman with symptomatic stage 3 enterocele was admitted for transvaginal uterosacral ligaments suspension according to the described technique.

RESULTS

Surgical procedure was successfully achieved without complications. Final examination revealed excellent pelvic supports and preservation of vaginal length. This step-by-step video tutorial may represent an important tool to improve surgical know-how.

CONCLUSIONS

Transvaginal uterosacral ligaments suspension provides a safe and effective technique for enterocele repair without the use of prosthetic materials. Identifying uterosacral ligaments, proper suture placement, and reapproximation of pubocervical and rectovaginal fascias with closure of the hernial port are the key points to achieve surgical success.