Total laparoscopic hysterectomy with laparoscopic uterosacral ligament suspension for the treatment of apical pelvic organ prolapse

Pelvic organ prolapse (POP) is a common problem requiring surgical correction in up to 19% of women. Abdominal sacrocolpopexy (SCP) is considered the gold standard treatment for apical POP and has been associated with lower rates of recurrent prolapse and dyspareunia compared with vaginal POP repair procedures. Total laparoscopic hysterectomy (TLH) with concurrent laparoscopic uterosacral ligament (USL) vaginal vault suspension provides a safe and effective alternative technique that has efficacy rates similar to abdominal SCP without the use of synthetic mesh. The uterosacral ligaments provide a strong supportive tissue for vaginal vault suspension that mimics the natural support system of the pelvic floor. The most challenging aspect of the TLH with laparoscopic USL suspension is laparoscopic suturing and intra/extracorporeal knot tying. Developing technologies such as robotics, automatic suturing devices, and new barbed suture materials are now providing simpler, alternative surgical techniques that will hopefully shorten operative times and increase adoption of this surgical procedure by gynecologists. With continued progress and refinement of this technique, the TLH with laparoscopic USL suspension may challenge the current standard of care for surgical treatment of POP.

Technical preferences of surgeons performing a sacrocolpopexy procedure

The purpose of this study is to report on the surgical preferences of international surgeons in the performance of the sacrocolpopexy procedure. Invitations to complete this Internet-based survey were sent to 2,854 International Urogynecological Association (IUGA) members from December 2010 through February 2011. Questions were related to various aspects of the surgeons' techniques and preferences in the performance of a sacrocolpopexy procedure by the abdominal, laparoscopic, and robotic routes. Descriptive statistics are reported. A total of 235 members from six continents completed the survey. Ninety percent of the respondents perform sacrocolpopexy procedures in their practices, including abdominal (n = 177), laparoscopic (n = 92), and robotic (n = 48) procedures. Participants reported reduced blood loss, shorter hospitalization, and longer operative time during laparoscopic and robotic procedures compared with open abdominal sacrocolpopexy, but no differences were reported in overall major complications. Overall, surgical preferences and techniques of international surgeons for sacrocolpopexy were similar among responders, regardless of the surgical route performed.

Laparoscopic repair of postcoital vaginal evisceration with intact pelvic organs

It is suggested that a laparoscopic approach may simplify repair of vaginal evisceration in patients with intact pelvic organs and limited vaginal exposure.

Vaginal evisceration following hysterectomy occurs predominately in postmenopausal patients. Laparotomic repair is most common. This case of a 17-year-old patient with postcoital vaginal evisceration represents the first reported laparoscopic repair in a premenopausal patient with intact pelvic organs.

Levator ani subtended volume: a novel parameter to evaluate levator ani muscle laxity in pelvic organ prolapse

OBJECTIVE

We describe a new parameter based on magnetic resonance 3-dimensional (3D) reconstructions proposed to evaluate levator ani muscle (LAM) laxity in women with pelvic organ prolapse (POP).

STUDY DESIGN

This is an institutional review board-approved, retrospective chart review of 35 women with POP, stages I-IV. The 3D Slicer software package was used to perform 2-dimensional and 3D measurements and the levator ani subtended volume (LASV) was described. Basically, the LASV represents the volume contained by LAM between 2 planes, which coincides with pubococcygeal line and H line. Correlations among measurements, ordinal POP stages, POP Quantification (POPQ) individual measurements, and validated questionnaires were performed.

RESULTS

The LASV differentiated major (III and IV) from minor (I and II) POPQ stages, which positively correlated to POP stages and POPQ individual measurements.

CONCLUSION

The LASV is a promising parameter to evaluate the LAM laxity.

Epidural anesthesia for cesarean delivery in a morbidly obese parturient with spinal meningioma

We report our experience with epidural anesthesia for cesarean section in a morbidly obese parturient with progressive paraplegia from a spinal meningioma. Epidural anesthesia may represent a safe anesthetic choice in such clinical situations.

Pacritinib (SB1518), a JAK2/FLT3 inhibitor for the treatment of acute myeloid leukemia

FMS-like tyrosine kinase 3 (FLT3) is the most commonly mutated gene found in acute myeloid leukemia (AML) patients and its activating mutations have been proven to be a negative prognostic marker for clinical outcome. Pacritinib (SB1518) is a tyrosine kinase inhibitor (TKI) with equipotent activity against FLT3 (IC₅₀=22 n) and Janus kinase 2 (JAK2, IC₅₀=23 n). Pacritinib inhibits FLT3 phosphorylation and downstream STAT, MAPK and PI3 K signaling in FLT3-internal-tandem duplication (ITD), FLT3-wt cells and primary AML blast cells. Oral administration of pacritinib in murine models of FLT3-ITD-driven AML led to significant inhibition of primary tumor growth and lung metastasis. Upregulation of JAK2 in FLT3-TKI-resistant AML cells was identified as a potential mechanism of resistance to selective FLT3 inhibition. This resistance could be overcome by the combined FLT3 and JAK2 activities of pacritinib in this cellular model. Our findings provide a rationale for the clinical evaluation of pacritinib in AML including patients resistant to FLT3-TKI therapy.

Laparoendoscopic single-site combined cholecystectomy and hysterectomy

Laparoendoscopic single-site (LESS) surgery has gained increased acceptance among surgeons in various specialties. The universal nature of port placement in the umbilicus during LESS surgery may enable concomitant procedures to be performed in these surgical specialties via this single incision. This case report presents a 37-year-old woman who underwent concomitant LESS cholecystectomy and hysterectomy to treat a symptomatic fibroid uterus and symptoms of cholelithiasis. The surgical procedure was performed in approximately 3 hours without any complications, and the patient was discharge to home 18 hours after the procedure. This case demonstrates that increasingly complex concomitant procedures can be performed using a LESS surgical approach.

Impact of HIV on liver fibrosis in men with hepatitis C infection and haemophilia

Hepatitis C virus (HCV) is the major cause of liver disease in haemophilia. Few data exist on the proportion with liver fibrosis in this group after long-term HCV and HIV co-infection. We conducted a cross-sectional multi-centre study to determine the impact of HIV on the prevalence and risk factors for fibrosis in haemophilic men with chronic hepatitis C. Biopsies were independently scored by Ishak, Metavir and Knodell systems. Variables were tested for associations with fibrosis using logistic regression and receiver operating curves (ROC). Of 220 biopsied HCV(+) men, 23.6% had Metavir ≥ F3 fibrosis, with higher mean Metavir fibrosis scores among HIV/HCV co-infected than HCV mono-infected, 1.6 vs. 1.3 (P = 0.044). Variables significantly associated with fibrosis included AST, ALT, APRI score (AST/ULN × 100/platelet × 10(9) /L), alpha-fetoprotein (all P < 0.0001), platelets (P = 0.0003) and ferritin (P = 0.0008). In multiple logistic regression of serum markers, alpha-fetoprotein, APRI and ALT were significantly associated with ≥ F3 fibrosis [AUROC = 0.77 (95% CI 0.69, 0.86)]. Alpha-fetoprotein, APRI and ferritin were significant in HIV(-) [AUROC = 0.82 (95% CI 0.72, 0.92)], and alpha-fetoprotein and platelets in HIV(+) [AUROC = 0.77 (95% CI 0.65, 0.88]. In a multivariable model of demographic and clinical variables, transformed (natural logarithm) of alpha-fetoprotein (P = 0.0003), age (P = 0.006) and HCV treatment (P = 0.027) were significantly associated with fibrosis. Nearly one-fourth of haemophilic men have Metavir ≥ 3 fibrosis. The odds for developing fibrosis are increased in those with elevated alpha-fetoprotein, increasing age and past HCV treatment.

Myofascial pain and pelvic floor dysfunction in patients with interstitial cystitis

INTRODUCTION AND HYPOTHESIS

The objectives of this study are to investigate myofascial pain in patients with interstitial cystitis (IC) and to correlate myofascial exam findings with validated questionnaires.

METHODS

A retrospective chart review was performed on 186 patients with a diagnosis of IC from April 2007 to December 2008. Demographics, history and physical examination, and validated pelvic floor dysfunction questionnaire scores were extracted. The data was evaluated with SPSS for Windows using Spearman's rho, Mann-Whitney, and Kruskal-Wallis statistical analyses.

RESULTS

Myofascial pain was demonstrated in 78.3% of IC patients with at least one myofascial trigger point, and 67.9% of patients had numerous areas of trigger points. Mild correlations were seen with trigger points and scores from the PUF, PFDI-20, and PFIQ-7 questionnaires.

CONCLUSIONS

Myofascial pain is prevalent among IC patients and positively correlated with pelvic floor dysfunction scores. These findings support evaluation of pelvic floor myofascial pain in IC patients and suggest a possible benefit from pelvic floor therapy.