The post-cesarean section symptomatic bladder flap hematoma: A modern reappraisal

The bladder-flap hematoma (BFH) is an unusual complication of the cesarean section (CS) performed by Misgaw Ladach method or Stark CS (performed without peritoneal closure) and it is an usual event after the visceral peritoneal closure performed during the traditional method. A BFH is generally thought of as a blood collection located in a space placed between the bladder and lower uterine segment (LUS), called vescico-uterine space. If, during a Stark CS, pathological fluid collections arise in this space by uterine suture bleeding, these decant into the large peritoneal cavity causing a hemoperitoneum. This last complication can be easily and accurately detectable by ultrasonography, which can be utilised by non-invasive monitoring as a guide for the clinical follow-up. In the authors' experience, the CS by Stark method is associated with a lower febrile and infective morbidity and it is possible also to perform a successful conservative laparoscopy for the BFH management. Laparoscopical treatment of BFH offers to patients the potential clinical benefits of the minimally invasive endoscopical treatments, but it should be reserved for surgeons trained in extensive laparoscopic procedures.

Pregnancy outcome and recurrence after conservative laparoscopic surgery for borderline ovarian tumors

BACKGROUND

The aim of this study was to evaluate the safety and efficacy of conservative laparoscopic management of borderline ovarian tumors, and to assess pregnancy outcome and recurrence after fertility-sparing surgery.

METHODS

From 1995 to 2005, 43 patients of reproductive age presented with adnexal mass, which was subsequently diagnosed as a borderline tumor of the ovary. These patients were treated by conservative laparoscopic surgery, with intraoperative staging of the disease. Patients were evaluated every 3 months for the first 2 years, and then every 6 months thereafter, to determine the best modality for following patients after conservative surgery.

RESULTS

Three (7%) patients developed a recurrence after conservative treatment. Among the 43 patients who had conservative surgery, 21 (49%) became pregnant during the follow-up period; 12 (57%) conceived spontaneously, and the remaining 9 (43%) patients underwent caesarean section.

CONCLUSIONS

In our opinion, conservative laparoscopic treatment of borderline ovarian tumors is an appropriate and reasonable therapeutic option for young women with low-stage disease who wish to preserve their childbearing potential, because the fertility results are encouraging. Recurrence can be noted after this type of treatment, but the cases of recurrent disease can be detected with close follow-up and treated accordingly. Careful selection of candidates for this kind of treatment is, of course, necessary, and close follow-up is required.

[First abdominal access in gynecological laparoscopy: which method to utilize?]

The choice of the technique to enter the peritoneal cavity, during a laparoscopy, depends on a lot of variables which hinder a standardized method and, actually, it appears impossible to show, with certainty, the best method to choose for the first abdominal access in gynecological laparoscopy. The preference for one or another technique depends on the operator experience, school and speciality of the surgeon, laparoscopical upgrading and the work environment; many surgical techniques are not yet used due the limits and fears of some surgeons to change the preference in first access approaching and for the lack of operating versatility by a method or another one. A review of the scientific literature, underlines that the major problems during the first laparoscopical abdominal access are two, vascular and intestinal and their percentage is variable. In this paper we describe the large range of methods for open and closed laparoscopy and for direct access, that permit to perform a first abdominal laparoscopical access, and their major possible problems.

[Urinary incontinence in postmenopausal period: clinical and pharmacological treatments]

Urinary incontinence is a common clinical problem in female sex and occurs especially in postmenopausal women; this disease, that represents an economical problem for society, begins in young age, arises in middle age and increases in women more than 65 years old. Studies carried out on etiological factors involved in urinary incontinence show that estrogens enhance the trophism and vascularization of the muscular and fascial support of the pelvic floor, the growth of fibroblasts and the collagen metabolism in the superficial fascia in postmenopausal women. The postmenopausal estrogenic deficit could be related to many urogenital problems, but many researches performed on the effects of estrogens in urogenital postmenopausal homeostasis and of hormonal replacement therapy in postmenopausal incontinent women, did not show conclusive findings; for this reason, even if many authors attributed to menopause a role of major risk factor for incontinence, a direct correlation has never been confirmed. The treatment of postmenopausal female incontinence may be clinical and pharmacological, and includes a first step therapy (bladder training, biofeedback techniques, electrical pelvic floor stimulation) and a second step therapy (pharmacological therapy, bladder devices and surgical operations). In this review the clinical and pharmacological treatments, their efficacy and their application in incontinent postmenopausal women are described.

[Current surgical management in ovarian cancer recurrences]

Ovarian cancer is a tumor with a high trend of recurrence and this occurrence consistently increases the difficulty of the patient cure and reduces the efficacy of current treatments. The role of surgery in persistent or recurrent ovarian cancer is controversial and the type of surgery can be different according to the different stages and invasion of tumor; it can be a debulking surgery followed by chemotherapy (to eradicate the most part of ovarian cancer, leaving a minimal tumoral residue), an interval surgery (for advanced ovarian cancer stage in previously operated patients, followed by 2 or 3 inductive chemotherapy cycles and subsequently a cytoreductive redo surgery) and a cytoreductive secondary surgery, after optimal primary surgical treatment and minimal tumoral recurrence. In some cases it is possible either to perform a debulking surgery during a primary (after the conclusion of primary treatment) or a salvage or palliative surgery (to improve, after an acceptable time period, clinical symptoms in patients with progressive cancer or resistant to treatments). The aims of surgical therapy, to be performed in a patient with ovarian cancer relapse, are to reduce, as much as possible, the tumour size, to increase the quality of life and to increase the survival time; in this review different surgical techniques to be carried out in each case, selected for disease staging, for tumour cells kinetic and for surgical goals, are discussed.

[Induction of labour: which method to use?]

Induction of labour is a common obstetric instrument to employ when the potential risk to continue a pregnancy is higher than to terminate it. The methods of induction can be pharmacological or mechanical; the choice of the method mainly depends by the cervical ripening, as it is significantly able to influence, according to the type of induction, its final issue. The mechanical methods are: stripping and sweeping of the membranes, hand dilatation of cervix, intrauterine pressure catheters, Laminaria Japonicum, transcervical Foley catheter and amniotomy. To pharmacological methods include some agents such as the prostaglandins (PG), the most common approach to induce a labour, and used above all by vaginal way in patients with unripe cervix. They simulate the natural PG effects at the beginning of delivery and show a great efficiency. There are a lot of PG on the market, but except some of them, as Dinoprostone for PGE2 and Misoprostol for PGE1, no one of them shows the same safety in management of labour. Oxytocin, another inductive method, administered by diluted intravenous infusion, is utilized alone or mainly with other methods when the labour is started or with rupture of the membranes, because it begins or maintains the myometrial contraction.

[Depression, menopause and hormonal replacement therapy (HRT)]

The ovarian failure and the termination of reproductive female functions could influence the mental neurotransmission and the cognitive activity of menopausal women; female menopausal brain, one of the favorite estrogens target, could suffer of a negative homeostasis modification, affecting the daily behavior. So, neurotransmissive degeneration could expose aged women to some psychological disturbances, some of these frequently associated to hypoestrogenic hot flushes rise. Many studies showed the estrogen influence on female brain, and tried to explain how the hormonal replacement therapy (HRT), act on mood, life energy and cognitive activities. Although brain estrogenic activity seems to establish a useful role on neuromodulation and on the prevention of some psychopathologies, the conventional administration of HRT, improves the mood and menopausal female well-being, but it does not act on clinically depressed women.

[Stress urinary incontinence: an overview on actual surgical trends]

Stress urinary female incontinence (IUS) is an unpleasant symptom describing a loss of urine during physical exertion; genuine stress incontinence (GSI) is a socially unacceptable, involuntary loss of urine in absence of detrusor activity from the urethra associated with sudden cough or strain. The incidence of IUS is less than 10% in reproductive-age women but may approach 10-20% in postmenopausal women. The IUS pathophysiology is connected with two specific mechanisms: the urethral-bladder sliding out of anatomical area involves the normal system of endobladder/intraabdominal pressures, with a loss of urine; the second mechanism involves the damaged urethral sphincteric function, with a reduction of the urethral closure pressure and a urinary loss after minimal physical stimulation. The IUS medical therapy is troublesome and often inefficient, and the only approved effective measures are the surgical procedures, actually reserved for cases of unsuccessful medical therapy; surgical treatments can be classified according to the access as: vaginal, abdominal, associated and complex. They intend to reposition the urethral-bladder sliding in its normal intra-abdominal position, to allow equal transmission of increased intraabdominal pressure to the bladder and the proximal urethra. In the scientific literature there are more than one hundred surgical procedures for IUS correction, but the IUS surgical approach is anyway the actual gold standard therapy.

[Medical treatment in abnormal uterine bleeding: evaluation of a GnRH therapy versus danazol therapy in perimenopausal women]

BACKGROUND

Dysfunctional uterine bleedings are uterine hemorrhage, frequent in the climacteric period and are a usual gynecologic pathology in ambulatorial controls (10%).

METHODS

60 premenopausal women, have been enrolled, all affected by hyper-polymenorrhea or dysfunctional uterine bleeding; than they were subdivided them into 2 groups; Group I: 30 patients with GnRH analogues treatment (Decapeptyl da 3.75 mg/month, 6 months of therapy); Group II: 30 patients with Danazol treatment (danatrol, 200 mg/daily, 6 months of therapy). Clinical controls were performed by visit, a questionnaire compilation (Kuppermann index) and biochemical examinations, with this frequency: 0, 3, 6 and 9 months. Statistical evaluation was performed by Student "t" test.

RESULTS

In both groups, either amenorrohea and symptomatic improvement after 3 months of therapy were observed, without statistical differences; a statistical difference (p>0.01) was assessed in patients compliance, since were observed, without statistical differences a major frequency in collateral effects in II Group, with danazol therapy was observed. The results of this study show that, the limited occurrence of side effects in perimenopausal patients affected by dysfunctional uterine bleeding, treated with GnRH analogues, could affect the choice of pharmacological therapy in favor of these one.

[Clinical effects of hormone replacement therapy with estradiol valerate and cyproterone acetate in perimenopausal women]

BACKGROUND

In perimenopause many women complain of psychogenic and organic disorders often connected with initial and increasing levels of hypoestrogenism. In this study we evaluated the effects of hormone replacement therapy (HRT) in symptomatic women in perimenopause.

METHODS

We enrolled 100 healthy and symptomatic women who were randomly distributed to two groups for a 12-month study. Group A: 50 patients received HRT with estradiol valerate and cyproterone acetate (Pausene(R)); Group B: 50 patients were used as a control group (treated with Cacit Vitamin D30(R)). A number of clinical and instrumental tests were performed at 0, 6 and 12 months to evaluate any changes in vasomotor and urogenital symptoms, bone and serum homeostasis and possible sexual disorders. The statistical analysis was performed using the c2 test.

RESULTS

The group of women receiving HRT showed a significant reduction in vasomotor clinical symptoms (p<0.001) and sexual disorders (p<0.002); this was not reflected in the control group where libido decreased steadily with apparent slight improvements only at the end of the study. The urogenital disorders disappeared almost completely in Group A, whereas they diminished in Group B. HRT patients also showed a slight increase (p<0.001) in the initial value of BMD (bone mineral density), a reduction in the marker for bone turnover and an improved lipid profile (p<0.05). These changes were unfortunately not noted in Group B.

CONCLUSIONS

On the basis of these results we conclude that HRT appeared to have a beneficial effect on perimenopausal clinical symptoms over the 12-month period, leading to marked improvements in the psychophysical wellbeing of symptomatic women in perimenopause.

[An alternative to postmenopausal Hormone Replacement Therapy? Selective Estrogens Receptors Modulators (SERMs)]

Hormone Replacement Therapy (HRT) represents the first and probably sole therapeutically approach for prevention and treatment of medical postmenopausal disease. Nevertheless, the adverse effects and the risks HRT associated, suggested, to clinical and pharmaceutical research new pharmacological treatment options. Actually a group of compounds, SERMs (Selective Estrogen Receptor Modulators), allows a large interest. These pharmacological agents, due to their estrogen agonist/antagonist properties, are able to bind Estrogen Receptors in female target tissues (bone, brain, heart, etc) with different actions; so, by these properties, SERMs represent actually a possible alternative to HRT.

[Effect of pretreatment with metoclopramide on plasma prolactin response to methergoline]

The Authors examined 20 voluntary women without endocrine diseases. The women took 4 mg of metergoline orally and 30-60-90-120-180-240 minutes after the medicament was given the serum prolactin levels were tested. After 3 weeks, 14 among 20 subjects repeated the test assuming during the 3 days before 50 mg of metoclopramide orally once a day. The Authors found a remarkable decline of prolactin serum levels after metergoline administration in all subjects. After metoclopramide administration prolactin serum levels increased meaningly. Metergoline administration gave again considerable fall of prolactin serum levels in the 14 subjects. From the data the Authors affirm that metergoline inhibits prolactin secretion with an antiserotonine action

[Effect of diet with different protein content on rats during gestation: repercussion on pregnancy development and litter size. Preliminary note]

Pregnant rats, Wistar strain, were treated from day 11 of gestation with synthetic diets containing different amounts of protein. The Group of rats fed a severely deficient protein diet (4% of casein, 2% of lactalbumin) showed reduced hematocrit, hemoglobin, total protein and an expressive increase of gamma globulins compared with rats treated with normal or elevated protein levels. Weight gain during pregnancy was higher for rats which received a larger amount of protein; on the contrary those that were subjected to malnutrition had no weight gain and bore prematurely with high percent of foetal mortality.