The Impact of Extracorporeal Magnetic Stimulation as Addition to Mirabegron in Overactive Bladder Treatment in Women: A Single-Centre Randomized Sham-Controlled Study

(1) Background: The purpose of our prospective, single-blinded, randomized, sham-controlled study was to investigate the effect of the additional extracorporeal magnetic stimulation (ExMI) to pharmacological treatment in overactive bladder syndrome (OAB) in women. (2) Methods: We recruited 56 women with OAB, who were allocated into two study groups: the active group received mirabegron 50 mg daily and a total of 16 sessions of ExMI in 8 weeks, whereas the sham group received mirabegron 50 mg daily and sham stimulation following the same treatment protocol. Treatment success was evaluated after 4 and 8 weeks. (3) Results: Both groups experienced significant reduction in daytime urinary frequency, nocturia, and number of weekly incontinence episodes after 8 weeks. There were no statistically significant differences in end-point daytime urinary frequency and nocturia between groups. However, the overall average reduction rate in weekly number of incontinence episodes was 43.7% in treatment group and 24.2% in the control group. The number of urinary incontinence episodes in the treatment and control group was reduced for 3.8 ± 11.8 vs. 2.5 ± 4.3 episodes at week 4 and additional 3.3 ± 6 vs. 0.4 ± 3.2 episodes at week 8, respectively (p = 0.013). Moreover, IIQ-7 score showed a significantly greater score reduction and patients' evaluated improvement of symptoms was higher in the active group. (4) Conclusions: The addition of ExMI to mirabegron in OAB treatment further improves the weekly incontinence episode reduction rate and also leads to grater improvement in symptoms.

Measurement of extraction forces of non-absorbable suture and different anchoring systems used for pelvic organ prolapse surgery using soft-embalmed cadavers: A feasibility study

OBJECTIVE

Success of pelvic organ prolapse (POP) mesh procedures also depends on reliable anchoring systems (AS). Our primary aim was to assess the use of soft-embalmed cadavers in testing of different AS and our secondary aim was to compare extraction forces (EF) of different AS and non-absorbable suture (NAS).

STUDY DESIGN

IRB approval was obtained. NAS (Ti-cron®) and different AS were attached to force-measuring instrument (Dynamometer SS25LA) and anchored to anterior longitudinal (ALL) and pectineal ligament (PL) (Protack®, Uplift®, NAS), and sacrospinous ligament (SSL) (Surelift®, Elevate PC®, NAS) of Thiel soft-embalmed cadavers. EF were measured 2-4 times in each cadaver. Data were compared using non-parametric tests. Statistical significance was set at p < 0.05.

RESULTS

Three female cadavers (age 59, 77 and 87) were used. NAS EF were significantly higher than AS EF for ALL and SSL, but not PL. Thiel soft-embalmed cadavers proved to be useful in testing of different AS.

CONCLUSIONS

Use of soft-embalmed cadavers in testing of different AS is feasible. According to our results, the NAS provides most reliable intra-corporeal fixation. However, significant inter- and intra-subject variability indicates that results may also be dependent on the tissue properties and anchoring procedure. Further testing using soft-embalmed cadavers could help optimise mesh procedures and establish a threshold EF necessary for reliable fixation.

Long-term patient satisfaction and removal rate after essure sterilization: a follow-up study

Background

The objective of our study was to assess the rate and causes for Essure® micro-insert system removal and patients’ long term satisfaction rate with the procedure.

Methods

All patients who underwent Essure® hysteroscopic sterilization at our tertiary centre between years 2007 and 2018 were included in this follow-up study. A questionnaire was sent to all patients per standard mail. Patients who did not respond to questionnaires per mail, were called by phone. The satisfaction with the Essure® sterilization, as well as any additional procedures after the insertion or insertion-related complications were analysed.

Results

From the year 2007 to 2018, we performed 427 Essure® hysteroscopic sterilizations and of these, 329 patients responded to the questionnaire (response rate 77%). Ten patients (3%) had Essure® removal, two of them due to pain (0.6%). Patients were very satisfied with the procedure (9.5 on scale 0–10). Most patients (95.3%) would recommend the procedure to their friend.

Conclusions

Essure® hysteroscopic sterilization is a procedure with a very high satisfaction rate and a very low removal rate due to sterilization-related complications.

Trial registration Institutional review board of University medical centre Maribor approved the study, approval number UKC-MB-KME-73/19.

Comparison of Conservative Treatment of Cervical Intraepithelial Lesions with Imiquimod with Standard Excisional Technique Using LLETZ: A Randomized Controlled Trial

(1) Background: There are limited data on the success of conservative treatment of high-grade cervical squamous intraepithelial lesions (HSIL) with imiquimod directly compared to standard of treatment with LLETZ. (2) Methods: Patients aged 18-40 with histological HSIL (with high-grade cervical intraepithelial neoplasia, CIN2p16+ and CIN3), were randomly assigned to treatment with imiquimod or LLETZ. The primary outcome was defined as the absence of HSIL after either treatment modality. The secondary outcomes were the occurrence of side effects. (3) Results: 52 patients were allocated in each group and were similar regarding baseline characteristics. In the imiquimod group, 82.7% of patients completed treatment, which was successful in 51.9%. All patients in the LLETZ group completed treatment, which was successful in 92.3% (p < 0.001). In the subgroup of CIN2p16+ patients, treatment with imiquimod was not inferior to LLETZ (73.9% vs. 84.2%, p = 0.477). During and after treatment, no cases of progression to cancer were observed. Side effects and severe side effects (local and systemic) were more prevalent in the imiquimod than in the LLETZ group (88.5% vs. 44.2% (p-value < 0.001) and 51.9% vs. 13.5% (p-value < 0.001), respectively). (4) Conclusion: Generally, in patients with HSIL, LLETZ remains the gold standard of treatment. However, in a subgroup analysis of patients with CIN2p16+, the success rate was comparable between the two treatment modalities. Due to the prevalence of side effects, the treatment compliance with imiquimod use may, however, present a clinically important issue.

Lower urinary tract symptoms in adolescent girls: a questionnaire-based study

OBJECTIVE

To determine the prevalence of lower urinary tract symptoms (LUTS) in female adolescent population.

STUDY DESIGN

We performed a questionnaire-based study in nine randomly selected high schools in our country. Our primary aim was to evaluate the prevalence of certain LUTS in adolescent girls: frequency, urgency, nocturia, feeling of incomplete bladder emptying, dysuria, and urinary incontinence. The secondary aim was to investigate the effect of some possible risk factors on LUTS prevalence. Statistical analysis was performed using SPSS Statistics Programme. Descriptive statistics were calculated. Non-parametric test was used for comparison of numerical and Pearson's Chi-square test for categorical data. Logistic regression was performed to identify the independent prognosticators for LUTS presence. Statistical significance was set at p < 0.05.

RESULTS

We included 2745 adolescent girls. Their average age was 16.8 ± 1.2 years and 17.8 % of them regularly experienced at least one LUTS. The frequency of occasional LUTS was even higher. The most common symptom was urinary incontinence (5.9 %), followed by frequency (5.1 %), feeling of incomplete bladder emptying (4.8 %), urgency (3.1 %), and nocturia (2.6 %). Risk factors for LUTS presence were girls' school success, frequent pelvic pain, previous cystitis, history of night enuresis in childhood, and sexual intercourses in the last three months.

CONCLUSIONS

According to our results, the prevalence of LUTS amongst female adolescents is high and can be associated with certain risk factors. In our opinion, further research should be directed into determining the effect of LUTS on adolescents' quality of life.

Diagnosis and management of rudimentary horn pregnancy rupture, misinterpreted as bicornuate uterus in the 14th week of pregnancy

We present a 26-year-old primigravida with rudimentary horn pregnancy rupture at 14 weeks of pregnancy. Uterine anomaly was first diagnosed at the time of nuchal translucency scan and was presumed to be a bicornuate uterus with normal intrauterine pregnancy in the right horn. One day later, she was admitted to our department with abdominal pain, shortly leading to massive hemoperitoneum and hypovolemic shock. Uterine rupture was confirmed ultrasonically, followed by immediate laparotomy. Ruptured rudimentary horn with already expulsed pregnancy was encountered during surgery. Despite significant advances in ultrasonography, diagnosis of prerupture stage remains controversial. However, high mortality of the condition should ensure low threshold for surgical exploration.

A Novel in situ Approach to Studying Detrusor Smooth Muscle Cells in Mice

The aim of our study was to develop a novel approach to investigating mouse detrusor smooth muscle cell (SMC) physiological activity, utilizing an acute tissue dissection technique and confocal calcium imaging. The bladder of a sacrificed adult female NMRI mouse was dissected. We used light and transmission electron microscopy to assess morphology of SMCs within the tissue. Calcium imaging in individual SMCs was performed using confocal microscopy during stimulation with increasing concentrations of carbamylcholine (CCh). SMCs were identified according to their morphology and calcium activity. We determined several parameters describing the SMC responses: delays to response, recruitment, relative activity, and contraction of the tissue. CCh stimulation revealed three different SMC phenotypes: spontaneously active SMCs with and without CCh-enhanced activity and SMCs with CCh-induced activity only. SMCs were recruited into an active state in response to CCh-stimulation within a narrow range (1-25 µM); causing activation of virtually all SMCs. Maximum calcium activity of SMCs was at about 25 µM, which coincided with a visible tissue contraction. Finally, we observed shorter time lags before response onsets with higher CCh concentrations. In conclusion, our novel in situ approach proved to be a robust and reproducible method to study detrusor SMC morphology and physiology.

Planned home birth in Slovenia-Are we ready?

Nowadays, women want a more intimate and familiar atmosphere during labour, which results in increased planned home birth rates. Every woman has the autonomy to decide where she will give birth; however, it is important that she is informed of risks and advantages beforehand. Home births can be distinguished between planned and unplanned home births. Planned home births can be conducted by professional birth attendants (licensed midwives) or birth assistants (doulas, etc). The rates of Slovenian women who decided to deliver at home are increasing year by year. Researches on home births still present discordant data about home birth safety. Their findings have shown that the main advantage of home birth is a spontaneous birth without medical interventions, especially in multiparous low-risk women. The main disadvantage, however, is a higher risk for neonatal death, in particular on occurrence of complications requiring a transfer to hospital and surgical intervention. Global guidelines emphasize careful selection of candidates suitable for home birth, well-informed pregnant women, education of birth attendants, and strict formation of transfer indications.

Medical management of first trimester missed miscarriage: the efficacy and complication rate

Our aim of the study was to evaluate the efficacy and complication rate of our inpatient medical management protocol for missed miscarriages. Three-hundred and ninety women hospitalised at our tertiary centre because of a missed miscarriage/anembryonic pregnancy in 2012-2013 were included in this retrospective study. The women underwent either a low (until 9 + 0 weeks of gestation) or high gestational age (from 9 + 1 until 15 + 6 weeks of gestation) management protocol. The success rate, curettage in the first 48 hours after the procedure, the complication rate and the factors that might influence these outcomes were evaluated. The overall success rate was 83.3%. The curettage in the first 48 hours after the procedure was performed in 7.4% of the patients and was more often in the high gestational age protocol. Complications that required another outpatient visit or hospitalisation occurred in 9% of the patients. Higher beta-hCG values 14 days after the procedure and the absence of evacuation of products of conception during hospitalisation were associated with a higher complication rate. IMPACT STATEMENT What is already known on this subject? As much as 10-20% of clinically recognised pregnancies end in a spontaneous abortion. A missed miscarriage and a blighted ovum represent a form of spontaneous abortion, which has long been treated with surgical evacuation. However, nowadays, medical management represents a well-established alternative with very high success rates and is considered as an equivalent and safe method that is also very well accepted by patients. What do the results of this study add? According to our results, a medical management of a first trimester missed miscarriage and a blighted ovum is very effective with an overall success rate of 83.3% and a very low percentage of curettage in the first 48 hours after the procedure (7.4%). Our study was also able to identify higher beta-hCG values 14 days after procedure and absence of evacuation of products of conception during hospitalisation as risk factors for complication occurrence. What are the implications of these findings for clinical practice and/or further research? Our study helps to identify patients who are at greater risk for developing complications after the medical management of a first trimester missed miscarriage.

A new affordable and easy-to-make pelvic model for training in complex urogynecological laparoscopic procedures

INTRODUCTION AND HYPOTHESIS

Our aim was to introduce a new affordable and easy-to-make pelvic model for training in complex urogynecological laparoscopic procedures.

METHODS

We modified a commercial female pelvic model consisting of sacrum, coccyx, two hip bones, the pubic symphysis, the fifth lumbar vertebra with intervertebral disc, and certain pelvic ligaments. We used sponge foam paper, felt fabric pieces, chenille stems, foam, plastic ties, fabric glue, and a thick, coated wire to create pelvic floor, uterus/vaginal cuff, bladder, both ureters, and anterior longitudinal and pectineal ligaments.

RESULTS

We created two different pelvic models: one with the uterus and one with the vaginal cuff. They enable training for laparoscopic pectopexy and hysteropexy/sacrocolpopexy. Trainees can practice proper mesh placement and suture the mesh to the corresponding anatomical structures. Because of the wire inserted in the uterus/vaginal cuff, it is possible to move the uterus/vaginal cuff in the anterior-posterior direction, thus mimicking the use of the manipulator during surgery. Besides the basic pelvis, all other parts of the model can be easily replaced when necessary.

CONCLUSIONS

We believe that our pelvic model could provide a valuable tool for training complex urogynecological laparoscopic procedures and help to reduce the long learning curve of these procedures.

Students as partners: Our experience of setting up and working in a student engagement friendly framework

BACKGROUND

Student engagement (SE) in the curriculum is a positive indicator in the development of students deeply involved in their learning. It also has several benefits for the schools' level of educational innovation and quality assurance.

METHOD

In order to identify the most important pearls from the last decade of educational developments within the field of SE at the Faculty of Medicine University of Maribor, we searched through our school's archives, publications and research in the field of medical education.

RESULTS

Three areas were identified as the most important SE complements: (i) peer teaching, (ii) school governance, and (iii) extracurricular activities. The paper highlights how many student-driven initiatives move from informal frameworks toward a formal structure, elective courses, and, in the end, compulsory components of the curriculum.

DISCUSSION

As demonstrated by the three educational achievements at our school, fostering a high level of SE can lead to innovative curricular changes, benefit the whole school and enable students to deliver highly impactful extracurricular projects.

A case of previously undiagnosed acute intermittent porphyria in a 34-year-old primigravida with gestational diabetes mellitus

Porphyrias are very rare and easily overlooked diseases in pregnancy. Among these eight known metabolic disorders, acute intermittent porphyria (AIP) is the most common and most severe type. An enzymatic alteration in the haem biosynthesis pathway causes liver overproduction of neurotoxic toxic metabolites, which cause attacks of acute neurovisceral symptoms, severe abdominal pain and/or skin lesions. Women with AIP can sometimes develop their first acute attack during pregnancy, and because the symptoms are unspecific, the diagnosis is difficult to obtain and often missed. However, prompt diagnosis of AIP during pregnancy is crucial as treatment can significantly improve the pregnancy outcome. The backbone of the therapy is food rich with carbohydrates, complemented by 20% glucose infusion and adequate pain control. We present a case of previously undiagnosed AIP in a 34-year primigravida, whose treatment was especially challenging due to co-existing gestational diabetes mellitus and problems with the central venous catheter.

Anterior compartment descent: A new measure in the assessment of urethral hypermobility in women with urinary incontinence

OBJECTIVES

To introduce a new, simple, non-invasive test to quantify urethral hypermobility.

METHODS

We reviewed data of women with urinary incontinence who were examined at the Department for General Gynaecology and Urogynaecology, Clinic for Gynaecology and Perinatology, Maribor, Slovenia, between October 2010 and March 2014. Patients' age, diagnosis, results of the Q-tip test and Pelvic Organ Prolapse Quantification measurements were collected. In addition, a new parameter was defined as anterior compartment descent, a midline distance between the external urethral meatus and maximum descent of the anterior vaginal wall when performed the Valsalva maneuver. Statistical analysis was performed with spss software using the Mann-Whitney test, correlation, regression and receiver operating characteristic curve analysis. The analysis was also carried out separately for patients with anterior compartment prolapse stage 0 or I.

RESULTS

A total of 472 women were included, 323 of them with anterior compartment prolapse stage 0 or I. Women with urethral hypermobility had significantly higher anterior compartment descent values than patients without urethral hypermobility (3.7 cm vs 2.6 cm, P < 0.001). A moderate correlation was found between anterior compartment descent and the Q-tip test (Spearman's rho = 0.55, P < 0.001). Age and anterior compartment descent were identified as independent variables for the presence of urethral hypermobility. When the cut-off value is set at 3.5 cm, anterior compartment descent represents a test for urethral hypermobility assessment with sensitivity of 65.2%, specificity of 88.6%, positive predictive value of 97.0% and negative predictive value of 30.7%. Anterior compartment descent values were also significantly higher in patients with anterior compartment prolapse stage 0 or I (3.4 ± 0.7 cm vs 2.6 ± 0.7 cm, P < 0.001).

CONCLUSIONS

The anterior compartment descent could be a valuable tool for the assessment of urethral hypermobility. Further effort should be directed into the standardization of the technique, determination of the normal range of anterior compartment descent, and its intra- and interobserver reliability.