Inguinovaginal sling procedure for female stress incontinence: introduction of a minimally invasive technique

PURPOSE

The inguinovaginal sling procedure is well accepted for surgical treatment of female stress urinary incontinence. Although the functional results are excellent, the operative trauma is higher compared to that of more recently used minimally invasive techniques.

MATERIALS AND METHODS

A modified inguinovaginal sling procedure was performed in 15 patients with urodynamically diagnosed intrinsic sphincter deficiency. With the assistance of a laparoscope, two fascial strips were dissected using two small suprapubic skin incisions. The pullthrough maneuver of the fascial slings was facilitated by opening the perivesical space with an inflatable balloon.

RESULTS

There were no intraoperative or postoperative complications. Mean follow-up of 7.7 months (range 4 to 11) was available in all patients. Stress incontinence was cured in 14 patients; only one woman reported using one pad per day. All patients were able to void spontaneously after a mean of 8 days (range 6 to 10).

CONCLUSIONS

The laparoscopically assisted inguinovaginal sling procedure is less invasive than the original technique. Good long-term results are known from the original inguinovaginal sling procedure, and there is no need for allografts or synthetic material.

Utero-ovarian interaction in the regulation of reproductive function

The physiological regulation of fertile reproductive cycle in mammals depends on interactions between hypothalamus-pituitary, ovarian and uterine stimuli. Over the past 20 years, much has been learned about the interrelation between the affluent and effluent lymph and vascular drainage in and around both ovarian and uterine tissues. An essential feature in the regulation of the fertile cycle is the functional status of the ovary, particularly the corpus luteum. During the time of implantation and the early pregnancy, an active corpus luteum is essential. As human chorionic gonadotrophin (HCG) is important in the maintenance of the corpus luteum, we investigated if it was produced by the cyclic endometrium. Immunohistochemical and in-situ hybridization reactions were performed but neither identified the presence of HCG during the proliferative phase. Positive staining and beta-human chorionic gonadotrophin (beta-HCG) mRNA were observed during the secretory phase in the glandular cells of the endometrium. The results were confirmed by Western blotting of secretory phase endometrium extracts and assessment of the functional secretory capacity of primary endometrial cultures. Polymerase chain reaction (PCR) investigations showed a positive result in the secretory phase. We postulate that, based on the very close morphological interrelation between the uterus and the ovary, the beta-HCG of the endometrium is the primary factor for the maintenance of the corpus luteum and early pregnancy.

[Cervical pregnancy: case report and review of the literature]

We report on a 22 years old patient with an intact cervical pregnancy located around the cervical isthmus in the 9th week of gestation. Because of the patients strong desire to maintain the reproductive capability, we performed a transvaginal amniotic sac puncture with local application of methotrexate. Later on we applied a systemic methotrexate therapy because of persistent high serum beta-hCG values. Five weeks later the patients developed heavy vaginal bleeding despite low beta-hCG levels so we are obliged to perform vaginal hysterectomy. Actual aspects about the etiology and diagnosis of this rare disease as well as about different opinions regarding conservative, fertility maintaining therapies are discussed.

[Risk assessment in ovarian hyperstimulation syndrome (OHS) using the machine learning system (Decision Master) in 155 in-vitro fertilisations and embryo-transfer (IVF/ET) cycles with a long stimulation protocol]

In 155 selected IVF/ET cycles stimulated with the long protocol 25 cycles with severe OHS are included which turned up later on (purposely overrepresented). An inductive machine learning program is described both in informatics and medical essentials. It is tested whether there exists an algorithm for ruling out the above-mentioned complication in the follicular phase of the same cycle already. By cross validation 89% of the OHS could be predicted and proven by practical rules using hormone and ultrasound values to avoid similar events in ongoing or further cycles.

[Pregnancy-induced trophoblast diseases--results from the years 1976-1992]

INTRODUCTION

Gestational trophoblastic diseases (GTD) represent a spectrum of different disorders, derived from the human placental trophoblast. GTDs are potentially fatal disorders and are of great importance for gynaecologists and pathologists.

STUDY DESIGN

In recent years 148 GTDs were treated at department of Obstetrics and Gynaecology of Leipzig University. We reexamined these cases with respect to diagnostic findings, diagnostic mistakes, the necessity of consecutive chemotherapy and outcome.

RESULTS

The 148 relevant cases included 103 complete hydatidiform moles, 13 invasive moles and 32 choriocarcinomas. 61.5% showed a spontaneous regression of HCG after molar evacuation. 57 cases developed persistent trophoblastic disease with consecutive mono-combined or polychemotherapy. An overall remission rate of 91.2% was achieved. The two patients, who died, showed a late stage of disease. 5.3% of the cases had a recurrence of disease. The most frequent side effect of chemotherapy was a moderate bone marrow depression in 58% of cases. 88.5% were diagnosed by suction curettage alone. Twelve patients had an operative intervention before chemotherapy, often due to diagnostic misinterpretation of the symptoms. Eight cases needed a secondary operation to attain complete remission.

CONCLUSIONS

Initiating chemotherapy is very important for therapy success. In cases of complete hydatidiform mole, it is difficult to make a prognostic statement with reference to biological behaviour of the disease by morphological methods alone. The difficulties are discussed. These cases emphasise the need for appropriate clinical monitoring and close cooperation between the gynaecologist, the pathologist and the clinician.

[Choriocarcinoma in extrauterine tubal pregnancy]

Hydatidiform moles and chorionic carcinomas associated with ectopic pregnancy are extremely rare. We report on three cases of non-metastatic GTD after tubar pregnancy of low and medium risk in the WHO prognostic score and FIGO-stage II in each case. Two of them required several courses of (poly-) chemotherapy to reach complete remission (CR). The follow-up was on average 36.6 months, without any metastases and recurrences. One woman was delivered of a healthy infant. All cases were surgically treated with extirpation of the affected adnexa. Additionally, in one case hysterectomy was necessary to reach CR. As reported in the literature, chorionic carcinomas associated with ectopic pregnancy are often very aggressive and show a metastasis rate of 75% at time of diagnosis. For this reason it is essential, to examine tubar pregnancy by histopathology carefully to define small and in situ changes. The cases presented stress the need for appropriate HCG and clinical monitoring.

Sesquiterpenlactone aus Arnica chamissonis IV.1,2 Ivalin und andere Sesquiterpenlactone aus den Blütenkörbchen der Subspecies genuina

The flowers of ARNICA CHAMISSONIS ssp. GENUINA afforded in addition to 8 helenanolides ivalin, the first eudesmanolide found in the genus ARNICA.