Comparison of Vaginal Hysterectomy Techniques and Interventions for Benign Indications: A Systematic Review

OBJECTIVE: To create evidence-based clinical practice guidelines based on a systematic review of published literature regarding the risks and benefits of available preoperative, intraoperative, and postoperative technical steps and interventions at the time of vaginal hysterectomy for benign indications. DATA SOURCES: We systematically searched the literature to identify studies that compared technical steps or interventions during the preoperative, intraoperative, and postoperative periods surrounding vaginal hysterectomy. We searched MEDLINE, Cochrane Central Register of Controlled Trials, Health Technology Assessments, and ClinicalTrials.gov from their inception until April 10, 2016, using the MeSH term "Hysterectomy, Vaginal" and associated text words. We included comparative studies, single-group studies, and systematic reviews published in English. METHODS OF STUDY SELECTION: We double-screened 4,250 abstracts, identifying 60 eligible studies. Discrepancies were adjudicated by a third reviewer. We followed standard systematic review methodology and the Grades for Recommendation, Assessment, Development and Evaluation approach to evaluate the evidence and generate guideline recommendations. TABULATION, INTEGRATION, AND RESULTS: Because of limited literature, only 16 perioperative risks, technical steps, and interventions were identified: obesity, large uteri, prior surgery, gonadotropin-releasing hormone agonists, vaginal antisepsis, bilateral salpingo-oophorectomy, morcellation, apical closure, uterine sealers, hemostatic injectants, hot cone, retractor, cystoscopy, vaginal packing, bladder management, and accustimulation. We organized and reported these as four domains: patient selection, preoperative, intraoperative, and postoperative. We did not identify any patient characteristics precluding a vaginal approach; chlorhexidine or povidone is appropriate for vaginal antisepsis; vasopressin decreases blood loss by 130 cc; tissue-sealing devices decrease blood loss by 44 cc and operative time by 15 minutes with uncertain complication implications; vertical cuff closure results in 1-cm increased vaginal length; either peritoneum or epithelium can be used for colpotomy closure; and routine vaginal packing is not advised. CONCLUSION: Minimal data exist to guide surgeons with respect to planning and performing a vaginal hysterectomy. This study identifies available information and future areas for investigation

Pyometra After Thermal Endometrial Ablation

BACKGROUND:Pyometra is a rare but serious complication after thermal endometrial ablation. CASE:A 48-year-old woman with type 2 diabetes and a prosthetic mitral valve underwent a thermal endometrial ablation for abnormal uterine bleeding. She subsequently developed pyometra that induced sepsis and cervical necrosis necessitating hysterectomy. CONCLUSION:The development of a pyometra after endometrial ablation is likely multifactorial

Characteristics associated with subjective and objective measures of treatment success in women undergoing percutaneous tibial nerve stimulation vs sham for accidental bowel leakage.

INTRODUCTION AND HYPOTHESIS: In randomized trials both percutaneous tibial nerve stimulation (PTNS) and sham result in clinically significant improvements in accidental bowel leakage (ABL). We aimed to identify subgroups who may preferentially benefit from PTNS in women enrolled in a multicenter randomized trial. METHODS: This planned secondary analysis explored factors associated with success for PTNS vs sham using various definitions: treatment responder using three cutoff points for St. Marks score (≥3-, ≥4-, and ≥5-point reduction); Patient Global Impression of Improvement (PGI-I) of ≥ much better; and ≥50% reduction in fecal incontinence episodes (FIEs). Backward logistic regression models were generated using elements with significance of p<0.2 for each definition and interaction terms assessed differential effects of PTNS vs sham. RESULTS: Of 166 women randomized, 160 provided data for at least one success definition. Overall, success rates were 65% (102 out of 158), 57% (90 out of 158), and 46% (73 out of 158) for ≥3-, ≥4-, and ≥5-point St Marks reduction respectively; 43% (68 out of 157) for PGI-I; and 48% (70 out of 145) for ≥50% FIEs. Of those providing data for all definitions of success, 77% (109 out of 142) met one success criterion, 43% (61 out of 142) two, and 29% (41 out of 142) all three success criteria. No reliable or consistent factors were associated with improved outcomes with PTNS over sham regardless of definition. CONCLUSIONS: Despite exploring diverse success outcomes, no subgroups of women with ABL differentially responded to PTNS over sham. Success results varied widely across subjective and objective definitions. Further investigation of ABL treatment success definitions that consistently and accurately capture patient symptom burden and improvement are needed

Expression of Fbln5 in targeted mice.

<p>rtTA/<i>Fbln5</i>^f/f/SMA⁺⁺/Cre^-, rtTA/<i>Fbln5</i>^f/-/SMA/Cre+, or rtTA/<i>Fbln5</i>^f/f/SMA⁺⁺/Cre⁺ mice were treated with doxycycline as outlined in Materials and Methods. Thereafter, Fbln5 was quantified in the fibromuscular layer of the vaginal wall. <b>A.</b> Representative immunoblot and coomassie stained protein gel. <b>B.</b> Quantification of Fbln5 in vaginal urea extracts from <i>Fbln5</i>^f/f/SMA⁺⁺/Cre^- (n = 7, solid bar), <i>Fbln5</i>^f/f/SMA/Cre+ (n = 9, open bar), or <i>Fbln5</i>^f/-/SMA⁺⁺/Cre+ (n = 7, grey bar) normalized to protein content. Tissue extracts from wild type (<b>WT)</b> animals were used as a standard on each gel. *p < 0.05 compared with Cre- animals, ANOVA followed by Dunnett’s test using WT as control. <b>C.</b> Gelatin zymography of soluble protein extracts from <i>Fbln5</i>^f/f/SMA⁺⁺/Cre^-, <i>Fbln5</i>^f/-/SMA/Cre+, or <i>Fbln5</i>^f/f/SMA⁺⁺/Cre+. Purified proMMP (<b>+ctl</b>), protein from <b>Fbln5</b>^<b>-/</b>-, and <b>Mmp9</b>^<b>-/-</b> vaginal tissues were used as positive and negative controls. <b>D.</b> Hart’s stain of mid-vagina from <i>Fbln5</i>^f/f/SMA⁺⁺/Cre^- (<b>a. Cre-</b>) or <i>Fbln5</i>^f/f/SMA⁺⁺/Cre+ (<b>b. Cre+</b>) mice in basal conditions. Vaginal wall from age-matched Fbln5^-/- mouse shown in <b>c</b> (<b>Fbln5</b>^<b>-/-</b>). Arrows indicate elastic fibers. <b>epi</b>, vaginal epithelium; <b>lp</b>, lamina propria; <b>m</b>, muscularis. Bar = 40 μm. Note decreased magnification in <b>c</b> to illustrate paucity of fibers. <b>E.</b> Effect of Fbln5 cKO on spontaneous development of prolapse as a function of age. Perineal body length was measured at 10–12, 20, and 52 weeks of age in <i>Fbln5</i>^f/f/SMA⁺⁺/Cre^- (<b>Ctl</b>, n = 3) and <i>Fbln5</i>^f/f/SMA⁺⁺/Cre⁺ (<b>cKO</b>, n = 4) mice. Magnitude of bulge did not differ among genotypes (not shown). All animals were treated with doxycycline at 6 weeks of age.</p

Effect of pregnancy and vaginal delivery on <i>Fbln5</i> cKO mice.

<p><b>A.</b> Perineal body length was measured at time 0 (prior to pregnancy) and 12 h to 12 wks postpartum in <i>Fbln5</i>^f/f/SMA⁺⁺/Cre⁺ (<b>Preg cKO</b>, n = 7) and <i>Fbln5</i>^f/f/SMA⁺⁺/Cre^- mice (<b>Preg Ctl</b>, n = 6) during 3 pregnancies. <b>B.</b> Gelatin zymography of vaginal tissue extracts from <i>Fbln5</i>^f/f/SMA⁺⁺/Cre⁺ (<b>cKO</b>) and <i>Fbln5</i>^f/f/SMA⁺⁺/Cre^- (<b>Ctl</b>) mice 48 h postpartum. Vaginal tissue extracts from <i>Fblin5</i>^<i>-/-</i> (<b>Fib5 KO</b>) and <i>Mmp9</i>^<i>-/-</i> (<b>MMP9 KO</b>) mice were used as positive and negative controls. Lane 2 is blank. <b>C.</b> Immunoblot of Fbln5 in urea extracts of vaginal muscularis from wild type nonpregnant control <b>(WT NP</b>), <b>cKO</b>, and <b>Ctl</b> animals 48 h postpartum. Arrow denotes cleaved form. All animals were treated with doxycycline at 6 weeks of age, mated, and tissues collected after the first pregnancy.</p

Expression of Fbln5 and urea-extractable soluble tropoelastin (TE) in tissues as a function of development in rats.

<p>Quantitative amounts of Fbln5 (PANEL A) and extracted tropoelastin <b>(B)</b> normalized to coomassie-stained protein in aorta, lung, vagina, and skin. Data represent mean ± SEM of 3–4 tissues in each group. <b>RU</b>, Relative Units, <b>E20</b>, embryonic day 20, <b>P1</b>, postnatal day 1; <b>P5</b>, postnatal day 5 *p<0.05 ANOVA with Dunnett’s post hoc testing with E20 as the control</p

Pelvic Organ Support in Animals with Partial Loss of Fibulin-5 in the Vaginal Wall - Fig 1

<p><b>A. Targeting strategy.</b> The exons 1a through 4 are numbered. Wild-type, targeting vector, targeted alleles (<i>neo-loxP</i>, <i>loxP</i>, <i>and KO</i>) are shown. <i>FLPe</i>-mediated excision removes a <i>Neo</i>^<i>r</i> cassette to generate <i>Fbln5</i>^<i>loxP</i> allele and Cre-mediated excision removes exons 1a and 1b to generate a null allele. DTA: Diphtheria Toxin A; H: Hind III; Xb: Xba I; Xo: Xho; Kp: Kpn I; B: Bam HI; RI: Eco RI, Sc: Sac I. <b>B.</b> Confirmation of mutant alleles by genomic PCR. Amplification with primer set A distinguishes <i>Fbln5</i>^<i>loxP</i> allele from wild-type (+/+) allele. Primer set B only amplifies <i>Fbln5</i>^<i>KO</i> allele. * non-specific band.</p

Expression of Fbln5 and urea-extractable tropoelastin (TE) in tissues from adult and postnatal (P5-6) rats.

<p><b>A. Representative immunoblot of Fbln5 (upper blot) and tropoelastin (TE, lower) of adult and postnatal tissues</b>. Coomassie-stained gel of protein extracts shown as an index of protein loading. Tissues were homogenized directly in urea buffer and extracted overnight. <b>Ao</b>, aorta; <b>Lu</b>, lung; <b>Sk</b>, skin; <b>Va</b>, vagina; <b>Bl</b>, bladder; <b>Ut</b>, uterus; <b>Cx</b>, cervix. Quantification of Fbln5 (<b>B</b>) and tropoelastin (<b>C</b>) in urea extracts of adult tissues. Data represent mean ± SEM of 3–4 tissues in each group. *p<0.05; **p<0.05 compared with vagina as the control, ANOVA with Dunnett’s post hoc testing</p