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Background: This study was carried out to evaluate the urodynamic and ultrasonographic findings after tension-free vagina tape (TVT) procedure on stress urinary incontinent women., Methods: Ninety women suffering from genuine stress incontinence without pelvic relaxation syndrome underwent surgery. Urodynamic measurement, one-hour pad test and introital ultrasonographic evaluation were performed preoperatively and one year after surgery. Additional ultrasonographic surveillance of the urethra was performed immediately after the operation. The position and mobility of the bladder neck was compared pre- and post-operatively in relation to the inferior edge of the pubic symphysis., Result: Eight women were excluded for various reasons. Among the 82 women who completed the study, 76 (93%) were cured, four were improved and two failed. No major intra- or post-operative complications occurred. The position and mobility of the bladder neck showed no significant difference before and after surgery. A urethral knee angle was noted ultrasonographically on cured and improved patients during maximum straining. Nine patients with immediate postoperative voiding difficulty were found to have a pronounced mid-urethra angulation. The symptom and sign were resolved by time after urethra depressing. Urodynamic assessment of the urethral pressure profile and other parameter showed no significant difference before and after the surgery except that a positive pressure transmission in the middle portion of the urethra was noted among 70 (87.5%) of cured and improved subjects., Conclusion: Tension-free vagina tape operation is an effective surgical procedure for the treatment of female urinary stress incontinence. The procedure seems neither to change hypermobility nor to elevate the position of bladder neck. Urinary continence after surgery is most probably achieved by creating a dynamic mid-urethral knee angulation by which the urethra is closed i.e. kinked at stress. Lifting of the mid-urethra resulted in postoperative voiding difficulty. It is the important that the tape is placed tension free under the urethra. Introital ultrasonographic surveillance is a suitable technique to visualize the result of the operation.

Background: Compelling evidence indicates that paclitaxel kills cancer cells through the induction of apoptosis. Paclitaxel binds microtubules and causes kinetic suppression (stabilization) of microtubule dynamics. The consequent arrest of the cell cycle at mitotic phase has been considered to be the cause of paclitaxel-induced cytotoxicity. However, the biochemical events, downstream from paclitaxel's binding to microtubules, that lead to apoptosis are not well understood., Methods: The authors examined recent scientific literature about the mechanisms by which paclitaxel exerts cytotoxicity., Results: In addition to an arrest of the cell cycle at the mitotic phase in paclitaxel-treated cells, recent discoveries of activation of signaling molecules by paclitaxel and paclitaxel-induced transcriptional activation of various genes indicate that paclitaxel initiates apoptosis through multiple mechanisms. The checkpoint of mitotic spindle assembly, aberrant activation of cyclin-dependent kinases, and the c-Jun N-terminal kinase/stress-activated protein kinase (JNK/SAPK) are shown to be involved in paclitaxel-induced apoptosis. Consistent with observations that microtubules of different status (e.g., cytoskeletal microtubules vs. mitotic spindles) have different sensitivity to paclitaxel, the concentration of paclitaxel appears to be the major determinant of its apoptogenic mechanisms., Conclusions: Advances in research of the cell cycle and apoptosis have extended our understanding of the mechanisms of paclitaxel-induced cell death. Further elucidation of resistance and enhancement of paclitaxel-induced apoptosis should expedite the development of better paclitaxel-based regimens for cancer therapy., (Copyright 2000 American Cancer Society.)

The purpose of our study was to assess the influence of intra-uterine insemination (IUI) on the results of maternal serum Down syndrome screening. 43 women with IUI pregnancies and 4507 healthy women who conceived were studied. Ovulation in IUI pregnancies was induced by clomiphene and/or human menopausal gonadotrophin (hMG). Maternal serum levels of free beta-human chorionic gonadotrophin (hCG) and alpha-fetoprotein (AFP) were measured for Down syndrome screening. It was considered screen-positive when the risk of Down syndrome was 1 in 270 or greater in the second trimester. The value of maternal serum AFP was significantly lower in the IUI group (median=0.760 MoM) than in the control group (median=1.050 MoM). However, the value of free beta-hCG was not significantly different between the two groups. The positive rate of maternal serum Down syndrome in IUI pregnancies was similar to that of the control group. Our results indicate that IUI pregnancy may be associated with a lower level of AFP, although the mechanism for this difference remains unknown.

A 28-year-old Taiwanese woman who had received ovulation induction by clomiphene citrate (CC), follicular-stimulating hormone (FSH), and human chorionic gonadotrophin (hCG) treatment was diagnosed with a quadruplet pregnancy containing a hydatidiform mole and three fetuses at nine weeks' gestation. Expectant management failed to achieve any viable neonate due to massive antepartum haemorrhage and preterm delivery at 25 weeks' gestation. Five other cases previously reported involving quadruplets or triplets with a complete hydatidiform mole and two or three fetuses are reviewed. All cases ended as premature non-viable fetuses. Analysis of the clinical features, management, and outcome both in our patient and these reports suggest that more efficacious treatment planning, such as selective feticide, should be considered in order to improve the likelihood of attaining an advanced gestational age for a single fetus.

Prenatal Down syndrome screening with maternal serum alpha-fetoprotein (AFP) and human chorionic gonadotrophin (hCG) has become common. High levels of maternal serum hCG and low levels of AFP have been associated with an increased risk of fetal Down syndrome. In this paper, we report five pregnancies in patients undergoing long-term haemodialysis, all of whom had false-positive second-trimester Down syndrome screening results. All of our five patients had extremely high levels of maternal serum hCG, but normal AFP values for their gestational age, and all had serious complications during pregnancy., (Copyright 1999 John Wiley & Sons, Ltd.)

Background: This study was to determine the incidence of chromosome abnormalities in Taiwanese women undergoing prenatal chromosome analysis after a second trimester Down syndrome screening by using maternal age and serum dual-marker testing (alpha-fetoprotein and free-beta unit human chorionic gonadotropin)., Methods: A total of 10,098 Taiwanese women with pregnancy between 15 and 23 weeks' gestation received second-trimester Down syndrome risk evaluation by dual-marker and maternal age specific risk testing in a single medical center. The study took 22 months. Ninety-seven percent of this study population was less than 34 years old. Ninety-six percent of our cases were screened between 15-20 weeks of gestation. This population was included only after a routine ultrasonography scan for correction of gestational age and exclusion of major structural anomalies. By using an algorithm to detect Down's syndrome, with a risk of 1:270 as a cut-off value, 816 patients were screen-positive for Down syndrome (screen-positive rate 8.0%). Karyotypes were reviewed for 670 (82.1%) mothers who received prenatal karyotype analysis., Results: Twelve cases of Down syndrome were identified in the screen positive group with an estimated detection rate of 67% (false positive rate 8%). Three cases of Down syndrome were detected in late trimester among the screen-negative group. Seven other fetal chromosome abnormalities were also found among the screen-positive pregnancy. In addition, seven cases were screen-positive for trisomy 18; all of these patients received amniocentesis and only one case was confirmed., Conclusion: These findings indicate that this screening program combining alpha-fetoprotein (AFP), free beta human chorionic gonadotropin (free-hCG) and maternal age-specific would achieve a screening efficiency in Taiwanese populations as comparable to those obtained in Caucasian populations. Our results also suggest that approximately 3% of pregnancies with a positive dual marker and maternal age-specific screen results will have a chromosome abnormality despite having a normal routine ultrasound scan. Mothers with positive screening results should be made aware of the implications of a positive result.

Background: To estimate the value of CA-125 for the diagnosis of endometriosis in women with dysmenorrhea, as well as its significance in monitoring therapy and follow-up., Methods: One hundred and fifty-seven women undergoing laparoscopy for dysmenorrhea were prospectively studied for serum CA-125 concentration. For those with advanced endometriosis receiving danazol treatment after conservative surgery, CA-125 was also determined every month during medication and once every 12 months after treatment., Results: The sensitivity and specificity of serum CA-125 for the diagnosis of endometriosis were 61.1% and 87.5% respectively. Elevated CA-125 (>35 U/ml) was noted in 65/75 cases (86.70%) with advanced endometriosis, but in only 15/56 patients (26.8%) with minimal and mild endometriosis. Although there were significantly higher CA-125 levels in unmarried women, and a negative correlation (r=-0.1970, p=0.0284) between CA-125 and parity, there was no statistical difference in incidence of endometriosis by the status of marriage or parity. Ten women with advanced endometriosis were found with persistent endometriosis by laparoscopy during danazol treatment, even though they tested with normal CA-125 levels (<35 U/ml) at that time. Fifteen patients had elevated CA-125 levels before and one year after therapy, and were confirmed with recurrence of endometriosis by laparoscopy. Nine women with elevated CA-125 levels before treatment, were found without recurrence of endometriosis and had normal CA-125 levels one year after therapy., Conclusion: For endometriosis, CA-125 is a valuable adjuvant in the follow-up of recurrence in patients with advanced endometriosis and initially elevated CA-125 levels. It is not an effective screening tool for patients with dysmenorrhea, or for monitoring therapy. There was no significant correlation between the development of endometriosis and reproductive factors.

Background: The presence of Epstein-Barr virus (EBV) has not been documented in previous reports of lymphoepithelioma-like carcinoma (LELC) of the uterine cervix by either polymerase chain reaction or in situ hybridization, and the histogenesis of the tumor remains unknown. Additionally, a relationship between human papillomavirus (HPV) and cervical LELC also has not been reported., Methods: In this article, the authors describe the clinical and histopathologic findings for 15 patients with cervical carcinoma that had a histologic pattern of LELC. The polymerase chain reaction detected the presence of EBV and HPV DNA sequences in cervical LELC., Results: All 15 tumors showed a typical syncytial growth pattern of undifferentiated cells with prominent lymphocytic infiltration. The detection rate of the EBV gene sequence in tissue samples from patients with LELC was more frequent than that in control patients with squamous cell carcinoma of the cervix (11 of 15 patients, 73.3%, vs. 4 of 15 patients, 26.7%; P = 0.01). However, the detection rate of HPV-16 and HPV-18 DNA was significantly lower in patients with LELC tumors than in patients with cervical squamous cell carcinoma (3 of 15 patients, 20.0%, vs. 12 of 15 patients, 80.0%; P = 0.001). After a median follow-up of 3.9 years (range, 1.8-5.3 years), the 15 patients showed no evidence of disease or metastasis after radical hysterectomy or radiotherapy., Conclusions: The finding of EBV associations in cervical LELC supports the hypothesis that EBV may be involved in the pathogenesis of tumors that arise in the cervix. It is possible that cervical LELC may follow a different pathway in the pathogenesis of LELC in Asian women as compared with the more common forms of squamous cell carcinoma.

Background: To illustrate our experience and evolution in management of urinary bladder injury in laparoscopically assisted vaginal hysterectomy., Methods: Four hundred and twenty-two women underwent laparoscopically assisted vaginal hysterectomy with or without adnexectomy during the period March 1991-September 1994. The indicators for hysterectomy included adenomyosis, myoma uteri, intractable menorrhagia, endometriosis and severe pelvic adhesion. There are six cases of urinary bladder injuries resulting from our 422 cases of laparoscopically assisted vaginal hysterectomy., Results: The first two cases of urinary bladder injuries were repaired through exploratory laparotomy. The third case was repaired through laparoscopic intracorporeal suture. The technique of the automatic linear stapler through laparoscopy was used in case 4. The last two cases were repaired vaginally. All these patients recovered well after primary repair with an indwelling catheter for five to seven days regardless of the method of repair. The operation time for repairing the injuries is shortest in vaginal approach., Conclusions: The urinary bladder injury is one of the most common complications associated with laparoscopically assisted vaginal hysterectomy. Early detection and treatment enable complications to be overcome easily. As the laparoscopist acquires further experience in dealing with these complications, the urinary bladder injury may be managed laparoscopically. However, vaginal approach may be an easier way in dealing with this complication. Thus, most laparotomy or high technique laparoscopically repair could be avoided.

Background: The purposes of this study were to explore whether serum levels of insulin, insulin-like growth factor-I (IGF-I), insulin-like growth factor-binding protein-1 (IGFBP-1) and IGFBP-3 in both maternal and fetal compartments were affected by the stress of labor, and to investigate the relationship between the fetal birthweight and serum levels of insulin, IGF-I and IGFBPs., Methods: Blood samples were collected at the time of delivery from 147 parturients with vaginal delivery and 128 cases of Cesarean section (112 cases without labor and 16 cases with arrest of cervical dilatation during the active phase of labor). Serum concentrations of insulin, IGF-I, IGFBP-1 and IGFBP-3 were determined by radioimmunoassays (insulin, IGFBP-1 and IGFBP-3) and immunoradiometric assay (IGF-I)., Results: Maternal circulating IGFBP-1 levels in parturients with normal spontaneous delivery (NSD) and in subjects receiving Cesarean section (CS) due to arrest of cervical dilatation during active phase of labor were higher than those undergoing scheduled CS without labor. By contrast, insulin levels in both maternal and umbilical cord serum were higher in parturients with CS without labor than those with NSD. No difference in maternal serum IGFBP-3 levels was observed between NSD and CS at the time of delivery. As for all measurements (insulin, IGF-I, IGFBP-1 and IGFBP-3), serum levels in pregnant women (from both NSD and CS) were strikingly higher than those in the fetus. Serum levels of IGFBP-1 in umbilical cords from both groups of NSD (p < 0.02) and scheduled CS (p < 0.01) were inversely correlated with birthweight (BW). By contrast, serum concentration of insulin and IGF-I in umbilical cords from NSD (p < 0.005 and p < 0.01; respectively) and scheduled CS (p < 0.01 and p < 0.05; respectively) were positively related to BW., Conclusions: From the present results, we conclude that insulin appears to be a regulator for circulating IGFBP-1 during pregnancy. The fetal growth may not be well reflected by maternal serum IGFBP-1 levels, nor by IGFBP-3. By contrast, cord serum IGFBP-1 from CS group without labor may preeminently reflect fetal weight. In additional, serum concentration of insulin and IGF-I in umbilical cord may also be good indicators to reflect the result of neonatal birthweight.

Background: The role of flow cytometry in predicting prognosis for cervical carcinoma remains unclear., Methods: Flow cytometric analysis was performed on tissues, fixed in formaldehyde solution and embedded in paraffin, from 411 patients with Stage IB or II cervical carcinoma who had been treated with radical abdominal hysterectomy and bilateral pelvic lymphadenectomy., Results: DNA aneuploid-multiploid tumors were found in 37.5%, tetraploid in 4.6%, and diploid-peridiploid in 57.9%. Five-year recurrence-free survival rates of the three groups were 74.3%, 77.8%, and 76.4%, respectively (P > 0.05). DNA aneuploidy and DNA index (DI) of greater than 1.3 were highly correlated to parametria extension. In univariate analysis, pelvic lymph node metastases, stage, parametrial extension, depth of cervical stromal invasion, tumor size, and DI (1.3, 1.4, 1.5 as breakpoint) were significant prognostic factors. DNA ploidy, S-phase fraction, and S-G2M fraction were not significant. In multivariate analysis, DI of greater than 1.3, pelvic node metastases, clinical Stage II, and depth of stromal invasion greater than two-thirds of full cervical thickness were independent and significant variables. The prognostic index (PI), defined by the model, was able to categorize the patients into three distinct risk groups. The 5-year recurrence free survival rates of the low-, intermediate-, and high-risk groups were 89.5%, 73.0%, and 58.9%, respectively (P < 0.0001)., Conclusions: The prognostic value of the DI as a single variable is promising and warrants additional investigation to establish its appropriate use.

The incidence of primary cervical choriocarcinoma is extremely low, with only approximately 60 cases reported. We present a case of primary cervical choriocarcinoma, which was originally mis-diagnosed as a cervical pregnancy. After failure of conservative treatment with methotrexate, the patient underwent a hysterectomy, followed by chemotherapy with actinomycin-D. After twenty months of follow-up, the patient is in good condition and her serum beta-hCG levels are normal.