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Study Objective To compare the cost-effectiveness of ultrasound (US)-guided aspiration and ethanol sclerotherapy versus laparoscopic surgery for benign-appearing ovarian endometrioma. Design Prospective, cohort pilot study. Setting Multiple centers, Spain. Patients Forty patients with suspected ovarian endometrioma identified by US, with a maximum diameter of 35 to 100 mm, of whom 33 met inclusion criteria. Interventions The study group (n = 17) underwent US-guided aspiration plus sclerotherapy with ethanol, and the control group (n = 14) underwent laparoscopic cystectomy. Measurements and Main Results Recurrence, complications, and direct costs were compared. One of 17 sclerotherapy patients recurred (5.9%) compared with 4 of 14 laparoscopic surgery patients (28.6%) (odds ratio 0.18, 0.01–1.53). No serious adverse effects (Clavien-Dindo ≥ III) were observed in the sclerotherapy group; 1 patient in the surgery group had a Clavien-Dindo IIIb complication. Median hospital direct costs were significantly lower in the sclerotherapy group than those in the surgery group—266 euros versus 2189 euros. Conclusion Ethanol sclerotherapy seems to be cost-effective for endometrioma and also appears to reduce complications. In this pilot study, recurrence was not higher than with conventional surgery.

BACKGROUND Hemorrhoidal disease in women during pregnancy is common in clinical practice. However, prospective data on its real prevalence and women's demographics are scarce. OBJECTIVE The aim of this study was to determine the prevalence of hemorrhoidal disease during pregnancy and to assess its impact on quality of life. In addition, this study aimed to identify the relationship between patients' characteristics, bowel habits, hormonal changes, and the presence of symptomatic hemorrhoids. DESIGN This is a prospective longitudinal cohort study. SETTING This study was conducted in the Obstetrics Department for pregnancy follow-up. PATIENTS The patients evaluated were a cohort of pregnant women. INTERVENTION The study was designed to follow a homogeneous cohort of women for 15 months. Visits took place in the first and third trimesters of pregnancy, and 3 and 6 months after delivery. Women's demographics (age, medical history, bowel habit, Bristol stool scale) and serum determination of pregnancy-related hormones (estrogen, progesterone, and relaxin) were determined. MAIN OUTCOME MEASURES The primary outcome was the development of hemorrhoidal disease. RESULTS Overall, 109 women (mean age, 31.2 ± 5.4 years) were included in the study. The prevalence of symptoms and physical findings of hemorrhoidal disease was present in 11% in the first trimester, 23% in the third trimester, 36.2% at 1 month after delivery, and 16.9% at 3 months after delivery. A medical history of hemorrhoidal disease was significantly associated with the diagnosis of hemorrhoids in the first trimester (p < 0.0001) and third trimester (p = 0.005). Symptoms of constipation were associated with this clinical disorder in the first trimester (p = 0.011) and the third trimester of pregnancy (p = 0.022). No association was found between hormonal changes and the development of hemorrhoidal disease. LIMITATIONS A larger sample would provide more information. CONCLUSIONS The prevalence of women with hemorrhoidal disease increases during pregnancy and after delivery. A history of hemorrhoidal disease and constipation is significantly associated with the diagnosis of symptomatic hemorrhoidal disease. See Video Abstract at http://links.lww.com/DCR/B504. INFLUENCIA DEL HBITO INTESTINAL Y LOS CAMBIOS HORMONALES EN EL DESARROLLO DE LA ENFERMEDAD HEMORROIDAL DURANTE EL EMBARAZO Y EL PERODO POSTERIOR AL PARTO UN ESTUDIO DE COHORTE PROSPECTIVO ANTECEDENTES:La enfermedad hemorroidal en mujeres durante el embarazo es comun en la practica clinica. Sin embargo, hay escasos datos prospectivos sobre su prevalencia real y la demografia de las mujeres.OBJETIVO:El objetivo fue determinar la prevalencia de enfermedad hemorroidal durante el embarazo y evaluar su impacto en la calidad de vida. Ademas, identificar la relacion entre las caracteristicas de los pacientes, los habitos intestinales, los cambios hormonales y la presencia de hemorroides sintomaticas.DISENO:Estudio prospectivo de cohorte longitudinal.AJUSTE:Este estudio se realizo en el Departamento de Obstetricia para el seguimiento del embarazo.PACIENTES:Una cohorte de mujeres embarazadas.INTERVENCION:El estudio se diseno para realizar un seguimiento de una cohorte homogenea de mujeres durante 15 meses. Las visitas se realizaron en el primer y tercer trimestre del embarazo, y a los 3 y 6 meses despues del parto. Se determinaron los datos demograficos de las mujeres (edad, antecedentes medicos, habito intestinal, escala de heces de Bristol) y la determinacion serica de hormonas relacionadas con el embarazo (estrogeno, progesterona y relaxina).PRINCIPALES MEDIDAS DE RESULTADO:El resultado principal fue el desarrollo de enfermedad hemorroidal.RESULTADOS:Se incluyo en el estudio a 109 mujeres (edad media, 31,2 ± 5,4 anos). La prevalencia de sintomas y hallazgos fisicos de enfermedad hemorroidal estuvo presente en 11% en el primer trimestre, 23% en el tercer trimestre, 36,2% 1 mes despues del parto y 16,9% 3 meses despues del parto. Un historial medico previo de enfermedad hemorroidal se asocio significativamente con el diagnostico de hemorroides en el primer trimestre (p

Objectives “Significant” obstetric anal sphincter injuries (OASIS) have been defined as visible defects of at least 30° in at least 4/6 slices using tomographic ultrasound imaging (TUI) with transperineal ultrasound (TPUS). The objective of this study was to assess if TUI is mandatory for the evaluation of OASIS. Methods Patients with a history of OASIS were evaluated by performing 3D-endoanal ultrasound (EAUS) and 3D-TPUS with and without TUI. Any damage to the internal (IAS) or external (EAS) anal sphincters was recorded and scored using the Starck’s and the Norderval’s systems. Intraobserver and inter-techniques correlations were calculated. Results From September 2012 to May 2015, 63 women, mean age 32.5 ± 4.6 years, with OASIS (3a: 26 pts., 41.3 %; 3b: 26 pts., 41.3 %; 3c: 6 pts., 9.5 %, 4: 4 pts., 6.3 %, “button hole” tear: 1 pt., 1.6 %). Inter-technique and intraobserver correlations were excellent (TUI: k = 0.9; sweeping technique: k = 0.85; EAUS: k = 0.9) in determining OASIS. Using the Starck’s Score, excellent correlation was found for both TPUS modalities (TUI: k = 0.86; sweeping technique: k = 0.89). However, for the different individual parameters, the correlation was moderate for EAS depth (TUI: k = 0.44; sweeping technique: k = 0.5) and good for IAS depth (TUI: k = 0.7; sweeping technique: k = 0.78). Similar results were found using the Norderval’s classification. Conclusions OASIS can be assessed by TPUS without TUI technique, dragging the rendered box and following the anal canal from the anal verge to the anorectal junction in the longitudinal plane and describing findings.

To study the relationship between symptoms of anal incontinence (AI) and the anatomy and functionality of the levator ani muscle in women with a history of obstetric anal sphincter injury (OASI). This is a cohort study including patients with OASI from 2013 to 2016. Patients were assessed by a physical examination, endoanal ultrasound using Starck Scale, perineometry and 4D transperineal ultrasound. AI in all patients was measured with the Wexner scale. Correlation between variables has been analyzed in these patients. 72 patients were analyzed: 28 with a IIIA degree tear, 26 with a IIIB, 13 with a IIIC and 5 with a IV. 38 patients showed a residual anal sphincter (AS) defect on endoanal ultrasound with an average Starck score of 6.5 ± 3.7. 21 patients expressed AI, with an average Wexner score of 4.1 ± 2.4. In 27 (37.5%) patients, a levator ani avulsion was observed: 17 unilateral and 10 bilateral. Patients with a levator ani defect had weaker pelvic floor muscle (PFM) function. These differences were statistically significant with perineometry (p = 0.01 and p = 0.03) but not for the Oxford test (p = 0.08). Patients with a residual AS defect as well as an injury to the levator ani muscle expressed greater AI symptomatology than patients with residual sphincter injury who maintain the integrity of the levator ani: Wexner 4.9 0.9 vs 3.3 1 (p = 0.02). The PFM has correlation with AI symptom development in patients with a history of OASI. Therefore, we suggest a key role of anatomical and functional assessments of the levator ani muscle in these patients.

For the treatment of stress urinary incontinence (SUI), various retropubic and transobturator techniques have demonstrated high cure rates. Single-incision tapes, such as Contasure-Needleless® (C-NDL), have demonstrated similar cure rates to the inside-out transobturator sling (TVT-O®). The aim of this study was to analyse if C-NDL® is equally as effective as an outside-in transobturator sling (Monarc®) for the treatment of SUI. We carried out a prospective, single-centre, randomised trial. The results were analysed for a non-inferiority test with a minimum postoperative follow-up of 12 months. The objective and subjective cure rates were evaluated by a stress test and a postoperative Sandvik Severity Index respectively. Patient satisfaction and operative complications were registered. The cure was defined by a negative stress test and SSI 0. A total of 187 patients were included, 89 and 98 undergoing C-NDL® and Monarc® respectively. Epidemiological and clinical data did not show and significant differences between both groups except a high prevalence of women who smoke (15.7% C-NDL® vs 6.1% Monarc®, p 0.03). The negative stress test was negative in 72 patients (80.9%) in C-NDL® compared with 85 (88.5%) in Monarc® (p 0.082). The SSI was 0 in 47 (66.2%) for C-NDL® and 61 (70.1%) for the Monarc® group (p 0.01). There were 14 (16.1%) and 8 (8.3%) dissatisfied patients for the C-NDL® and Monarc® groups respectively (p 0.068). The rate of complications was similar in both groups. According to the non-inferiority test, C-NDL® is not inferior to Monarc® (post-surgical SSI test), but it is inferior in the comparison of a negative stress test and patient satisfaction.

There is a distinct lack of literature on postoperative management after anterior colporrhaphy (AC). Our traditional postoperative protocol consisted of 24 h of indwelling catheterisation followed by 24 h of self-intermittent catheterisation. We hypothesised that a new protocol consisting of only 24 h of indwelling catheterisation might produce better results without additional complications. From April 2014 to July 2017, all candidates for AC were randomised to catheter removal 24 or 48 h after surgery. The primary outcome was the postoperative urinary retention (POUR) rate. Secondary outcomes included: asymptomatic bacteriuria (AB), urinary tract infection (UTI) and postoperative pain after 24 h. A total of 79 patients were recruited. Thirty-seven and 40 patients were randomised to follow the 48-h protocol and the 24-h protocol respectively. There were no significant differences in relation to the POUR rate: 3 patients (8.1%) vs 1 (2.5%) in the 48-h vs the 24-h group respectively (p = 0.346). The UTI rate was 2 (8.1%) vs 0 patients respectively (p = 0.139) and the postoperative AB rate was 3 (9.1%) vs 0 patients (p = 0.106). In the postoperative pain evaluation, the visual analogue scale score was significantly higher in the 48 h group (0.35 vs 0.13, p = 0.02). According to our results, reducing the catheterisation from 48 to 24 h after AC does not increase the risk of POUR and decreases the rate of UTI, AB and postoperative pain. This new postoperative management protocol of pelvic floor surgery would improve postoperative outcomes and shorten the stay in hospital.

INTRODUCTION AND HYPOTHESIS: The aim was to analyze the correlation between residual anal sphincter (AS) defects and pelvic floor muscle (PFM) strength on anal incontinence (AI) in patients with a history of obstetric AS injuries (OASIS). METHODS: From September 2012 to February 2015, an observational study was conducted on a cohort of females who underwent repair of OASIS intrapartum. The degree of OASIS was scored intrapartum according to Sultan's classification. Participants were assessed at 6 months postpartum. Incontinence symptoms were evaluated using Wexner's score and PFM strength using the Modified Oxford Scale (MOS). 3D-endoanal ultrasound was performed to classify AS defects according to Starck's system. Correlation between Sultan's and Starck's classifications was calculated using Cohen's kappa and Spearman's rho (R(s)) test. The impact of residual AS defects and PFM strength on AI was analyzed using a multiple regression model. RESULTS: A total of 95 women were included in the study. Good correlation (?= 0.72) was found between Sultan's and Starck's classifications. Significant positive correlation was observed between Wexner's score and both Sultan's (p = 0.023, R(s) =0.212) and Starck's (p < 0.001, R(s) =0.777) scores. The extent of the residual AS defect was the most relevant factor correlating with AI symptoms. In patients with severe AS injuries, higher MOS values were associated with lower Wexner's score. CONCLUSIONS: The degree of AS tear measured intrapartum was the most important factor related to AI after primary repair of OASIS. PFM strength was associated with lower incontinence symptoms in the postpartum period.

The term mucocele is simply defined as the macroscopic description of an appendix that is grossly distended by intraluminal accumulation of mucoid material. Its incidence ranges from 0.2% to 0.7% of all appendectomies and during pregnancy it is even less frequent. After a mucocele diagnosis, the selection of an adequate surgical method is, in general, very important. But during pregnancy it is an even more complicated decision because of the lack of experience and evidence on elective surgical treatments in pregnant women. We present a commentary based on a case of a low-grade appendiceal mucinous neoplasm of the appendix, found on an appendectomy specimen because of a mucocele in a second trimester pregnant woman.