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Objective: This study assessed the distribution of Müllerian duct anomalies in two verified classifications of female genital tract malformations, and the presence of associated renal defects., Study Design: 621 women with confirmed female genital tract anomalies were retrospectively grouped under the European (ESHRE/ESGE) and the American (AFS) classification. The diagnosis of uterine malformation was based on findings in hysterosalpingography, two-dimensional ultrasonography, endoscopies, laparotomy, cesarean section and magnetic resonance imaging in 97.3% of cases. Renal status was determined in 378 patients, including 5 with normal uterus and vagina., Results: The European classification covered all 621 women studied. Uterine anomalies without cervical or vaginal anomaly were found in 302 (48.6%) patients. Uterine anomaly was associated with vaginal anomaly in 45.2%, and vaginal anomaly alone was found in 26 (4.2%) cases. Septate uterus was the most common (49.1%) of all genital tract anomalies, followed by bicorporeal uteri (18.2%). The American classification covered 590 (95%) out of the 621 women with genital tract anomalies. The American system did not take into account vaginal anomalies in 170 (34.7%) and cervical anomalies in 174 (35.5%) out of 490 cases with uterine malformations. Renal abnormalities were found in 71 (18.8%) out of 378 women, unilateral renal agenesis being the most common defect (12.2%), also found in 4 women without Müllerian duct anomaly., Conclusions: The European classification sufficiently covered uterine and vaginal abnormalities. The distribution of the main uterine anomalies was equal in both classifications. The American system missed cervical and vaginal anomalies associated with uterine anomalies. Evaluation of renal system is recommended for all patients with genital tract anomalies., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

The frequency and outcome of twin pregnancies in women with uterine malformation were studied. The cohort comprised 13 (4.9%) women with twin pregnancy found among 263 women. They had 483 deliveries, 13 of them twins (2.7%; 95% CI 1.6-4.6%). Among 38 patients with unicornuate uterus 5 (6.8%) out of 74 deliveries were twins, 39 women with didelphic uterus 2 (3.2%) out of 62 deliveries and 147 women with septate or subseptate uterus 6 (2.3%) out of 264 deliveries were twins. The mean duration of gestation was 249 days (range 190-268 days), 5 (38%) out of 13 deliveries were premature, 25 out of 26 newborns were alive. Mean durations of gestation and mean weights of newborns did not differ when 7 cases with unicornuate or didelphic uterus were compared to 6 cases with complete or partial uterine septum. A congenital malformed uterus can bear twin pregnancy without severe complications apart from prematurity.

Objective: To assess the effect of hysterectomy with or without pelvic organ prolapse (POP) on health-related quality of life (HRQoL) and pelvic floor disorders., Study Design: Prospective clinical study at two central hospitals in Finland. During one year 322 women underwent elective hysterectomy for benign conditions with or without vaginal wall repair. The study population was divided in two groups, patients with and without POP. The HRQoL questionnaires RAND-36 and 15D, and questionnaires assessing urinary and bowel dysfunction symptoms were obtained preoperatively and 12 months postoperatively. POP was defined as the descent of apical, anterior or posterior compartment of vaginal wall grade ≥2 in the Baden-Walker classification at any site. Main outcome measures were HRQoL, improvement of symptoms and de novo symptoms., Results: At baseline the mean 15D score of all patients was lower than that of the age-standardized population sample (p<0.001). At one year postoperatively, the mean 15D score of the patients had improved (p=0.001), this resulting mainly on dimensions of excretion (voiding and defecation), usual activities, discomfort and symptom, distress, vitality and sexual activity. HRQoL improved especially in patients with POP. They reported improvement of symptoms in urinary incontinence, urinary frequency, constipation and sense of bulging but surgery had no effect on anal incontinence. Patients without POP reported improvement in pain dimension, urinary frequency and feeling of bulging. Urinary incontinence was the most common (15.4% and 13.8%) de novo symptom in both groups., Conclusions: Hysterectomy with or without concomitant pelvic organ prolapse surgery improves health-related quality of life and reduces pelvic floor symptoms in one-year follow-up., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Objective: The rectovesical ligament is a peritoneal band in women with failure of fusion of the two Müllerian ducts. The aim was to evaluate existence of this abnormal structure in women with dysfused uterus and its possible relations to concomitant vaginal and renal anomalies., Study Design: The study group comprised 47 women with uterine fusion defect (37 didelphic and 10 bicornuate uterus). They had undergone laparoscopy or laparotomy to visualize the pelvic cavity, and imaging for renal evaluation. The rectovesical ligament was present if inspection of the pelvic cavity revealed a broad peritoneal band between the two hemiuteri, attached anteriorly to the bladder and posteriorly to the sigmoid. Presence or absence of the ligament was reported, and concomitant renal and vaginal anomalies were evaluated., Results: The rectovesical ligament was not visualized in 14 patients with didelphic or complete bicornuate uterus associated with unilateral renal agenesis: of these 13 had a previously treated obstructive longitudinal vaginal septum. A peritoneal band was found in 27 women with didelphic uterus with longitudinal vaginal septum with no obstruction and normal bilateral kidneys. Six women with bicornuate uterus had normal kidneys and an identified rectovesical ligament between the uterine hemicorpora, except for one with partial bicornuate uterus., Conclusion: The rectovesical ligament is not merely a consequence of the failed fusion of two Müllerian ducts, but its relation to uterine malformation with or without vaginal and renal anomalies indicates some share of this structure in the early development of the urogenital system., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Purpose: The aim of this study was to evaluate the outcome of pregnancies in women who had uterine malformation and surgically treated obstructed hemivagina with ipsilateral renal agenesis., Methods: The study group comprised 21 women with malformed uterus (12 didelphic, 6 septate and 3 bicornuate uterus). All of them had a history of surgical excision of the longitudinal vaginal septum caused obstructed hemivagina and ipsilateral renal agenesis. All pregnancies and possible surgical interventions were evaluated during the follow-up period (median 13.2 years)., Results: Thirteen out of 21 women attempting pregnancy conceived. They produced 22 pregnancies, 17 (77 %) were contralateral to the treated obstructed hemivagina and unilateral renal agenesis. The median interval between surgical treatment of obstructed hemivagina and the first pregnancy was 10.5 years. Twenty (91 %) pregnancies ended in delivery of a living infant. Preeclampsia (14 %), preterm delivery (36 %), high frequency (38 %) of fetal breech presentation and the cesarean section rate (67 %) were found., Conclusions: Accurate diagnosis and appropriate surgery to open an obstructed hemivagina in adolescence assure fertility. Preterm birth is associated with malformed uterus and unilateral renal agenesis may predispose to preeclampsia.

Objective: To evaluate outcomes of anterior vaginal wall mesh augmentation with concomitant sacrospinous ligament fixation (SSLF) or with concomitant posterior intravaginal slingplasty (IVS) for uterovaginal or vaginal vault prolapse., Study Design: Women with symptomatic uterovaginal or vaginal vault prolapse were randomly allocated to SSLF or IVS. All underwent concomitant anterior repair augmented with self-tailored multifilament polypropylene and polyglactin composite mesh. Before and 2, 12, 24 and 36 months after surgery, the outcome was assessed by examination and standard questions. The primary endpoint was anatomic recurrence of pelvic organ prolapse at stage II or beyond (-1 cm or greater) at any site of the vaginal wall. Secondary outcomes included perioperative and postoperative complications, symptom resolution, reoperation and mesh exposure., Results: Twenty-two women were recruited from March 2003 to December 2005. At 3-year follow-up3 (2 posterior and 1 apical) out of 14 (21%) in the IVS group had anatomic recurrences of pelvic organ prolapse, and 1 anterior out of 8 (13%) in the SSLF group. Severe operative complications or reoperations did not occur. The proportions of symptomatic patients, including those with dyspareunia, did not differ between the groups. Erosion of the anterior multifilament mesh was found in 2 out of 22 cases (9%; 95% CI 3-28%)., Conclusion: At 3-year follow-up anterior repair reinforced with a composite mesh with concomitant sacrospinous ligament fixation or with concomitant posterior intravaginal slingplasty allowed feasible support in patients with severe pelvic organ prolapse., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Objective: The objective of the study was to compare anterior colporrhaphy with and without a mesh., Study Design: Two hundred two women with anterior prolapse were assigned to undergo colporrhaphy alone or reinforced with a tailored polypropylene mesh. Before and 2, 12, 24, and 36 months after surgery, the outcome was assessed by examination and standard questions. The primary endpoint was anatomic recurrence of anterior vaginal prolapse. Secondary outcomes were symptom resolution, reoperation, and mesh exposure., Results: Recurrences of anterior vaginal prolapse were noted in 40 of the 97 (41%) in the colporrhaphy group and 14 of 105 (13%) in the mesh group (P < .0001). The number needed to treat was thus 4. The proportion of symptomatic patients, including those with dyspareunia, did not differ between the groups. The mesh erosion rate was 19%., Conclusion: At 3 year follow-up, anterior colporrhaphy with mesh reinforcement significantly reduced anatomic recurrences of anterior vaginal prolapse, but no difference in symptomatic recurrence were noted and the mesh erosion rate was high. The use of mesh was not associated with an increase in dyspareunia., (Copyright 2010 Mosby, Inc. All rights reserved.)

Intrauterine adhesions known as Asherman's syndrome evolve after trauma to the basal layer of the endometrium usually secondary to curettage of a recently pregnant uterus. The lesions range from minor to severe cohesive adhesions that affect menstrual function and fertility. Operative hysteroscopy is the mainstay of diagnosis, classification and treatment of the intrauterine adhesions. Significantly obliterated cavity may require multiple hysteroscopic adhesiolysis to achieve a satisfactory anatomical and functional result. Operative hysteroscopy for selective curettage of residual trophoblastic tissue instead of nonselective conventional curettage may prevent intrauterine adhesions.

Objective: To determine the effect of 1,25(OH)(2)D(3) and 25(OH)D(3) vitamin D derivates on the growth of leiomyoma and myometrial cells in vitro., Design: In vitro study., Setting: Cell biology research laboratory., Patient(s): Six premenopausal women with uterine leiomyomas undergoing hysterectomy., Intervention(s): Samples of leiomyomas and normal myometrial tissue were obtained, and paired cultures were established., Main Outcome Measure(s): A colorimetric crystal violet assay to determine the effect of 1,25(OH)(2)D(3) and 25(OH)D(3) on cell growth., Result(s): In both myometrial and leiomyoma cells, 0.1 nM physiologic level of 1,25(OH)(2)D(3) inhibited growth by 12% when compared with controls. The growth inhibition was concentration dependent; the highest concentration of 1,25(OH)(2)D(3) (100 nM) inhibited growth by 62% in both cell types. All the differences were statistically significant. A slight stimulation (<4%) of cell proliferation was observed with the lowest 25(OH)(2)D(3) concentrations. When treated with either a 500 nM or 1000 nM concentration of the compound, the growth of both cell types fell to approximately 50% of that of the control cultures, and the level of inhibition with the latter concentration was statistically significant., Conclusion(s): Both myometrial and leiomyoma cell growth in vitro was effectively inhibited by 1,25(OH)(2)D(3). Vitamin D may play a role in the growth of uterine leiomyomas.

Objectives: To evaluate the long-term outcomes and hysterectomy rates after hysteroscopic endometrial resection with or without myomectomy for menorrhagia., Study Design: Fifty-three women who had submucous myomas with intramural extension of less than 50% and smaller than 5 cm in diameter underwent endometrial resection and concomitant hysteroscopic myomectomy. Each of them was matched with a patient who had no submucous myomas and who had been treated by endometrial resection only. These two groups were compared for operative outcomes, additional procedures, outcome of menstrual bleeding and for subsequent hysterectomy, which was the endpoint of this study., Results: During the mean follow-up period of 6.5 years, 18 (34.6%) women with endometrial resection and myomectomy and 21 (39.6%) without myomectomy underwent at least one gynecological procedure. Hysterectomy was performed in 26.9% [95% confidence interval (CI) 16.8-40.3] of the patients with myomectomy and in 17.0% (95% CI 9.2-29.2) of the patients without myomectomy (P = 0.22). The main indications for hysterectomy were pain and spotting bleeding in seven out of 14 cases with myomectomy and in four out of nine with endometrial resection only. Leiomyomas were found in 12 out of the 14 women who had hysterectomy after hysteroscopic myomectomy and in four out of nine with hysterectomy after endometrial resection only (P = 0.06). Most (75.6%) of the 82 women who had not required hysterectomy had reached menopause. All the patients without hysterectomy in both groups reported amenorrhea or slight bleeding, and this response maintained for years after the treatment., Conclusion: Endometrial resection may be combined with hysteroscopic myomectomy without a significant increase or decrease in hysterectomy rates during a long-term follow-up.

To evaluate whether symptom resolution and sexual function is better after reinforcement with polypropylene mesh than with traditional anterior repair. Ninety-seven patients were randomized to anterior colporrhaphy and 105 to an operation with mesh. Participants were evaluated up to 24 months by physical examination, standard questions, and questionnaire. The overall symptom rate did not differ between the groups, but a sensation of vaginal bulge was reported less frequently in the mesh group, the figures being 17 versus 5 (p = 0.003). The recurrence rate for the no-mesh group was 41% and for the mesh group 11% (p < 0.001). The dyspareunia score was statistically significantly lower in the mesh group (p = 0.015). The mesh exposure rate was 8%. Sensation of vaginal bulge was relieved more efficiently by the mesh technique without causing dyspareunia.

The selective estrogen receptor modulator tamoxifen is widely used in breast cancer therapy though its use is associated with an elevated risk of endometrial carcinoma. An organotypic culture model was employed here to examine the effects of tamoxifen and raloxifene, a related compound with no known adverse uterine effects, on epithelial cells of the premenopausal human endometrium. Changes in the expression levels of the proliferation marker Ki67, and estrogen and progesterone receptors were evaluated. No change in the Ki67 index compared to untreated controls was detected in cultures exposed to tamoxifen or tamoxifen+estradiol. In response to tamoxifen, the level of progesterone receptor-expressing organoids was shown to vary markedly between individual samples, whereas no change in estrogen receptor expression could be demonstrated. A significant decrease in Ki67 expression was observed in raloxifene-exposed cultures. Raloxifene or raloxifene+estradiol had no effect on progesterone receptor expression. The expression of estrogen receptor was markedly inhibited in response to raloxifene or raloxifene+estradiol in all but two samples displaying an intense estrogen receptor labelling. The present observations add to current clinical data on the respective estrogen receptor agonist and antagonist activities of tamoxifen and raloxifene on the human uterus by providing novel insights into the interindividual variation in cellular responses. Our organotypic model may have uses as an alternative to animal experimentation in preclinical screening of the endometrial effects of selective estrogen receptor modulators and may serve as a tool in personalized medicine by identifying patients with an increased risk of developing endometrial pathologies.

Objective: To evaluate the accuracy of a formula combining the prolate ellipsoid (uterine corpus) and cylinder (uterine cervix) formulas in estimating the preoperative weight of the total uterus using a transvaginal ultrasound probe to obtain the uterine dimensions for the formulas., Study Design: Three dimensions of the uterine corpus (length, width and anteroposterior diameter) and cervical length and cervical anteroposterior diameter were preoperatively determined using a transvaginal ultrasound probe in 12 women with symptomatic leiomyomas scheduled to undergo hysterectomy. In two patients whose uteruses were the largest, part of the measurements had to be taken with a transabdominal ultrasound. Three investigators repeated all the rounds of measurements three times, producing in total 108 of findings (12 subjects x 3 investigators x 3 rounds of measurements). The geometric formula of prolate ellipsoid was compared to a formula combining the ellipsoid and cylinder formulas for accuracy in predicting overall uterine size (corpus and cervix) through correlation with hysterectomy specimens. The weight of the uterus in grams was directly derived from the volume of the uterus., Results: All measurements of the uterine corpus and cervix could be obtained preoperatively with a transvaginal ultrasound probe except in two patients who had the largest uteruses. The plain, traditional formula for the prolate ellipsoid overestimated the weight of the uterus and differences between the estimated and the true weight were statistically significant. The difference was not significant when the formula combining the formulas of the prolate ellipsoid and cylinder was used., Conclusion: The new formula combining the prolate ellipsoid and cylinder formulas is more accurate in predicting the true total weight of the uterus than the plain prolate ellipsoid formula. The transvaginal ultrasound probe proved useful in evaluating the dimensions of the uterine corpus and cervix.

Objective: To review clinical implications, reproductive outcome, and long-term consequences in women with complete septate uterus and longitudinal vaginal septum., Design: A retrospective study., Setting: A university hospital., Patient(s): Sixty-seven patients who had a complete septate uterus including the cervix and a longitudinal vaginal septum., Intervention(s): The longitudinal vaginal septum was incised in 36 cases and metroplasty for uterine septum was undertaken in 4 patients., Main Outcome Measure(s): Fertility, outcome of pregnancies, possible late consequences, and presence of other anomalies., Result(s): Eight (15.7%) of 51 women attempting pregnancy had primary infertility of nonuterine causes. Forty-nine women not undergoing metroplasty produced 115 pregnancies, abortion rate 27%, preterm delivery 12%, and live birth rate 72%. Only five women with no metroplasty had only miscarriages and 44 women at least one delivery. One of four women undergoing metroplasty delivered preoperatively and three after metroplasty. During the follow-up period endometriosis was observed in two (3%) of 61 cases and two patients had borderline ovarian tumors. Kidney abnormalities were found in 11 (20%) of 55 patients studied, double ureter being the most common., Conclusion(s): Complete septate uterus with longitudinal vaginal septum is not associated with primary infertility, and pregnancy may progress successfully without surgical treatment. The results do not support elective hysteroscopic incision of the septum in asymptomatic patients or before first pregnancy.

Introduction: The aim of this study is to evaluate the clinical effectiveness and safety of the enucleation of uterine leiomyomas by traction method via colpotomy., Methods: Ten women with menorrhagia, pelvic pain, or secondary infertility associated with single uterine myomas underwent transvaginal myomectomy with screw traction by colpotomy. The feasibility of the procedure, operative complications, postoperative recovery, pregnancies, and relief of symptoms were the main outcome measures., Results: Traction myomectomy was completed vaginally in all patients. The mean operating time was 71 min and average blood loss 385 ml. The mean size of a single myoma was 6.7 cm (range 5.6-8.0 cm) and weight 153 g. One patient developed a transient hematoma. All women reported relief of their symptoms after a mean follow-up of 24 months. Three patients had a term delivery postoperatively., Conclusions: Traction myomectomy by colpotomy is a feasible approach for selected patients wishing to preserve their ability to conceive. A single well-lined myoma of 5-8 cm diameter and possible to reach via colpotomy is a suitable subject for the procedure, which proved a viable surgical approach.

Background: A novel organotypic culture system was established for modelling the hormonal responses of the normal human endometrium in vitro., Methods: Endometrial epithelial cells were cultured as glandular organoids within reconstituted extracellular matrix (Matrigel) in tissue culture inserts and stromal cells on plastic below the epithelial compartment. The effects of estradiol (E2) and E2 together with medroxyprogesterone acetate (MPA) on cell proliferation and the expression of estrogen receptor alpha (ERalpha) and progesterone receptor (PR) were studied in 10 epithelial-stromal co-cultures and in three parallel monocultures of epithelial organoids., Results: In co-cultures, E2 was shown to increase the percentage of Ki67-positive cells by approximately 2-fold relative to untreated controls. In the presence of MPA, a significant decrease in cell proliferation was detected. Similar results were obtained when the corresponding percentages of Ki67-positive organoids were calculated instead of individual cells. In the absence of stromal fibroblasts, Ki67 epithelial labelling remained below the control value after both hormonal treatments. Epithelial organoids retained their capacity to express estrogen and progesterone receptors in culture. E2 was shown to markedly increase and MPA to down-regulate the expression of PR. The expression of ERalpha was only slightly affected by either hormonal treatment., Conclusions: The present organotypic model provides a novel in vitro system in which to study the effects of steroids in the normal human endometrium both in terms of cell proliferation and gene expression. The culture system holds promise as a useful method to screen novel steroid compounds and may help to circumvent problems related to the use of animal models.

Purpose: This study was designed to compare outcomes of transanal and vaginal techniques for rectocele repair., Methods: Thirty females with symptomatic rectocele were enrolled in a prospective, randomized study. Fifteen underwent transanal rectoceleplasty, the other 15 underwent vaginal posterior colporrhaphy. Patients were assessed by clinical interview and examination, defecography, colon transit study, and anorectal manometry before randomization and 12 months postoperatively. Patients with compromised anal sphincter function or other symptomatic prolapse were excluded., Results: The study groups were comparable in terms of demographic factors and rectocelerelated symptoms and signs. Eleven (73 percent) patients in the vaginal group and 10 (66 percent) in the transanal group digitally assisted rectal emptying preoperatively. The mean depth of the rectocele was 6.0 +/- 1.6 cm vs. 5.6 +/- 1.8 cm (P = 0.53) in the respective groups. At follow-up, 14 (93 percent) patients in the vaginal group and 11 (73 percent) in the transanal group reported improvement in symptoms (P = 0.08). Need to digitally assist rectal emptying decreased significantly in both groups, to one (7 percent) for the vaginal group and four (27 percent) for the transanal group (P = 0.17 between groups). The respective recurrence rates of rectocele were one (7 percent) vs. six (40 percent) (P = 0.04), and enterocele rates were zero vs. four (P = 0.05). In the vaginal group defecography showed a significant decrease in rectocele depth whereas in the transanal group the difference did not reach statistical significance. None of the patients reported de novo dyspareunia, but 27 percent reported improvement., Conclusion: Patients' symptoms were significantly alleviated by both operative techniques. The transanal technique was associated with more clinically diagnosed recurrences of rectocele and/or enterocele. Adverse effects on sexual life were avoided by use of both techniques.

Introduction: The purpose of this study was to evaluate the feasibility, clinical outcome and complications of laparoscopic surgery in women with endometrial cancer and to compare surgical outcome and postoperative early and late complications with results of traditional laparotomy., Methods: Forty women with endometrial cancer underwent laparoscopic hysterectomy, bilateral salpingo-oophorectomy and pelvic lymphadenectomy. Each patient operated by laparoscopy was matched by age, preoperative clinical stage and histology of the endometrial cancer with a patient treated by the same operation but using traditional laparotomy. Half of these patients underwent total pelvic lymphadenectomy and half had pelvic lymph node sampling. The groups were compared in clinical characteristics, surgical outcomes, recoveries and early and late postoperative complications., Results: The patients in the laparoscopy group had less blood loss, more lymph nodes removed, shorter hospital stay but longer operation time than those treated by laparotomy. Only one (2.5%) laparoscopy was converted to laparotomy due to pelvic adhesions. There were no intraoperative complications in either group. Postoperative complications were more common (55.0%) in the laparotomy than in the laparoscopy group (37.5%). Only one major complication (2.5%) occurred among patients undergoing laparoscopy as compared with three (7.5%) major complications in the laparotomy group. Superficial wound infection was the most common (20%) infection in laparotomy patients while vaginal cuff cellulitis occurred in 10% of laparoscopy patients. Late (>42 days) postoperative complications were almost equally frequent (20.0 and 22.5%) in both groups. Lower extremity lymph edema or pelvic lymph cyst was found in 12.5% of all cases. As a result of surgical staging the disease of 6 women (15%) in both groups was upgraded., Conclusions: Laparoscopic surgery is a viable alternative to traditional surgery in the management of endometrial cancer. The surgical outcome is similar in both cases. In laparoscopic procedures the operation time is longer but the postoperative recovery time shorter than in laparotomy. Severe complications were limited in both groups, while wound infections can be avoided using laparoscopy.

Objective: To evaluate the possible connection between gestational hypertensive disorder and unilateral renal agenesis in women with congenital uterine anomalies., Study Design: Thirty-three (16%) out of 206 women with uterine anomalies had unilateral renal agenesis. Nineteen of them had delivered and comprised the study group. The control group consisted of 44 women among the 206 with similar uterine malformations who had normal bilateral kidneys and matched in age and parity with the study group. Retrospective analysis considered the presence of gestational hypertension, proteinuria, preeclampsia, perinatal outcomes and manifestations of hypertension and renal disease during the follow-up period in both groups. The median follow-up was 166 months (range 24-372 months)., Results: Women with unicornuate uterus most frequently (25%) evinced unilateral renal agenesis. Eight (42%) out of 19 women with malformed uterus and unilateral renal agenesis had in at least one pregnancy gestational hypertension, preeclampsia or gestational proteinuria compared to 8 (18%) out of 44 women with two kidneys (relative risk, RR 2.33, 95% CI 1.02, 5.29). Seventeen (35%) out of all 49 pregnancies in the study group were complicated by gestational hypertensive disorder or proteinuria as against 10 (11%) out of 90 pregnancies in the control group (RR 3.12, 95% CI 1.55, 6.28). Perinatal outcomes were similar in both groups. During follow-up none had diagnosed proteinuria or chronic renal disease, but two out of 19 women (11%) with unilateral renal agenesis had commenced medication for chronic hypertension., Conclusion: Unilateral renal agenesis predisposes women with uterine anomalies to preeclampsia.

Objectives: Estrogens modulate lipid metabolism and the increased risk of atherosclerosis in postmenopausal women is at least partly due to the reduction of estrogen production after menopause. We studied the effect of menopause on the contents of long-chain fatty acids, free cholesterol (FC) and cholesterol ester (CE) in uterine artery wall., Methods: The uterine artery intima samples were obtained in connection with surgery of 21 postmenopausal and 51 premenopausal women. The amount of FC, CE and phospholipid fatty acids were measured by gas chromatography after extraction and fractionation and these lipid values were related to menopausal status, age and serum total and low-density lipoprotein (LDL) cholesterol levels., Results: Premenopausal females had significantly less intimal FC (161 +/- 50 vs. 407 +/- 276 microg/100 mg wet weight, P = 0.003) and CE (19 +/- 34 vs. 305 +/- 348 microg/100 mg wet weight, P = 0.050) and smaller proportion of linoleic acid out of all phospholipid fatty acids (4.2 vs. 7.2%, P = 0.002) than postmenopausal women after adjustment with age. The content of CE (r = 0.34, P = 0.025) and the FC-to-CE ratio (r = -0.45, P = 0.002) correlated with age in premenopausal but not in postmenopausal women. Moreover, the intimal content of CE correlated with the percentage of intimal phospholipid linoleic acid in postmenopausal women (r = 0.79, P = 0.020). The same was true for FC (r = 0.73, P < 0.001)., Conclusions: These results indicate that CE and FC accumulation into the wall of uterine artery depends on menopausal status, independently of age, and that the phospholipid long-chain fatty acid composition differs significantly between premenopausal and postmenopausal women. This suggests that estrogens may be involved in the regulation of artery wall lipid composition.

Objective: To study the expression of nuclear receptors and cofactors in human endometrium and myometrium in proliferative and secretory phases of the menstrual cycle., Methods: Multiprobe ribonuclease protection assay and real-time reverse transcriptase polymerase chain reaction were used to quantitate mRNA levels of steroid receptors, vitamin D receptor (VDR), retinoic acid receptors (RAR), and cofactors AIB1 (amplified in breast cancer-1), CBP (cyclic adenosine monophosphate response element binding protein), pCAF (p300/CBP-associated factor), TIF2 (transcription intermediary factor-2), N-CoR (nuclear receptor corepressor), and SMRT (silencing mediator of repressed transcription). Cyclin A expression was analyzed to determine the proliferation status of the tissues., Results: The expression of androgen receptor, estrogen receptors alpha and beta, progesterone receptor, and RARalpha followed cyclin A expression. There was more abundant expression in the proliferative phase endometrium than in the secretory phase endometrium. Glucocorticoid receptor, VDR, RARbeta, and RARgamma were stably expressed during the menstrual cycle in both endometrium and myometrium. Cofactors N-CoR, SMRT, pCAF, CBP, TIF2, AIB1, and p300 mRNAs were expressed in all samples in both endometrium and myometrium. N-CoR, pCAF, AIB1, and p300 appeared not to be regulated when comparing proliferative and secretory phases of the cycle. Individual differences were found in the expression levels of both nuclear receptors and cofactors., Conclusion: The menstrual cycle-dependent regulation of nuclear receptor expression was more apparent in the endometrium than in the myometrium, whereas cofactor expression was not cycle dependent. There were individual differences in the expression levels of different receptors and cofactors. In hormonal therapy these differences might result in different responses, depending on the patient as well as the ligand used.

Objective: To evaluate presenting and long-term clinical consequences in females with obstructing vaginal anomalies., Design: A retrospective study., Setting: A university hospital in southern Finland., Participants: Twenty-six females with obstructing vaginal malformations. The conditions were classified into transverse vaginal obstruction (transverse septum or imperforate hymen) and longitudinal vaginal obstruction (longitudinal vaginal septum). INTERVENTIOS: 13 out of 16 women with transverse vaginal obstruction underwent incision of the imperforate hymen and three underwent excision of a complete transverse vaginal septum. Ten patients with obstructing hemivagina had incision of the longitudinal vaginal septum., Main Outcome Measures: Presenting symptoms and delay in diagnosis, outcome of primary surgical treatment, possible late complaints associated with obstruction, fecundity, perinatal outcome, and presence of other anomalies were studied. The mean followup period in the transverse and longitudinal obstruction group respectively was 13 years (range 1-29) and 16 years (range 1-44)., Results: Transverse vaginal obstructions were diagnosed within less than a month from the primary symptoms, while the diagnosis of longitudinal obstruction was delayed for an average of 27 months. Two out of three females with transverse vaginal septum underwent re-operation for vaginal constriction and three out of 10 with longitudinal vaginal septum had re-excision of the septum. All females with longitudinal obstruction had uterine and renal malformations as opposed to those with transverse vaginal obstruction. In the transverse vaginal obstruction group, two out of the six females who had their renal status assessed had double ureters. Dysfunctional uterine bleeding (19% in the transverse and 40% in the longitudinal obstruction group), dyspareunia (30% and 0%) and dysmenorrhea (19% and 20%) were the most common complaints during the followup. No endometriosis was found in the group that underwent a subsequent laparotomy or laparoscopy (18/26). Female infertility was not found in those 14 females who were attempting to conceive. Twenty-five (89%) out of 28 pregnancies ended in delivery, the live birth rate being 82% in the longitudinal and 94% in the transverse obstruction group., Conclusion: Accurate diagnosis together with adequate treatment may reduce the need for re-operations in cases with obstructing vaginal malformations. No specific gynecologic long-term clinical symptoms were identified in obstructing vaginal anomalies.

We studied fecundity and late sequelae of 39 women who had laparoscopic and microbiological sampling-proven acute pelvic inflammatory disease (PID) treated with the same antimicrobial regimen. The grade and etiology of index PID were classified using laparoscopy, endometrial biopsy and microbiological cultures from the cervix, endometrium and tubes: 20 had mild and 19 severe PID. The mean (SD) follow-up period after the index PID was 125 (44) [range 8-204] months. The primary end-point was pregnancy. All other or recurrent infections or other diseases related to the infection, including infertility, were evaluated. Twenty (51%) women had laparotomy or second laparoscopy during follow-up and findings were evaluated. Chlamydia trachomatis was isolated in 38% of all cases. Eleven (28%) of 39 women avoided conception or it was no longer possible. Twenty-eight women had tried to conceive after the index PID and 25 (89%) of them had at least one pregnancy. Twenty-five women had 56 pregnancies, 33 (59%) of which ended in delivery, 9 (16%) miscarried, 13 (23%) were induced abortion and only one (1.8%) tubal pregnancy occurred. Etiologic factors or severity of PID made no difference to the conception rate. Patients with mild or moderate salpingitis had a high conception rate. Endometriosis was found in 6 (30%) out of 20 women with second laparoscopy or laparotomy. Hysterectomy had been performed in 4 cases. Precise diagnosis of acute PID is the cornerstone for the treatment of the condition. Combination regimens, including drugs against the most common factors underlying acute PID against both aerobic and anaerobic microbes, prevent late sequelae in cases with mild or moderate salpingitis but not in cases with tubal or pelvic abscess.

Background: To identify risk factors in recurrence and to evaluate anatomic and functional results of vaginal sacrospinous ligament fixation and pelvic floor reconstruction for genital prolapse., Methods: One hundred and thirty-eight women underwent surgery for uterovaginal or vault prolapse. Follow-up data were available for 122 cases; 83% were examined and others were interviewed by telephone. The median (range) follow-up was 24 (1-141) months. Cox regression was used to identify risk factors associated with recurrence; uni- and multivariate regression was used to identify risk factors underlying postoperative infections because infections were found to be a risk factor of recurrence. Recurrence-free survival was estimated using the Kaplan-Meier method., Results: Seven (5%) patients suffered severe cardiopulmonary complications including one postoperative death due to a pulmonary embolism. Twenty-six (21%) patients suffered a recurrence, 14 with cystocele. Ten patients with recurrence were symptomatic and six underwent a re-operation. The Cox regression model showed that vaginal cuff infection raised the odds ratio (OR) for recurrence to 6.13 [confidence interval (CI) 1.80-20.83] and urinary tract infection to 3.65 (CI 1.40-9.47). In both uni- and multivariate analysis, lack of intravenous antibiotic prophylaxis, age less than 73 years and vaginal ulcerations were statistically significant risk factors for postoperative infection. Eleven (33%) out of 33 sexually active women reported improvement and three (9%) complained of dyspareunia., Conclusions: Transvaginal sacrospinous ligament fixation with pelvic floor repair is an effective means of correcting both vault prolapse and uterine procidentia. Women who wish to preserve coital function will also benefit from this operation. Postoperative infection is an independent and most important individual risk factor underlying recurrence. Prophylactic antibiotics seem to be effective in reducing the rate of postoperative infections.

Background: Ovarian cysts are found in some premenopausal women with autosomal dominant polycystic kidney disease (ADPKD). Liver cysts are the major extrarenal manifestations, frequently found in postmenopausal women. Female steroid hormones may regulate hepatic cystogenesis, but ovarian manifestations in postmenopausal women are unknown. The aim of the present study is to investigate possible ovarian manifestations associated with ADPKD in premenopausal and postmenopausal women., Methods: The study group included 19 premenopausal or postmenopausal women with ADPKD and 19 age- and parity-matched control women with no history of renal disease. Ovarian structures and volumes were measured by means of transvaginal ultrasonography., Results: Three of 8 premenopausal and 1 of 11 postmenopausal women with ADPKD had a small unilateral single ovarian cyst; there were none in controls. Eight women with ADPKD and 8 controls of premenopausal age had similar ovarian volumes (4.92 +/- 2.97 versus 3.92 +/- 2.60 cm3). Eleven postmenopausal women with ADPKD had an increased mean ovarian volume compared with 11 postmenopausal controls (4.11 +/- 2.60 versus 1.66 +/- 0.96 cm3; P < 0.01). Ovarian volume was not associated with the use of hormonal replacement therapy or impaired renal function in postmenopausal women with ADPKD., Conclusion: ADPKD is not associated with cystic ovaries, although single ovarian cysts are occasionally found. Equal ovarian volumes between premenopausal and postmenopausal women with ADPKD suggest a possible indirect effect of polycystic kidneys on gonads in aging women., (Copyright 2002 by the National Kidney Foundation, Inc.)

Study Objectives: To report a rare reason for primary amenorrhea, a Frasier syndrome, XY gonadal dysgenesis associated with renal failure with eventual development of gonadoblastoma. To study immunohistochemical analysis of gonadoblastoma and dysgerminoma. To analyze the possibility of androgen receptor mutation in this rare syndrome., Methods: We report a case of a 16-yr-old female with this syndrome. She underwent a laparoscopic bilateral gonadectomy and salpingectomy. A histopathological examination revealed gonadoblastoma with focal malignant dysgerminoma in the left dysgenetic gonad and an immunohistochemical of these fairly rare, malignant tumors. An androgen receptor was coded. Analysis was done., Results: Immunohistochemical analysis showed that inhibin was strongly positive in gonadoblastoma but negative in dysgerminoma. No mutations of the androgen receptor gene were found., Conclusions: Inhibin positivity in gonadal stroma and in gonadoblastoma may indicate hormonal activity causing advanced puberty in patients with XY gonadal dysgenesis.

Objective: To assess the feasibility of vaginal sacrospinous ligament fixation for women over 80 years of age with massive vaginal vault or uterovaginal prolapse., Design: Retrospective observational study with long term follow up., Setting: Department of Obstetrics and Gynaecology, Tampere University Hospital, Finland., Sample: and Methods The study group consisted of 25 women with a mean (SD) [range] age of 83 (3) [80-93] years: 13 had posthysterectomy vaginal vault prolapse and 12 had massive uterovaginal prolapse. All underwent vaginal sacrospinous ligament fixation with repair of pelvic floor relaxation. Women with uterovaginal prolapse also underwent concomitant vaginal hysterectomy. The long term outcome was assessed in 19 women. The mean follow up period was 33 (31) [2-113] months., Main Outcome Measures: Intra- and post-operative morbidity, mortality and recurrence of prolapse., Results: Sixteen of the 25 women (64 %) had no major intra- or post-operative complications. The mean estimated blood loss was 400 (280) mL, and seven women received blood transfusions. Four women (16%) had cardiovascular complications, and one died of pulmonary embolism. All four had a history of vascular disease. One woman had symptomatic recurrence of vault prolapse treated with a vaginal pessary; two women had asymptomatic cystocele and one had an enterocele requiring no treatment. The outcomes were similar for women with or without concurrent vaginal hysterectomy., Conclusion: Transvaginal sacrospinous ligament fixation is an effective treatment for massive vaginal vault or uterovaginal prolapse in aged women. Increased blood loss may elevate the risk of cardiovascular complications especially in elderly patients with a history of vascular disease, thus indicating the importance of intraoperative bleeding control.

Background: Since the late 1980s, the option of laparoscopic hysterectomy has raised questions about the most suitable approach to hysterectomy., Methods: To evaluate the influence of the type of approach, in causing or avoiding certain complaints in hysterectomies a prospective nationwide study was conducted comprising all hysterectomies for benign disease performed in Finland during 1996. The primary outcomes of interest were the operation-related morbidity, common surgical details and post-operative complications., Results: A total of 10 110 hysterectomies, including 5875 abdominal, 1801 vaginal and 2434 laparoscopic operations showed a low rate of overall complications, 17.2, 23.3 and 19.0% respectively. Infections were the most common complications with incidences of 10.5, 13.0 and 9.0% in the abdominal, vaginal and laparoscopic group respectively. The most severe type of haemorrhagic events occurred in 2.1, 3.1 and 2.7% in the abdominal, vaginal and laparoscopic group respectively. Ureter injuries were predominant in laparoscopic group [relative risk (RR) 7.2 compared with abdominal] whereas bowel injuries were most common in vaginal group (RR 2.5 compared with abdominal). Surgeons who had performed >30 laparoscopic hysterectomies had a significantly lower incidence of ureter and bladder injuries (0.5 and 0.8% respectively) than those who had performed < or =30 operations (2.2 and 2.0% respectively). A decreasing trend of bowel complications was also seen with increasing experience in vaginal hysterectomies., Conclusions: This large-scale observational study on hysterectomies provides novel information on operation-related morbidity of abdominal, vaginal or laparoscopic approach. The results support the importance of the experience of the surgeon in reducing severe complications, especially in laparoscopic and vaginal hysterectomies.

Objective: The aim of the study was to evaluate reproductive performance of women with didelphic uterus and to consider possible long-term consequences associated with this uterine anomaly., Study Design: Forty-nine women were diagnosed as having a didelphic uterus with a longitudinal vaginal septum at Tampere University Hospital, Finland between 1962 and 1998. The presence of other anomalies, gynecologic disorders, fertility and outcome of pregnancies were reviewed. The long-term clinical implications associated with a didelphic uterus were evaluated during the mean (S.D.) follow-up period of 9.1 (6.3) years., Results: An obstructed hemivagina was found in nine (18%) out of forty-nine cases; eight of these had ipsilateral renal agenesis. A longitudinal vaginal septum was excised in twenty-six (53%) cases, but metroplasty in none. Five (13%) patients had primary infertility. Thirty-four (94%) out of thirty-six women who wanted to conceive had at least one pregnancy, and they produced seventy-one pregnancies; 21% miscarried, and ectopic pregnancy occurred in 2%. The fetal survival rate was 75%, prematurity 24%, fetal growth retardation 11%, perinatal mortality 5. 3%, and cesarean section rate 84%. Pregnancy located more commonly (76%) in the right uterus than in the left. During the follow-up period endometriosis was observed in seven (16%) out of forty-five cases. Ovarian neoplasm was found in four (9%) cases, one of them had ovarian cancer., Conclusions: Fertility in women with didelphic uterus is not notably impaired. The prognosis of pregnancy is comparatively good, while prematurity and fetal growth retardation indicate meticulous prenatal care. Long-term follow-up did not reveal that didelphic uterus is associated with increased frequency of endometriosis or genital neoplasm.

A retrospective analysis was performed to evaluate the reproductive performance of 17 women with uterine anomalies who underwent in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) and embryo transfer (ET). Eight women had a unicornuate uterus, and two a didelphic uterus. Seven women with a subseptate uterus underwent metroplasty before assisted reproduction. Ten (58.8%) out of 17 women achieved 11 (18.0%) pregnancies out of 61 embryo transfers in 55 stimulated cycles. The implantation rate per embryo was 8/83 (9.6%) for women with a unicornuate uterus, one of 17 (5. 9%) for those with didelphic uterus and four of 48 (8.3%) for those with subseptate uterus. Pregnancy rates per embryo transfer were 19. 4, 11.1 and 19.0%, respectively. Three out of 11 pregnancies were ectopic, three were miscarriages and five were full-term deliveries, two sets of twins. Delivery rate per embryo transfer was 5.0% in patients with unicornuate or didephic uterus and 14.3% in women who had a subseptate uterus operated prior to assisted reproduction. Women with uterine anomalies treated by IVF or ICSI had low implantation rates. Pregnancy in a subseptate uterus which has been previously operated had a trend to end more frequently in delivery than that in a unicornuate uterus or in a didelphic uterus.

A retrospective analysis of 467 births among 255 women with uterine malformations revealed that three (0.64%) newborns had limb reduction defects. Two women had a subseptate uterus and one a complete septate uterus with a longitudinal vaginal septum. One newborn had a bilateral split hand and split foot, one had absence of left hand and wrist. One infant born without left hand, wrist and one antebrachial bone associated with omphalocele and diaphragmatic hernia died during the neonatal period. An association between severe limb reduction defects and septate uterus is possible, although the mechanism is unclear. The findings indicate a need to evaluate the uterine cavity if a newborn has this invalid defect, and a detailed ultrasound examination of fetal limbs is warranted in a case of a pregnant septate uterus.

The feasibility of performing hysteroscopic endomyometrial resection using isotonic 2.2% glycine as distension medium was studied in 181 consecutive operations. A standard continuous flow loop-resectoscope was used. Distension was achieved by means of a gravity-fed system and glycine flowed out under its own pressure. The mean (+/-SEM) glycine deficit was 160+/-20 ml and in only 7 patients was it >1 liter (maximum 1,800 ml). Only in patients with >1 liter glycine absorption was there a significant decrease in serum sodium level (mean 9 mmol/l), while serum osmolality remained normal. Apart from 1 case of transient nausea, these patients had no sequelae. We experienced isotonic 2.2% glycine as a useful and safe distending medium for operative hysteroscopy.

Background: To compare the advantages and disadvantages of the two endoscopic procedures, hysteroscopic endometrial resection and laparoscopic assisted vaginal hysterectomy (LAVH), in the treatment of menorrhagia., Methods: Forty women requiring surgical treatment for menorrhagia underwent LAVH. These women were compared retrospectively with forty women having had endometrial resection for menorrhagia. The operations were performed between November 1991 and February 1995., Results: Operating time, hospitalization and postoperative recovery were significantly shorter with endometrial resection than with LAVH. In the hysteroscopy group amenorrhea or hypomenorrhea was achieved in 80% of cases. Hysterectomy was performed in two cases (5%). In the hysteroscopy group all but three women (92%) were satisfied with the procedure, in the LAVH group all but one (97%)., Conclusions: In the surgical treatment of menorrhagia both procedures are effective. LAVH is associated with a longer recovery period, but it offers a permanent relief of menorrhagia. Even though endometrial resection does not render all women treated amenorrhoic, the satisfaction rate during the follow-up period was high; it is a useful alternative with many short-term benefits.

Objective: To evaluate clinical implications of the unicornuate uterus and rudimentary horn., Design: A retrospective study., Setting: A university hospital., Patient(s): Forty-two women who had a unicornuate uterus with or without rudimentary horn., Intervention(s): The rudimentary horn was removed in 21 cases., Main Outcome Measure(s): Presence of other anomalies, fertility, and outcome of pregnancies were studied., Result(s): A right unicornuate uterus with noncommunicating rudimentary horn was the most common type of uterine anomaly. Unilateral renal agenesis was found in 13 (38%) of 34 cases. Six (14%) of the 42 patients had primary infertility. Thirty-four women produced 93 pregnancies; ectopic pregnancy (EP; rudimentary horn, tubal) occurred in 20 of these cases (22%). The pregnant uterine horn ruptured in 3 of 7 cases. Eight (57%) of the 14 women with infertility underwent treatment by IVF-ET; 4 of them conceived, and 2 had term delivery. The fetal survival rate was 61%, prematurity 17%, fetal growth retardation 5%, and the spontaneous intrauterine (IU) abortion rate was 16%. Pregnancy-induced hypertension (PIH) was more common in women lacking a kidney than in those with two kidneys., Conclusion(s): The high number of EPs indicates removal of rudimentary horn and its tube when diagnosed. The prognosis of IU pregnancy is not impaired in the unicornuate uterus although prematurity threatens. Unilateral renal agenesis is associated with PIH.

Study Objective: To evaluate reproductive performance in women with a confirmed uterine anomaly treated by abdominal or hysteroscopic metroplasty, or by no surgical procedure., Design: Retrospective study., Setting: A university hospital., Patients: Four hundred four women with uterine anomaly, of whom 247 had complete or partial septate uterus or partial bicornuate uterus., Interventions: Hysteroscopic metroplasty was performed in 32 patients with septate or subseptate uterus. Twenty women underwent abdominal metroplasty (Jones or Tompkins procedure) and 140 had no operative treatment., Measurements and Main Results: Fetal survival improved from 13% to 91% after hysteroscopic metroplasty and from 3% to 86% after the abdominal procedure. A living child was born in 67% of 264 pregnancies in 116 women with septate uterus with no surgical treatment. When 19 patients with hysteroscopic metroplasty were matched by age, gravidity, and type of uterine anomaly with 19 women not subjected to metroplasty, the rates were 86% and 68%, respectively (p = 0.089)., Conclusions: Hysteroscopic metroplasty has replaced abdominal metroplasty in the treatment of septate uterus. It improves the fetal survival rate in women with repeated miscarriage. It does not enhance pregnancy rates in infertile women with septate uterus, but as a minimally invasive uterine repair, it may be carried out before assisted reproduction. Pregnancy in the septate uterus can also progress without any surgical treatment. Metroplasty seems to prevent breech delivery and to decrease the cesarean section rate, which are potential benefits.

Objective: We evaluated the advantages and disadvantages of laparoscopic hysterectomy over a 2-year period when this new technique was introduced to several hospitals in Finland., Study Design: A nationwide register was founded and a prospective multicenter survey of 1165 laparoscopic hysterectomies was carried out from January 1993 to December 1994. The operations were performed because of uterine fibroids (54%), menorrhagia (27%), dysmenorrhea (8%), endometriosis (2%), and other reasons (9%) by 68 gynecologists at 30 hospitals., Results: The mean operation time was 132 minutes. The patients stayed in hospital for an average of 3.3 days, and the mean convalescence period was 17.9 days, half that after abdominal hysterectomy. Complications occurred in 10.2% of the procedures: infections in 5.6%, vascular complications in 1.2%, urinary tract complications in 2.7%, and bowel complications in 0.4%., Conclusions: Laparoscopic hysterectomy offers a short hospital stay and convalescence time to the patient, but effective teaching is imperative to minimize, in particular, the risk of urinary tract injuries.