Surgical Outcomes In Women Research Articles

Does preoperative urodynamics improve outcomes for women undergoing surgery for stress urinary incontinence? A systematic review and meta-analysis.

Urodynamics is widely used in the investigation of urinary incontinence. The existing evidence questions its add-on value in improving the outcome of surgical treatment for stress urinary incontinence (SUI). To compare the surgical outcomes in women with SUI or stress-predominant mixed urinary incontinence (MUI) based on urodynamic diagnoses compared with diagnoses based on office evaluation without urodynamics. We searched Cochrane, MedLine, Embase, CINAHL, LILACS, metaRegister of Controlled Trials (mRCT) and Google Scholar databases from inception until March 2013. We included randomised controlled trials (RCTs) comparing surgical outcomes in women investigated by urodynamics and women who had office evaluation only. Two independent reviewers (S.R. and P.L.) extracted the data and analysed it using review manager (revman) 5.2 software. Of the 388 articles identified, only four RCTs met our criteria. The data from one study are as yet unpublished. In the other three RCTs, the women with SUI or stress-predominant MUI were randomised either to office evaluation and urodynamics (n = 388) or to office evaluation only (n = 387). There was no statistical difference in the risk ratio (RR) of subjective cure in the two groups (RR 1.02, 95%CI 0.90-1.15, P = 0.79, I(2) = 45%), objective cure (RR 1.01, 95%CI 0.93-1.11, P = 0.28, I(2) = 20%) or complications such as voiding dysfunction (RR 1.54, 95%CI 0.61-3.89, P = 0.27, I(2) = 18%) or urinary urgency (RR 0.80, 95%CI 0.28-2.3, P = 0.19, I(2) = 40%). In women undergoing primary surgery for SUI or stress-predominant MUI without voiding difficulties, urodynamics does not improve outcomes - as long as the women undergo careful office evaluation.

Capsule commentary on Olchanski et al., abdominal aortic aneurysm screening: how many life years lost from underuse of the medicare screening benefit?

This study by Olchanski et al.1 investigated utilization of the abdominal aortic aneurysm (AAA) screening benefit through the Screening Abdominal Aortic Aneurysms Very Efficiently (SAAAVE) Act for Medicare beneficiaries, and estimated whether increasing its utilization would increase life expectancy. The authors conclude that screening benefits have been underutilized (< 1 % each year among those newly eligible) and that increasing utilization to 80 % of the eligible population would yield substantial gains in life expectancy. They also note that expanding screening to women with smoking history also has the potential for substantial health benefits. The reported estimates may have been confounded by two factors. First, the current prevalence of AAA and the incidence of AAA rupture are on the decline among men, as the prevalence of smoking has decreased considerably in the past decade, though the prevalence continues to rise among women.2 Second, the data on AAA prevalence and rupture rates and surgical outcomes in women are less robust than for men.3 The authors estimate the numbers indirectly from other available studies, and therefore the projected estimates may not be accurate in that population. The results of the study are important from the preventive and policy viewpoint. Why is AAA screening largely underutilized in the U.S? More studies are needed to further explore the reasons behind the underutilization. The authors cite Medicare’s requirement that screening be conducted within the limited eligibility period, the out of pocket deductible and the physician reimbursement as barriers to screening. Lack of physician awareness may be a larger contributor. As there are currently no quality measures around AAA screening, it may get lost among the myriad other recommended tests. The rates of AAA screening are significantly lower than colon cancer screening among Medicare beneficiaries. These missed opportunities can be corrected by raising awareness of the benefits and eventually linking it as a quality metric. Lastly, as is evident from this study, increasing utilization may yield significant gains in life expectancy among both men and women.

Impact of geographic location on surgical outcomes of women with breast cancer

The aim of this study is to use the Breast Surgeons of Australia and New Zealand Quality Audit to evaluate the diagnostic work up and surgical treatment path for Australian women with early breast cancer in relation to geographic location. We accessed data on patient geographic demographics, diagnostic and surgical procedures and cancer characteristics in 115,872 episodes of early breast cancer reported to the Quality Audit between 1998 and 2012. Tumour size, grade and number, lymph node positivity and lymphovascular invasion are the major prognostic factors adjusted for. Core biopsy is the most frequently performed diagnostic method and open biopsy the least (P=0.001). Remote locations have the highest proportion of open biopsies and cities the lowest (13.8 versus 9.8%, P=0.001). The outer regional/remote patient group has a higher likelihood of an open biopsy than city patients (odds ratio 1.5; 95% confidence interval 1.1-2.2 P=0.02). Reconstruction rates are low throughout ranging from 3 to 4% (P=0.001). Cities have the highest proportion of no surgery (1.5%, P=0.001). Cities have the highest proportion of breast conserving surgery and the remote the lowest (64.5% versus 29.9%, P=0.001). Outer regional locations have the highest proportion of mastectomies and cities the lowest (38 versus 29.9%, P=0.001). The likelihood of receiving radiotherapy is associated with geographic location of residence and geographic distribution of the radiotherapy facility (P=0.002, P=0.001). Geographic location of residence is associated with the diagnostic work up and surgical treatment of Australian women with early breast cancer.

Vaginal versus abdominal hysterectomy for the enlarged non-prolapsed uterus: a retrospective cohort study

ObjectiveTo compare surgical outcomes in women with enlarged uteri >12 weeks’ size who underwent vaginal hysterectomy compared to abdominal hysterectomy for non-prolapse indications. Study designRetrospective cohort study performed between 2007 and 2012 in a North London teaching hospital. The study group comprised 39 women who had vaginal hysterectomy (VH) with uteri >12 weeks size (200g) for non-prolapse indications. The next successive total abdominal hysterectomy (TAH) following the index case for similar indications (and with similar uterine weights) served as control (n=33). The groups were compared for pre- and post-operative demographic data, and main outcome measures were estimated blood loss, operation time, length of stay and complications. ResultsBoth VH and TAH groups had statistically similar pre-operative mean haemoglobin levels, age, body mass index, previous abdominal surgery, and American Society of Anesthesiologists (ASA) grade. Mean uterine weight (403.1±239.5 vs 460.5±236.2g) was comparable in both groups (both p>0.05). The mean duration of the procedure was similar (123.5±45.8 vs 119.8±44.9min, p=0.580) but women who had TAH lost 117ml more of blood (525.7±427.6 vs 408.2±411.8ml, p=0.039). Although overall complication rates were comparable between the groups (30.8% vs 36.4%, p=0.627), the mean post-operative stay was 55% shorter following VH (40.7±29.4 vs 90.7±46.2h, p<0.0001). ConclusionIn women with non-prolapsed uteri >12 weeks’ size, VH is a safe and cost effective option. The vaginal route is associated with significantly lower estimated blood loss and 55% shorter post-operative stay, with no increase in complication rates.

Transvulvar ultrasound of urethrovesical junction and proximal urethra as prognostic markers of burch procedure outcome

Objective: To compare sonographic pre- and post-op parameters related to the urethrovesical junction (UVJ) and proximal urethra (PU) in women with stress urinary incontinence (SUI) surgically cured or not with the Burch procedure, and to evaluate whether these can be used as prognostic markers. Methods: Thirty female patients were selected by convenience sampling and assigned into two groups: 15 patients considered as clinically cured (the case group) and 15 as not cured (the control group). The enrollees were submitted to pre- (30 days prior) and post-op (180 days after) transvulvar ultrasound assessments of the UVJ and PU. Results: On post-op assessments measured on strain, the vertical UVJ distance from the inferior pubic border and the PU length were significantly larger in cured patients (12.87 ± 5.80mm vs 5.13 ± 6.55mm in controls, P <0.01; and 13.07 ± 6.44mm vs 6.20 ± 6.14mm in controls, P <0.01) respectively. The vertical UVJ displacement or descent and PU displacement or variation were significantly shorter in cured patients (8.47 ± 3.98mm vs 5.13 ± 2.36mm in controls, P < 0.001; and 8.33 ± 4.54mm vs 5.20 ± 2.90mm in controls, P < 0.05) respectively. More importantly, on pre-op assessments, only the PU displacement or variation was significantly larger in cured patients (15.87 ± 4.55mm vs 12.47 ± 3.52 mm in controls, P <0.05). Conclusions: Transvulvar ultrasound of the UVJ and PU can be used as prognostic markers of surgical outcomes in women with SUI treated with the Burch procedure.

Quality of life scores improve in women undergoing colpocleisis: a pilot study

To evaluate the quality of life and surgical outcomes in women who had undergone colpocleisis. This was a prospective small cohort study conducted between August 2010 and September 2011. Twelve women with pelvic organ prolapse were offered obliterative vaginal surgery and were informed about the surgical procedure. Ten women accepted this operation and were included in the study. Before and after colpocleisis, cases were evaluated by urogynecological examination, and quality of life was assessed by the Turkish language validated prolapse quality of life questionnaire (P-QOL), in which a low total score indicates a good quality of life. The mean age was 74.9±4.5 (range 68-85). The general score of the P-QOL was reduced during the follow-up period, reflecting a significant effect on quality of life and clinical improvement in women with the colpocleisis operation. There was no morbidity due to colpocleisis or recurrent pelvic organ prolapse in follow-up period. In our small cohort including elderly women, colpocleisis provided high levels of surgical outcomes as well as a significant improvement in quality of life without significant morbidity.

Preoperative Staging with Magnetic Resonance Imaging, with Confirmatory Biopsy, Improves Surgical Outcomes in Women with Breast Cancer without Increasing Rates of Mastectomy

Needle biopsy to evaluate findings on MRI that could alter surgical planning has been recommended. This study is a retrospective review to evaluate MRI preoperative staging with biopsy confirmation of suspicious findings. A total of 184 women were diagnosed with breast cancer between January 2004 and June 2008. Of these, 79 underwent bilateral MRI before definitive surgery and 105 did not. Suspicious findings on MRI, mammography, or clinical exam underwent additional needle biopsy at the discretion of the surgeon. A retrospective chart review was performed to compare the two groups with respect to rates of reoperative surgery, successful breast conservation, and confirmatory biopsies. Sensitivity and specificity of MRI for preoperative staging is 0.81 and 0.84, respectively. There were no significant differences in demographics or cancer characteristics between the MRI and non-MRI groups. Fewer women who underwent preoperative MRI staging required repeat breast surgery (11% versus 26%, p = .04) or repeat axillary surgery (10% versus 20%, p = .05). There is no difference in the proportion of women who successfully completed conservative therapy and those treated radically (52% versus 53%), but there is a significant increase in women who undergo additional needle biopsy to confirm suspicious findings after initial diagnosis in the MRI group (25% versus 11% p = .04). In this study, mastectomy rates are not increased; suggesting that women who undergo mastectomy following staging would undergo mastectomy following failed conservative therapy if they were not staged. The downside of this improvement is a 14% increase in women who require confirmatory biopsy.

The Impact of Prior Breast Augmentation on Short and Long Term Surgical Outcomes for Women Diagnosed with Breast Cancer

The Impact of Prior Breast Augmentation on Short and Long Term Surgical Outcomes for Women Diagnosed with Breast Cancer

Clinical manifestations in women with isolated fallopian tubal torsion; a rare but important entity

The diagnosis of adnexal torsion can be difficult to make, especially in isolated fallopian tube torsion (FTT). Only small series and several case reports on isolated FTT have been published in the literature. To demonstrate symptom presentations, objective findings and surgical outcomes in women with isolated FTT over a 12-year period at a tertiary hospital. Using the International Classification of Disease, Ninth Revision, and Clinical Modification, we reviewed the clinical records of women with isolated FTT during 1996 and 2008 at our institute. Seventeen women, age 13-50 (mean 32) with surgically proven isolated FTT, were included. Five women (29.4%) had tubal ligation history. None of these cases were diagnosed before operation. Pain characteristics were variable; the onset was sudden in 10 (58.8%) and 17 (100%) complained of lower abdominal pain, but only six (35.3%) had peritoneal signs. Other clinical manifestations were as follows: nausea or vomiting in seven women (41.2%), lower urinary tract symptoms in four (23.5%) and fever in three (17.6%). All the women had a cystic adnexal mass on ultrasound. An enlarged tubal mass (5-14 cm) was found in all the cases at surgery. Eleven women (64.7%) underwent laparoscopy, and six (35.3%) laparotomy for salpingectomy. The diagnosis of isolated FTT is often not made before surgical intervention because clinical features are non-specific. However, it needs to be considered in women with acute lower abdominal pain with a unilateral cystic adnexal mass.

Sexual Function and Surgical Outcome in Women with Congenital Adrenal Hyperplasia Due to CYP21A2 Deficiency: Clinical Perspective and the Patients' Perception

Sexual Function and Surgical Outcome in Women with Congenital Adrenal Hyperplasia Due to CYP21A2 Deficiency: Clinical Perspective and the Patients' Perception

Surgical treatment of female stress urinary incontinence with a transobturator tape (Monarc): Short‐term results of a prospective multicenter study

Transobturator tape (TOT) kits approved as medical instruments are still not available in Japan. This study aimed to: (1) assess the outcomes of TOT using Monarc (American Medical Systems; AMS Inc, Minnetonka, MN, USA) in women with stress urinary incontinence (SUI); (2) evaluate possible different surgical outcomes in women with urethral hypermobility (UH) and/or intrinsic urethral deficiency (ISD); and (3) evaluate the possibility of improvement of preoperative urgency and urge urinary incontinence after TOT in mixed urinary incontinence (MUI). Data from 140 women with SUI in a prospective multicenter study were examined at 3-6 months follow-up. 82.1% of the patients were cured and 10.7% showed improvement. The surgical outcome was significantly better in UH than in UH combined with ISD or ISD. In 44 MUI patients, 79.6% were cured and 15.9% showed improvement. Urgency improved in about 75% of patients after TOT. TOT is effective for both SUI and MUI, with urgency improving.

Sexual Function and Surgical Outcome in Women with Congenital Adrenal Hyperplasia Due toCYP21A2Deficiency: Clinical Perspective and the Patients’ Perception

Females with congenital adrenal hyperplasia (CAH) due to a CYP21A2 deficiency are exposed to androgens during fetal development, resulting in virilization of the external genitalia. Little is known about how these women feel that the disease has affected their lives regarding surgery and psychosexual adaptation. Our objective was to investigate the correlation between the surgical results, the self-perceived severity of the disease, and satisfaction with sexual life and relate the results to the CYP21A2 genotype. Sixty-two Swedish women with CAH and age-matched controls completed a 120-item questionnaire, and a composite score for sexual function was constructed. The surgical outcome, including genital appearance and clitoral sensitivity, was evaluated by clinical examination. The patients were divided into four CYP21A2 genotype groups. The sexual function score, but not for genital appearance, was higher in the patients satisfied with their sexual life. This was also true of the patients who were satisfied with the surgical result. There were discrepancies between the patients' perception of the impact of the condition on their sexual life and what health professionals would assume from clinical examination. The patients in the null genotype group scored lower on sexual function and satisfaction with their sexual life and had more surgical complications, also compared with the slightly less severe I2-splice genotype group. Our data show that the null genotype group was considerably more affected by the condition than the other groups and should be regarded as a subgroup, both psychologically and from a surgical perspective. Genotyping adds clinically valuable information.

IJU this issue

Various modalities of hormonal therapy for prostate cancer have been developed since Dr Charles B Huggins introduced the principle of the therapy. This issue starts with the Editorial by Suzuki (Deputy Editor), who describes current topics and future perspectives of hormonal therapy for prostate cancer. Readers are encouraged to submit letters in response to any part of the Editorial. This issue also includes two excellent review articles that describe current topics related to urological oncology. The first one, written by Van Poppel (Leuven, Belgium), is on current evidence of efficacy and safety of nephron-sparing surgery (NSS). Many studies have already shown that NSS is effective and safe for localized renal cell cancer, not only for T1a but also for T1b tumors. Recent progress in surgical instruments has enabled laparoscopic partial nephrectomy to be a well-suited technique when carried out at high-volume centers. This review helps us to understand the pros and cons of the latest surgical procedures. The other review by Dohle (Rotterdam, the Netherlands) focuses on fertility in male cancer survivors. Currently, cryopreservation of sperm before cancer treatment is the only method to guarantee future male fertility; however, this method is not available for pre-pubescent boys. Recent studies have shown the possibility of fertility preservation by using spermatogonial stem cells. Among the following original articles, two are related to the management of advanced urological cancers. Yokomizo et al. (Fukuoka, Japan) investigated the incidence of skeletal-related events (SRE) in urological cancer patients with bone metastases in Japan. This multicenter retrospective study determined the type and incidence of SRE (fracture, radiotherapy, spinal cord compression, surgery, hypercalcemia and bone pain). The incidence of fracture was shown to be lower in Japanese renal cancer patients, although the overall incidence of SRE in Japanese patients was similar to that in Western patients. It has been reported that adrenal androgens are the source of intratumoral androgens in patients with castration-resistant prostate cancer (CRPC). Narimoto et al. (Kanazawa, Japan) measured concentrations of five androgens in order to investigate the relationship between adrenal androgens and effectiveness of flutamide as a second-line antiandrogen in 16 patients with CRPC treated with bicalutamide as the first-line antiandrogen. According to the data, metabolites from adrenal androgens seem to contribute to the development of CRPC. Introduction of tension-free vaginal tape (TVT) and mesh (TVM) procedures resulted in improved surgical outcomes in women with stress urinary incontinence (SUI) and pelvic organ prolapse (POP), respectively. Xu et al. (Shanghai, China) investigated the prevalence of dysfunctional voiding (DV) in female SUI and its alteration after the TVT procedure. DV was determined based on urodynamic evaluation. The urodynamic study was repeated in some patients who received the TVT procedure. This study suggests that DV is alleviated after surgery in patients with a shortened functional profile length. Takahashi et al. (Tokyo, Japan) prospectively evaluated the TVM procedure for POP in 310 female patients. Quality of life (QOL) was also evaluated by using the Short Form-36 (SF-36) and the prolapse-QOL questionnaires. The anatomical cure rate at 12 months after surgery was 92.3% with a low incidence of surgical complications. SF-36 and prolapse-QOL parameters were significantly improved. Bone marrow-derived mesenchymal stem cells (BMSC) are capable of differentiating into various cell types. Kinebuchi et al. (Matsumoto, Japan) examined the effect of autologous BMSC transplantation on the recovery of the injured rat urethral sphincter. This study suggests a potential benefit of BMSC transplantation for recovering leak point pressure. Further study is required to determine the possibility of clinical applications for the treatment of SUI. Cell–cell interaction is the important mechanism in the progression of cancers. Kaneko et al. (Saga, Japan) found that adipocytes could modulate the proliferation and differentiation of prostate cancer cell lines. Ultrasonic laparoscopic coagulation shears (LCS) have contributed to an increase in the number of laparoscopic surgery. However, surgeons should be aware that the active blade produces a high temperature, which causes damage to the surrounding tissue. Kim et al. (Nagoya, Japan) have found that the temperature of the LCS tissue pad (contrary to the active blade) is also elevated, which is enough to cause histological changes. We should pay attention to the neighboring tissue and organs around the tissue pad, as well as the active blade, during activation. This study also provides useful information on the activation time by concluding that a short activation time within 5 s is a safe method of use.

Urodynamic assessment of urinary incontinence

ContextUrodynamic evaluation in the assessment of women complaining of urinary incontinence remains controversial with recent UK National Institute of Health and Clinical Excellence guidance maintaining that it is unnecessary prior to surgery for women with a primarily stress leakage. Other experts contend it should be part of routine preoperative assessment since it establishes a diagnosis, allows more careful patient counseling and predicts surgical outcome.ObjectivesTo summarize current literature to define the evidence level on which these conflicting opinions are based.Materials and MethodsA systematic literature search was performed and retrieved publications summarized in a narrative evidence review using both original papers and previous reviews.ResultsFive hundred and one primary research papers and 65 previous reviews were retrieved. The findings were summarized in a narrative comprising overview, description of methods of bladder and urethral pressure measurement, and a summary of the literature concerning four key questions.ConclusionThe level of evidence was low regarding answering each of the questions posed, preventing firm conclusions. Urodynamic findings do correlate with relevant symptoms and, to some extent, with symptom severity, giving reasonable diagnostic accuracy. There is no reliable evidence that preoperative urodynamic diagnosis improves outcome from surgery for stress incontinence although it is likely to facilitate preoperative discussion. Tests to differentiate sphincter deficiency and urethral hypermobility are not currently recommended due to poor validity and reproducibility. This along with the current use of mid-urethral tapes as the universal primary surgical procedure means differentiation is not a necessity. Preoperative diagnosis of detrusor overactivity does not appear to worsen surgical outcome in women with a primary symptom of stress leakage. Large, well-designed prospective studies are now underway to provide a definitive answer to these questions.

Long-term histologic response to synthetic and biologic graft materials implanted in the vagina and abdomen of a rabbit model

We sought to evaluate the effects of graft type, site of implantation, and ovariectomy on the long-term histologic response to graft materials used in pelvic reconstructive surgery. In all, 45 rabbits underwent ovariectomy or sham laparotomy and were implanted with polypropylene (PP) mesh (n = 23) or cross-linked porcine dermis (PS) (n = 22) in the vagina and abdomen. Grafts were harvested 9 months later and were processed for histology to evaluate the host inflammatory response and degree of tissue incorporation within the grafts. Polypropylene induced a milder (P < .007), more uniform response than PS, whereas PS elicited a more variable response and degraded by 9 months. Vaginal grafts had higher scores for inflammation (P = .005) and neovascularization (P < .001), and had lower scores for fibroblastic proliferation (P < .001) than abdominal grafts. Ovariectomy had no effect (P > .05). Synthetic and biologic grafts evoke different foreign body responses, which may have implications for surgical outcomes in women.

Short-term outcome of fertility-sparing laparoscopic excision of deeply infiltrating pelvic endometriosis performed in a tertiary referral center

To examine the short-term surgical outcomes in women undergoing fertility-sparing laparoscopic excision of deeply infiltrating pelvic endometriosis. Retrospective cohort study. Tertiary referral center for treatment of endometriosis, a university teaching hospital, London, United Kingdom. A total of 177 women who underwent fertility-sparing laparoscopic excision of deeply infiltrating endometriosis between January 1, 2006, and December 31, 2007. Eligible women were identified from the surgeons' database, and their medical notes were reviewed. Data from preoperative assessment, surgery, and postoperative outcomes were analyzed. Complication rate. One hundred seventy-seven women underwent fertility-sparing laparoscopic excision of deeply infiltrating endometriosis including excision of uterosacral ligaments (43, 24.3%), excision of rectovaginal septum (56, 31.6%), rectal shave (56, 31.6%), disk excision (7, 4%) or bowel resection (15, 8.5%). The median operative time was 95 minutes with a range of 30 to 270 minutes (interquartile range 75-120 minutes). Overall, complications developed in 18 women (10.2%). In 12 (6.8%) of these only uncomplicated pyrexia developed whereas significant intraoperative and/or postoperative complications developed in the remaining 6 (3.4%). Women spent a median of 2 days recovering in hospital (range 1-7, interquartile range 2-3 days). Fertility-sparing laparoscopic excision of deeply infiltrating endometriosis appears to be safe with a low short-term complication rate.

Primary Systemic Therapy in Breast Cancer: Past Lessons and New Approaches

Primary systemic therapy (PST) is a common treatment strategy used to optimize surgical outcomes for women with locally advanced breast cancer. Several cooperative group trials have shown equivalent survival outcomes between neoadjuvant and adjuvant chemotherapy and have identified pathologic complete response (pCR) as a biologic marker for survival. Research efforts to optimize PST include the development of strategies to predict individual response and to guide the choice of chemotherapy. These emerging approaches are informed by our knowledge of subtypes of breast cancer, as well as genomic technologies, such as chemosensitivity signatures. Following definitive surgery, the management of residual disease is controversial.

249: The Use of a Vessel-sealant Device (LigaSure) Compared with Ultrasonic Surgical Instrumentation (Harmonic Ace) in Radical Hysterectomy for Cervical Cancer

To evaluate surgical outcomes in women undergoing laparoscopic radical hysterectomy for cervical cancer using a vessel-sealant device (LigaSure Atlas, Valleylab, Boulder, Colorado, USA) compared with an ultrasonic surgical device (Harmonic ACE, Ethicon Endo-Surgery, Cincinnati, Ohio).

The Volume at Which Women Leak First on Urodynamic Testing is Not Associated With Quality of Life, Measures of Urethral Integrity or Surgical Failure

We determined if the bladder volume at which urodynamic stress incontinence is first detected is related to preoperative quality of life, urethral sphincter assessment or surgical outcome in women undergoing continence surgery. Charts of consecutive women who underwent a sling or Burch procedure were reviewed. Preoperative and postoperative assessment included the Incontinence Impact Questionnaire and Urogenital Distress Inventory. Urodynamic stress incontinence volume is the bladder volume at which urodynamic stress incontinence was first detected. Women were divided into 4 groups according to urodynamic stress incontinence volume, and compared with respect to maximum urethral closure pressure, Valsalva leak point pressure, Incontinence Impact Questionnaire and Urogenital Distress Inventory. Urodynamic stress incontinence persistence was evaluated only in patients who had sling surgery. A total of 168 women were recruited for the study. Urodynamic stress incontinence volume was 100 ml for 31% of women, 200 ml for 17%, 300 ml for 17% and 400 ml or greater for 35%. Baseline and postoperative Urogenital Distress Inventory, Incontinence Impact Questionnaire, maximal urethral closure pressure and Valsalva leak point pressure did not differ by urodynamic stress incontinence volume. Among the 116 patients who had the sling procedure, urodynamic stress incontinence persistence did not differ by urodynamic stress incontinence volume (p=0.72). Women who demonstrate urodynamic stress incontinence at lower bladder volumes do not report greater bother from incontinence than women who leak at higher volumes, suggesting leakage severity on urodynamics is not an adequate reflection of incontinence related quality of life.

Rates for mastectomy are lower in women attending a breast‐screening programme

Mammographic screening for breast cancer facilitates earlier recognition of lesions, thus potentially allowing for breast-conserving surgery. Few studies have compared the final surgical outcomes of women presenting through breast screening programmes with those presenting via other sources. Are breast cancer patients presenting through BreastScreen more likely to undergo breast-conserving surgery than those presenting from other sources? Using the Royal Perth Hospital (RPH) Multidisciplinary Breast Service Database, the final surgical outcomes were reviewed for 723 women treated for breast cancer at RPH between January 2000 and August 2002. During this period, 397 patients were referred to the RPH Multidisciplinary Breast Clinic from BreastScreen WA, and 326 were referred from other sources. Of all patients undergoing surgery for breast cancer, 58% in the screen group and 36% in the non-screen group had breast-conserving surgery (P < 0.0001). When surgical outcomes for women in the BreastScreen target age range of 50-69 years were analysed, 59.5% in the screen group and 42.3% in the non-screen group had breast-conserving surgery (P < 0.001). Patient choice was second only to disease extent as a factor determining the outcome of mastectomy. In both cohorts, more than 40% of patients who underwent re-excisional surgery for positive margins, after initial breast-conserving surgery, had residual invasive or in situ disease present. At RPH, BreastScreen patients were more likely to undergo breast-conserving surgery than those who presented from other sources. A significant proportion of women with positive margins after initial breast-conserving surgery had residual in situ or invasive disease. Re-excision for positive margins was thus warranted.