Orientador: José Luiz Laus / Banca: Aline Adriana Bolzan / Banca: Cristiane dos Santos Honsho / Banca: Marcia Rita Fernandes Machado / Banca: Cintia Lucia Maniscalco / Resumo: Com o trabalho, propõe-se apresentar um modelo experimental de prolapso da glândula da terceira pálpebra em cães, valendo-se, para tal, da ressecção do retináculo glandular periorbitário e de estudos macro e microscópicos, bem como das intercorrências clínicas, quanto à produção lacrimal. As variáveis foram estudadas em bulbos dos olhos com glândulas prolapsadas, em outros com glândulas sepultadas cirurgicamente e em bulbo do olhos que passaram por exérese glandular. Mediante análise dos resultados constatou-se que a produção lacrimal diminuiu, comparativamente às glândulas normais não prolapsadas, notadamente naqueles casos em que as glândulas prolapsadas não foram sepultadas. Glândulas prolapsadas apresentaram-se maiores, quanto ao comprimento, à largura e à espessura. Microscopicamente, glândulas prolapsadas não sepultadas cirurgicamente, exibiram alterações inflamatórias glandulares e ductais em maior intensidade. Das glândulas prolapsadas, 84,2% assim permaneceram, permitindo que fossem estudadas quanto às variáveis concebidas. / Abstract: The work proposes to present an experimental model of prolepsis of the third eyelid gland in dogs, using for such a thing the resection of the periorbital glandular support and macro and rnicroscopic studies, as well as the c1inical intercurrences, related to the lacrimal production. The variables weíe studied in the eyes bulb with prolapsed glands, in others with surgically buried glands and eyes bulb that passed by glandular exerese. Through the results analysis, it was evidenced that the lacrimal production diminished, when compared with the normal ones not prolapsed, mainly in those cases where the prolapsed glands were not buried. Prolapsed glands are presented bigger, in relation to their length, width and thickness. Microscopically, prolapsed glands that were not buried surgically, showed glandular and duct inflammatory changes in higher intensity. Qut of the prolapsed glands, 84.2% remained in the same way, allowing that they were studied in relation to the conceived variables. / Doutor

O prolapso uterino tem sua incidência aumentada na pós-menopausa. O objetivo deste estudo é identificar as alterações na matriz extracelular do ligamento cardinal associadas à menopausa e ao prolapso uterino. Ligamento cardinal de três diferentes grupos de mulheres, pré-menopausa, prolapso uterino e pós-menopausa, foram identificados e biopsiados durante 57 histerectomias abdominais ou vaginais. As amostras foram processadas por métodos bioquímicos para caracterização e quantificação de glicosaminoglicanos sulfatados e colágeno. As concentrações relativas de glicosaminoglicanos foram obtidas por eletroforese. Procedimentos histológicos foram feitos para identificar fibras elásticas (Weigert), distribuição de colágeno (Picro Sirius) e decorin (imunohistoquímica). Nossos resultados mostraram aumento na concentração de GAG de 72,2%, redução na concentração de colágeno de 37% e diminuição de 22% de fibras elásticas no grupo de prolapso uterino quando comparado ao grupo da pós-menopausa (p<0,05, p<0,04 e p<0,05 respectivamente). As concentrações relativas de glicosaminoglicanos sulfatados para condroitin sulfato, heparan sulfato e dermatan sulfato não mostraram diferenças entre os três grupos. A organização do colágeno foi similar entre os três grupos e a marcação do decorin pareceu estar diminuída no grupo de prolapso uterino. Nossos resultados indicam alterações no metabolismo do tecido conjuntivo. O ligamento cardinal da mulher na pós-menopausa possui uma matriz extracelular mais densa. Esta alteração não ocorre na mulher com prolapso uterino. / Uterine prolapse has increase of incidence after menopause. The aim of this study was to identify the changes in extracellular matrix of cardinal ligaments associated to menopause and uterine prolapse. Cardinal ligament of 3 different groups (pre-menopause, menopause and uterine prolapse) are identified and biopsied during 57 womens abdominal or vaginal hysterectomy. Biopsy specimens were assessed by biochemical methods to characterize and quantify sulfated glycosaminoglycans and collagen. Relative concentrations of GAG were obtained by electrophoresis. Histological procedures are made to identify elastic fibers (Weigert) collagen distribution (Picro sirius) and decorin (immunohistochemistry). Our results showed increase in GAG concentration 72.2% in uterine prolapse group compared to menopause group (p<0.05). Collagen concentration was 37% lower in uterine prolapse group compared to menopause group (p<0.04). Relative concentration of GAG: heparan sulfate, chondroitin sulfate and dermatan sulfate showed no differences among three groups. Elastic fibers showed a significant reduction of approximately 22% uterine prolapse group compared to menopause group (p<0.05). Collagen organization was similar in three groups and the staining pattern of decorin seemed to be decreased in uterine prolapse group. Our results indicate changes in connective tissue metabolism. Cardinal ligament in postmenopausal women has a denser extracellular matrix. This change is not observed in women with uterine prolapse.

abstract: The objective of this research is to develop a biocompatible scaffold based on dextran and poly acrylic acid (PAA) with the potential to be used for soft tissue repair. In this thesis, physical and chemical properties of the scaffold were investigated. The scaffolds were made using electrospinning and cross-linked under high temperature. After heat treatment, Scanning Electron Microscope (SEM) was used to observe the structures of these scaffolds. Fourier transform infrared spectroscopy (FTIR) was used to measure the cross-linking level of scaffold samples given different times of heat treatment by detecting and comparing the newly formed ester bonds. Single-walled carbon nanotubes (SWCNT) were added to enhance the mechanical properties of dextran-PAA scaffolds. Attachment of NIH-3T3 fibroblast cells to the scaffold and the response upon implantation into rabbit vaginal tissue were also evaluated to investigate the performance of SWCNT dextran-PAA scaffold. SEM was then used to characterize morphology of fibroblast cells and rabbit tissues. The results suggest that SWCNT could enhance cell attachment, distribution and spreading performance of dextran-PAA scaffold. / Dissertation/Thesis / Masters Thesis Bioengineering 2014

Orientador: Viviane Herrmann Rodrigues / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-10T03:27:58Z (GMT). No. of bitstreams: 1 Castro_EdilsonBeneditode_M.pdf: 1738241 bytes, checksum: ddc9c76f04b9f7476ede4b0a887d468a (MD5) Previous issue date: 2006 / Resumo: Objetivos: Avaliar pelo sistema de quantificação do prolapso dos órgãos pélvicos (POP-Q), preconizado pela Sociedade Internacional de Continência (ICS) os compartimentos vaginais anterior, posterior e apical em mulheres submetidas à colpofixação sacroespinhal para o tratamento do prolapso uterino ou de cúpula vaginal e analisar os sintomas urinários antes e depois da cirurgia. Sujeitos e métodos: Estudo retrospectivo realizado no Setor de Uroginecologia do Hospital Estadual Sumaré da Universidade Estadual de Campinas em 2006. Foram analisados os prontuários de 47 mulheres submetidas à colpopexia sacroespinhal entre março de 2003 e fevereiro de 2006. Foram avaliados os sintomas urinários (incontinência urinária de esforço, urgência, incontinência de urgência, noctúria e enurese noturna) no pré e pós-operatório, considerando-se sintomas presentes ou ausentes e analisados pelo Teste de qui-quadrado de Mc Nemar. Os pontos Aa, Ba, C, D, Ap, Bp, tvl, gh e pb do POP-Q foram avaliados na primeira consulta e na revisão pós-operatória. O Teste de Wilcoxon foi aplicado para comparar os pontos e os estágios do prolapso genital antes e depois da cirurgia. Complicações intra e pós-operatórias foram descritas. Resultados: A média dos pontos do POP-Q no pré e pós-operatório foi respectivamente: Aa (+0,7; -1,7); Ba (+3,2; -1,7); C (+3,2; -7,6); Ap (-0,2; -2,7) e Bp (+2,1; -2,7) (p<0.001). A taxa de cura foi 97,9% para o prolapso apical. Avaliação pré e pós-operatória do compartimento vaginal anterior foi respectivamente: estágio 1 (4,3%; 57,4%), estágio 2 (8,5%; 31,9%), estágio 3 (76,6%; 0%) e estágio 4 (10,6%; 0%). Cistocele ocorreu em 89,4% no pós-operatório. Onze de 12 mulheres que apresentavam urgência miccional tiveram melhora após a cirurgia (p=0,0039) e uma das 45 que não tinham a queixa passou a apresentá-la. Das 8 pacientes que se queixavam de incontinência de urgência, 7 apresentaram remissão do sintoma após a cirurgia (p=0,0082). Houve melhora da noctúria em 7 de 8 casos após a cirurgia (p=0,0399) e 1 dos 39 casos que eram assintomáticos desencadeou o sintoma no pós-operatório. Conclusão: A colpofixação sacroespinhal é um método eficiente para o tratamento do prolapso apical e de parede posterior levando, porém 89,4% das pacientes a apresentarem prolapso de parede anterior estágio 1 e 2 devido ao desvio posterior do eixo vaginal. Ocorreu melhora dos sintomas urinários irritativos (urgência, incontinência de urgência e noctúria) nas pacientes submetidas à fixação sacroespinhal da cúpula vaginal pelo restabelecimento do sistema de sustentação apical posterior / Abstract: Objectives: To evaluate the extent of prolapse of the anterior, posterior and apical vaginal compartments in women undergoing sacrospinous ligament fixation using the pelvic organ prolapse quantification system (POP-Q), recommended by the International Continence Society (ICS) for the treatment of uterine and vaginal vault prolapse and examine urinary symptoms before and after surgery. Subjects and methods: A study was conducted in the Urogynecology Sector of the Sumaré Municipal Hospital of the Universidade Estadual de Campinas in 2006. Medical charts of 47 women undergoing sacrospinous colpopexy between March 2003 and February 2006 were assessed. Urinary symptoms (stress urinary incontinence, urgency, incontinence of urgency, nocturia and nocturnal enuresis) were evaluated in the preoperative and postoperative period, categorizing symptoms as present or absent, and applying the Mc Nemar chi-square test for analysis. Aa, Ba, C, D, Ap, Bp, tvl, gh and pb points of POP-Q were evaluated in the first consultation and postoperative revision. Wilcoxon?s test was applied to compare points and stages of genital prolapse before and after surgery. Intraoperative and postoperative complications were described. Results: Mean POP-Q points in the preoperative and postoperative period were, respectively: Aa (+0.7; -1.7); Ba (+3.2; -1.7); C (+3.2; -7.6); Ap (-0.2; -2.7) and Bp (+2.1; -2.7) (p<0.001). The cure rate was 97.9% for apical prolapse. Preoperative and postoperative evaluation of the anterior vaginal compartment was, respectively: stage 1 (4.3%; 57.4%), stage 2 (8.5%; 31.9%), stage 3 (76.6%; 0%) and stage 4 (10.6%; 0%). Cystocele occurred in 89.4%. Eleven of 12 women with mictional urgency showed improvement of symptom after surgery (p=0.0039) and one of the 45 patients who had no previous complaint, started to suffer from the symptom. Of 8 patients whose complaint was incontinence of urgency, 7 had remission of symptom after surgery (p=0.0082). Nocturia improved in 7 out of 8 cases after surgery (p=0.0399) and the symptom was triggered postoperatively in 1 out of 39 asymptomatic women. Conclusion: Sacrospinous ligament fixation is an efficient method for the treatment of apical and posterior wall prolapse, despite leading to stage 1 and 2 anterior wall prolapse in 89.4% of women due to posterior deviation of the vaginal apex. Improvement in irritative urinary symtoms (urgency, incontinence of urgency and nocturia) took place in patients undergoing sacrospinous ligament fixation of the vaginal vault by reconstitution of the posterior apical support system / Mestrado / Cirurgia / Mestre em Cirurgia

Orientador: Cassia Raquel Teatin Juliato / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-28T01:56:55Z (GMT). No. of bitstreams: 1 Mazzer_MairaFurtadoGreco_M.pdf: 1022810 bytes, checksum: a9f39810ef9b570472a358045117778c (MD5) Previous issue date: 2015 / Resumo: Introdução: O prolapso genital apical (uterino ou de cúpula vaginal) é uma condição que afeta a qualidade de vida das mulheres. Existem diversos tipos de tratamentos cirúrgicos para esses prolapsos, entre eles a colpopromontofixação e a colpofixação ao ligamento sacroespinhal. Esta última técnica tem menor morbidade, mas cursa com aumento nas taxas de prolapso em parede anterior após a cirurgia. O uso de telas sintéticas na parede vaginal poderia diminuir a ocorrência destes prolapsos de parede anterior, diminuindo o número de reintervenções necessárias. Objetivo: comparar a eficácia e a segurança da colpopromontofixação com a técnica de colpofixação ao ligamento sacroespinhal com uso de tela anterior para correção do prolapso genital apical. Sujeitos e métodos: Este foi um estudo corte transversal, com avaliação de 89 prontuários de mulheres submetidas à correção do prolapso apical pelas duas técnicas cirúrgicas, no Departamento de Tocoginecologia CAISM/UNICAMP, no período de 2005 a 2012. Os prolapsos uterinos foram avaliados no pré e pós-operatórios através da técnica de POP-Q. Foram comparadas as taxas de cura objetiva, complicações imediatas e tardias, índices de recidiva do prolapso. As taxas de cura, complicações e recidiva foram avaliadas pela prevalência simples e comparadas através do teste de qui-quadrado ou teste exato de Fisher. Para as variáveis não paramétricas foi utilizado teste de Mann-Whitney. Para as variáveis avaliadas nos momentos de seguimento, foi realizado teste de Wilcoxon pareado para medidas do POP-Q. O nível de significância foi de 5% e o software utilizado para análise foi o SAS. Resultados: Das 89 mulheres, 41 submeteram-se à colpofixação ao ligamento sacroespinhal e 48 à colpopromontofixação. Não houve diferença entre a média de idade, raça, IMC, tabagismo e presença de comorbidades entre os grupos. Das mulheres incluídas no estudo, 40,4% tinham prolapso de cúpula, também sem diferença entre os dois grupos estudados (p=0,9361). Ao analisar as complicações imediatas, observou-se que a grande maioria dos casos operados não apresentou complicações (93,2 %), sem diferença entre os dois grupos (p=0,9418). Não ocorreu nenhuma lesão vascular, intestinal ou de vias urinárias. Aproximadamente 30% das mulheres tiveram complicações tardias, sendo que a complicação mais frequente foi a dor local, presente apenas nas mulheres submetidas à técnica abdominal (25,6%) (p=0,001). Apenas as mulheres submetidas ao procedimento vaginal tiveram exposição de tela (18,4%). Um terço das mulheres submetidas à cirurgia para correção de prolapso apresentou sintomas miccionais após a cirurgia, sem diferença entre os grupos (p=0,5732), sendo que destas 22,1% apresentavam incontinência urinária de esforço e 9,1% apresentavam a urgência (tabela 3). A taxa de cura objetiva foi de 95,8%, sem diferença entre os grupos (p= 0,0955). Com relação ao prolapso de parede anterior após a cirurgia foi observado que não houve diferença entre as mulheres submetidas às duas técnicas cirúrgicas (p=0,2970), Conclusões: Ambas as cirurgias foram seguras e obtiveram resultados semelhantes na cura objetiva. O uso de tela em parede anterior na técnica vaginal mostrou-se eficaz na prevenção de prolapso genital anterior no pós-operatório / Abstract: Introduction and hypothesis: compare safety and efficacy of abdominal sacral colpopexy and sacrospinous ligament suspension with the use of vaginal mesh in apical prolapse. Methods: This retrospective study was conducted from 2005 to 2012, and included 89 women with apical prolapse who underwent surgery. Assessments included pre- and postoperative Pelvic Organ Prolapse Quantification (POP-Q) stage. Rates of objective cure and imediate/late complications were compared. Results: 41 of 89 women underwent sacrospinous ligament suspension and 48 women abdominal sacral colpopexy. 40, 4 % had apical prolapse (p=0, 9361).Most of them had no complications (93, 2 %) (p=0, 9418). Aproximately 30 % of women had late complications; local pain was the main symptom, only in women who underwent abdominal procedure (25, 6%) (p=0,001).Only women who were submitted to the vaginal procedure had mesh erosion (18,4%).Objective sucess rate and anterior vaginal prolapse (p= 0,2970) was similar in both techniques. Conclusion: Sacrospinous ligament suspension was as effective and had similar objective sucess rate as abdominal sacral colpopexy. Sacrospinous ligament suspension performed with vaginal mesh in the anterior compartment was effective to prevent anterior vaginal prolapse after surgery / Mestrado / Fisiopatologia Ginecológica / Mestra em Ciências da Saúde

Pelvic floor dysfunction in the form of pelvic organ prolapse (POP) is a common gynaecological condition, especially in the elderly. Although the aetiology is poorly understood, several risk factors such as vaginal childbirth, chronically raised intra-abdominal pressure (such as asthma and chronic constipation), ageing, previous hysterectomy and connective tissue disorders are thought to play a role in the pathophysiology of POP. Studies have shown that vaginal childbirth can result in both gross and micro-architectural distortion/alteration of the pelvic floor musculature and is thus considered to play a major role in the development of POP. Although ethnicity has been proposed as a risk factor, there are limited studies on this subject. Recently, transperineal ultrasound (TPUS) has been used to study the structural integrity and the dynamic interaction between the pelvic organs and pelvic floor musculature. Using a specified methodology we intended to determine and compare pelvic floor morphology, namely pelvic organ descent and levator hiatal distensibility in a multi-ethnic South African population (Asian, Caucasian and Black) in both asymptomatic nulliparous and symptomatic multiparous women. Secondly we also intended to study the association between prolapse symptoms and functional anatomy of the pelvic floor, and finally to determine the impact of vaginal childbirth on the pelvic floor morphology 3-6 month postpartum. For all the studies women were recruited from the local nursing school, general gynaecology and tertiary urogynaecology clinic. Pregnant women were recruited from the district antenatal clinic. This cohort included only Black pregnant women. After informed consent all ultrasound volumes were acquired at rest, maximal pelvic floor contraction and Valsalva maneuver. Volumes were deindentified and analysed 6-8 weeks later using GE Kretz 4D View (GE Kretztechnik Gmbh, Zipf, Austria). In the nulliparous cohort, we found that Black South African women had greater pelvic organ descent on ultrasound and clinically and greater distensibility compared to South Asian and Caucasian women. Multivariate modelling revealed that Black 2 ethnicity remained a significant factor for pelvic organ mobility on clinical examination, (P=0.024). In women with symptomatic POP, there was significant variation in clinical prolapse stage, levator distensibility and pelvic organ descent in this racially diverse population presenting with pelvic organ prolapse, with South Asians having a lower avulsion rate than the other two ethnic groups (P= 0.014). As regards the association between prolapse symptoms and functional anatomy of the pelvic floor we found a significant association between awareness, visualization and/or feeling of a vaginal lump and abnormal pelvic floor functional anatomy, that is, hiatal ballooning and levator avulsion (all P< 0.05). The fourth part of the study included eighty four women who returned at a mean of 4.8 months postpartum. We found significant alteration in pelvic organ support and levator hiatal distensibility after vaginal delivery i.e. a significant increase in mean values from ante to postpartum measurements, more so for the vaginal delivery group. 15% of Black primiparous women sustained levator trauma after their first vaginal delivery. In conclusion, to the author‘s knowledge this is the first study on pelvic floor morphology in South African women. Contrary to previous publications inferring that Black women rarely develop PFD, we have shown that this particular ethnic group had significantly different pelvic floor dynamics than Caucasian and South Asian women for both nulliparous and multiparous symptomatic women. Levator trauma occurs in 15% of Black women after vaginal childbirth. / Thesis (PhD)--University of Pretoria, 2017. / Obstetrics and Gynaecology / PhD / Unrestricted

The uterosacral ligaments (USLs) are important anatomical structures that support the uterus and apical vagina within the pelvis. As these structures are over-stretched, become weak, and exhibit laxity, pelvic floor disorders such as pelvic organ prolapse occur. Although several surgical procedures to treat pelvic floor disorders are directed toward the USLs, there is still a lot that is unknown about their function. These surgeries often result in poor outcomes, demonstrating the need for new surgical approaches and biomaterials. The first chapter of this dissertation presents a review of the current knowledge on the mechanical properties of the USLs. The anatomy, microstructure, and clinical significance of the USLs are first reviewed. Then, the results of published experimental studies on the {emph{in vivo}} and {emph{ex vivo}}, uniaxial and biaxial tensile tests are compiled. Based on the existing findings, research gaps are identified and future research directions are discussed. The second chapter proposes the use of planar biaxial testing, digital image correlation (DIC), and optical coherence tomography (OCT) to quantify the deformations of the USLs, both in-plane and out-of-plane. Using virgin swine as an animal model, the USLs were found to deform significantly less in their main direction (MD) of {emph{in vivo}} loading than in the direction perpendicular to it (PD) at increasing equibiaxial stresses. Under constant equibiaxial loading, the USLs deformed over time equally, at comparable rates in both the MD and PD. The thickness of the USLs decreased as the equibiaxial loading increased but, under constant equibiaxial loading, the thickness increased in some specimens and decreased in others. The third chapter presents new experimental methods for testing the {emph{ex vivo}} tensile properties of the uterosacral ligaments (USLs) in rats. USL specimens were carefully dissected to preserve their anatomical attachments, and they were loaded along their main {emph{in vivo}} loading direction (MD) using a custom-built uniaxial tensile testing device. This chapter reports the first mechanical data on the rat USLs in isolation from surrounding organs. It is also the first experimental study to provide measurements of the inhomogeneous deformations of the USLs during loading along their main textit{in vivo} loading direction, revealing that the USLs may behave as auxetic structures. The fourth and final chapter presents preliminary findings on novel imaging applications to characterize the evolving structure of the USLs before, during, and after tensile pulling along the ligaments' main textit{in vivo} axis of loading. Rat USLs were excised using the proposed novel dissection method and pulled uniaxially as was performed in the previous chapter. Before and after mechanical testing, second harmonic generation (SHG) was used to image collagen and muscle within the three anatomical regions of the USLs. During mechanical testing, OCT was used to collect out-of-plane images of the cervical/intermediate regions of the USL specimens, resulting in 3D volume scans of the regions. SHG images showed the USLs to have complex microstructures with significant wavy collagen bundles interwoven with muscle bundles. Preliminary observation of the microstructure during testing revealed interwoven sections of tissue with collagenous fibers that reoriented in all directions illustrating how the USLs may expand laterally during uniaxial loading, causing the auxetic properties documented in the previous chapter. Though more quantitative work remains to be done, the findings presented in this dissertation improve our understanding of how the USLs deform with increasing load, such as what occurs during pregnancy. Together, these studies serve as a springboard for future investigations on the supportive function of the USLs in animal models by offering guidelines on testing methods that capture their complex mechanical behavior. / Doctor of Philosophy / The uterosacral ligaments (USLs) are important anatomical structures that support the uterus and vagina and are often used to restore the support of pelvic organs during surgeries for pelvic organ prolapse. These surgeries often result in poor outcomes, demonstrating the need for new surgical approaches and graft materials. Due to their supportive role, the mechanical properties of the USLs are important for their physiological function, and they must be investigated to improve current treatment strategies for pelvic organ prolapse. To this end, we designed new equipment, dissection, and testing methods to characterize the mechanical behavior of the USLs using swine and rats as animal models. We provided the first three-dimensional characterization of time-dependent deformations of swine USLs as they were pulled along their two physiological loading directions using advanced imaging methods, including digital image correlation and optical coherence tomography. We isolated the USLs from rats with their anatomical attachments and mechanically tested them along their main physiological loading direction, reporting the first mechanical data on the rat USLs in isolation from surrounding organs. Finally, we used the advanced imaging techniques optical second harmonic generation microscopy and optical coherence tomography to determine how the microstructure (e.g., collagen and muscle) of the rat USLs evolves before, during, and after mechanical testing. These findings advance our understanding of the three-dimensional, nonlinear, heterogeneous, elastic, and viscoelastic deformations of the USLs. Our work may serve as a springboard for future investigations on the supportive function of the USLs by offering guidelines on testing methods that capture their complex mechanical behavior.

Mulheres com prolapso genital estádio 3 e 4 são consideradas de risco para desenvolver incontinência urinária de esforço após a correção cirúrgica do prolapso. A provável explicação para estas pacientes manterem-se, subjetivamente, continentes seria porque o prolapso poderia gerar um acotovelamento na uretra ou compressão da mesma. O objetivo do estudo foi avaliar o impacto de procedimentos anti-incontinência durante a correção cirúrgica de prolapso genital estádio 3 e 4 em mulheres sem sintomas de incontinência urinária de esforço. Método: Realizou-se revisão sistemática com ensaios clínicos. A casuística incluiu mulheres com prolapso genital estádio 3 e 4 sem sintomas clínicos de incontinência urinária de esforço. O desfecho primário foi a presença de incontinência urinária ou necessidade de tratamento para incontinência urinária. Os resultados serão apresentados com o risco relativo, com 95% de intervalo de confiança. Resultados: Inicialmente, 5618 estudos foram identificados com a estratégia de busca, mas apenas oito preencheram os critérios de inclusão. Realizou-se metanálise com as variáveis em comum dos estudos que tivessem mesma escala de quantificação. Observou-se que realizar qualquer procedimento anti-incontinência no mesmo momento do tratamento cirúrgico do prolapso não reduziu a incidência de incontinência urinária no pós-operatório (RR 0.61; 95%CI 0.34-1.10]). Todavia, quando os procedimentos são analisados separadamente, encontraram-se resultados distintos. O subgrupo de pacientes submetidas ao sling retropúbico foi o único que diminuiu a incidência de IUE (RR 0.09; 95%CI 0.02-0.36). Conclusão: O tratamento profilático em mulheres com prolapso genital estádio 3 e 4 com sling retropúbico reduziu a incidência de IUE / Women with high-grade pelvic organ prolapse (POP) are considered at risk of developing postoperative stress urinary incontinence (SUI) once the prolapse has been repaired The probable explanation for the patients to remain subjectively continent, is that POP can affect the urethra by urethral kinking or compression. Our objective was to evaluate the impact of anti-incontinence procedures during surgical POP correction stage 3 and 4 in women with no symptoms for stress urinary incontinence. Methods: A systematic review of randomized trials was performed. The subjects were women with severe POP and no symptoms of SUI. The primary outcomes were UI or treatment for this condition after the surgical procedure. The results were presented as relative risk (RR), with 95% confidence interval (95%CI). Results: Initially, 5618 studies were identified by the search strategy, but only eight trials met the inclusion criteria. We performed a meta-analysis with common variables of studies and with the same scale of quantification. We found that performing an anti-incontinence procedure at the same time of prolapse repair did not reduce the incidence of (SUI) post-operatively (RR 0.61; 95%CI 0.34-1.10]). However, when the types of anti-incontinence procedure were analyzed separately, we found different results. The subgroup of patients who underwent a retropubic sling surgery was the only one that benefited from the antiincontinence procedure, with a decrease in the incidence of SUI (RR 0.09; 95%CI 0.02- 0.36). Conclusions: A prophylactic treatment of women with severe POP using retropubic sling reduced the risk of SUI

Mulheres com prolapso genital estádio 3 e 4 são consideradas de risco para desenvolver incontinência urinária de esforço após a correção cirúrgica do prolapso. A provável explicação para estas pacientes manterem-se, subjetivamente, continentes seria porque o prolapso poderia gerar um acotovelamento na uretra ou compressão da mesma. O objetivo do estudo foi avaliar o impacto de procedimentos anti-incontinência durante a correção cirúrgica de prolapso genital estádio 3 e 4 em mulheres sem sintomas de incontinência urinária de esforço. Método: Realizou-se revisão sistemática com ensaios clínicos. A casuística incluiu mulheres com prolapso genital estádio 3 e 4 sem sintomas clínicos de incontinência urinária de esforço. O desfecho primário foi a presença de incontinência urinária ou necessidade de tratamento para incontinência urinária. Os resultados serão apresentados com o risco relativo, com 95% de intervalo de confiança. Resultados: Inicialmente, 5618 estudos foram identificados com a estratégia de busca, mas apenas oito preencheram os critérios de inclusão. Realizou-se metanálise com as variáveis em comum dos estudos que tivessem mesma escala de quantificação. Observou-se que realizar qualquer procedimento anti-incontinência no mesmo momento do tratamento cirúrgico do prolapso não reduziu a incidência de incontinência urinária no pós-operatório (RR 0.61; 95%CI 0.34-1.10]). Todavia, quando os procedimentos são analisados separadamente, encontraram-se resultados distintos. O subgrupo de pacientes submetidas ao sling retropúbico foi o único que diminuiu a incidência de IUE (RR 0.09; 95%CI 0.02-0.36). Conclusão: O tratamento profilático em mulheres com prolapso genital estádio 3 e 4 com sling retropúbico reduziu a incidência de IUE / Women with high-grade pelvic organ prolapse (POP) are considered at risk of developing postoperative stress urinary incontinence (SUI) once the prolapse has been repaired The probable explanation for the patients to remain subjectively continent, is that POP can affect the urethra by urethral kinking or compression. Our objective was to evaluate the impact of anti-incontinence procedures during surgical POP correction stage 3 and 4 in women with no symptoms for stress urinary incontinence. Methods: A systematic review of randomized trials was performed. The subjects were women with severe POP and no symptoms of SUI. The primary outcomes were UI or treatment for this condition after the surgical procedure. The results were presented as relative risk (RR), with 95% confidence interval (95%CI). Results: Initially, 5618 studies were identified by the search strategy, but only eight trials met the inclusion criteria. We performed a meta-analysis with common variables of studies and with the same scale of quantification. We found that performing an anti-incontinence procedure at the same time of prolapse repair did not reduce the incidence of (SUI) post-operatively (RR 0.61; 95%CI 0.34-1.10]). However, when the types of anti-incontinence procedure were analyzed separately, we found different results. The subgroup of patients who underwent a retropubic sling surgery was the only one that benefited from the antiincontinence procedure, with a decrease in the incidence of SUI (RR 0.09; 95%CI 0.02- 0.36). Conclusions: A prophylactic treatment of women with severe POP using retropubic sling reduced the risk of SUI

Foram estudados, prospectivamente, por um período médio de 4,9 anos, os resultados do tratamento de 31 mulheres com incontinência urinária e afecção benigna do útero que foram submetidas à cirurgia de sling fascial associada à histerectomia vaginal, atendidas na Clínica Ginecológica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, no período de fevereiro de 2000 a outubro de 2006. O objetivo foi avaliar os resultados do tratamento comparando-se os diagnósticos urodinâmicos pré- e pós-tratamento. As mulheres foram submetidas à cirurgia de histerectomia vaginal, para tratamento da afecção benigna do útero e sling fascial para correção da incontinência urinária. Realizou-se estudo urodinâmico no pré- e pós-tratamento, para avaliação da taxa de cura da incontinência urinária e do comportamento vesical nas fases de enchimento e esvaziamento, os quais foram avaliados por meio dos parâmetros urodinâmicos de fluxometria e cistometria. Na fluxometria avaliou-se o fluxo urinário máximo, fluxo urinário médio e volume de urina residual e na cistometria, determinou-se a capacidade vesical no 1° desejo miccional, capacidade vesical máxima e a pressão vesical necessária para ocorrer ou não a perda de urina. Os resultados mostraram, em relação á fluxometria diminuição significante do fluxo máximo, tendência à diminuição do fluxo médio e redução significante do volume de urina residual. Em relação à cistometria, houve aumento estatisticamente significante da capacidade vesical no 1° desejo miccional, da capacidade vesical máxima e valor da pressão vesical necessária para avaliar a presença ou não de perda urinária. Com relação ao diagnóstico urodinâmico, foi demonstrada a cura da incontinência urinária em 96,8% dos casos. Avaliando-se os parâmetros de cura objetiva da incontinência urinária, em seguimento de 4,9 anos, podemos inferir que o tratamento da incontinência urinária de esforço pode ser realizado simultaneamente, quando houver também, a indicação de histerectomia vaginal / We studied, prospectively, for a 4.9 years period the results of the treatment of 31 women with urinary incontinence and benign uterine disease that were submitted the surgery fascial sling associated to vaginal hysterectomy, the patients were all treated in the Gynecology Department of the Clinic Hospital of the University of Sao Paulo, in the period between February 2000 to October 2006. The objective was evaluate the results of the treatment comparing the urodinamic diagnosis pre and post treatment. All women were submitted to vaginal hysterectomy for treatment of benign uterine disorders and to facial sling to treat the urinary incontinence. An urodinamic study was performed pre and post treatment to define the rate of cure of the urinary incontinence and vesical behaviour in the filling and emptying fases, witch will evaluate through urodinamic parameters of flowmetry and cystometry, In the flowmetry were evaluated maximum urinary flow, medium urinary flow and residual urinary volume; and in the cystometry were determinated the bowel capacity in the first urinary desire, maximum bowel capacity in the first urinary desire, maximum bowel capacity and the needed bowel pressure to occur or not the urinary loss. The results showed in relation to the flowmetry significant reduction of the maximum flow, medium flow and urinary residual volume. In relation to cystometry we demonstrated an increase statistically significant in the vesical capacity in the first miccional desire, in the maximum bowel capacity and the value of the bowel pressure to evaluate the presence or not of urinary lost. In relation to the urodimanic diagnosis we could demonstrate the cure of urinary incontinence in 96.8% of cases. Evaluating the parameters of objective cure of urinary incontinence, in a follow up of 4.9 years, we can affirm that the treatment of urinary incontinence should be always be together with the vaginal hysterectomy when it is needed