Mid-urethral slings for treatment of stress urinary incontinence : long- and mid-term follow-up

Urinary incontinence is a common problem, affecting one third of the women at least at some time during their lives. The prevalence of urinary incontinence increases with advancing age, and the everyday impact of incontinence on women and on health services is enormous. Urinary incontinence is usually divided into three different subtypes, of which stress urinary incontinence (SUI) is the most common. Surgical treatment is often needed to cure SUI, and modern mid-urethral sling procedures give the possibility to cure this condition with a low risk of adverse events, a problem often associated with the so-called traditional incontinence operations. Life expectancy among women in Western countries has grown beyond 80 years of age. Long-term efficacy of treatment options for urinary incontinence therefore becomes an important issue in a world with limited eco-nomic resources. The purpose of the present study was to prospectively evaluate the long-term efficacy and safety of the first minimally invasive mid-urethral tape procedure, the Tension-free Vaginal Tape (TVT) procedure. The long-term (5-year) follow-up results of the TVT procedure as a repeat operation af-ter an unsuccessful mid-urethral tape operation were studied and the reasons for failure of the first operation were analyzed. Another purpose was to compare the original TVT procedure with a newer modification, the Tension-free Vaginal Tape Obturator (TVT-O) procedure within a multi-centre, randomized context in order to find out possible differences between these procedures re-garding efficacy and complications and the effects on symptoms of urgency. The first study of the present thesis is a prospective, Nordic, three-centre follow-up study of 90 women suffering from SUI, who were treated by means of the TVT procedure. The mean follow-up time was more than eleven years, and the study is the first to be published in connection with more than ten years of follow-up. The second study is a retrospective analysis of 26 women who were treated with a repeat TVT procedure after an unsuccessful primary mid-urethral tape procedure. The third and fourth studies concern 273 women in seven centres in Finland who were ran-domly assigned to the TVT and TVT-O procedures, the 3-year follow-up results of which are pre-sented in this thesis. After eleven years of follow-up, 90% of the women had a negative cough stress test result and a negative 24-h pad test result. The subjective cure rate measured as the women s global impression of cure was 77%, the rate of improvement 20%, and only 3% thought that the treatment had failed. No late-onset adverse effects were found. The repeat TVT procedure was successful in 75% of the cases when women who were cured and women who were significantly improved were included. The reasons for failure of the first operation could be separated into four different groups: tape material-related, operation technique-related, concomitant illness-related and a group with no identifiable reason. There were no intra-operative complications during the repeat operation. In the randomized trial comparing the TVT with the TVT-O procedure a cough stress test results were negative in 94.6% and 89.5% of the women in the two groups, respectively, after a 3-year follow-up period. There were no statistical differences in the cure rate or the rate of complications be-tween the two procedures. Symptoms of urgency were analyzed more closely and the main finding was that the prevalence of urgency symptoms decreased significantly after both mid-urethral sling procedures. The TVT operation was found to be an effective and safe procedure even after eleven years of follow-up. Long-term follow-up after a repeat TVT procedure revealed that the TVT procedure can well be considered after an unsuccessful mid-urethra tape procedure, because 75% of the patients showed significantly improvement of their incontinence. The TVT and TVT-O procedures showed no statistically significant differences in efficacy and rate of complications after three years of follow-up. In most cases these procedures alleviate preoperative symptoms of urgency and the risk of developing de novo urgency is low.

Bear Shields of Plains Indians : Motifs and Meanings

The study is the outcome of two research projects on the North American Indian traditions: the role of the shields within the Plains Indians traditional culture and religion, and the bear ceremonialism of the Native North America, especially the significance of the bear among the Plains Indians. This article-based dissertation includes seven separately published scholar papers, forming Chapters 6 12. The introduction formulates the objectives and frame of reference of the study and the conclusions pulls together its results. The study reconsiders the role of the Plains Indian shields with bear motifs. Such shields are found in rock art, in the Plains Indian s paintings and drawings, and in various collections, the main source material being the shields in European and North American museums. The aim is not only to study shields with bear power motifs and the meanings of the bear, but also to discuss appropriate methods for studying these subjects. There are three major aims of the study: to consider methodical questions in studying Plains Indian shields, to examine the complexity of the Plains Indian shields with the bear power motifs, and to offer new interpretations for the basic meanings of the bear among the Plains Indians and the interrelationship between individualism and collectivism in the Plains Indians visionary art that show bear power motifs on the shields. The study constructs a view on the bear shields taking account of all sources of information available and analysing the shields both as physical artefacts and religious objects from different perspectives, studying them as a part of the ensemble of Plains culture and religious traditions. The bear motifs represented the superhuman power that medicine men and warriors could exploit through visions. For the Plains Indians, the bear was a wise animal from which medicine men could get power for healing but also a dangerous animal from which warriors could get power for warfare. The shields with bear motifs represented the bear powers of the owners of the shields. The bear shield was made to represent the vision, and the principal interpretation of the symbolism was based on the individual experience of spiritual world and its powers. The study argues that the bear shield as personal medicine object is based on wider tribal traditions, and the basic meaning is derived from the collective tradition. This means that the bear seen in vision represented particular affairs and it was represented on the shield surface using conventional ways of traditional artistry. In consequence of this, the bear shields reflect not only the individual experiences of bear power but whole field of tribal traditions that legitimated the experiences and offered acceptable interpretations and conventional modes for the bear symbols.