Sexual function following outside-in transobturator midurethral sling procedures: a prospective study

Introduction and hypothesis

Midurethral tapes have shown favorable clinical outcomes for treating stress urinary incontinence (SUI), but the effects of outside-in transobturator midurethral sling procedures (TOT) on women??s sexual function are unclear. We hypothesized that TOT might improve sexual function in women with SUI and therefore conducted this study to investigate sexual function alteration among women who underwent TOT for urodynamic stress incontinence (USI).

Methods

From November 2009 to October 2010, we recruited 102 women scheduled for correction of USI by TOT procedures in a tertiary hospital. In addition to urogynecologic history, pelvic examination, and urodynamic testing, participants were required to complete three validated questionnaires: Incontinence Impact Questionnaire (IIQ-7), Urogenital Distress Inventory (UDI-6), and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). Preoperative and postoperative results of these validated questionnaires were evaluated.

Results

Eighty-three patients comprising 57 sexually active and 26 sexually inactive patients participated in the 12-month evaluation. Of the 83 patients undergoing TOT, six (7.2?%) had postoperative SUI 12?months postoperatively. Both UDI-6 and IIQ-7 scores were significantly improved postoperatively. The total PISQ-12 score did not change significantly after surgery. Postoperatively, the individual incontinence-related items of the PISQ-12 improved, but climax with intercourse and negative emotional reactions during intercourse worsened (both with p <0.001). There was a negative correlation between SUI-related items on UDI-6 and those on PISQ-12 preoperatively.

Conclusions

TOT procedures for correcting USI had favorable clinical outcomes and did not alter overall sexual function; however, climax during sexual intercourse and emotional response worsened postoperatively.     

Sexual function after robot-assisted prolapse surgery: a prospective study

Introduction and hypothesis

Female pelvic organ prolapse (POP) can severely influence sexual function. Robot-assisted surgery is increasingly used to treat POP, but studies describing its effect on sexual function are limited. The objective of this study was to evaluate sexual function after robot-assisted POP surgery.

Methods

This prospective cohort study included all patients who underwent a robot-assisted sacrocolpopexy (RASC) or supracervical hysterectomy with sacrocervicopexy (RSHS). Exclusion criteria were unknown preoperative sexual activity status or concomitant surgery. In sexually active women, sexual function was measured with the translated validated version of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). Changes in sexual activity were scored. Prolapse stages were described using the simplified Pelvic Organ Prolapse Quantification (S-POP) system.

Results

A total of 107 women were included (median follow-up 15.3 months). No difference was found in the total number of sexually active women before and after surgery [63 (58.9%) vs. 61 (63.5%), p?=?0.999]. Significantly fewer women avoided sexual intercourse postoperatively compared with preoperatively. Preoperatively, sexual intercourse was avoided due to vaginal bulging (2% vs. 24%, respectively, p?=?0.021). Total mean PISQ-12 scores improved significantly 1 year after prolapse correction (33.5 vs. 37.1; p?=?0.004), mainly due to improved scores on the physical and behavioral–emotive domain. No significant difference in pre- and postoperative complains of dyspareunia was found.

Conclusion

Robot-assisted middle-compartment surgery improved sexual function 1 year after surgery according to enhanced physical and emotional scores. The total number of sexually active women and complains of dyspareunia before and after surgery did not differ.

     

Beyond the complications: medium-term anatomical, sexual and functional outcomes following removal of trocar-guided transvaginal mesh. A retrospective cohort study

Introduction and hypothesis

The aims of this study were to assess the anatomical, sexual and functional outcomes of women undergoing surgical intervention for complications of the trocar-guided transvaginal mesh (TVM) procedure.

Methods

This was a retrospective analysis of a clinical database of women who had developed a complication following a TVM procedure. This included dyspareunia, mesh erosion, urinary symptoms, mesh contraction and prolapse recurrence. Pre- and post-operatively, we assessed the women for prolapse, stress incontinence, urgency, defecatory difficulty, digitation, pain, dyspareunia and apareunia. We also recorded the Pelvic Organ Prolapse Quantification (POP-Q) score. The TVM was removed and a Biodesign graft was used in the majority of cases to prevent further prolapse. Follow-up was at 6?weeks, 6?months, 1 and 2?years.

Results

In our cohort of 21 women, 18 required surgery for pain and/or dyspareunia; 20 women had reached the 6-week follow-up at the time of analysis. At 6?weeks, two women still had pain and required a second intervention. Fifteen women had reached a 6-month follow-up and only one woman had persistent pain requiring repeat surgery. Of the 15 women, 7 were sexually active and in 6 cases the dyspareunia had resolved completely with 1 woman retaining an element of pain at intercourse. Six women had been seen at 12?months and all four of the sexually active women had no dyspareunia. There were no symptoms relating to prolapse in any of the women at 6?weeks, 6, 12 or 24?months.

Conclusions

We report satisfactory outcomes following removal of a complicated TVM kit.     

Laparoscopic sacrocolpopexy for recurrent pelvic organ prolapse after failed transvaginal polypropylene mesh surgery

Introduction and hypothesis

A prospective case series to assess the safety and efficacy of laparoscopic sacrocolpopexy for the surgical management of recurrent pelvic organ prolapse (POP) after transvaginal polypropylene mesh prolapse surgery.

Methods

Between January and December 2010, women with post-hysterectomy recurrent prolapse (≥ stage 2 POP-Q) after transvaginal polypropylene mesh prolapse surgery were included. Perioperative morbidity and short-term complications were recorded and evaluated. Surgical outcomes were objectively assessed utilising the Pelvic Organ Prolapse Quantification system (POP-Q), the validated, condition-specific Australian Pelvic Floor Questionnaire (APFQ) and the Patient Global Impression of Improvement (PGI-I) at 12 months.

Results

All 16 women in this study had undergone surgery with trocar-guided transvaginal polypropylene mesh kits. In 75% the recurrent prolapse affected the compartment of prior mesh surgery with the anterior (81%) and apical (75%) compartment prolapse predominating. At a mean follow-up of 12 months, all women had resolution of awareness of prolapse, had < stage 2 POP-Q on examination and high levels of satisfaction on PGI-I post surgery. There were no serious peri- or postoperative complications.

Conclusions

This preliminary study suggests that laparoscopic sacrocolpopexy for recurrent prolapse after failed transvaginal mesh surgery is feasible and safe. Further widespread evaluation is required.     

Responsiveness of the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire in women undergoing treatment for pelvic floor disorders

Introduction and hypothesis

This study evaluated the responsiveness and minimal important differences (MID) of the Chinese Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ) in women undergoing urodynamic stress incontinence (USI) and/or pelvic organ prolapse (POP) treatment.

Methods

One hundred and fifty-six women were assessed using the PFDI and PFIQ before and after they received continence surgery and or pelvic floor repair (PFR) surgery, or vaginal pessary. Symptom severity was recorded using a visual analog scale (VAS) before and after treatment as was rating of their satisfaction with the treatment they received. Responsiveness of the PFDI and PFIQ were evaluated by effect sizes, standardized response mean, paired samples t test or Wilcoxon Signed Rank Test. MID in the PFDI and PFIQ for different treatments were determined by satisfaction rating, change in VAS scoring, and distribution-based methods.

Results

There were significant improvements in the respective subscales of PFDI and PFIQ, demonstrating moderate to great responsiveness after different treatments. The estimation of MID for the Urinary Distress Inventory (UDI) was ?30 to ?14 and the Urinary Impact Questionnaire (UIQ) was ?28 to ?14 for women who underwent continence surgery. The MID for the Pelvic Organ Prolapse Distress Inventory (POPDI) was ?44 to ?21, the Pelvic Organ Prolapse Impact Questionnaire (POPIQ) ?40 to ?27, the UDI ?22 to ?16, the UIQ ?37 to ?31, the Colo-Rectal-Anal Distress Inventory (CRADI) ?37 to ?14, and the Colo-Rectal-Anal Impact Questionnaire (CRAIQ) ?34 to ?6 for women who underwent PFR surgery; and estimation of MID for the POPDI was ?16, the POPIQ ?29, the UDI ?28, the UIQ ?17, the CRADI ?25, and the CRAIQ ?31 for women who received a vaginal pessary. The MID of the respective subscales were supported by the distribution-based methods.

Conclusions

The Chinese PFDI and PFIQ instruments are responsive to change in women undergoing continence surgery, PFR surgery or vaginal pessary for USI or POP.     

Synthetic graft use in vaginal prolapse surgery: objective and subjective outcomes

Introduction and hypothesis

This study reports 1-year outcomes in women who underwent transvaginal pelvic organ prolapse (POP) surgery with Prolift^® transvaginal mesh.

Methods

Pre- and postoperative objective vaginal Pelvic Organ Prolapse Quantification (POP-Q) and subjective symptom and impact assessments (Pelvic Floor Distress Inventory (PFDI)-20 and Pelvic Floor Impact Questionnaire (PFIQ)-7, respectively) were performed. Postoperative vaginal tenderness, stricture, and patient satisfaction were also obtained. Paired t tests were utilized for analysis.

Results

Mean age was 61.8?±?9.8 years; mean follow-up interval was 425.0?±?80.0 days (range, 237–717). POP-Q measurements of Ba, Bp, and C were significantly improved (all p values?p values?≤?0.004). Thirty-five of 48 (73%) were completely satisfied, and two (4%) were not satisfied. Complications (n (percent)) included graft exposure (1 (2%)), dyspareunia (2 (4%)), and granulation tissue (3 (6%)).

Conclusions

Women undergoing transvaginal repair of POP with the Prolift^® mesh system showed significant improvement in 1-year anatomic and subjective measures.     

Analysis of changes in sexual function in women undergoing pelvic organ prolapse repair with abdominal or vaginal approaches

Introduction and hypothesis

To examine changes in sexual function after abdominal and transvaginal pelvic organ prolapse repair.

Methods

Women enrolled in our prospective, longitudinal prolapse database with abdominal sacrocolpopexy (ASC) or transvaginal (TVR) pelvic organ prolapse (POP) repair with or without mesh, between 19 December 2008 through 4 June 2014. The Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) and the Pelvic Floor Distress Inventory (PFDI?-20) were mailed preoperatively, and at 6 and 12 months postoperatively. Patients completed Global Response Assessments to rate their overall satisfaction.

Results

Two hundred and four of the 300 women met the inclusion criteria: 74 out of 204 (36 %) had ASC and 130 out of 204 (64 %) had TVR. Seventy-two out of seventy-four ASCs were performed robotically and 2 were open. Baseline demographics were similar except that the ASC patients were significantly younger (60 vs 63, P?=?0.019) and had a higher rate of apical repair (77 % vs 55 %). Thirty-six out of seventy-four ASC (48.7 %) and 63 out of 128 TVR patients (49.2 %) were sexually active at baseline (P?=?0.94). Sixteen out of thirty-eight ASC (42.1 %) and 18 out 63 TVR patients (28.6 %; P?=?0.16) reported dyspareunia at baseline. Seventy-two out of seventy-four ASC (97 %) and 86 out of 130 TVR patients (66 %) had mesh-augmented repairs. There was no difference in sexual activity or dyspareunia between the groups at the 6- or 12-month follow-up. PISQ and PFDI scores improved significantly in both the ASC and TVR groups over time compared with the baseline (p?<?0.0001). Most women in the ASC (77.5 %) and TVR (64.8 %) groups were satisfied with the results of prolapse surgery at 12 months.

Conclusions

Sexual function and pelvic floor symptoms improved in a similar manner in patients after abdominal and transvaginal POP surgery.

     

Sexual function in women before and after transvaginal mesh repair for pelvic organ prolapse

The aim of the study was to assess sexual function in women before and after surgery with transvaginal mesh for pelvic organ prolapse. Women were invited to complete a sexual function questionnaire including the Lemack and the Pelvic Organ Prolapse Urinary Incontinence Sexual Questionnaires (PISQ-12) before undergoing surgery and 1 year after surgery. Eighty-three complete pre and postoperative questionnaires were analyzed. Mean age was 65.1 years. Forty-six were sexually inactive and 37 were sexually active women. Two sexually active women completed the preoperative PISQ-12 questionnaire retrospectively after surgery. There were no significant differences after surgery in the answers to the Lemack questionnaire and PISQ-12 scores. These results suggest that nonabsorbable transvaginal mesh repair of genital prolapse does not impair sexual function 1 year after surgery. Nevertheless, patients should not necessarily expect a significant improvement in sexual function outcome following transvaginal mesh repair for genital prolapse.     

The association between fecal incontinence and sexual activity and function in women attending a tertiary referral center

Introduction and hypothesis

To determine whether fecal incontinence (FI) is associated with sexual activity and to compare sexual function in women with and without FI.

Methods

We conducted a retrospective chart review of all new patients seen in an academic urogynecology clinic. Women who reported fecal incontinence, as defined by loss of fecal material on the Wexner scale, were compared with those without fecal incontinence. We compared sexual activity and Pelvic Organ Prolapse Incontinence Sexual Questionnaire-12 (PISQ-12) scores between groups.

Results

In our population of women with pelvic floor disorder, 588 women reported FI compared with 527 who did not. On multivariate analysis, FI was not associated with sexual activity status, but was associated with worsened PISQ-12 scores (p?<?0.001). PISQ-12 item analysis found that women with FI reported more dyspareunia, fear, and avoidance of sexual activity with greater partner problems (all p <0.05) than women without FI.

Conclusions

Women with FI were as likely to engage in sexual relations as women without FI; however, sexually active women with FI had poorer sexual function than those without FI.     

Prospective study of an ultra-lightweight polypropylene Y mesh for robotic sacrocolpopexy

Introduction and hypothesis

To prospectively evaluate the use of a particular polypropylene Y mesh for robotic sacrocolpopexy.

Methods

This was a prospective study of 120 patients who underwent robotic sacrocolpopexy. We compared preoperative and 12-month postoperative objective and subjective assessments via the Pelvic Organ Prolapse Quantification (POP-Q), the Pelvic Floor Distress Inventory, Short Form 20 (PFDI-20); the Pelvic Floor Impact Questionnaire, Short Form 7 (PFIQ-7); and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire 12 (PISQ-12). Objective “anatomical success” was defined as POP-Q stage 0 or 1 at all postoperative intervals. We further defined “clinical cure” by simultaneously considering POP-Q points and subjective measures. To be considered a “clinical cure,” a given patient had to have all POP-Q points ≤0, apical POP-Q point C ≤5, no reported pelvic organ prolapse symptoms on the PFDI-20, and no reoperation for prolapse at all postoperative intervals.

Results

Of the 120 patients, 118 patients completed the 1-year follow-up. The objective “anatomical success” rate was 89 % and the “clinical cure” rate was 94 %. The PFDI-20 mean score improved from 100.4 at baseline to 21.0 at 12 months (p?<?0.0001); PFIQ-7 scores improved from 61.6 to 8.0 (p?<?0.0001); and PISQ-12 scores improved from 35.7 to 38.6 (p?<?0.0009). No mesh erosions or mesh-related complications occurred.

Conclusion

The use of this ultra-lightweight Y mesh for sacrocolpopexy, eliminated the mesh-related complications in the first postoperative year, and provided significant improvement in subjective and objective outcomes.     

Long-term outcomes of synthetic transobturator nonabsorbable anterior mesh versus anterior colporrhaphy in symptomatic,advanced pelvic organ prolapse surgery

Introduction and hypothesis

Anterior vaginal mesh (AVM) combined with sacrospinous ligament fixation (SSF) yields better long-term success rates over anterior colporrhaphy (AC) in advanced pelvic organ prolapse (POP) surgery, with a low rate of mesh-related complications.

Methods

Medical records of 198 patients who underwent surgery for POP between January 2006 and March 2010 were reviewed retrospectively. Patients’ assessment at baseline and third-year postoperative follow-up were analyzed. SSF plus AC or AVM was performed for apical and anterior compartment repair. Primary outcome was objective cure [Pelvic Organ Prolapse Quantification (POP-Q) stage?≤?1)], and subjective cure defined as negative response to questions 2 and 3 on the POPDI-6. Secondary outcomes were complications, symptoms severity and quality of life as measured with validated questionnaires.

Results

Post-operative data were available for 186 patients, 72 in AC group and 114 in AVM group were analyzed. The mean age, parity and operating time in AVM group were significantly higher as compared to AC group. The overall objective and subjective cure rate in AVM group was significantly higher than AC group (90.3 % and 88.6 % versus 73.6 % and 70.8 %, with P value?=?0.003 and 0.002 respectively). Mesh exposure rate was 3.5 %. Improvement in both POPDI-6 and PISQ-12 in AVM group was statistically significant compared to AC group.

Conclusion

Transobturator synthetic nonabsorbable AVM combined with SSF yielded a favorable and sustainable result over 5 years as compared to traditional AC, both in anatomical and subjective success rate. Mesh related morbidities were low and acceptable.     

Do we need meshes in pelvic floor reconstruction?

Objectives

Transvaginally placed mesh in pelvic reconstructive surgery for women with pelvic organ prolapse has gained popularity because of excellent anatomical outcomes, but postoperative mesh-related complications have lead to a number of cautious reviews and warnings. This review focuses on functional outcomes after synthetic transvaginal mesh placement.

Methods

MEDLINE database was searched from 2010 to August 2011 for original articles on transvaginal mesh surgery for pelvic organ prolapse not included in recent reviews. The following search terms were used: pelvic organ prolapse, genital prolapse, cystocele, rectocele and mesh, synthetic graft, and repair. Studies were assessed and appropriate data extracted and tabularized. Studies were excluded if the follow-up time was less than 12?months and if studies did not contain original data or data on subjective outcome.

Results

Eleven studies irregularly reported functional outcomes. After trocar-guided transobturator vaginal mesh surgery, symptomatic recurrence of pelvic organ prolapse was reported between 7 and 33%. If analyzed cumulatively, 76 of 370 patients (21%) complained of prolapse symptoms postoperatively. De novo stress urinary incontinence occurred in 12–17% and persisted in up to 68% after trocar-guided mesh surgery. De novo dyspareunia was present between 2 and 15%, worsened or de novo dyspareunia between 25 and 44%. Deteriorating coital incontinence was described in 6 of 16 women after anterior Prolift in one trial.

Conclusions

When counseling women for pelvic reconstructive surgery, we should provide them with evidence-based information on functional outcomes and subsequently take the patient’s concerns and preferences into account. Pelvic floor symptoms were scarcely reported in reviewed trials, but demonstrated a worse scenario than anatomical outcomes.     

Transischioanal trans-sacrospinous ligament rectocele repair with polypropylene mesh: a prospective study with assessment of rectoanal function

Introduction and hypothesis

Despite good anatomical outcomes of pelvic organ prolapse (POP) repair by the vaginal route using synthetic mesh, complications limit their use. Clinical data are needed to generalize prolapse mesh repair by the vaginal route. The current study aims to evaluate midterm rectoanal function and clinical outcomes after transischioanal rectocele repair using a medium weight polypropylene mesh.

Methods

Between March 2003 and June 2004, 230 patients with stage II–IV anterior and/or posterior POP were included in a prospective multicenter study. The current study is based on the analysis of the 116 patients who underwent a rectocele repair via the infracoccygeal route through the sacrospinous ligament. Anatomical cure was defined when rectocele was at stage <II in the Pelvic Organ Prolapse Quantification (POP-Q) system. Postoperative functional results were evaluated using the self-administered Pelvic Floor Distress Inventory (PFDI) and the Pelvic Floor Impact Questionnaire (PFIQ).

Results

Of the 116 patients who received a posterior mesh with two arms via the infracoccygeal route through the sacrospinous ligament, midterm anatomical results were available for 78 women representing 67 % (78/116) of the operated patients. The mean follow-up was 36 (± 8.1) months. No rectal injury occurred during surgery. The objective success rate was 94.8 % and subjective (by patient satisfaction) was 93.23 %. Colorectal-Anal Impact (CRAI) and Colorectal-Anal Distress Inventory (CRADI) scores were both significantly decreased at midterm follow-up in comparison with baseline (42.7 at baseline vs 11.4 at 24- or 36-month follow-up, p?=?0.001 for CRAI, and 81.1 vs 34.4, p?<?0.001 for CRADI) highlighting the benefits of rectocele repair on colorectal-anal function.

Conclusions

Polypropylene mesh with two arms via the infracoccygeal route through the sacrospinous ligament has good anatomical results at midterm follow-up with significant improvement in symptoms and quality of life and is associated with few complications. Obstructive symptoms reported in cases of rectocele can be improved by transvaginal mesh repair.     

Long-term follow-up of persistent vaginal polypropylene mesh exposure for transvaginally placed mesh procedures

Introduction and hypothesis

The surgical treatment of a cystocele via the vaginal route may require the placement of a synthetic mesh below the bladder. However, the placement of a synthetic mesh via the vaginal route can be associated with specific complications, such as vaginal mesh exposure. There is a lack of data concerning the long-term follow-up of asymptomatic persistent vaginal polypropylene mesh exposure.

Methods

This was a retrospective case series of nine patients presenting with persistent vaginal mesh exposure following the placement of a macroporous monofilament polypropylene mesh for cystocele treatment. Expectant management has been proposed since the patients were asymptomatic.

Results

The median follow-up duration was 121?months [interquartile range (IQR) 119–132]. The median surface area of vaginal mesh exposure (1?cm²; IQR 1–1) did not change significantly during the follow-up. No pelvic or perineal abscess occurred during the follow-up. Only one of them was sexually active; she complained of dyspareunia at the last follow-up, but refused renewed surgery since she had sexual intercourse on only a small number of occasions per year. Clinical examination using the International Continence Society Pelvic Organ Prolapse Quantification system: Ba ?3 to ?2 (n?=?7; 88?%), Ba ?1 (n?=?1; 12?%), Ba 0 or greater (n?=?0).

Conclusions

Persistent asymptomatic vaginal polypropylene mesh exposure is associated with few complications at long-term follow-up.     

Long-term outcome after transvaginal mesh repair of pelvic organ prolapse

Introduction and hypothesis

The aim of this study was to report long-term subjective and objective outcomes after the transvaginal mesh (TVM) procedure in long-term. Possible late-onset complications were of particular interest.

Methods

This was a retrospective analysis of TVM performed using Prolift? transvaginal mesh measuring subjective outcome using validated questionnaires. Objective outcome was assessed using the Pelvic Organ Prolapse Quantification (POP-Q) system using two definitions: POP-Q stage?≤?1, and vaginal wall prolapse at or above the hymen or vaginal apex not descending below the upper third of the vagina. Complications were reported with the Prosthesis/Graft Complication Classification Code designed by the International Continence Society/International Urogynecological Association (ICS/IUGA).

Results

Of 195 patients, 161 (82.6 %) participated this study after a median of 7 years. The scores in questionnaires evaluating urinary (UI) or anal incontinence and constipation or pelvic floor symptoms were low, indicating favorable surgical outcomes. Altogether, 80.1 % of patients were satisfied with the procedure. Anatomical cure was 56.4 % and 69.3 % depending on the definition used. Reoperation due to POP in any compartment was performed in 16.2 % of patients. Mesh exposure rate was 23 %, most of these being asymptomatic and of late onset.

Conclusions

Outcome of the TVM procedure was satisfactory. Anatomical cure was inferior to subjective cure. Mesh exposure rate was high; most exposures observed in the long-term were of late onset and were asymptomatic.

     

Total transvaginal mesh (TVM) technique for treatment of pelvic organ prolapse: a 3-year prospective follow-up study

Introduction and hypothesis

To evaluate clinical outcomes at 3 years following total transvaginal mesh (TVM) technique to treat vaginal prolapse.

Methods

Prospective, observational study in patients with prolapse ≥stage II. Success was defined as POP-Q-stage 0-I and absence of surgical re-intervention for prolapse. Secondary outcome measures were: quality of life (QOL), prolapse-specific inventory (PSI), impact on sexual activity and complications.

Results

Ninety women underwent TVM repair, 72 a hysterectomy. Anatomical failure rate was 20.0% at 3 years. Three patients required re-intervention for prolapse. Improvements in QOL- and PSI-scores were observed at 1 and 3 years. Vaginal mesh extrusion occurred in 14.4% patients. After 3 years, 4.7% asymptomatic extrusions remained present. Of 61 sexually active women at baseline, a significant number of patients (41%) ceased sexual activity by 3 years; de novo dyspareunia was reported by 8.8%. One vesico-vaginal fistula resolved after surgery.

Conclusion

Medium-term results demonstrate that the TVM technique provides a durable prolapse repair.     

Levator ani defects and the severity of symptoms in women with anterior compartment pelvic organ prolapse

Introduction and hypothesis

The aims of this study were to evaluate the prevalence of levator ani muscle (LAM) avulsions in a selected cohort of patients with primary anterior compartment pelvic organ prolapse (POP) and to assess whether LAM avulsions, as an independent factor, affect the degree of POP symptoms and sexual dysfunction. Additionally, clinical and demographic variables of women with and those without avulsions were compared.

Methods

We carried out a cross-sectional analysis of a prospective cohort study including 197 women scheduled for anterior compartment POP surgery. LAM avulsions were diagnosed on transperineal 4D ultrasound. Preoperative symptom severity and sexual dysfunction were evaluated using validated questionnaires (Pelvic Floor Disability Index [PFDI-20] and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-Short Form 12 [PISQ-12]). Linear regression was performed with avulsion as the main independent variable against total PFDI-20 and domain scores, bulge symptoms, and PISQ-12 score. Clinical and demographic variables for women with and without avulsions were compared using independent samples t test, Mann–Whitney U test or Chi-squared test.

Results

The prevalence of LAM avulsions was 50.3%. Avulsions were not associated with symptom severity or sexual dysfunction. “Chronic disease causing pain, fatigue or increased intra-abdominal pressure” was the only independent factor associated with all domains of the PFDI-20. Women with avulsions were younger at presentation, older at their first delivery, had lower BMI, and more often had a history of forceps delivery (p < 0.01).

Conclusions

LAM avulsions were highly prevalent in this preoperative POP cohort. Avulsions were not associated with the severity of POP symptoms or sexual dysfunction. Women with avulsions seem to require fewer additional cofactors for developing POP.

     

The effect of pelvic organ prolapse severity on improvement in overactive bladder symptoms after pelvic reconstructive surgery

Introduction and hypothesis

This study evaluates the effect of baseline pelvic organ prolapse (POP) severity on improvement in overactive bladder (OAB) symptoms after pelvic reconstructive surgery.

Methods

We performed a retrospective cohort study of women with POP and OAB who underwent surgical correction of symptomatic apical and/or anterior POP. OAB was defined as an affirmative response to item #15 (urinary frequency) and/or item #16 (urge incontinence) of the Pelvic Floor Distress Inventory (PFDI). POP severity was dichotomized as Pelvic Organ Prolapse Quantification (POP-Q) stage 1–2 versus stage 3–4. Our primary outcome was complete resolution or improvement of urinary frequency or urge incontinence on the PFDI 12 months postoperatively.

Results

At 12 months postoperative, 41 (89%) women with stage 1–2 POP versus 47 (85 %) with stage 3–4 POP reported improvement in urinary frequency (p?=?0.58). Thirty five (90 %) with stage 1–2 and 34 (85 %) with stage 3–4 POP reported improvement in urge incontinence (p?=?0.74). On multiple logistic regression, women with stage 3–4 POP had a decreased odds of improvement in frequency or urge incontinence compared with women with stage 1–2 POP (adjusted odds ration [AOR]?=?0.06 [95 % CI 0.01–0.67]), after adjusting for confounders.

Conclusions

Women with coexisting POP and OAB who undergo surgical correction of POP experience improvement in OAB symptoms after surgery, although women with more severe POP may be at a higher risk of persistent frequency or urge incontinence.     

Outcome of coexistent overactive bladder symptoms in women with urodynamic urinary incontinence following anti-incontinence surgery

Introduction and hypothesis

The objective was to investigate the outcome of stress urinary incontinence (SUI) and overactive bladder (OAB) symptoms in women with urodynamic stress incontinence (USI) after transobturator sling procedures (TOTs).

Methods

We evaluated 109 consecutive patients with USI, who had undergone TOT in a tertiary hospital between 2012 and 2014. All patients received evaluations, including structured urogynecological questionnaires and pelvic organ prolapse quantification examination before, and 3 and 12 months after surgery. One-hour pad test and urodynamic testing were performed before and 3–6 months postoperatively. Patient demographics, lower urinary tract symptoms, and urodynamic results were analyzed between pure USI and USI with OAB symptoms.

Results

Persistent SUI occurred in 8 patients at 3 months (7.3 %) and 7 patients at 12 months (6.4 %) postoperatively. The most common OAB symptom was frequency (54.1 %), followed by urgency urinary incontinence (52.3 %), urinary urgency (42.2 %), and nocturia (33 %). Most of these OAB symptoms were resolved at the 3-month and 12-month follow-ups both in patients treated with TOT only and in those treated with TOT combined with other pelvic surgeries. There was no significant difference in the preoperative urodynamic changes between patients with pure USI and USI without OAB groups. However, postoperative urodynamic results showed a significant decrease in the maximal urethral closure pressure in the group of patients with USI and OAB symptoms, but no significant urodynamic changes in the group with pure USI.

Conclusions

Coexistent OAB symptoms are common in women who were diagnosed with USI and most of these symptoms may resolve 3 and 12 months after TOT.

     

Preoperative clinical, demographic, and urodynamic measures associated with failure to demonstrate urodynamic stress incontinence in women enrolled in two randomized clinical trials of surgery for stress urinary incontinence

Introduction and hypothesis

The unexpected absence of urodynamic stress incontinence (USI) in women planning surgery for stress urinary incontinence (SUI) is a challenge to surgeons. We examined the prevalence and clinical and demographic factors associated at baseline (preoperatively) with the unexpected absence of USI among study participants of two multicenter randomized clinical trials of surgery for treating SUI.

Methods

Women with SUI symptoms and positive stress tests on physical examination enrolled in two separate clinical trials—one comparing the autologous fascial sling with the Burch colposuspension [Stress Incontinence Surgical Treatment Efficacy Trial (SISTEr), and the other comparing the retropubic mid-urethral sling with the transobturator midurethral sling [Trial of Mid-Urethral Slings (TOMUS)]—were evaluated for USI preoperatively. The association of clinical, demographic, and urodynamic parameters was examined in women without USI in univariate and multivariate analyses.

Results

Overall, 144 of 1,233 women (11.7 %) enrolled in the two studies showed no USI. These women had a significantly lower mean volume at maximum cystometric capacity than those with USI (347.5 vs. 395.8 in SISTEr, p?=?0.012), (315.2 vs. 358.2 in TOMUS, p?=?0.003) and a lower mean number of daily accidents reported on a 3-day diary (2.2 vs 2.7 in SISTEr, p?=?0.030) (1.7 vs 2.7 in TOMUS, p?<?0.001). Additionally, those without demonstrable USI were more likely to have Pelvic Organ Prolapse Quantification (POP-Q) stage III/IV (31.7 % vs 14.4 % in SISTEr, p?=?0.002), (15.5 % vs 6.9 % in TOMUS, p?=?0.025). SUI severity as recorded on the Urogenital Distress Inventory (UDI) correlated strongly with the presence of USI in both studies.

Conclusions

We observed that about one of eight women planning surgery for SUI does not show USI. Stage 3/4 POP was strongly associated with the unexpected absence of USI. A diminished urodynamic bladder capacity among women who did not display USI may reflect an inability to reach the limits of capacity during urodynamics, at which these women normally leak.