Concomitant trocar-guided transvaginal mesh surgery with a midurethral sling in treating advanced pelvic organ prolapse associated with stress or occult stress urinary incontinence

ObjectiveThe purpose of this study was to evaluate the efficacy and feasibility of concomitant trocar-guided transvaginal mesh (TVM) surgery with a midurethral sling (MUS) for treating women with advanced pelvic organ prolapse (POP) and stress urinary incontinence (SUI) or occult SUI (OSUI).Materials and methodsEighty-nine women with advanced POP and SUI or OSUI were retrospectively enrolled. The Total Prolift and Tension-free Vaginal Tape-Obturator Systems were used for trocar-guided TVM surgery and MUS. Patients received regular follow-up at 1 week, and 1 month, 3 months, 6 months, and 12 months postoperatively, and then annually thereafter. The endpoints were the success rate for POP, and perioperative and postoperative complications. Functional outcomes were the presence of voiding difficulty, persistent or de novo overactive bladder symptoms, postoperative SUI, and paresthesia.ResultsThe median follow-up period was 35 months (range, 12–50 months). Within the follow-up period, 84 patients (94.4%) were objectively cured, five patients (5.6%) had vaginal apical mesh exposure, 29 individuals (32.6%) had persistent or de novo overactive bladder symptoms, six individuals (22.5%) had de novo SUI (two were found by urodynamics), and nine individuals (10.1%) had voiding difficulties (two were found by urodynamics). In addition, the vaginal hysterectomy group had greater blood loss, longer operation times, and a higher mesh erosion rate compared to the uterine suspension group.ConclusionConcomitant trocar-guided TVM surgery and MUS with the use of total Prolift and Tension-free Vaginal Tape-Obturator offer good efficacy in treating women with advanced POP and SUI or OSUI. The vaginal hysterectomy group had more perioperative complications.     

Long-term results of prolapse recurrence and functional outcome after vaginal hysterectomy

ObjectiveTo evaluate the incidence of prolapse and prolapse-related symptoms following vaginal hysterectomy.MethodsData were reviewed from women who underwent vaginal hysterectomy between 1988, and 1995, at St George's Hospital, London, UK, and attended long-term follow-up. Outcome measures included a questionnaire for prolapse, urinary, bowel, and sexual symptoms; and a vaginal examination.ResultsAmong 94 women attending long-term evaluation, the mean follow-up time was 100.7 months (range 67.0–156.0 months). Before vaginal hysterectomy, urgency was noted among 23 (24.5%), urge incontinence among 11 (11.7%), and stress incontinence among 8 (8.5%) women. At follow-up, these symptoms were observed among 23 (24.5%), 13 (13.8%), and 6 (6.4%) women, respectively. De novo urge incontinence and de novo stress incontinence were observed among 3 (3.2%) and 2 (2.1%) women, respectively. Vaginal examination data were compared for 70 women, of whom 18 (25.7%) had grade 1, 40 (57.1%) had grade 2, and 6 (8.6%) had grade 3 uterine prolapsed before surgery. Postoperatively, vaginal vault prolapse occurred in 7 (10.0%) women and correlated with degree of posterior prolapse (P = 0.007), but not with severity of uterine descent (P = 0.205) or previous prolapse surgery (P = 0.573).ConclusionThe incidence of post-hysterectomy vault prolapse correlated with the degree of preoperative rectocele.     

The effect of prolapse surgery on vaginal sensibility

IntroductionProlapse surgery has been shown to have major impact on sexual function. Since prolapse surgery not only influences psychological factors but might also influence physiological conditions such as vaginal innervation, there is a need for objective outcome measurements to better understand the effects of prolapse surgery on sexual function.AimsTo assess the effects of prolapse surgery with or without stress incontinence surgery on vaginal sensibility and to assess the relationship between vaginal wall sensibility and sexual well‐being.MethodsThis study was performed parallel to a randomized controlled trial comparing vaginal and abdominal prolapse surgery with or without incontinence surgery in women with uterine prolapse stage 2 or more.Main Outcome MeasuresVaginal wall sensibility was defined as mean sensation threshold to electrical stimulation of the vaginal wall at four standardized places, measured before and 6 months after surgery. Higher sensation thresholds postsurgery relative to presurgery indicate diminished vaginal wall sensibility. Sexual function was assessed at the same time points using a questionnaire.ResultsData on vaginal wall sensibility were obtained from 65 patients. The sensibility of the distal posterior (P = 0.02) and distal anterior (P = 0.10) vaginal wall decreased after vaginal surgery compared to abdominal surgery. Abdominal prolapse surgery with incontinence surgery decreased sensibility of the distal part of the anterior vaginal wall significantly more than abdominal prolapse surgery only (P = 0.01). Before surgery, vaginal wall sensibility was lower in women who reported vaginal dryness or anorgasmia. The presence of genital pain was associated with higher vaginal wall sensibility. Postoperative vaginal wall sensibility was similar in women with and without sexual problems.ConclusionVaginal prolapse surgery as well as abdominal prolapse surgery with additional incontinence surgery resulted in decreased vaginal wall sensibility. This pilot study shows no influence of the decreased vaginal wall sensibility on sexual well‐being. Larger studies are needed to better understand the association between changes in vaginal wall sensibility and changes in sexual well‐being. Lakeman MME, van der Vaart CH, Laan E, and Roovers J‐PWR. The effect of prolapse surgery on vaginal sensibility..     

Evaluating the efficacy of the single-incision uphold system for pelvic organ prolapse repair

Objective

The aim of this study was to assess the efficacy and clinical outcomes of pelvic floor reconstruction with transvaginal mesh of the Uphold? Vaginal Support System (Boston Scientific Corporation).

The Effects of Vaginal Prolapse Surgery Using Synthetic Mesh on Vaginal Wall Sensibility,Vaginal Vasocongestion,and Sexual Function: A Prospective Single‐Center Study

IntroductionVaginal mesh surgery in patients with pelvic organ prolapse (POP) has been associated with sexual dysfunction. Implantation of synthetic mesh might damage vaginal innervation and vascularization, which could cause sexual dysfunction.AimWe aim to evaluate the effects of vaginal mesh surgery on vaginal vasocongestion and vaginal wall sensibility in patients with recurrent POP.MethodsA prospective study was performed among patients with previous native tissue repair, scheduled for vaginal mesh surgery. Measurements were performed before and 6 months after surgery, during nonerotic and erotic visual stimuli, using a validated vaginal combi‐probe.Main Outcome MeasuresThe combi‐probe involves vaginal photoplethysmography to assess Vaginal Pulse Amplitude (VPA) (representing vaginal vasocongestion) and four pulse‐generating electrodes to measure vaginal wall sensibility (representing vaginal innervation). Sexual function was assessed using validated questionnaires (Female Sexual Function Index, Female Sexual Distress Scale‐Revised, and Subjective sexual arousal and affect questionnaire).ResultsSixteen women were included, 14 completed the 6‐month follow‐up visit. Vaginal vasocongestion under erotic conditions did not significantly alter after mesh implantation. Vaginal wall sensibility of the distal posterior wall was significantly increased after mesh surgery (preoperative threshold 6.3 mA vs. postoperative 3.4 mA, P = 0.03). Sexual function as assessed with questionnaires was not significantly affected.ConclusionsIn women with a history of vaginal prolapse surgery, vaginal mesh surgery did not decrease vaginal vasocongestion or vaginal wall sensibility. Vaginal vasocongestion prior to mesh surgery appeared to be lower than that of women never operated on. Apparently, native tissue repair decreased preoperative vaginal vasocongestion levels to such extent that subsequent mesh surgery had no additional detrimental effect. Our findings should be interpreted cautiously. Replication of the findings in future studies is essential. Weber MA, Lakeman MME, Laan E, and Roovers JPWR. The effects of vaginal prolapse surgery using synthetic mesh on vaginal wall sensibility, vaginal vasocongestion, and sexual function: A prospective single‐center study. J Sex Med 2014;11:1848–1855.     

Vaginal vault suspension by abdominal sacral colpopexy for prolapse: a follow up study of 40 patients

OBJECTIVES: Vaginal vault prolapse is a rare event after hysterectomy. Vaginal repair often results in a narrowed and shortened vagina with diminished function. Abdominal sacral colpopexy attaches the vaginal apex to the sacral promontory and restores the physiological position of the vagina. The objective of the study was to evaluate follow up results of the abdominal sacral colpopexy in 40 patients by a questionnaire and a gynaecologic examination. METHODS: We performed a cohort study. Between 1992 and 1998, 45 consecutive patients with a vaginal vault prolapse treated with an abdominal sacral colposcopy were included. RESULTS: Forty patients were included in the study. No serious complications occurred during surgery. Two patients per- or postoperative hemorrhage required blood transfusion. In two patients, one with a concomittant hysterectomy, the Gore-tex graft infected within 3 months after the operation. If vaginal 'protrusion' was the only preoperative complaint, in 93% (13/14) of the cases, surgery resulted in a condition without any complaint, related to the vaginal prolapse. If initially a combination of complaints (vaginal protrusion, urinary incontinence, defecation problems, sexual dysfunction) was the reason for surgery, only ten of 27 (37%) patients were symptom-free at follow up (P=0.002, Yates corrected). In the whole group 34 (85%) patients noticed before the operation a feeling of vaginal protrusion. At follow-up, 23 patients (56%) had no symptoms at all that could be related to the vaginal prolapse. Problems concerning defecation, like constipation were present before surgery in eight patients. In six of them, these complaints were resolved after surgery. However, in five patients de novo constipation developed after surgery. There were no cases of de novo urinary incontinence. At gynaecological examination in three patients, the vaginal vault prolapse recurred within the follow-up period, accounting for a success rate of 93%. In ten more patients a moderate enterorectocele developed or persisted. No reoperations were performed for that reason. CONCLUSIONS: Abdominal sacral colpopexy is a safe and efficacious treatment of the posthysterectomy vaginal vault prolapse. To prevent the persistence or development of an enterorectocele, a culdoplasty according to Halban or McCall might possibly be helpful. Peritonisation of the graft seems not to be necessary. The use of banked collagen tissue as graft material is promising and needs further investigation.     

Suburethral sling treatment of occult stress incontinence and intrinsic sphincter deficiency in women with severe vaginal prolapse of the anterior vs posterior/apical compartment

OBJECTIVE: The purpose of this study was to compare the efficacy of a Mersilene mesh suburethral sling for occult stress urinary incontinence (SUI) and intrinsic sphincter deficiency (ISD) in women with severe vaginal prolapse of the anterior compartment to the posterior/apical compartment. STUDY DESIGN: This was a retrospective study that compared women with stage or grade III/IV prolapse of the anterior compartment (group 1) with the posterior/apical compartment (group 2); both groups demonstrated occult SUI (leakage only with prolapse reduced) and ISD on urodynamics, and underwent concurrent pelvic reconstructive surgery. The sling was defined as efficacious if SUI was prevented in 85% of women and if obstructive symptoms (de novo or worsening urge incontinence, or urinary retention greater than 2 weeks) occurred in less than 10% of women. RESULTS: There were 39 women in group 1 and 25 women in group 2. There were no differences between women in group 1 or group 2 in preoperative demographics (except parity) or urodynamic findings. SUI cure rates were lower for group 1 than group 2, but this difference was not significant (87% vs 100%, P = .15). Rates of de novo or worsening urge incontinence (8% vs 4%, P = 1.00) and urinary retention (none occurred) were similar between groups. CONCLUSION: In women with severe vaginal prolapse, slings effectively treat occult SUI and ISD, whether associated with anterior or posterior/apical prolapse.     

Transvaginal Natural Orifice Transluminal Endoscopic Hysterectomy and Apical Suspension of the Vaginal Cuff to the Uterosacral Ligament

Study ObjectiveTransvaginal natural orifice transluminal endoscopic surgery (vNOTES) offers similar advantages of traditional vaginal surgery including no incisional pain as well as a better cosmetic outcome. Furthermore, vNOTES allows the surgeon to overcome the limited surgical space and lack of exposure when using the traditional vaginal instrumentation. Vaginal uterosacral ligament suspension subsequent to vaginal hysterectomy has the advantages of a mesh-free, minimally invasive approach for the treatment of pelvic organ prolapse. The objective of this video is to demonstrate a surgical technique and a few tips and tricks for vNOTES hysterectomy and uterosacral ligament suspension.DesignStepwise demonstration of the vNOTES technique for hysterectomy and vaginal apical suspension to the uterosacral ligament with narrated video footage.SettingAn academic tertiary referral center. The ethics committee ruled that approval was not required for this study.PatientsA 53-year-old woman.InterventionsvNOTES hysterectomy and apical suspension to the uterosacral ligament.Measurements and Main ResultsA 53-year-old woman (gravida 5, para 4) presented with Pelvic Organ Prolapse Quantification System stage III symptomatic uterine prolapse. The patient was selected to be operated on via a vaginal port. The video presents some tips and tricks to aid the surgeon to perform this surgery in a safe and timely manner using the vaginal GelPOINT system (Applied Medical, Rancho Santa Margarita, CA).ConclusionvNOTES for repair of POP by uterosacral ligament suspension via a vaginal port is a feasible technique with promising cosmetic results. This technique allows the surgeon to expose the ureter well and lower the risk of ureteric injury. Additionally, this approach avoids mesh complications and should also decrease the risk of abdominal wound infection because of the absence of incisions on the abdomen.     

Peri- and Postoperative Outcomes of Outpatient vs Inpatient Laparoscopic Apical Prolapse Repair

Study ObjectiveTo assess the feasibility of outpatient laparoscopic management of apical pelvic organ prolapse along with indicated vaginal repairs and anti-incontinence procedures.DesignRetrospective cohort study.SettingTertiary-care academic center, Boston, MA.PatientsTotal of 112 patients seen in the minimally invasive gynecologic surgery and urogynecology clinics with symptomatic pelvic organ prolapse.InterventionsLaparoscopic hysterectomy, sacrocervico- or sacrocolpopexy along with vaginal prolapse and anti-incontinence procedures as indicated from 2013 to 2017 at Brigham & Women's Hospital and Brigham & Women's Faulkner Hospital performed by a minimally invasive gynecologic surgery and urogynecology team.Measurements and Main ResultsOf the 112 patients, 52 were outpatient and 60 were admitted (median stay in admission group = 1 day; range 1–3). Patient baseline characteristics, American Society of Anesthesiologists’ class, and pelvic organ prolapse quantification stage were similar between the outpatient and admitted cohorts. Most patients underwent hysterectomy at the time of the sacropexy (65.4% outpatient vs 73.3% admitted, p = .08). Concomitant apical prolapse repair was more common in the outpatient group (98.1% vs 85%, p = .02). The proportion of outpatient procedures increased from 17% in 2013 to a peak of 70% in 2016. Operating room time was shorter for the outpatient cohort (103.9 minutes vs 115.5 minutes, p = .04), but other perioperative outcomes were similar. There were no intraoperative complications. The numbers of postoperative complications, readmission, and reoperations were low and similar between outpatient and admitted cohorts. No factor was predictive of admission on regression analysis.ConclusionLaparoscopic apical prolapse repair with concomitant vaginal repairs can be performed safely as an outpatient procedure. A unique team approach may foster a shorter, more efficient procedure without compromising short-term outcomes.     

Laparoscopic repair of vaginal vault prolapse by lateral suspension with mesh

Background

To evaluate the long-term outcomes of laparoscopic lateral suspension using mesh reinforcement for symptomatic posthysterectomy vaginal vault prolapse.

Materials and methods

We analyzed in a prospective cohort study all the women treated by laparoscopic lateral suspension with mesh for symptomatic vaginal vault prolapse between January 2004 and September 2010. In this procedure, the mesh is laterally suspended to the abdominal wall, posterior to the anterior superior iliac spine. We performed systematic follow-up examinations at 4 weeks, 6 months and yearly postoperatively. Clinical evaluation of pelvic organ support was assessed by the pelvic organ prolapse quantification (POP-Q) grading system. Main outcome measures were recurrence rate, reoperation rate for symptomatic recurrence or de novo prolapse, mesh erosion rate, reoperation rate for mesh erosion, total reoperation rate.

Observations and results

Of the 73 patients seen at a mean 17.5 months follow-up, recurrent vaginal vault prolapse was registered in only one woman (success rate of 98.6 %). When considering all vaginal sites, we observed a total of 13 patients with recurrent or de novo prolapse (17.8 %). The non-previously treated posterior compartment was involved in eight cases (new appearance rate of 11 %). Of these 13 women, only 6 were symptomatic, requiring surgical management (reoperation rate for genital prolapse of 8.2 %). Four patients presented with mesh erosion into the vagina (5.5 %). Two required partial vaginal excision of the mesh in the operating room (2.7 %). There were no mesh-related infections. The total reoperation rate was 11 %.

Conclusion

Laparoscopic lateral suspension with mesh interposition is a safe and effective technique for the treatment of vaginal vault prolapse. This approach represents an alternative procedure to the laparoscopic sacrocolpopexy.     

De novo stress urinary incontinence after vaginal repair for pelvic organ prolapse: one-year follow-up

Objective

A few studies have reported a wide range (2–43%) in incidence of de novo stress urinary incontinence (SUI) following surgical repair of pelvic organ prolapse (POP) in previously continent women. The aim of this study was to re-examine this incidence up to one year following vaginal repair of prolapse.

Study design

Retrospective review of a cohort of women who underwent reconstructive vaginal repair of POP without a concomitant anti-incontinence procedure between 2003 and 2007 at two tertiary referral centers. Women were considered eligible if they were stress continent by symptoms and objective assessment (including urodynamics testing) prior to surgical repair. All women who had had any anti-incontinence procedure previously were excluded. The endpoint was subjective SUI that prompted the patient to undergo any treatment within one year from their prolapse surgery.

Results

64 women, with a mean age of 61 (±11) years, were eligible for the study: 26 (41%) had preoperative symptoms of overactive bladder. Fifty-four patients were available for analysis at the one-year visit. Seven women (13.5%) had symptoms of SUI but only one (2%) was found to have SUI objectively. Another patient underwent anti-incontinence surgery following her prolapse surgery.

Conclusion

The incidence of de novo SUI requiring treatment in previously continent women who underwent vaginal repairs for POP without concomitant anti-incontinence surgery is low (4%). A large-scale prospective study is necessary to further evaluate this finding.     

Combined Pelvic Reconstructive Surgery and Transobturator Tape (Monarc) in Women with Advanced Prolapse and Urodynamic Stress Incontinence: A Case Control Series

Study ObjectiveThe aim was to evaluate the safety and efficacy of transobturator tape (TOT) using Monarc with extensive vaginal reconstructive surgery in patients with urodynamic stress incontinence (USI) and advanced genital prolapse (stage ≥ III pelvic organ prolapse quantification system staging).DesignCase control study. Canadian Task Force classification II-2.SettingMedical school-affiliated hospital.PatientsA total of 57 women were surgically treated (28 stage III and 29 stage IV prolapse). Urodynamic stress incontinence was defined as demonstrable involuntary urine leakage with negative pressure transmission observed at stress urethral pressure profile. Severe USI was defined as leak on 1-hour pad test of more than 10 g.InterventionsThe indicated extensive pelvic reconstructive procedures including anterior colporrhaphies, posterior colporrhaphies, vaginal total hysterectomies, sacrospinous ligament fixations, and LeFort procedures were completed before the TOT procedure. The TOT procedure using Monarc device was performed through a separate small vaginal incision sparing vaginal reconstructive procedures.Measurements and Main ResultsThe mean follow-up period was 18.2 months. Objective data were available for 51 patients. In all, 44 (86.3%) were completely dry at 1 year postoperatively. Among the 7 failures, 5 had severe preoperative USI. No major surgical complications, including bladder injury, occurred. The mean blood loss was 154 mL; the mean operating time for complete procedure and TOT alone was 86 minutes and 18 minutes, respectively; and the mean postoperative hospital stay was 4.1 days. Six (10.5%) patients maintained intermittent catheterization for more than 72 hours. All were classified as having severe bladder outlet obstruction preoperatively. Two patients developed recurrent prolapse onto stage II (pelvic organ prolapse quantification system staging). Urodynamic parameters related to voiding dysfunction showed an improvement after the surgery. De nova detrusor instability was observed in 2 patients.ConclusionUsing separate incisions and sequencing the TOT as the last procedure, the combination surgery is safe and effective for USI and advanced pelvic prolapse. The bladder outlet obstructions caused by severe prolapse and preoperative severity of urinary incontinence seem to be a risk factor for prolonged postoperative catheterization and failure of antiincontinent procedure, respectively. Additional information on treatment of recurrent prolapse required a longer period of follow-up.     

Impact of incontinence surgery on sexual function: a systematic review and meta-analysis

IntroductionUrinary incontinence has an adverse impact on sexual function. The reports on sexual function following the treatment of urinary incontinence are confusing.AimTo investigate the impact of surgery for stress incontinence on coital incontinence and overall sexual function.MethodsCochrane Incontinence Group Specialized Register of Controlled Trials, The Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE were searched for trials of incontinence surgery assessing sexual function and coital incontinence before and after surgery. Observational studies and randomized controlled trials investigating the impact of surgical correction of stress urinary incontinence on sexual function were included. Surgical interventions included tension‐free vaginal tape (TVT), Tension Free Vaginal Tape‐Obturator (TVT‐O), transobturator tape (TOT), Burch, and autologous fascial sling (AFS). Studies that included patients undergoing concurrent prolapse surgery were excluded from the analysis. Data extraction and analysis was performed independently by two authors. Coital incontinence was analyzed separately and odds ratios (ORs) with 95% confidence intervals (CI) calculated. The data were analyzed in Review Manager 5 software.Main Outcome MeasureChanges in sexual function and coital incontinence following surgery for urinary incontinence.ResultsTwenty‐one articles were identified, which assessed sexual function and/or coital incontinence following continence surgery in the absence of prolapse. Results suggest evidence for a significant reduction in coital incontinence post surgery (OR 0.11; 95% CI 0.07, 0.17).ConclusionsCoital incontinence is significantly reduced following continence surgery. There were several methodological problems with the quality of the primary research particularly related to heterogeneity of studies, use of different outcome measures, and the absence of well‐designed randomized controlled trials. Jha S, Ammenbal M, and Metwally M. Impact of incontinence surgery on sexual function: A systematic review and meta‐analysis. J Sex Med 2012;9:34–43.     

Vaginal paravaginal repair with an AlloDerm graft

OBJECTIVE: This study was undertaken to describe outcomes of a technique of vaginal paravaginal repair that used AlloDerm graft (LifeCell, Branchburg, NJ) in women with recurrent stage II or with primary or recurrent stage III/IV anterior vaginal wall prolapse. STUDY DESIGN: This was an observational study. Thirty-three women underwent a vaginal paravaginal repair using AlloDerm graft. Anterior vaginal wall prolapse was staged using the pelvic organ prolapse quantification system preoperatively and every 6 months after surgery. Recurrence of prolapse, changes in functional status (urinary symptoms, prolapse symptoms, and sexual activity), and complications were recorded. Objective failure was defined as recurrent anterior vaginal wall prolapse, stage II or greater, and subjective failure as symptomatic recurrent anterior vaginal wall prolapse. Life-table analysis evaluated objective and subjective failure. Risk factors for recurrent anterior vaginal wall prolapse were evaluated. RESULTS: The mean age was 65.2 years and 93% of the women were white. Preoperatively, 6 women had recurrent stage II, 24 women had stage III, and 3 women had stage IV anterior vaginal wall prolapse. The median length of follow-up was 18 months. Postoperatively, 12 women had asymptomatic stage II anterior vaginal wall prolapse (not beyond the hymen) develop, and 1 woman had symptomatic stage II prolapse develop. Thus, there were 13 (41%) objective failures and 1 (3%) subjective failure. Life-table analysis demonstrated the cumulative probability of an objective failure was 0.24 at 1 year and 0.50 at 2, 3, and 4 years. The cumulative probability of a subjective failure was 0.00 at 1 and 2 years and 0.11 at 3 and 4 years. No risk factors for objective failure were identified. Voiding complaints resolved in 11 of 14 (79%) women (P=.004), incontinence symptoms resolved in 17 of 19 (89%) women (P<.001), and urgency symptoms resolved in 20 of 23 (87%) women (P<.001) (all two-tailed Fisher exact test). Twenty-one women (64%) were sexually active, and none complained of postoperative dyspareunia. Complications included 1 case of febrile morbidity, 1 cystotomy, and 1 anterior wall breakdown secondary to hematoma formation caused by heparin therapy. No other erosions or rejections were seen. CONCLUSION: Vaginal paravaginal repair with AlloDerm graft in women with recurrent stage II or stage III/IV anterior vaginal wall prolapse is safe and has good subjective but only fair objective success within the first 2 years.     

Clinical outcome of transobturator tape concomitant with vaginal hysterectomy plus anterior posterior colporrhaphy

Objective  Transobturator tape (TOT) is a newly described procedure for the treatment of female stress urinary incontinence. The success of TOT operation along with prolapsed surgery has not been well described. The aim of this study is to determine the complication and success rates of TOT concomitant with pelvic prolapse surgery. Study design  Totally, 72 women who had TOT operation along with vaginal hysterectomy, anterior posterior colporrhaphy were re-evaluated with UDI6 and IIQ7 forms 1 year of surgery. Preoperatively, all patients had clinically pure stress incontinence. Results  At 1 year, 80.6% of patients were cured with only 16.7% presenting de novo urge incontinence, while 2.8% of women retaining stress urinary incontinence. The patients with lower gravida and number of vaginal delivery had significantly higher operation success rates. The IIQ7 score significantly increased by increase in urinary catheter stay day. The women with the history of cesarean delivery and lower hospital stay had significantly higher satisfaction scores. Of the factors only, the number of gravida could be used to predict treatment failure in the entire group. Conclusion  Transobturator tape procedure could be accompanied safely with prolapse surgery.     

Resultado de la cirugía del prolapso del suelo pélvico a largo plazo

Objective

To evaluate the long-term outcomes of pelvic floor prolapse surgery.

Patients and methods

We recruited 252 patients who underwent surgery in Donostia Hospital between 2000 and 2001. There were 194 vaginal hysterectomies, 219 anterior colpoplasties, 218 posterior colpoplasties, 41 placements of tension-free vaginal tape associated with prolapse surgery, 15 colpopexies and three colpocleises. Follow-up was performed in November and December 2005. The patients were questioned about risk factors for pelvic organ prolapse, current symptoms, and subjective appraisal of surgical outcomes. A questionnaire on symptoms and quality of life was administered. The Pelvic Organ Prolapse Quantification System (POPQ) was used for pelvic examination. We defined surgical failure as a symptomatic prolapse or POPQ-S grade II or higher.

Results

Five years after surgery, the reintervention rate was 2.7%. Surgical failure in one or more compartment was found in 28.18% of the examined women, distributed in 18.12% anterior, 4% apical and 11.4% posterior. Eighty-five percent of the interviewed patients had no sensation of prolapse. Urgency incontinence was reported by 17.1% and stress incontinence by 7.3%. Dyspareunia was found in 14.3%. In the subjective appraisal, 86.2% reported they were symptom-free, 6.3% felt marked improvement, 2.9% felt slight improvement, 1.96% experienced no change, 1.96% felt worse and 0.5% did not know.

Conclusions

Our long-term outcomes are good compared with those of other series. There is little correlation between symptomatic and anatomical failure. Secondary symptoms of the surgery should be included in the appraisal of surgical outcome. Further studies should be carried out with a higher number of patients and long-term prospective follow-up to correctly define the criteria for surgical failure.     

The Impact of Mid‐Urethral Slings for the Treatment of Urodynamic Stress Incontinence on Female Sexual Function: A Multicenter Prospective Study

IntroductionUrinary incontinence is a common condition that negatively impacts on female sexuality (FS).AimTo evaluate FS before and after a mid‐urethral sling (MUS) procedure using the Female Sexual Function Index (FSFI). We included women that were both sexually and nonsexually active at baseline.MethodsOne hundred fifty‐seven women complaining of urodynamic stress incontinence underwent a MUS procedure and were enrolled in the study. All patients answered the Italian translation of FSFI, before and 12 months after surgery. To understand the real impact of the MUS on female sexual function, for the first time in the literature, we also monitored and included in the final analysis all the women who are nonsexually active at baseline. We evaluated the prevalence of female sexual dysfunction according to the FSFI cutoff point (26.55).Main Outcome MeasuresFSFI total score, pads use, and stress test presurgery and postsurgery.ResultsOne hundred thirty‐three patients completed the study protocol: 105 out of 133 underwent to a trans‐obturator procedure, while 28 out of 133 had a retropubic procedure. After the 12‐month follow up, 115 out of 133 patients (86%) were dry, 10 improved their symptoms, and the remaining 8 were unchanged. Seventy‐nine out of 133 (59%) patients reported an active sexual life before surgery. Fifty‐four (41%) reported they were not sexually active before surgery. Twelve months after surgery, 22 out of 54 nonsexually active women (40%) reestablished sexual activity, whereas only 6 out of 79 (7.5%) patients, sexually active at baseline, were not sexually active 1 year after surgery (P < 0.05). After adjusting for multiple testing, only age, menopause, and storage symptoms remained significantly correlated with the FSFI total score postsurgery as independent variables.ConclusionsOur data showed that after a MUS procedure, female sexual function improves. We also found that a very relevant percentage of nonsexually active women reported renewed sexual activity after MUS. Filocamo MT, Serati M, Frumenzio E, Li Marzi V, Cattoni E, Champagne A, Salvatore S, Nicita G, and Costantini E. The impact of mid‐urethral slings for the treatment of urodynamic stress incontinence on female sexual function: A multicenter prospective study. J Sex Med 2011;8:2002–2008.     

Pessary test to predict postoperative urinary incontinence in women undergoing hysterectomy for prolapse

OBJECTIVE: We sought to demonstrate that a positive pessary test could predict postsurgical stress urinary incontinence in women with severe pelvic organ prolapse and that performing tension-free vaginal taping (TVT) could effectively prevent its occurrence. METHODS: Among the 79 patients evaluated for severe pelvic organ prolapse without symptoms of stress urinary incontinence, all underwent meticulous urogynecologic evaluations and pessary testing. In group 1, 32 patients had positive pessary tests and underwent vaginal hysterectomy, anterior and posterior colporrhaphy, and TVT. In group 2, 47 patients (17 of whom had positive pessary tests and 30 of whom had negative pessary tests) underwent vaginal hysterectomy and anterior and posterior colporrhaphy alone. A comparison in terms of surgical outcome and clinical manifestations was made between these 2 groups of patients. RESULTS: After surgery, a small proportion of patients had de novo idiopathic detrusor overactivity (7.6%, n = 6), urinary tract infections (7.6%, n = 6), mild recurrent prolapse (5.1%, n = 4), and urinary retention (3.8%, n = 3). Eleven (64.7%) of 17 patients with positive pessary tests who did not undergo TVT had urine leakage after their hysterectomies in contrast with the 30 patients who had negative pessary test, none of whom developed symptomatic stress urinary incontinence after vaginal hysterectomy. Among the 32 patients with positive pessary tests who had TVT with their hysterectomies, 3 developed urine leakage later; the cure rate was 90.6%. CONCLUSION: Continent patients suffering from severe pelvic organ prolapse but with a positive pessary test are considered to be at high risk of developing postoperative symptomatic stress urinary incontinence. Among the patients in our medium-range study, TVT effectively prevented postsurgical urinary incontinence. LEVEL OF EVIDENCE: II-1