The development of pelvic organ prolapse after colposuspension: a prospective, long-term follow-up study on the prevalence and predisposing factors

The objectives of this prospective study were to determine the prevalence of pelvic organ prolapse (POP) after colposuspension and to investigate possible preoperative and operative risk factors. Seventy-seven women who underwent colposuspension between 1996 and 1997 were investigated. POP was assessed before colposuspension using the pelvic organ prolapse quantification system (POPQ). Women were reassessed at one and seven to eight years (or when referred with symptomatic POP). By seven to eight years, of the 77 women, 29 (38%) had developed symptomatic prolapse, 29 (38%) had asymptomatic prolapse, 7 (9%) had no symptoms and no prolapse, and 12 (15%) could not be assessed. POP at one year was significantly associated with the presence of posterior vaginal descent before colposuspension (odds ratio 3.07, 95% CI 1.10–8.60, p=0.03). No variable reached statistical significance by eight years postcolposuspension. In conclusion, this is the first study to assess POP prospectively using a validated method before and after colposuspension. The results add support to the view that there is an association between colposuspension and the development of symptomatic POP (requiring surgery).     

Review of synthetic mesh-related complications in pelvic floor reconstructive surgery

There is significant risk of re-operation after pelvic reconstructive surgery. In an attempt to improve outcome, synthetic materials are increasingly being used to augment pelvic organ prolapse repair despite lack of strong evidence to support their routine use. The use of synthetic mesh to correct apical, anterior and posterior vaginal wall prolapse is not without complications. This review aims to evaluate the long-term complications of synthetic mesh in pelvic reconstructive surgery.     

Correlation between vaginal stiffness index and pelvic floor disorder quality-of-life scales

The objective of this study was to determine if vaginal stiffness index, an in vivo vaginal biomechanical property, is correlated with pelvic floor disorder symptom distress, impact on quality of life, or sexual function as measured by disease-specific quality-of-life scales. Forty-eight women completed validated quality-of-life scales (pelvic floor distress inventory-short form, pelvic floor impact questionnaire, and pelvic organ prolapse/urinary incontinence sexual questionnaire) and underwent in vivo vaginal biomechanical testing. After bivariate relationships between vaginal stiffness index and demographic, obstetric, and gynecologic variables were explored, multiple linear regression controlling for pelvic organ prolapse quantitative (POP-Q) stage of prolapse was performed. The vaginal stiffness index was inversely correlated with pelvic organ prolapse distress severity (POPDI-6) after controlling for POP-Q stage of prolapse (p = 0.011, r = 0.67, r (2) = 0.450, beta = -2.3). These findings provide initial evidence for the construct validity of in vivo vaginal biomechanical testing for pelvic organ prolapse evaluation because an increasing vaginal stiffness index is correlated with decreasing symptomatic and anatomic severity of disease.     

Quality of life after surgery for genital prolapse in elderly women: obliterative and reconstructive surgery

The objective of this study was to determine if obliterative and reconstructive vaginal surgery for advanced pelvic organ prolapse improve quality of life in elderly women. Women age 65 years or older with stage 3 or 4 pelvic organ prolapse who desired surgical correction were prospectively enrolled. The subjects underwent either obliterative or reconstructive vaginal surgery based on their personal preference and sexual expectations. The subjects received a pelvic organ prolapse quantitation examination and completed the pelvic floor distress inventory (PFDI), the pelvic floor impact questionnaire (PFIQ), the SF-36, and the Beck depression inventory preoperatively, 6 and 12 months after surgery. Seventy-nine subjects were enrolled, 70 of whom completed follow-up: 30 in the obliterative group and 40 in the reconstructive group. Both groups demonstrated significant improvements in the pelvic organ prolapse, urinary, and colorectal scales of the PFDI and PFIQ 6 and 12 months after surgery with no differences between the two treatment groups. In addition, there were significant and clinically important improvements noted in the bodily pain, vitality, social functioning, role–emotional, and mental health summary scales of the SF-36 in both groups after surgery, with no significant difference between groups. In appropriately selected elderly women, both obliterative and reconstructive vaginal surgery for advanced pelvic organ prolapse significantly improved health-related quality of life.     

Perioperative outcomes of the Prolift® pelvic floor repair systems following introduction to a urogynecology teaching service

The safety information of the vaginal mesh systems upon introduction to a teaching urogynecology service is limited to date. To determine the frequency of perioperative complications associated with the use of Prolift® kits (Gynecare/Ethicon, Somerville, NJ, USA) by a teaching urogynecology service, data from the first 100 consecutive women were analyzed. The primary outcome was any deviation from a normal intraoperative or perioperative course. Complications were graded using the Dindo morbidity scale. Univariate analyses were performed to identify risk factors. Complications included bladder perforation (2%), blood transfusion (2%), mesh exposure (4%), and urinary tract infections (28%). Eleven percent of women reported postoperative pain, and 34% required catheterization at discharge for incomplete bladder emptying. Univariate analysis showed no association between morbidities and patient characteristics, attending experience, or fellow involvement. The integration of Prolift® kits for prolapse repair into a urogynecology training program can be achieved with few perioperative complications.     

Effectiveness of the McCall culdeplasty in maintaining support after vaginal hysterectomy

The aim of this study was to evaluate the effectiveness of a McCall culdeplasty in maintaining support of the post-hysterectomy vaginal cuff in women undergoing surgery for uterine prolapse. A retrospective chart review was performed on all patients who had a vaginal hysterectomy and McCall culdeplasty for uterine prolapse without prolapse of the posterior vaginal fornix. Patients were examined pre- and postoperatively using the International Continence Society (ICS) staging system. Data were analyzed using repeated measures analysis of variance (ANOVA) for correlation between preoperative point D and the two postoperative point C measurements. Of the 43 patients studied, 39 (90%) had stage 0 prolapse and 3 (7%) had stage I prolapse of the vaginal cuff 1 year postoperatively. In patients who have hysterectomies for uterine prolapse with good support of the posterior vaginal fornix, the McCall culdeplasty is a highly successful procedure in maintaining proper anatomic support of the vaginal cuff.     

The effect of training with vaginal weighted cones and pelvic floor exercises on the strength of the pelvic floor muscles: A pilot study

A pretest-post-test design (n=14) was used to investigate pelvic floor muscle (PFM) strength over a 2-month training period using vaginal cones with pelvic floor exercises in the treatment of female stress incontinence, and to correlate any changes in muscle strength with objective and subjective measures of stress incontinence. PFM strength was assessed by vaginal examination and the ability to retain the cones. The symptom of stress incontinence was assessed using rating scales, and measured objectively by the extended pad test. The results showed a significant increase in muscle strength (P<0.05). An unexpected finding was that most of the improvement in PFM function occurred in a 1-week baseline assessment period before training was commenced. It is therefore suggested that the increase in force generation occurred due to a process of neural adaptation rather than muscle hypertrophy. No significant correlations were found between muscle strength and objective or subjective measures of stress incontinence.Editorial Comment: Vaginal cones are gaining in popularity as a method of therapy for stress incontinence. As in this study, the symptom of stress incontinence was enough to begin treatment and objective documentation of the diagnosis was not undertaken. The therapy has no side-effects and only requires that the patient is motivated enough to put the cone in the vagina and take it out after a prescribed time period. Everything else is automatic. Biofeedback from the perception of the cone falling out provides the stimulus for pelvic floor contraction. Success rates are high, with 21% cured and 29% improved for an overall improvement rate of 50%. Such therapies may be tried before diagnosis, and certainly before expensive surgical treatment.     

Magnetic resonance assessment of pelvic anatomy and pelvic floor disorders after childbirth

To compare pelvic anatomy, using magnetic resonance imaging, between postpartum women with or without pelvic floor disorders. We measured postpartum bony and soft tissue pelvic dimensions in 246 primiparas, 6–12-months postpartum. Anatomy was compared between women with and without urinary or fecal incontinence, or pelvic organ prolapse; P < 0.01 was considered statistically significant. A deeper sacral hollow was significantly associated with fecal incontinence (P = 0.005). Urinary incontinence was marginally associated with a wider intertuberous diameter (P = 0.017) and pelvic arch (P = 0.017). There were no significant differences in pelvimetry measures between women with and without prolapse (e.g., vaginal or cervical descent to or beyond the hymen). We did not detect meaningful differences in soft tissue dimensions for women with and without these pelvic floor disorders. Dimensions of the bony pelvis do not differ substantially between primiparous women with and without postpartum urinary incontinence, fecal incontinence and prolapse.     

Postpartum pelvic floor conditioning using vaginal cones: Not only for prophylaxis against urinary incontinence and descensus

Seventy-one women were examined 6–8 weeks after spontaneous delivery by pelvic floor (PF) palpation, inspection, manometry and gravimetry. Re-examination was performed in the same way after 4–6 weeks of daily cone training. Control groups included 20 women prior to and after conventional puerperal exercises, and 8 nulliparae prior to and after the same cone training, using a five-cone set. The number of puerperae not capable of voluntary PF contraction declined from 34% before to 6% after training. Optimum initial and post-training responses were exhibited by all nulliparae. Differences between cone and conventional exercise groups were of minor importance. Contractility increased from 5 to 10 mmHg on average in puerperae and from 15 mmHg to 21 mmHg in nulliparae. Cone nos. 1–3 were most frequently required at the beginning of training, and nos. 3–5 towards the end. Cone training works well as an alternative or complement to conventional postpartum exercises, and may therefore be recommended especially to puerperae who are not capable of holding vaginal cones of 20–70 g 6 weeks after delivery.Editorial commentThe investigators set out to show that vaginal cones can be used for postpartum pelvic floor conditioning, and their results do indeed indicate an improvement in pelvic floor strength based on the speculum lift test, manometry and cone holding. Unfortunately, the study does not answer, and was not designed to answer, whether the use of vaginal cones is better than, equal to or worse than pelvic floor exercises for reconditioning the pelvic floor after vaginal delivery. To answer this question requires randomization, blinding and appropriate control groups (i.e. postpartum patients who do not perform any type of exercise of the pelvic floor).     

Patient-selected goals: the fourth dimension in assessment of pelvic floor disorders

The purpose of the study was to assess the relationship between self-expressed urogynecologic goals, symptoms, and treatment choice. Charts of women presenting for urogynecology consultation were reviewed. Demographics, diagnoses and responses to the pelvic floor distress inventory and medical, social, and epidemiologic aspects of aging questionnaires were recorded. Patients listed urogynecology goals before consultation. We categorized goals into five categories and then compared these categories by symptom type, severity, and treatment. Three hundred five women reported 635 goals (median 2, range 1–6). The number of goals listed per patient did not differ by age, race, comorbidities, or clinical diagnosis (p > 0.05). The most frequent goal category was symptoms (67%), followed by information seeking (12%), lifestyle (11%), emotional (4%), and “other” (6%). Women selecting non-surgical treatment were more likely to list information seeking as primary goal than those who chose surgery (p = 0.009). One third of participants expressed a primary non-symptom goal and were more likely to seek non-surgical therapy.     

Prospective clinical and functional results of combined rectal and urogynecologic surgery in complex pelvic floor disorders

Background

The aim of this prospective study was to evaluate the results of combined rectal and urogynecologic surgery in women with associated obstructed defecation, urinary incontinence, or genital prolapse.

Methods

One hundred forty-two selected patients with obstructed defecation in isolation or associated with urinary incontinence, enterocele, or genital prolapse were consecutively operated on by stapled transanal rectal resection alone or associated with transobturator tape, vaginal repair of the enterocele, or vaginal hysterectomy, respectively, and followed up by clinical controls and defecography.

Results

At 2 years, all symptom, quality-of-life, and defecographic parameters had significantly improved in all groups (P < .001). The association with hysterectomy showed higher risk for severe complications, longer operative time, hospital stay, and time of inability (P < .001). Recurrence of urinary incontinence was observed in 3 of 24 patients, while 2 of 21 showed residual vaginal prolapse.

Conclusion

The combination of rectal and urogynecologic surgery is effective, with higher morbidity in the association with vaginal hysterectomy. Randomized trials comparing surgery in 1 and more stages and longer follow-up are necessary for a definitive conclusion.     

生物反馈电刺激联合药物在绝经后盆腔器官脱垂盆底重建术后应用

目的探究生物反馈电刺激技术联合雌二醇凝胶用于绝经后盆腔器官脱垂（POP）患者盆底重建术后的疗效及其对并发症的影响。 方法选取2019年10月至2021年10月秦皇岛市第一医院妇科病区及妇科门诊收治的绝经后POP行盆底重建术的患者222例为研究对象,将符合入组标准的患者按随机数字表法分成3组：生物反馈电刺激组（A组）、药物疗法组（B组）、生物反馈电刺激联合药物疗法组（C组）。每组各74例患者。观察3组患者盆底肌力、盆底肌电活动评分、尿动力学、并发症及生活质量。 结果干预后C组盆底肌力等级较A、B组显著升高（P<0.05）,A、B组比较差异无统计学意义（P=0.952）;干预后3组盆底肌电活动评分及生活质量（SF-36）评分均升高,C组指标均优于A、B组（P<0.05）,A、B组比较差异均无统计学意义（P=0.118,P=0.881）;干预后3组尿动力学指标均升高,且C组指标均显著高于A、B组（P<0.05）,A、B组比较差异均无统计学意义（P=0.621,P=0.668,P=0.306）;干预后C组并发症总发生率明显低于A、B组（P<0.05）。 结论生物反馈电刺激技术联合雌二醇凝胶用于绝经后POP患者盆底重建术后疗效显著,可降低并发症发生率。     

Management of ureteral injuries associated with vaginal surgery for pelvic organ prolapse

Due to the anatomic proximity of the urinary and genital tracts, iatrogenic ureteral injury during pelvic organ prolapse repairs is a serious complication that we have managed in increasing number at our institution. However, few centers have reported on their experience with ureteric injuries associated with gynecologic reconstructive surgery. These ureteral injuries may lead to much morbidity, in particular the formation of ureterovaginal fistula, and the potential loss of renal function especially when diagnosed postoperatively. It is necessary, therefore, for surgeons to have a thorough knowledge of ureteral anatomy and to take precautions to prevent such injuries. The purpose of this article is to review this pertinent anatomy and the key principles of management of ureteric complications of transvaginal surgery for pelvic organ prolapse. The present study illustrates the application of our treatment algorithm based on the time of presentation and the patient condition.     

A systematic review of clinical studies on dynamic magnetic resonance imaging of pelvic organ prolapse: the use of reference lines and anatomical landmarks

Introduction and hypothesis  The aim of our study was to provide a systematic literature review of clinical studies on pelvic organ prolapse staging with use of dynamic magnetic resonance (MR) imaging. Methods  The databases EMBASE and PubMed were searched. Clinical studies were included in case they compared pelvic organ prolapse stages as assessed on dynamic MR imaging (using a reference line) with a standardized method of clinical prolapse staging. Results  Ten studies were included, which made use of seven different reference lines in relation to a wide variety of anatomical landmarks. Conclusion  Only few studies have compared pelvic organ prolapse stages as assessed by dynamic MR imaging and clinical examination in a standardized manner. The available evidence suggests that prolapse assessment on dynamic MR imaging may be useful in the posterior compartment, but clinical assessment and dynamic MR imaging seem interchangeable in the anterior and central compartment.     

经阴道网片盆底重建术治疗盆底脏器脱垂患者临床疗效

目的探讨经阴道网片盆底重建术治疗盆底脏器脱垂（pelvic organ prolapse,POP）患者的临床效果观察及安全性疗效。 方法选取2016年1月至2017年12月,河北省邯郸市中心医院118例POP患者的临床资料,按照术式不同分为2组,每组患者59例。对照组采用传统的手术方式进行治疗,试验组采用经阴道网片盆底重建术进行治疗。 结果试验组手术时间、术后首次下床活动及住院时间均短于对照组,差异有统计学意义（P<0.05）。试验组术中出血量与对照组比较比较,差异无统计学意义（P>0.05）。试验组术后有效率明显高于对照组,差异有统计学意义（P<0.05）。 结论经阴道网片盆底重建术是治疗POP患者有效、安全的术式,可显著改善患者的临床症状,但需严格按照手术适应症进行。     

Surgical management of posterior vaginal wall prolapse: an evidence-based literature review

The aim of this review is to summarize the available literature on gynecological management of posterior vaginal wall prolapse. A MEDLINE search and a hand search of conference proceedings of the International Continence Society and International Urogynecological Association was performed. Two randomized trials demonstrated that the transvaginal approach to rectocele is superior to the transanal repair in terms of recurrent prolapse. The traditional posterior colporrhaphy with levator ani plication was largely superceded by fascial repairs with similar anatomic success rates but favorable functional outcome. The midline fascial plication may offer a superior anatomic and functional outcome compared to the discrete site-specific fascial repair. Controlled studies are necessary to evaluate whether a sacrocolpopexy combined with posterior mesh interposition is an effective alternative to the transvaginal repair. There is currently no evidence to recommend the routine use of any graft and complications such as mesh erosion, infection, and rejection have to be considered.     

Urinary tract injuries during pelvic surgery: incidence rates and predisposing factors

Objective To review the cases of urinary tract injury following major pelvic surgery that were treated in our hospital over the last 12 years, in relation to possible predisposing factors and incidence rates of injury arising in various surgical procedures.Materials and methods From 8,824 major gynecological operations performed in our department, 29 cases of intraoperative urinary tract injury were found. Thirty eight patients visited the urology department during the same period for the management of urogenital fistula following pelvic surgery. Parameters that were examined included type of urinary tract injury, indication for surgery, type of operation, coexisting pathological conditions, past history of pelvic surgery or pelvic irradiation, and the delay in the recognition and management of the urinary tract injury.Results The overall incidence of urinary tract injury in pelvic surgery was 0.33%. The incidence of urinary tract injury in radical hysterectomy was higher than that of total abdominal hysterectomy(0.76 vs 0.26%). Of the intraoperative urinary tract injuries, 48.4% coexisted pelvic pathologies. Of all the cases with urinary tract injury, the most common type of operation was total abdominal hysterectomy (n=45, 67.2%), and the most common indication was uterine myoma (n=25, 36.9%). The most common type of urinary tract injury was bladder injury, including bladder laceration and vesicovaginal fistula(n=57, 76.1%). The frequency of reoperation was found to be lower in patients with a shorter delay in the recognition of the injury (p<0.05).Conclusion Possible predisposing factors for urinary tract injury are coexisting pelvic adhesion, distortion of normal pelvic configuration, previous irradiation history, previous operation history, and the extent of surgery. In high-risk patients, proper evaluation is needed to avoid urology complications before operation.     

A 5-year prospective follow-up study of vaginal surgery for pelvic organ prolapse

The objective of this study was to evaluate anatomic, functional, short- and long-term outcome of vaginal surgery for pelvic organ prolapse. This was a prospective observational study of 185 consecutive women planned for vaginal prolapse reconstructive surgery. Stage of prolapse, urinary incontinence (UI), bowel and mechanical symptoms were assessed preoperatively and at 1, 3 and 5 years postoperatively. The mean follow-up time was 53 months. The anatomic recurrence rate was 41.1% but less than half of them were symptomatic. Anterior compartment was most prone for recurrence and the majority of the recurrences took place within the first year. UI remained at the same level at 1-year follow-up. De novo urge occurred in 22.6% and de novo stress incontinence in 6.0%. An improvement was seen in difficulty in emptying bowel 1 year after surgery (54%). Patients were primarily cured from mechanical symptoms. Re-operation rate was 9.7%; if additional operation for incontinence was included, it was13.5%.