Pelvic organ prolapse surgery and quality of life-a nationwide cohort study

Early safety and efficiency outcomes of a novel interdisciplinary laparoscopic resection rectopexy combined with sacrocolpopexy for women with obstructive defecation syndrome and pelvic organ prolapse: a single center study

BACKGROUND

Obstructive defecation syndrome (ODS) defines a disturbed defecation process frequently associated with pelvic organ prolapse (POP) in women that substantially compromises quality of life. Conservative management offers limited relief and a surgical intervention may be required. This is characterized by individual approaches. AIM OF THE STUDY: This retrospective single center study evaluated the surgical and clinical short-term outcome of a novel interdisciplinary laparoscopic resection rectopexy (L-RRP) with mesh- sacrocolpopexy (L-SCP) for women suffering from ODS and POP.

METHODS

The study participants underwent surgery in an interdisciplinary laparoscopic approach. Safety was the primary endpoint, assessed via postoperative morbidity classified by Clavien-Dindo scale. Secondary outcomes included evaluation of bowel function, fecal and urinary incontinence and pelvic organ prolapse status at 12 months follow-up. Additionally, a biological mesh (BM) was offered to women, who asked for an alternative to synthetic mesh material (SM).

RESULTS

Of the 44 consecutive patients requiring surgery for ODS and POP, 36 patients underwent the interdisciplinary surgical approach; 28 patients with SM and 8 patients with BM. In total 5 complications occurred, four of them were classified as minor. One minor complication was observed in the BM group. One anastomotic leakage occurred in the SM group. The two ODS scores, the bowel dysfunction score, and the incontinence score improved significantly (p = 0.006, p = 0.003, p < 0.001, and p = 0.0035, respectively). Pelvic floor anatomy was fully restored (POP-Q 0) for 29 (80%) patients after surgery. 17 patients (47%) suffered from urinary incontinence before surgery, which was restored in 13 patients (76.5%).

CONCLUSIONS

The interdisciplinary approach with L-RRP and L-SCP and the use of a BM in a small subgroup were technically feasible, safe, and effective in this single center setting. The study's retrospective design, the small sample size and the lack of comparators limit the generalizability of the findings requiring future randomized trials.

TRIAL REGISTRATION

Retrospectively registered at clinicaltrials.gov, trial number NCT05910021, date of registration 06/10/2023.

Defecatory dysfunction and anal incontinence symptoms among women with pelvic organ prolapse: 5-year retrospective study in a tertiary center

OBJECTIVE

To investigate the prevalence of DD and AI with POP symptoms in females attending a urogynecology clinic, and to identify factors associated with DD and AI in POP symptoms patients.

METHODS

Computer-based medical records of women with POP symptoms attending a urogynecology clinic in a referral tertiary center between January 2016 and December 2020 were reviewed. Demographic data were collected. Selected defecatory dysfunction (DD) and anal incontinence (AI) were recorded. The associations between patient characteristics, site and severity of prolapse, and DD and AI symptoms in POP patients were investigated for identified associated factors.

RESULTS

The mean age of the 754 participants was 65.77 ± 9.44 years. Seven hundred and fifteen (94.83%) were menopause. The prevalence of DD and AI in patients with POP symptoms was 44.03% (332/754) and 42.04% (317/754) according to the PFBQ and medical history records, respectively. Advanced posterior wall prolapse (OR 1.59, 95% CI 1.10-2.30) and wider GH (OR1.23, 95% CI 1.05-1.43) were identified as risk factors for DD by multivariate analysis. Additionally, single-compartment prolapse (OR 0.4, 95% CI 0.21-0.76) and a stronger pelvic floor muscle assessed with brink score (OR 0.94, 95% CI 0.88-0.98) are protective factors for AI.

CONCLUSION

DD and AI are prevalent among women with POP symptoms who visit a urogynecology clinic. DD should be evaluated in women with POP symptoms especially in women with increased genital hiatus and point Ap beyond the hymen. To prevent AI, women with POP should be encouraged to perform pelvic floor muscle training in order to increase pelvic floor muscle strength.

Quality-of-life improvements in patients after various surgical treatments for pelvic organ prolapse

OBJECTIVE

To compare the improvements in quality of life of patients with pelvic organ prolapse (POP) treated using various surgical methods.

MATERIALS AND METHODS

The PUBMED, MEDLINE and Cochrane Library online databases were searched using the keywords "pelvic organ prolapse", "surgery", "PFDI-20" and "PFIQ-7" for articles published from January 2010 to December 2022 that included quality-of-life scores before and after surgery.

RESULTS

Forty-nine articles were include. The mean postoperative PFDI-20 and PFIQ-7 scores decreased by 67.50% and 76.98%, respectively, compared with those before surgery. In 76.9% of patients, this change did not decrease with increased postoperative time. The improvement rate in PFDI-20 scores after colpocleisis did not differ statistically from that after sacrocolpopexy and was significantly higher than that after other procedures. The improvement rate in PFIQ-7 scores after colpocleisis did not statistically differ from that after high uterosacral ligament suspension and was significantly higher than that after other procedures. The improvement rate in PFDI-20 scores after transvaginal mesh-based repair (TVM) did not significantly differ from that after sacrospinous ligament fixation and was significantly lower than that after other procedures except traditional vaginal wall repair. The improvement rate in PFIQ-7 scores after TVM did not significantly differ from that after new procedures and was significantly lower than that after other procedures.

CONCLUSIONS

Surgical treatment can significantly improve the quality of life of patients with POP. Colpocleisis may offer more advantages than those of other surgical procedures, and improvement was lower after TVM than after other procedures.

A Randomized Clinical Trial Comparing Dubuisson Laparoscopic Lateral Suspension with Laparoscopic Sacropexy for Pelvic Organ Prolapse: Short-Term Results

BACKGROUND

Laparoscopic sacrocolpopexy (LSC) is the gold standard for the treatment of apical prolapse, although dissection of the promontory may be challenging. Laparoscopic lateral suspension (LLS) with mesh is an alternative technique for apical repair with similar anatomical and functional outcomes, according to recent studies. The purpose of this study was to compare these operative techniques.

METHODS

Women with uterine Pelvic Organ Prolapse Quantification (POP-Q) stage 2 were enrolled in this prospective study and were randomly allocated to the LLS or LSC group. At the 12-month follow-up, primary measures included both anatomical and functional outcomes. Perioperative parameters and complications were recorded.

RESULTS

A total of 93 women were randomized, 48 in the LLS group and 45 in the LSC group, with 2 women lost to follow-up in both groups. LSC anatomic success rates were 81.82% for the apical compartment and 95.22% for the anterior compartment. LLS anatomic success rates for the apical and anterior compartments were 90% and 92.30%, respectively. The mean operative time for LLS was 160.3 min, while for LSC it was 168.3 min. The mean blood loss was 100 mL in both procedures. Conversion to laparotomy was necessary in three women. Mesh erosion was not observed in any of the cases. In terms of the complication, Clavien-Dindo grade 1 was observed in two patients in the LLS group and a complication rated grade 3b was observed in one patient in LSC group.

CONCLUSIONS

LLS is a good alternative to LSC, with promising anatomical and quality-of-life results.

The double-edged sword of mesh use in pelvic organ prolapse surgery: a case report

Introduction

Pelvic organ prolapse (POP) is a prevalent condition among parous women, often warranting surgical intervention. This case accentuates the complications associated with mesh in POP surgeries, iterating the imperative need for an evidence-based approach towards its utilization and exhaustive patient counselling.

Case presentation

A 60-year-old female, post-mesh-augmented POP repair, embarked on a 13-year journey characterized by persistent pelvic pain and multiple interventions. Despite undergoing several surgeries across different countries, involving mesh and stone removals, her symptoms, notably pelvic pain and dyspareunia, persisted. Clinical examinations revealed mesh erosion into the perivesical tissue, bladder, and associated stones, which were addressed through multiple interventions, albeit with transient success.

Discussion

The complex journey of this patient exemplifies the intricate challenges mesh poses in POP surgeries. While mesh application offers a minimally invasive approach and has proven successful in numerous cases, it simultaneously opens a Pandora's box of potential severe complications, necessitating thorough patient counselling and post-surgery management.

Conclusion

The case delineates the challenging path that clinicians and patients tread when navigating through mesh-associated complications post-POP repair. Although mesh has been heralded as a revolutionary approach in POP surgeries, its potential drawbacks necessitate judicious application, ensuring clinicians are well-versed with its associated risks and are adept in managing ensuing complications.

The mechanism of adipose mesenchymal stem cells to stabilize the immune microenvironment of pelvic floor injury by regulating pyroptosis and promoting tissue repair

Pelvic organ prolapse (POP) has a high incidence rate among Chinese women. Repeated mechanical stimulation is an important factor causing POP, but the injury mechanism has not yet been elucidated. The purpose of this study is to explore the related mechanisms of pelvic floor supporting tissue damage caused by mechanical force and the application of stem cell therapy. First, we obtained vaginal wall and sacral ligament tissue samples from clinical patients for examination. Pelvic floor support tissues of POP patients displayed high expression of inflammation and immune disorders. Then, we constructed a rat model of childbirth injury. In vivo and in vitro experiments investigated the key mechanism of pelvic floor support tissue injury caused by mechanical force. We discovered that after mechanical force, a large number of reactive oxygen species (ROS) and macrophages rapidly accumulated in pelvic floor tissues. ROS stimulated macrophages to produce NLRP3 inflammatory complex, induced the release of interleukin (IL-1β) and pyroptosis and exacerbated the inflammatory state of damaged tissues, persisting chronic inflammation of fibroblasts in supporting tissues, thus causing the pelvic floor's extracellular matrix (ECM) collagen metabolic disorder. Resultingly impeding the repair process, thereby causing the onset and progression of the disease. Through their paracrine ability, we discovered that adipose mesenchymal stem cells (ADSCs) could inhibit this series of pathological processes and promote tissue repair, asserting a good therapeutic effect. Simultaneously, to overcome the low cell survival rate and poor therapeutic effect of directly injecting cells, we developed a ROS-responsive PVA@COLI hydrogel with ADSCs. The ROS-scavenging properties of the gel could reshape the site of inflammation injury, enhance cell survival, and play a role in subsequent treatment. The findings of this study could serve as a basis for early, targeted intervention therapy for POP and representing a promising approach.

Impact of preoperative pelvic floor muscle function on the success of surgical treatment of pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

The objective of this study was to identify the potential characteristics of pelvic floor muscles (PFM) in the preoperative assessment that could be associated with post-surgical prolapse severity. We hypothesized that the same variables, if identified, could be addressed in preoperative rehabilitation to improve surgical results.

METHODS

This was a single-center prospective observational study that included women who underwent surgical pelvic organ prolapse repair between 2020-2022. Genital prolapse was evaluated according to the Pelvic Organ Prolapse Quantification (POP-Q) system. All the participants underwent a PFM assessment, including a vaginal digital assessment and manometry (Peritron™ 9300 V) before surgery and at 1-, 3-, and 6-month follow-ups. Several PFM variables were recorded: vaginal resting pressure, vaginal pressure during maximal voluntary contraction (MVC), area under the curve during a 10-second MVC, ability to correctly contract the PFMs, and reflexive activation during cough and relaxation. The primary endpoint of the analysis was objective surgical success defined as POP-Q 0 or 1 at the 6-month follow-up. Additionally, a change in pelvic floor muscle function was recorded during postoperative visits.

RESULTS

A total of 106 females were included in the study. Fifty-one were lost during the 6-month follow-up, which is a major limitation of the study. None of the examined parameters evaluating PFM were associated with surgical success. No statistically significant difference was found in MVC and PFM endurance before and after surgery. Post-surgery, a significant change was observed in the vaginal resting pressure and the ability to correct PFM activation and relaxation.

CONCLUSIONS

Preoperative PFM function is not associated with surgical success 6 months after surgery.

Influence of pelvic floor disorders on quality of life in women

Objective

To determine whether the different pelvic floor disorders are associated with changes in perceived quality of life (QoL), globally and in its sub-dimensions.

Methods

An observational study was conducted with women in Spain between 2021 and 2022. Information was collected using a self-developed questionnaire on sociodemographic data, employment, history and health status, lifestyle and habits, obstetric history, and health problems. The SF-12 questionnaire was used to assess quality of life. The Pelvic Floor Distress Inventory (PFDI-20) was used to assess the presence and impact of pelvic floor problems, and includes the POPDI-6 subscales for prolapse, CRADI- 8 for colorectal symptoms, and UDI-6 for urinary symptoms. Crude (MD) and adjusted mean differences (aMD) were estimated with their respective 95% confidence intervals (CI).

Results

Thousand four hundred and forty six women participated in the study with a mean age of 44.27 (SD = 14.68). A statistical association was observed between all the pelvic floor disorders and QoL, overall and in all its dimensions (p <0.001), in the bivariable analysis. The lowest scores were observed in the emotional component. After adjusting for confounding factors, the pelvic floor disorders in general (aMD -0.21, 95% CI: -0.23 to -0.20), the impact of uterine prolapse symptoms (aMD -0.20, 95% CI: -0.27 to -0.12), the colorectal-anal symptoms (aMD -0.15, 95% CI: -0.22 to -0.09), and urinary symptoms (aMD -0.07, 95% CI: -0.13 to -0.03) was negatively associated on the score on the SF-12 questionnaire (p <0.05).

Conclusions

Women who have a pelvic floor dysfunction, symptoms of pelvic organ prolapse, colorectal-anal symptoms, or urinary symptoms, have a worse perceived quality of life in all dimensions. Prolapse symptoms have the biggest impact, and the emotional component of QoL is the most affected sub-domains.

Pessary management practices for pelvic organ prolapse among Australian health care practitioners: a cross-sectional study

INTRODUCTION AND HYPOTHESIS

Vaginal pessaries are a low-cost, effective treatment for pelvic organ prolapse (POP) and an alternative to surgery. Whilst traditionally pessary management (PM) has been provided by medical professionals, particularly gynaecologists, recent international studies found other professionals, including physiotherapists and nurses, may be involved. It is unknown which health care practitioners (HCPs) provide PM for POP in Australia or the distribution of services.

METHODS

In a cross-sectional study design, a self-reported electronic survey investigated Australian HCPs providing PM for POP. Purposive and snowball sampling targeted HCPs, professional organisations and health care facilities. Descriptive statistics described PM in relation to HCP professional profile, PM provision and geographical location.

RESULTS

There were 536 respondents (324 physiotherapists, 148 specialists, 33 general practitioners (GPs) and 31 nurses providing PM. Most worked within metropolitan regions (n = 332, 64%), 140 (27%) in rural, 108 (21%) in regional and 10 (2%) in remote areas. Most worked privately (n = 418, 85%), 153 (46%) worked publicly and 85 (17%) in both. Ring pessaries were most commonly used, followed by cube and Gellhorn. HCPs reported variable training in PM, and 336 (69%) had no mandatory workplace competency standard; however, 324 (67%) wanted further training. Women travelled long distances to access services.

CONCLUSIONS

Doctors, nurses and physiotherapists provided PM in Australia. HCPs had variable training and experience in PM, with rural and remote HCPs particularly wanting further training. This study highlights the need for accessible PM services, standardised and competency-based training for HCPs, and governance structures ensuring safe care.

Pelvic floor parameters predict postpartum stress urinary incontinence: a prospective MRI study

OBJECTIVE

To investigate the pelvic floor changes in primiparas with postpartum stress urinary incontinence (SUI) after vaginal delivery using pelvic floor MRI.

MATERIALS AND METHODS

Fifty-two women were enrolled in the primiparous stress urinary incontinent (PSUI) group and 51 in the primiparous continent (PC) group. Thirty nulliparas were also recruited as the nulliparous control (NC) group. Levator ani muscle (LAM) injury, levator hiatus area (LHA), H-line, M-line, the distance from the bladder neck and cervix to the pubococcygeal line (B-PCL and U-PCL), levator plate angle, the anterior angle of the urethra, bladder neck descent, retrovesicourethral angle, functional urethral length, and a bladder neck funnel were evaluated on MRI images. Univariate and multivariate logistic regression analyses were used to explore anatomical predictors for SUI.

RESULTS

The primiparas in the PSUI group showed more obvious LAM injuries than in the PC groups (p = 0.001). LAM function assessment: the PSUI group had larger LHA and shorter B-PCL and U-PCL than the other groups during straining. Assessment of urethral mobility and function: the PSUI group had larger anterior angle of the urethra, bladder neck descent, retrovesicourethral angle, and shorter functional urethral length than the other two groups (all p < 0.05). Up to 88.5% of primiparas in the PSUI group showed bladder funnel (p < 0.001). The logistic regression analysis showed that retrovesicourethral angle, functional urethral length, and the presence of bladder funnel were significantly associated with postpartum SUI (p < 0.05).

CONCLUSIONS

Increased retrovesicourethral angle, shortened functional urethral length, and the presence of bladder funnel may be anatomical predictors for SUI in the early postpartum period. Urethral sphincter dysfunction plays an essential role in developing postpartum SUI.

CRITICAL RELEVANCE STATEMENT

This study used several measurements to reflect the anatomical structure and functional changes of the pelvic floor to identify the best anatomical predictors associated with postpartum stress urinary incontinence (SUI), aiming to provide new insights into treatment strategies for postpartum SUI.

KEY POINTS

• Increased retrovesicourethral angle, shortened functional urethral length, and the presence of bladder funnel are more commonly seen in primiparas with SUI. • The combination of retrovesicourethral angle, functional urethral length, and bladder funnel had the highest diagnostic performance in predicting postpartum SUI (AUC=0.947). • Urethral sphincter dysfunction may be the main pathophysiological foundation in SUI development.

Comparative anatomy of the ovine and human pelvis for laparoscopic sacrocolpopexy: evaluating the effectiveness of the ovine model

INTRODUCTION AND HYPOTHESIS

Laparoscopic sacrocolpopexy (LSC) is a functional reconstructive surgery used to treat pelvic organ prolapse (POP) in middle-aged women. Although LSC is widely used, its implementation is hindered by perceived technical difficulties and surgical learning curves. Surgeons require adequate experience with LSC prior to performing the procedure on patients to improve their quality of life. This study is aimed at demonstrating the effectiveness of the ovine model (OM) for training and research in LSC, while also comparing anatomical differences between ovine and human models during the procedure.

METHODS

The animal model and training were provided by the Jesús Usón Minimally Invasive Surgery Centre. Urologists and gynecologists with experience in LSC participated in a course and their findings were recorded and documented.

RESULTS

Differences in patient positioning, trocar placement, and reperitonealization were identified between the ovine and human models. Hysterectomy is always performed in the ovine model, whereas it is not mandatory in humans. There are also differences in the dissection of the levator ani muscle and attachment point of the posterior mesh to the uterus between the two models. Despite differences in some areas, the ovine pelvic structure and vagina are similar in size to those of humans.

CONCLUSIONS

The ovine model is a valuable tool for surgeons in their learning curve for LSC, allowing for safe and effective practice prior to performing the procedure on patients. The use of the OM can help to improve the quality of life for women affected by pelvic organ prolapse.

Comparative analysis of transvaginal natural orifice transluminal endoscopic surgery versus laparoendoscopic single-site sacrocolpopexy for pelvic organ prolapse: A propensity score matching study

Purpose

To compare the safety, feasibility, and effectiveness of transvaginal natural orifice transluminal endoscopic sacrocolpopexy (vNOTES-SC) and laparoendoscopic single-site sacrocolpopexy (LESS-SC) for pelvic organ prolapse (POP).

Method

Ninety-four patients with POP who underwent vNOTES-SC or LESS-SC from October 2016 to November 2018 were included. The propensity score matching method was used for 1:1 matching between the two surgery groups. After matching, the general perioperative indicators, surgical complications, and the subjective and objective therapeutic effects of the two groups 3 years post-surgery were analyzed.

Results

After matching, 36 patients in each group were included, exhibiting balanced and comparable baseline data and an average follow-up of 48.6 ± 7.44 months. The operation time and postoperative hospitalization days were significantly reduced in the vNOTES-SC group (P < 0.05). However, perioperative complication incidence was not significantly different between the two groups (P > 0.05). Additionally, no significant differences were detected in de novo stress urinary incontinence (16.7% vs. 13.9%), de novo overactive bladder (de novo OAB, 8.3% vs. 0.0%), urination disorder (2.8% vs. 0.0%), defecation disorder (0.0% vs. 2.8%), lumbosacral pain (0.0% vs. 2.8%), or mesh complication (2.8% vs. 5.6%) incidences between the vNOTES-SC and LESS-SC groups (P > 0.05). Prolapse recurrence was not reported in either group. The quantitative description of pelvic organ position (POP-Q), Pelvic Floor Impact Questionnaire-7 (PFIQ-7), and Patient Global Impression of Improvement scale (PGI-I) scores showed improvement after the operation, but no significant differences were observed between the two groups (P > 0.05).

Conclusion

The 3-year follow-up revealed that vNOTES-SC and LESS-SC had similar complications and efficacy rates. Compared with LESS-SC, vNOTES-SC resulted in shorter operation time and fewer postoperative hospitalization days (corresponding to the enhanced recovery after surgery [ERAS] concept), along with better cosmetic results without a scar. Therefore, our study findings suggest that clinicians should choose the surgery method based on the specific situation, and we recommend choosing vNOTES-SC when both surgeries are suitable.

PEOPLE: Lifestyle and comorbidities as risk factors for pelvic organ prolapse-a systematic review and meta-analysis PEOPLE: PElvic Organ Prolapse Lifestyle comorbiditiEs

INTRODUCTION AND HYPOTHESIS

The literature is scarce regarding the effects of comorbidities, clinical parameters, and lifestyle as risk factors for pelvic organ prolapse (POP). This study was performed to systematically review the literature related to body mass index (BMI), waist circumference, diabetes mellitus (DM), hypertension (HT), dyslipidemia, chronic constipation, smoking, chronic cough, occupation, and striae and varicose veins as determinants for POP.

METHODS

Search terms in accordance with Medical Subject Headings were used in PubMed, Embase, LILACS, and the Cochrane Library. Clinical comparative studies between women with and without POP and containing demographic and/or clinical raw data related to lifestyle and/or comorbidities were included. The ROBINS-I (risk of bias in non-randomized studies of interventions) instrument was used. Fixed-effects and random-effects models were used for homogeneous and heterogeneous studies, respectively.

RESULTS

Forty-three studies were included in the meta-analysis. BMI < 25 kg/m2 was found to be a protective factor for POP [OR 0.71 (0.51, 0.99); p = 0.04], and BMI > 30 kg/m2 was a risk factor for POP [OR 1.44 (1.37, 1.52); p < 0.00001]. Waist circumference (≥ 88 cm) was reported as a risk factor for POP [OR 1.80 (1.37, 2.38); p < 0.00001], along with HT [OR 1.18 (1.09, 1.27); p = 0.04], constipation [OR 1.77 (1.23, 2.54); p < 0.00001], occupation [OR 1.86 (1.21, 2.86); p < 0.00001], persistent cough [OR 1.52 (1.18, 1.94); p < 0.0001]), and varicose veins [OR 2.01 (1.50, 2.70); p = 0.12].

CONCLUSIONS

BMI < 25 kg/m2 is protective while BMI > 30 kg/m2 is a risk factor for POP. Large waist circumference, dyslipidemia, HT, constipation, occupation, persistent cough, and varicose veins are also determinants for POP.

Multimodality Imaging of Anterior Compartment Pelvic Floor Repair

Pelvic organ prolapse (POP) and stress urinary incontinence (SUI) are two common disorders that affect the anterior compartment of the pelvic floor in women. These can be treated conservatively or surgically. Among patients treated surgically, a substantial number present with pain, recurrent POP or SUI, or other conditions that warrant additional interventions. In many of these cases, imaging is key to identifying and characterizing the type of procedure performed, locating synthetic materials that may have been placed, and characterizing complications. Imaging may be particularly helpful when prior surgical records are not available or a comprehensive physical examination is not possible. US and MRI are the most commonly used modalities for such patients, although radiopaque surgical materials may be visible at voiding cystourethrography and CT. The authors summarize commonly used surgical treatment options for patients with SUI and POP, review imaging techniques for evaluation of such patients, and describe the normal imaging appearance and complications of pelvic floor surgical repair procedures in the anterior compartment of the pelvis. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Pain With Differing Insufflation Pressures During Robotic Sacrocolpopexy: A Randomized Controlled Trial

OBJECTIVE

To evaluate whether decreasing insufflation pressure reduces postoperative pain and opioid use in women undergoing robotic-assisted sacrocolpopexy.

METHODS

In a single-blinded randomized trial, women with pelvic organ prolapse underwent robotic-assisted sacrocolpopexy at either 12 mm Hg (experimental) or 15 mm Hg (standard) insufflation pressure. The primary outcome was pain rating on a visual analog scale (VAS) on postoperative day 1 within 24 hours of surgery. Secondary outcomes included VAS pain rating at outpatient follow-up, inpatient and outpatient use of opioids, operative time, and estimated blood loss. A margin of 15 mm was considered clinically different on the VAS, and at 80% power, a sample size of at least 64 participants was needed to show significance.

RESULTS

From April 27, 2021, to May 17, 2022, 80 women were enrolled, with 41 in the experimental group and 39 in the standard group. All participants underwent surgery as planned and attended a 2-week postoperative follow-up. Participants in the experimental group had less pain on postoperative day 1 with median VAS of 17.0 mm (interquartile range 26.0) compared with 29.0 mm (interquartile range 32.0, P=.007) in the standard group. No differences were noted in the secondary outcomes of operative time, estimated blood loss, or length of stay. Participants in the experimental group were noted to use fewer opioids while an inpatient (P=.04) and outpatient (P=.02). In multivariable analyses, lower insufflation pressure and increasing age were negatively associated with postoperative VAS scores.

CONCLUSION

Lowering insufflation pressure (12 mm Hg) during robotic-assisted sacrocolpopexy safely reduced postoperative pain and opioid use compared with standard pressure (15 mm Hg).

CLINICAL TRIAL REGISTRATION

ClinialTrials.gov, NCT04858438.

Pelvic Organ Prolapse Syndrome and Lower Urinary Tract Symptom Update: What's New?

(1) Background: This narrative review aimed to analyze the epidemiological, clinical, surgical, prognostic, and instrumental aspects of the link between pelvic organ prolapse (POP) and lower urinary tract symptoms (LUTS), collecting the most recent evidence from the scientific literature. (2) Methods: We matched the terms "pelvic organ prolapse" (POP) and "lower urinary tract symptoms" (LUTS) on the following databases: Pubmed, Embase, Scopus, Google scholar, and Cochrane. We excluded case reports, systematic reviews, articles published in a language other than English, and studies focusing only on a surgical technique. (3) Results: There is a link between POP and LUTS. Bladder outlet obstruction (BOO) would increase variation in bladder structure and function, which could lead to an overactive bladder (OAB). There is no connection between the POP stage and LUTS. Prolapse surgery could modify the symptoms of OAB with improvement or healing. Post-surgical predictive factors of non-improvement of OAB or de novo onset include high BMI, neurological pathologies, age > 65 years, and the severity of symptoms; predictors of emptying disorders are neurological pathologies, BOO, perineal dysfunctions, severity of pre-surgery symptoms, and severe anterior prolapse. Urodynamics should be performed on a specific subset of patients (i.e., stress urinary incontinence, correct surgery planning), (4) Conclusions: Correction of prolapse is the primary treatment for detrusor underactivity and for patients with both POP and OAB.

A web-based decision aid for shared decision making in pelvic organ prolapse: the SHADE-POP trial

INTRODUCTION AND HYPOTHESIS

Among women worldwide, pelvic organ prolapse (POP) is a common problem. There are three different treatment options for POP: pelvic floor muscle therapy, pessary treatment and prolapse surgery. As none of the three treatment options is clearly superior, shared decision making (SDM) is very important. A decision aid (DA) is known to facilitate patient participation and SDM. We hypothesise that the use of a web-based DA for POP increases patients' satisfaction with information and care and reduces decisional conflict.

METHODS

This two-arm, multicentre, cluster randomised controlled trial was performed in women with POP in five different Dutch hospitals. The control group received usual care (UC) and the intervention group received the DA in addition to UC. Primary outcome measures were satisfaction with treatment decision making and satisfaction with information. Analyses were performed using independent sample t tests, Chi-squared tests, and multilevel linear regression analyses.

RESULTS

Between the DA group (n=40) and the UC group (n=56) no differences were found concerning patients' satisfaction with information, with scores of 45.63 and 46.14 out of 50 respectively (p=0.67). Also, no differences were found concerning the perceived role in decision making, as patients scored 46.83 in the DA group and 46.41 in the UC group, out of a maximum of 54 (n=0.81).

CONCLUSIONS

No differences were found concerning patients' satisfaction with information and treatment decision making between the DA and UC. However, both groups scored high on the questionnaires, which suggests that the decision process is already of high quality.

Clinical-Psychological Aspects Involved in Gynecological Surgery: Description of Peri-Operative Psychopathological Symptoms and Illness Behavior

Background

Within the current literature concerning the gynecological surgery, there are only a few studies that focus on the psychological aspects that characterize the peri-operative period. In this research, the psychopathological symptoms and the illness behavior were assessed in order to confirm previous results about clinical variables such as the type and method of intervention, as well as psychological aspects regarding the positive anamnesis for mental disorders. Moreover, other factors including the desire for maternity and previous surgical interventions and pregnancies were also investigated.

Methods

In this observational research, 58 women (age = 41.5±8.8), that undergone gynecological surgery (conservative and non-conservative) for benign pathologies, were consecutively recruited. Information on psychopathological symptoms was collected 15 days (T0) and one day before surgery (T1), and at the time of discharge (T2) through the Symptom Questionnaire (SQ). At T2, the Illness Behavior Questionnaire (IBQ) was also administered.

Results

The descriptive analyzes conducted on the total sample demonstrated that while anxious activation and irritable mood decrease from T0 to T1, somatizations and depression mood increase between T1 and T2. Moreover, the comparisons between groups, dividing the sample according to the clinical-medical and psychological variables, highlighted that the type and modality of the intervention, as well as a positive history for the presence of psychological disorders, the desire for maternity, and previous surgical interventions and pregnancies, can influence the course of psychopathological symptoms.

Conclusion

This study highlights the need to include a clinical-psychological evaluation and to pay attention to specific clinical variables regarding women that are undergoing a conservative or non-conservative gynecological surgery. Considering the psychological impact of these type of interventions, the clinical history of these women, as well as their fears and desires, could facilitate a better management of the patients in terms of well-being, adherence to treatment, and recovery.

Knowledge mapping and visualization analysis of pelvic organ prolapse repair with mesh from 2001 to 2021

Aims: In recent decades, extensive attention has been paid to the application of mesh to repair pelvic floor defects. However, a large body of related literature has not been system summarized. The purpose of this study is to summarize and visualize the literature on pelvic organ prolapse (POP) repair with mesh using bibliometrics. Methods: Medical literature regarding POP repair with mesh were searched and obtained in the Web of Science™ Core (WoSCC) database from 2001 to 2021. Microsoft Excel 2020, CiteSpace and VOSviewer were used to conduct the bibliometric and knowledge-map analysis. Results: In the past 20 years, a total of 2,550 articles and reviews have been published in 35 journals, and the published and cited results show a growing trend. Cosson M and International Urogynecology Journal were the authors and journals with the highest output, respectively. The United States, France and the United Kingdom are among the top three countries/organizations in relevant publications in worldwide. 584 key words in the literature are divided into 8 clusters, which are mainly related to prolapse type, risk factors, surgical methods, imaging, quality of life and bioengineering. Using clinical research and tissue engineering technology to reduce mesh complications is the current hot spot in this field. Conclusion: Reasonable application of mesh and avoiding mesh complications are still the most concerned topics in POP research. Although clinical research, surgical improvement, biological mesh and bioengineering technology have shown promising results, it is still urgent to carry out clinical transformation application research.

Study of pelvic organ prolapse as a predictor of osteoporotic fracture risk

Purpose: The present study aimed to examine the association between the stage of pelvic organ prolapse (POP) and the risk of fracture in postmenopausal women.Methods: A cross-sectional design was used, which included 133 women with POP over 50 years of age. The participants were classified according to their POP stage, underwent blood tests (hemogram, biochemistry, bone remodeling markers, and hormone tests), and completed a sociodemographic and lifestyle questionnaire along with densitometry, FRAX, and FRIDEX tests.Results: Of the 133 women studied, 66 presented stages I-II POP (49.6%) and 67 III-IV POP (50.4%). The mean age of the participants was 64.47 years. Women with a high POP stage showed higher FRAX scores for major osteoporotic and hip fracture (p .001 and p < .001p). Bivariate analysis revealed that higher scores on the FRIDEX scale were associated with a higher POP stage (p = .032). In addition, there was a marginally significant negative association between bone mineral density (BMD) and POP stage (p = .054).Conclusions: High-stage POP can be considered an independent predictor of osteoporotic fracture risk, as measured using the FRAX and FRIDEX scales.

Review of Vaginal Approaches to Apical Prolapse Repair

PURPOSE OF REVIEW

To review recent literature and provide up-to-date knowledge on new and important findings in vaginal approaches to apical prolapse surgery.

RECENT FINDINGS

Overall prolapse recurrence rates following transvaginal apical prolapse repair range from 13.7 to 70.3% in medium- to long-term follow-up, while reoperation rates for prolapse recurrence are lower, ranging from 1 to 35%. Subjective prolapse symptoms remain improved despite increasing anatomic failure rates over time. The majority of studies demonstrated improvement in prolapse-related symptoms and quality of life in over 80% of patients 2-3 years after transvaginal repair, with similar outcomes with and without uterine preservation. Contemporary studies continue to demonstrate the safety of transvaginal native tissue repair with most adverse events occurring within the first 2 years. Transvaginal apical prolapse repair is safe and effective. It is associated with long-term improvement in prolapse-related symptoms and quality of life despite increasing rates of prolapse recurrence over time. Subjective outcomes do not correlate with anatomic outcomes.

Quality of Life Following Pelvic Organ Prolapse Treatments in Women: A Systematic Review and Meta-Analysis

Introduction: Quality of life (QoL) improvement is one of the main outcomes in the management of pelvic organ prolapse as a chronic illness in women. This systematic review aimed to investigate the impact of surgical or pessary treatment for pelvic organ prolapse (POP) on quality of life. Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was applied. Electronic databases, including PubMed, Scopus, and Web of Science, were searched for original articles that evaluated the QoL before and after surgical interventions or pessary in pelvic organ prolapse from 1 January 2012 until 30 June 2022 with a combination of proper keywords. Included studies were categorized based on interventions, and they were tabulated to summarize the results. Results: Overall, 587 citations were retrieved. Of these, 76 articles were found eligible for final review. Overall, three categories of intervention were identified: vaginal surgeries (47 studies), abdominal surgeries (18 studies), and pessary intervention (11 studies). Almost all interventions were associated with improved quality of life. The results of the meta-analysis showed a significant association between the employment of surgical approach techniques (including vaginal and abdominal surgeries) and the quality of life (Pelvic Floor Distress Inventory (PFDI) (MD: −48.08, 95% CI: −62.34 to −33.77, p-value < 0.01), Pelvic Floor Impact Questionnaire (PFIQ) (MD: −33.41, 95% CI: −43.48 to −23.34, p < 0.01)) and sexual activity of patients with pelvic organ prolapse (Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ) (MD: 4.84, 95% CI: 1.75 to 7.92, p < 0.01)). Furthermore, narrative synthesis for studies investigating the effect of the pessary approach showed a positive association between the use of this instrument and improvement in the quality of life and sexual activity. Conclusions: The results of our study revealed a significant improvement in the women’s quality of life following abdominal and vaginal reconstructive surgery. The use of pessary was also associated with increased patient quality of life.

Effect of new-style anterior and posterior vaginal wall repair combined with modified ischial spine fascia fixation on patients with pelvic organ prolapse and their postoperative quality of life

Objective

This study aims to explore the effect of new-style anterior and posterior vaginal wall repair combined with modified ischial spine fascia fixation on patients with pelvic organ prolapse (POP) and their postoperative quality of life.

Methods

A total of 88 patients with POP and elective surgery admitted to Anqing Hospital affiliated to Anhui Medical University from March 2018 to March 2021 were retrospectively analyzed. According to their surgical methods, patients were divided into an observation group [44 cases, all underwent new-style anterior and posterior vaginal wall repair combined with modified ischial spine fascia fixation (new-style APVR-modified ISFF)] and a control group [44 cases, all underwent traditional anterior and posterior vaginal wall repair combined with sacrospinous ligament fixation (traditional APVR- SLF)]. The perioperative indicators were compared between the two groups. The pelvic floor function, pelvic organ prolapse quantification (POP-Q) classification, and quality of life were observed before operation, 3 months after operation, and 6 months after operation. All patients were followed-up.

Results

Compared with the control group, the observation group had more advantages in intraoperative blood loss, operation time, urinary catheter indwelling time, postoperative anal exhaust time, and hospitalization time (P < 0.05). In terms of pelvic floor function, patients of both groups showed significant improvement at 3 months and 6 months after surgery (P < 0.05). In terms of quality of life, the two groups exhibited significant improvement at 6 months after surgery (P < 0.05). PFIQ-7, PFDI-20, and UDI-6P of the observational group were lower than those of the control group, while PISQ-12 was higher than that of the control group but all with no significant difference (P > 0.005). In addition, the total complication rate of the observation group was 2.27% (1/44), which was significantly lower than 22.73% (10/44) of the control group (P < 0.05).

Conclusion

New-style APVR-modified ISFF can effectively treat POP and improve the quality of life of such patients, with less postoperative complications and high safety.

Global burden and trends of pelvic organ prolapse associated with aging women: An observational trend study from 1990 to 2019

Purpose

Worldwide, about 40% of women will experience pelvic organ prolapse (POP), and this proportion is expected to increase with the aging of the population. We investigated the global, regional and national influenza burden in the past 30 years through the age and sociodemographic index (SDI).

Patients and methods

Data were extracted from the Global Burden of Disease (GBD) 2019 database for 195 countries and territories between 1990 and 2019. Estimated annual percentage changes (EAPCs) were used to explore the age-standardized incidence rate (ASIR) and age-standardized disability adjusted life years (AS-DALYs) trends, and the corresponding 95% uncertainty intervals (UI). In addition, the time cut-off points of 1990 and 2019 were used to separately analyze the incidence rate and DALYs.

Results

In 2019, the global ASIR and AS-DALYs for POP were 316.19 (95%UI: 259.84-381.84) and 10.37 (95%UI: 5.79-17.99) per 100,000 population, respectively. Moreover, from 1990 to 2019, the ASR of both showed a downward trend, and EAPCs were -0.46 (95%CI: -0.52 to -0.4) and -0.53 (95%CI: -0.58 to -0.47), respectively. In addition, DALYs of POP also showed a downward trend in most regions and countries with high SDI. From 1990 to 2019, the global incidence rate and DALYs rate were highest in the 65-75 and ≥60 age groups, respectively.

Conclusion

Over the past three decades, the incidence and DALY of POP have been decreasing from 1990 to 2019. However, POP remains a major health problem, especially among females in less developed countries. Primary and secondary prevention measures of POP should be integrated into the practice of healthcare professionals dealing with aging women.

Resilience, pain, and health-related quality of life in gynecological patients undergoing surgery for benign and malignant conditions: a 12-month follow-up study

Background

Gynecological surgery has many impacts on women’s physical and mental health, and efforts to improve recovery from surgery are constantly under evaluation. Resilience is an ability to overcome stressors and adversities, such as traumas and surgeries. This study aimed to explore patients’ resilience and psychological symptoms in relation to recovery, health-related quality of life (HRQoL), and pain one year after gynecological surgery.

Methods

In a prospective cohort study, we enrolled consecutive elective gynecologic surgery patients who completed questionnaires before and at one year after surgery: the Resilience Scale-25, the 15D instrument of HRQoL (15D), the Life Satisfaction Scale-4, and the Hospital Anxiety and Depression Scale. Their mean 15D scores were compared to those of an age-matched sample of women from the general Finnish population (n = 2743).

Results

We enrolled 271 women who underwent gynecological surgery due to benign (n = 190) and malignant (n = 81) diagnoses. Resilience was equally high in women with benign and malignant diagnoses at both time points. Higher resilience associated with less pain, analgesic use, and better pain relief from the use of pain medication at 12 months after surgery. Pain intensity was similar in the two groups, but patients with benign diseases had less pain at 12 months than before surgery. Before surgery, patients’ HRQoL was worse than that of the general population, but at 12 months the mean HRQoL of patients with benign diseases had improved to the same level as that in the general population but had decreased further in patients with malignant diseases. Anxiety was higher and life satisfaction was lower in patients with malignant diseases before surgery. At 12 months, anxiety had decreased in both groups, and life satisfaction had increased in patients with malignant diseases. Depression was similarly low in both groups and time points.

Conclusions

Resilience correlated with less pain one year after surgery. After surgery, HRQoL improved in patients with benign diseases but deteriorated in patients with malignant diseases. Patients with low resilience should be identified during preoperative evaluation, and health care professionals should give these patients psychological support to enhance their resilience.

Trial Registration ClinicalTrials.gov; registered October 29, 2019; identifier: NCT04142203; retrospectively registered.

MRI biomarker of muscle composition is associated with severity of pelvic organ prolapse

BACKGROUND

The pathophysiology of pelvic organ prolapse is largely unknown. We hypothesized that reduced muscle mass on magnetic resonance defecography (MRD) is associated with increased pelvic floor laxity. The aim of this study was to compare the psoas and puborectalis muscle mass composition and cross-sectional area among patients with or without pelvic laxity.

METHODS

An observational retrospective study was conducted on women > age 18 years old who had undergone MRD for pelvic floor complaints from January 2020 to December 2020 at Stanford Pelvic Health Center. Pelvic floor laxity, pelvic organ descent, and rectal prolapse were characterized by standard measurements on MRD and compared to the psoas (L4 level) and puborectalis muscle index (cross-sectional area adjusted by height) and relative fat fraction, quantified by utilizing a 2-point Dixon technique. Regression analysis was used to quantify the association between muscle characteristics and pelvic organ measurements.

RESULTS

The psoas fat fraction was significantly elevated in patients with abnormally increased resting and strain H and M lines (p < 0.05) and increased with rising grades of Oxford rectal prolapse (p = 0.0001), uterovaginal descent (p = 0.001) and bladder descent (p = 0.0005). In multivariate regression analysis, adjusted for age and body mass index, the psoas fat fraction (not muscle index) was an independent risk factor for abnormal strain H and M line; odds ratio (95% confidence interval) of 17.8 (2-155.4) and 18.5 (1.3-258.3) respectively, and rising Oxford grade of rectal prolapse 153.9 (4.4-5383) and bladder descent 12.4 (1.5-106). Puborectalis fat fraction was increased by rising grades of Oxford rectal prolapse (p = 0.0002).

CONCLUSIONS

Severity of pelvic organ prolapse appears to be associated with increasing psoas muscle fat fraction, a biomarker for reduced skeletal muscle mass. Future prospective research is needed to determine if sarcopenia may predict postsurgical outcomes after pelvic organ prolapse repair.

Effect of Psychological Intervention on Pelvic Floor Function and Psychological Outcomes After Hysterectomy

Background

Hysterectomy is one of the most frequently performed operations worldwide. However, postoperative complications and body image changes may induce psychological distress after hysterectomy. The study aimed to evaluate the effect of psychological intervention on pelvic floor function and psychological outcomes following hysterectomy among patients with benign indications.

Methods

Ninety-nine patients underwent hysterectomy were randomly divided into intervention group (n = 50) and control group (n = 49). Patients in the control group received routine postoperative nursing care, while extra psychological intervention was provided to patients in the intervention group, including psychological support, regular lectures and family support. After 6 months, patient's psychological statuses were assessed by Generalized Anxiety Disorder scale (GAD-7) and Patient Health Questionnaire-9 (PHQ-9). The pelvic floor function of patients was evaluated using Pelvic Floor Impact Questionnaire (PFIQ-7) and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). Furthermore, the incidence of postoperative complications, including uracratia, pelvic organ prolapses, sexual dysfunction and chronic pelvic pain, was evaluated.

Results

After 6-month intervention, the GAD-7 and PHQ-9 scores were significantly decreased in the intervention group (p &lt; 0.001 and p = 0.018 respectively). Both scored were significantly lower than that in the control group (p &lt; 0.001 and p &lt; 0.001). Compared with control group, the incidence of uracratia, pelvic organ prolapse, sexual dysfunction and chronic pelvic pain for intervention group was significantly lower (p = 0.003, p = 0.027, p = 0.001, p = 0.002 respectively) and the pelvic floor muscle strength was significantly stronger (p = 0.001). Besides, the postoperative Urinary Incontinence Impact Questionnaire (UIQ-7), Pelvic Organ Prolapse Impact Questionnaire (POPIQ-7), and Colorectal-Anal Impact Questionnaire (CRAIQ-7) scores were significantly lower (p = 0.025, p = 0.04, p &lt; 0.001) and PISQ-12 score was significantly higher in intervention group (p &lt; 0.001).

Conclusion

Psychological intervention could effectively improve the psychological condition of patients with hysterectomy, which may facilitate patients' postoperative recovery in pelvic floor function. These findings emphasized the necessity of psychological intervention in routine postoperative nursing care.

Perioperative and Long-Term Anatomical and Subjective Outcomes of Laparoscopic Pectopexy and Sacrospinous Ligament Suspension for POP-Q Stages II-IV Apical Prolapse

The aim of this paper was to analyze perioperative and long-term outcomes in 114 women undergoing surgery for POP-Q ≥ 2 apical prolapse: sacrospinous ligament colpo/hysteropexy (SSLF/SSHP)—61; laparoscopic pectopexy (LP)—53. Validated questionnaires (PGI-I, ISI, #35 EPIQ, PFIQ-7, PFDI-20) were completed at baseline and follow-up. POP-Q stages II, III and IV were diagnosed in 1 (0.9%), 84 (73.7%) and 29 (25.4%) patients, respectively. Mean operative time and hospital stay were 151.8 ± 36.2 min/2.6 ± 1.1 days for LP and 69 ± 20.4 min (p < 0.001)/2.7 ± 1.0 days for SSLF. Severe intraoperative complications occurred in two (1.8%) patients. Mean follow-up was 26.9 ± 12 and 37.3 ± 17.5 months for LP and SSLF, respectively. At follow-up, significant improvement for all POP-Q points was observed in both groups (p < 0.001). Shortening of total vaginal length was found in both groups, but predominantly in SSLF patients (p = 0.01). The sensation of vaginal bulge (EPIQ) was reduced, and total PFDI-20 and PFIQ-7 scores improved (p < 0.04) in both groups. Subjective success was reported by 40 (75.5%) LP and 44 (72.1%) SSLF patients. ISI detected no deterioration in urinary incontinence. PGI-I, PFDI-20, #35 EPIQ, PFIQ-7 and ISI did not differ between the groups. In conclusion both, SSLF and LP for apical prolapse generate good anatomical and subjective outcomes, with protective effect on the anterior compartment observed for LP.

Women’s Experiences with Compliance with Pelvic Floor Home Exercise Therapy and Lifestyle Changes for Pelvic Organ Prolapse Symptoms: A Qualitative Study

In this study, we aimed to investigate women’s experiences with compliance with prescribed pelvic floor muscle exercises (PFMEs) and lifestyle changes 6–12 months after completing an individual pelvic floor physiotherapy program. This study was targeted to understanding factors affecting adherence to PFMEs and lifestyle changes to deal with pelvic organ prolapse (POP) symptoms. We designed this research as a descriptive qualitative study. We conducted this study from December 2016 to September 2017 in Madrid, Spain. Twenty-six women with symptomatic POP selected using a purposive sampling method participated in six focus groups and three one-to-one semi-structured interviews. Three authors coded and inductively analyzed transcript contents with iterative theme development. A thematic analysis revealed three main themes: (1) symptoms change; (2) PFMEs and lifestyle changes performance; and (3) a health practitioner–patient relationship. Women identified as adherent reported improvement in physical symptoms and emotional and general state as a result of the new knowledge achieved. Fear also promoted compliance with performing PFMEs and adopting lifestyle changes. Likewise, PFMEs preference and routine, integration of PFMEs and lifestyle changes into activities of daily living, support guides, therapeutic alliance, individual supervision, follow-up, and feedback were also identified as adherence facilitators. One of the biggest barriers that we identified was responsibility. Compliance with prescribed PFMEs and lifestyle changes can be improved with effective individual, women-centered, and supervised physiotherapy programs reducing symptoms, including exercises aligned with women’s preferences that are easy to integrate in daily living, promoting knowledge and awareness of their condition, providing written or electronic guidelines, with routine follow-up visits offering both positive feedback and clear and consistent messages, and enhancing therapeutic alliance.

Interaction and main effects of physical and depressive symptoms on quality of life in Korean women seeking care for rectal prolapse: a cross-sectional observational study

Purpose

Rectal prolapse is still a relatively understudied medical condition, especially in women, whereas physical symptoms, depressive symptoms, and quality of life (QOL) in women with pelvic organ prolapse have been steadily studied. This study aimed to examine the interaction and main effects of physical and depressive symptoms on physical and mental QOL of women seeking care for rectal prolapse in Korea.

Methods

Ninety-two women with rectal prolapse were recruited from a colorectal surgery clinic of a tertiary teaching hospital in Gwangju, Korea. Physical symptoms related to rectal prolapse (pelvic organ prolapse distress, POPD; colorectal-anal distress, CRAD; and urinary distress, UD), depression, and QOL were measured. The data were analyzed using descriptive statistics, Pearson correlation coefficient, and two-way analysis of variance.

Results

The interaction between POPD symptoms and depressive symptoms (F=4.51, p=.037) affected physical QOL. The interaction between POPD (F=9.66, p=.003) and CRAD symptoms (F=7.48, p=.008), respectively, and depressive symptoms affected mental QOL. Depressive symptoms had a significant main effect on the physical QOL in the CRAD (F=6.22, p=.014) and UD (F=6.01, p=.016) groups and on mental QOL in the UD group (F=24.54, p<.001).

Conclusion

Physical and depressive symptoms should be considered together to improve the QOL in women with rectal prolapse. Nursing interventions and medical treatments to decrease rectal prolapse-related physical and depressive symptoms are required to improve QOL in women with symptomatic rectal prolapse.

Symptomatic improvement after mesh removal: a prospective longitudinal study of women with urogynaecological mesh complications

OBJECTIVE

To compare clinical characteristics and outcomes in patients undergoing excision of polypropylene urogynaecological mesh for pain, mesh exposure or both.

DESIGN

Prospective, longitudinal cohort.

SETTING

Academic tertiary referral centre.

POPULATION

Women undergoing complete vaginal mesh excision for mesh exposure and/or pain.

METHODS

Clinical and patient-reported outcomes assessing pain (visual analog scale, VAS), bother (Pelvic Floor Distress Inventory, PFDI) and functional impact (Pelvic Functional Impact Questionnaire, PFIQ) were collected at baseline, 6, 12 and 24 months after complete mesh excision. Outcomes were compared by mesh type (sling, prolapse [transvaginal or sacrocolpopexy mesh], both) and complication (pain, exposure, both).

MAIN OUTCOME MEASURES

'Much better' or 'Very much better' on Patient Global Impression of Improvement (PGI-I) up to 2 years after removal.

RESULTS

Of 173 women, 48 underwent removal for pain, 27 for exposure and 98 for exposure plus pain. 'Moderate to severe' baseline symptoms were reported by 75%; the most prevalent and severe symptom was dyspareunia. Patients with pain alone were most bothered (PFDI median 234.2, interquartile range 83, P = 0.02) and had the highest functional impact (PFIQ median 181, interquartile range 138, P < 0.001). After excision, only 33.3% of women with pain alone reported 'improved' symptoms (PGI-I), versus 73.9% with exposure, 58.3% with exposure plus pain (P = 0.03) with no differences in PGI-I by mesh type. VAS scores decreased in all groups, but PFDI and PFIQ did not improve in pain patients.

CONCLUSIONS

In women experiencing a pain complication after urogynaecological mesh insertion, mesh removal often does not improve symptoms.

TWEETABLE ABSTRACT

Only 33% of women with pain complications have improved symptoms after urogynaecological mesh removal.

Vaginal Pessary for Pelvic Organ Prolapse: A French Multidisciplinary Survey

Objective: Pessary fitting and follow-up for women with pelvic organ prolapse (POP) can be performed by different health care practitioners (HCPs). We aimed to investigate knowledge and current practices among the main HCPs involved in pessary use in France. Materials and Methods: We sent an electronic questionnaire about pessary use to the members of eight French learned societies between April and October 2020. Results: During the study period, 1017 HCPs responded to the questionnaire: 712 (70.0%) were doctors, 208 (20.4%) physiotherapists, 95 (9.3%) midwives, and 7 (0.6%) nurses. Of the respondents, 69.1% claimed to be comfortable with pessary fitting and follow-up, and 54.1% think that a pessary can be offered as a first-line treatment in the management of POP. However, 60.1% reported that the main indications for pessaries were "older women," 71.3% for women with contraindications to surgery, and 60.5% for women waiting for surgery. 23.9% do not prescribe local estrogen therapy with a pessary for postmenopausal women. The main pessaries used are the ring and cube types (63.7 and 57.5%, respectively). Wide introitus (53.3%), difficulties of use (56.3%), a short vagina (41.4%), and major unmasked urinary incontinence (47.2%) are considered to be the main risk factors for pessary failure. The most common complications related to pessaries reported by the patients are vaginal discharge (48.6%) and pain or discomfort (40.6%). Up to 43.4% of respondents considered that a follow-up visit every 3-6 months was optimal. The need for training ranged from 42.8% for nurses to 65.2% for general practitioners. Conclusions: This national multidisciplinary survey revealed that HCPs in France are on the whole comfortable with pessaries and mainly prescribe the ring and cube form. Even if opinion about pessaries appears to be changing, HCPs would welcome additional training to improve knowledge and practices.

Proteins in plasma as a potential biomarkers diagnostic for pelvic organ prolapse

Background

Pelvic organ prolapse (POP) is the most common and widespread type of female pelvic floor dysfunction disease (PFD). At present, the diagnosis of POP is mainly based on a complicated systematic evaluation of the clinical phenotype, medical history, and relevant functional examinations. Rapid and simple tests that are based on biochemical biomarkers that surpass the sensitivity and specificity of the current methods for the diagnosis of POP will greatly facilitate the timely diagnosis and treatment of women with POP.

Methods

A protein array was used to screen plasma samples collected from healthy controls and women with POP. Enzyme-linked immunosorbent assays (ELISAs) were used to determine the levels of three novel and potentially useful analytes: heat shock protein 10 (HSP10), zinc finger CCCH domain-containing protein 8 (ZC3H8), and unc-45 myosin chaperone A (UNC45A). We then determined the diagnostic value of each of these analytes as potential diagnostic biomarkers for clinical application.

Results

The mean levels of HSP10, ZC3H8, and UNC45A, were lower in the plasma samples from 76 patients with POP than in 56 samples from healthy controls (P<0.05). Comparisons between patients with POP and healthy controls demonstrated the sensitivity and specificity of HSP10 (73.7% and 71.4%), ZC3H8 (71.1% and 62.5%), and UNC45A (70.7% and 62.5%).

Conclusions

Analysis indicated that plasma levels of HSP10, ZC3H8, and UNC45A, are sensitive and specific biomarkers for the diagnosis of POP.

Transforming Growth Factor Beta 1 and p44/42 Expression in Cardinal Ligament Tissues of Patients with Pelvic Organ Prolapse

Background

Pelvic organ prolapse (POP) is a disease associated with collagen loss and decreased fibroblast proliferation. Transforming growth factor beta 1 (TGF-β1) controls collagen synthesis and degradation in pelvic connective tissue. Although the p44/42 MAPK pathway has been implicated in collagen production and extracellular matrix disorders, its expression in POP remains unknown. This study aimed to investigate TGF-β1 and p44/42 expression in cardinal ligament tissues in patients with POP.

Material/Methods

Cardinal ligament tissues were obtained from 30 patients with POP (POP group) and 30 patients with benign gynecological disorders who had undergone total hysterectomy (control group). The clinical characteristics of the 2 groups were summarized. Immunohistochemical staining and western blotting analysis were performed to measure the expression of TGF-β1, p44/42, phospho-p44/42, MMP9, TIMP1, caspase 3, collagen I, and collagen III in the cardinal ligament tissues.

Results

Patients with POP had significantly lower TGF-β1 and phospho-p44/42 levels than did control patients (P<0.05). The expression of TIMP1, collagen I, and collagen III was significantly lower, and the expression of MMP9 and caspase 3 was significantly higher in the POP group than in the control group (P<0.05). Moreover, the expression of phospho-p44/42 was positively correlated with the expression of TGF-β1, collagen I, and collagen III.

Conclusions

The expression levels of phospho-p44/42 and TGF-β1 were decreased in patients with POP and were positively correlated with collagen expression. Low levels of TGF-β1 and phospho-p44/42 expression in patients with POP may be associated with the occurrence of POP.

Impact of surgery on quality of life of Ugandan women with symptomatic pelvic organ prolapse: a prospective cohort study

Background

Pelvic organ prolapse (POP) is a significant public health issue that negatively affects the Quality of Life (QOL) of women in both low and high-income countries. About 20% of women will undergo surgery for POP over their lifetime. However, there is a paucity of information on the effect of surgery on QOL especially in resource-limited settings. We therefore assessed the QOL among women with symptomatic POP living in rural southwestern Uganda and the impact of surgery on their quality of life.

Methods

We conducted a prospective cohort study among 120 women with symptomatic POP scheduled for surgery at the urogynecology unit of Mbarara Regional Referral Hospital. The QOL at baseline and at 1 year after surgery in the domains of physical performance, social interaction, emotional state, sexual life, sleep quality, personal hygiene and urinary bladder function was determined using a King’s Quality of Life questionnaire. A paired t-test was used to compare the difference in mean scores at baseline and at 1-year post-surgery.

Results

Of the 120 participants that were enrolled at baseline, 117(98%) completed the follow-up period of 1 year. The baseline QOL was poor. The domains with the poorest QOL were physical, social, sexual, emotional and sleep quality. The mean QOL scores in all the domains and the overall QOL significantly improved 1 year after surgery (p < 0.001). The overall QOL improved by 38.9% after surgery (p < 0.001).

Conclusions

The QOL was poor among women with symptomatic POP and surgery improved the QOL in all the domains of life. We recommend that surgery as an option for treatment of symptomatic POP should be scaled up to improve on the QOL of these women.

The health-related quality of life of patients with a benign gynecological condition: a 2-year follow-up

Aim: To assess health-related quality of life (HRQoL) of patients with benign gynecological disorders. Materials & methods: Prospective 2-year follow-up with the 15D HRQoL-instrument of 311 women treated in Helsinki-area hospitals in 2012-2013. Results: The initially impaired HRQoL regarding excretion, discomfort and symptoms, and vitality and sexual activity improved after treatment. However, only sexual activity reached similar levels as in the general population. Treatment of endometriosis, fibroids and polyps resulted in best and that of unspecific pelvic pain and bleeding disorders in worst HRQoL scores. Results were independent of hospital size. Conclusion: The impaired HRQoL dimensions were improved by treatment but HRQoL still remained poorer than in the general female population. Treatment of unspecific pelvic pain and bleeding disorders needs further evaluation.

Quality of life recovery after laparoscopic high uterosacral ligament suspension: a single centre observational study

OBJECTIVE

Laparoscopic high uterosacral ligament suspension (l-HUSLS) is a laparoscopic-transposed vaginal technique for the treatment of pelvic organ prolapse. Nowadays data regarding quality of life and sexual functions in patients who underwent l-HUSLS for pelvic organ prolapse are few and generic with most of the study investigating the anatomical outcome. For these reasons, the aim of our study is to evaluate these subjective outcomes in women undergoing this surgical procedure with the support of validated questionnaires.

STUDY DESIGN

This is a retrospective study with the primary aim of analysing the quality of life, sexual function, patient satisfaction rates and anatomical outcome among patients who underwent l-HUSLS in our institution. The SPSS Version 26.0 for Windows (Statistical package for the social studies, Chicago, IL, USA) was used for the statistical analysis.

RESULTS

A total of 60 patients underwent l-HUSLS between 2016 and 2018. All patients had a high grade of apical prolapse. No intraoperative and major postoperative complications were registered. The median follow-up was 24 months (24-48). PGI-I score was 1-2 in 55 (91.6 %) women. We observed a significant improvement of EQ-5D index and VAS scores from the baseline to the 2 years follow-up: from 0.72 (0.67-1) to 0.91 (0.79-1) and from 50 (30-90) to 70 (50-100) respectively (p = 0.000). All women showed a statistically significant amelioration of FSDS and ICIQ-SF scores. Anatomical success rate after 24 months was 83.7 %.

CONCLUSIONS

l-HUSLS appears to be a safe, feasible and effective treatment for advanced pelvic organ prolapse with high rates of patient self-reported cure.

Laparoscopic Pectopexy-CUSUM Learning Curve and Perioperative Complications Analysis

The study aimed to examine the learning curve and perioperative complications for laparoscopic pectopexy (LP). A total of 60 women with stage II–IV apical prolapse who underwent LP were dichotomized into groups: LSH(+) with concomitant laparoscopic supracervical hysterectomy (LSH), LSH(−) after previous supracervical/total hysterectomy. Operative time, estimated blood loss and hospitalization length were evaluated with cumulative sum (CUSUM) analysis and the Kwiatkowski–Phillips–Schmidt–Shin (KPSS) test, separately for two surgeons (A and B). Intraoperative and perioperative complications according to the Clavien–Dindo (C–D) classification were analyzed. Mean operative time, change in hemoglobin level, and postoperative hospital stay were 143.5 ± 23.1 min—1.5 ± 0.5g/dL and 2.5 ± 0.9 days, respectively. LSH during pectopexy was associated with longer operative time (p = 0.01) but not with higher intraoperative bleeding or prolonged hospital stay. Severe complications rate was low (1.7%) with one bowel injury in LSH(−) (C–D grade IIIb). No C–D grade II, IV and V complications were found. Conversion to open pectopexy, return to the operating room or blood transfusion were not required. The KPSS test showed that a steady operative time for Surgeon A was achieved after 28 procedures. A proficiency for laparoscopic pectopexy based on CUSUM analysis was observed after 38–40 procedures.

Agreement between patient global impression scale of improvement, pelvic floor distress inventory and 15D in measuring the outcome of pelvic organ prolapse surgery

AIMS

To evaluate the correlation between three commonly used patient-reported outcome measures, two generic and one condition-specific instrument, in assessing the change in health-related quality of life following pelvic organ prolapse surgery.

METHODS

The generic health-related quality of life measure 15-dimensional instrument (15D), Patient Global Impression of Improvement (PGI-I), and prolapse-specific Pelvic Floor Distress Inventory (PDFI-20) were used to assess the effectiveness of pelvic organ prolapse surgery in the national FINPOP study of 3535 surgeries (83% of all pelvic organ prolapse operations) performed in Finland in 2015. Spearman correlations between PGI-I, change in 15D and its dimensions and change in PFDI-20 and its subscales over a 2-year follow-up were investigated. The proportion of concordant ratings was also studied by investigating the proportion of women rated similarly (worse/no change/better/much better) by two instruments according to validated cutoffs.

RESULTS

Among 2248 women for whom the 2-year change in all instruments could be measured, changes in PFDI-20 and 15D and its dimensions were weak (ρ < 0.2 for all except excretion; ρ = 0.39 and sexual activity; ρ = 0.27). PFDI-20 change (ρ = 0.39) and its subscales (ρ = 0.19-0.40, all P < .001) were more strongly correlated with PGI-I. The proportion of fully concordant ratings were higher for PFDI-20 and PGI-I (50.6%) than for PFDI-20 and 15D (33.0%).

CONCLUSION

The weak correlations between 15D, PGI-I, and PDFI-20 observed in this study show that the quantified health gains are strongly dependent on the chosen patient-reported outcome measures. This demonstrates the importance of using condition-specific sensitive outcome measures in assessing the impact of surgical treatment in pelvic organ prolapse.