A Roadmap for Training in Urogynecology: IUGA International Initiative

INTRODUCTION AND HYPOTHESIS

Training in urogynecology is an important mission of the International Urogynecological Association (IUGA). Promoting official training programs in countries around the world is an integral part of this mission.

METHODS

The IUGA established the Fellowship Development Committee to develop a roadmap to assist countries to develop a professional training program in urogynecology. Two focus groups were created: the curricula topics focus group and the survey focus group. The curricula topics focus group is aimed at developing a list of subjects that can be the basis for a training syllabus. The survey focus group is aimed at understanding the main steps and the difficulties in establishing an official training program by interviewing representatives from both accredited and non-accredited countries and developing a roadmap for an official training program recognized by the local authorities.

RESULTS

The fellowship development committee included 13 members. The curricula topics focus group developed a format for the description of each included topic. Each topic had to include a description of the required related skills and procedures. Two curricula topics lists were created: one for basic training and a second for advanced training. The survey focus group conducted two table discussions with representatives from countries with accredited training programs and countries without accredited training programs. The comments of these meetings were summarized in documents submitted to the IUGA board of directors.

CONCLUSION

The fellowship development committee studied the main hurdles to developing an official training program in urogynecology. The roadmap document should form the basis of the IUGA international initiative to assist countries around the world to develop an official training program in urogynecology recognized by the local authority.

Anterior-apical Transvaginal Mesh (Calistar-S) for Treatment of Advanced Urogenital Prolapse: Surgical and Functional Outcomes at 1 Year

INTRODUCTION AND HYPOTHESIS

Calistar-S is a single-incision synthetic mesh kit that addresses apical and anterior compartment prolapse. The aims of this study were to evaluate the short-term objective and subjective outcomes at the 1-year follow-up. The secondary objectives were to evaluate quality of life and lower urinary tract symptoms (LUTS) outcomes, as well as surgical complications.

METHODS

Records of 108 patients with symptomatic advanced pelvic organ prolapse (stages III and IV) who underwent prolapse surgery using the Calistar-S system from June 2018 to August 2022 were reviewed. The primary outcome was the objective cure of anterior and apical prolapse < stage 1, and the subjective cure was the negative response to questions 2 and 3 of the Pelvic Organ Prolapse Distress Inventory-6. Secondary outcomes measured quality of life, the presence of lower urinary tract symptoms, and complications.

RESULTS

A total of 101 patients were evaluated. The overall objective cure rate is 97% and the subjective cure rate is 92.1%. Good outcomes were seen in all three compartments. Secondary outcomes show significant improvement in all validated questionnaires. Persistence and de novo urinary incontinence were 15.2% and 18.2% post-operatively. There is one case of bladder injury and one case of vaginal mesh exposure.

CONCLUSIONS

The Calistar-S System is a safe and efficient method for treating advanced-stage POP. We observed good anatomical results and subjective relief with a minimal complication rate. LUTS have also been positively affected, showing a high success rate. Additional studies are needed to establish the long-term efficacy of this system.

Polypropylene anterior-apical single-incision UPHOLD-LITE mesh surgery in women with severe pelvic organ prolapse: Outcome at 53 months follow up

BACKGROUND AND PURPOSE

We present this current study to complement with mesh inlays plausible benefits (UPHOLD-LITE System) on available long-term study amidst FDA's concern on mesh complications. This study aims to assess the medium-term outcomes of UPHOLD-LITE system for treatment of advanced pelvic organ prolapse (POP) and its complications, and lower urinary tract symptoms.

METHODS

This is a retrospective case series of 53 months follow-up of 123 consecutive patients who underwent UPHOLD-LITE system. Objective outcome measures the anatomical correction of prolapse with POP-Q ≤ Stage 1. Subjective outcome was patient's feedback to questions 2 and 3 of POPDI-6. Secondary outcome measures the quality of life, presence of lower urinary tract symptoms and complications. Quality of life is assessed by validated questionnaires on Urogenital Distress Inventory 6 (UDI-6), Incontinence Impact Questionnaire 7 (IIQ-7), Pelvic Organ Prolapse Distress Inventory 6 (POPDI-6), and Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire 12 (PISQ-12) at 1 and 3 years post-operatively.

RESULTS

Objective outcome at 1 and 3 years was at 96.7 % and 95.4 % respectively. The subjective cure was 95.1 % and 91.6 %. Five-year cumulative cure rate maintained at 87.2 %. Secondary outcomes observed improvement on UDI-6, IIQ-7, POPDI-6 and PISQ-12 postoperatively. Bladder outlet obstruction improved while de novo urodynamic stress incontinence (USI) increased slightly post surgically. Mesh erosion rate was 0.8 %.

CONCLUSION

The UPHOLD-LITE system demonstrated good medium term anatomical correction of apical and anterior prolapse, with good subjective cure and improved quality of life. Whilst complication rate was low, slight increase in de novo USI was observed.

Voiding Dysfunction in Patients With Advanced Pelvic Organ Prolapse and Bladder Outlet Obstruction Following Pelvic Reconstructive Surgery: Urodynamic Profile and Predictive Risk Factors

STUDY OBJECTIVE

To determine the outcome of voiding function 1 year after pelvic reconstructive surgery (PRS) in women with bladder outlet obstruction (BOO).

DESIGN

Retrospective cohort study.

SETTING

Tertiary referral hospital.

PATIENTS

A total of 1894 women underwent PRS for advanced pelvic organ prolapse (POP) stages 3 to 4 with urodynamic findings of BOO.

INTERVENTIONS

PRS.

MEASUREMENTS

The primary outcome measured was the resumption of normal voiding function, defined clinically with multichannel urodynamic testing at 1 year postoperatively. The secondary outcomes were to identify the different risk factors for persistence voiding dysfunction (VD) 1 year after PRS.

MAIN RESULTS

A total of 431 women with Pelvic Organ Prolapse Quantification stages 3 and 4, urodynamic study of maximum urinary flow rate ≤15 mL/s, and detrusor pressure at maximum flow ≥20 cm H2O were included. Resumption of normal voiding function was found in 91% (n = 392 of 431), whereas 9% (n = 39 of 431) remained to have VD 1 year postoperatively. Those with persistent VD, 20.5% (n = 8 of 39) remained having urodynamic diagnosis of BOO. Univariate and multivariate logistic regression revealed factors associated with postoperative VD were pre-operative maximal cystometric capacity ≥500 mL and postvoid residual volume ≥200 mL.

CONCLUSION

VD may persist in women with BOO after PRS, particularly in those with preoperative maximal cystometric capacity of >500 mL and postvoid residual volume >200 mL.

Urinary beta 3-adrenoceptor as a diagnostic biomarker for overactive bladder in women

This study was to investigate urinary beta 3-adrenoceptor concentration as a biomarker for overactive bladder (OAB) and predictor of treatment outcomes in women receiving the beta 3-adrenoceptor agonist mirabegron. The study comprised 50 women identified with OAB and 35 women considered as healthy controls. All women with OAB received daily dosage of 50 mg of mirabegron for 12 weeks. Bladder diaries, OAB-related questionnaires, and global response assessment scale (GRAS) data were collected. Urinary beta 3-adrenoceptor concentration was measured through enzyme-linked immunosorbent assay. All OAB-related questionnaires and GRAS indicated improved posttreatment urinary health. After mirabegron treatment, the frequency of micturition and urgency episodes decreased, but the urinary beta 3-adrenoceptor/creatinine (Cr) ratio increased. The urinary beta 3-adrenoceptor/creatinine ratio was identified as a sensitive biomarker for OAB with a confidence interval of 0.656 to 0.856 (p < 0.001). A negative correlation (- 0.431, p = 0.040) between this biomarker and health-related quality of life (HRQL) scores. The Beta 3-adrenoceptor/Cr levels increased significantly in the treatment-responsive group, while they remained unchanged in the unsatisfactory outcome group. This study shows that 12 weeks of mirabegron treatment improves OAB symptoms and HRQL. Furthermore, urinary beta 3-adrenoceptor concentration may be a diagnostic biomarker for OAB.

Correlation between overactive bladder and detrusor overactivity: a retrospective study

INTRODUCTION

The primary objective of this study is to determine the prevalence of overactive bladder (OAB) and detrusor overactivity (DO) in female patients who were referred for urodynamic study (UDS) because of lower urinary tract symptoms (LUTS). The secondary objective is to determine the subjective and objective differences between female OAB patients with and without DO.

MATERIALS AND METHODS

All female patients who underwent UDS for LUTS between June 2016 and September 2019 were retrospectively reviewed. Personal history, medical history, physical examination, and validated questionnaires were collected. One-hour pad test and multichannel urodynamic study was performed. All statistical analyses were conducted by SAS 9.4. P-value < 0.05 was considered statistically significant.

RESULTS

A total of 4184 female patients underwent UDS because of LUTS between June 2016 and September 2019; 1524 patients were analyzed for OAB or DO. The occurrence of OAB was 36.4%. The overall incidence of DO in OAB patients was 15.5%; 9.5% of all patients had DO findings on UDS, and 4.6% were incidental findings. There were significant differences among mean age, parity, ICIQ-UI SF, OABSS, POPDI-6, and all UDS parameters (except for maximal urethral pressure and pressure transmission ratio) between patients with and without DO. In patients with DO, there were no significant differences among age, parity, and BMI with or without OAB symptoms. However, there were significant differences among mean OABSS, ICIQ-UI SF, UDI-6, POPDI-6, IIQ-7, and pad test.

CONCLUSIONS

Patients with DO are associated with older age, increased parity, greater urine leakage, and worse storage and micturition functions on UDS. Combinations of subjective and objective measurements are better predictive models for OAB patients.

Use of low-intensity extracorporeal shock wave therapy in the management of interstitial cystitis/bladder pain syndrome patients: A thirty case study in a tertiary medical center

INTRODUCTION

Low-energy extracorporeal shock wave therapy (LiESWT) is a new potential treatment for intractable interstitial cystitis/bladder pain syndrome (IC/BPS), and this paper will evaluate its therapeutic effects on IC/BPS.

MATERIALS AND METHODS

This prospective clinical trial enrolled 30 women who have been diagnosed with IC/PBS to receive LiESWT treatment at an intensity of 0.25 mJ/mm² and a frequency of 3 pulses/second, for a total of 3000 pulses within 8 weeks. And we assessed questionnaires (including O'Leary-Sant Interstitial Cystitis Symptom Index (ICSI)), 3-day voiding diary, and urodynamic study at the following intervals: 4 weeks of LiESWT (W4), 8 weeks of LiESWT (W8), 1-month follow-up (F1), 3-month follow-up (F3) after LiESWT, and 1 year follow-up (F12).

RESULTS

The primary outcome of questionnaires showed significant improvement of symptoms compared to baseline (W0), especially on ICSI(12.87 ± 3.44 before treatment and 7.87 ± 5.27 at F12, p < 0.05). 3-day voiding diary also revealed significant decrease in daytime voiding frequency (15.57 ± 5.22 times before treatment and 10.70 ± 4.21 times at F1, p < 0.05) and significant increase on average voiding volume (95.85 ± 35.30 mL before treatment and 161.27 ± 74.21 mL at F1, p < 0.05). However, there were no significant differences in all parameters of the urodynamic study.

CONCLUSION

LiESWT can mitigate pain and lower urinary tract symptoms and improve the quality of life in IC/PBS patients, but does not increase the maximal cystometric capacity.

Interstitial cystitis/bladder pain syndrome patient is associated with subsequent increased risks of outpatient visits and hospitalizations: A population-based study

Interstitial cystitis/bladder pain syndrome (IC/BPS) is not only a chronic urinary bladder pain syndrome but is also associated with multifactorial etiology. Our study aimed to test the hypothesis that IC/BPS is associated with subsequent increased risks of outpatient visits and hospitalizations. Using nationwide database, the diagnoses were based on the International Classification Codes (ICD-9-CM) (595.1) of at least three outpatient services during 2002-2008, (n = 27,990) and cystoscopic finding Hunner type and/or glomerulation with pre-audit criteria. All recruited cases monitored for subsequent outpatient visits and hospitalizations for 2 years, including all-cause and specialty-specific departments, were classified according to medical specialty and age group (<40, 40-60, ≥60 years of age). IC/BPS patients have more overall outpatient department (OPD) visits and an overall adjusted incidence rate ratio (IRR) of 1.64. As for specialty, IRRs were higher in psychiatry (2.75), Chinese medicine (2.01), and emergency medicine (2.00), besides urology and gynecology. The IRRs decreased as age advanced (2.01, 1.71, and 1.44, respectively), except for gynecology (2.42, 2.52, and 2.81). A similar phenomenon happens in hospitalization with IRR of 1.69. Due to claim data characteristics, whether ulcer type IC/BPS findings can be deductive to non-ulcer type remains inclusive. Current results indicate the impacts of healthcare burden in broad spectrum about IC/PBS patients. IC/BPS has been suggested to be associated with lower threshold of healthcare visits and some coexisting disease and is comprised of systemic dysregulation, and is beyond the scope of local bladder-urethra disease. Adequate recognition of associated or comorbid factors and possible recommendation or referral for IC/BPS patients can help provide better healthcare quality.

Ultrasonography and clinical outcomes following anti-incontinence procedures (Solyx™ tape): a 3-year post-operative review

INTRODUCTION AND HYPOTHESIS

Our primary objective was to study objective and subjective outcomes of patients with urodynamic stress incontinence (USI) following Solyx™ at 3-year follow-up. Our secondary objective was to evaluate ultrasonographic tape and bladder neck position and mobility.

METHODS

Records of 88 women who received Solyx™ surgery between September 2015 and December 2017 were reviewed. Ultrasonographic sling evaluation was performed at 6 months and 3 years postoperatively. Primary outcomes were objective and subjective cure of stress incontinence, defined as no involuntary urine leakage during filling cystometry, 1-h pad test < 2 g and negative response to Urogenital Distress Inventory-6 Question 3.

RESULTS

Subjective and objective cure rates at 3 years were 85.2% and 87.5%, respectively, with no complications reported. QOL improvements were maintained. Bladder neck position and mobility had no significant change between 6-month and 3-year follow-up. Tape position demonstrated significant shifts in the y-axis at both rest and Valsalva and in the x-axis at Valsalva between 6 months and 3 years; overall mobility was unchanged. Percentile of sling location remained unchanged at 60.1%, as did percentage of urethral kinking (67.9%) achieved. Risk factors for failure were bladder neck hypomobility postoperatively and no urethral kinking postoperatively.

CONCLUSIONS

There was good sustained objective and subjective cure with improved QOL in women who underwent Solyx™ for USI at 3-year follow-up. Ultrasonographic evaluation showed a tape position shift upwards and backwards with unchanged tape and bladder neck mobility. Percentile of sling location and rates of dynamic kinking were maintained.

De novo detrusor overactivity and urgency after mid-urethral slings for urodynamic stress incontinence

INTRODUCTION AND HYPOTHESIS

The objective was to identify incidence and risk factors of de novo urgency and detrusor overactivity (DO) following mid-urethral slings (MUS) in patients with urodynamic stress incontinence (USI) without urgency.

METHODS

A total of 688 women between January 2004 and July 2017 were reviewed retrospectively. De novo urgency was established with a positive response to question 2 on the Urogenital Distress Inventory-6 questionnaire (UDI-6). Objective cure of USI is no involuntary urine leakage during filling cystometry and pad test < 2 g. Subjective cure of stress urinary incontinence (SUI) is defined as a negative response to question 3 on UDI-6. Multivariate logistic regression was used to identify risk factors for failure.

RESULTS

Forty-four out of 688 women (6.4%) developed de novo urgency, with 16 out of 688 (2.3%) demonstrating de novo DO. Subjective cure for women with de novo urgency was significantly lower at 35 out of 44 (79.5%) compared with 556 out of 644 (86.3%) in those with no urgency (p < 0.001). Objective cure for women with de novo DO was significantly lower at 8 out of 16 (50%) compared with 599 out of 672 (89.1%) in those with detrusor stability (p < 0.001). Quality of life improved for all. Age ≥ 66 (OR, 1.23; 1.07), increased bladder sensation (OR, 4.18; 3.80), lower bladder capacity (OR, 5.28; 4.97), lower maximum urethral closure pressure (OR, 2.32; 5.20), and pad test > 100 g (OR, 1.08; 1.15) were independent risk factors for de novo urgency and DO. Diabetes (OR, 1.32) was an independent predictor of de novo urgency.

CONCLUSION

Cure is significantly reduced in women who report symptoms of de novo urgency or demonstrate DO after MUS at 1 year. Independent risk factors include age ≥ 66, increased bladder sensation, lower bladder capacity, lower maximum urethral closure pressure, greater pad loss, and diabetes.

Fabrication of Drug-Eluting Polycaprolactone/poly(lactic-co-glycolic Acid) Prolapse Mats Using Solution-Extrusion 3D Printing and Coaxial Electrospinning Techniques

We developed biodegradable drug-eluting prolapse mats using solution-extrusion 3D printing and coaxial electrospinning techniques. The mats were composed of polycaprolactone (PCL) mesh and lidocaine-, estradiol-, metronidazole-, and connective tissue growth factor (CTGF)-incorporated poly(lactic-co-glycolic acid) (PLGA) nanofibers that mimic the structure of the natural extracellular matrix of most connective tissues. The mechanical properties of degradable prolapse membrane were assessed and compared to commercial non-degradable polypropylene knitted meshes clinically used for pelvic organ prolapse (POP) repair. The release behaviors of the drug-loaded hybrid degradable membranes were also characterized. The experimental results suggest that 3D-printed PCL meshes exhibited comparable strengths to commercial POP meshes and survived through 10,000 cycles of fatigue test without breakage. Hybrid PCL meshes/PLGA nanofibrous membranes provided a sustainable release of metronidazole, lidocaine, and estradiol for 4, 25, and 30 days, respectively, in vitro. The membranes further liberated high levels of CTGF for more than 30 days. The animal tests show that the mechanical property of PCL mesh decreased with time, mainly due to degradation of the polymers post-implantation. No adverse effect of the mesh/nanofibers was noted in the histological images. By adopting solution-extrusion 3D printing and coaxial electrospinning, degradable drug-eluting membranes can be fabricated for POP applications.

Impact of intrinsic sphincter deficiency on mid-urethral sling outcomes

INTRODUCTION AND HYPOTHESIS

Our primary objective was to study outcomes of patients with intrinsic sphincter deficiency (ISD) following mid-urethral slings (MUS) at 1-year. Our secondary objective was to delineate factors affecting success in these patients.

METHODS

Six hundred eighty-eight patients who had MUS between January 2004 and April 2017 were reviewed retrospectively; 48 women were preoperatively diagnosed with ISD. All completed urodynamic studies and validated quality-of-life (QOL) questionnaires at baseline and 1 year. Primary outcomes were objective and subjective cure of stress incontinence, defined as no involuntary urine leakage during filling cystometry and 1-h pad test < 2 g and negative response to Urogenital Distress Inventory-6 Question 3. Ultrasound was performed to determine tape position, urethral mobility and kinking at 1 year.

RESULTS

Women with ISD had significantly lower objective and subjective cure rates of 52.1% and 47.9%, respectively, compared to an overall of 88.2% and 85.9%. QOL scores significantly improved in those with successful surgeries. The sling type did not make a difference. Multivariate logistic regression identified reduced urethral mobility [OR 2.11 (1.24-3.75)], lower maximum urethral closure pressure (MUCP) [OR 1.61 (1.05-3.41)] and tape position [OR 3.12 (1.41-8.71)] to be associated with higher odds of failed slings for women with ISD.

CONCLUSIONS

Although there are good overall success in women undergoing MUS, those with ISD have significantly lower cure rates at 1 year. Factors related to failure include reduced urethral mobility, low MUCP and relative tape position further away from the bladder neck. Optimal management of patients with ISD and reduced urethral mobility remains challenging.

The efficacy and complications of using transvaginal mesh to treat pelvic organ prolapse in Taiwan: A 10-year review

Transvaginal mesh (TVM) insertion for the treatment of pelvic organ prolapse (POP) is significantly associated with lower failure rates, although its use remains controversial due to the potential risk of mesh-related complications. In this review, we collected the published literature regarding the use of TVM to treat POP in an attempt to assess both the efficacy and complications related to TVM usage in Taiwan. We searched 25 English language articles using PubMed related to TVM in Taiwan from 2010 to 2019. The present article focuses on the efficacy and complications of TVM and analyzes the data. There were 25 studies on TVM selected for this review. Regarding their success rate, 21 out of the 22 studies (95.5%) had more than a 90% objective success rate. Twenty studies (90.9%) had less than 10% major complications of TVM. Twenty out of the 25 studies (80.0%) had 5% or less mesh exposure. For self-cut TVM and the later single-incision TVM, both the complication rates and exposure rates decreased. The rate of de novo dyspareunia ranged from 2.6% to 14.3%, and the incidence decreased yearly from 2011 to 2019. This review showed both the high treatment efficacy and low complication rate of TVM usage for the short-term treatment of POP in Taiwan. However, a longer-term study is needed to draw a conclusion regarding the safety of this treatment.

Beneficial effect of Bletilla striata extract solution on zymosan-induced interstitial cystitis in rat

AIMS

Interstitial cystitis (IC) is a chronic pain syndrome that is characterized by suprapubic pain upon bladder filling. Bletilla striata, a well-known traditional Chinese herb with established efficacy in wound healing and anti-inflammation, was hypothesized to improve the symptoms of IC possibly though forming a physical barrier that could isolate the bladder tissue from irritants. This study was conducted to evaluate the beneficial effects of intravesical treatment with B. striata extract solution (BSES) on visceral pain and bladder function of rats with zymosan-induced IC.

METHODS

Thirty female rats were randomly divided into control group, zymosan-induced cystitis rats treated with normal saline (Z + NS), and zymosan-induced cystitis rats treated with BSES (Z + BSES). All rats underwent evaluation for abdominal withdrawal reflex (AWR) scores to assess visceral hypersensitivity, cystometrography, and electromyogram (EMG) of both external urethral sphincter and bladder detrusor. Data were analyzed by one way analysis of variance.

RESULTS

The Z + NS group had an increased visceral hypersensitivity as compared to control group. Rats treated with BSES (Z + BSES group) had decreased AWR scores and amplitude of bladder detrusor-EMG. Besides, BSES treatment improved overactive bladder with significant effects on the extend of micturition interval and increase of storage of urine.

CONCLUSIONS

Intravesical instillation of BSES can significantly alleviate zymosan-induced visceral hypersensitivity and bladder overactivity associated with IC. This study suggested that intravesical instillation with BSES might be a promising treatment for IC.

Surgical Trend and Volume Effect on the Choice of Hysterectomy Benign Gynecologic Conditions

With the advance of minimally invasive surgery (MIS), the surgical trends of hysterectomy changed significantly during past 2 decades. Total number (age-standardized) of all types of hysterectomy decreased, which may be due to the availability of some other alternatives, e.g. hysteroscopy, laparoscopic myomectomy. However, laparoscopic hysterectomy (LH) still remains the mainstream of surgical treatment. LH significantly increases for benign gynecologic conditions in Taiwan and worldwide. The increase of LH was accompanied with decrease of TAH; VH kept stationary, and SAH increased slightly. The increase in popularity of LH and SAH; provides evidence of surgical trends and a paradigm shift for hysterectomy. This time-frame shift suggests LH has reached a u during the later years. Older patients tend to receive AH, while middle-aged women tend to receive LH. Oder surgeons tend to perform AH, while younger surgeons tend to perform LH. However, all type hysterectomy and LH were more commonly performed by older surgeons aged over 50 years. It means both patients and surgeons became older during the time-frames. The above phenomena may also happen due to less young surgeons entered in the gynecologic practice. Most of the LHs were performed by high-volume surgeons, however, there is a shift from high-volume, to medium- and low-volume surgeons. The above scenario may be due to the wide spread of LH techniques. Surgical volume has important impacts on both complications and costs. The high-volume surgeons have lower complications, which result in lower costs. In the future, how to increase the use of LH, to improve the training and monitoring system deserves more attentions.

Immunochemical analysis on polypropylene mesh: does mesh size make a difference?

INTRODUCTION AND HYPOTHESIS

The aim of the study is to demonstrate the impact of the size of implanted mesh in relation to its immunohistochemical reaction implanted into animal models.

METHODS

An experimental study utilizing 54 female Sprague Dawley (SD) rats was divided into five groups: control, sham, and study groups (mesh-small [M-S], mesh-medium [M-M], mesh-large [M-L]). The M-S group used a mesh size of 0.2 × 0.2 cm, the M-M group a mesh size of 0.5 × 0.5 cm, and the M-L a mesh size of 0.7 × 1.0 cm. The sham group underwent vaginal dissection with no mesh implantation. The rats were sacrificed using isoflurane overdose on days 7 and 30. The mesh with the surrounding vaginal and bladder wall tissues were removed and processed for histochemical and western blot analysis.

RESULTS

There is a significant increase in IL-1 and TNF-α immunoreactivity in the M-M and M-L groups on day 7 when compared with the sham group with p values of 0.001 and < 0.001 respectively. M-L showed significantly higher immunoreactivity to TNF-α persisting until day 30. All study groups presented a significantly higher immunoreactivity to MMP-2 and NGF on day 7. However, reactivity to NGF does not persist to day 30 in all groups. Immunoreactivity to CD 31 on days 7 and 30 appears significantly greater in the M-M and M-L groups, with the reaction in the M-L group continuing until day 30.

CONCLUSION

Mesh size is directly proportional to the inflammatory reaction in the host tissue. The prolonged inflammatory process leads to delayed tissue remodeling and angiogenesis, which could delay mesh-tissue integration.

Anterior-Apical Transvaginal Mesh (Surelift) for Advanced Urogenital Prolapse: Surgical and Functional Outcomes at 1 Year

STUDY OBJECTIVE

To determine the objective and subjective outcomes of pelvic organ prolapse (POP) surgery using a modified Surelift system (Neomedic International, Barcelona, Spain) and to evaluate surgical complications and postoperative impact on quality of life (QOL) and lower urinary tract symptoms.

DESIGN

Retrospective cohort study.

SETTING

Tertiary-care university hospital.

PATIENTS

Patients with symptomatic anterior or apical POP stage III and above.

INTERVENTIONS

All patients underwent pelvic reconstructive surgery with a modified Surelift transvaginal mesh kit.

MEASUREMENTS AND MAIN RESULTS

Eighty-three women who underwent pelvic reconstructive surgery with a modified Surelift for symptomatic anterior or apical prolapse stage III and above from April 2018 to January 2019 were reviewed retrospectively. All completed a 72-hour voiding diary, urodynamic study, and multiple validated QOL questionnaires at baseline and at between 6 and 12 months postoperatively. Descriptive statistics were used for demographics and perioperative data. Paired-samples t test and the McNemar test were applied for comparison of pre- and postoperative continuous and categoric data, respectively. The primary outcomes were the objective cure of POP, defined as anterior and apical prolapse Pelvic Organ Prolapse Quantification System ≤ stage I, and subjective cure on the basis of negative answers to Pelvic Organ Prolapse Distress Inventory 6. The objective and subjective cure rates at 1 year were 97.6% and 92.8%, respectively. There were significant improvements in QOL scores postoperatively. Although bladder outlet obstruction improved, de novo urodynamic stress incontinence and stress urinary incontinence were increased at 18.9% and 21.6%, respectively, at 1-year follow-up. The mesh extrusion rate was 4.8%.

CONCLUSION

A modified Surelift has good objective and subjective cure rates at 1 year postoperatively with 4.8% mesh extrusion rate. There was significant improvement in lower urinary tract symptoms and QOL. De novo urodynamic stress incontinence at 6 months to 12 months was increased, but it was not sufficiently bothersome to warrant surgery.

Is maternal serum inhibin A a good predictor in preterm labor? - Experience from a community hospital in Taiwan

Background

We aimed to determine whether inhibin A could be a reliable and accurate predictor of preterm birth, and discuss the possible pathogenic processes of inhibin A leading to preterm birth.

Methods

A retrospective cohort study was conducted on consecutive singleton pregnant women who underwent the second-trimester quad screen test at a gestational age of 15–20 weeks at Keelung Chang-Gung Memorial Hospital from March 2011 to May 2015. Data including maternal characteristics and pregnancy outcomes were collected from an electric medical record database. Data regarding pregnancy terminations before a gestational age of 24 weeks and regarding pregnancies that involved chromosomal or congenital anomalies were excluded from this analysis. One-way analysis of variance was used to compare second-trimester α-fetoprotein, human chorionic gonadotropin, unconjugated estriol, and inhibin A in women with preterm deliveries versus those with term deliveries.

Results

Although a total of 935 women with singleton pregnancies were enrolled, pregnancy outcome and complete maternal data were obtained from only 770 (82.3%)of them. In total, 687 (89.2%) women delivered at or after 37 weeks of gestation and 83 (10.8%) women delivered before 37 weeks of gestation. The results showed that the inhibin A level was significantly increased in the preterm labor group (p = 0.009). A cutoff inhibin A value above 2.25 was identified statistical significantly in the preterm labor group.

Conclusions

From our results, an inhibin A level above 2.25 multiples of the median in the quad screen test may be associated with preterm labor afterward. Closely monitoring for uterine contractions or cervical length measurement in the second trimester may be indicated in patients with unexplained elevated inhibin A levels.

Urodynamics mixed type urinary incontinence with advanced pelvic organ prolapse, management and outcomes

Patients with pelvic organ prolapse (POP) often have accompanying lower urinary tract symptoms. Symptoms such as stress urinary incontinence(SUI-_UD) and detrusor overactivty(DO) would co-exist in a number of patients. Management entails relieving the obstructive element. To determine the clinical outcome of patients with urodynamics mixed type urinary incontinence(MUI-U) after vaginal pelvic reconstructive surgery(PRS), a retrospective study was conducted. MUI-U was defined as having urodynamic findings of both of DO/DOI (derusor overactivity incontinence) and SUI-_UD. Main outcome measures: Objective cure- absence of involuntary detrusor contraction on filling cystometry and no demonstrable leakage of urine during increased abdominal pressure; Subjective cure- assessment index score of <1 on UDI-6 question #2 and #3. Of the 82 patients evaluated, 14 underwent vaginal PRS with concomitant mid-urethral sling(MUS) insertion while 68 had vaginal PRS alone. Pre-operatively, 49(60%) patients had stage III and 33(40%) had stage IV prolapse. Post-operatively, 1-year data shows an objective cure of 56% (46/82) and subjective cure of 54% (44/82). MUI-U was significantly improved. Improvement of SUI_UD and results of the 1-hour pad test were more pronounced in patients with concomitant MUS insertion. Ergo, vaginal PRS cures symptoms of MUI-U in >50% of patients and concomitant MUS can be offered to SUI predominant MUI.

Dissecting of the paravesical space associated with lower urinary tract dysfunction - a rat model

To determine the association of opening the paravesical space in relation to its occurrence of de novo SUI in an animal model. Thirty five female Sprague Dawley rats were divided into 5 groups of 7 rats each: Control group, Sham groups(F, H), and Study groups(MF, MH). Groups labeled with "F" had the paravesical space opened, "H" had tissue dissection with no opening of the space, and "M" had mesh implanted inside the vaginal wall. Urodynamic studies, immunohistochemical analysis, and western blot were done at day 40. The mean weight and age of 35 rats were 302.1 ± 25.1 grams and 12.8 ± 1.2 weeks old. No significant differences were noted among the control, Sham F, Sham H, Study MF, and Study MH on the voiding pressure and voided volume. The Sham F and Study MF (opened paravesical space) groups had significantly lower values on leak point pressures (LPP) (p = 0.026; p < 0.001) and shorter voiding intervals (p = 0.032; p = 0.005) when compared to other groups. Immunohistochemical analysis showed IL-1 and TNF-α to be intensely increased for the Study MF group (p = 0.003; p = <0.001). MMP-2 and CD 31 markers were also significantly higher in the Study MH and MF group. NGF expression was significantly increased in the Study MF and Sham F groups. Thus, opening of the paravesical space causes an increased inflammatory reaction, which leads to tissue destruction and lower urinary tract dysfunction, exemplified in the study with low leak point pressure and shortened voiding intervals.

Risks of interstitial cystitis among patients with systemic lupus erythematosus: A population-based cohort study

OBJECTIVE

To investigate whether the risk of interstitial cystitis increases among the patients with systemic lupus erythematosus.

METHODS

This was a nationwide population-based cohort study. Data were obtained from the National Health Insurance Research Database in Taiwan. Women aged >18 years newly diagnosed as systemic lupus erythematosus during 2001-2008 were identified as the control group. The comparison included individuals randomly selected from the National Health Insurance Research Database in the year of 2000, by matching one systemic lupus erythematosus participant with eight non-systemic lupus erythematosus participants with sex and age. These participants were followed up until being diagnosed as interstitial cystitis, or the end of 2011. Women diagnosed with lupus cystitis were excluded from this study.

RESULTS

This study included 7240 women with systemic lupus erythematosus and 57 920 women without systemic lupus erythematosus as controls. The incidence rate of interstitial cystitis was significantly higher in the systemic lupus erythematosus group, with an incidence rate ratio of 2.26 (95% confidence interval 1.57-3.27, P < 0.0001). After adjustment, the risk increased by 2.45-fold (adjusted hazard ratio 2.45, 95% confidence interval 1.57-3.27, P < 0.05). Age as a factor increases incidence rate ratios among all age groups, 2.12-, 3.32- and 4.65-fold. Age ≥45 years had an increased adjusted hazard ratio (2.07, 95% confidence interval 1.37-3.13, P < 0.05). Comorbidities, for example, hypertension, diabetes mellitus, dyslipidemia and renal disease, were insignificant.

CONCLUSIONS

This is the first population-based cohort study showing a higher incidence of interstitial cystitis among patients with systemic lupus erythematosus. These findings support the concordance of interstitial cystitis with autoimmune diseases, and the temporal relationship to develop interstitial cystitis in patients with systemic lupus erythematosus.

Surgical Trends and Time Frame Comparison of Surgical Types of Hysterectomy: A Nationwide, Population-based 15-year Study

STUDY OBJECTIVE

To investigate the surgical trends among different types of hysterectomy (abdominal, vaginal, laparoscopic, and subtotal) over a 15-year period in Taiwan.

DESIGN

A retrospective cohort study.

SETTING

A population-based National Health Insurance Research Database.

PATIENTS

Women undergoing various types of hysterectomy for noncancerous lesions.

INTERVENTIONS

Data for this study were extracted from the inpatient expenditures by admissions files of Taiwan's National Health Insurance Research Database from 1998 through 2012 and divided into three 5-year time frames: first (1998-2002), second (2003-2007), and third (2008-2012). The variables included types of hysterectomy, patient age, gynecologist age and sex, hospital accreditation level, and surgical volume. Chi-square and trend tests were used to examine the association between the variables.

MEASUREMENTS AND MAIN RESULTS

A total of 329 438 patients who underwent various types of hysterectomy were identified; 306 257 were included in the study. During the 15-year period, 45% underwent total abdominal hysterectomy, 41% underwent laparoscopic hysterectomy (LH), 9.8% underwent vaginal hysterectomy, and 4.2% underwent subtotal abdominal hysterectomy. The frequency of LHs increased from 35.9% in the first period to 43.9% in the second period and remained at 44.2% in the third period. During the same time period, there was a decrease in the frequency of total abdominal hysterectomies. Typically, younger patients underwent LHs by gynecologists with large volume surgical practices and medical centers.

CONCLUSION

This 15-year study describes an increase of LHs and subtotal abdominal hysterectomies over time and provides evidence of surgical trends and a paradigm shift of hysterectomies. Surgical skills and performance extended from high- to low-surgical volume gynecologists and from medical centers to regional and local hospitals. This shift may have a great influence on patient and health care provider choice of treatment.

Ultrasonography and clinical outcomes following anti-incontinence procedures (Monarc vs MiniArc): A 3-year post-operative review

Objective

To compare the ultrasonographic positional changes of mid-urethral sling(MUS) tape in relation to symphysis pubis, and the different clinical outcomes among women who underwent MUS insertion with MiniArc^TM or Monarc^TM for the treatment of stress urinary incontinence 3 years after.

Materials and methods

A retrospective follow-up study on patients with clinically confirmed stress urodynamic incontinence and urodynamic stress incontinence who had undergone MiniArc or Monarc surgery. Data regarding preoperative evaluation, intraoperative complications and post-operative follow-ups were collated. Main outcome is to determine the change in position of the sling through measurement of the x- and y-axis at rest and during Valsalva maneuver using the 3D introital ultrasound.

Results

A total of 138 patients were evaluated, 82 belonged to Monarc and 56 to MiniArc. At 3years, objective and subjective cure rates for MiniArc and Monarc were comparable (88%, 91%; p>0.05; 83%, 89%, p>0.05 respectively). Ultrasonographic changes between MiniArc and Monarc from 6 months to 3 years, showed MiniArc to exhibit significant movement in both x- [3.0 ±0.4 mm vs. 2.2 ±0.3 mm (p = 0.02) at rest; 2.6 ±0.3 mm vs. 1.6 ±0.3 mm (p<0.001) during valsalva] and y-axis [3.5 ±0.5 mm vs. 2.0 ±0.3 mm (p<0.001) at rest; 3.3 ±0.5 mm vs. 2.9 ±0.3 mm (p = 0.037) during Valsalva]. The mobility of MiniArc was significantly more than Monarc from rest to Valsalva (1.1 ±0.4 mm vs. 0.3 ±0.3 mm, p = 0.001). Tightness of the sling assessed from the major and minor axis of the urethral core had no significant difference in both groups at rest and during Valsalva. Urethral kinking percentage and the location of the sling did not yield statistical difference.

Conclusion

Maintenance of continence rates of mid-urethral slings depends on the compressive effect of the sling on the urethra, urethral kinking, and sling fixation. From 6months to 3 years, MiniArc changed its position in both x- and y-axis over time, which the authors attribute to loosening of the anchoring mechanism since no clinical relevance could be sought.

Clinical outcomes on tension-releasing suture appendage on single-incision sling devices for postoperative voiding dysfunction involving undue tape tension

INTRODUCTION AND HYPOTHESIS

To determine the clinical outcomes of adding a tension-releasing suture (TRS) appendage for manipulation of over-tensioned single-incision slings (SIS) as a means to relieve postoperative voiding dysfunction.

METHODS

A retrospective observational study conducted from January 2010 to July 2017. The records of patients with urodynamic stress incontinence (USI) without needing concurrent procedures who underwent anti-incontinence surgery using MiniArc, Solyx, and Ajust with voiding dysfunction were collated and analyzed. The primary outcome measure was the recovery of normal post-void residual urine (PVR) after TRS manipulation. The secondary outcome measures were the pain intensity noted during manipulation (quantified by visual analog scale) and the continence rate [assessed by (1) objective cure: 1-h pad test weight < 2 g and absence of USI; (2) subjective cure index score ≤ 1 on question 3 of the UDI-6: "Urine leakage related to physical activity, coughing, or sneezing?"].

RESULTS

There were 73 patients with high post-void residual (PVR) urine. The 42 (9.5%) patients with over-tensioned slings were managed with TRS manipulation while the 31 patients (7%) with high PVR and no sling over-tension were managed with intermittent catheterization. All patients in both groups regained normal PVR. The TRS-manipulated group demonstrated an objective cure rate of 92.9% (39/42) and subjective cure rate of 91% (38/42). Pain experienced during TRS manipulation was significantly higher with the Ajust system (p = 0.018). Three patients had persistence of USI, two with MiniArc and one with Solyx.

CONCLUSIONS

The TRS manipulation is a well-tolerated procedure that can effectively relieve voiding dysfunction for over-tensioned SIS without affecting continence cure rates.

Evaluation of Clinical Outcome and Risk Factors for Failure of Single-incision Midurethral Short Tape Procedure (Solyx Tape) for Stress Urinary Incontinence

STUDY OBJECTIVE

To evaluate the clinical outcome and identify risk factors for failure of the Solyx (Boston Scientific Corporation, Marlborough, MA) single-incision sling (SIS) in the treatment of urodynamic stress incontinence (USI).

DESIGN

A retrospective observational study (Canadian Task Force classification II-2).

SETTING

A tertiary referral center.

PATIENTS

Patients diagnosed with USI without needing concurrent procedures that underwent continence surgery using the Solyx SIS from February 2015 to May 2017.

INTERVENTIONS

Anti-incontinence surgery.

MEASUREMENTS AND MAIN RESULTS

The primary outcome of this study was the rate of objective cure defined as the absence of demonstrable leakage of urine on the cough stress test and a 1-hour pad test weight of less than 2g. The secondary outcome was the rate of subjective cure defined as a negative response to Urinary Distress Inventory question 3 (no leakage on coughing, sneezing, or laughing) and the identification of the different risk factors of cure failure. A total of 113 patients were evaluated in the study. Postoperative USI and the 1-hour pad test significantly improved from 24.2 ± 26.9 gm (range, 19.1-29.3) to 2.5 ± 8.7 gm (range, 0.9-4.2); p <0.001 through 1 year. Data analysis showed an objective cure rate of 90% (102/113) and a subjective cure rate of 86% (97/113). USI recurred in 11 patients with no repeat surgery done becausesymptoms were tolerable to the patients. No patient had bladder outlet obstruction. Peak flow rates 23.7 ± 9.1 ml/s (20.0-27.4) and residual urine volume 38.5 ± 25.8 ml (29.8-47.2) were within normal limits with no significant changes. Previous anti-incontinent surgery, previous prolapsed surgery, intrinsic sphincter deficiency, maximum urethral closure pressure <40cm H₂O, and neurogenic disease were significant risk factors for sling failure. Subjective assessment on the quality of life significantly improved (p <0.001).

CONCLUSION

The Solyx SIS is an effective and safe treatment option for women with USI, showing high objective and subjective cure rates with a low incidence of complications 1 year after treatment. The identified independent risk factors forfailure are related to poor urethral function and previous pelvic reconstructive surgery.

Sacrospinous ligament fixation for hysteropexy: does concomitant anterior and posterior fixation improve surgical outcome?

INTRODUCTION AND HYPOTHESIS

Uterine preservation in uterine prolapse is an option for young patients. We hypothesized that sacrospinous hysteropexy (SSH) with anchorage to both the anterior and posterior cervix (SSH-ap) would have a better outcome than SSH with anchorage to the posterior cervix only (SSH-p).

METHODS

This was a retrospective study including 75 patients who underwent SSH at Chang Gung Memorial Hospital between March 2008 and August 2013. Five were excluded due to incomplete data. Of the remaining 70 patients, 35 underwent SSH-p between March 2008 and June 2011, and 35 underwent SSH-ap between June 2010 and August 2013. The primary outcome was the objective anatomical result, and a successful outcome was considered anatomical correction (POP-Q stage 1 or less) of anterior and apical prolapse. Subjective outcome was evaluated using the POPDI-6 questionnaire, and a patient response of "No or mild abdominal organ falling out sensation" together with "No or mild heaviness" was considered to indicate a successful outcome. Anterior fornix and cervical diameter measurements were included. The secondary outcome was quality of life according to the UDI-6, IIQ-7, POPDI-6, and PISQ-12 questionnaires. The 3-year outcome was used for comparison.

RESULTS

The subjective overall cure rates were significantly different between the SSH-p and SSH-ap groups (74.3% and 94.3%, respectively; p = 0.023). However, the objective overall cure rates were not significantly different (74.3% and 82.9%, respectively).

CONCLUSION

Anchorage of the anterior cervix and vaginal wall together with the usual posterior anchorage yield better subjective outcomes and apical suspension at 3 years after surgery than anchorage of the posterior cervix and vaginal wall only. The cervix position affected the subjective outcome. Concurrent trachelectomy did not affect the outcome.

Trans-vaginal mesh surgery for management of recurrent pelvic organ prolapse following abdominal sacrocolpopexy

OBJECTIVE

To evaluate the outcome of transvaginal mesh surgery as a management of recurrent pelvic organ prolapse, in patients previously treated with sacrocolpopexy.

CASE REPORT

A series of three patients who developed recurrent pelvic organ prolapse more than 9 years after sacrocolpopexy. A 50-year-old and two 77-year-old patients who presented with recurrent pelvic organ prolapse at 9, 15 and 17 years, respectively after the primary abdominal sacrocolpopexy were managed by transvaginal mesh surgery.

CONCLUSION

Management of recurrent pelvic organ prolapse using transvaginal mesh would be an option for patients treated previously by sacrocolpopexy.

Five-Year Outcome of MiniArc Single-Incision Sling Used in the Treatment of Primary Urodynamic Stress Incontinence

STUDY OBJECTIVE

To evaluate the effectiveness and safety of the MiniArc single-incision sling in the treatment of urodynamic stress incontinence (USI) through 5 years.

DESIGN

Retrospective observational study (Canadian Task Force classification II-2).

SETTING

Tertiary referral center.

PATIENTS

Eighty-five patients with USI without needing concurrent procedures who underwent anti-incontinence surgery using the MiniArc SIMS from February 2010 to December 2011.

INTERVENTIONS

Anti-incontinence surgery.

MEASUREMENTS AND MAIN RESULTS

Objective cure was defined as no demonstrable leakage of urine on the cough stress test and 1-hour pad test weight <2 g. Subjective cure was based on negative response to Urinary Distress Inventory question 3, no leakage on coughing, sneezing, or laughing. Most patients were postmenopausal, overweight, and multiparous. Postoperative USI significantly improved (p < .001) through 3 years, and the 1-hour pad test showed significant improvement through 5 years (p < .001). Although 13 patients had recurrence of USI, no repeat surgery was done. The cumulative cure rates may show a declining trend of cure, yet subjective cure was 80.0% and objective cure 84.7%, with age as a significant risk factor for sling failure.

CONCLUSION

MiniArc maintains its effectiveness and safety in treatment of USI through 5 years with high objective and subjective cure rates and low incidence of complications.

A complicated urethrovaginal fistula following an inappropriate urethral diverticulum management

OBJECTIVE

Urethral diverticulum is uncommon, therefore appropriate evaluation, preoperative planning and counseling must be done in order to make correct diagnosis and prevent complications.

MATERIALS AND METHODS

A case of anterior vaginal wall mass was treated elsewhere by a gynecologist as periurethral cyst abscess; incision and drainage were done but a symptom of pus discharge was observed after 2 weeks. Therefore, exploration, cyst wall excision and primary closure were done though histopathological examination surprisingly confirmed the presence of urethral tissue suggestive of diverticulum.

RESULTS

Subsequently, she developed persistent urinary leakage along with urethrovaginal fistula for which they again performed pervaginal multilayer closure. Patient was later referred to us with recurrent urethrovaginal fistula. We performed posterior urethral fistulectomy with anterior vaginal wall flap and multilayer closure. Three years follow up reveals complete recovery.

CONCLUSION

Even urethral diverticulum is a rare condition, should be kept in mind as early diagnosis and management.

[The Life Impacts and Symptom Distress in Women With Pelvic Organ Prolapse Syndrome Before Pelvic Reconstruction Surgery]

BACKGROUND

The decision whether or not to undergo pelvic reconstructive surgery is difficult for women suffering from pelvic organ prolapse. However, little research has examined the symptom distress and life impacts that these women face prior to this surgery. Thus, it is crucial that gynecology nurses learn about these life impacts and symptom distresses in order to help these women make the best decisions with regard to surgery.

PURPOSE

To explore the life impacts and degree of symptom distress in pre-surgery women with pelvic organ prolapse; to explore the relationships between demographic data and the variables of life impact and degree of symptom distress; and to identify the factors that relate to the explainable variance in the life impacts of these women.

METHODS

A cross-sectional and correlational research design was used and a total of 110 women with pelvic organ prolapse who had not yet undergone pelvic reconstruction surgery were recruited in the gynecological clinics of one medical center in Taiwan.

RESULTS

Daytime urination frequency was the most prevalent urinary tract symptom noted by the participants; vaginal protrusion was the most prevalent pelvis-related symptom noted; and depression and anxiety were the most prevalent life impacts noted. Moreover, greater lower-urinary-tract symptom distress was associated with greater pelvic-symptom distress. Furthermore, greater lower urinary tract and pelvic symptom distresses were associated with a greater negative impact on life. Education background and pelvis-related symptoms were the explained variances in pre-surgery life impacts.

CONCLUSIONS

Women with pelvic organ prolapse should pay particular attention to symptoms that include: daytime urinary frequency, vaginal protrusion, and emotional problems including depression and anxiety. Education background and level of symptom distress should be taken into consideration when caring for the life impacts of this vulnerable group of women.

Transvaginal management of severe pelvic organ prolapse in nulliparous women

AIM

The aim of this study was to evaluate the management outcomes of advanced pelvic organ prolapse (POP) in nulliparous women.

METHODS

Eight nulliparous women diagnosed with POP ≥ stage 3 between January 2005 and August 2013, according to the Pelvic Organ Quantification System (POPQ), were reviewed. Seven were managed surgically and one was managed with pessary. Primary outcome was surgical objective cure (POP-Q ≤ 1) and subjective cure, defined as negative response to questions 2 and 3 on Pelvic Organ Prolapse Distress Inventory 6. Secondary outcomes were complications, symptoms' severity and quality of life according to validated questionnaires.

RESULTS

A total of 1275 prolapse patients with POP-Q ≥ stage 3 were managed surgically, among whom seven (0.55%) were nulliparous. Each woman had at least one risk factor associated with POP. Risk factors identified were history of pelvic trauma, obesity, menopause, chronic cough, hard physical labor and constipation. Five patients underwent surgical correction (vaginal hysterectomy with sacrospinous fixation) with mesh (Perigee, n = 3; Avaulta, n = 2). Two patients had uterine preservation without mesh (hysteropexy with sacrospinous ligament fixation). One patient preferred treatment with pessary. The total cure rate (objective and subjective cure rates) was 86% after surgical reconstructive surgery.

CONCLUSION

Management of nulliparous advanced POP poses significant challenges with regard to uterine preservation, future pregnancy and childbirth. Conservative management with pessary insertion should be offered followed by surgical correction. Reconstructive surgery with mesh may improve prolapse symptoms objectively and subjectively.

Predictors of voiding dysfunction following extensive vaginal pelvic reconstructive surgery

INTRODUCTION AND HYPOTHESIS

The objective of this study was to identify the predictors of postoperative voiding dysfunction in women following extensive vaginal pelvic reconstructive surgery.

METHODS

We enrolled 1,425 women who had pelvic organ prolapse of POP-Q stage III or IV and had undergone vaginal pelvic reconstructive surgery with or without transvaginal mesh insertion from January 2006 to December 2014. All subjects were required to complete a 72-h voiding diary, and the IIQ-7, UDI-6, POPDI-6 and PISQ-12 questionnaires. Urodynamic study was performed preoperatively and postoperatively.

RESULTS

Of the 1,425 women, 54 were excluded due to incomplete data, and 1,017 of the remaining 1,371 (74.2 %) had transvaginal mesh surgery and 247 (18 %) had concurrent midurethral sling insertion. Of 380 women (27.7 %) with preoperative voiding dysfunction, 37 (9.7 %) continued to have voiding dysfunction postoperatively. Of the remaining 991 women (72.3 %) with normal preoperative voiding function, 11 (1.1 %) developed de novo voiding dysfunction postoperatively. The overall incidence of postoperative voiding dysfunction was 3.5 % (48/1,371). Those with concurrent midurethral sling insertion were at higher risk of developing voiding dysfunction postoperatively (OR 3.12, 95 % CI 1.79 - 5.46, p < 0.001). Diabetes mellitus, preoperative detrusor pressure at maximal flow (Dmax) <10 cm H₂O and postvoid residual volume ≥200 ml were significant risk factors for the development of postoperative voiding dysfunction (OR 3.07, 1.84 and 2.15, respectively; 95 % CI 1.69 - 5.60, 1.39 - 2.91 and 1.10 - 3.21, respectively).

CONCLUSIONS

Diabetes mellitus, concurrent midurethral sling insertion, preoperative Dmax <10 cm H₂O and postvoid residual volume ≥200 ml in patients with advanced pelvic organ prolapse were risk factors for the development of postoperative voiding dysfunction after vaginal pelvic reconstructive surgery. Therefore, counseling is worthwhile before considering vaginal pelvic reconstructive surgery.

Risk factors for failure of repeat midurethral sling surgery for recurrent or persistent stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

To study the outcomes following repeat midurethral sling (MUS) surgery in patients with persistent or recurrent stress urinary incontinence after failure of primary MUS surgery and risk factors for surgical failure.

METHODS

The medical records of 24 patients who underwent repeat MUS surgery at a single tertiary center from January 2004 to February 2014 were reviewed. The types of MUS used for the repeat surgey were transobturator, retropubic and single incision slings. Objective cure was defined as no demonstrable involuntary leakage of urine during increased abdominal pressure in the absence of a detrusor contraction observed during filling cystometry, and subjective cure was defined as a negative response to Urogenital Distress Inventory six (UDI-6) question 3 during follow-up between 6 months and 1 year postoperatively. The change in the inclination angle between the urethra and pubic axis was measured with introital ultrasonography and the cotton swab test performed.

RESULTS

The objective and subjective cure rates were 79.2 % and 75 %, respectively. There were no differences in demographics between the patients with failure of surgery and those with successful surgery. Significant independent risk factors for failure of repeat MUS surgery were a change in cotton swab angle at rest and straining of <30° (OR 4.6, 95 % CI 2.5 - 7.9°), a change in inclination angle of <30° (OR 4.6, 95 % CI 2.5 - 7.9°), intrinsic sphincter deficiency (OR 3.4, 95 % CI 1.8 - 6.1) and a mean urethral closure pressure of <60 cm H2O (OR 2.9, 95 % CI 1.5 - 4.5). In one patient the bladder was perforated.

CONCLUSIONS

Repeat MUS surgery is safe and has a good short-term success rate, both objectively and subjectively, with independent risk factors for failure related to bladder neck hypomobility and poor urethral function.