["Do uro-gynecology multidisciplinary team meeting modify therapeutic management?"]

INTRODUCTION

Since the banning of trans-vaginal meshes for pelvic organ prolapse treatment by the FDA in 2019, French authorities have been gradually regulating the use of prosthetic materials in urogynecology. The decision to fit a mid-urethral sling or a reinforcement implant for the cure of prolapse, as well as the management of complex genital prolapse and serious post-implant complications, must be the subject of multidisciplinary consultation and a shared medical decision. To comply with these regulations, multidisciplinary team meetings (MDTMs) have been set up. The aim of the study was to evaluate the impact of these meetings on patient management.

MATERIAL

We carried out a retrospective study in a tertiary hospital in France on all cases presented in MDTM of urogynecology over the year 2022. MDTMs were held weekly, with a "Prosthesis MDTM" focusing on slings, sacrocolpo/hysteropexies and prosthetic complications, lead by the urology team, and a "Prolapse MDTM" focusing on pelvic organ prolapse and complex prolapses, lead by the gynecology team. We compared the initial proposal of the patient's referring physician versus the final proposal of the MDTM.

RESULTS

Three hundred and seventy-five cases were presented in our center in 2022: 188 in Prosthetic MDTM and 187 in Prolapse MDTM. The Prosthetic and Static MDTMs agreed with the initial proposal in 83 and 64% of cases respectively, while the therapeutic strategy was questioned in 12 and 36% of cases respectively.

CONCLUSION

For almost a quarter (24%) of patients, the MDTM of urogynecology opted for a different management from that proposed by the referring physician. The presentation of cases to the MDTM is a legal obligation in specific indications. It also plays an educational role, enabling shared decision-making and responsibility, which is an asset in functional surgery.

LEVEL OF EVIDENCE: 4

[Photobiomodulation and vulvovaginal disorders after anticancer treatments]

Anticancer treatments induce vulvovaginal complications that alter the quality of life and sexuality of patients. New technologies, such as photobiomodulation, could address this problem, for which few effective therapeutic solutions exist. The objective of this study was to describe the characteristics of patients seeking treatment and to observe the effects of photobiomodulation. This is a prospective cohort of patients treated for cancer, in failure of first-line medical treatment, managed at the University Hospital of Nîmes. The history, symptoms and impact of the disorders on their quality of life were collected. At follow-up, improvement was assessed using the PGI-I and FSFI questionnaires. Twenty-eight patients were treated. They were all menopausal, half of them after anticancer treatments [chemotherapy (78%), radiotherapy (36%), hormone therapy (36%)]. The main symptom reported was vaginal dryness (72%). Seventy-one percent of patients (n=20) felt that their daily life was affected≥8/10. All patients had sexual dysfunction. Twenty-two patients received at least 6 sessions of photobiomodulation. Seventy-two percent (n=18) of patients felt better or much better after treatment (PGI-I≤2). The median improvement estimated by the patients was 65% (Q1=50%; Q3=72.5%). There was also a significant clinical improvement. No serious adverse events were reported. Due to the small number of patients in a heterogeneous population with no control group, we cannot extrapolate our results. However, the objective was to assess the status of these pathologies and the contribution of photobiomodulation in patients who have failed first-line treatment; and these results are encouraging.

Trans-labial or introital ultrasounds for midurethral slings

Stress urinary incontinence is common in adult women. The use of introital or trans-labial ultrasound can help the surgeon (urologist or gynecologist) to better assess the type of incontinence the patient presents in order to guide him in the management of the patient. Often, surgical treatment with a mid-urethral sling (MSU) placement can be chosen in case of failure of non-invasive therapies (such as local estrogen or physical therapy) and if the clinical examination shows an urethral hypermobility. The use of ultrasound can help in this choice. Although rare, complications of MSU can sometimes cause disabling symptoms and be difficult to diagnose. Introital or trans-labial ltrasound can help diagnose them. The objective of this work was to describe the realization of ultrasound of stress urinary incontinence before or after the placement of a MSU, in order to make their realization easier for young surgeons which can use them in current practice.

Functional and sexual outcomes following surgical vaginal introital reduction

OBJECTIVE

Surgical introital reduction procedures are commonly performed for the treatment of vaginal laxity (VL), yet poorly studied. The aim of this study was to assess clinical outcomes following surgical vaginal introital reduction for VL.

METHODS

This was an ambidirectional cohort study conducted in a single urogynecology center. All sexually active women who had vaginal introital surgical reduction for VL between March 2015 and September 2020 were included in this study. VL was defined as a genital hiatus distance ≥4cm according to the POP-Q classification, associated with symptoms of laxity. The primary endpoint was sexual health assessed by the Pelvi-Perineal Surgery Sexuality Questionnaire (PPSSQ), while the secondary endpoints included postoperative pain, perioperative complications, rate of dyspareunia, patient satisfaction and success rate based on the Patient Global Improvement Index (PGI-I) and Vaginal Laxity Questionnaire (VLQ).

RESULTS

Of the 27 patients sent the questionnaires, 23 sexually active patients returned the completed ones and were included in the study. Participants had a mean age and BMI of 41 years (range 24-74) and 21.3 (range 17.6-31.9) respectively. The most prevalent preoperative symptom was feeling of VL in 82.6% followed by bulging sensation in 47.8%. Preoperative dyspareunia was reported in 8/23 (34.8%). Surgical interventions involved perineorrhaphy with (n=14) or without (n=9) levator ani plication. The PPSSQ mean sexual health score was 86.7/100 (SD 5.8; range 16.7-93.3) and the mean discomfort and pain score was 27.5/100 (SD 26.0; range 0-80). Postoperative sexuality was reported to better, identical or worse in 16 (69.6%), 2 (8.7%) and 5 (21.7%) patients respectively. On PGI-I, patients reported feeling much better, better, slightly better and no change in 10 (43.5%), 5 (21.7%), 5 (21.7%) and 3 (13.0%) respectively. None of the women reported feeling worse. The overall post-operative complication rate was 3/23 (13.0%), including a perineal hematoma, and two cases of reoperation for narrow introitus. De novo dyspareunia was reported by 11/18 (61.1%) patients, occurring often or more in 4/18 (22.2%) patients, due to narrow introitus (n=2), enlarge introitus (n=1) and vaginal dryness (n=1).

CONCLUSION

Vaginal introital reduction surgery is a viable treatment option for symptoms of vaginal laxity after failure of conservative measures. However, patients should be made aware of the risk of de novo dyspareunia.

LEVEL OF EVIDENCE: 4

[Mirror survey of patients with urge urinary incontinence and healthcare professionals]

BACKGROUND

This survey assessed how much of a taboo surrounds urge or mixed urinary incontinence (UI), through questions to affected patients and healthcare professionals using online questionnaires, with the objective to contrast the patients' perceptions with that of the doctors.

METHODS

This quantitative study was preceded by a qualitative phase carried out with general practitioners, specialists, and UI patients. Following these phases, questionnaires were made available on the internet. They covered questions pertaining to perceptions of UI, degree of embarrassment and its consequences, patient-doctor relationship, and treatments.

RESULTS

Overall, 310 UI patients of male or female gender participated in the study, as did 101 general practitioners, 50 urologists, and 30 gynecologists. The analysis revealed that 60% of patients felt embarrassment about UI, the condition representing for them a taboo topic similar to cancer. This taboo was shown to be seen further enhanced by doctors. UI was associated with a loss of self-esteem (51%) and restriction to daily life (44%). The patients' answers revealed that UI was only brought up by doctors in 6% of cases, whereas the patient was the first to bring it up in 55%, primarily with their general practitioner (80%). Thus, in 4 out of 10 cases, the issue was not addressed; 49% of patients stated they did not discuss their condition with their partner and 33% did not discuss it with anybody.

CONCLUSION

UI is still a major taboo and we have a long way to go to change attitudes.

LEVEL OF EVIDENCE

3.

Prospective ultrasonographic follow-up of transvaginal lightweight meshes: a 1-year multicenter study

INTRODUCTION AND HYPOTHESIS

The use of new lightweight meshes in pelvic organ prolapse (POP) surgery may reduce complications related to mesh retraction (chronic pain, dyspareunia, and mesh exposure). The aim of this study was to investigate changes in the area and position of Uphold Lite™ mesh 6 weeks and 12 months after anterior and/or apical prolapse repair.

METHODS

This observational prospective multicenter study included patients who had undergone transvaginal surgery for symptomatic POP-Q stage ≥ II anterior and/or apical compartment prolapse with placement of Uphold Lite mesh. The dimensions and position of the mesh were evaluated at 6 weeks and 12 months by ultrasonography. Correlations between ultrasonographic mesh characteristics and POP recurrence were analyzed.

RESULTS

Fifty evaluable women with an average age of 66.8 years were included. No statistically significant difference in mesh area was found between week 6 and month 12 postoperatively, either at rest (1746.92 vs. 1574.48 mm²; p = 0.15) or on Valsalva (1568.81 vs. 1542.98 mm²; p = 0.65). The ROC-AUC of the distance between the mesh and the bladder neck (M-BN) at 6 weeks for predicting cystocele recurrence at 12 months was 0.764 (95% CI 0.573-0.955) at rest and 0.724 (95% CI 0.533-0.916) on Valsalva. An M-BN distance > 12.5 mm could predict cystocele recurrence at month 12 with a sensitivity of 80% and a specificity of 69%.

CONCLUSIONS

Ultrasonographic measurements of the Uphold Lite™ mesh appear to remain stable between 6 weeks and 12 months postoperatively. M-BN distance correlates with cystocele recurrence. These results appear to confirm the value of ultrasound in mesh evaluation.

Stress urinary incontinence after transvaginal mesh surgery for anterior and apical prolapse: preoperative risk factors

INTRODUCTION AND HYPOTHESIS

Debate persists over whether surgery to correct pelvic organ prolapse (POP) should be combined with midurethral sling (MUS) insertion. The aim of this study was to evaluate the incidence of stress urinary incontinence (SUI) up to 12 months after transvaginal mesh surgery, with or without MUS, and to identify risk factors for postoperative SUI.

METHODS

This retrospective single-center study included patients who underwent transvaginal mesh surgery with Uphold™ between October 2010 and December 2017. The primary outcome was the prevalence of SUI at 12 months postoperatively. Univariate and multivariate logistic regression was used to identify risks factors for postoperative SUI.

RESULTS

Of the 308 women included, 123 (40%) were continent (no SUI), 108 (35%) had SUI, and 76 (25%) had occult SUI. Forty-nine patients (15.9%) had a concomitant MUS procedure. At 12 months after surgery, 35.9% of patients without concomitant MUS had SUI vs 14.3% with (p = 0.003). Thirty-five patients (29%) developed de novo SUI. Postoperative complications were more common in patients with concomitant MUS (30.6% vs 17%; p = 0.003). The best predictor of postoperative SUI was the presence of preoperative SUI (OR 2.52 (1.25-5.09). Concomitant MUS (p < 0.001), and prior POP surgery (p = 0.034) were protective factors for postoperative SUI.

CONCLUSION

Preoperative SUI is the most important risk factor for postoperative SUI. However, given the higher risk of postoperative complications with concomitant MUS and the acceptable rate of de novo SUI rate without it, two-stage surgery seems preferable for patients with preoperative SUI.

[Use of botulinum toxin A in pelvic floor dysfunctions in the elderly: A review]

INTRODUCTION

The present article is the final report of a multi-disciplinary meeting supported by the GRAPPPA (group for research applied to pelvic floor dysfunctions in the elderly). The objective was to conduct a comprehensive review on the role of botulinum toxin A (BonTA) in the treatment of pelvic floor dysfunctions in the elderly.

METHODS

The present article, written as a comprehensive review of the literature, combines data issued from the scientific literature with expert's opinions. Review of the literature was performed using the online bibliographic database MedLine (National Library of Medicine). Regarding intra-detrusor BonTA injections, only articles focusing on elderly patients (>65 yo) were included. Regarding other localizations, given the limited number of data, all articles reporting outcomes of BonTA were included, regardless of studies population age. In case of missing or insufficient data, expert's opinions were formulated.

RESULTS

Although, available data are lacking in this specific population, it appears that BonTA could be used in the non-fraily elderly patients to treat overactive bladder or even neurogenic detrusor overactivity, with a success rate comparable to younger population at 3 months (88.9% vs. 91.2%), 6 months (49.4% vs. 52.1%) and 12 months (23.1% vs. 22.3%), as well as a significant decrease in number of voids per day (11.4 vs. 5.29 P<0.001) and in the number of pads per day (4.0 vs. 1.3, P<0.01). Furthermore, BonTA is likely to be offered in the future as a treatment of fecal incontinence and obstructed defecation syndrome symptoms. Concerning bladder outlet obstruction/voiding dysfunction symptoms, intra-urethral sphincter BonTA should not be recommended.

CONCLUSION

BonTA injections are of interest in the management of various pelvic floor dysfunctions in the elderly, and its various applications should be better evaluated in this specific population in order to further determine its safety and efficacy.

[Antibiotic prophylaxis in urodynamics: Clinical practice guidelines using a formal consensus method]

OBJECTIVE

The aim of this work was to issue clinical practice guidelines on antibiotic prophylaxis in urodynamics (urodynamic studies, UDS).

MATERIALS AND METHODS

Clinical practice guidelines were provided using a formal consensus method. Guidelines proposals were drew up by a multidisciplinary experts group (pilot group = steering group), then rated by a panel of 12 experts (rating group) using a formal consensus method, and then peer reviewed by a reviewing/reading group of experts (different from the rating group).

RESULTS

Urine (bacterial) culture with antimicrobial susceptibility testing is recommended for all patients before UDS (strong agreement). In patients with no neurologic disease, the risk factors for tract urinary infection (UTI) after UDS are age > 70 years, recurrent UTI, and post-void residual volume > 100ml. In patients with neurologic disease, the risk factors for UTI after UDS are recurrent UTI, vesicoureteral reflux, and intermicturition pressure > 40cmH₂O. If the urine culture is negative before UDS and there is no risk factor for UTI, antibiotic prophylaxis is not recommended (Strong agreement). If the urine culture is negative before UDS, but there are one or more risk factors for UTI, antibiotic prophylaxis is optional. If antibiotic prophylaxis is initiated, a single oral dose (3g) of fosfomycin-tromethamine two hours before UDS is recommended (Strong agreement). If there is bacterial colonization on UCB before UDS, antibiotic therapy is optional (Undecided). If prescribed, it should be adapted to the antimicrobial susceptibility of the identified bacterium or bacteria, started the day before and stopped after UDS (except for fosfomycin-tromethamine: a single dose the day before UDS is necessary and sufficient) (Strong agreement). In the event of UTI before UDS, the UTI should be treated and UDS postponed (Strong agreement). The proposed recommendations should not be changed for patients with a hip or knee replacement (Strong agreement). No antibiotic prophylaxis of bacterial endocarditis is necessary, including in high-risk patients with valvular heart disease (Strong agreement).

CONCLUSION

These new guidelines should help to harmonize clinical practice and limit exposure to antibiotics.

LEVEL OF EVIDENCE

4.

An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for the assessment of sexual health of women with pelvic floor dysfunction

AIMS

The terminology in current use for sexual function and dysfunction in women with pelvic floor disorders lacks uniformity, which leads to uncertainty, confusion, and unintended ambiguity. The terminology for the sexual health of women with pelvic floor dysfunction needs to be collated in a clinically-based consensus report.

METHODS

This report combines the input of members of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA), and the International Continence Society (ICS), assisted at intervals by many external referees. Internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus). Importantly, this report is not meant to replace, but rather complement current terminology used in other fields for female sexual health and to clarify terms specific to women with pelvic floor dysfunction.

RESULTS

A clinically based terminology report for sexual health in women with pelvic floor dysfunction encompassing over 100 separate definitions, has been developed. Key aims have been to make the terminology interpretable by practitioners, trainees, and researchers in female pelvic floor dysfunction. Interval review (5-10 years) is anticipated to keep the document updated and as widely acceptable as possible.

CONCLUSION

A consensus-based terminology report for female sexual health in women with pelvic floor dysfunction has been produced aimed at being a significant aid to clinical practice and a stimulus for research.

[Could we perform vaginal mesh surgery for treatment of pelvic organ prolapse in elderly women?]

INTRODUCTION

Prevalence of pelvic organ prolapse will increase with the aging of the population. Concerning the treatment of pelvic organ prolapse, transvaginal route is often preferred for elderly women. However few data are available concerning transvaginal mesh surgery in this population. The aim of this study was to compare efficiency and complications of transvaginal mesh surgery between women aged over 75 and younger women.

MATERIALS AND METHODS

A monocentric, retrospective study included all women who underwent anterior sacrospinous suspension with mesh for treatment of pelvic organ prolapse. The primary endpoint was anatomical success at the last follow-up, defined by a pelvic organ prolapse stage 0 or 1 of POP-Q classification. The secondary endpoints were rate of complications and urinary, colorectal and sexual functional results.

RESULTS

We included 329 patients, 69 were under 75 years old and 260 were aged over 75. The median of follow-up was 12 months (IQR: 6). The rate of anatomical success was significantly higher in patients aged over 75: 92% versus 85% in younger patients (P=0.02). However this difference was no more significant in multivariate analysis after inclusion of confusions factors (P=0.82). The rate of perioperative complications was low and similar in the 2 groups even in multivariate analysis.

CONCLUSION

Utero-vaginal suspension using bilateral vaginal anterior sacrospinous fixation with mesh seems to achieve at least similar results between women aged more than 75 years and younger women. There is no excess risk of complications in elderly women.

LEVEL OF EVIDENCE

4.

Synthetic mesh repair of an anterior perineal hernia following robotic radical urethrocystectomy

Introduction:

Perineal hernia is a protrusion of intra-abdominal viscera through a defect in the pelvic floor and is a rare but challenging complication after extensive abdominoperineal surgery. There have been small series published after colorectal exenteration, but no cases have been reported after radical cystectomy and urethrectomy.

Case Presentation:

A 68 years old woman developed an anterior perineal hernia, with no vaginal prolapse, after an anterior exenteration for bladder cancer. A perineal approach with the use of a synthetic polypropylene mesh was chosen to resolve the condition. After 6 months of follow-up, the patient has no symptoms or recurrence of the anterior perineal hernia.

Conclusion:

To our knowledge, this case is the first report of perineal hernia after radical urethrocystectomy. Although being a case report, this article describes a potential and challenging complication after extensive anterior pelvic surgery, that could increase its incidence in the future. Literature review shows that whether perineal, abdominal or combined approach is chosen, surgery must respect hernia repair principles.

Long-term efficacy and safety of tension free vaginal tape in a historic cohort of 463 women with stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

We report retrospective data on the long-term safety and efficacy of the retropubic midurethral sling (MUS) in a large series of women with stress urinary incontinence.

METHODS

In all, 517 patients were treated during the period January 2005 to June 2012 at a single centre in France. The Urinary Symptoms Profile score was used to identify women who were subjectively cured or improved or in whom treatment had failed. The rates of peroperative, and early (<30 days) and late postoperative complications were recorded.

RESULTS

A total of 463 patients were evaluable at a mean (±SD) follow-up of 71 ± 23 months. At the last follow-up, 344 patients (74.3 %) demonstrated subjective cure, 55 (11.9 %) were improved and 64 (13.8 %) had treatment failure. Bladder perforations occurred in 33 patients (7.1 %); however, this had no effect on cure rate. In the early postoperative period, temporary intermittent self-catheterization was required in 10 patients (2.2 %) due to voiding difficulties. The most frequent long-term postoperative complication was de novo urge incontinence that was reported by 59 patients (12.7 %); seven patients (1.5 %) needed tape excision due to voiding difficulties and six (1.3 %) needed tape removal due to erosion or chronic pain.

CONCLUSIONS

The retropubic MUS was shown to be durable at a mean follow-up of 71 ± 23 months, with a high success/improvement rate and no serious long-term tape-induced adverse effects.

[Prevalence and initial management of overactive bladder in France: A cross-sectional study]

AIMS

To determine the prevalence of overactive bladder (OAB) syndrome in France and gather data about initial patient trajectories in the healthcare system.

METHODS

A dedicated questionnaire (41 questions) has been sent to a 12,000 sample of people representative of the global population. The following data were investigated: social and demographic features, medical history, Urinary Symptom Profile questionnaire, bother, history of symptoms, care seeking and treatments received. Patient were considered having OAB in case if presenting at least two episodes of urgency per week, or being under treatment of OAB. OAB prevalence was the main outcome, and associated factors were characterized by univariate and multivariate analysis.

RESULTS

Based on 8842 available questionnaires, the global prevalence of OAB was estimated to be 14.4%. Prevalence was significantly higher in women, older age groups, as well as obesity, irritable bowel syndrome, urinary tract infections, enuresia, constipation, anxiety/depression, neurological diseases, sleep apnea syndrome, asthma, chronic obstructive pulmonary disease, diabetes and hypertension. Only 34.6% of patients with OAB had visited a health practitioner for this problem. General practitioners were most frequently implicated in patient primary care and evaluation. Seventy-two percent of patients with OAB had had additional investigations (mostly a urine culture) and only 6% of patients had to complete a bladder diary. The most frequent treatment option was oral antimuscarinics. Physical therapy and rehabilitation have been prescribed in 26% of cases, as well as dietary advice.

CONCLUSIONS

OAB is a frequent syndrome. Its prevalence increases with age, and OAB frequently concern elderly frail people with many other associated diseases.

LEVEL OF EVIDENCE

3.

Utero-vaginal suspension using bilateral vaginal anterior sacrospinous fixation with mesh: intermediate results of a cohort study

INTRODUCTION AND HYPOTHESIS

Pelvic organ prolapse is a major burden for the public health system, affecting up to 30 % of all women. One mesh kit has been introduced for pelvic organ prolapse surgery that can be inserted via a single anterior incision with the mesh arms driven through the sacrospinous ligament in a tension-free manner. The aim of this study was to describe the medium-term results of this vaginal mesh kit procedure for the combined treatment of the anterior vaginal wall and vault prolapse.

METHODS

This is a longitudinal case series of patients undergoing an anterior mesh operation between 2009 and 2013. All patients presenting with symptomatic stage II prolapse or higher were included when a minimum follow-up of 12 months was achieved. A structured interview and clinical examination were performed pre- and postoperatively.

RESULTS

One hundred and eighteen consecutive patients were operated with the Uphold® system during the study period. Three patients did not complete the 12-month follow-up and were excluded from the analysis, leaving 115 patients. Anatomical success at a mean follow-up of 23 months was 93 %, with a patient satisfaction rate of 95 %. Four patients (8 %) experienced de novo dyspareunia related to the mesh. The reoperation rate for mesh-related complications was 3.4 %; no patients were re-operated for POP recurrence.

CONCLUSIONS

The subjective and objective cure rates were high and the mesh-related re-operation rate was 3 % in the medium term, suggesting that this surgical technique may be an option for women requiring anterior and apical prolapse repair.

[Idiopathic overactive bladder and BOTOX(®): Literature review]

AIM

Systematically review literature on the efficacy and tolerability of botulinum toxin A (onabotulinumtoxineA, BOTOX(®), Allergan, CA, USA) in refractory idiopathic overactive bladder (iOAB) METHODS: Pubmed search on the efficacy, toxicity and adverse events of onabotulinumtoxinA in clinical trials only with level 1 and 2 evidence.

RESULTS

Eleven controlled randomised trials have been selected, of which 3 phase III trials. The studies published data of 1008 patients with refractory iOAB treated with onabotulinumtoxineA. In the phase II and III trials, doses from 50 U to 300 U have been evaluated; more than half of the patients (n = 676) with 100 U. In the 2 main phase III trials, onabotulinumtoxinA has demonstrated to be more efficient compared to placebo on continence, symptoms and quality of live (QoL). Urodynamic results, reported in the phase II trials, demonstrated higher changes compared to placebo only from dose 100 U on, although not always significant. Adverse events (urinary retention, dysuria, urinary tract infection) were easily treated and did not influence patient's QoL.

CONCLUSION

Intradetrusor injections of onabotulinumtoxinA (BOTOX(®)), a minimally-invasive procedure, seem to be efficient and well tolerated in the treatment of refractory iOAB.

[Evaluation of urine postvoid residuals in post-partum period: a prospective and descriptive clinical study]

INTRODUCTION

Few studies have evaluated urine postvoid residuals (PVRs) and their risk factors during the post-partum (PP) period. The aim of this prospective study was to screen postvoid residuals in a cohort of patients in PP, and to identify the risk factors.

MATERIALS AND METHODS

For three months, patients in PP were given an evaluation of their PVR (ultrasounds method) after a spontaneous urination. Clinical data as regards delivery were collected.

RESULTS

One hundred and sixty-eight patients were included. Among them, 61% had a urine volume at the first urination over 500 mL, and 52% presented with a pathological PVR (PVR over 150 mL for a urine volume over 150 mL). The median PVR was 153.50 mL. The median volume of the first spontaneous urination was 400 mL. Among patients with a pathological PVR, the total duration of the labor and the duration of its second phase were significantly longer (P=0.003 and P<0.05, respectively), and the volume of the first urination was higher. Indwelling catheterization during the delivery decreased the volume of the first spontaneous urination (volume over 500 mL in 28% vs 72% of patients, P=0.017) but was not associated with a decreased PVR in non-pathological deliveries. Instrumental deliveries were associated with higher PVRs than caesarean or physiological deliveries (244 mL, 180 mL et 156 mL; P=0.033). A bacteriuria was not significantly associated with PVR (54% vs 49%, P>0.05).

CONCLUSION

We were able to identify risk factors for PVR in the PP, such as the duration of labor, instrumental delivery and elevated volume of the first urination after delivery.

[Intra-detrusor injection of botulinum toxin for female refractory idiopathic overactive bladder syndrome]

INTRODUCTION

Botulinum toxin-A detrusor injections are now approved for use (extension of marketing authorization) in the management of refractory idiopathic overactive bladder. The goal of the current study was to study the value and efficacy of this therapy.

PATIENTS AND METHODS

A literature review was performed on Medline, Embase and Cochrane databases, using the following keywords: botulinum toxin; overactive bladder syndrome; urinary incontinence; detrusor injection.

RESULTS

The recommended first step dose is 50 units of BOTOX(©) (dose selected for tolerance assessment). However, the cure rates for urge incontinence are greater with 100 units. Before proposing an injection, it is recommended to ensure the feasibility and acceptability of self-catheterisation by the patient, because of the risk of urinary retention (6%). The administration of BOTOX(©) comprises an intra-detrusor injection using a cystoscope, performed under local anesthesia. Clinical improvement is generally observed in the first two weeks after the injection. Patients should be considered for reinjection when the clinical effect of the previous injection has diminished, approximately 6-9 months after the first injection. An injection of 100 units may be considered when the clinical benefit of the 50-unit injection is not satisfactory concerning incontinence symptoms.

CONCLUSION

Botulinum toxin detrusor injections may be offered to women who develop refractory OAB.

[Surgical site infections in vaginal prolapse surgery]

INTRODUCTION

Vaginal prolapse surgery is at high risk of surgical site infections (SSI) because it's a "clean-contaminated surgery" and it's frequently associated with implantation of meshes.

OBJECTIVES

To evaluate the rate of SSI and associated risk factors in vaginal prolapse surgery with mesh support.

METHODS

In a retrospective unicenter study, two groups of patients were operated by vaginal route for a pelvic floor reconstructive surgery with mesh support. Colporraphy was made by classic surgical sutures non-coated (Monosyn(®) 3/0, B-Braun) in the first group, and surgical sutures coated with triclosan in the second group. We collected risk factors of SSIs using the procedure of the CCLIN and analyzed the occurrence of SSIs with a statistical comparative univariate analysis.

RESULTS

Study included 78 patients in the first group and 72 in the second group. SSIs total rate was 2.6 % (4 of 150), as part of 3 in the group with surgical sutures non-coated and one in the group with surgical sutures coated with triclosan (P=0.62).

CONCLUSION

In our study, SSIs rate in vaginal prolapse surgery was twice higher than classic gynecologic surgery. As the interest of using a surgical suture coated with triclosan to reduce SSI has not been demonstrated statistically, we can't recommend it.

Total transvaginal mesh (TVM) technique for treatment of pelvic organ prolapse: a 5-year prospective follow-up study

INTRODUCTION AND HYPOTHESIS

To evaluate clinical effectiveness and complication rates at 5 years following the total Trans Vaginal Mesh (TVM) technique to treat pelvic organ prolapse.

METHODS

Prospective, observational, multi-centre study in patients with prolapse of stage II or higher.

RESULTS

Of the 90 women enrolled in the study, 82 (91%) were available for the 5-year follow-up period. At the 5-year endpoint, success, defined as no surgical prolapse reintervention and leading edge <-1 (International Continence Society [ICS] criteria) or above the level of the hymen, was 79% and 87% respectively. A composite criterion of success defined as: leading edge above the hymen (<0) and no bulge symptoms and no reintervention for prolapse was met by 90%, 88% and 84% at the 1-, 3-, and 5-year endpoints respectively. Quality of life improvement was sustained over the 5 years. Over the 5-year follow-up period, a total of only 4 patients (5%) required re-intervention for prolapse, while a total of 14 patients (16%) experienced mesh exposure for which 8 resections needed to be performed. Seven exposures were still ongoing at the 5-year endpoint, all asymptomatic. Only 33 out of 61 (54%) sexually active patients at baseline remained so at 5 years. De novo dyspareunia was reported by 10%, but no new cases at the 5-year endpoint. One patient reported de novo unprovoked mild pelvic pain at 5 years, 5 reported pains during pelvic examination only.

CONCLUSIONS

Five-year results indicated that TVM provided a stable anatomical repair. Improvements in QOL and associated improvements in prolapse-specific symptoms were sustained. Minimal new morbidity emerged between the 1- and 5-year follow-up.

Voiding difficulties after vaginal mesh cystocele repair: does the perivesical dissection matter?

INTRODUCTION AND HYPOTHESIS

Our purpose was to verify whether extensive dissection toward the sacrospinous ligament (SSL) needed for mesh fixation during anterior compartment repair increases the risk of postoperative voiding difficulties.

METHODS

A total of 124 patients after anterior compartment mesh repair without simultaneous suburethral sling placement operated on in the period 2005-2012 were enrolled in this retrospective observational study. Patients with previous anti-incontinence surgery with normal urodynamics were not excluded; 30 patients with incomplete data, severe perioperative complications, and urinary retention before and after the surgery were excluded. Urinary retention was defined as post-void residual over 150 ml more than 48 h after permanent catheter removal. The rate of urinary retention after anterior compartment repair by mesh anchored to the SSL from an anterior approach (SSLS group) was compared to that following transobturator mesh repair often combined with SSL fixation from the posterior approach (TOT group).

RESULTS

Of the 94 patients considered for statistical analysis, 62 were from the SLSS group and 32 from the TOT group. The groups were comparable in age (mean 65.5 vs 66.3), body mass index (24.8 vs 25.9), and parity (2.4 vs 2.9). Patients from the SSLS group had higher rates of prior vaginal reconstructive (27 vs 19 %) and anti-incontinence surgery (26 vs 19 %). Postoperative urinary retention was statistically significantly more frequent in the SSLS group compared to the TOT group [(17 (27 %) vs 2 (6.25 %), odds ratio 5.7, 95 % confidence interval 1.2-26.3, p = 0.027]. Hospital discharge with self-catheterization was statistically insignificantly more frequent in the SSLS group [8 % (5) vs 3 % (1)].

CONCLUSIONS

Extensive dissection needed for SSL suspension from an anterior approach may lead to more frequent postoperative voiding difficulties. This phenomenon could be explained by more considerable injury to pelvic splanchnic nerves during the dissection. A large prospective study is needed for validation of our results.

[Utero-vaginal suspension using a bilateral vaginal anterior sacrospinous fixation with mesh. Preliminary results]

OBJECTIVE

To assess anatomical and functional preliminary results, and safety of a new surgical approach for a combined treatment of pelvic organ prolapse (POP) of anterior and medium compartments, using a mesh attached through the sacrospinous ligaments with the UpHold(®) system (Boston Scientific) and the Capio(®).

MATERIAL AND METHODS

A longitudinal case series of 59 consecutive patients operated between October 2009 and January 2012, by five senior surgeons in a single tertiary unit.

RESULTS

Mean age was 66.9 years. Ten patients (17%) had previous pelvic organ prolapse (POP) surgery. There was no intraoperative complication. Mean follow-up was 12 months. Anatomical success for both anterior and apical compartments, i.e. Ba and C/D point<1, was 93% (52/56). Anatomical results shown correction of cystocele with a mean Ba point from+0.79 cm (range -3 to +8) to -2.35 cm (range -3 to 0), correction of uterine/vaul prolapse with a mean C/D point from+0.14 cm (range -6 to+8) to -7.29 cm (range -9 to -1), and correction of rectocele with a mean Bp point from -0.68 cm (range -3 to 7) to -2.77 cm (range -3 to -1). Two patients required further surgery for mesh exposure (3.5%). One patient had a unilateral pudendal neuropathic pain postoperatively.

CONCLUSION

In the current series, utero-vaginal suspension using a bilateral vaginal anterior sacrospinous fixation with mesh was associated with good anatomical success rates. Prospective, comparative and long-term data are needed.

[Management of neurogenic bladder patients in France: a survey carried out by the French-speaking neurourology study group (GENULF)]

OBJECTIVE

To design and run a survey aiming at investigating urologists' and physiatrists' clinical practices in France when managing neurogenic bladder patients.

PATIENTS AND METHODS

Three thousand one hundred and eighty questionnaires were sent to the members of four French societies involved in treating neurogenic bladder dysfunction. Questions were focused on consultations, clinical follow-up and patient management.

RESULTS

Two hundred and seventy-four urologists and 109 physiatrists completed the questionnaire. The frequency of systematic follow-up differed between urologists (6 months) and physiatrists (12 months). Upper urinary tract imaging and systematic urodynamic follow-up were usually performed yearly. The latter was carried out by 56% urologists and 83% physiatrists. Urinary retention was essentially treated by intermittent catheterization. Less than 15% of urologists and physiatrists were treating bacteriuria. Symptomatic urinary infections were treated for 11 to 12 days (men) and for 8 to 9 days (women). To treat their patients, both specialists used self-catheterization education and botulinum toxin A injections.

CONCLUSION

Our survey showed differences in approach between urologists and physiatrists in the management of patients with neurogenic bladder dysfunction. Their clinical practice was most of the time in line with national and international guidelines.

An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint terminology and classification of the complications related directly to the insertion of prostheses (meshes, implants, tapes) and grafts in female pelvic floor surgery

INTRODUCTION AND HYPOTHESIS

A terminology and standardized classification has yet to be developed for those complications arising directly from the insertion of synthetic (prostheses) and biological (grafts) materials in female pelvic floor surgery.

METHODS

This report on the above terminology and classification combines the input of members of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS) and a Joint IUGA/ICS Working Group on Complications Terminology, assisted at intervals by many expert external referees. An extensive process of 11 rounds of internal and external review took place with exhaustive examination of each aspect of the terminology and classification. Decision-making was by collective opinion (consensus).

RESULTS

A terminology and classification of complications related directly to the insertion of prostheses and grafts in female pelvic floor surgery has been developed, with the classification based on category (C), time (T) and site (S) classes and divisions, that should encompass all conceivable scenarios for describing insertion complications and healing abnormalities. The CTS code for each complication, involving three (or four) letters and three numerals, is likely to be very suitable for any surgical audit or registry, particularly one that is procedure-specific. Users of the classification have been assisted by case examples, colour charts and online aids (www.icsoffice.org/complication).

CONCLUSION

A consensus-based terminology and classification report for prosthesis and grafts complications in female pelvic floor surgery has been produced, aimed at being a significant aid to clinical practice and research.