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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Autologous platelet rich plasma (A-PRP) combined with pelvic floor muscle training for the treatment of female stress urinary incontinence (SUI): A randomized control clinical trial

IMPORTANCE

Autologous platelet-rich plasma (A-PRP) injection is a novel intervention for stress urinary incontinence (SUI) in women. However, no Phase II clinical trial has compared the outcomes of A-PRP injection combined with pelvic floor muscle training (PFMT) with those of PFMT alone in these women.

OBJECTIVE

The primary aim was to compare the efficacy of A-PRP + PFMT versus PFMT alone in women with SUI. The secondary aim was to determine any adverse effects of A-PRP injection.

DESIGN

Randomized clinical trial, single-blind assessment.

SETTING

Urogynecology clinic at a tertiary medical center.

PARTICIPANTS

Women with previously untreated SUI. Women in whom there was any suspicion of urgency, those with an Overactive Bladder Symptoms Score of ≥1, and those with obesity, pelvic organ prolapse, thrombocytopenia, or coagulopathy were excluded.

INTERVENTIONS

Two injections of A-PRP were administered with a 1-month interval between injections in the A-PRP injection + PFMT group. Both groups received PFMT.

MAIN OUTCOMES AND MEASURES

The primary outcome was determined using the 1-h pad weight test (PWT). Secondary outcomes were measured using the Incontinence Quality of Life Questionnaire, item 11 on the International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms questionnaire, Patient Global Impression of Improvement, and the percentage subjective improvement score.

RESULTS

Data for 60 study participants were available for analysis (A-PRP + PFMT group, n = 31; PFMT group, n = 29). The 1-h PWT decreased significantly in the A-PRP + PFMT group but only slightly in the PFMT group at the 5-month follow-up. There was a statistically significant between-group difference in the 1-h pad weight of about 8 g in favor of the A-PRP + PFMT group. A statistically significant difference in symptoms of SUI measured by the questionnaires was found between the A-PRP + PFMT group and the PFMT group at the 2- and 5-month follow-up assessments. There were no reports of adverse events following injection of A-PRP.

CONCLUSIONS AND RELEVANCE

A-PRP + PFMT could be a treatment option for women with SUI. Large Phase III randomized controlled trials are required to confirm our findings.

Comparison of Low-Energy Radiofrequency Thermal Vaginal Therapy with Sham Treatment for Stress Urinary Incontinence in Postmenopausal Women: A Randomized Controlled Trial

Introduction and Hypothesis

Low-energy radiofrequency (RF) thermal vaginal therapy for vaginal laxity and the genitourinary syndrome of menopause denatures collagen fibrils in the endopelvic fascia; fiber tightening during healing may stabilize the urethra and bladder neck, thereby resolving female stress urinary incontinence (SUI), especially in postmenopausal women. This study compared RF vaginal therapy with sham treatment for mild to moderate SUI.

Methods

This double-blinded, randomized controlled trial, conducted at a tertiary center from September 2018 to April 2021, recruited postmenopausal women with mild to moderate degree of SUI who had never undergone surgery, energy-based therapy, or vaginal estrogen treatment. The intervention group received vaginal RF laser treatment; the sham group did not. The primary outcome was the 1-hour pad-weight test (PWT) result. Secondary outcomes were Incontinence Quality of Life (I-QOL), Urogenital Distress Inventory (UDI-6), Incontinence Impact Questionnaire (IIQ-7), Patient Global Impression of Improvement (PGI-I), percentage of improvement among all participants, and adverse events. Data were analyzed using STATA 17.0.

Results

Forty-nine participants randomized to RF (n = 23) and sham (n = 26) groups were eligible for analysis. PWT decreased during follow-up in the RF group but remained stable in the sham group; PWT did not significantly differ between groups. The 1-year post-treatment success rate was higher in the RF group (69.6%) than in the sham group (38.5%). At 1 year post-treatment, there were no statistically significant differences in any secondary outcomes.

Conclusion

Low-energy RF vaginal therapy is an alternative treatment for mild to moderate SUI in postmenopausal women without serious adverse events. Larger randomized controlled trials should be conducted.

Mobile Application Based Pelvic Floor Muscle Training for Treatment of Stress Urinary Incontinence: An Assessor-Blind, Randomized, Controlled Trial

A first-line treatment for stress urinary incontinence (SUI) is pelvic floor muscle training (PFMT) for at least three months. The key problem is that patients do not understand the importance of these exercises and their effectiveness. Mobile health apps offer new possibilities to increase treatment adherence. This study compared a reduction in SUI, exercise adherence, and quality of life in PFMT with animation vs. standard instruction. A prospective, single-blind, randomized control trial was collected. SUI patients were randomized into the application or control groups confirmed using a one-hour pad test. In the intervention group, the PFMT application was applied via mobile phone (PFMT with animations, recording system, and reminder system). The standard exercise protocol was similar in both groups. Additional follow-up was conducted at 4, 8, and 12 weeks. A total of 51 participants were randomized to the application (n = 26) and control groups (n = 25), respectively. At the 12-week follow-up, there was no significant difference between the two groups in terms of SUI cure rate, SUI severity by pad test, and daily SUI episodes from the bladder diary (p-value of 0.695, 0.472, and 0.338, respectively). The mean PFME adherence in the application group was higher than the control group at 8 weeks (66.3 ± 13.6 vs. 52.7 ± 16.6, p = 0.002) and 12 weeks (59.1 ± 13.9 vs. 37.8 ± 11.0, p = 0.001). The application group reported no difference from the conventional PFMT group in terms of improvements in SUI cure rate, symptom severity, and quality of life effects at 12-week follow-up. However, the improvement evaluated by the mean difference in SUI episodes and quality of life effects (ICIQ-UI SF) reported a better outcome in the mobile app group. The PFMT application has been proven to be an effective tool that improves PFMT adherence.

Vesicovaginal Fistulas: Prevalence, Impact, and Management Challenges

Background and Objectives: Vesicovaginal fistulas (VVFs) are an abnormal communication between the vagina and bladder and the most common type of acquired genital fistulas. This review will address the prevalence, impact, and management challenges of VVFs. Materials and Methods: Epidemiologic studies examining VVFs are considered. In addition, publications addressing the treatment of VVFs are reviewed. Results: VVFs in developing countries are often caused by obstructed labor, while most VVFs in developed countries have iatrogenic causes, such as hysterectomy, radiation therapy, and infection. The reported prevalence of VVFs is approximately 1 in 1000 post-hysterectomy patients and 1 in 1000 deliveries. VVFs affect every aspect of quality of life, including physical, mental, social, and sexual aspects. Prevention of VVFs is essential. Early diagnosis is necessary to reduce morbidity. Nutrition, infection control, and malignancy detection are important considerations during evaluation and treatment. Conservative and surgical treatment options are available; however, these approaches should be customized to the individual patient. The success rate of combined conservative and surgical treatments exceeds 90%. Conclusions: VVFs are considered debilitating and devastating. However, they are preventable and treatable; key factors include the avoidance of prolonged labor, careful performance of gynecologic surgery, and early detection.

Prevalence of precancerous gynecological lesions and gynecological cancer in patients undergoing vaginal hysterectomy for pelvic organ prolapse

OBJECTIVES

This retrospective cohort study aimed to determine the prevalence of precancerous or malignant lesions of the cervix and/or endometrium among patients who underwent vaginal hysterectomy.

MATERIALS AND METHODS

Medical record of patients who had been diagnosed with pelvic organ prolapse (POP) and undergone vaginal hysterectomy from January 2009 to September 2018 in tertiary hospital was reviewed. The exclusion criteria included individuals who had previously received a diagnosis of gynecologic precancerous lesions or cancer, had abnormal preoperative findings, presented abnormal cervical cancer screening test results or abnormal results from preoperative endometrial biopsy, and had incomplete operative notes or pathological results.

RESULTS

The electronic medical records of 530 patients were reviewed and included in the analysis. Nine of the 530 patients (1.7%) had precancerous or malignant lesions of the cervix and/or endometrium. The prevalence of atypical endometrial hyperplasia and endometrial carcinoma were 0.19% and 0.57%, respectively. All of the patients with endometrial cancer subsequently underwent complete surgical staging. Precancerous cervical lesions were found in five patients (0.95%): CIN II 0.38% and CIN III 0.57%. No cases of cervical cancer were identified.

CONCLUSIONS

It is possible to detect a minor prevalence of precancerous and malignant lesions following post-operative procedures in POP. The assessment of the elderly through the use of risk-based evaluation merits attention for the purpose of early identification. This study offers valuable insights that can be utilized in preoperative counseling and enhancing the preoperative evaluation process.

The Surgical Management of Large Bladder Calculi and Irreducible Uterine Prolapse: A Case Report and Review of Literature

Bladder calculi are rare in women. We report a case of bladder calculi complicating irreducible uterovaginal prolapse. It provides diagnostic and operative challenges to the management team. A 77-year-old woman presented with irreducible complete uterovaginal prolapse. Bladder stones were appreciated on examination and confirmed with imaging. The patient was managed surgically with transabdominal hysterectomy with bilateral uterosacral colpopexy followed by cystolithotomy. The patient's postoperative course was uncomplicated, and she had an uneventful recovery at her 3-month postoperative visit without a recurrence of prolapse and gained good continence. The presence of bladder calculi should be considered in the setting of irreducible pelvic organ prolapse. The abdominal approach of cystolithotomy with a concomitant hysterectomy and vaginal apical suspension is safe and effective.

Rate of Postoperative Urinary Retention after Anterior Compartment Prolapse Surgery: A Randomized Controlled Trial Comparing Early versus Conventional Transurethral Catheter Removal

BACKGROUND

Pelvic organ prolapse is a common condition of pelvic floor dysfunction in women, especially in adult vaginally parous and elderly women. Because of its anatomy, the anterior compartment has a significant effect on urinary symptoms. Anterior colporrhaphy and colpocleisis are major anterior compartment prolapse-related surgeries. As we know, postoperative urinary retention (POUR) is one of the most common complications following pelvic floor surgery. To prevent this complication, indwelling bladder catheterization is routinely applied. In contrast, to minimize risk of infection and the patient's discomfort, the catheter should be removed as soon as possible. However, there is a lack of clarity regarding the optimal timing for catheter removal. Therefore, the aim of this trial is to compare the rate of POUR after anterior prolapse surgery between early transurethral catheter removal (24 h postoperatively) and our standard practice (on postoperative day 3).

METHODS

We conducted a randomized controlled trial among patients undergoing anterior compartment prolapse surgery between 2020 and 2021 at a university hospital. Women were randomized into two groups. After removal, if the second void residual urine volume exceeded 150 mL, POUR was diagnosed, and intermittent catheterization was performed. The primary outcome was the POUR rate. The secondary outcomes included urinary tract infection, asymptomatic bacteriuria, time to ambulation, time to spontaneous voiding, length of hospitalization, and patient satisfaction. Analysis was performed according to the intention to treat principle. The calculated sample size was 68 patients (34 patients in each group) for a 95% confidence interval, 80% power, 5% probability of type I error, and 10% data loss.

DISCUSSION

This study demonstrated that early catheter removal was comparable in POUR rate to conventional treatment with shorter hospitalization among patients undergoing anterior compartment prolapse surgery. Additionally, we observed no re-hospitalization owing to POUR. Therefore, early transurethral catheter removal is preferable following anterior compartment prolapse-related surgery.

Effects of testosterone treatment on transgender males: A single-institution study

Objectives:

Data regarding gender-affirming hormone therapy in the Asian population are sparse. We aimed to evaluate the efficacy and safety of testosterone therapy in transgender men.

Methods:

A retrospective study chart review was conducted in a single university-based transgender clinic. Transgender men aged >18 years who newly started testosterone therapy during January 2015 to October 2019 were recruited. Physical changes, laboratory results, and adverse events, including cancer, thromboembolism, cardiovascular events, and death after masculinizing hormone therapy, were evaluated.

Results:

A total of 39 transgender men (mean age: 27.8 ± 6.0 years) were included. All individuals were treated with intramuscular testosterone injection with a mean follow-up of 25.2 ± 12.9 months. The most common maintenance regimen was testosterone enanthate 250 mg every 4 weeks. Masculinizing effects developed in all transgender men. There were no changes in body weight, and systolic and diastolic blood pressure. Hematocrit levels were 12% significantly increased from 39.9 ± 3.3% to 48.9 ± 2% (p < 0.001). Ten individuals (25.6%) had hematocrit >50%. Significant changes were found in decreased fasting plasma glucose, increased creatinine, and increased uric acid levels. A non-significantly increased alanine aminotransferase, increased low-density lipoprotein cholesterol, and decreased high-density lipoprotein cholesterol were observed. No thromboembolism, cancer, stroke, or coronary artery disease occurred.

Conclusions:

Gender-affirming hormone therapy is an effective and safe short-term treatment in Thai transgender men. Apart from the standard recommendation, uric acid, plasma glucose, and creatinine level evaluation before and during masculinizing hormone therapy are rational practices. An intramuscular testosterone enanthate 250 mg every 4 weeks is an alternative masculinizing regimen with decent efficacy and safety profile.

Incidence of complete vaginal cuff wound healing at sixth and eighth week after total abdominal hysterectomy

AIM

To assess the incidence and risk factors of complete vaginal cuff wound healing at sixth and eighth week after total abdominal hysterectomy (TAH).

METHODS

A retrospective chart review of women who underwent TAH for benign conditions from January 2015 to December 2015 at Ramathibodi Hospital was conducted. The primary outcome was the incidence of complete vaginal cuff healing at 6 and 8 weeks after operation as determined by complete vaginal mucosal approximation without the presence of suture material or granulation tissue.

RESULTS

The medical records of 235 patients who underwent TAH for benign conditions were reviewed. The incidence of complete vaginal cuff wound healing at 6 and 8 weeks after operation were 189 and 225 cases, respectively (80.4% vs 95.7%, P value <0.001). Forty-six (19.6%) patients had incomplete vaginal cuff healing at 6 weeks after operation. Of those, 33 patients had vaginal cuff granulation. Spontaneous regression of lesions had occurred in 69.7% at 8 weeks. Independent risk factors of delay vaginal cuff healing were the used of electrosurgery for vaginal incision (adjusted odds ratio 13.4, 95% confidence interval 2.63-67.74) and suturing cuff with continuous technique (adjusted odds ratio 9.1, 95% confidence interval 2.12-39.01).

CONCLUSION

The incidence of complete vaginal cuff wound healing was significantly higher at 8 weeks than at 6 weeks after TAH for benign conditions. Therefore, 8 weeks after operation would be an appropriate time for the first vaginal cuff examination.

Quality of life following vaginal reconstructive versus obliterative surgery for treating advanced pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

Although colpocleisis is effective in selected women, the low-morbidity obliterative procedure for treating pelvic organ prolapse (POP) and its impact on postoperative quality of life (QOL) have rarely been studied. Our aim was to assess QOL in women after colpocleisis and compare it with that of women after reconstructive vaginal surgery.

METHODS

This retrospective cohort study included women (aged 35-85 years) with POP who underwent obliterative or reconstructive surgical correction during 2009-2015. Patients who met the inclusion criteria underwent telephone interviews that included the validated Prolapse QOL questionnaire (P-QOL Thai).

RESULTS

Of 295 potential participants, 197 (67%) completed the questionnaire: 93 (47%) with obliterative and 104 (53%) with reconstructive surgery. Most were Thai (95.4%), multiparous (87%), and sexually inactive (76%). Their histories included hysterectomy (12%), incontinence or prolapse surgery (11%), and POP stage 3/4 (77%). Patients undergoing obliterative surgery were significantly older than those undergoing a reconstructive procedure (69 vs 58 years, P < 0.05). The obliterative group had more children, less education, and more advanced POP. There were no significant differences in operative parameters or complications. The obliterative surgery group had a significantly shorter hospital stay: median 2 (range 1-17) days vs 3 (1-20) days (P = 0.016). P-QOL scale revealed significantly less postoperative impairment in the obliterative surgery group (1.75 vs 5.26, P = 0.023). There were no significant differences in other P-QOL domains.

CONCLUSIONS

Colpocleisis improves condition-specific QOL in selected patients with advanced POP and remains an option for this group. Surgeons should consider counseling elderly women with advanced POP about obliterative vaginal surgery.

Exploring Legal Restrictions, Regulatory Reform, and Geographic Disparities in Abortion Access in Thailand

Despite decades of advocacy among Thai governmental and nongovernmental actors to remove abortion from the country's 1957 Criminal Code, this medically necessary service remains significantly legally restricted. In 2005, in the most recent regulatory reform to date, the Thai Medical Council established regulatory measures to allow a degree of physician interpretation within the confines of the existing law. Drawing on findings from a review of institutional policies and legislative materials, key informant interviews, and informal discussions with health service providers, government representatives, and nonprofit stakeholders, this article explores how legal reforms and health policies have shaped the abortion landscape in Thailand and influenced geographic disparities in availability and accessibility. Notwithstanding a strong medical community and the recent introduction of mifepristone for medication abortion (also known as medical abortion), the narrow interpretation of the regulatory criteria by physicians further entrenches these disparities. This article examines the causes of subnational disparities, focusing on the northern provinces and the western periphery of Thailand, and explores strategies to improve access to abortion in this legally restricted setting.

Indications and Complications Associated with the Removal of 506 Pieces of Vaginal Mesh Used in Pelvic Floor Reconstruction: A Multicenter Study

STUDY OBJECTIVE

Synthetic mesh utilized to treat stress urinary incontinence (SUI) and pelvic organ prolapse (POP) can often result in postoperative complications. The objectives of this study were to determine: 1) the most common indications for mesh removal; 2) the incidences of the removal of specific mesh procedures (such as suburethral sling [SUS], transvaginal mesh [TVM], or sacrocolpopexy); and 3) the idences and types of surgical complications associated with mesh removal.

DESIGN

This was a retrospective study. Design Classification: Canadian Task Force II-3.

SETTING

Three tertiary referral centers in the United States.

PATIENTS

We examined data from all patients at the three centers who underwent surgical removal of synthetic materials from previous SUS, TVM, and sacrocolpopexy procedures for mesh-related complications from 2011 to 2013.

INTERVENTION

Patients underwent vaginal, intra-abdominal, and inguinal mesh revisions by cutting, partial removal, or total removal of the mesh for mesh-related complications.

MEASUREMENTS AND RESULTS

Overall, 445 patients with complications underwent mesh removal laparoscopically, via groin dissection and/or transvaginally. There were a total of 506 mesh products removed. Of these, 56.5% were slings and 43.5% were for pelvic organ prolapse (POP). Synthetic mesh removed from patients included: transvaginal mesh (TVM) anterior for anterior vaginal prolapse, TVM posterior for posterior vaginal prolapse, sacrocolpopexy mesh, and suburethral slings (SUS) for stress urinary incontinence. Synthetic SUS removed included: retropubic (RPS), transobturator (TOT), and single-incision slings (SIS). TOT was the most common type of sling removed. Patients with a sling who only complained of vaginal pain with or without intercourse underwent a vaginal approach for surgical revision/removal of the sling (86.6%). Patients with an RPS with lower abdominal/suprapubic pain and vaginal pain underwent a vaginal and laparoscopic approach for sling removal (18.4%). Patients with a TOT sling who complained of vaginal and groin pain underwent a vaginal and inguinal approach for sling removal (4.3%). In patients who had POP mesh removal, 42.3% had an anterior TVM, 30.6% had a posterior TVM, 14% had both anterior and posterior TVMs, and 13.1% underwent sacrocolpopexy mesh removal. Complications encountered during mesh revision/removal surgery were: two blood transfusions from complete RPS removal (vaginal and laparoscopic approach), three urethral injuries during TOT sling removal (vaginal approach), two ureteral injuries during anterior vaginal wall mesh removal, and two rectal injuries during posterior vaginal wall mesh removal. All injuries were repaired at the time of mesh removal without recurrence.

CONCLUSION

In our study, the most common indication for mesh removal was pain with or without intercourse. The most common mesh procedure resulting in removal was the TOT sling. Use of a vaginal approach only for sling removal had the lowest incidence of intraoperative complications. Laparoscopic RPS removal had the highest incidence of required blood transfusions, anterior TVM had the highest incidence of ureteral injury, and posterior TVM had the highest incidence of rectal injury. Overall, sling, TVM, and sacrocolpopexy mesh removal are safe procedures when performed by experienced surgeons.

The Indication and Surgical Treatment of 286 Midurethral Synthetic Sling Complications: A Multicenter Study

INTRODUCTION AND HYPOTHESIS

1) Evaluate the most common indication for sling removal in patients with synthetic mesh slings; 2) identify the location of pain for each of the three types of synthetic sling procedures including retropubic (RP) sling, transobturator (TOT) sling, and single incision slings (SIS), and 3) describe the surgical approach to each of the above and its associated complications.

MATERIALS AND METHODS

A retrospective chart review of all patients who underwent surgical removal of a sling due to a mesh-related complications from 2011 to 2013 at three referral centers.

RESULTS

There were 337 sling complications followed by the IUGA/ICS mesh complication classification. RP slings were more likely to have urinary tract complications (category 4) and intra-abdominal site complications (S5). Of those, 286 slings were removed, 106 (37.1%) were RP, 131 (45.8%) TOT, and 44 (15.4%) SIS. Vaginal pain was the most common reason for sling removal. Twenty-one percent of the TOT had groin pain which was a five times higher risk than RP (OR 5.3, 95% CI 1.5-18.7), and the RP was three times more likely to have suprapubic pain than the TOT (OR 2.97, 95% CI 1.3-7.0). Fifteen percent of the TOT had either unilateral or bilateral groin mesh removal.

CONCLUSION

The most common indication for sling removal was vaginal pain. RP sling had a higher risk of suprapubic pain and TOT sling had a higher risk of groin pain. Patients with a history of SIS had a higher incidence of urethral erosion. TOT removal had the highest intraoperative complication rate.

De novo stress urinary incontinence after pelvic organ prolapse surgery in women without occult incontinence

INTRODUCTION AND HYPOTHESIS

There is a paucity of data evaluating the risk of de novo stress urinary incontinence (SUI) after surgery for pelvic organ prolapse (POP) in women with no preoperative occult SUI. We hypothesized that apical suspension procedures would have higher rates of de novo SUI.

METHODS

This was a retrospective database review of women who had surgery for POP from 2003 to 2013 and developed de novo SUI at ≥6 months postoperatively. Preoperatively, all patients had a negative stress test and no evidence of occult SUI on prolapse reduction urodynamics. The primary objective was to establish the incidence of de novo SUI in women with no objective evidence of preoperative occult SUI after POP surgeries at ≥6 months.

RESULTS

A total number of 274 patients underwent POP surgery. The overall incidence of de novo SUI was 9.9 % [95 % confidence interval (CI) 0.07-0.14]. However, the incidence of de novo SUI in those with no baseline complaint of SUI was 4.4 % (95 % CI 0.03-0.1). There was no difference in de novo SUI rates between apical [9.7 % (n = 57)] and nonapical [10.5 %, (n = 217] procedures (p = 0.8482). Multivariate logistic regression identified sacrocolpopexy [adjusted odds ratio (OR) 4.54, 95 % CI 1.2-14.7] and those with a baseline complaint of SUI (adjusted OR 5.1; 95 % CI 2.2-12) as risk factors for de novo SUI.

CONCLUSIONS

The incidence of de novo SUI after surgery for POP without occult SUI was 9.9 %. We recommend counseling patients about the risk of de novo SUI and offering a staged procedure.

Are suburethral slings less successful in the elderly?

INTRODUCTION AND HYPOTHESIS

We aimed to evaluate the success of suburethral slings in women ≥70 years of age.

METHODS

This was a retrospective cohort study of women who underwent suburethral sling placement. Subjects were separated into three groups: ≤50 years of age (group 1), 51 to 69 years of age (group 2), and ≥70 years of age (group 3). The primary aim was to evaluate success as defined by ≥ improved on a validated patient improvement satisfaction score and a negative postoperative standardized stress test.

RESULTS

There were 1,464 subjects. Mean age was 44.51 ± 4.25 (n = 296) for group 1, 60.5 ± 5.28 (n = 680) for group 2, and 77.68 ± 5.41 (n = 488) for group 3. The median follow-up was 26 (6-498) weeks, 45 (6-498) weeks, and 42 (6-543) weeks, for groups 1, 2, and 3 respectively. Multiple logistic regression analysis demonstrated no difference in sling success according to age stratification. Lower success was associated with having had a previous sling (adjusted OR 0.25, 95 % CI 0.12-0.5), having detrusor overactivity (adjusted OR 0.44, 95 % CI 0.28-0.69), and having a history of urge urinary incontinence (UUI) for ≥ 4 years (adjusted OR 0.54, 95 % CI 0.31-0.95).

CONCLUSIONS

There is no difference in sling success between the elderly and younger populations. However, those with previous sling surgery or a long standing history of UUI may be at a higher risk of failure.

Laparoscopic Burch urethropexy at time of mesh sling removal: A cohort study evaluating functional outcomes and quality of life

AIM: To theorize that performing a laparoscopic Burch urethropexy at time of sling removal would significantly decrease subjective symptoms of stress urinary incontinence (SUI) and improve patient satisfaction.

METHODS: Women who underwent a combined sling removal and laparoscopic Burch procedure between 2009 and 2014 were matched via age and sling-type in a 1:2 ratio to women who only underwent a sling removal. Those who underwent surgery within 6 mo of data collection were excluded from the study, as were women who underwent multi-stage surgery. Preoperative assessment for both groups included a focused clinical exam with or without functional testing and questionnaires including urogenital distress inventory-6 (UDI-6) and incontinence impact questionnaire-7 (IIQ-7) per the standard clinical practice. All non-exempt women were sent a questionnaire that included UDI-6 and IIQ-7 in addition to standard follow-up questions. Research staff contacted participants via email, mail, and telephone using the same questionnaire template and script. Data was analyzed by using χ² test for categorical data, and Student’s t test and Wilcoxon Rank Sum test for continuous data. The measure of effect was determined by logistic regression analysis.

RESULTS: A total of 48 women out of 146 selected patients were successfully recruited with n = 22 in the Burch cohort and n = 26 in the control cohort. The mean age was 54.7 ± 7.8 years and mean body mass index was 22.0 ± 13.9 kg/m². The majority of patients were Caucasian (73.3%), postmenopausal (91.1%), nonsmokers (57.9%), with a history of hysterectomy (81.4%). Six nineteen point six percent of women presented after at least 2 years from placement, which was significantly more common in the Burch cohort. Pain was the most common chief complaint (64.4%) in both groups at the time of initial presentation, and 78.9% of women reported concomitant urinary incontinence. There was no significant difference in pre-operative UDI-6 and IIQ-7 scores between the two cohorts. However, the change in UDI-6 score postoperatively was significantly improved in the Burch cohort with an average drop in score of 28.41 points compared to a decrease of 4.01 points in the control group (P = 0.02, 95%CI: 3.84 to 44.97). Although not statistically significant, the Burch cohort was 58% more likely to show an overall improvement in their score after surgery and 40% more likely to meet the minimal important difference of 11 points (RR = 1.58, 95%CI: 0.97 to 2.57; RR 1.40, 95%CI: 0.79 to 2.46). The difference in IIQ scores was nonsignificant. There was no significant difference in blood loss, complications, or postoperative pain or dyspareunia.

CONCLUSION: Performing a Burch urethropexy during sling removal does not increase complication rates and results in a significant change in validated symptom-related quality of life scores.

Laparoscopic Paravaginal Defect Repair: Surgical Technique and a Literature Review

Paravaginal defects, commonly seen in patients with anterior vaginal wall prolapse, are due to the detachment of pubocervical fascia from the arcus tendineus fascia pelvis (ATFP), at or near its lateral attachment. The majority of anterior vaginal wall prolapse is thought to be caused by paravaginal defects. Richardson et al. first described and demonstrated the anatomy of the paravaginal defect, as well as described the initial technique of the abdominal approach to repair. Since that time, the laparoscopic approach for repair has been developed and described with success rates of laparoscopic paravaginal defect repair reported in the range of 60% to 89%. This minimally invasive approach to address anterior wall prolapse eliminates the need for a vaginal incision, reduces risk of vaginal shortening and can be completed at the same time as other laparoscopic procedures, such as hysterectomy, sacralcolpopexy, and/or Burch Urethropexy. Compared to the open abdominal approach, there is improved visualization, less risk of bleeding, and faster recovery with the laparoscopic method. Compared to an anterior colporrhaphy, laparoscopic paravaginal repair is a much more anatomic repair of lateral defects and does not result in vaginal shortening. The laparoscopic paravaginal repair should be considered as the first-line treatment of anterior vaginal wall prolapse caused by lateral defects, including at time of laparoscopic/robotic sacralcolpopexy.

Vaginal reconstruction/rejuvenation: is there data to support improved sexual function? An update and review of the literature

Vaginal rejuvenation is a term that is commonly utilized to describe surgical repair of the vaginal canal and introitus following childbirth and/or aging to treat sexual dysfunction related to vaginal relaxation. It is well known that vaginal prolapse may lead to sexual dysfunction and in many studies repair of prolapse improves this dysfunction. During the progression of prolapse, sexual dysfunction or decreased vaginal sensation due to vaginal wall laxity may be one of the early symptoms that women suffer prior to the prolapse itself becoming symptomatic. Surgical repair or reconstruction of this type of vaginal defect may be indicated if repair will improve symptoms of sexual dysfunction caused by vaginal wall laxity. In this review, we will examine the existing data and make conclusions regarding vaginal rejuvenation and its impact on female sexual function. Core tip: This is the first review of vaginal rejuvenation that shows improvement of sexual function. In this review, we covered the topic of relaxed vagina and sexual function, prolapse repair and sexual function, vaginal rejuvenation surgical techniques, and data to support vaginal rejuvenation techniques.

Evaluation of sexual function outcomes in women undergoing vaginal rejuvenation/vaginoplasty procedures for symptoms of vaginal laxity/decreased vaginal sensation utilizing validated sexual function questionnaire (PISQ-12)

Sexual function outcomes were analyzed in a group of women (n = 78) presenting for vaginal rejuvenation/vaginoplasty procedure for a chief complaint of vaginal laxity and decreased sensation with intercourse. Outcomes were analyzed utilizing the validated Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 (PISQ-12) before and at least 6 months after repair with vaginal rejuvenation/vaginoplasty procedure (VR). Mean age was 43.6 ± 7.9 (range 25-62), and 19 patients (24.3%) were found to have prolapse at time of initial exam and underwent vaginal vault suspension in addition to VR. Compared preoperatively and postoperatively, the overall sexual function (Total PISQ-12) statistically improved (30.3 ± 6.6 vs. 38.2 ± 5.2, P < 0.001). All individual scores statistically improved except in 3 categories in which there was no change (Q1-desire, Q5-pain, and Q11- partner premature ejaculation). Overall sexual satisfaction improved as well as subcategories of increased sexual excitement during intercourse and overall increase in intensity of orgasms. Pain with intercourse subscores were found to be no different from preoperatively to postoperatively. Previous studies have shown that sexual function improves with repair of prolapse; however, this is the first study to show improved function using a validated questionnaire in patients undergoing VR for laxity.

New-onset atrial fibrillation after aortic valve replacement: comparison of transfemoral, transapical, transaortic, and surgical approaches

OBJECTIVES

This study sought to determine the incidence of new-onset atrial fibrillation (AF) associated with different methods of isolated aortic valve replacement (AVR)-transfemoral (TF), transapical (TA), and transaortic (TAo) catheter-based valve replacement and conventional surgical approaches.

BACKGROUND

The relative incidences of AF associated with the various access routes for AVR have not been well characterized.

METHODS

In this single-center, retrospective cohort study, we evaluated a total of 231 consecutive patients who underwent AVR for degenerative aortic stenosis (AS) between March 2010 and September 2012. Patients with a history of paroxysmal, persistent, or chronic AF, with bicuspid aortic valves, and patients who died within 48 h after AVR were excluded. A total of 123 patients (53% of total group) qualified for inclusion. Data on documented episodes of new-onset AF, along with all clinical, echocardiographic, procedural, and 30-day follow-up data, were collated.

RESULTS

AF occurred in 52 patients (42.3%). AF incidence varied according to the procedural method. AF occurred in 60% of patients who underwent surgical AVR (SAVR), in 53% after TA-TAVR, in 33% after TAo-TAVR cases, and 14% after TF-TAVR. The episodes occurred at a median time interval of 53 (25th to 75th percentile, 41 to 87) h after completion of the procedure. Procedures without pericardiotomy had an 82% risk reduction of AF compared with those with pericardiotomy (adjusted odds ratio: 0.18; 95% confidence interval: 0.05 to 0.59).

CONCLUSIONS

AF was a common complication of AVR with a cumulative incidence of >40% in elderly patients with degenerative AS who underwent either SAVR or TAVR. AF was most common with SAVR and least common with TF-TAVR. Procedures without pericardiotomy were associated with a lower incidence of AF.