Complications of pelvic organ prolapse surgery and methods of prevention

Clinician perspectives on hysterectomy versus uterine preservation in pelvic organ prolapse surgery: A systematic review and meta-analysis

BACKGROUND

Previous reviews on hysterectomy versus uterine-sparing surgery in pelvic organ prolapse (POP) repair did not consider that the open abdominal approach or transvaginal mesh use have been largely abandoned.

OBJECTIVES

To provide up-to-date evidence by examining only studies investigating techniques currently in use for POP repair.

SEARCH STRATEGY

MEDLINE and Embase databases were searched from inception to January 2023.

SELECTION CRITERIA

We included randomized and non-randomized studies comparing surgical procedures for POP with or without concomitant hysterectomy. Studies describing open abdominal approaches or transvaginal mesh implantation were excluded.

DATA COLLECTION AND ANALYSIS

A random effect meta-analysis was conducted on extracted data reporting pooled mean differences and odds ratios (OR) between groups with 95% confidence intervals (CI).

MAIN RESULTS

Thirty-eight studies were included. Hysterectomy and uterine-sparing procedures did not differ in reoperation rate (OR 0.93; 95% CI 0.74-1.17), intraoperative major (OR 1.34; 95% CI 0.79-2.26) and minor (OR 1.38; 95% CI 0.79-2.4) complications, postoperative major (OR 1.42; 95% CI 0.85-2.37) and minor (OR 1.18; 95% CI 0.9-1.53) complications, and objective (OR 1.38; 95% CI 0.92-2.07) or subjective (OR 1.23; 95% CI 0.8-1.88) success. Uterine preservation was associated with a shorter operative time (-22.7 min; 95% CI -16.92 to -28.51 min), shorter hospital stay (-0.35 days, 95% CI -0.04 to -0.65 days), and less blood loss (-61.7 mL; 95% CI -31.3 to -92.1 mL). When only studies using a laparoscopic approach for both arms were considered, no differences were observed in investigated outcomes between the two groups.

CONCLUSIONS

No major differences were observed in POP outcomes between procedures with and without concomitant hysterectomy. The decision to preserve or remove the uterus should be tailored on individual factors.

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.

Physiotherapeutic Approach in Enhancing Recovery and Quality of Life After Vaginal Hysterectomy: A Case Report

Uterine prolapse is a manifestation of pelvic organ prolapse distinguished by the descent of the uterus from its normal anatomical position into the vaginal canal. Vaginal hysterectomy is a surgical intervention performed to excise the uterus via the vaginal canal. Hysterectomy is correlated with various complications; thus, prompt mobilization and engagement in physiotherapy are imperative postoperatively. This is a case report of a 78-year-old female who reported a persistent sensation of something protruding from her vagina over the past two years. Investigations revealed a third-degree uterocervical descent, leading to the decision for a vaginal hysterectomy. Commencing on Day 5 post-surgery, early mobilization and a comprehensive physiotherapeutic regimen were implemented, encompassing breathing exercises, upper limb mobility exercises, core strengthening routines, pelvic floor exercises, and postural correction. Evaluation using the Modified Oxford Pelvic Floor Muscle Contraction Scale, Pelvic Floor Impact Questionnaire (PFIQ), and World Health Organization Quality of Life (WHO-QOL) demonstrated notable improvement. The findings suggest that promoting early mobilization and facilitating the rehabilitation of pelvic musculature, along with core strengthening through physiotherapy, plays a pivotal role in expediting recovery and enhancing the overall quality of life for hysterectomy patients, potentially alleviating difficulties in performing daily activities.

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

Introduction

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

Case presentation

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

Discussion

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

Conclusion

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

Safety and Efficacy of Vaginal Implants in Pelvic Organ Prolapse Surgery: A Meta-analysis of 161 536 Patients

CONTEXT

Among the many surgical treatments for pelvic organ prolapse (POP), better results can be achieved with the use of vaginal implants. However, owing to perceived complications, vaginal implant surgeries have been restricted or banned in many countries.

OBJECTIVE

To assess the real value of vaginal implants in POP surgery and compare the safety and efficacy of operations with and without implants.

EVIDENCE ACQUISITION

A systematic search was performed in three medical databases. Randomised controlled trials and observational studies comparing the safety and efficacy of vaginal POP surgery with implants versus native tissue were included. Safety outcomes were defined as different types of complications (functional and non-functional) and reoperations for complications. Efficacy outcomes were parameters of anatomical success and the rate of reoperations due to recurrence. A multivariate meta-analysis framework was used to estimate pooled odds ratios (ORs) with confidence intervals (CIs) with simultaneous control for study correlations and estimation of multiple correlated outcomes.

EVIDENCE SYNTHESIS

We included 50 comparative studies in the analysis. Rates of reoperation for complications (OR 2.15, 95% CI 1.20-3.87), vaginal erosion (OR 14.05, 95% CI 9.07-21.77), vaginal bleeding (OR 1.67, 95% CI 1.25-2.23), and de novo stress urinary incontinence (OR 1.44, 95% CI 1.18-1.75) were significantly higher in the implant group. Rates of anatomical success (OR 3.22, 95% CI 2.06-5.0) and reoperation for recurrence (OR 0.55, 95% CI 0.36-0.85) were superior in the implant group.

CONCLUSIONS

POP surgeries with vaginal implants are more effective than surgeries without implants, with acceptable complication rates. Therefore, the complete prohibition of implants for POP surgeries should be reconsidered.

PATIENT SUMMARY

We compared vaginal surgery with and without implants for repair of pelvic organ prolapse. Despite higher complication rates, vaginal implants provide better long-term results overall than surgery without implants.

Effects of topical dehydroepiandrosterone therapy in women after pelvic organ prolapse surgery

OBJECTIVE

Pelvic organ prolapse (POP) occurs predominantly in postmenopausal women. Restoration of the proper estrogenization of vaginal mucosa is important in preoperative and postoperative treatment, increasing the effectiveness of this approach. The objective of this study was the development of intravaginal vaginal suppositories containing DHEA and comparison of the clinical effects of vaginal topical therapy with DHEA, estradiol, or antibiotic after POP surgery.

METHOD

Nine types of vaginal suppositories containing 6.5 mg DHEA in different bases were prepared to find optimal formulation for the vaginal conditions. Ninety women referred for POP surgery were randomly assigned to one of three groups receiving topical treatment in the postoperative period (estradiol, DHEA, or antibiotic). On admission to hospital and during follow-up vaginal pH, vaginal maturation index and vaginal symptoms were assessed.

RESULTS

Vaginal suppositories with the base made from polyethylene glycol 1,000 without surfactants characterized the highest percentage of the released DHEA. In women treated with topical estradiol or DHEA a significant decrease in the number of parabasal cells, increase in superficial and intermediate cells in the vaginal smears, decrease in vaginal pH, and reduction of vaginal symptoms were observed.

CONCLUSIONS

The use of topical therapy with DHEA or the use of topical therapy with estradiol in the postoperative period were both shown to improve maturation index, vaginal pH, and vaginal symptoms. The benefits of topical therapy with DHEA after pelvic organ prolapse repair brings similar results as estradiol, without potential systemic exposure to increased concentrations of sex steroids above levels observed in postmenopausal women.

Polypropylene Pelvic Mesh: What Went Wrong and What Will Be of the Future?

Background: Polypropylene (PP) pelvic mesh is a synthetic mesh made of PP polymer used to treat pelvic organ prolapse (POP). Its use has become highly controversial due to reports of serious complications. This research critically reviews the current management options for POP and PP mesh as a viable clinical application for the treatment of POP. The safety and suitability of PP material were rigorously studied and critically evaluated, with consideration to the mechanical and chemical properties of PP. We proposed the ideal properties of the ‘perfect’ synthetic pelvic mesh with emerging advanced materials. Methods: We performed a literature review using PubMed/Medline, Embase, Cochrane Library (Wiley) databases, and ClinicalTrials.gov databases, including the relevant keywords: pelvic organ prolapse (POP), polypropylene mesh, synthetic mesh, and mesh complications. Results: The results of this review found that although PP is nontoxic, its physical properties demonstrate a significant mismatch between its viscoelastic properties compared to the surrounding tissue, which is a likely cause of complications. In addition, a lack of integration of PP mesh into surrounding tissue over longer periods of follow up is another risk factor for irreversible complications. Conclusions: PP mesh has caused a rise in reports of complications involving chronic pain and mesh exposure. This is due to the mechanical and physicochemical properties of PP mesh. As a result, PP mesh for the treatment of POP has been banned in multiple countries, currently with no alternative available. We propose the development of a pelvic mesh using advanced materials including emerging graphene-based nanocomposite materials.

Transvaginal Mesh-related Complications and the Potential Role of Bacterial Colonization: An Exploratory Observational Study

STUDY OBJECTIVE

This study aimed to investigate the potential role of transvaginal mesh bacterial colonization in the development of mesh-related complications (MRCs).

DESIGN

An observational and exploratory study.

SETTING

Tertiary referral center (Amsterdam UMC, location AMC, Amsterdam, The Netherlands). PATIëNTS: 49 patients indicated for mesh removal and 20 women of whom vaginal tissue was retrieved during prolapse surgery as a reference cohort.

INTERVENTIONS

collection of mesh-tissue complex (patient cohort) or vaginal tissue (reference cohort) MEASUREMENTS AND MAIN RESULTS: Homogenized samples were used for quantitative microbiological culture. Inflammation and fibrosis were semiquantitatively histologically scored; Gram staining and fluorescence in situ hybridization were used to detect bacteria and bacterial biofilms. Of the 49 patients, 44 samples (90%) were culture positive, with a higher diversity of species and more Gram-negative bacteria and polymicrobial cultures in the MRC cohort than the reference cohort, with mostly staphylococci, streptococci, Actinomyces spp., Cutibacterium acnes, and Escherichia coli. Patients with clinical signs of infection or exposure had the highest bacterial counts. Histology demonstrated moderate to severe inflammation in most samples. Gram staining showed bacteria in 57% of culture-positive samples, and in selected samples, fluorescence in situ hybridization illustrated a polymicrobial biofilm.

CONCLUSION

In this study, we observed distinct differences in bacterial numbers and species between patients with MRCs and a reference cohort. Bacteria were observed at the mesh-tissue interface in a biofilm. These results strongly support the potential role of bacterial mesh colonization in the development of MRCs.

Clinical outcomes and complications of laparoscopic sacrocolpopexy with versus without concomitant hysterectomy for pelvic organ prolapse in Hong Kong Chinese patients after median follow-up of 7 years

INTRODUCTION AND HYPOTHESIS

This retrospective cohort study is aimed at comparing outcomes and complications of laparoscopic sacrocolpopexy (LSC) with or without concomitant hysterectomy in the Hong Kong Chinese population.

METHODS

Women with stage II or above uterine or apical vault prolapse who underwent LSC with or without concomitant hysterectomy in a regional referral unit from 2007 to 2019 were included. The primary objectives were to compare the anatomical outcomes by pelvic organ prolapse quantification system (POP-Q) and recurrence of apical vault prolapse (≥stage II). The secondary objective was to compare the functional outcomes and complications. Anatomical recurrence and incidence of mesh exposure were analyzed using the Kaplan-Meier method. Cox proportional hazard regression was performed to identify risk factors of anatomical recurrence.

RESULTS

Seventy-six women were included for analysis. The recurrence rate of apical vault prolapse was 3.9% after a median follow-up time of 83 months (20-190 months). A significant reduction of POP-Q scores of three compartments in both groups of women were demonstrated (p<0.001). There was no difference between the two groups in terms of functional outcomes and complications. 6.6% of women developed mesh exposure. The time to recurrence of apical vault prolapse was shorter in women who had LSC with prior hysterectomy (p =0.019). No risk factors were identified for recurrence of apical vault prolapse.

CONCLUSIONS

Laparoscopic sacrocolpopexy with concomitant hysterectomy is comparable with LSC alone. The recurrence and complication rates are low. We suggest that LSC with concomitant hysterectomy might be offered to women with pelvic organ prolapse, with women's preference taken into account.

Long-Term Outcomes after Pelvic Organ Prolapse Repair in Young Women

The aim of the study was to describe the long-term outcomes of Pelvis Organ Prolapse (POP) repair in women under 40 years old. A retrospective chart review of all POP repairs performed in women ≤40 years old between January 1997 and December 2015 in the Gynecologic Surgery Department of Lille University Hospital was performed. Inclusion criteria were all women ≤40 years old who underwent a POP repair with a stage ≥2 POP according to the Baden and Walker classification. The study population was separated into three groups: a sacrohysteropexy group, a vaginal native tissue repair (NTR) group, and a transvaginal mesh surgery (VMS) group. The primary outcome was reoperation procedures for a symptomatic recurrent POP. Secondary outcomes were other complications. During the study period, 43 women ≤ 40 years old who underwent a POP repair were included and separated into three groups: 28 patients (68%), 8 patients (19%), and 7 patients (16%) in the sacrohysteropexy, VMS, and NTR groups respectively. The mean followup time was 83 ± 52 months. POP recurrence, reoperated or not, was essentially diagnosed in the VMS group (87.5%) and the NTR group (50%). POP recurrence repairs were performed for nine patients (21%): 7%, 62.5%, and 25% in the sacrohysteropexy, VMS, and NTR groups, respectively. Global reoperation concerned 10 patients (23%) whatever the type of POP surgery, mainly patients from the VMS group (75%) and from the NTR group (25%). It occurred in only 7% of patients from the sacrohysteropexy group. Two patients (4%) presented a vaginal exposure of the mesh (in the VMS group). De novo stress urinary incontinence was encountered by nine patients (21%): 29% and 12.5% in the sacrohysteropexy and NTR groups, respectively. Despite the risk of recurrence, POP repair should be proposed to young women in order to restore their quality of life. Vaginal native tissue repair or sacrohysteropexy should be performed after explaining to women the advantages and disadvantages of each procedure.

Design, mechanical and degradation requirements of biodegradable metal mesh for pelvic floor reconstruction

Pelvic organ prolapse (POP) is the herniation of surrounding tissue and organs into the vagina and or rectum, and is a result of weakening of pelvic floor muscles, connective tissue,...

Wound dehiscence prevalence and relationship with prosthetic material extrusion in women underwent anterior colpotomy

Aim:

To assess the prevalence of anterior vaginal wall dehiscence in women who underwent anterior vaginal wall colpotomy for pelvic organ prolapse or stress urinary incontinence and to evaluate the influence of suture materials and techniques on wound dehiscence.

Materials and Methods:

This multicenter, prospective study enrolled naïve women for urogynecological surgery affected by anterior vaginal wall defect or stress urinary incontinence. Performed surgical procedures were anterior vaginal wall repair (AVWR) with native tissue (N-AVWR) or polypropylene mesh (M-AVWR), trans-obturator polypropylene in-out middle urethral sling (MUS). Used suture materials were Vicryl 2-0, Vicryl Rapide 2-0, and Monocryl 3-0. Suture techniques were running interlocking or interrupted. Follow-up was performed daily during hospitalization and in outpatient clinic after 10–14, 30 days, and after 3 months.

Results:

A total of 1139 patients were enrolled. AVWR were 790: 89.1% N-AVWR, and 10.9% M-AVWR. Polypropylene MUS were 349. Women with prosthetic implantation were 38.2%, while 61.8% had native tissue repair. Overall Vicryl was used in 53.9%, Vicryl Rapide in 37.4%, and Monocryl in 8.7%. Overall running interlocking sutures were 66.5%, while interrupted were 33.5%. Overall wound dehiscence prevalence was 0.9% (10/1139). Wound dehiscence rate of 0.6% (5/790) was documented in AVWR: 0.3% (2/704) in N-AVWR, and 3.5% (3/86) in M-AVWR. Among women underwent MUS, 1.4% (5/349) showed wound dehiscence. In patients who underwent prosthetic surgery, the overall dehiscence prevalence was 1.8% (8/435). A statistically significant higher rate of wound dehiscence was found in women with implanted prosthetic materials.

Discussion:

We reported for the first time the prevalence of wound dehiscence in females who underwent colpotomy for AVWR or MUS. Wound dehiscence occurrence was low, but non-negligible. We found that this complication was poorly associated to the suture methods and materials, while prosthetic material represented a risk factor for wound healing.

Modified laparoscopic lateral suspension with a five-arm mesh in pelvic organ prolapse surgery

Background

Laparoscopic lateral suspension (LLS) is a laparoscopic technique used to treat pelvic organ prolapse (POP) in apical and anterior compartment defect with the use of a synthetic T-shaped mesh graft. The posterior compartment is repaired using a second mesh or a procedure along with LLS, such as posterior colporrhaphy. The aim of this study was to evaluate the clinical results of LLS for POP using a five-arm mesh instead of a T-shaped mesh graft to repair the defect of the posterior compartment in addition to the apical and anterior compartments.

Methods

Data from 37 patients with a diagnosis of advanced-stage (≥ 3) POP undergoing LLS with the use of a five-arm mesh were retrospectively analysed. Pre-operative and post-operative examinations and, surgical outcomes were determined. The results of measurements and examinations, reoperation rates, erosion rates, lower urinary tract symptoms, and complications were analysed. The Prolapse Quality of Life Questionnaire (P-QOL) was also used.

Results

The median post-operative follow-up was 20 (13–34) months. There was a significant improvement in POP-Q scores in all treated compartments, with overall objective cure rates of 94.5% for the apical compartment, 86.4% for the anterior compartment, and 91.8% for the posterior compartment. The median operative time was 96 (76–112) minutes. The median length of hospitalization was 2 (1–3) days. A significant improvement in vaginal bulge, urinary urgency, incomplete voiding, urinary frequency, and constipation was observed after surgery. The sexuality among patients increased from 13 (35.1%) preoperatively to 22 (59.4%) post-operatively. De novo stress urinary incontinence developed in 7 (18.9%) patients. The P-QOL scores improved significantly after surgery.

Conclusions

In advanced-stage POP patients, the posterior compartment damage can also be repaired in LLS with the use of a single five-arm mesh without the need for an additional procedure, and the recurrence rate can be reduced.

Association between surgical volumes and real-world healthcare cost when using a mesh capturing device for pelvic organ prolapse: A 5-years comparison between single- versus multicenter use

Introduction and hypothesis

The aim of this study was to evaluate whether high surgical volume at a single center was associated with lower healthcare costs compared to lower surgical volume in a multicenter setting.

Methods

All patients had symptomatic and anatomical apical prolapse (POP-Q ≥ stage II) with or without cystocele and were operated on by a standard surgical procedure using the Uphold mesh. Data on time of resource use in terms of surgery time, hospital stay and re-interventions across 5 years were compared between the single center (97 patients) and multicenter (173 patients, at 24 clinics). Unit costs for surgical time, inpatient and outpatient visits were extracted from the single-center hospital’s operation analysis program and prime production cost. Total costs were estimated for primary surgery and during 5-year follow-up.

Results

Costs for primary surgery were comparable between the single and the multicenter ($13,561 ± 2688 and $13,867 ± 1177, P = 0.29). Follow-up costs 5 years after primary surgery were 2.8 times higher at the multicenter than single center ($3262 vs. $1149, P < 0.001). Mean cost per patient over 5 years was significantly lower at the single than multicenter [$14,710 (CI: 14,168–15,252) vs. $17,128 (CI: 16,952–17,305), P < 0.001)].

Conclusions

Using a mesh kit for apical pelvic organ prolapse in a high surgical volume center was associated with reduced healthcare costs compared with a lower volume multiple-site setting. The cost reduction at the high surgical volume center increased over time because of lower surgical and medical re-intervention rates for postoperative complications and recurrence.

[Pelvic and perineal pain after genital prolapse: A literature review]

INTRODUCTION

Pelvic and perineal pain after genital prolapse surgery is a serious and frequent post-operative complication which diagnosis and therapeutic management can be complex.

MATERIALS ET METHODS

A literature review was carried out on the Pubmed database using the following words and MeSH : genital prolapse, pain, dyspareunia, genital prolapse and pain, genital prolapse and dyspareunia, genital prolapse and surgery, pain and surgery.

RESULTS

Among the 133 articles found, 74 were selected. Post-operative chronic pelvic pain persisting more than 3 months after surgery according to the International Association for the Study of Pain. It can be nociceptive, neuropathic or dysfunctional. Its diagnosis is mainly clinical. Its incidence is estimated between 1% and 50% and the risk factors are young age, the presence of comorbidities, history of prolapse surgery, severe prolapse, preoperative pain, invasive surgical approach, simultaneous placement of several meshes, less operator experience, increased operative time and early post-operative pain. The vaginal approach can cause a change in compliance and vaginal length as well as injury to the pudendal, sciatic and obturator nerves and in some cases lead to myofascial pelvic pain syndrome, whereas the laparoscopic approach can lead to parietal nerve damage. Therapeutic management is multidisciplinary and complex.

CONCLUSION

Pelvic pain after genital prolapse surgery is still obscure to this day.

Effect of different electrical stimulation protocols for pelvic floor rehabilitation of postpartum women with extremely weak muscle strength: Randomized control trial

BACKGROUND

Pregnancy is one of the main risk factor of pelvic floor muscle dysfunction. Postpartum women with extremely weak muscle strength have difficulty to do voluntary pelvic floor muscle training. This study aims to evaluate the effects of different protocols of electrical stimulation in the treatment of postpartum women with extremely weak muscle strength.

METHODS

A total of 67 women were randomized into 2 groups: group A received transvaginal electrical stimulation (TVES) for 5 times, and group B received TVES for 3 times with electromyogram (EMG)-triggered neuromuscular stimulation twice. Subjects were evaluated before and after treatment. Pelvic muscle strength was measured by both digital vaginal palpation and EMG variables, and quality of life was investigated by 4 kinds of pelvic floor disease-related questionnaires.

RESULTS

According to the intention-to-treat principle, compared with baseline, in group A, EMG of contractile amplitude of endurance phase was significantly elevated (P = .03), variation of contractile amplitude in tonic phase was more stable after treatment (P = .004), and EMG of mean value of final rest was significantly elevated after treatment (P = .047). After 5 times treatments, the incidence of correct pelvic floor muscle contraction in group A was significantly elevated (P = .045). No significant difference of muscle strength test by digital vaginal palpation was detected between the 2 groups, so did questionnaires.

CONCLUSION

For postpartum women with extremely weak muscle strength, TVES for 5 times might be more benefit for control ability of pelvic muscle contractions and elevating muscle strength even in short-time treatment.

Laparoscopic sacral colpopexy for pelvic organ prolapse recurrence after transvaginal mesh surgery

OBJECTIVE

Pelvic organ prolapse (POP) recurrence in transvaginal mesh surgery patients has become increasingly common, due to widespread mesh use before the FDA alert. The aim was to assess feasibility, effectiveness and safety of laparoscopic sacral colpopexy (LSCP) in recurrent POP after previous vaginal surgery with polypropylene mesh.

STUDY DESIGN

Medical records of 20 patients with ≥ stage 2 POP recurrence, who underwent LSCP from January 2015 to July 2018, were retrospectively analyzed in a monocentric observational study. We analyzed operative time, intraoperative complications - defined as bowel, bladder, ureteral, or vascular injuries, post-operative complications - assessed with Clavien-Dindo's classification, and postoperative patient satisfaction - evaluated with the Patient Global Impression of Improvement questionnaire. Pre- and postoperative data were compared using t-test.

RESULTS

All women presented apical prolapse recurrence regardless of mesh type implanted and most of them involved the posterior compartment. No perioperative complications or cases of mesh extrusion, de novo urinary stress, urge incontinence, dyspareunia were recorded. At 12-month follow-up the POP-Q examinations demonstrated a statistically significant improvement of all parameters with a complete resolution of bulge, voiding and storage symptoms in all patients.

CONCLUSION

LSCP suggests safety, feasible and efficacy in the treatment of recurrent POP after prior transvaginal polypropylene mesh surgery. We suggest to conduct a prospective research with larger sample size to gain further insights.

Landmarks in vaginal mesh development: polypropylene mesh for treatment of SUI and POP

Vaginal meshes used in the treatment of stress urinary incontinence (SUI) and pelvic organ prolapse (POP) have produced highly variable outcomes, causing life-changing complications in some patients while providing others with effective, minimally invasive treatments. The risk:benefit ratio when using vaginal meshes is a complex issue in which a combination of several factors, including the inherent incompatibility of the mesh material with some applications in pelvic reconstructive surgeries and the lack of appropriate regulatory approval processes at the time of the premarket clearance of these products, have contributed to the occurrence of complications caused by vaginal mesh. Surgical mesh used in hernia repair has evolved over many years, from metal implants to knitted polymer meshes that were adopted for use in the pelvic floor for treatment of POP and SUI. The evolution of the material and textile properties of the surgical mesh was guided by clinical feedback from hernia repair procedures, which were also being modified to obtain the best outcomes with use of the mesh. Current evidence shows how surgical mesh fails biomechanically when used in the pelvic floor and materials with improved performance can be developed using modern material processing and tissue engineering techniques.

Hysteropexy with single-incision vaginal support system associated with a modified culdoplasty for enterocele prevention

Our study assessed the safety and clinical outcomes of hysteropexy with a single-incision mesh associated with a modified culdoplasty, for the surgical management or prevention of enterocele, in women with pelvic organ prolapse (POP). We carried out a 1-year prospective single-cohort study, including 51 women with symptomatic, multi-compartmental POP. Anatomical outcome was assessed with a POP-Q system and the subjective outcomes were assessed using ICSQ-SF and PGI-I. One-year follow-up data were available for 48 out of 51 patients. The POP-Q cure rate was 91%, 83% of patients were satisfied or very satisfied (PGI-I ≤ 2). No major complications occurred; the most common minor complications were mesh erosion (6%) and pelvic pain (8%). Lower urinary tract dysfunctions arose in 16% of the patients. Anatomical prolapse recurrence (POP-Q stage ≥2) in anterior or apical compartments occurred in four patients (8%). No case of de novo prolapse occurred in the posterior compartment. None of the patients required further surgery for recurrent prolapse. This standardised procedure provided satisfactory 'restitutio ad integrum' of the vaginal anatomy and symptom relief.Impact statementWhat is already known on this subject? The post-surgical evidence of de novo prolapse in untreated compartments is well-known, especially in prosthetic surgery. The insertion of polypropylene mesh causes a vigorous support, consequently the forces on the pelvic floor are transmitted to the least consolidated vaginal compartment. A lack of simultaneous repair of all the segments involved in the POP increases the risk of surgical recurrence even in those areas that did not appear to be pre-operatively affected by the uterine descensus.What the results of this study add? Our prospective study showed that hysteropexy with a single-incision vaginal support system plus a modified culdoplasty was able to prevent the enterocele and the occurrence of prolapse in the posterior compartment, by closing the Douglas pouch and restoring the connection of the rectovaginal septum with the apical support.What the implications are of these findings for clinical practice and/or further research? This study may be relevant for clinicians in selecting the technique for pelvic floor surgery, and it may be of interest for researchers investigating the reasons for de novo occurrence of posterior segment prolapse.

Perioperative morbi-mortality after pelvic organ prolapse surgery in a large French national database from gynecologist surgeons

OBJECTIVE

To assess morbidity and mortality following pelvic organ prolapse surgery in France, irrespective of the surgical technique, using a broad national database.

MATERIALS AND METHODS

This descriptive multicenter retrospective study was conducted using a database populated via an application run by a professional association.

RESULTS

286 gynecologists contributed data to the database. Of the 4322 surgeries analyzed, an abdominal approach was used in 975 of cases (22.5%), a vaginal approach in 3277 (75.9%), and a combined approach in 68 (1.6%). After one year, abdominal surgery was associated with higher rates of de novo urinary incontinence, constipation, and intestinal obstruction, whereas vaginal surgery was associated with higher rates of urinary retention, hematoma, de novo chronic pain, and vaginal mesh extrusion. There was no significant difference between the groups in the incidence of severe complications. After one year, vaginal mesh-augmented cystocele repair was associated with higher rates of de novo urinary incontinence, de novo chronic pain, and reoperation than native tissue repair. Mesh repair was also associated with higher rates of severe complications at one year.

CONCLUSION

After pelvic organ prolapse surgery, the perioperative morbidity and mortality associated with transabdominal and transvaginal approaches are similar. However, transvaginal mesh repair is associated with greater perioperative morbidity than transvaginal native tissue repair.

Complications related to use of mesh implants in surgical treatment of stress urinary incontinence and pelvic organ prolapse: infection or inflammation?

The surgical mesh material used in the surgical treatment of stress urinary incontinence (SUI) and pelvic organ prolapse (POP) in women is associated with significant complications in some women. This has recently become a public health issue with involvement of national parliaments and regulatory bodies. The occurrence of mesh complications is thought to be a result of multifactorial processes involving problems related to the material design, the surgical techniques used and disease, and patient-related factors. However, the infectious complications and mesh–tissue interactions are least studied. The aim of this article is to review any previous clinical and basic scientific evidence about the contribution of infectious and inflammatory processes to the occurrence of mesh-related complications in SUI and POP. A literature search for the relevant publications without any time limits was performed on the Medline database. There is evidence to show that vaginal meshes are associated with an unfavourable host response at the site of implantation. The underlying mechanisms leading to this type of host response is not completely clear. Mesh contamination with vaginal flora during surgical implantation can be a factor modifying the host response if there is a subclinical infection that can trigger a sustained inflammation. More basic science research is required to identify the biological mechanisms causing a sustained inflammation at the mesh–tissue interface that can then lead to contraction, mesh erosion, and pain.

Questions surrounding the optimal time for surgical treatment of pelvic organ prolapse

OBJECTIVE

The purpose of study is to evaluate the recurrence rate of pelvic organ prolapse after surgical treatment and pre- to postoperative changes in sexual function of patients with different stages of pelvic organ prolapse.

METHODS

The presented study was a single-centre observational nonrandomized analysis of an ongoing prospective cohort study evaluating anatomical and clinical outcomes in reproductive aged women scheduled for nature tissue repair of POP staged I-III. Two hundred and ten women were recruited, of whom 120 (57.1%) had the advanced prolapse form (POP-Q III). Women at preoperative POP stage I-II were compared with women at stage III without apical prolapse.

RESULTS

The best effectively rate with low recurrence depends on preoperative prolapse stage. The overall objective success rate was about 80% in five years in patients with preoperative stage I-II. Study shows a significant improvement in sexual function in all patients with pelvic organ prolapse in five years after surgery.

CONCLUSION

This study showed that women with advanced POP have a higher risk of recurrence after POP native tissue repair compared with early stages and proved the improvement of sexual function especially in women with advanced prolapse forms. Women with early stage of POP should be advised to postpone surgery until progression of complaints because of the high recurrence risk.

Rectal mesh erosion after posterior vaginal kit repair

INTRODUCTION AND HYPOTHESIS

The present video shows a rare case of erosion through the full rectal wall into the rectum after a transperineal implant of a double-arm polypropylene kit.

METHODS

A 70-year-old woman underwent a transperineal implant of a double-arm polypropylene kit. One year after surgery, she developed bothersome symptoms in the posterior perineum including heaviness, pain and rectal bleeding during defecation. A clinical examination showed the presence of a part of the prothesis traversing the rectal cavity. A minimally invasive transanal approach was performed to remove the mesh and restore the rectal integrity.

RESULTS

This surgical technique demonstrates rectal mesh removal with a transanal approach.

CONCLUSIONS

To our knowledge, this is a rare complication of rectal erosion of a posterior transperineal mesh kit. The aim of this video is to show a complete transanal approach to treating this serious complication avoiding the more invasive and traumatic abdominal procedure.

Uterine preservation vs hysterectomy in pelvic organ prolapse surgery: a systematic review with meta-analysis and clinical practice guidelines

OBJECTIVE

We aimed to systematically review the literature on apical pelvic organ prolapse surgery with uterine preservation compared with prolapse surgeries including hysterectomy and provide evidence-based guidelines.

DATA SOURCES

The sources for our data were MEDLINE, Cochrane, and clinicaltrials.gov databases from inception to January 2017.

STUDY ELIGIBILITY CRITERIA

We accepted randomized and nonrandomized studies of uterine-preserving prolapse surgeries compared with those involving hysterectomy.

STUDY APPRAISAL AND SYNTHESIS METHODS

Studies were extracted for participant information, intervention, comparator, efficacy outcomes, and adverse events, and they were individually and collectively assessed for methodological quality. If 3 or more studies compared the same surgeries and reported the same outcome, a meta-analysis was performed.

RESULTS

We screened 4467 abstracts and identified 94 eligible studies, 53 comparing uterine preservation to hysterectomy in prolapse surgery. Evidence was of moderate quality overall. Compared with hysterectomy plus mesh sacrocolpopexy, uterine preservation with sacrohysteropexy reduces mesh exposure, operative time, blood loss, and surgical cost without differences in prolapse recurrence. Compared with vaginal hysterectomy with uterosacral suspension, uterine preservation in the form of laparoscopic sacrohysteropexy improves the C point and vaginal length on the pelvic organ prolapse quantification exam, estimated blood loss, postoperative pain and functioning, and hospital stay, but open abdominal sacrohysteropexy worsens bothersome urinary symptoms, operative time, and quality of life. Transvaginal mesh hysteropexy (vs with hysterectomy) decreases mesh exposure, reoperation for mesh exposure, postoperative bleeding, and estimated blood loss and improves posterior pelvic organ prolapse quantification measurement. Transvaginal uterosacral or sacrospinous hysteropexy or the Manchester procedure compared with vaginal hysterectomy with native tissue suspension both showed improved operative time and estimated blood loss and no worsening of prolapse outcomes with uterine preservation. However, there is a significant lack of data on prolapse outcomes >3 years after surgery, the role of uterine preservation in obliterative procedures, and longer-term risk of uterine pathology after uterine preservation.

CONCLUSION

Uterine-preserving prolapse surgeries improve operating time, blood loss, and risk of mesh exposure compared with similar surgical routes with concomitant hysterectomy and do not significantly change short-term prolapse outcomes. Surgeons may offer uterine preservation as an option to appropriate women who desire this choice during apical prolapse repair.

No. 351-Transvaginal Mesh Procedures for Pelvic Organ Prolapse

OBJECTIVE

This guideline reviews the evidence related to the risks and benefits of using transvaginal mesh in pelvic organ prolapse repairs in order to update recommendations initially made in 2011.

INTENDED USERS

Gynaecologists, residents, urologists, urogynaecologists, and other health care providers who assess, counsel, and care for women with pelvic organ prolapse.

TARGET POPULATION

Adult women with symptomatic pelvic organ prolapse considering surgery and those who have previously undergone transvaginal mesh procedures for the treatment of pelvic organ prolapse.

OPTIONS

The discussion relates to transvaginal mesh procedures compared with other surgical options for pelvic organ prolapse (mainly about vaginal native tissue repairs and minimally about other alternatives such as biological and absorbable vaginal mesh and abdominally placed surgical mesh).

OUTCOMES

The outcomes of interest are objective and subjective success rates and intraoperative and postoperative complications, such as adjacent organ injury (urinary, gastrointestinal), infection, hematoma/bleeding, vaginal mesh exposure, persistent pain, dyspareunia, de novo stress urinary incontinence, and reoperation.

EVIDENCE

PubMed, Medline, the Cochrane Database, and EMBASE were searched using the key words pelvic organ prolapse/surgery*, prolapse/surgery*, surgical mesh, surgical mesh*/adverse effects, transvaginal mesh, and pelvic organ prolapse.

RESULTS

were restricted to English or French language and human research. Articles obtained through this search strategy were included until the end of June 2016. Pertinent new studies were added up to September 2016. Grey literature was not searched. Clinical practice guidelines and guidelines of specialty societies were reviewed. Systematic reviews were included when available. Randomized controlled trials and observational studies were included when evidence for the outcome of interest or in the target population was not available from systematic reviews. New studies not yet included in systematic reviews were also included. Only publications with study groups larger than 20 individuals were selected because this criterion was used in the largest meta-analysis referenced in this guideline. A total of 1470 studies were obtained; after selecting only applicable studies and excluding duplicates, 68 manuscripts were reviewed and included.

VALUES

The content and recommendations were drafted and agreed upon by the principal authors and members of the Urogynaecology Committee. The Board of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation methodology framework. The Summary of Findings is available upon request.

BENEFITS, HARMS, AND/OR COSTS

It is expected that this guideline will benefit women with pelvic organ prolapse by ensuring that health care providers are aware of outcomes related to transvaginal mesh procedures and steps in the management of related complications. This should guide patient-informed consent before such procedures are undertaken. The benefits clearly outweigh the potential harms or costs of implementation of this guideline, although no direct harms or costs are identified.

GUIDELINE UPDATE

Evidence will be reviewed 5 years after publication to decide whether all or part of the guideline should be updated. However, if important new evidence is published prior to the 5-year cycle, the review process may be accelerated for a more rapid update of some recommendations.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Long term Follow-up of Transvaginal Anatomical Implant of Mesh in Pelvic organ prolapse

Transvaginal mesh (TVM) is a minimally invasive but effective treatment for pelvic organ prolapse (POP). However, mesh exposure is a common and problematic complication after TVM. This study assessed the safety and long-term outcomes of TVM. A retrospective review was performed on the medical records of 175 consecutive patients who underwent TVM with the anatomical implant technique for pelvic organ prolapse at our center from April 2007 to December 2012. All operations were performed using TVM with the anatomical implant technique. Intraoperative variables, postoperative complications, and TVM outcomes were assessed. In average of 8 years (ranging from 4 to 10 years), the objective cure ratio reached 99.4%; and the subjective success rate of the TVM operation was 91.4%. Only 2 cases (1.1%) were identified as having mesh exposure. The reoperation rate was 4.0% (95% CI, 1.1–6.9%). No patients abstained from sex due to the operation or postoperative discomfort. Our anatomical implant technique for correcting POP is feasible in TVM procedures, which lead to favourable subjective and objective outcomes with the lowest rates of mesh exposure (1.1%) in published data. Therefore, performing TVM operations with the appropriate technique could consider to be permitted.

Solvent-dehydrated dermal allograft (AXIS™) augmented cystocele repair: longitudinal results

INTRODUCTION AND HYPOTHESIS

Surgical repair options for pelvic organ prolapse (POP) include native tissue, allograft, xenograft, and synthetic grafts. Solvent-dehydrated dermal allograft (SDDG) has an improved safety profile. We evaluated the long-term safety and efficacy of SDDG use for cystocele repair.

METHODS

A total of 184 patients completed a minimum follow-up of 12 months. Incontinence Impact Questionnaire (IIQ), Urogenital Distress Inventory (UDI), and Visual Analogue Scale (VAS) were used pre and post operatively. Recurrent cystocele grade ≥ II and/or repeat cystocele repair were considered objective failure.

RESULTS

Preoperatively, 17 patients (10%) had grade IV cystocele, 87 (47%) grade III, 70 (38%) grade II, and 10 (5%) grade I. All patients underwent SDDG cystocele repair with/without vaginal sling and/or POP repair and/or hysterectomy. Mean hospital stay was 0.58 days (range 0-4), mean estimated blood loss (EBL) was 111 mL, and mean length of Foley catheterization was 1.85 days (range 0-28). Postoperatively, 113 patients (64%) had no recurrent cystocele, 34 (19%) had grade I, 19 (11%) grade II, and 10 (6%) grade III cystocele. None had grade IV cystocele. Nineteen patients (10.3%) underwent repeat cystocele repair. Thirty-eight patients (21.6%) had postoperative recurrence (recurrent cystocele grade ≥ II and/or repeat cystocele repair). Dermal allograft related adverse events included 1 (0.5%) allograft vaginal exposure, dyspareunia 1 (0.5%), and transient hydronephrosis in 1 (0.5%). There were no vascular, vesical, visceral or neurological injuries.

CONCLUSIONS

These results indicate that SDDG augmented cystocele repair is a safe procedure, with low morbidity, and it's success is comparable to other techniques.

Incidence and risk factors for mesh erosion after laparoscopic repair of pelvic organ prolapse by lateral suspension with mesh

INTRODUCTION AND HYPOTHESIS

The objective of our study was to estimate the incidence and identify the risk factors for mesh erosion after laparoscopic repair of pelvic organ prolapse (POP) by lateral suspension with mesh.

METHODS

We conducted a nested case-control study among 480 women who underwent POP repair by laparoscopic lateral suspension with mesh from January 2004 to October 2012. Cases (n = 18) were women who showed mesh erosion following the first intervention through December 2014. Controls (n = 133) were women randomly selected from the same cohort who did not have any erosion.

RESULTS

The risk of mesh erosion was 3.8 % with a mean follow-up of 82.3 months (range 28.2 - 130.6 months). The main risk factor was the use of a type 3 mesh (macroporous with either multifilamentous or microporous components) rather than a type 1 mesh (macroporous and monofilamentous; adjusted OR 13.0, 95 % CI 1.5 - 110.6; P = 0.02). Risk factors included smoking (adjusted OR 10.4, 95 % CI 2.3 - 46.5; P < 0.01) and posterior mesh placement (adjusted OR 5.1, 95 % CI 1.2 - 21.8 P = 0.03).

CONCLUSIONS

The risk of mesh erosion is low and may be further reduced by using the appropriate mesh material, and by identifying specific patient characteristics such as tobacco use. As conventional vaginal surgery is effective for the treatment of the posterior compartment, the use of posterior mesh during laparoscopic pelvic floor repair needs to be questioned.

Endoscopic lithotripsy and vaginal excision of a calcified bladder-mesh extrusion

INTRODUCTION AND HYPOTHESIS

Synthetic meshes have proven to increase efficacy of pelvic organ prolapse (POP) repair, but associated complications are not rare. Bladder mesh extrusion is one of the most serious adverse events following POP surgery with mesh. The aim of this video was to describe endoscopic and vaginal approaches for treating a bladder-mesh extrusion.

METHODS

A 52-year-old female patient with a history of vaginal POP surgery with mesh was referred for severe pelvic and perineal pain, dyspareunia, and dysuria. She was found to have a bladder calculus on a mesh extrusion. The calculus was removed by endoscopic lithotripsy before vaginal mesh excision was performed.

CONCLUSIONS

With the use of synthetic vaginal mesh, the incidence of bladder-mesh extrusion could increase. This didactic video will be helpful to surgeons required to manage such cases using a minimally invasive treatment.

The efficacy of pelvic floor muscle training for pelvic organ prolapse: a systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

Our objective was to assess the effectiveness of pelvic floor muscle training (PFMT) as a treatment for women with pelvic organ prolapse (POP) or as an adjunct to prolapse surgery.

METHODS

Relevant literature sources were searched using databases including PubMed, Ovid, Web of Science, Scopus, ClinicalTrials.gov, EBSCO, CINAHL, the Cochrane Central Register of Controlled Trials, CNKI, VIP, Wanfang, and CBM until 5 July 2015. Eligible studies were restricted to randomized controlled trials (RCT). The available data were pooled using Review Manager version 5.2. For data deemed not appropriate for synthesis, a narrative overview was conducted.

RESULTS

In total, 13 studies with 2,340 patients were included. Our results indicated women receiving PFMT gained a greater improvement than controls in prolapse symptom score [mean difference (MD) -3.07, 95 % confidence interval (CI) -3.91 to -2.23] and POP stages [risk ratio (RR) 1.70, 95 % CI 1.19-2.44]. The number of women who said their prolapse was getting better was higher (RR 5.48, 95 % CI 2.19-13.72) and other discomfort syndromes, such as vaginal, bladder, and rectum, were lower in the PFMT groups than in controls. Meanwhile, women after PFMT had greater improvement in muscle strength and endurance but did not show a significant difference for further treatment needs. In addition, the results evaluating PFMT as an adjunct to prolapse surgery were inconclusive because of the variability in methods of measuring outcome.

CONCLUSIONS

Our meta-analysis demonstrated women who received PFMT showed a greater subjective improvement in prolapse symptoms and an objective improvement in POP severity.

Diagnosis and treatment of faecal incontinence: Consensus statement of the Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists

Faecal incontinence is a common and disturbing condition, which leads to impaired quality of life and huge social and economic costs. Although recent studies have identified novel diagnostic modalities and therapeutic options, the best diagnostic and therapeutic approach is not yet completely known and shared among experts in this field. The Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists selected a pool of experts to constitute a joint committee on the basis of their experience in treating pelvic floor disorders. The aim was to develop a position paper on the diagnostic and therapeutic aspects of faecal incontinence, to provide practical recommendations for a cost-effective diagnostic work-up and a tailored treatment strategy. The recommendations were defined and graded on the basis of levels of evidence in accordance with the criteria of the Oxford Centre for Evidence-Based Medicine, and were based on currently published scientific evidence. Each statement was drafted through constant communication and evaluation conducted both online and during face-to-face working meetings. A brief recommendation at the end of each paragraph allows clinicians to find concise responses to each diagnostic and therapeutic issue.

Transvaginal repair of stage III-IV cystocele using a lightweight mesh: safety and 36-month outcome

INTRODUCTION AND HYPOTHESIS

The aim of this study was to assess the 36-month safety and efficacy of a lightweight polypropylene mesh used for the transvaginal repair of stage III-IV cystocele.

METHODS

A multicenter prospective cohort study was performed. Preoperative assessment included an interview and evaluation with the Pelvic Organ Prolapse Quantification (POP-Q) system. Inclusion criteria were stage III-IV cystocele and no contraindications for mesh use. A lightweight (28 g/m(2)) four-arm transobturator polypropylene mesh was used for the study. Pre- and postoperative symptoms and quality of life were assessed using the Urinary Symptoms Measurement (MHU), Pelvic Floor Distress Inventory (PFDI-20), Pelvic Floor Impact Questionnaire (PFIQ-7), and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). The main endpoint was mesh safety. Secondary endpoints were anatomic (Ba point ≤ -1) and functional success.

RESULTS

In all, 111 patients with a mean age of 67 ± 9 years (range 47-89) were included in the study, and 94 (84.7%) were included in the analysis. Two intraoperative complications occurred (one bladder and one rectal injury, 2.2%). Medium-term analysis of 79 patients (84%) after 36 months showed a satisfaction rate of 98.7% (78/79), a mesh contraction rate of 5.1% (4/78), only one case of vaginal mesh exposure (1.3%), no cases of chronic pelvic pain, and a postoperative dyspareunia rate of 2.8% (1/36). The anatomic success rate of cystocele repair was 75/79 (94.9%) and a highly significant improvement was noted for symptoms and on quality of life questionnaires. Overall, 7/79 patients (8.9%) were reoperated, including 1 for hemorrhage, 1 for vaginal mesh exposure, 3 for stress urinary incontinence, and 2 for cystocele recurrence (2.5%).

CONCLUSION

Transvaginal cystocele repair using a lightweight transobturator polypropylene mesh was safe and efficient in the medium term. Long-term data and comparative studies are needed.

Postpartum pelvic floor muscle training and pelvic organ prolapse--a randomized trial of primiparous women

OBJECTIVE

Pelvic organ prolapse (POP) is a common and distressing condition. The aim of the present study was to evaluate the effect of pelvic floor muscle training (PFMT) on prevention and treatment of symptoms and signs of POP in primiparous postpartum women.

STUDY DESIGN

This was a parallel group assessor blind randomized controlled trial. One hundred seventy-five primiparous postpartum women, mean age 29.8 years (standard deviation 4.1), stratified on major levator ani defects or no defect diagnosed by 3-/4-dimensional ultrasound, participated in a 4-month PFMT starting at 6-8 weeks' postpartum or control. All participants had thorough individual instruction and assessment of ability to perform correct pelvic floor muscle contractions. The PFMT group followed a supervised, weekly group training program and performed 3 sets of 8-12 daily maximal contractions at home. Main outcome was POP stage II or greater assessed by POP quantification and bladder neck position assessed by 3-/4- dimensional transperineal ultrasonography. Secondary outcome was symptoms of vaginal bulge using International Consultation on Incontinence Vaginal Symptoms questionnaire.

RESULTS

Ninety-six percent of the intervention group adhered to ≥80% of both group and home training sessions. At postintervention, there was no significant risk difference in POP (rational ratio, 1.62; 95% confidence interval, 0.55-4.75), bladder neck position or symptoms of vaginal bulging.

CONCLUSION

No effect was found of postpartum PFMT on POP in primiparous women. More randomized controlled trials are needed before strong conclusions can be drawn on the effect of PFMT on POP in the particular population.

Pelvic Organ Prolapse-Associated Cystitis

Pelvic organ prolapse (POP) and urinary tract infection (UTI) are important problems, estimated to affect around 14 and 40 % of women, respectively, at some point in their lives. Positive urine culture in the presence of symptoms is the cornerstone of diagnosis of UTI and should be performed along with ultrasound assessment of postvoid residual (PVR) in all women presenting with POP and UTI. PVR over 30 mL is an independent risk factor for UTI, although no specific association with POP and UTI has been demonstrated. The use of prophylactic antibiotics remains controversial. The major risk factors for postoperative UTI are postoperative catheterisation, prolonged catheterisation, previous recurrent UTI and an increased urethro-anal distance—suggesting that global pelvic floor dysfunction may play a role.