Repair of the Anterior Vaginal Compartment

Recommended standardized terminology of the anterior female pelvis based on a structured medical literature review

BACKGROUND

The use of imprecise and inaccurate terms leads to confusion amongst anatomists and medical professionals.

OBJECTIVE

We sought to create recommended standardized terminology to describe anatomic structures of the anterior female pelvis based on a structured review of published literature and selected text books.

STUDY DESIGN

We searched MEDLINE from its inception until May 2, 2016, using 11 medical subject heading terms to identify studies reporting on anterior female pelvic anatomy; any study type published in English was accepted. Nine textbooks were also included. We screened 12,264 abstracts, identifying 200 eligible studies along with 13 textbook chapters from which we extracted all pertinent anatomic terms.

RESULTS

In all, 67 unique structures in the anterior female pelvis were identified. A total of 59 of these have been previously recognized with accepted terms in Terminologia Anatomica, the international standard on anatomical terminology. We also identified and propose the adoption of 4 anatomic regional terms (lateral vaginal wall, pelvic sidewall, pelvic bones, and anterior compartment), and 2 structural terms not included in Terminologia Anatomica (vaginal sulcus and levator hiatus). In addition, we identified 2 controversial terms (pubourethral ligament and Grafenberg spot) that require additional research and consensus from the greater medical and scientific community prior to adoption or rejection of these terms.

CONCLUSION

We propose standardized terminology that should be used when discussing anatomic structures in the anterior female pelvis to help improve communication among researchers, clinicians, and surgeons.

Body mass index based evaluation of 6-year outcomes after transobturator tension-free vaginal tape for female urinary incontinence

INTRODUCTION

The long-term results will be presented according to the body mass index (BMI) rates for transobturator tension-free vaginal.

METHODS

Three hundred nineteen female patients were evaluated (2008-2014). Their incontinence was classified according to the Stamey classification. The International Consultation on Incontinence Questionnaire-Short form was filled in before and after surgery. The Pelvic Organ Prolapse quantification system was utilized. The Female Sexual Function Index and the International Index of Erectile Functions were asked to be filled in. Their satisfaction level was assessed in the sixth year with the modified Clavien classification system. BMI cut-off points for public health action for the Asian population were adopted in the present study as follows: 18.5-23.0 kg/m2 (normal), 23.1-27.4 kg/m2 (high) and at least 27.5 kg/m2 (obese), respectively.

RESULTS

The median success rate on the 12th month was calculated as 81.25% in the follow-ups after TOT; it was observed that the median success rate after 72 months decreased to 79.15%. Significant improvements were observed in the Female Sexual Function Index and the Index of Erectile Dysfunction. The objective cure rates detected according to normal, high and obese BMI rates, respectively, were 93.1%, 75.9% and 81.4%, while the patient satisfaction rates were 83.3%, 81.3% and 83.1%, respectively.

CONCLUSIONS

It was observed that the objective and subjective patient satisfaction rates were very good in the long term in all BMI groups. No statistically significant differences were observed in perioperative complication rate, 6-year success rates and patient satisfaction among the three different BMI groups in the long term.

Outcomes of two different incision techniques for surgical treatment of stress urinary incontinence with concomitant anterior vaginal wall prolapse

PURPOSE

To assess the outcomes of two different incision techniques used in the surgical treatment of stress urinary incontinence (SUI) with concomitant anterior vaginal wall prolapse and to identify possible associated risk factors with a medium-term follow-up in patients who underwent TOT procedure.

METHODS

We conducted a retrospective cohort study of 233 women who underwent transobturator tape procedure with cystocele repair. The women were divided into two groups according to two different incision techniques. The outcomes were analyzed considering five postoperative parameters: objective cure, subjective cure, patient satisfaction, resolution of urgency urinary incontinence and complications. The mean follow-up period was 43.6 months (range 12-85).

RESULTS

A total of 226 women were documented in this study: 79 women in single-incision technique (group 1) and 147 women in double-incision technique (group 2). The objective and subjective cure and patient satisfaction (visual analog scale score ≥80) rates were 89.8, 73.4, 84.8 % and 90.4, 74.1, 86.4 % in group 1 and group 2, respectively. Complications reported according to the Clavien-Dindo classification were grade I 5.2 %, grade II 42.1 %, grade IIIa 47.3 %, and grade IIIb 5.2 %, and grade I 22.2 %, grade II 77.7 %, grade IIIa 0 % and grade IIIb 0 % in group 1 and group 2, respectively. The mean operative time was significantly shorter in group 1 compared to group 2 (p = 0.001).

CONCLUSIONS

Both incision techniques have satisfactory outcomes in the surgical treatment of SUI with cystocele; nevertheless, the postoperative complications favor the double-incision technique.

Sexual function after anterior vaginal wall prolapse surgery

OBJECTIVE

The aim of this study was to compare female sexual function after surgical treatment of anterior vaginal prolapse with either small intestine submucosa grafting or traditional colporrhaphy.

METHODS

Subjects were randomly assigned, preoperatively, to the small intestine submucosa graft (n = 29) or traditional colporrhaphy (n = 27) treatment group. Postoperative outcomes were analyzed at 12 months. The Female Sexual Function Index questionnaire was used to assess sexual function. Data were compared with independent samples or a paired Student's t-test.

RESULTS

In the small intestine submucosa group, the total mean Female Sexual Function Index score increased from 15.5±7.2 to 24.4±7.5 (p<0.001). In the traditional colporrhaphy group, the total mean Female Sexual Function Index score increased from 15.3±6.8 to 24.2±7.0 (p<0.001). Improvements were noted in the domains of desire, arousal, lubrication, orgasm, satisfaction, and pain. There were no differences between the two groups at the 12-month follow-up.

CONCLUSIONS

Small intestine submucosa repair and traditional colporrhaphy both improved sexual function postoperatively. However, no differences were observed between the two techniques.

Ex vivo comparison of microbicide efficacies for preventing HIV-1 genomic integration in intraepithelial vaginal cells

Vaginally applied microbicides hold promise as a strategy to prevent sexual HIV transmission. Several nonspecific microbicides, including the polyanion cellulose sulfate, have been evaluated in large-scale clinical trials but have failed to show significant efficacy. These findings have prompted a renewed search for preclinical testing systems that can predict negative outcomes of microbicide trials. Moreover, the pipeline of potential topical microbicides has been expanded to include antiretroviral agents, such as reverse transcriptase, fusion, and integrase inhibitors. Using a novel ex vivo model of vaginal HIV-1 infection, we compared the prophylactic potentials of two forms of the fusion inhibitor T-20, the CCR5 antagonist TAK-778, the integrase inhibitor 118-D-24, and cellulose sulfate (Ushercell). The T-20 peptide with free N- and C-terminal amino acids was the most efficacious compound, causing significantly greater inhibition of viral genomic integration in intraepithelial vaginal leukocytes, measured by an optimized real-time PCR assay, than the more water-soluble N-acetylated T-20 peptide (Fuzeon) (50% inhibitory concentration [IC50], 0.153 microM versus 51.2 microM [0.687 ng/ml versus 230 ng/ml]; P<0.0001). In contrast, no significant difference in IC50s was noted in peripheral blood cells (IC50, 13.58 microM versus 7.57 microM [61 ng/ml versus 34 ng/ml]; P=0.0614). Cellulose sulfate was the least effective of all the compounds tested (IC50, 1.8 microg/ml). These results highlight the merit of our model for screening the mucosal efficacies of novel microbicides and their formulations and potentially rank ordering candidates for clinical evaluation.

Urodynamic Changes in Pelvic Organ Prolapse and the Role of Surgery

BACKGROUND

Pelvic organ prolapse (POP) is a major health problem of the "elderly" lady. The urological changes associated with POP and the beneficial effects of surgery on these changes continues to be controversial. We studied the urodynamic changes in POP and the effect of definitive surgery on these changes.

METHODS

A total of 50 cases of POP, over a two year period, were subjected to urodynamic studies both pre and postoperatively and the data analyzed, to ascertain the effect of surgery on the urological profile of a patient with POP.

RESULT

Four of the 50 patients studied had demonstrable stress urinary incontinence and two of these benefited significantly after surgery. In addition it was observed that four new patients developed stress urinary incontinence (SUI) postoperatively. It was also observed that the values of Qmax significantly improved after surgery from 9.2ml/s to 18.6ml/s.

CONCLUSION

Definitive surgery improves the urological profile of the patient with POP, to a certain extent. A good clinical examination of patients with POP from the urological viewpoint, is essential preoperatively, to pick up the patients who are likely to develop stress incontinence postoperatively, so that corrective action can be initiated during surgery.

Surgical repair of anterior wall vaginal defects

OBJECTIVE

To compare the clinical efficacy of 3 surgical procedures for central types of anterior vaginal wall defect.

METHODS

A total of 138 patients diagnosed with central types of anterior vaginal wall defect who underwent classic transvaginal repair (n=72), transvaginal repair with polypropylene mesh (n=28), and internal repair (n=38) were followed up for at least 1 year.

RESULTS

There were no differences in development of fever, vaginal erosion, detrusor overactivity, and voiding difficulty among the 3 groups, but the incidence of postoperative urinary tract infections was significantly higher in the polypropylene mesh repair group. The difference in preoperative and postoperative hemoglobin levels and wound infection incidence were significantly higher in the internal repair group. Moreover, the recurrence rate of the anterior vaginal wall defect was significantly higher at 1 year in the internal repair group.

CONCLUSION

Transvaginal surgical repair seems to be more efficacious than internal surgical repair for central types of anterior vaginal wall defects.