Introduction of newer surgical prostheses and procedures in pelvic reconstruction: a challenge for pelvic surgeons

De novo stress incontinence and pelvic muscle symptoms after transvaginal mesh repair

OBJECTIVE

We sought to determine the rate of de novo stress incontinence, pelvic muscle symptoms, mesh exposure, visceral injury rate, and recurrent prolapse after transvaginal mesh repair.

STUDY DESIGN

We conducted a retrospective review of 335 consecutive women with stage II or worse vaginal prolapse who underwent Prolift (Ethicon, Somerville, NJ) between July 7, 2005 and Jan. 31, 2008.

RESULTS

In all, 71% underwent total Prolift, 20% anterior, and 8% posterior alone. Average age was 62 years and mean follow-up was 8 months. The intraoperative visceral injury rate was 6.6%, mesh exposure rate was 3.8%, and recurrent failure rate was 5.2%. The postoperative de novo stress incontinence rate was 24.3%. In this series, 18% of women had pelvic muscle symptoms postoperatively; 74% of these resolved within 6 months with conservative management.

CONCLUSION

After Prolift, surgeons can expect a low rate of recurrent prolapse and mesh exposure. However, pelvic muscle dysfunction and de novo stress incontinence will be encountered postoperatively in a moderate number of women.

Operations and pelvic muscle training in the management of apical support loss (OPTIMAL) trial: design and methods

The primary aims of this trial are: 1) to compare surgical outcomes following sacrospinous ligament fixation to uterosacral vaginal vault suspension in women undergoing vaginal surgery for apical or uterine pelvic organ prolapse and stress urinary incontinence and 2) to examine the effects of a structured perioperative program consisting of behavioral techniques and pelvic floor muscle training compared to usual care. This trial is performed through the Pelvic Floor Disorders Network (PFDN), which is funded by National Institute of Child Health and Human Development. Subjects will be enrolled from hospitals associated with seven PFDN clinical centers across the United States. A centralized biostatistical coordinating center will oversee data collection and analysis. Two approaches will be investigated simultaneously using a 2x2 randomized factorial design: a surgical intervention (sacrospinous ligament fixation versus uterosacral vaginal vault suspension) and a perioperative behavioral intervention (behavioral and pelvic floor muscle training versus usual care). Surgeons have standardized essential components of each surgical procedure and have met specific standards of expertise. Providers of the behavioral intervention have undergone standardized training. Anatomic, functional, and health-related quality of life outcomes will be assessed using validated measures by researchers blinded to all randomization assignments. Cost-effectiveness analysis will be performed using prospectively collected data on health care costs and resource utilization. The primary surgical endpoint is a composite outcome defined by anatomic recurrence, recurrence of bothersome vaginal prolapse symptoms and/or retreatment and will be assessed 2 years after the index surgery. Endpoints for the behavioral intervention include both short-term (6-month) improvement in urinary symptoms and long-term (2-year) improvement in anatomic outcomes and prolapse symptoms. This article describes the rationale and design of this randomized trial, focusing on several key design features of potential interest to researchers in the field of female pelvic floor disorders and others conducting randomized surgical trials.