Soft-tissue dystocia due to paradoxical contraction of the levator ani as a cause of prolonged second stage: concept, diagnosis, and potential treatment

Smaller pelvic floor dimensions seem to have been an evolutionary need to provide adequate support for the pelvic organs and the fetal head. Pelvic floor dimension and shape contributed to the complexity of human birth. Maternal pushing associated with pelvic floor muscle relaxation is key to vaginal birth. Using transperineal ultrasound, pelvic floor dimensions can be objectively measured in both static and dynamic conditions, such as pelvic floor muscle contraction and pushing. Several studies have evaluated the role of the pelvic floor in labor outcomes. Smaller levator hiatal dimensions seem to be associated with a longer duration of the second stage of labor and a higher risk of cesarean and operative deliveries. Furthermore, smaller levator hiatal dimensions are associated with a higher fetal head station at term of pregnancy, as assessed by transperineal ultrasound. With maternal pushing, most women can relax their pelvic floor, thus increasing their pelvic floor dimensions. Some women contract rather than relax their pelvic floor muscles under pushing, which is associated with a reduction in the anteroposterior diameter of the levator hiatus. This phenomenon is called levator ani muscle coactivation. Coactivation in nulliparous women at term of pregnancy before the onset of labor is associated with a higher fetal head station at term of pregnancy and a longer duration of the second stage of labor. In addition, levator ani muscle coactivation in nulliparous women undergoing induction of labor is associated with a longer duration of the active second stage of labor. Whether we can improve maternal pelvic floor relaxation with consequent improvement in labor outcomes remains a matter of debate. Maternal education, physiotherapy, and visual feedback are promising interventions. In particular, ultrasound visual feedback before the onset of labor can help women increase their levator hiatal dimensions and correct levator ani muscle coactivation in some cases. Ultrasound visual feedback in the second stage of labor was found to help women push more efficiently, thus obtaining a lower fetal head station at ultrasound and a shorter duration of the second stage of labor. The available evidence on the role of any intervention aimed to aid women to better relax their pelvic floor remains limited, and more studies are needed before considering its routine clinical application.

Coexisting overactive-underactive bladder and detrusor overactivity-underactivity in pelvic organ prolapse

OBJECTIVE

The coexisting overactive-underactive bladder (COUB) syndrome could be related to the increased urethral resistance caused by severe pelvic organ prolapse (POP). We aimed to evaluate the clinical and urodynamic findings of patients with COUB and/or detrusor overactivity-underactivity (DOU) in a cohort of patients scheduled for POP surgery and the possible risk factors of COUB after surgery.

METHODS

This retrospective study analyzed all patients who underwent POP repair between 2008 and 2013, excluding women with a history of pelvic floor surgery. Patients were divided into COUB and non-COUB according to baseline symptoms and into DOU and non-DOU based on urodynamic findings. A multivariate model was performed to identify risk factors for COUB symptoms after surgery.

RESULTS

A total of 533 women underwent POP surgery. Preoperatively, patients with COUB had more severe anterior compartment prolapse (Pelvic Organ Prolapse Quantification staging system Aa point, P = 0.008) and more frequently had overactive bladder compared with controls (P = 0.023). The rate of COUB decreased significantly after surgery. Preoperative opening detrusor pressure resulted as the only independent predictor of postoperative COUB symptoms (P = 0.034).

CONCLUSION

POP is a valid pathogenetic model for COUB development. POP repair induced a significant decrease in COUB symptoms with low opening detrusor pressure resulting as the only independent predictor of postoperative COUB.

The Perinatal Assessment of Paternal Affectivity (PAPA): Italian validation of a new tool for the screening of perinatal depression and affective disorders in fathers

BACKGROUND

Questionnaires for the screening of paternal perinatal psychological distress are based on clinical manifestations expressed by women, showing limitations in capturing the wide array of signs and symptoms exhibited by men. The current study aimed to validate the Perinatal Assessment of Paternal Affectivity, a new self-report tool for the screening of paternal depressive and affective disorder.

METHOD

This study used a cross-sectional design with a 3-month test-retest, involving respectively 385 (T1) and a sub-sample of 111(T2) fathers. Confirmatory factor analysis (CFA) was performed to test structural validity and concurrent validity was assessed by Spearman correlations. We assessed reliability using McDonald's ω and ordinal alpha. Group differences in PAPA scores based on sociodemographic were also tested.

RESULTS

The CFA reported a one factor structure as the optimal solution. The PAPA also showed adequate reliability and internal consistency as well as acceptable test-retest indices. Concurrent validity was confirmed by significant correlations between PAPA total score and standardized test scores. Non-Italian fathers and fathers who experienced recent stressful life events reported higher PAPA scores.

LIMITATIONS

Our sample was not homogeneous in terms of nationality and most of the participants, were from Northern Italy. Some risk factors associated with paternal parental psychological distress (e.g., unplanned pregnancy) have not been considered.

CONCLUSION

This study provides initial evidence of validity and reliability of the PAPA as a brief and sensitive screening tool to detect signs and symptoms of paternal affective disorder during both prenatal and postnatal period.

Native-tissue prolapse repair: efficacy and adverse effects of uterosacral ligaments suspension at 10-year follow up

Objective

To evaluate the 10‐year outcomes of high uterosacral ligaments suspension as a primary repair for apical prolapse and to evaluate the long‐term impact of prognostic factors.

Methods

A retrospective study analyzed 10‐year follow up after repair of primary apical prolapse through high uterosacral ligament suspension. Bulging symptoms and postoperative prolapse stage II or above were considered subjective and objective recurrences, respectively. Patient Global Impression of Improvement score was used to evaluate subjective satisfaction after surgery.

Results

A total of 287 women were analyzed. Ten‐year recurrence rates were 19.1% for objective recurrence and 6.3% for subjective recurrence; surgical retreatment rate was 2.1%. Premenopausal status was related to 15‐fold increased risk of developing either objective or subjective recurrence. Conversely, anterior and posterior repair were protective factors against reoperation.

Conclusion

High uterosacral ligaments suspension is a safe and long‐lasting effective procedure for the treatment of uterovaginal prolapse even 10 years after index surgery. Premenopausal status and lack of anterior and posterior repair represented long‐term risk factors for surgical failure.

Mode of birth in women with low-lying placenta: protocol for a prospective multicentre 1:3 matched case-control study in Italy (the MODEL-PLACENTA study)

INTRODUCTION

The term placenta praevia defines a placenta that lies over the internal os, whereas the term low-lying placenta identifies a placenta that is partially implanted in the lower uterine segment with the inferior placental edge located at 1-20 mm from the internal cervical os (internal-os-distance). The most appropriate mode of birth in women with low-lying placenta is still controversial, with the majority of them undergoing caesarean section. The current project aims to evaluate the rate of vaginal birth and caesarean section in labour due to bleeding by offering a trial of labour to all women with an internal-os-distance >5 mm as assessed by transvaginal sonography in the late third trimester.

METHODS AND ANALYSIS

The MODEL-PLACENTA is a prospective, multicentre, 1:3 matched case-control study involving 17 Maternity Units across Lombardy and Emilia-Romagna regions, Italy. The study includes women with a placenta located in the lower uterine segment at the second trimester scan. Women with a normally located placenta will be enrolled as controls. A sample size of 30 women with an internal-os-distance >5 mm at the late third trimester scan is needed at each participating Unit. Since the incidence of low-lying placenta decreases from 2% in the second trimester to 0.4% at the end of pregnancy, 150 women should be recruited at each centre at the second trimester scan. A vaginal birth rate ≥60% in women with an internal-os-distance >5 mm will be considered appropriate to start routinely admitting to labour these women.

ETHICS AND DISSEMINATION

Ethical approval for the study was given by the Brianza Ethics Committee (No 3157, 2019). Written informed consent will be obtained from study participants. Results will be disseminated by publication in peer-reviewed journals and presentation in international conferences.

TRIAL REGISTRATION NUMBER

NCT04827433 (pre-results stage).

Single-incision slings for the treatment of stress urinary incontinence: efficacy and adverse effects at 10-year follow-up

INTRODUCTION AND HYPOTHESIS

Single-incision slings are not considered a first-choice surgical treatment owing to a lack of data about long-term outcomes. We aimed to assess the long-term results of urinary incontinence treatment after single-incision sling implantation at 10 years' follow-up and to investigate possible deterioration over time.

METHODS

This retrospective study analyzed women with subjective and urodynamically proven stress urinary incontinence who underwent single-incision sling procedure. The objective cure rate was assessed with a 300-ml stress test. The subjective cure rate was determined by the Patient Global Impression of Improvement (PGI-I) questionnaire. International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) questionnaire scores and self-answered patient-satisfaction scales were collected to assess symptom severity. Findings were compared with short-term outcomes in the same patients, available through our previous database, in order to detect possible outcome deterioration over time.

RESULTS

The records of 60 patients were analyzed. Nine patients (15%) were lost to follow-up. A total of 51 patients completed the evaluation, with a mean follow-up of 10.3 ± 0.7 years. Objective and subjective cure resulted 86.3% and 88.2% respectively. Mean PGI-I scores and ICIQ-SF were 1.5 ± 1.0 and 3.2 ± 4.8 respectively. Patients' satisfaction scored 8.6 ± 2.6 out of 10. No long-term complications occurred. Comparison of short-term (2.6 ± 1.4 years after surgery) and long-term follow-up did not show a significant deterioration of outcome over time.

CONCLUSIONS

Single-incision slings were shown to be a procedure with a great efficacy and safety profile at very long-term follow-up. Cure rates and functional outcomes did not show any deterioration over time compared with short-term results.

The PLART study: incidence of preterm labor and adverse pregnancy outcomes after assisted reproductive techniques-a retrospective cohort study

KEY MESSAGE

Even though assisted reproductive techniques represent one of the greatest achievements in modern medicine, the risk of preterm birth related to these pregnancies is about twice as high. This must be highlighted and further investigated to optimize the management of both mothers and newborns.

PURPOSE

The purpose of this study was to compare adverse pregnancy outcomes after assisted reproductive techniques (ART) and spontaneous conceptions, focusing on the incidence of preterm births (PTB) and distinguishing between iatrogenic and spontaneous events.

METHODS

This retrospective cohort study analyzed single births of one Italian hospital. The incidence of PTBs in ART pregnancies, divided into iatrogenic procedures, spontaneous preterm labors and preterm premature ruptures of the membranes (pPROMs), was compared with the non-ART control group. The incidence of other adverse pregnancy outcomes and the types of delivery were also reported and compared.

RESULTS

Of the 11,769 single births included, 2.39% were conceived by ART. The incidence of PTBs was 4.74% for spontaneous pregnancies and 12.8% for ART pregnancies (aOR 1.93; 95% CI 1.29-2.88). The percentage of iatrogenic procedures was 27.78% in the ART-PTBs' group and 30.88% in the non-ART-PTBs' controls. ART pregnancies showed an increased incidence of pPROMs (6.40% versus 2.41%), preterm labors (2.85% versus 0.93%), hypertensive disorders of the pregnancy (8.19% versus 2.32%), placenta previa (3.20% versus 0.59%), cesarean sections (28.47% versus 16.27%) and vacuum extractions (10.32% versus 5.19%).

CONCLUSIONS

Singleton ART pregnancies have a higher risk of PTB which is mostly linked to a higher incidence of pPROMs and spontaneous preterm labor. The concurrency of a demonstrated higher risk of hypertensive gestational disorders and placenta previa suggests that placental development plays an important role in the pathogenesis of PTB.

Long-term outcomes and five-year recurrence-free survival curves after native-tissue prolapse repair

OBJECTIVE

To evaluate the long-term objective and subjective outcomes to build recurrence-free survival curves after mesh-free uterosacral ligament suspension and to evaluate the long-term impact of prognostic factors on outcome measures.

METHODS

A retrospective study analyzed 5-year follow-up after repair of primary prolapse through high uterosacral ligament suspension. Bulging symptoms and post-operative prolapse stage II or above were considered subjective and objective recurrences, respectively. The cumulative proportion of relapse-free patients in time was analyzed by Kaplan-Meier curves.

RESULTS

A total of 353 women were analyzed. Five-year recurrence rates were 15.0% for objective recurrence, 13.0% for subjective recurrence, and 4.0% for the combined objective and subjective recurrences. Premenopausal status was shown to be a risk factor for anatomic (P=0.022), symptomatic (P=0.001), and combined (P=0.047) recurrence. Conversely, anterior repair was shown to be a protective factor for symptomatic (P=0.012) and combined (P=0.002) recurrence. Most of the recurrences occurred within 2 years after surgery.

CONCLUSION

Long-term outcomes after high uterosacral ligament suspension were satisfactory. Premenopausal status and lack of anterior repair represented risk factors for recurrence in the long term.

Efficacy of needle retractor device in single-incision slings for treatment of stress urinary incontinence

BACKGROUND

Single-incision slings demonstrated overall similar effectiveness and less pain and recovery time compared to standard tapes. Efficacy rates vary widely among different commercial kits and may be affected by device characteristics. The aim was to evaluate the impact needle removal device of single-incision sling on objective, subjective and functional outcomes.

METHODS

This was a retrospective study. Single-incision sling without needle removal device (Group A) were compared to same single-incision sling with needle removal device (Group B) in terms of complications, objective, subjective and functional outcomes.

RESULTS

A total of 191 patients were analyzed: 51 in group A and 140 in group B. Estimated blood loss, operative time and overall complications were not different. No bladder perforation or other intraoperative complications were observed. At 12-month follow-up visit, objective cure rate was similar irrespective of the presence of the needle retractor lever (Group A: 84.3%, Group B: 87.1%; P=0.61). Subjective outcomes evaluated as International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) score, ICIQ-SF score improvement and Patient Global Impression of Improvement score were similar between groups. De-novo onset of overactive bladder syndrome resulted more frequent in Group A (Group A: 19.6%, Group: B 7.9%; P=0.02) while voiding symptoms were reported without differences between groups.

CONCLUSIONS

The current study showed that the presence of a needle retractor device to avoid unintentional tip displacement for single-incision sling had no impact on objective and subjective postoperative continence. However, a reduced rate of de-novo overactive bladder syndrome was observed after implantation of single-incision sling with needle retractor.

Transvaginal native-tissue repair of vaginal vault prolapse

BACKGROUND

Posthysterectomy vaginal vault prolapse repair is a challenge for pelvic floor surgeons. Native-tissue repair procedures imply lower costs and reduced morbidity. Our study aims to evaluate operative data, complications, objective, subjective and functional outcomes of transvaginal native-tissue repair for posthysterectomy vaginal vault prolapse. We also investigated differences among available techniques.

METHODS

Retrospective study including patients with symptomatic vaginal vault prolapse (≥stage 2), previously treated with transvaginal vault suspension through native-tissue repair. Objective recurrence was defined as the descent of at least one compartment ≥II stage according to Pelvic Organ Prolapse Quantification (POP-Q) system or need of reoperation. Subjective recurrence was defined as the presence of bulging symptoms. Patients satisfaction was evaluated with PGI-I Score.

RESULTS

The study included 111 patients. Apical suspension was achieved either by uterosacral ligament suspension (16), levator myorrhaphy (17), iliococcygeus fascia fixation (65) or sacrospinous ligament fixation (13). No intraoperative complications were observed. Perioperative/postoperative complications occurred in 8 patients (7.2%). Mean follow-up was 24.5±12.1 months. Objective recurrence was observed in 28 patients (25.2%). Reintervention was required by 3 patients (2.7%). Subjective recurrence was referred by 6 patients (5.4%). Mean satisfaction evaluated with PGI-I Score was 1.2±0.6. No differences in terms of operative data, overall complications, objective, subjective cure rate and perceived satisfaction were found among different techniques.

CONCLUSIONS

Transvaginal repair with native-tissue procedures is safe and effective in correcting posthysterectomy vaginal vault prolapse and represents a valid alternative to prosthetic procedures for vaginal vault prolapse treatment.

Risk factors for stress urinary incontinence after native-tissue vaginal repair of pelvic organ prolapse

OBJECTIVE

To identify risk factors for postoperative stress urinary incontinence (POSUI) after native-tissue prolapse repair without a concomitant anti-incontinence procedure.

METHODS

The present single-center retrospective study included women with genital prolapse who underwent high uterosacral ligament suspension without a concomitant anti-incontinence procedure during 2008-2013. Univariate and multivariate analyses were performed to identify risk factors for POSUI (identified through clinical interview and International Consultation on Incontinence Modular Questionnaire-Short Form [ICIQ-SF] self-administration) at 6 months.

RESULTS

In total, 87 (20.9%) of 417 women developed POSUI. Preoperative stress urinary incontinence (SUI) and urodynamically diagnosed SUI were significantly associated with POSUI; moreover, women with POSUI had a higher preoperative ICIQ-SF score, a lower opening detrusor pressure, and a lower detrusor pressure at maximum flow than did women without POSUI (P<0.05 for all comparisons). In the multivariate analysis, preoperative SUI (odds ratio 3.11), a detrusor pressure at maximum flow of less than 30 cm H₂ O (odds ratio 2.93), and urodynamically diagnosed SUI (odds ratio 2.26) were independent risk factors for POSUI.

CONCLUSION

Preoperative urodynamic parameters, obtained before prolapse repair surgery, were associated with POSUI and could be useful in providing adequate counseling to facilitate decision making on whether to add a concomitant anti-incontinence procedure.

Risk factors for recurrence after hysterectomy plus native-tissue repair as primary treatment for genital prolapse

INTRODUCTION AND HYPOTHESIS

Identification of risk factors for pelvic organ prolapse (POP) recurrence is crucial to provide adequate preoperative counselling and tailor surgical treatment. The aim of this retrospective study was to identify risk factors for recurrence in a large series of patients with POP treated with primary transvaginal native-tissue repair involving high uterosacral ligament suspension.

METHODS

Postoperative descent of POP-Q stage 2 or higher in any compartment was considered as recurrence. Global recurrence (GR) was defined as any recurrence in any compartment irrespective of the surgical procedures performed during primary prolapse surgery. True recurrence (TR) was defined as recurrence in a compartment repaired during primary prolapse surgery.

RESULTS

Of a total of 533 eligible women, 519 were available for follow-up. Univariate analysis showed that age ≤50 years, premenopausal status, obesity (BMI >30 kg/m²), history of severe macrosomia (>4,500 g), preoperative POP stage 3 or higher and absence of anterior repair at the time of POP surgery were risk factors for GR. Multivariate analysis confirmed lack of posterior repair (odds ratio, OR, 1.8), severe macrosomia (OR 2.7), premenopausal status (OR 3.9), obesity (OR 2.2) and preoperative stage 3 or higher (OR  2.6) as risk factors for GR. Univariate analysis showed that premenopausal status and preoperative POP stage 3 or higher were risk factors for TR. Multivariate analysis confirmed premenopausal status (OR 4.0) and preoperative stage 3 or higher (OR 4.5) as risk factors for TR.

CONCLUSIONS

This study confirmed preoperative stage 3 or higher as a risk factor for prolapse recurrence. The study also identified additional risk factors for surgical failure including lack of posterior repair, severe macrosomia, premenopausal status and obesity.

Mini-sling efficacy in obese versus non-obese patients for treatment of stress urinary incontinence

BACKGROUND

The impact of obesity on single-incision has been object of concerns. The aim of the study was to compare the outcomes of MiniArc single-incision sling in normal weight, overweight and obese patients.

METHODS

This retrospective study analyzed women with proven stress urinary incontinence (SUI). Patients were divided into three groups according to BMI: normal weight (group A), overweight (group B) and obese (group C). Objective cure rate was assessed with stress test and subjective cure rate was determined by ICIQ-SF and PGI-I scores. Postoperative overactive bladder syndrome and voiding symptoms were recorded.

RESULTS

One hundred ninety-two patients were analyzed (A=97; B=68; C=27). Mean follow-up was 23.2 months without differences among groups. Estimated blood loss and operative time were not influenced by BMI. No bladder perforation were observed. Objective cure rate (A=87.6%; B=86.8%; C=81.5%) and subjective outcomes resulted similar irrespective of BMI class. De novo onset of overactive bladder syndrome and voiding symptoms were reported without significant differences among groups.

CONCLUSIONS

The current study showed that single-incision sling Miniarc seems to be an effective treatment irrespective of BMI. Operative data, complications, objective and subjective outcomes were similar for normal weight, overweight and obese women.

Voiding disorders as etiologic cofeature of overactive bladder syndrome. An observational study

BACKGROUND

Overactive bladder (OAB) is very common in the urological and gynecological practice. It is well known that the correlation between clinical features and urodynamics findings is often poor. In this observational study urodynamic findings of an OAB population have been retrospectively analyzed with the aim to identify a possible role of voiding disorders in the pathophysiology of OAB syndrome.

METHODS

Urodynamics executed between January 2005 and December 2010 have been analyzed. Female patients presenting characteristics of OAB syndrome according to International Continence Society definition were identified. Urodynamic investigations have been carried out according to the good practice guidelines for urodynamics. The Blaivas-Groutz cut off for female urinary obstruction was to detect voiding disorders.

RESULTS

According to the selection criteria 258 patients presenting OAB syndrome have been considered eligible to join the study. Eighty-one patients (30%) showed voiding difficulties: in 21 of them pressure-flow study was diagnostic for frank outlet obstruction, in 47 a mild form and 13 bladder sphincter pseudo-dyssynergia.

CONCLUSIONS

OAB syndrome can be related to voiding disorders mostly represented by a mild degree of obstruction. Such condition could trigger irritative symptoms. These clinical findings require an instrumental assessment represented by a pressure-flow analysis. This approach seems to be mandatory in patients refractory to drug therapy.

Histologic and metabolic assessment in a cohort of patients with genital prolapse: preoperative stage and recurrence investigations

BACKGROUND

Biological basis of prolapse development and recurrence are still unclear. Aim of this observational and prospective study is to correlate clinical stage of anterior vaginal wall prolapse and anatomical recurrence to histological and metabolic characteristics of vaginal tissue.

METHODS

Patients undergoing surgery were divided into two groups according to anterior stage ≤II (group A) and ≥III (group B). Full-thickness excisional biopsies of the anterior vaginal wall were obtained after hysterectomy. Hystological characteristics and metalloproteinases activity (MMP-2) were analyzed.

RESULTS

Sixty-nine patients (35 group A; 34 group B) completed evaluation. Mean follow-up was 35 months. Collagen amount and organization were significantly higher in group B both in lamina propria and fascia specimens, but MMP-2 activity was significantly lower in this group. Recurrence rate of anterior compartment was 10.1%. Collagen cellularity of fascia was higher in recurrence groups. On the contrary MMP-2 activity showed a close to significant correlation to surgical success (P=0.07).

CONCLUSIONS

Patients with advanced stages of prolapse have increased collagen amount associated to decreased MMP-2 activity. This suggests that connective tissue is more abundant but less metabolically active in patients with severe prolapse. A similar trend can be found in recurrences.

Repair of a traumatic cloaca after obstetric anal sphincter injury

INTRODUCTION AND HYPOTHESIS

Unsuccessful primary repair of fourth-degree obstetric trauma can lead to permanent communication between the rectum and the vagina, which, in association with full-thickness anal sphincter defects, is characterized by complete fecal incontinence and severe impairment of quality of life. The aim of this video is to serve as a tutorial for repair.

METHODS

A 27-year-old woman who developed a full-thickness recto-vaginal defect extended from the perineum to the upper third of the vagina has been managed through layered surgical repair without flaps.

RESULTS

Anatomy and fecal continence have been completely restored by a follow-up of 24 months.

CONCLUSION

The procedure described in this video has been shown to be effective and safe.

Stem cell augmented mesh materials: an in vitro and in vivo study

INTRODUCTION AND HYPOTHESIS

To test in vitro and in vivo the capability of mesh materials to act as scaffolds for rat-derived mesenchymal stem cells (rMSCs) and to compare inflammatory response and collagen characteristics of implant materials, either seeded or not with rMSCs.

METHODS

rMSCs isolated from rat bone marrow were seeded and cultured in vitro on four different implant materials. Implants showing the best rMSC proliferation rate were selected for the in vivo experiment. Forty-eight adult female Sprague-Dawley rats were randomly divided into two treatment groups. The implant of interest-either seeded or not with rMSCs-was laid and fixed over the muscular abdominal wall. Main outcome measures were: in vitro, proliferation of rMSCs on selected materials; in vivo, the occurrence of topical complications, the evaluation of systemic and local inflammatory response and examination of the biomechanical properties of explants.

RESULTS

Surgisis and Pelvitex displayed the best cell growth in vitro. At 90 days in the rat model, rMSCs were related to a lower count of neutrophil cells for Pelvitex and a greater organisation and collagen amount for Surgisis. At 7 days Surgisis samples seeded with rMSCs displayed higher breaking force and stiffness.

CONCLUSIONS

The presence of rMSCs reduced the systemic inflammatory response on synthetic implants and improved collagen characteristics at the interface between biological grafts and native tissues. rMSCs enhanced the stripping force on biological explants.

[Laparoscopic approach in the pelvic floor surgery]

Laparoscopy offers great exposure and surgical detail, reduces blood loss and the need for excessive abdominal packing and bowel manipulation making it an excellent modality to perform pelvic floor surgery. Laparoscopic repair of level I or apical vaginal prolapse may be challenging, due to the need for extensive dissection and advanced suturing skills. However it offers the efficacy of open abdominal sacrocolpopexy, such as lower recurrence rates and less dyspareunia than sacrospinous fixation, as well as the reduced morbidity of a laparoscopic approach.

Medium-term anatomic and functional results of laparoscopic sacrocolpopexy beyond the learning curve

BACKGROUND

Limited prospective data on the anatomic and functional outcome after laparoscopic sacrocolpopexy (LSC) are available in the literature.

OBJECTIVE

To describe the medium-term anatomic and functional outcome of LSC.

DESIGN, SETTING, AND PARTICIPANTS

Prospective consecutive series of 132 women with vaginal vault prolapse undergoing LSC between 2001 and 2006, which was after our learning curve. Patients with urodynamically proven stress incontinence (SI) underwent a concomitant tension-free vaginal tape (TVT) procedure.

INTERVENTION

Patients underwent LSC with a polypropylene implant.

MEASUREMENTS

Principal outcome measures were anatomic cure (stage 1 or lower) assessed by the Pelvic Organ Prolapse Quantification (POPQ) system and subjective cure and impact on quality of life measured by a standardised interview and, since its introduction in 2004, by a prolapse-specific quality-of-life questionnaire (P-QOL).

RESULTS AND LIMITATIONS

At a mean follow-up of 12.5 mo, the anatomic cure rate for the apex was 98%. Anatomic failures elsewhere were mainly at the posterior compartment (18%). Subjective prolapse cure rate was 91.7%, and no patients required reoperation for recurrent prolapse. Symptoms of preoperative SI, urge incontinence, or constipation were cured in 43%, 46%, and 42% of patients, respectively. The rate of de novo SI was 7.3%. De novo constipation developed in 5% and de novo dyspareunia developed in 19%. Patients' quality of life improved significantly. Erosions occurred in 4.5%, all within 1 yr. A limitation of the study is that the quality-of-life assessment score became available halfway through the study, limiting the number of preoperative observations (n=36).

CONCLUSIONS

We demonstrated that LSC results in good anatomic outcome and subjective cure of prolapse symptoms at medium term. The posterior compartment was most vulnerable for recurrence.

The biology behind fascial defects and the use of implants in pelvic organ prolapse repair

Implant materials are increasingly being used in an effort to reduce recurrence after prolapse repair with native tissues. Surgeons should be aware of the biology behind both the disease as well as the host response to various implants. We will discuss insights into the biology behind hernia and abdominal fascial defects. Those lessons from "herniology" will, wherever possible, be applied to pelvic organ prolapse (POP) problems. Then we will deal with available animal models, for both the underlying disease and surgical repair. Then we will go over the features of implants and describe how the host responds to implantation. Methodology of such experiments will be briefly explained for the clinician not involved in experimentation. As we discuss the different materials available on the market, we will summarize some results of recent experiments by our group.

Tensile strength and host response towards silk and type i polypropylene implants used for augmentation of fascial repair in a rat model

OBJECTIVE

We compared host response, architectural integration and tensile strength of two different macroporous silk constructs to a polypropylene type I implant in a rat model for augmentation of primary fascial defect repair.

MATERIALS AND METHODS

Animals were sacrificed on days 7, 14, 30 and 90 after implantation. The explants were evaluated macroscopically for infections, herniations and adhesions, mechanically for tensile strength, and histopathologically, to evaluate collagen deposition and inflammatory response.

RESULTS

The tensile strength of the explants showed a gradual increase for all materials. All implants uniformly shrank around one fifth by 90 days. In the silk implants, the inflammatory reaction showed a remarkable higher number of foreign body giant cells that characteristically spread from the periphery into implants. Collagen deposition was comparable for all the materials. In Silk a higher grade of neovascularisation was observed.

CONCLUSION

Silk explants expressed high tensiometric strength, which was associated with a marked fibrotic process. The silk implants induced a strong foreign body reaction accompanied by microscopic signs of architectural degradation at 90 days. Polypropylene explants showed a more moderate foreign body reaction without architectural disturbance.

Invasive assessment of fetal renal abnormalities: urinalysis, fetal blood sampling and biopsy

There are a number of potential biochemical markers that may have some role in predicting renal function postnatally. These include urinary sodium, calcium and beta2-microglobulin. The latter may also be measured in fetal serum. However, the accuracy of these parameters at a point in time is far from perfect as urinary tract obstruction is a progressive disease which may be best defined by repeated observations throughout pregnancy.