The changes in bladder function and symptoms after robot-assisted sacrocolpopexy and transvaginal mesh surgery for pelvic organ prolapse

OBJECTIVE

This study is aimed to compare the impact on bladder function and symptoms between robotic sacrocolpopexy (RSC) and transvaginal mesh surgery (TVM) in women with pelvic organ prolapse.

MATERIALS AND METHODS

This prospective controlled study enrolled patients who received RSC or TVM at our hospital between March 2020 and June 2022. We compared preoperative and postoperative bladder function between two groups by using a questionnaire of lower urinary tract symptom (LUTs) for subjective assessment and urodynamic study for objective assessment.

RESULTS

A total of 60 patients were enrolled, of whom 30 received RSC and 30 received TVM. In LUTs analysis, the RSC group had a higher risk of de novo stress urinary incontinence than the TVM group (33.3% vs. 3.3%, p = .007). Urodynamic studies showed that both groups had a deterioration in maximal urethral closure pressure postoperatively (RSC: 56.9 ± 17.1 vs. 44.2 ± 15.5 cmH2O; and TVM: 61.2 ± 29.4 vs. 47.6 ± 19.7 cmH2O, p < .01 and p = .03, respectively). The incidence of urodynamic stress incontinence was also significantly increased after RSC (33.3% vs. 76.7%, p = .01). The de novo urodynamic stress incontinence rate was 46.7% after RSC, which was not significantly different to the TVM group (26.7%, p = .16). In the TVM group, the incidence of voiding difficulty decreased after surgery (43.3% vs. 10.0%, p < .01), and urodynamic measurements revealed that the prevalence of urine retention decreased (43.3% vs. 16.7%, p < .01). In the RSC group, the incidence of incomplete emptying sensation decreased (36.7% vs. 13.3%, p = .04), and urodynamic measurements showed that none of the patients had bladder outlet obstruction, underactive detrusor, or urine retention after surgery.

CONCLUSION

RSC and TVM are both beneficial to improve voiding function in women with pelvic organ prolapse. However, a deterioration in urethral function was observed and the de novo SUI rate was higher in the RSC group than in the TVM group.

Pressure-Volume Loop Analysis of Voiding Workload: An Application in Trans-Vaginal Mesh-Repaired Pelvic Organ Prolapse Patients

Although trans-vaginal mesh (TVM) offers a successful anatomical reconstruction and can subjectively relieve symptoms/signs in pelvic organ prolapse (POP) patients, its objective benefits to the voiding function of the bladder have not been well established. In this study, we investigated the therapeutic advantage of TVM on bladder function by focusing on the thermodynamic workload of voiding. The histories of 31 POP patients who underwent TVM repair were retrospectively reviewed. Cystometry and pressure volume analysis (PVA) of the patients performed before and after the operation were analyzed. TVM postoperatively decreased the mean voiding resistance (mRv, p < 0.05, N = 31), reduced the mean and peak voiding pressure (mPv, p < 0.05 and pPv, p < 0.01, both N = 31), and elevated the mean flow rate (mFv, p < 0.05, N = 31) of voiding. While displaying an insignificant effect on the voided volume (Vv, p < 0.05, N = 31), TVM significantly shortened the voiding time (Tv, p < 0.05, N = 31). TVM postoperatively decreased the loop-enclosed area (Apv, p < 0.05, N = 31) in the PVA, indicating that TVM lessened the workload of voiding. Moreover, in 21 patients who displayed postvoiding urine retention before the operation, TVM decreased the residual volume (Vr, p < 0.01, N = 21). Collectively, our results reveal that TVM postoperatively lessened the workload of bladder voiding by diminishing voiding resistance, which reduced the pressure gradient required for driving urine flow.

FIGO recommendations: Use of midurethral slings for the treatment of stress urinary incontinence

BACKGROUND

Stress urinary incontinence (SUI) is a global problem. It can significantly adversely impact a woman's quality of life. The use of synthetic mesh in vaginal surgery is controversial, especially when used for pelvic organ prolapse surgery. Although negative effects have been reported, the synthetic mesh midurethral sling (MUS) is considered to be safe and effective in the surgical treatment of SUI.

OBJECTIVES

To provide evidence-based data and recommendations for the obstetrician/gynecologist who treats women with SUI and performs or plans to perform MUS procedures.

METHODS

Academic searches of MEDLINE, the Cochrane Library, Embase, and Google Scholar articles published between 1987 and March 2020 were performed by a subgroup of the Urogynecology and Pelvic Floor Committee, International Federation of Gynecology and Obstetrics (FIGO).

SELECTION CRITERIA

The obtained scientific data were associated with a level of evidence according to the Oxford University Centre for Evidence-Based Medicine and GRADE Working Group system. In the absence of concrete scientific evidence, the recommendations were made via professional consensus.

RESULTS

The FIGO Urogynecology and Pelvic Floor Committee reviewed the literature and prepared this evidence-based recommendations document for the use of MUS for women with SUI.

CONCLUSIONS

Despite the extensive literature, there is a lack of consensus in the optimal surgical treatment of SUI. These recommendations provide a direction for surgeons to make appropriate decisions regarding management of SUI. The MUS is considered safe and effective in the treatment of SUI, based on many high-quality scientific publications and professional society recommendations. Comprehensive long-term data and systemic reviews are still needed, and these data will become increasingly important as women live longer. These recommendations will be continuously updated through future literature reviews.

Efficacy of Biofeedback and Electrostimulation-Assisted Pelvic Floor Muscle Training between Women with Mild and Moderate to Severe Stress Urinary Incontinence

BACKGROUND

To evaluate the efficacy of biofeedback and electrical stimulation-assisted pelvic floor muscle training (PFMT) between women with mild and moderate to severe stress urinary incontinence (SUI).

METHODS

This retrospective cohort study was conducted at a single center from 2014 to 2021. We included 57 patients with urodynamically proven SUI who underwent a biofeedback and electrical stimulation-assisted PFMT. They were categorized into mild and moderate to severe SUI. One-hour pad test from 2 to 10 g was defined as mild SUI, and ≥11 g was defined as moderate to severe SUI.

RESULTS

Fifty-seven patients were reviewed during the study period. Incontinence-related symptoms of distress, including the UDI-6, ISI, and VAS, all significantly improved in the mild SUI group (p = 0.001, p = 0.001 and p = 0.010, respectively), while only UDI-6 and VAS statistically improved in the moderate to severe SUI group (p = 0.027 and p = 0.010, respectively). There was significant improvement in IIQ-7 in the mild SUI group during serial treatments, but only in Session 6 in the moderate to severe SUI group. After 18 sessions of treatment, the UDI-6, ISI, and IIQ-7 scores showed significantly greater improvements in the mild SUI group compared to the moderate to severe SUI group (p = 0.003, p = 0.025, and p = 0.002, respectively).

CONCLUSIONS

Although biofeedback and electrical stimulation-assisted PFMT is an effective treatment option for SUI, it is more beneficial for patients with mild SUI and a 1-h pad weight ≤ 10 g urine leak.

Modification of bladder thermodynamics in stress urinary incontinence patients submitted to trans-obturator tape: A retrospective study based on urodynamic assessment

Importance: It needs to be clarified whether trans-obturator tape (TOT)-enhanced urethral resistance could impact the voiding function.

Objective: Although TOT has been well-recognized for enhancing urethral resistance to restore continence in stress urinary incontinence (SUI) patients, whether the bladder’s voiding functions adapt to the TOT-enhanced resistance has not been adequately investigated. This study thereby aimed to investigate whether TOT impacts the bladder’s thermodynamic efficacy during the voiding phase.

Design: A retrospective analysis of urodynamics performed before and after TOT was assessed.

Setting: A tertiary referral hospital in Taiwan.

Participants: A total of 26 female SUI patients who underwent urodynamic investigations before and after TOT.

Main outcomes and measures: The area enclosed by the pressure-volume loop (Apv), which represents the work performed by the bladder during voiding, in a pressure-volume analysis established by plotting the detrusor pressure versus intra-vesical volume was retrospectively analyzed. Paired Student’s t-tests were employed to assess the difference in values before and after the operation. Significance in difference was set at p &lt; 0.05.

Results: TOT increased Apv in 20 of 26 (77%) patients and significantly increased the mean Apv compared to the preoperative control (2.17 ± 0.18 and 1.51 ± 0.13 × 103 cmH2O-ml, respectively p &lt; 0.01). TOT also increased the mean urethral resistance (1.03 ± 0.30 vs. 0.29 ± 0.05 cmH2O-sec/ml, p &lt; 0.01) and mean voiding pressure (25.87 ± 1.72 and 19.30 ± 1.98 cmH2O p &lt; 0.01) but did not affect the voided volume and voiding time. Moreover, the TOT-induced Apv increment showed a moderate correlation with the changes in urethral resistance and voiding pressure (both r &gt; 0.5) but no correlation with changes in voided volume or voiding time. It is remarkable that the TOT-induced urethral resistance increment showed a strong correlation with changes in voiding pressure (r &gt; 0.7).

Conclusion and Relevance: The bladder enhances thermodynamic efficacy by adapting the voiding mechanism to increased urethral resistance caused by TOT. Further studies with higher case series and longer follow-ups should assess whether this effect could be maintained over time or expire in a functional detrusor decompensation, to define diagnostic criteria that allow therapeutic interventions aimed at its prevention during the follow-up.

Clinical Trial Registration: (clinicaltrials.gov), identifier (NCT05255289)

Minimal requirement in urogynecological knowledge for obstetrics and gynecology specialists

OBJECTIVE

To investigate the current knowledge and practice patterns of obstetrics and gynecology (obs/gyn) physicians regarding the diagnosis, evaluation, and management of pelvic floor disorders (PFD) including stress urinary incontinence (SUI), pelvic organ prolapse (POP) and lower urinary tract symptoms (LUTS). The knowledge related to urodynamic study (UDS) is also evaluated.

MATERIALS AND METHODS

A 25-item questionnaire was developed and sent for the physician members who participated in the annual congress of Taiwan Association of Obstetrics and Gynecology (TAOG). Response to the questionnaire was voluntary and anonymous. The questionnaires were collected prior to the ending of the congress.

RESULTS

2000 copies of the questionnaire were sent and 1443 TAOG members responded. 86 poor respondents and 45 copies from urogynecologists were excluded. 1312 copies of the completed questionnaires were analyzed. 77.7% of the respondents were male physicians and 50.6% were over 55 years old. Up to 53.7% of the physicians had completed their residency training for over twenty years. Generally, around half of the respondents didn't reach well a level of well understanding regarding the various PFD. Most of the physicians would like to have further knowledge in urogynecological field for their daily practice. Regular delivery of updated information about various urogynecological diseases is mandatory.

CONCLUSION

With the aging population worldwide, the need for management of PFD is increasing. The obs/gyn physician plays an important role in the primary evaluation and management of PFD. This study offered important information related to the current investigation, management, practice patterns and future expectation from obs/gyn physicians as references for the future continuing medical education programs.

Effect of aging on lower urinary tract symptoms and urodynamic parameters in women

OBJECTIVE

Lower urinary tract symptoms (LUTS) are common in women. However, due to multifactorial etiologies, it is difficult to determine the prevalence, and functional changes with age. The aim of this study is to assess the effect of age on female LUTS, urethral and bladder function after their midlife.

MATERIALS AND METHODS

This was an observational cohort study conducted at a tertiary referral medical center. Women who visited for bothersome LUTS, valid quality of life questionnaires, and urodynamic tests were recruited into the this study. Patients The patients were divided into four groups (<50, 50-59, 60-69, and >69 years). All LUTS, and urodynamic parameters were reviewed, and compared between groups.

RESULTS

A total of 364 women were enrolled and analyzed. The urodynamic tests showed the that maximal cystometric bladder capacity, the average and maximal urine flow rate, and pressure of detrusor contractility at maximal urine flow rate were all significantly decreased with age. Besides, the voiding time, and post-voiding residual urine volume significantly increased with age. For urethral competence, the maximal urethral closure pressure deteriorated with age. All storage symptoms did not change with age, except for nocturnal enuresis. However, the effect of age on some voiding symptoms significantly increased with age, including straining to void, hesitancy, and intermittency.

CONCLUSIONS

Lower urinary tract symptoms, bladder and urethral functions change with age, particularly voiding function. Physicians should be aware of the aging process when counseling and before implementing management strategies, particularly for older people.

Evaluation of efficacy and safety of single-incision sling versus transobturator sling in women with stress incontinence and intrinsic sphincter deficiency

INTRODUCTION AND HYPOTHESIS

Urethral intrinsic sphincter deficiency (ISD) is associated with severe urine leakage and a higher risk of sling failure. The aim of this study is to evaluate the efficacy and safety of single-incision slings (SISs) versus transobturator slings (TOSs) in such patients.

METHODS

Patients who had stress incontinence and ISD who underwent SIS or TOS procedures from 2010 to 2017 were retrospectively reviewed. The objective and subjective cure rates and surgical adverse events were compared between different slings. Objective cure was defined as no stress urine leakage with a comfortably full bladder. Subjective cure was determined by the patient's satisfaction. Incontinence-related symptom distress and quality of life were evaluated using the short forms of the Urogenital Distress Inventory (UDI-6) and Incontinence Impact Questionnaire (IIQ-7).

RESULTS

Among 111 patients, 37 underwent SIS and 72 underwent TOS with a median follow-up of 21 (range: 12-72) months and 24 (range: 14-84) months (p = 0.265). For both groups, the UDI-6, IIQ-7, and 1-h pad test all significantly improved after surgery (all p < 0.001). The objective and subjective cure rates were comparable after SIS and TOS procedures (objective: 76% vs. 76%, p = 0.837; subjective: 78% vs. 83%, p = 0.212). There were no significant differences in adverse events, except SISs had a shorter surgery time (16.4 ± 9.3 vs. 27.3 ± 12.4 min, p = 0.020) and lower postoperative visual analog scale pain score (1.3 ± 1.1 vs. 3.9 ± 1.4, p < 0.001).

CONCLUSION

SISs and TOSs had similar surgical results in women with stress incontinence and ISD after at least 1 year of follow-up. However, SISs had a shorter operation time and lower postoperative pain than TOSs.

The efficacy and complications of using transvaginal mesh to treat pelvic organ prolapse in Taiwan: A 10-year review

Transvaginal mesh (TVM) insertion for the treatment of pelvic organ prolapse (POP) is significantly associated with lower failure rates, although its use remains controversial due to the potential risk of mesh-related complications. In this review, we collected the published literature regarding the use of TVM to treat POP in an attempt to assess both the efficacy and complications related to TVM usage in Taiwan. We searched 25 English language articles using PubMed related to TVM in Taiwan from 2010 to 2019. The present article focuses on the efficacy and complications of TVM and analyzes the data. There were 25 studies on TVM selected for this review. Regarding their success rate, 21 out of the 22 studies (95.5%) had more than a 90% objective success rate. Twenty studies (90.9%) had less than 10% major complications of TVM. Twenty out of the 25 studies (80.0%) had 5% or less mesh exposure. For self-cut TVM and the later single-incision TVM, both the complication rates and exposure rates decreased. The rate of de novo dyspareunia ranged from 2.6% to 14.3%, and the incidence decreased yearly from 2011 to 2019. This review showed both the high treatment efficacy and low complication rate of TVM usage for the short-term treatment of POP in Taiwan. However, a longer-term study is needed to draw a conclusion regarding the safety of this treatment.

The Prevalence of Vaginal Flatus in Women With Pelvic Floor Disorders and Its Impact on Sexual Function

BACKGROUND

Vaginal flatus is involuntarily passing gas from the vagina. Women seldom voluntarily report it, and related data are limited.

AIM

To investigate the prevalence of vaginal flatus in women with pelvic floor disorders and its impact on sexual function.

METHODS

This was an observational study involving women who visited a urogynecologic clinic in a tertiary medical center. Patients were asked about their experience of vaginal flatus. Other evaluations included urodynamics, genital prolapse stage, and quality-of-life questionnaires, including the short form of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, Urogenital Distress Inventory, and Incontinence Impact Questionnaire.

OUTCOMES

Clinical characteristics, vaginal anatomic landmarks, stage of prolapse, urodynamic parameters, and quality-of-life scores were compared between women with and without vaginal flatus.

RESULTS

Among 341 women, 118 (35%) reported vaginal flatus, which was more common in those who were younger (a mean age of 49.3 ± 9.2 years; range 25-74 years vs 49.3 ± 9.2 years; range 25-74 years, P < .001) and sexually active (98% vs 55%, P < .001). Women with vaginal flatus had significantly worse sexual function (Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, 16.3 ± 15.9 vs 30.9 ± 8.0, P < .001) and incontinence-related quality of life (Urogenital Distress Inventory, 23.4 ± 10.5 vs 17.8 ± 8.9, P = .039; Incontinence Impact Questionnaire, 25.5 ± 14.5 vs 17.2 ± 12.5, P = .012). For frequency and bother, 48 of 116 (46%) women reported often or always having symptoms during sexual activity, 5 of 34 (15%) when performing daily activities, and 4 of 31 (12%) when exercising, and 70 of 116 (60%) felt least moderate bothersome during sexual activity compared with 2 of 34 (5%) when performing daily activities and 6 of 31 (18%) when exercising.

CLINICAL IMPLICATIONS

Vaginal flatus is prevalent in women with pelvic floor disorders, particularly in those who are younger and sexually active.

STRENGTHS & LIMITATIONS

The strength of this study is to evaluate the sexual function with validated questionnaires. The lack of data after pelvic floor management is the major limitation.

CONCLUSIONS

Among women with pelvic floor disorders, those with vaginal flatus reported poorer sexual function. Routine counseling should be considered for these patients. Lau H-H, Su T-H, Chen Y-Y, et al. The Prevalence of Vaginal Flatus in Women With Pelvic Floor Disorders and Its Impact on Sexual Function. J Sex Med 2021;18:487-492.

Potassium bromate-induced cell model of age-related macular degeneration in vitro

Age‑related macular degeneration (AMD) progression occurs due to oxidative stress in retinal pigment epithelium (RPE) cells. To develop a new model of AMD, the present study investigated the effects of potassium bromate (KBrO₃) on ARPE‑19 cells. Incubation with KBrO₃ for 24 h significantly decreased ARPE‑19 cell viability in a concentration‑dependent manner compared with the control group. The MTT and lactate dehydrogenase assay results indicated that KBrO₃ induced cell apoptosis. Compared with the control group, KBrO₃ treatment significantly decreased the Bcl2/Bax ratio, as determined via western blotting, and caspase‑3 mRNA expression levels. Fluorescence microscopy indicated the increased ROS levels in cells treated with KBrO₃. Endogenous antioxidant enzyme activities, including superoxide dismutase and glutathione peroxidase, were significantly inhibited by KBrO₃ compared with the control group. Moreover, the antioxidants tiron and phloroglucinol inhibited KBrO₃‑mediated effects on ARPE‑19 cells in a dose‑dependent manner. Additionally, GPR109A is the binding site of 4‑hydroxynonenal (4‑HNE). KBrO₃ displayed cytotoxic effects in 293 cells, which naturally lack the GPR109A gene, but these effects were not observed in 4‑HNE‑treated 293 cells, suggesting that KBrO₃ induced apoptosis without increasing endogenous 4‑HNE levels in cells. Moreover, the results suggested that KBrO₃‑induced oxidative stress may activate STAT3 to increase VEGF expression in ARPE‑19 cells. Collectively, the results of the present study supported the potential use of KBrO₃ to induce an in vitro model of AMD in ARPE‑19 cells.

iDPGK: characterization and identification of lysine phosphoglycerylation sites based on sequence-based features

Background

Protein phosphoglycerylation, the addition of a 1,3-bisphosphoglyceric acid (1,3-BPG) to a lysine residue of a protein and thus to form a 3-phosphoglyceryl-lysine, is a reversible and non-enzymatic post-translational modification (PTM) and plays a regulatory role in glucose metabolism and glycolytic process. As the number of experimentally verified phosphoglycerylated sites has increased significantly, statistical or machine learning methods are imperative for investigating the characteristics of phosphoglycerylation sites. Currently, research into phosphoglycerylation is very limited, and only a few resources are available for the computational identification of phosphoglycerylation sites.

Result

We present a bioinformatics investigation of phosphoglycerylation sites based on sequence-based features. The TwoSampleLogo analysis reveals that the regions surrounding the phosphoglycerylation sites contain a high relatively of positively charged amino acids, especially in the upstream flanking region. Additionally, the non-polar and aliphatic amino acids are more abundant surrounding phosphoglycerylated lysine following the results of PTM-Logo, which may play a functional role in discriminating between phosphoglycerylation and non-phosphoglycerylation sites. Many types of features were adopted to build the prediction model on the training dataset, including amino acid composition, amino acid pair composition, positional weighted matrix and position-specific scoring matrix. Further, to improve the predictive power, numerous top features ranked by F-score were considered as the final combination for classification, and thus the predictive models were trained using DT, RF and SVM classifiers. Evaluation by five-fold cross-validation showed that the selected features was most effective in discriminating between phosphoglycerylated and non-phosphoglycerylated sites.

Conclusion

The SVM model trained with the selected sequence-based features performed well, with a sensitivity of 77.5%, a specificity of 73.6%, an accuracy of 74.9%, and a Matthews Correlation Coefficient value of 0.49. Furthermore, the model also consistently provides the effective performance in independent testing set, yielding sensitivity of 75.7% and specificity of 64.9%. Finally, the model has been implemented as a web-based system, namely iDPGK, which is now freely available at http://mer.hc.mmh.org.tw/iDPGK/.

Amniotic Membrane Graft in the Management of Complex Vaginal Mesh Erosion

Vaginal mesh erosion is a devastating complication after pelvic floor mesh surgery and it can be treated conservatively or with surgical revision. However, the management options following a failed primary revision or complex vaginal erosions are very limited. The aim of this study is to describe a novel treatment using an amniotic membrane as an inlay graft for such patients. Eight patients who failed conservative or primary surgical revision were enrolled. The complex erosions included vaginal agglutination, multiple vaginal erosions, recurrent erosions, and mesh cutting through the urethra. We used an amniotic membrane as a graft to cover the vaginal defect after partial excision of the mesh erosion and we describe the technique in this study. There were no intraoperative complications and none of the patients reported any further symptoms at a mean of 27 months follow-up. Only one patient had recurrent erosion, however, the erosion size was narrower and was subsequently successfully repaired. No further vaginal mesh erosions were noted in the other patients who all had good functional recovery. The use of an amniotic graft can be an economic and alternative method in the management of complex vaginal mesh erosions.

The Outcome of a Single-Incision Sling versus Trans-Obturator Sling in Overweight and Obese Women with Stress Urinary Incontinence at 3-Year Follow-Up

Background: Being overweight or obese is a risk factor for incontinence and has negative impacts on the surgical outcomes. Compared with trans-obturator sling (TOS), single incision sling (SIS) is a new generation of anti-incontinence surgery. However, the data on SIS in overweight and obese women remains limited. Methods: This retrospective study analyzed the objective and subjective cure rate of overweight and obese women who underwent sling surgeries. Other evaluations included valid questionnaires to assess quality of life and 1-hour pad test to quantify urine leakage. Surgical characteristics and adverse events were also analyzed. Results: A total of 217 patients were analyzed with a median follow-up period of 37.3 months (range, 9–84 months). For overweight and obese patients, the objective and subjective cure rate were comparable (all p > 0.05). However, the SIS group had worse post-operative incontinence-related symptom distress (p < 0.001) and 1-hour pad test (p = 0.047). On the other hand, SIS had a shorter surgery time (p = 0.017) and lower pain score (p < 0.001). Conclusions: Compared with TOS, SIS had non-significant cure rates in the overweight and obese women. SIS had worse urine leakage and incontinence symptoms, but less surgical and wound pain in obese women. Thorough pre-operative counseling is necessary.

Changes in Female Sexual Function After Vaginal Mesh Repair Versus Native Tissue Repair for Pelvic Organ Prolapse: A Meta-Analysis of Randomized Controlled Trials

AIM

To evaluate changes in female sexual function after transvaginal mesh (TVM) repair versus native tissue repair for pelvic organ prolapse.

METHODS

Eligible studies, published through November 2017, were retrieved through searches of ClinicalTrials.gov, MEDLINE, Embase, and Cochrane Review databases and associated bibliographies. We included randomized control trials of transvaginal prolapse surgery with either mesh repair or native tissue repair regarding the outcomes of sexual function, de novo and postoperative dyspareunia with a minimum of 3 months of follow-up.

RESULTS

Seventeen trials including 2,976 patients (1,488 with TVM repair and 1,488 with native tissue repair) were identified. There was no significant difference in postoperative dyspareunia after TVM repair versus native tissue repair (risk ratio [RR] = 1.07; 95% confidence interval [CI] = 0.76-1.50). Likewise, there was no significant difference in de novo dyspareunia after TVM repair versus native tissue repair (RR = 0.91; 95% CI = 0.52-1.61). There was also no significant difference in the short form Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire score after TVM mesh repair versus native tissue repair (mean difference = 0.26; 95% CI = -1.34 to 1.85).

CONCLUSION

Sexual function and de novo and postoperative dyspareunia were similar between the patients who underwent TVM repair and those who underwent native tissue repair. Liao S-C, Huang W-C, Su T-H, et al. Changes in Female Sexual Function After Vaginal Mesh Repair Versus Native Tissue Repair for Pelvic Organ Prolapse: A Meta-Analysis of Randomized Controlled Trials. J Sex Med 2019;16:633-639.

Risk factors and management of vaginal mesh erosion after pelvic organ prolapse surgery

OBJECTIVE

Mesh erosion is a serious and not uncommon complication in women undergoing vaginal mesh repair. We hypothesized that mesh erosion is associated with the patient's comorbidities, surgical procedures, and mesh material. The aims of this study were to identify the risk factors and optimal management for mesh erosion.

MATERIALS AND METHODS

All women who underwent vaginal mesh repair from 2004 to 2014 were retrospectively reviewed. Data on patients' characteristics, presenting symptoms, treatment and outcomes were collected from their medical records.

RESULTS

A total of 741 women underwent vaginal mesh repairs, of whom 47 had mesh erosion. The median follow-up period was 13 months (range 3-84 months). Another nine patients with mesh erosion were referred form other hospitals. Multivariate analysis revealed that concomitant hysterectomy (odds ratio 27.02, 95% confidence interval 12.35-58.82; p < 0.01) and hypertension (odds ratio 5.95, 95% confidence interval 2.43-14.49; p < 0.01) were independent risk factors for mesh erosion. Of these 56 women, 20 (36%) were successfully treated by conservative management, while 36 (64%) required subsequent surgical revision. Compared with surgery, conservative treatment was successful if the size of the erosion was smaller than 0.5 cm (p < 0.01). Six patients (17%) had recurrent erosions after primary revision, but all successfully healed after the second surgery.

CONCLUSION

Concomitant hysterectomy and hypertension were associated with mesh erosion. In the management of mesh erosion, conservative treatment can be tried as the first-line treatment for smaller erosions, while surgical repair for larger erosions. Recurrent erosions could happen and requires repairs several times.

Urinary leakage during sexual intercourse among women with incontinence: Incidence and risk factors

BACKGROUND

Coital incontinence is an under-reported disorder among women with urinary incontinence. Women seldom voluntarily report this condition, and as such, related data remains limited and is at times conflicting.

AIMS AND OBJECTIVES

To investigate the incidence and quality of life in women with coital incontinence and to determine associated predictors.

METHODS

This observational study involved 505 sexually active women attending the urogynecologic clinic for symptomatic urinary incontinence at a tertiary medical center. All of the patients were consulted about the experience of coital incontinence and completed evaluations including urodynamics, and valid questionnaires including the short form of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, the Urogenital Distress Inventory and the Incontinence Impact Questionnaire.

RESULTS

Of these women, 281 (56%) had coital incontinence, while 224 (44%) did not. Among women with coital incontinence, 181 (64%) had urodynamic-proven stress incontinence, 29 (10%) had mixed incontinence, and 15 (5%) had detrusor overactivity. Only 25 (9%) sought consultation for this disorder before direct questioning. Fifty percent (84/281) of the women rarely or sometimes had incontinence during coitus, while 33% (92/281) often had incontinence, and 17% (48/281) always had incontinence. The frequency of coital incontinence was not different regarding the types of incontinence (p = 0.153). Women with mixed incontinence had the worst sexual quality of life and incontinence-related symptom distress. Based on univariate analysis, higher body mass index (OR 2.47, p = 0.027), and lower maximal urethral closure pressure (≤ 30 cmH2O) (OR 4.56, p = 0.007) were possible predictors for coital incontinence. Multivariate analysis showed lower MUCP was independently significant predictors (OR3.93, p = 0.042).

CONCLUSIONS

The prevalence of coital intercourse in urinary incontinence women was high. Coital incontinence in these women was associated with abnormal urodynamic diagnosis and urethral dysfunction.

Outcome of transvaginal pelvic reconstructive surgery with Prolift after a median of 2 years' follow-up

INTRODUCTION AND HYPOTHESIS

This study seeks to analyze the medium- to long-term outcome of transvaginal pelvic reconstructive surgery using the Prolift™ system for pelvic organ prolapse.

METHODS

Sixty-five patients who underwent pelvic floor reconstruction using Prolift™ were followed for 1 to 3 years postoperatively. Assessment included pre- and postoperative Pelvic Organ Prolapse Quantification (POP-Q) stage, Urogenital Distress Inventory (UDI-6), and Incontinence Impact Questionnaire (IIQ-7) scores.

RESULTS

The overall anatomic success rate was 97% after a median of 24.5 months and 94% for the 34 women followed for more than 2 years. POP-Q stage, UDI-6, and IIQ-7 scores all improved significantly after surgery. Complications included one bladder perforation (1.5%) and one bowel perforation (1.5%), prolonged catheterization in four patients (6%), and mesh erosion in one (2%). Eight received blood transfusion (12%).

CONCLUSIONS

Prolift™ surgery yielded a good anatomical outcome and satisfactory symptom improvement that appeared to be durable after 2 years.

Short term impact on female sexual function of pelvic floor reconstruction with the Prolift procedure

INTRODUCTION

The Prolift system is an effective and safe procedure using mesh reinforcement for vaginal reconstruction of pelvic organ prolapse (POP), but its effect on sexual function is unclear.

AIM

To evaluate the impact of transvaginal pelvic reconstruction with Prolift on female sexual function at 6 months post-operatively.

METHODS

Thirty-three sexually active women who underwent Prolift mesh pelvic floor reconstruction for symptomatic POP were evaluated before and 6 months after surgery. Their sexual function was assessed by using the short form of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) before and after surgery. The quality of life was also evaluated with the short forms of the Urogenital Distress Inventory (UDI-6) and the Incontinence Impact Questionnaire (IIQ-7) as a control for efficacy of the procedure. The Pelvic Organ Prolapse Quantification system was used to evaluate the degree of prolapse.

MAIN OUTCOME MEASURES

PISQ-12 scores at 6 months post-operatively.

RESULTS

The total PISQ-12 score decreased from 29.5 +/- 9.0 to 19.3 +/- 14.7 (P < 0.001), indicating worsening of sexual function 6 months post-operatively. The behavioral, physical, and partner-related domains of PISQ-12 were each significantly reduced (5.2 +/- 3.7 vs. 2.9 +/- 3.7, P = 0.016; 15.4 +/- 4.7 vs. 10.4 +/- 8.6, P = 0.001; 8.9 +/- 3.8 vs. 6.4 +/- 5.5, P = 0.01, respectively). UDI-6 and IIQ-7 scores were significantly improved at the 6-month follow-up, as was anatomic recovery. Of the 33 subjects, 24 (73%) had worse sexual function 6 months after the procedure.

CONCLUSION

The Prolift procedure provided an effective anatomic cure of POP, but it had an adverse effect on sexual function at 6 months after surgery.

Stereoselectivity of activation of 7,12-dimethylbenz[a]anthracene- 3,4-dihydrodiol to the anti-diol epoxide metabolite in a human mammary carcinoma MCF-7 cell-mediated V79 cell mutation assay

7,12-Dimethylbenz[a]anthracene (DMBA), one of the most carcinogenic polycyclic aromatic hydrocarbons in rodent bioassays, is metabolically activated in many tissues to "bay-region" DMBA-3,4-diol-1,2-epoxides (DMBADE). Unlike benzo[a]pyrene, for which the high biological activity of the (7R,8S)-diol-(9S,10R)-epoxide has been established, the low chemical stability of anti-DMBADE has made it impossible to evaluate the role of specific stereoisomers in the biological activity of DMBA. In order to characterize the role of formation of DMBADE diastereomers in the induction of mutations, postlabeling assays using [35S]phosphorothioate with adduct separation by HPLC and immobilized boronate chromatography analyses were developed to allow separation and quantitation of DNA adducts formed from each stereoisomer of DMBADE. In DMBA-treated hamster embryo cell cultures, large quantities of three major adducts (anti-DMBADE-deoxyguanosine, anti-DMBADE-deoxyadenosine, and syn-DMBADE-deoxyadenosine) along with five minor adducts were completely resolved and quantitated. The DNA isolated from a human mammary carcinoma MCF-7 cell-mediated V79 cell mutation assay treated with increasing doses of racemic DMBA-3,4-dihydrodiol contained large amounts of two anti-DMBADE-DNA adducts. The anti-DMBADE adducts accounted for more than 90% of the total adducts at all doses. The number of 6-thioguanine-resistant mutants was proportional to the amount of anti-DMBADE-DNA adducts.(ABSTRACT TRUNCATED AT 250 WORDS)

Separation and characterization of post-labeled DNA adducts of stereoisomers of benzo[a]pyrene-7,8-diol-9,10-epoxide by immobilized boronate chromatography and HPLC analysis

The carcinogenic polycyclic aromatic hydrocarbon (PAH) benzo[a]pyrene (BaP) is enzymatically activated in cells to an ultimate carcinogenic metabolite, benzo[a]pyrene-7,8-dihydrodiol-9,10- epoxide (BaPDE), which reacts with DNA to form covalent adducts involved in the initiation of cancer. Previously, a post-labeling procedure that uses adenosine-5'-O-(3'-[35S]-thiotriphosphate) was developed to facilitate adduct analysis by HPLC. The much greater carcinogenic potency of (+)-anti-BaPDE makes it essential to be able to separate and identify the adducts formed by all four BaPDE enantiomers in DNA of cells exposed to BaP. Reversed-phase HPLC (RPHPLC) resolved the major (+)-anti-BaPDE-N2-deoxyguanosine [(+)-anti-BaPDE-N2-dG] adduct from the (+)-syn-BaPDE-N2-dG adduct. However, anti-BaPDE-N2-dG adducts formed by (+)- and (-)-anti-BaPDE were not resolved. By using ion-pair RPHPLC (IP-RPHPLC) with tetrabutylammonium phosphate, the [35S]post-labeled (-)-anti-BaPDE-N2-dG adduct eluted 3 min prior to the [35S]labeled (+)-anti-BaPDE-N2-dG adduct. In contrast, the major syn-BaPDE-N2-dG adducts were resolved better by RPHPLC than by IP-RPHPLC. The difference in conditions required for optimal separation of anti- and syn-BaPDE-DNA adducts necessitated the development of an immobilized boronate chromatography technique for the separation of anti- from syn-BaPDE-DNA adducts prior to analytical HPLC analysis. At 4 degrees C and with elution buffers containing high salt concentrations, the [35S]post-labeled anti-BaPDE-DNA adducts were selectively retained by a boronate column whereas the [35S]labeled syn-BaPDE-DNA adducts were not. Analysis of the multiple BaP-DNA adducts formed in BaP-treated hamster embryo cells by these techniques gave results comparable to those obtained by other methods. The major BaP-DNA adducts were anti-BaPDE-N2-dG, 14% from (-)- and 86% from (+)-anti-BaPDE. The ability of these techniques to detect low levels of PAH-DNA adducts because of the high specific radioactivity of 35S and to separate the DNA adducts formed by stereoisomeric PAH diol epoxides adducts by boronate by stereoisomeric PAH diol epoxides adducts by boronate chromatography and HPLC will facilitate studies of the role of individual PAH-DNA adducts in the induction of biological effects such as toxicity and carcinogenesis.

The potent carcinogen dibenzo[a,l]pyrene is metabolically activated to fjord-region 11,12-diol 13,14-epoxides in human mammary carcinoma MCF-7 cell cultures

Dibenzo[a,l]pyrene (DB[a,l]P), an environmental hydrocarbon and very potent carcinogen in rodent bioassays, could be activated to DNA-binding intermediates in cells through formation of three different regioisomeric bay- or fjord-region diol-epoxides or other more highly oxidized metabolites. The mechanism of metabolic activation of DB[a,l]P in the human mammary carcinoma cell line MCF-7 was elucidated by analyzing the DB[a,l]P-DNA adducts formed by [35S]phosphorothioate postlabeling, immobilized boronate chromatography, and high-performance liquid chromatography. Six DB[a,l]P-DNA adducts were detected. Comparison with those formed in cells by DB[a,l]P-11,12-diol and by reaction of DNA with syn- and anti-(benzylic hydroxyl and epoxide oxygen cis and trans, respectively) DB[a,l]P-11,12-diol-13,14-epoxide (DB[a,l]PDE) demonstrated that all DB[a,l]P-DNA adducts in MCF-7 cells were formed by these diol-epoxide isomers. Cellular DNA contained large amounts of two syn- and one anti-DB[a,l]PDE-DNA adducts and small amounts of one syn- and two anti-DB[a,l]PDE-DNA adducts. The ability of human cells to activate DB-[a,l]P to its fjord-region 11,12-diol 13,14-epoxides suggests that environmental exposure to DB[a,l]P could pose a risk for humans.

Base sequence selectivity in the binding of 7(R),8(S)-dihydroxy-9(S),10(R)-epoxy-7,8,9,10-tetrahydrobenzo[a]pyrene to oligodeoxyribonucleotide duplexes

The effect of nucleotide sequence on the binding of 7(R),8(S)-dihydroxy-9(S),10(R)-epoxy-7,8,9,10-tetrahydrobenzo[a]pyrene [(+)-anti-BPDE] to the exocyclic amino group of deoxyguanosine was investigated in duplexes formed by self-complementary oligodeoxyribonucleotide decamers which contained two deoxyguanosines (dGs) within unique sequences. A 35S-postlabeling procedure was developed for analysis of (+)-anti-BPDE adducts as dinucleotides containing 5'-(+)-anti-BPDE-dG adducts. This allows identification of the 3' neighbor of the reacted guanine and permits quantitation of the binding of (+)-anti-BPDE to each specific guanine in the oligodeoxyribonucleotide duplexes. Of all the central dG-containing sequences studied, dG surrounded by deoxycytidines (CGC) reacted to the greatest extent: over 4-fold more (+)-anti-BPDE bound to this central dG compared to the least reactive deoxyguanosine (AGT). (+)-anti-BPDE exhibited a preference for binding to a central deoxyguanosine when either the 5' or 3' neighbor was deoxyguanosine. The binding of (+)-anti-BPDE to oligodeoxyribonucleotide duplexes containing different numbers of consecutive dGs was analyzed in order to determine how the length of these sequences influences binding. Increases in the length of consecutive deoxyguanosine residues from 3 to 5 had little effect on the quantity of (+)-anti-BPDE bound to dG above that expected from the presence of a neighboring dG and an increase in the number of dG residues available for reaction. The results obtained with these oligodeoxyribonucleotide duplexes were consistent with the data available for the reaction of (+)-anti-BPDE with DNA, indicating that these duplexes are a valuable model for studying the effect of base sequence on the interaction of BPDE isomers with DNA. The dinucleotide postlabeling technique developed for these studies, with appropriate oligodeoxyribonucleotides and chromatographic conditions, will be useful for determining the effect of base sequence on the binding of other hydrocarbon diol epoxides as well as other reactive hydrocarbon metabolites to deoxyguanosine or deoxyadenosine in oligodeoxyribonucleotide duplexes and fragments of DNA.

High selectivity of polyclonal antibodies against DNA modified by diastereomeric benzo[c]phenanthrene-3,4-diol-1,2-epoxides

Polyclonal antibodies were developed in New Zealand White rabbits against DNA modified with diastereomeric benzo[c]phenanthrene-3,4-diol-1,2-epoxide (B[c]PhDE)-1 (4-hydroxyl and epoxide cis) and B[c]PhDE-2 (4-hydroxyl and epoxide trans). Antiserum developed against B[c]PhDE-2-DNA was stereoselective. In competitive ELISA assays using wells coated with 160 fmol B[c]PhDE-2-DNA adducts, B[c]PhDE-2-DNA gave 50% inhibition at 200 fmol adducts/well. B[c]PhDE-1-DNA required a 10-fold higher amount of adducts/well to give 50% inhibition. Benzo[a]pyrene-7,8-diol-9,10-epoxide-2-DNA and 7,12-dimethylbenz[a]anthracene-3,4-diol-1,2-epoxide-1-DNA caused only a 30% inhibition even at the highest doses tested (greater than 4000 fmol adducts/well). For antiserum developed against B[c]PhDE-1-DNA, 50% inhibition required 570 fmol B[c]PhDE-1-DNA adducts in wells coated with 100 fmol B[c]PhDE-1-DNA adducts. 7,12-Dimethylbenz[a]anthracene-3,4-diol-1,2-epoxide-1-DNA and B[c]PhDE-2-DNA were also effective competitors: they caused 50% inhibition at 1900 and 1800 fmol adducts/well respectively. In contrast, benzo[a]pyrene-7,8-diol-9,10-epoxide-2-DNA gave no inhibition at the highest dose of competitor tested (4050 fmol adducts/well). Antisera from three rabbits immunized with B[c]PhDE-2-DNA demonstrated similar antigen specificities. The properties of these antisera differ from those reported previously for antibodies developed against benzo[a]pyrene-DNA in that they show selectivity for DNA modified by specific hydrocarbon diolepoxides, in one case for B[c]PhDE-2-DNA and in the other for B[c]PhDE-DNA or 7,12-dimethylbenz[a]anthracene-3,4-diol-1,2-epoxide-1-DNA. The specificity of these antisera will facilitate analysis of the modification of DNA by different polycyclic aromatic hydrocarbon diolepoxides.

The co-carcinogen benzo[e]pyrene increases the binding of a low dose of the carcinogen benzo[a]pyrene to DNA in Sencar mouse epidermis

The mechanism of the co-carcinogenic activity of benzo[e]pyrene (BeP) was investigated by determining the effects of BeP on the binding of the carcinogen benzo[a]pyrene (BaP) to DNA in Sencar mouse epidermis. The dose of BaP used was 20 nmol/mouse, a dose which is not carcinogenic in a single application but is carcinogenic after multiple treatments such as those in the BaP-BeP co-carcinogenesis experiments described by Van Duuren and Goldschmidt (J. Natl. Cancer Inst., 56, 1237, 1976). After 3 h of exposure to [3H]BaP and BeP at BaP:BeP dose ratios of 1:3 and 1:10, [3H]BaP-DNA adducts in both BeP-treated groups were lower than in an acetone-BaP control group. After 12 and 24 h of exposure, the BaP-BeP (1:10) group contained 19% and 33% higher [3H]BaP-DNA adduct levels than the control. In the BaP-BeP (1:3) group, the amount of [3H]BaP-DNA adduct levels was higher than the control after 12 h. BeP co-treatment with either [3H]BaP-7,8-dihydrodiol or anti-[3H]BaPDE had no effect on the amount of BaPDE-DNA adducts present. These results demonstrate that the co-carcinogen BeP increases the amount of a low dose of BaP that binds to mouse epidermal DNA and indicate that the increase in BaP-DNA adducts results from increased metabolism of BaP to the proximate carcinogen BaP-7,8-dihydrodiol.

Detection and identification of benzo[a]pyrene-DNA adducts by [35S]phosphorothioate labeling and HPLC

Two generally applicable [35S]phosphorothioate postlabeling procedures for the HPLC analysis of polycyclic aromatic hydrocarbon (PAH)-DNA adducts have been developed based upon [32P]phosphate postlabeling assays described by Gupta and Randerath et al. In one procedure, benzo[a]pyrene (B[a]P)-modified DNA was digested to nucleoside 3'-phosphates by micrococcal nuclease and spleen phosphodiesterase and the adducted nucleotides were extracted with 1-butanol. The adducted nucleoside-3'-phosphates were 5'-thiophosphorylated by T4 polynucleotide kinase (T4PNK) and adenosine 5'-O-(3-[35S]thiotriphosphate) to yield [35S]B[a]P-nucleoside-5'-phosphorothioate-3'-phosphate adducts. Although thiophosphorylation of B[a]P-DNA adducts was slower than the corresponding phosphorylation reaction, similar recoveries of the postlabeled adducts were achieved with longer incubation times and higher concentrations of T4PNK. A major advantage of this procedure over the 32P-postlabeling procedure is that the resistance of phosphorothioates to degradation by phosphatases allows selective removal of the unlabeled 3'-phosphate from the [35S]B[a]P-nucleoside-5'-phosphorothioate-3'-phosphate adducts by brief treatment with alkaline phosphatase. [35S]B[a]P-nucleoside-5'-phosphorothioate adducts were also prepared using a nuclease P1/prostatic acid phosphatase DNA degradation method. For anti-7,8-dihydroxy-9,10-epoxy-7,8,9,10-tetrahydrobenzo[a]pyrene (BPDE)-modified DNA, overall adduct recoveries were substantially higher with the nuclease P1/prostatic acid phosphatase method (48-51%) than with the micrococcal nuclease/spleen phosphodiesterase/alkaline phosphatase method (22-29%). There were no significant differences in the HPLC profiles of the [35S]phosphorothioate-postlabeled adducts obtained from these two procedures. HPLC analysis of B[a]P-DNA adducts formed in B[a]P-treated hamster embryo cell cultures demonstrated the formation of two major adducts, (+)syn-BPDE-deoxyguanosine-5'-phosphorothioate and (+)anti-BPDE-deoxyguanosine-5'-phosphorothioate, along with other minor adducts. Based upon an overall adduct recovery of 20% and 0.5 mol as the detection limit of this 35S-postlabeling/HPLC assay, the sensitivity of this assay is 1 adduct/10(8) nucleotides for a 60 micrograms DNA sample. This method offers the advantages of using 35S which has a longer half-life and lower radioactive decay energy than 32P and the ability to prepare PAH-DNA adducts at the monophosphorothioate level which greatly facilitates separation of individual 35S-postlabeled PAH-DNA adducts by HPLC.