Are older patients with prolapse likely to continue pessary use? A retrospective observational study

INTRODUCTION AND HYPOTHESIS

To review the outcomes and complications of vaginal prolapse management with pessaries in women aged 75 years or older, to ascertain whether pessaries are providing satisfactory long-term outcomes for older women.

METHODS

A retrospective observational study was performed on women aged 75 years or older presenting to a tertiary Urogynaecology service with vaginal prolapse who opted for management with a vaginal pessary. Demographic and clinical data were collected by reviewing clinical files. The primary outcome was the proportion of women who opted for pessary management who later required prolapse surgery. Secondary outcomes included pessary complications and risk factors for failure. Kaplan-Meier survival estimates were performed to analyse pessary failure.

RESULTS

Of the 218 women who presented with prolapse, 78% opted for pessary management, and pessary fitting was successful in 84%. Sixty-nine percent of women who opted for initial pessary management underwent surgery later, with a mean time from pessary insertion to surgery of 21.6 months. Vaginal erosions were reported in 42% of pessary users. Risk factors for pessary failure were younger age and previous history of hysterectomy or prolapse surgery.

CONCLUSIONS

Although vaginal pessary use was the preferred first-line management choice for vaginal prolapse in most older women, surgery for prolapse was ultimately required in two-thirds of those conservatively managed. As three-quarters of older women presenting with prolapse had surgery as either a primary or secondary procedure; patients need to be advised of the high chance of requiring surgery at a later stage if they opt for pessary management.

Counseling for stress urinary incontinence in the era of adverse publicity around mesh usage: Results from a large-sample global survey

OBJECTIVE

To investigate doctors' opinions of the use of synthetic mesh for the treatment of stress urinary incontinence (SUI) and the effect on patient's attitude following recent adverse publicity and legal findings.

METHODS

Electronic survey approved by International Urogynecological Association (IUGA) and American Urogynecologic Society (AUGS), distributed to their members.

RESULTS

A total of 593 respondents completed the survey. The preferred initial surgical treatment for SUI was retropubic midurethral sling (MUS) (62%), followed by trans-obturator MUS (19%), mini-slings (10%), and then bulking agents (5%). Despite prolongation of consultation, most respondents (87%) believed that clinicians should provide a patient information leaflet (PIL) for their patients. However, only 70% of respondents were doing this. Most participants would use either the IUGA PIL or their institution PIL (61%). Only 8% felt that patients have a positive preconception of synthetic mesh for SUI. Eighty-three per cent of respondents had not changed their recommendations for treatment and the consent process. A logistic regression model identified preferences of certain geographic areas as predictors of consenting practices.

CONCLUSION

Despite the negative publicity and the current medicolegal litigation involving MUS for SUI treatment, the majority of respondents still prefer this as the initial surgical treatment. Most clinicians value PIL in the surgical consent process.

Long-term effectiveness and safety of open Burch colposuspension vs retropubic midurethral sling for stress urinary incontinence-results from a large comparative study

BACKGROUND

There are few adequately powered long-term trials comparing midurethral sling and Burch colposuspension. Recent concerns about synthetic mesh with new stringent clinical and research governance support the need for evidence to facilitate shared decision making.

OBJECTIVE

This study aimed to compare long-term outcomes of open Burch colposuspension with the retropubic midurethral sling.

STUDY DESIGN

A matched cohort study of 1344 women with urodynamic stress incontinence (without intrinsic sphincter deficiency) who underwent surgery for stress urinary incontinence. Women had either open Burch colposuspension or the retropubic midurethral sling, from January 2000 to June 2018, in a tertiary center. Follow-up was by chart review and one-time phone follow-up until 2019, using a dedicated database. Primary outcomes were the presence or absence of stress urinary incontinence on follow-up, the success of index surgery based on response to validated questionnaires of patient-reported outcomes, and retreatment rates. Secondary outcomes are described below. Matching (1:3) was done at baseline to avoid confounding.

RESULTS

The study included 1344 women who had either Burch colposuspension (336) or retropubic midurethral sling (1008). Mean follow-up was 13.1 years for Burch colposuspension and 10.1 years for retropubic midurethral sling. In the Burch colposuspension group, 83.0% of patients (279 of 336) reported no ongoing stress urinary incontinence at the time of the latest follow-up vs 85.0% (857 of 1008) in the retropubic midurethral sling group (P=.38). Success in terms of the latest reported International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (defined as International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form score of ≤6) where these data were available were similar within both groups: 76.0% (158 of 208 where this was available) in Burch colposuspension vs 72.1% (437 of 606 where this was available) in retropubic midurethral sling (P=.32). Where this information was available, success defined by a Patient Global Impression of Improvement of "very much improved" and "much improved" was similar between Burch colposuspension and retropubic midurethral sling groups (84.1% [243 of 289] vs 82.0% [651 of 794]; P=.88). Where data were available, 88.1% of women (178 of 202) in the Burch colposuspension group said they were very likely to recommend the surgery to family or a friend vs 85.0% (580 of 682) in retropubic midurethral sling (P=.30).Overall, 3.6% needed repeat incontinence procedures (13 in Burch colposuspension group [3.8%] vs 35 in retropubic midurethral sling group [3.5%]; P=.73). The incidence of mesh exposure was 1.0 %. Notably, 1 Burch colposuspension patient had a suture in the bladder during follow-up; 5 patients have reported long-standing pain across the study population. Overall, 51 women reported new-onset overactive bladder symptoms on follow-up: 10 of 336 (3.0%) had Burch colposuspension and 41 of 1008 (4.1%) had retropubic midurethral sling (P=.41). The need for future prolapse surgery per index procedure was 3.3% after Burch colposuspension vs 1.1% postretropubic midurethral sling (P=.01). Moreover, 9 of the 11 patients who needed a prolapse repair after Burch colposuspension required a posterior repair. The incidence of long-term severe voiding difficulty needing self-catheterization was similar in both groups (0.3% in Burch colposuspension and 0.5 % in retropubic midurethral sling group; P=1.00).

CONCLUSION

This study shows no difference in success, patient satisfaction, or complications between Burch colposuspension and retropubic midurethral sling, although the risk of posterior compartment prolapse operations after Burch colposuspension is increased. Reoperation rates for incontinence were similar in both groups. Chronic pain was a rare outcome.

Extraperitoneal high vaginal cuff suspension at the time of vaginal hysterectomy for advanced uterovaginal prolapse: Results of a modified McCall technique from a longitudinal clinical study

BACKGROUND

Women with high-grade uterovaginal prolapse have a greater risk of recurrent prolapse after pelvic organ prolapse surgery. Royal College of Obstetricians and Gynaecologists guidelines have recommended sacrospinous suspension (sacrospinous fixation) at the time of vaginal hysterectomy, whenever there is a marked uterovaginal prolapse. We have modified the McCall culdoplasty by placing sutures extraperitoneally, higher and more lateral into the uterosacral/cardinal ligaments to re-support the vaginal cuff at the time of a vaginal hysterectomy.

AIMS

To evaluate the results of a modified technique of McCall high culdoplasty and native tissue repair at time of vaginal hysterectomy in women with advanced uterovaginal prolapse.

MATERIAL AND METHODS

Longitudinal clinical follow-up conducted between 2000-2018, in a tertiary urogynaecology centre for patients presenting with stage 3-4 uterovaginal prolapse, who underwent vaginal hysterectomy and modified McCall vault suspension.

RESULTS

There were 176 cases meeting the inclusion criteria. Mean follow-up was 19.35 months. There were 25 recurrences (14%) of ≥ stage 2 (76% not symptomatic). Twelve of these recurrences (48%) occurred in anterior compartment, six (25%) posterior, three (12%) combined anterior/posterior, two (8%) combined posterior/central and one case had recurrence in all compartments. Only six cases (3%) required another surgical procedure for symptomatic prolapse, all with an enterocele recurrence.

CONCLUSIONS

Our described modified McCall technique incorporates high extraperitoneal approach to apical resuspension along with closure of any existing large hiatal defects of the levator plate at the time of vaginal hysterectomy for advanced uterine prolapse has excellent outcomes and extremely low complication rates and avoids the need for sacrospinous fixation.

Extraperitoneal uterosacral suspension technique for post hysterectomy apical prolapse in 472 women: results from a longitudinal clinical study

OBJECTIVES

The study aims to evaluate the long-term results of the extraperitoneal uterosacral ligament suspension (bilateral) technique in women with apical prolapse following hysterectomy.

DESIGN

Longitudinal clinical follow up conducted between June 2002 and December 2017.

SETTING

Tertiary urogynaecology centre in Melbourne, Australia.

POPULATION

A total of 472 women with symptomatic vault prolapse who underwent bilateral extraperitoneal uterosacral ligament suspension (EPUSLS). Of these patients, 61% (287/472) had previously had a procedure for pelvic organ prolapse (POP).

METHODS

Follow up using structured, standardised questionnaires and examination by POP-Q and Baden-Walker system pre- and postoperatively.

MAIN OUTCOME MEASURES

Functional and anatomical results and surgical complications.

RESULTS

Mean follow-up duration was approximately 5 years. The objective success rate at vaginal cuff support was 89% (420/472). Only 4% needed revision surgery for vault recurrence. There was improvement in bladder, bowel, and sexual symptoms after the procedure. Mesh exposure rate was 17% (of the 138 having mesh augmentation), with the majority of cases managed conservatively or with minor interventions. The ureteric injury rate was 1% and mainly occurred in patients operated early on in the series. No women had buttock pain.

CONCLUSION

EPUSLS is an effective, suture-based procedure for vault prolapse with few complications even on long-term follow up. This technique avoids the need to open the peritoneum vaginally and has a low risk of ureteric injury and gluteal pain.

TWEETABLE ABSTRACT

Bilateral extraperitoneal USL suspension of vault is effective with low morbidity and a high success rate.

Technique of extraperitoneal uterosacral ligament suspension for apical suspension

AIM OF THE VIDEO/INTRODUCTION

Vaginal vault prolapse can occur alone or in combination with anterior or posterior compartment prolapse. Apical prolapse has shown a strong correlation with anterior wall prolapse and a moderate correlation with posterior wall prolapse. The McCall culdoplasty uses the extraperitoneal vaginal approach to support the vault at the time of hysterectomy. Sacrospinous fixation and ileococcygeus suspension with or without mesh have also been used for the treatment of vaginal vault prolapse. The uterosacral ligaments can also be used to re-suspend the vaginal vault using the extraperitoneal or transperitoneal approach. With the extraperitoneal approach, the peritoneal sac, which can be difficult to access at times, especially when there are dense pelvic adhesions, does not need to be opened. The extraperitoneal approach also carries a lower risk of ureteric injury, as the ureters and the bladder can be retracted from the field using a Breisky-Navratil retractor.

METHODS

This video, which documents the surgical treatment of a woman with a complete vaginal eversion and grade 3 pelvic organ prolapse (POP), was recorded in a live workshop during the 2015 Urogynaecology and Reconstructive Pelvic Surgery Conference, held in Chennai, India, in January 2015. It is aimed at educating interested surgeons in the technique of extraperitoneal uterosacral suspension.

CONCLUSIONS

This video demonstrates the extraperitoneal approach to uterosacral ligament suspension for apical support in women with vaginal vault prolapse.

Randomized trial of a single incision versus an outside-in transobturator midurethral sling in women with stress urinary incontinence: 12 month results

OBJECTIVE

The objective of the study was to evaluate objective and subjective outcomes of MiniArc and Monarc (American Medical Systems, Minnetonka, MN) midurethral sling (MUS) in women with stress incontinence at 12 months.

STUDY DESIGN

A total of 225 women were randomized to receive MiniArc or Monarc. Women with intrinsic sphincter deficiency, previous MUS, or untreated detrusor overactivity were excluded. Objective cure was defined as negative cough stress test with a comfortably full bladder. Subjective cure was defined as no report of leakage with coughing or exercise on questionnaire. Validated questionnaires, together with urodynamic and clinical cough stress test, were used to evaluate the objective and subjective outcomes following surgery. Participants and clinicians were not masked to treatment allocation. Outcomes were compared with exact binomial tests (eg, Fisher exact test for dichotomous data) for categorical data and Student t tests or exact versions of Wilcoxon tests for numerical data as appropriate.

RESULTS

There was no statistically significant difference in the subjective (92.2% vs 94.2%; P = .78; difference, 2.0%; 95% confidence interval, -2.7% to +6.7%) or objective (94.4% vs 96.7%; P = .50; difference, 2.3%; 95% confidence interval, -1.5% to +6.1%) cure rates between MiniArc and Monarc at 12 m, respectively, with a significant improvement in overactive bladder outcomes and incontinence impact from baseline in both arms.

CONCLUSION

MiniArc outcomes are not inferior to Monarc MUS outcomes at 12 months' follow-up in women without intrinsic sphincter deficiency.

The effects of mode delivery on postpartum sexual function: a prospective study

OBJECTIVE

To determine the effect of mode of delivery and perineal injury on sexual function at 6 and 12 months postpartum.

DESIGN

Prospective cohort study.

SETTING

Tertiary women's hospital in Melbourne, Australia.

POPULATION

A cohort of 440 primigravid women.

METHODS

The Female Sexual Function Index (FSFI) was completed at first visit (7-19 weeks of gestation), and at 6 and 12 months postpartum.

MAIN OUTCOME MEASURES

A statistically significant difference in total FSFI or domain scores over time according to mode of delivery or perineal injury.

RESULTS

In this cohort 54% of women had a normal vaginal delivery, 21% had an instrumental delivery, and 25% gave birth by caesarean section. No difference was found in total FSFI or domain scores according to mode of delivery over time between antenatal assessment and 12 months postpartum. Pain was decreased in the caesarean group only at 6 months postpartum. All groups showed pain scores at 12 months that were comparable with antenatal levels. For those who gave birth vaginally, 27% had an intact perineum, 50% had an episiotomy, and 6%, 14%, and 3% had first, second, and third-degree tears, respectively. The only differences between groups were found over time according to perineal injury at 6 months in the arousal domain. At 12 months, total FSFI and domain scores were no different to initial scores.

CONCLUSIONS

At 12 months postpartum sexual function has returned to early pregnancy levels, irrespective of mode of delivery or perineal injury.

Pelvic organ prolapse surgery with and without tension-free vaginal tape in women with occult or asymptomatic urodynamic stress incontinence: a randomised controlled trial

INTRODUCTION

We set out to determine if insertion of a retropubic tension-free vaginal tape (TVT) sling at the time of pelvic organ prolapse surgery improves continence outcomes in women with pre-operative occult stress incontinence (OSI) or asymptomatic urodynamic stress incontinence (USI).

METHODS

We conducted a randomised controlled study of prolapse surgery with or without a TVT midurethral sling. The pre- and post-operative assessment at 6 months included history, physical examination and urodynamic testing. Quality of life (QOL) and treatment success was assessed with the UDI-6 SF, IIQ-7 SF and a numerical success score. The primary outcome was symptomatic stress urinary incontinence (SUI) requiring continence surgery (TVT) at 6 months. Long-term follow-up continued to a minimum of 24 months. Secondary outcomes were quality of life parameters.

RESULTS

Eighty women received prolapse surgery alone (n = 43) or prolapse surgery with concurrent TVT (n = 37). Six months following prolapse surgery 3 out of 43 (7 %) patients in the no TVT group requested sling surgery compared with 0 out of 37 (0 %) in the TVT group (ARR 7 % [95 %CI: 3 to 19 %], p = 0.11). After 24 months there was one further participant in the no TVT group who received a TVT for treatment of SUI compared with none in the TVT group (4 out of 43, 9.3 % versus 0 out of 37; ARR 9.3 % [95 %CI: -1 to 22 %], p = 0.06). Both groups showed improvement in QOL difference scores for within-group analysis, without difference between groups.

CONCLUSION

These results support a policy that routine insertion of a sling in women with OSI at the time of prolapse repair is questionable and should be subject to shared decision-making between clinician and patient.

An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint terminology and classification of the complications related directly to the insertion of prostheses (meshes, implants, tapes) and grafts in female pelvic floor surgery

INTRODUCTION AND HYPOTHESIS

A terminology and standardized classification has yet to be developed for those complications arising directly from the insertion of synthetic (prostheses) and biological (grafts) materials in female pelvic floor surgery.

METHODS

This report on the above terminology and classification combines the input of members of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS) and a Joint IUGA/ICS Working Group on Complications Terminology, assisted at intervals by many expert external referees. An extensive process of 11 rounds of internal and external review took place with exhaustive examination of each aspect of the terminology and classification. Decision-making was by collective opinion (consensus).

RESULTS

A terminology and classification of complications related directly to the insertion of prostheses and grafts in female pelvic floor surgery has been developed, with the classification based on category (C), time (T) and site (S) classes and divisions, that should encompass all conceivable scenarios for describing insertion complications and healing abnormalities. The CTS code for each complication, involving three (or four) letters and three numerals, is likely to be very suitable for any surgical audit or registry, particularly one that is procedure-specific. Users of the classification have been assisted by case examples, colour charts and online aids (www.icsoffice.org/complication).

CONCLUSION

A consensus-based terminology and classification report for prosthesis and grafts complications in female pelvic floor surgery has been produced, aimed at being a significant aid to clinical practice and research.

Sexual function following retropubic TVT and transobturator Monarc sling in women with intrinsic sphincter deficiency: a multicentre prospective study

INTRODUCTION AND HYPOTHESIS

A prospective study comparing the effect of the tension-free vaginal tape (TVT) to the Monarc sling on sexual function in women with urodynamic stress incontinence (USI) and intrinsic sphincter deficiency (ISD) is presented.

METHODS

Eighty-seven sexually active women with USI and ISD were enrolled. Sexual function was assessed pre-operatively and at 6 and 12 months post-operatively by history, PISQ-12, UDI-6 and IIQ-7 questionnaires.

RESULTS

A significant increase was detected in PISQ-12 score following both TVT and Monarc insertion. This score was greater in the TVT group at 6 months but not at 12 months when compared to the Monarc group. A significant decrease in UDI-6 and IIQ-7 score was detected. Specifically, coital incontinence and fear of leakage were reduced in both groups, and no change in dyspareunia or orgasm intensity was found.

CONCLUSIONS

Sexual function improves 6 months after TVT or Monarc sling, and this benefit is maintained at 12 months.

Chronic pelvic pain in urogynecological practice: a personal view

Women with chronic pelvic pain are frequently referred to gynaecologists as over 50% also have genitourinary or irritable bowel symptoms or both. When no specific pathology is found and the pathophysiology is unclear, the aetiology is probably an interplay of neuropathic, inflammatory and functional factors. The principles of medical and surgical treatment are discussed and should be based on evidence-based medicine.

Repeat synthetic mid urethral sling procedure for women with recurrent stress urinary incontinence

PURPOSE

We reported and compared the outcomes of repeat mid urethral sling with primary mid urethral sling in women with stress urinary incontinence.

MATERIALS AND METHODS

A total of 1,225 consecutive women with urodynamic stress incontinence underwent a synthetic mid urethral sling procedure (955 retropubic, 270 transobturator) at our institution between 1999 and 2007. Of the patients 91% (1,112) were interviewed via telephone call with a structured questionnaire and were included in the analysis. Mean +/- SD followup was 50 +/- 24 months (range 12 to 114). A comparison between repeat (77, mean age 62 +/- 12 years) and primary (1,035, mean age 60 +/- 13 years) mid urethral sling groups was performed. Repeat sling was placed without removal of the previous sling.

RESULTS

The preoperative incidence of intrinsic sphincter deficiency was higher in patients who had a repeat mid urethral sling (31% vs 13%, p <0.001). The subjective stress incontinence cure rate was 86% and 62% in the primary and repeat group, respectively (p <0.001). The repeat retropubic approach was significantly more successful than the repeat transobturator approach (71% vs 48%, p = 0.04). The rates of sling related and general postoperative complications were similar between the primary and the repeat groups. However, de novo urgency (30% vs 14%, p <0.001) and de novo urge urinary incontinence (22% vs 5%, p <0.001) were more frequent in the repeat group compared with the primary group.

CONCLUSIONS

A repeat synthetic mid urethral sling procedure has a significantly lower cure rate than a primary mid urethral sling procedure. The repeat retropubic approach has a higher success rate than the repeat transobturator approach. The incidence of de novo urgency and urge incontinence are significantly higher in repeat procedures.

Effectiveness of midurethral slings in intrinsic sphincteric-related stress urinary incontinence

PURPOSE OF REVIEW

Previous literature has shown that urodynamic evidence of intrinsic sphincter deficiency (ISD) decreases the surgical success of traditional antistress incontinence surgeries. The aim of this review is to assess recent evidence on the effectiveness of the increasingly popular midurethral slings (MUS) in women with ISD and stress urinary incontinence.

RECENT FINDINGS

Using the ISD definition of maximum urethral closure pressure of 20 cm H2O or less and/or abdominal/valsalva leak point pressure of 60 cm H2O or less, current literature would suggest that the effectiveness of retropubic MUS is reduced but remained acceptable in women with stress urinary incontinence and ISD. There are conflicting data on whether coexisting poor urethral mobility could further compromise surgical success. Of note, there is now emerging evidence to suggest that transobturator tapes are associated with much higher failure rates in this setting and retropubic MUS should be used instead. Currently, there is too little data on the new single-incision mini-slings for any recommendation of use in women with stress incontinence with good or poor intrinsic urethral function.

SUMMARY

MUS is an effective treatment for stress urinary incontinence. However, when urodynamic evidence of ISD is present, the retropubic approach may be preferable to the transobturator approach.

Risk factors of treatment failure of midurethral sling procedures for women with urinary stress incontinence

INTRODUCTION AND HYPOTHESIS

Midurethral sling (MUS) is now the first line surgical treatment for female stress urinary incontinence. Our aim was to identify predictors for MUS failure.

METHODS

A total of 1,225 consecutive women with urodynamic urinary stress incontinence had a synthetic MUS (955 retropubic and 270 transobturator) at our institution between 1999 and 2007. Multivariate analysis was performed in order to identify independent risk factors for failure.

RESULTS AND CONCLUSIONS

At a mean follow-up of 50 +/- 24 months (range, 12-114), the subjective cure rate was 84.7%. Multivariate analysis revealed that BMI >25 (OR, 2.9), mixed incontinence (OR, 2.4), previous continence surgery (OR, 2.2), intrinsic sphincter deficiency (OR, 1.9), and diabetes mellitus (OR, 1.8) are significant independent predictors for MUS failure. Concomitant prolapse surgery decreased the likelihood of surgical failure after MUS (OR, 0.6). Patient's age and the type of the sling were not found to be risk factors for surgical failure.

Urinary leakage during coitus in women

During a 4-year period from 1993 to 1997, a total of 2153 women were referred to our urogynaecology clinic complaining of urinary incontinence. Of these women, 228 (10.6%) admitted to coital incontinence. Only 22 of these 228 women complained of this symptom without direct questioning. Urine loss occurred during penetration in 158 women, during orgasm in 45 women and during both in 25 women. Comparison of these groups showed few other differences in their presenting symptoms, examination findings, urodynamic data or diagnosis. Genuine stress incontinence was present in 79.8% of women with urinary leakage during penetration, in 93.2% with leak on orgasm and in 92.0% who leaked on both. Detrusor instability was uncommon. In most women who complain of urinary leakage during sexual intercourse, the underlying pathophysiological mechanism is urethral sphincter incompetence. Compared with women presenting with urinary incontinence in the absence of coital incontinence, women with coital leakage had a higher incidence of stress and urge incontinence, and a significantly greater incidence of anterior vaginal wall prolapse and demonstrable stress incontinence on examination.