PROSPECT: 4- and 6-year follow-up of a randomised trial of surgery for vaginal prolapse

INTRODUCTION AND HYPOTHESIS

Our aim was to compare the mid-term results of native tissue, biological xenograft and polypropylene mesh surgery for women with vaginal wall prolapse.

METHODS

A total of 1348 women undergoing primary transvaginal repair of an anterior and/or posterior prolapse were recruited between January 2010 and August 2013 from 35 UK centres. They were randomised by remote allocation to native tissue surgery, biological xenograft or polypropylene mesh. We performed both 4- and 6-year follow-up using validated patient-reported outcome measures.

RESULTS

At 4 and 6 years post-operation, there was no clinically important difference in Pelvic Organ Prolapse Symptom Score for any of the treatments. Using a strict composite outcome to assess functional cure at 6 years, we found no difference in cure among the three types of surgery. Half the women were cured at 6 years but only 10.3 to 12% of women had undergone further surgery for prolapse. However, 8.4% of women in the mesh group had undergone further surgery for mesh complications. There was no difference in the incidence of chronic pain or dyspareunia between groups.

CONCLUSIONS

At the mid-term outcome of 6 years, there is no benefit from augmenting primary prolapse repairs with polypropylene mesh inlays or biological xenografts. There was no evidence that polypropylene mesh inlays caused greater pain or dyspareunia than native tissue repairs.

An assessment of techniques and practices used to elevate intra-abdominal pressure when assessing pelvic floor dysfunction

AIMS

To determine terminology and methods for raising intra-abdominal pressure (IAP) currently used by clinicians to assess pelvic floor dysfunction (PFD) and to measure the effect of these maneuvers on IAP.

METHODS

Three-hundred questionnaires were distributed at two scientific meetings in the United Kingdom to determine methods clinicians used to raise IAP and their perceptions of these methods. Twenty healthy volunteers were also recruited to measure the effect of two methods of raising IAP: Valsalva maneuver (VM) and bear down maneuver (BDM). IAP pressure was measured with rectal catheters connected to pressure sensors. The IAP was measured during each maneuver in both standing and supine positions.

RESULTS

Maneuvers used in practice were cough (79%), BDM (60%), and VM (38%). 44% of clinicians felt patients found it difficult to raise their IAP. There was uncertainty among clinicians as to which method was the most effective in raising IAP and whether the different methods produced the same rise in IAP. On testing IAP in 20 healthy volunteers, median (interquartile range) IAP generated during BDM; 101 (59.1) cmH₂ O was significantly higher than that generated during VM; 80.3 (43.6) cmH₂ O (p < .0001).

CONCLUSION

Clinicians varied widely in the maneuvers they used to raise patients' IAP to test for PFD and there was uncertainty about the maneuvers' effect on IAP. In healthy volunteers, BDM produced significantly higher IAP than VM. We recommend standardization of terminology and techniques used to raise IAP when assessing PFD, to ensure consistency of diagnosis and assessment of treatment outcomes.

Two parallel, pragmatic, UK multicentre, randomised controlled trials comparing surgical options for upper compartment (vault or uterine) pelvic organ prolapse (the VUE Study): study protocol for a randomised controlled trial

BACKGROUND

One in three women who have a prolapse operation will go on to have another operation, though not necessarily in the same compartment. Surgery can result in greater impairment of quality of life than the original prolapse itself (such as the development of new-onset urinary incontinence, or prolapse at a different site). Anterior and posterior prolapse surgery is most common (90 % of operations), but around 43 % of women also have a uterine (34 %) or vault (9 %) procedure at the same time. There is not enough evidence from randomised controlled trials (RCTs) to guide management of vault or uterine prolapse. The Vault or Uterine prolapse surgery Evaluation (VUE) study aims to assess the surgical management of upper compartment pelvic organ prolapse (POP) in terms of clinical effectiveness, cost-effectiveness and adverse events.

METHODS/DESIGN

VUE is two parallel, pragmatic, UK multicentre, RCTs (Uterine Trial and Vault Trial). Eligible for inclusion are women with vault or uterine prolapse: requiring a surgical procedure, suitable for randomisation and willing to be randomised. Randomisation will be computer-allocated separately for each trial, minimised on: requiring concomitant anterior and/or posterior POP surgery or not, concomitant incontinence surgery or not, age (under 60 years or 60 years and older) and surgeon. Participants will be randomly assigned, with equal probability to intervention or control arms in either the Uterine Trial or the Vault Trial. Uterine Trial participants will receive either a vaginal hysterectomy or a uterine preservation procedure. Vault Trial participants will receive either a vaginal sacrospinous fixation or an abdominal sacrocolpopexy. Participants will be followed up by postal questionnaires (6 months post surgery and 12 months post randomisation) and also reviewed in clinic 12 months post surgery. The primary outcome is the participant-reported Pelvic Organ Prolapse Symptom Score (POP-SS) at 12 months post randomisation.

DISCUSSION

Demonstrating the efficacy of vault and uterine prolapse surgeries is relevant not only to patients and clinicians but also to health care providers, both in the UK and globally.

TRIAL REGISTRATION

Current controlled trials ISRCTN86784244 (assigned 19 October 2012), and the first subject was randomly assigned on 1 May 2013.

Managing unsatisfactory outcome after mid-urethral tape insertion

This article reviews the literature on the assessment and management of women whose previous mid-urethral tape surgery to manage stress urinary incontinence symptoms has failed to produce a satisfactory outcome. In many areas the literature is deficient and the article includes consensus statements drawn from the International Continence Society Research Society meeting in Bristol in June 2010. The need for a structured approach to assessment and management is highlighted, so that further research into areas of uncertainty can be prioritized. The article concludes with a number of research recommendations.

Laparoscopic versus open colposuspension: which one should we choose?

PURPOSE OF REVIEW

The aim of this review is to present a summary of recently published research comparing laparoscopic and open colposuspension. It also examines the place of colposuspension in light of the continuing development other minimally invasive procedures for stress urinary incontinence.

RECENT FINDINGS

The results of two large multicentre randomised controlled trials were published in 2006 comparing open and laparoscopic colposuspension. Carey et al. randomised 200 women to open or laparoscopic colposuspension. The primary outcome objective was cure 6 months postoperatively. Cure was defined as the absence of urodynamic stress incontinence. Patients' subjective outcomes were assessed 3-5 years postoperatively. Kitchener et al. reported a randomised controlled trial in which 291 women were recruited. The primary end point of the study was objective cure at 2 years. This was defined as <1 g of urinary leakage during a 1 h standardised pad test. Both trials demonstrated no significant differences between laparoscopic and open colposuspension in objective and subjective measures of cure of stress urinary incontinence at 24 months.

SUMMARY

There is now level 1 evidence that the clinical outcomes with laparoscopic Burch colposuspension are similar to open Burch colposuspension.

Which questionnaire? A psychometric evaluation of three patient-based outcome measures used to assess surgery for stress urinary incontinence

AIMS

The aim of the study was to further validate three patient-based outcome measures (PBOM) used to assess the outcome of surgery for stress urinary incontinence and to compare their psychometric properties with a view to determining the most appropriate measure for clinical use.

METHODS

The work was embedded within a randomized controlled trial of laparoscopic and open colposuspension. The trial recruited 291 women from six centers. The three instruments compared were Bristol Female Lower Urinary Tract Symptom Questionnaire (BFLUTS), Kings Health Questionnaire (KHQ), and the Symptom Severity Index and Symptom Impact Index (SSI/SII). The International Consultation on Incontinence (ICI) ABC grading system of psychometric propertie's reliability, validity, and responsiveness was used to evaluate the instruments.

RESULTS

From the analysis of the psychometric properties of the three instruments, the SSI/SII appeared to have the best psychometric profile; Grade A, BFLUTS was of grade A, and KHQ was of grade B. SSI/SII had a good degree of internal consistency (Cronbach's alpha 0.74-0.78). BFLUTS and KHQ both had domains in which the internal consistency was <0.7. The SSI domain of the SSI/SII was the only domain to correlate to the 1-hr pad test. All domains of the SSI/SII were able to distinguish those cured from not cured and it was most responsive to change. Unlike the KHQ, the SSI/SII had no significant ceiling or floor effects.

CONCLUSIONS

This study has demonstrated that when instruments are used in different populations their psychometric properties may change. All three instruments analyzed had limitations when used as an outcome measure for surgery for stress urinary incontinence.

Laparoscopic versus open colposuspension--results of a prospective randomised controlled trial

OBJECTIVE

To compare the effectiveness and cost effectiveness of open and laparoscopic colposuspension in the treatment of stress urinary incontinence.

DESIGN

A randomised controlled trial. Women were randomised between March 1999 and February 2002 and were seen for assessment at 6, 12 and 24 months, postoperatively.

SETTING

Women were recruited from six gynaecology units in the UK.

POPULATION

Women with proven stress urinary incontinence requiring surgery.

METHODS

Open abdominal retropubic colposuspension or laparoscopic colposuspension.

MAIN OUTCOME MEASURES

Primary outcomes were subjective (satisfaction with outcome) and objective (negative 1-hour pad test). Secondary outcomes were operative and postoperative morbidity and quality of life. The study was powered to demonstrate noninferiority, i.e. that the absolute cure rate of laparoscopic colposuspension was no more than 15% below that of open colposuspension.

RESULTS

A total of 291 women were randomised, with 24-month data on subjective and objective outcomes in 88 and 82.5%, respectively. The intention-to-treat analysis indicated no significant difference in cure rates between open and laparoscopic surgery. The objective cure rates for open and laparoscopic were 70.1 and 79.7%, respectively. Subjective cure rates by satisfaction were lower than objective cure; 54.6 and 54.9%, respectively, and there was considerable nonconcordance both ways.

CONCLUSIONS

Laparoscopic colposuspension is not inferior to open colposuspension in terms of curing stress urinary incontinence.

Cost-effectiveness analysis of open colposuspension versus laparoscopic colposuspension in the treatment of urodynamic stress incontinence

OBJECTIVES

To compare the cost effectiveness of laparoscopic versus open colposuspension for the treatment of female urinary stress incontinence.

DESIGN

Cost utility analysis alongside a randomised controlled trial.

SETTING

Six gynaecological surgical centres within the UK.

POPULATION/SAMPLE

Women with proven stress urinary incontinence requiring surgery.

METHODS

Open abdominal retropubic colposuspension or laparoscopic colposuspension carried out by experienced surgeons.

MAIN OUTCOME MEASURES

Cost, measured in pounds sterling and generic health-related quality of life, measured using the EQ-5D. The latter was used to estimate patient-specific quality-adjusted life years (QALYs).

RESULTS

Healthcare resource use over 6-month follow up translated into costs of pound 1805 for the laparoscopic arm and pound 1433 for the open arm (differential mean cost pound 372; 95% credibility interval [CrI]: 274-471). At 6 months, QALYs were slightly higher in the laparoscopic arm relative to the open arm (0.005; 95% CrI: -0.012 to 0.023). Therefore, the cost of each extra QALY in the laparoscopic group (the incremental cost-effectiveness ratio [ICER]) was pound 74,400 at 6 months. At 24 months, the laparoscopic arm again had a higher mean QALY score compared to the open surgery group. Thus, assuming that beyond 6 months the laparoscopic colposuspension would not lead to any significant additional costs compared with open colposuspension, the ICER was reduced to pound 9300 at 24 months. Extensive sensitivity analyses were carried out to test assumptions made in the base case scenario.

CONCLUSIONS

Laparoscopic colposuspension is not cost effective when compared with open colposuspension during the first 6 months following surgery, but it may be cost effective over 24 months.

A valsalvometer can be effective in standardising the Valsalva manoeuvre

A prospective randomised controlled study was performed in order to study the effectiveness of a device designed to reduce the variability in intra-abdominal pressures generated by individuals performing the Valsalva manoeuvre. One hundred women were recruited to take part in the project which compared a traditional Valsalva manoeuvre following standardised verbal instruction with forced expiration through a flow restriction device called a "valsalvometer". The abdominal pressure was measured using an air-filled rectal balloon catheter linked to a pressure transducer. The use of the valsalvometer was associated with a reduction in variation of intra-abdominal pressure between women to 50% of the standard deviation. The new device has the capacity to reduce the variation in intra-abdominal pressure produced when performing the Valsalva manoeuvre. The rise in intra-abdominal pressure may act as a standard against which other measurements are made.

Long term review of laparoscopic sacrocolpopexy

OBJECTIVE

Assessment of long term outcome following laparoscopic sacrocolpopexy.

DESIGN

Retrospective follow up study using standardised examination with pelvic organ prolapse quantification system (POP-Q) and questionnaires.

SETTING

A tertiary urogynaecology unit in the North West of England.

POPULATION

One hundred and forty consecutive cases who had a laparoscopic sacrocolpopexy at St Mary's Hospital, Manchester, between 1993 and 1999.

METHODS

Women completed questionnaires and were examined in gynaecology clinic or sent postal questionnaires if unable to attend the clinic.

MAIN OUTCOME MEASURES

Adequacy of vault support and recurrent vaginal prolapse assessed by POP-Q score. Assessment of prolapse, urinary and bowel symptoms and sexual function using questionnaires.

RESULTS

One hundred and three women were contacted after a median of 66 months. Sixty-six women were examined and a further 37 women filled in questionnaires only. Recurrent vault prolapse occurred in 4 of the 66 women who were examined. Prolapse had recurred or persisted in 21 of 66 women, with equal numbers of anterior and posterior vaginal wall prolapse. Overall, 81/102 (79%) said that their symptoms of prolapse were 'cured' or 'improved'; 39/103 (38%) still had symptoms of prolapse. For every two women who were cured of their urinary or bowel symptoms, one woman developed worse symptoms.

CONCLUSIONS

Among the 66 women available for examination laparoscopic sacrocolpopexy provided good long term support of the vault in 92%. Forty-two percent of these women had recurrent vaginal wall prolapse. Despite this, 79% of women felt that their symptoms of prolapse were cured or improved following surgery.

Ambulatory surgery in urogynaecology

Ambulatory surgery offers advantages to both patients and providers. It is imperative to ensure appropriate case selection, pre-operative counseling, a suitable environment, trained staff, adequate analgesia and post-operative care both in the hospital and the community. Many well-established urogynaecological procedures such as cystoscopy and vaginal repair may be performed in an ambulatory setting. Newer procedures such as injection of botulinum toxin or peri-urethral bulking agents and tension-free tapes for stress incontinence may also be performed in this way. To date, the literature is deficient in robust studies comparing outcomes and patient satisfaction between conventional and ambulatory surgical procedures, and randomized controlled trials are required.

Opening detrusor pressure and the influence of age on success following colposuspension

OBJECTIVE

Women with urodynamic stress incontinence (USI) have lower opening and closing detrusor pressures than women without USI. This study was undertaken to determine whether a change occurs in opening and closing detrusor pressures after colposuspension, whether cure is associated with change, and whether age influences cure.

DESIGN

Retrospective cohort study.

SETTING

Tertiary referral urogynaecology department.

PARTICIPANTS

Consecutive women who had undergone colposuspension between 1998-2000 and 1993-1995.

METHODS

Pre- and post-operative urodynamic records were reviewed. Eighty eight women were included. Objective cure was defined as an absence of USI and subjective cure as an absence of symptoms of stress incontinence.

RESULTS

Mean age was 52.4 (11.0) years. Sixty nine percent (61/88) were objectively cured and 48% (42/88) were subjectively cured. Postoperatively, opening detrusor pressure increased (P = 0.0001) and maximum flow rate decreased (P= 0.0464) in women objectively cured but these parameters did not change in the not cured group (P > 0.05). Women had a 4.5 times higher chance of failed surgery if post-op opening detrusor pressure was < or =20 cmH2O (P = 0.035). Opening detrusor pressure declined with age (P < 0.001) and women who were objectively cured were on average almost 7 years younger (P = 0.0330).

CONCLUSIONS

Increase in opening detrusor pressure occurs only in women who are cured following colposuspension. Change in opening detrusor pressure is dependent on age and objective cure is higher in younger women. The effects of ageing on sub-urethral supports might explain why surgery is more likely to fail in older women.

Stress incontinence and pelvic floor neurophysiology 15 years after the first delivery

HEADLINE: This is a longitudinal study of a cohort of primigravidae recruited between 1985 and 1987 and followed up 7 and 15 years later. Pelvic floor neurophysiology was performed and questionnaires were administered to determine the natural history of stress incontinence and to establish whether pelvic floor denervation after the first delivery is associated with symptoms of stress urinary incontinence in the future.

OBJECTIVES

To study the natural history of stress urinary incontinence arising during the first pregnancy, to determine whether postnatal pelvic floor denervation progresses with time and whether it predisposes to stress urinary incontinence in the future.

DESIGN

Prospective longitudinal cohort study.

SETTING

Tertiary referral urogynaecology unit.

SAMPLE

Cohort of 96 primigravidae studied prospectively between 1985 and 1987 and followed up 7 years (n = 76) and 15 years (n = 55) later.

METHODS

Urinary incontinence symptoms were recorded and pelvic floor neurophysiology was performed antenatally and postnatally between 1985 and 1987. Repeat neurophysiological tests and questionnaires were completed by those relocated 7 and 15 years later.

MAIN OUTCOME MEASURE

Symptoms of stress urinary incontinence.

SECONDARY OUTCOMES

Symptoms of urge urinary incontinence and anal incontinence; motor unit potential duration and pudendal nerve terminal latency; vaginal squeeze pressure measured by perineometry.

RESULTS

Prevalence of stress incontinence was highest during pregnancy and had increased seven years after the first postnatal period (P = 0.0129). Two-thirds of women with antenatal stress incontinence had stress incontinence 15 years later. One-third of women with stress incontinence at any time appear to undergo resolution of symptoms. Motor unit potential duration increased at seven years (P = 0.036). Vaginal squeeze pressure improved during the same period (P = 0.0007).

CONCLUSIONS

When stress urinary incontinence arises during the first pregnancy, the risk of stress incontinence occurring 15 years later is doubled. Although pelvic floor reinnervation progressed after the postnatal period, the absence of an adequate marker for pelvic floor denervation makes it of uncertain clinical significance.

Evidence-based practice in urogynaecology

Urogynaecology practice is rapidly progressing, with a trend towards minimally invasive techniques. This article attempts to cover the evidence behind the assessment and treatment of urinary and anal incontinence, and vaginal prolapse.

Strength-duration testing of the external anal sphincter in females with anorectal dysfunction

PURPOSE

The strength-duration test has been suggested as a means of assessing external anal sphincter function. This study was designed to investigate this claim by comparing the strength-duration test with established measures of external anal sphincter function.

METHODS

Forty-nine females undergoing diagnostic anorectal testing (manometry, rectal sensation, electromyogram, pudendal nerve terminal motor latency, and endoanal ultrasound) also had the strength-duration test performed (which was repeated for each patient after a short rest period).

RESULTS

The strength-duration test was repeatable. Statistically significant correlations were found between this test at pulse durations of 3 ms, 1 ms, and 0.3 ms with electromyographic activity of the external anal sphincter and with pressure in the anal canal during voluntary contraction. Significant correlations were found for durations of 100 ms, 30 ms, 10 ms, and 3 ms with the pudendal nerve terminal motor latency on the right and for the 3 ms and 0.3 ms durations with latency on the left. There were no correlations between the strength-duration test and resting pressure in the anal canal.

CONCLUSION

The strength-duration test significantly correlates with the established measures of external anal sphincter function and its innervation. Therefore, this simple test appears to provide a simple measure of external anal sphincter denervation.