Two-Year Preclinical Evaluation of Long-Term Absorbable Poly-4-hydroxybutyrate Scaffold for Surgical Correction of Pelvic Organ Prolapse

INTRODUCTION AND HYPOTHESIS

Fully absorbable implants may be an alternative to permanent meshes in the correction pf pelvic organ prolapse (POP) as they may reduce adverse events by promoting tissue regeneration and collagen metabolism. This study was aimed at evaluating the long-term host and biomechanical response to a fully absorbable poly-4-hydroxybutyrate (P4HB) scaffold in comparison with polypropylene (PP) mesh.

METHODS

Poly-4-hydroxybutyrate scaffold (n = 16) and PP mesh (n = 16) were surgically implanted in the posterior vaginal wall of parous female Dohne Merino sheep. Vaginal explants were evaluated in terms of gross necropsy, host response (immune response, collagen deposition, tissue regeneration), biomechanics, and degradation of P4HB at 12 and 24 months post-implantation.

RESULTS

Gross necropsy revealed no infection or fluid collection using P4HB or PP. At 12 months, exposures were observed with both P4HB (3 out of 8) and PP (4 out of 8), whereas at 24 months, exposures were observed only with PP (4 out of 8). The tensile stiffness of the P4HB explants was maintained over time despite complete absorption of P4HB. The collagen amount of the vaginal tissue after P4HB implantation increased over time and was significantly higher than PP at 24 months. P4HB scaffolds exhibited significantly lower myofibroblast differentiation than PP meshes at 24 months.

CONCLUSIONS

The P4HB scaffold allowed for gradual load transfer to the vaginal wall and resulted in mechanically self-sufficient tissue. P4HB scaffold had a more favorable host response than PP mesh, with higher collagen content, lower myofibroblastic differentiation, and no exposures at 24 months. P4HB scaffolds have potential as an alternative to permanent implants in treating POP.

Complications of Synthetic Midurethral Slings: Is There a Relevant Discrepancy Between Observational Data and Clinical Trials?

CONTEXT

The complications of synthetic midurethral slings (MUSs) in women with stress urinary incontinence (SUI) have become a globally debated issue.

OBJECTIVE

To systematically review the short- and long-term complications of mesh slings reported in observational data compared with clinical trial data, to determine whether the complication rates from clinical trials reflects "real-world" observational data.

EVIDENCE ACQUISITION

PubMed and Cochrane Library were searched. Methods as detailed in Preferred Reporting Items for Systematic Reviews and Meta-analyses and Cochrane Handbook for Systematic Reviews of Interventions were followed.

EVIDENCE SYNTHESIS

Thirty registries/databases including 709 335 MUS procedures (1-22 yr of follow-up) were identified. MUS procedures were associated with intraoperative bladder perforation in 0.86-3.6%, urethral perforation in 0-0.1%, vascular injury in 0.04-0.1%, voiding lower urinary tract symptoms (LUTS) in 1.47-3.5%, vaginal exposure in 0.2-1.9%, and reoperation in up to 9% of cases. Forty-three randomised clinical trials were identified, including 6284 women who underwent MUS procedures and 2177 women who underwent other interventions (1-10 yr of follow-up). MUS procedures were associated with urinary tract perforation in 2.58%, vaginal injury in 1.43%, de novo voiding LUTS in 4.37%, de novo storage LUTS in 5.41%, mesh extrusion/exposure (vaginal/urinary tract) in 2.54%, dyspareunia in 2.26%, pain (pelvic/suprapubic/perineal) in 2.83%, and reoperation for complications required in 1.82% of cases. Meta-analyses of the randomised controlled trials revealed that retropubic MUSs were associated with more events of urinary tract perforation (risk ratio [RR] 9.81, 95% confidence interval [CI] 5.05-19.04, high certainty of evidence [COE]) and voiding LUTS (RR 1.57, 95% CI 1.19-2.07, high COE) than transobturator MUSs. MUSs were associated with more events of pain than mini-slings (RR 1.72, 95% CI 1.04-2.87, moderate COE).

CONCLUSIONS

Short- and long-term data on complications of polypropylene mesh used for female SUI are fairly comparable when using outcome data from well-designed clinical trials or from less structured prospective or retrospective registries. Comparisons have to be made with caution since the two systems of data collection are inherently incomparable. This knowledge should be incorporated in the discussion on how to implement polypropylene mesh for female stress incontinence.

PATIENT SUMMARY

In order to know whether mesh tapes used for treating stress incontinence work well and are safe, high-quality information is important. It appears that well-designed clinical studies give similar results to large registration databases. These data should be interpreted with caution in view of the different ways the information was collected. These results will help physicians and patients understand the risks of mesh tapes.

Role of Fibroblasts and Myofibroblasts on the Pathogenesis and Treatment of Pelvic Organ Prolapse

Pelvic organ prolapse (POP) is a multifactorial connective tissue disorder caused by damage to the supportive structures of the pelvic floor, leading to the descent of pelvic organs in the vagina. In women with POP, fibroblast function is disturbed or altered, which causes impaired collagen metabolism that affects the mechanical properties of the tissue. Ideal surgical repair, either native tissue repair or POP surgery using an implant, aims to create a functional pelvic floor that is load-bearing, activating fibroblasts to regulate collagen metabolism without creating fibrotic tissue. Fibroblast function plays a crucial role in the pathophysiology of POP by directly affecting the connective tissue quality. On the other hand, fibroblasts determine the success of the POP treatment, as the fibroblast-to-(myo)fibroblast transition is the key event during wound healing and tissue repair. In this review, we aim to resolve the question of “cause and result” for the fibroblasts in the development and treatment of POP. This review may contribute to preventing the development and progress of anatomical abnormalities involved in POP and to optimizing surgical outcomes.

Evaluation of the short-term host response and biomechanics of an absorbable poly-4-hydroxybutyrate scaffold in a sheep model following vaginal implantation

Objective

To evaluate the host‐ and biomechanical response to a fully absorbable poly‐4‐hydroxybutyrate (P4HB) scaffold in comparison with the response to polypropylene (PP) mesh.

Design

In vivo animal experiment.

Setting

KU Leuven Center for Surgical Technologies.

Population

Fourteen parous female Mule sheep.

Methods

P4HB scaffolds were surgically implanted in the posterior vaginal wall of sheep. The comparative PP mesh data were obtained from an identical study protocol performed previously.

Main outcome measures

Gross necropsy, host response and biomechanical evaluation of explants, and the in vivo P4HB scaffold degradation were evaluated at 60‐ and 180‐days post‐implantation. Data are reported as mean ± standard deviation (SD) or standard error of the mean (SEM).

Results

Gross necropsy revealed no implant‐related adverse events using P4HB scaffolds. The tensile stiffness of the P4HB explants increased at 180‐days (12.498 ± 2.66 N/mm SEM [p =0.019]) as compared to 60‐days (4.585 ± 1.57 N/mm) post‐implantation, while P4HB degraded gradually. P4HB scaffolds exhibited excellent tissue integration with dense connective tissue and a moderate initial host response. P4HB scaffolds induced a significantly higher M2/M1 ratio (1.70 ± 0.67 SD, score 0–4), as compared to PP mesh(0.99 ± 0.78 SD, score 0–4) at 180‐days.

Conclusions

P4HB scaffold facilitated a gradual load transfer to vaginal tissue over time. The fully absorbable P4HB scaffold, in comparison to PP mesh, has a favorable host response with comparable load‐bearing capacity. If these results are also observed at longer follow‐up in‐vivo, a clinical study using P4HB for vaginal POP surgery may be warranted to demonstrate efficacy.

Tweetable Abstract

Degradable vaginal P4HB implant might be a solution for treatment of POP.

Degradable vaginal P4HB implant might be a solution for treatment of POP.

Can we predict continued pessary use as primary treatment in women with symptomatic pelvic organ prolapse (POP)? A prospective cohort study

INTRODUCTION AND HYPOTHESIS

The objective of this study was creating a prediction model for continued pessary use in patients with symptomatic pelvic organ prolapse (POP) and evaluating the percentage of continued pessary use after 12 months.

METHODS

We performed a prospective cohort study in patients with symptomatic POP stage ≥ 2. All patients received a pessary as primary treatment. Factors for continuation were identified from baseline characteristics and data from validated disease-specific quality of life (DSQOL) questionnaires. Univariate and multivariate analyses for predictors were performed and a prediction model was made. Improvement of POP was measured using the Patient Global Impression of Improvement (PGI-I) and DSQOL at 12 months' follow-up. Primary outcome was factors related to continued use. Secondary outcomes were the percentage continued pessary use after 12 months, improvement of complaints and DSQOL.

RESULTS

Two hundred ninety-one patients were included; 184 (63%) patients continued pessary use after 12 months. Factors related to continuation following the univariate analysis were age, sexual activity, POP-Q point c ≥ 0 and obstructive micturition. GH < 4 was not significant but added significantly to the prediction model. After multivariate analysis, age, point c ≥ 0 and GH < 4 cm remained predictors for continuation. The ROC showed an AUC of 0.65 (95% CI 0.58-0.71). PGI-I showed 83% perceived their prolapse complaints much or very much improved.

CONCLUSIONS

Continued pessary use was found in 63%. Main predictors for continued pessary use were higher age, more prominent apical compartment prolapse (c ≥ 0) and a GH < 4 cm.

Vaginal Er:YAG laser application in the menopausal ewe model: a randomised estrogen and sham-controlled trial

OBJECTIVE

To describe effects of non-ablative erbium-doped:yttrium-aluminium-garnet (Er:YAG) laser on vaginal atrophy induced by iatrogenic menopause in the ewe.

DESIGN

Animal experimental, randomised, sham and estrogen-treatment controlled study with blinding for primary outcome.

SETTING

KU Leuven, Belgium.

SAMPLE

Twenty-four ewes.

METHODS

Menopause was surgically induced, after which the ewes were randomised to three groups receiving vaginal Er:YAG laser application three times, with a 1-month interval; three sham manipulations with a 1-month interval; or estrogen replacement and sham manipulations. At given intervals, ewes were clinically examined and vaginal wall biopsies were taken. Vaginal compliance was determined by passive biomechanical testing from explants taken at autopsy.

MAIN OUTCOME MEASURES

Vaginal epithelial thickness (primary), composition of the lamina propria (collagen, elastin, glycogen and vessel content), vaginal compliance, clinical signs.

RESULTS

Animals exposed to Er:YAG laser application and sham manipulation, but not to estrogens, displayed a significant and comparable increase in vaginal epithelial thickness between baseline and 7 days after the third application (69% and 67%, respectively, both P < 0.0008). In laser-treated ewes, temporary vaginal discharge and limited thermal injury were observed. Estrogen-substituted ewes displayed a more prominent increase in epithelial thickness (202%; P < 0.0001) and higher vaginal compliance (P < 0.05). None of the interventions induced changes in the lamina propria.

CONCLUSIONS

Vaginal Er:YAG laser has comparable effect to sham manipulation in menopausal ewes.

TWEETABLE ABSTRACT

Vaginal Er:YAG laser has comparable effect to sham manipulation in menopausal ewes #LASER #GSM #RCT.

Dutch translation and validation of the pelvic organ prolapse/incontinence sexual questionnaire-IUGA revised (PISQ-IR)

INTRODUCTION AND HYPOTHESIS

Condition-specific sexual questionnaires are important patient-reported outcome measures. The aim of this study was to translate and validate the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire-International Urogynecology Association Revised (PISQ-IR) into Dutch.

METHODS

The translated PISQ-IR was linguistically validated, followed by psychometrical validation among women presenting with symptoms of pelvic floor dysfunction in urogynecology clinics. For analysis of the criterion validity, the Pelvic Floor Dysfunction Inventory-20 (PFDI-20) and Female Sexual Function Index (FSFI) were used. Descriptive statistics, floor and ceiling effects, internal consistency using Cronbach's alpha coefficient and Pearson's and Spearman's correlations were calculated for all PISQ-IR subscales.

RESULTS

The PISQ-IR was completed by 220 women, of whom 61 (27.7%) considered themselves not sexually active (NSA) and 159 (72.3%) sexually active (SA). The mean age of participating women was 57 years; 49.5% reported symptoms of pelvic organ prolapse (POP), 66.8% urinary incontinence and 2.3% anal incontinence. The PISQ-IR subscales were analyzed separately for SA and NSA women with Cronbach's alpha coefficient ranging from 0.61 to 0.87. Moderate to high correlations were observed between PISQ-IR subscales and corresponding FSFI subscales and a moderate correlation between urinary distress and the condition impact (CI) subscale among NSA subjects.

CONCLUSIONS

The Dutch PISQ-IR demonstrated a good internal consistency and criterion validity compared with the FSFI, but criterion validity compared with the PFDI-20 was poor except for urinary distress in NSA women and needs further attention.

Laparoscopic sacrocolpopexy versus vaginal sacrospinous fixation for vaginal vault prolapse, a randomized controlled trial: SALTO-2 trial, study protocol

BACKGROUND

Hysterectomy is one of the most performed surgical procedures during lifetime. Almost 10 % of women who have had a hysterectomy because of prolapse symptoms, will visit a gynaecologist for a surgical correction of a vaginal vault prolapse thereafter. Vaginal vault prolapse can be corrected by many different surgical procedures. A Cochrane review comparing abdominal sacrocolpopexy to vaginal sacrospinous fixation considered the open abdominal procedure as the treatment of first choice for prolapse of the vaginal vault, although operation time and hospital stay is longer. Literature also shows that hospital stay and blood loss are less after a laparoscopic sacrocolpopexy compared to the abdominal technique. To date, it is unclear which of these techniques leads to the best operative result and the highest patient satisfaction. Prospective trials comparing vaginal sacrospinous fixation and laparoscopic sacrocolpopexy are lacking. The aim of this randomized trial is to compare the disease specific quality of life of the vaginal sacrospinous fixation and laparoscopic sacrocolpopexy as the treatment of vaginal vault prolapse.

METHODS

We will perform a multicentre prospective randomized controlled trial. Women with a post-hysterectomy symptomatic, POP-Q stage ≥2, vaginal vault prolapse will be included. Participants will be randomized to the vaginal sacrospinous fixation group or the laparoscopic sacrocolpopexy group. Primary outcome is disease specific quality of life at 12 months follow-up. Secondary outcome will be the effect of the surgical treatment on prolapse related symptoms, sexual functioning, procedure related morbidity, hospital stay, post-operative recovery, anatomical results using the POP-Q classification after one and 5 years follow-up, type and number of re-interventions, costs and cost-effectiveness. Analysis will be performed according to the intention to treat principle and not as a per protocol analysis. With a power of 90% and a level of 0.05, the calculated sample size necessary is 96 patients. Taking into account 10% attrition, a number of 106 patients (53 in each arm) will be included.

DISCUSSION

The SALTO-2 trial is a randomized controlled multicentre trial to evaluate whether the laparoscopic sacrocolpopexy or vaginal sacrospinous fixation is the first-choice surgical treatment in patients with a stage ≥2 vault prolapse.

TRIAL REGISTRATION

Netherlands Trial Register (NTR): NTR3977 ; Registered 28 April 2013.

A nationwide survey concerning practices in pessary use for pelvic organ prolapse in The Netherlands: identifying needs for further research

Introduction and hypothesis

To identify practice variation in management of patients with a vaginal pessary for pelvic organ prolapse (POP).

Methods

A nationwide survey was sent to all Dutch gynecologists with a special interest in urogynecology.

Results

The response rate was 59 %. Of the respondents, 13 % had a written protocol for pessary treatment in their department. Pessary treatment was proposed by 69 % of respondents as a treatment option. Counseling about side effects varied. All respondents provided information concerning the possibility of serious vaginal discharge. Concerning this side effect, 15 % of the respondents stated that it occurs in 5 – 20 % of patients, 27 % that it occurs in 20 – 40 % of patients, and 57 % that it occurs in more than 40 % of patients. Another item concerned counseling for the likelihood of vaginal blood loss. All respondents provided information concerning the possibility of vaginal blood loss. Concerning this side effect, 53 % of the respondents stated that it occurs in 5 – 20 % of patients, 33 % that it occurs in 20 – 40 %, and 14 % that it occurs in more than 40 % of patients. Follow-up after initial placement was done by 69 % of the respondents at 2 – 6 weeks, by 2 % at 8 weeks, and by 29 % at 12 weeks or more. Most (98 %) of the respondents extended the interval between visits when the patient had no complaints, and 96 % of the respondents reported that they routinely instruct patients about self-management.

Conclusions

Pessaries are suggested as a treatment option by a majority of gynecologists, but practice varies widely. We consider that the variation in practice is due to a lack of available protocols and lack of evidence.

Four-defect repair in women with symptomatic anterior compartment prolapse: a large cohort study

INTRODUCTION AND HYPOTHESIS

We aimed to collect long-term follow-up data and report on both objective and subjective outcome, including morbidity, reinterventions, and sexual function following four-defect repair (FDR) as surgical correction of symptomatic anterior vaginal wall prolapse with or without stress urinary incontinence (SUI).

METHODS

Consecutive patients who underwent FDR between 1999 and 2005 were included in this study. We performed a retrospective analysis to evaluate anatomical and functional outcome by reviewing medical charts and sending validated questionnaires (Urogenital Distress Inventory and Defecatory Distress Inventory) to all patients. We also sent a self-developed, nonvalidated questionnaire to assess sexual function and inform the patient about reinterventions for pelvic floor dysfunction.

RESULTS

Two hundred and twenty-nine (60 %) of the 381 patients who underwent FDR participated. At a median follow-up of 40 months (range 5-88), 21 % of patients reported bothersome prolapse symptoms, and 11 % reported bothersome SUI. Temporary postoperative urinary retention occurred in 23 %. During follow-up, posterior vaginal wall prolapse was observed in 14 % of patients. Overall surgical reintervention rates were 15 % and 4 % for (all types of) pelvic organ prolapse and SUI, respectively; dyspareunia was reported by 30 %.

CONCLUSIONS

Functional cure rates of FDR as surgical treatment for anterior vaginal wall prolapse with or without SUI are satisfying. Nevertheless, given the negative side effects of FDR (urinary retention, high reintervention rate for posterior vaginal wall prolapse, high risk of sexual dysfunction), we question the superiority of FDR over standard anterior colporrhaphy in patients with anterior vaginal wall prolapse only.

Evaluation of the female pelvic floor in pelvic organ prolapse using 3.0-Tesla diffusion tensor imaging and fibre tractography

Objectives

To prospectively explore the clinical application of diffusion tensor imaging (DTI) and fibre tractography in evaluating the pelvic floor.

Methods

Ten patients with pelvic organ prolapse, ten with pelvic floor symptoms and ten asymptomatic women were included. A two-dimensional (2D) spin-echo (SE) echo-planar imaging (EPI) sequence of the pelvic floor was acquired. Offline fibre tractography and morphological analysis of pelvic magnetic resonance imaging (MRI) were performed. Inter-rater agreement for quality assessment of fibre tracking results was evaluated using weighted kappa (κ). From agreed tracking results, eigen values (λ1, λ2, λ3), mean diffusivity (MD) and fractional anisotropy (FA) were calculated. MD and FA values were compared using ANOVA. Inter-rater reliability of DTI parameters was interpreted using the intra-class correlation coefficient (ICC).

Results

Substantial inter-rater agreement was found (κ = 0.71 [95% CI 0.63–0.78]). Four anatomical structures were reliably identified. Substantial inter-rater agreement was found for MD and FA (ICC 0.60–0.91). No significant differences between groups were observed for anal sphincter, perineal body and puboperineal muscle. A significant difference in FA was found for internal obturator muscle between the prolapse group and the asymptomatic group (0.27 ± 0.05 vs 0.22 ± 0.03; P = 0.015).

Conclusion

DTI with fibre tractography permits identification of part of the clinically relevant pelvic structures. Overall, no significant differences in DTI parameters were found between groups.

Key Points

• Diffusion tensor MRI offers new insights into female pelvic floor problems.

• DTI allows 3D visualisation and quantification of female pelvic floor anatomy.

• DTI parameters from pelvic floor structures can be reliably determined.

• No significant differences in DTI parameters between groups with/without prolapse.

Feedback or biofeedback to augment pelvic floor muscle training for urinary incontinence in women

BACKGROUND

Pelvic floor muscle training (PFMT) is an effective treatment for stress urinary incontinence in women. Whilst most of the PFMT trials have been done in women with stress urinary incontinence, there is also some trial evidence that PFMT is effective for urgency urinary incontinence and mixed urinary incontinence. Feedback or biofeedback are common adjuncts used along with PFMT to help teach a voluntary pelvic floor muscle contraction or to improve training performance.

OBJECTIVES

To determine whether feedback or biofeedback adds further benefit to PFMT for women with urinary incontinence.To compare the effectiveness of different forms of feedback or biofeedback.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 13 May 2010) and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised trials in women with stress, urgency or mixed urinary incontinence (based on symptoms, signs or urodynamics). At least two arms of the trials included PFMT. In addition, at least one arm included verbal feedback or device-mediated biofeedback.

DATA COLLECTION AND ANALYSIS

Trials were independently assessed for eligibility and risk of bias. Data were extracted by two reviewers and cross-checked. Disagreements were resolved by discussion or the opinion of a third reviewer. Data analysis was conducted in accordance with the Cochrane Handbook for Systematic Reviews of Intervention (version 5.1.0). Analysis within subgroups was based on whether there was a difference in PFMT between the two arms that had been compared.

MAIN RESULTS

Twenty four trials involving 1583 women met the inclusion criteria; 17 trials contributed data to analysis for one of the primary outcomes. All trials contributed data to one or more of the secondary outcomes. Women who received biofeedback were significantly more likely to report that their urinary incontinence was cured or improved compared to those who received PFMT alone (risk ratio 0.75 , 95% confidence interval 0.66 to 0.86). However, it was common for women in the biofeedback arms to have more contact with the health professional than those in the non-biofeedback arms. Many trials were at moderate to high risk of bias, based on trial reports. There was much variety in the regimens proposed for adding feedback or biofeedback to PFMT alone, and it was often not clear what the actual intervention comprised or what the purpose of the intervention was.

AUTHORS' CONCLUSIONS

Feedback or biofeedback may provide benefit in addition to pelvic floor muscle training in women with urinary incontinence. However, further research is needed to differentiate whether it is the feedback or biofeedback that causes the beneficial effect or some other difference between the trial arms (such as more contact with health professionals).

Comparing clean intermittent catheterisation and transurethral indwelling catheterisation for incomplete voiding after vaginal prolapse surgery: a multicentre randomised trial

OBJECTIVE

To compare clean intermittent catheterisation with transurethral indwelling catheterisation for the treatment of abnormal post-void residual bladder volume (PVR) following vaginal prolapse surgery.

DESIGN

Multicentre randomised controlled trial.

SETTING

Five teaching hospitals and one non-teaching hospital in the Netherlands.

POPULATION

All patients older than 18 years experiencing abnormal PVR following vaginal prolapse surgery, with or without the use of mesh. Exclusion criteria were: any neurological or anxiety disorder, or the need for combined anti-incontinence surgery.

METHODS

All patients were given an indwelling catheter directly after surgery, which was removed on the first postoperative day. Patients with a PVR of more than 150 ml after their first void were randomised for clean intermittent catheterisation (CIC), performed by nursing staff, or for transurethral indwelling catheterisation (TIC) for 3 days.

MAIN OUTCOME MEASURE

Bacteriuria rate at end of treatment.

RESULTS

A total of 87 patients were included in the study. Compared with the TIC group (n = 42), there was a lower risk of developing bacteriuria (14 versus 38%; P = 0.02) or urinary tract infection (UTI; 12 versus 33%; P = 0.03) in the CIC group (n = 45); moreover, a shorter period of catheterisation was required (18 hours CIC versus 72 hours TIC; P < 0.001). Patient satisfaction was similar in the two groups, and no adverse events occurred.

CONCLUSION

Clean intermittent catheterisation is preferable over indwelling catheterisation for 3 days in the treatment of abnormal PVR following vaginal prolapse surgery.

A new method to measure vaginal sensibility

INTRODUCTION

Vaginal surgery may affect sexual function both positively and negatively. Possibly, negative consequences of surgical interventions on sexuality may be caused by reduced sensibility of the vaginal wall.

AIMS

To develop a new method to measure vaginal sensibility.

METHODS

We developed a technique to measure the sensibility of the vaginal wall consisting of a St Marks electrode on a gloved index finger, with a stimulating electrode mounted at the tip. Measurements were performed in four different target areas (caudal and cranial, posterior and anterior) by two independent female researchers in a random order. Subjects were 12 healthy women.

RESULTS

The intra-observer reproducibility of both researchers was almost perfect (Pearsons-Rho correlation coefficient 0.77-0.96 < 0.001). The inter-observer reproducibility was moderate (Pearsons-Rho correlation coefficient 0.39-0.49). Both researchers measured increased sensibility in the cranial posterior vaginal wall relative to the cranial anterior vaginal wall, but for all measurements, researcher 2 obtained higher sensibility ratings than researcher 1. In addition, researcher 2 found a decreased sensibility in the cranial anterior vaginal wall for women not using oral contraceptives. Phase of the menstrual cycle did not influence vaginal sensibility.

CONCLUSION

We developed a new instrument to measure vaginal sensibility. The instrument has excellent intra-observer reproducibility. This method is sufficiently sensitive so as to differentiate between anterior and posterior cranial vaginal wall sensibility, but outcome differs as a function of researcher. Further evaluation of the clinical use of this method is needed, provided that measurements are performed by the same researcher.

A nationwide survey to measure practice variation of catheterisation management in patients undergoing vaginal prolapse surgery

INTRODUCTION AND HYPOTHESIS

Urinary catheterisation following vaginal prolapse surgery causes inconvenience for patients, risk of urinary tract infections and potentially longer hospitalisation. Possibly, practice variation exists concerning diagnosis and management of abnormal postvoid residual (PVR) volume implying suboptimal treatment for certain subgroups.

METHODS

Nationwide questionnaire-based survey.

RESULTS

Post-operatively, 77% performed transurethral indwelling catheterisation, 12% suprapubic catheterisation and 11% intermittent catheterisation. Catheterisation was applied 3 days (1-7 days) following anterior repair and 1 day (1-3 days) following all other procedures. The median cut-off point for abnormal PVR was 150 mL (range 50-250 mL). Treatment of abnormal PVR consisted mostly of prolonging transurethral indwelling catheterisation for 2 days (range 1-5 days; 57%), 29% by intermittent and 12% by suprapubic catheterisation. Antibiotics were administered by 21% either routinely or based on symptoms only.

CONCLUSIONS

Due to insufficient evidence and suboptimal implementation of available evidence, practice variation in catheterisation regimens is high.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN, SETTING, AND PARTICIPANTS

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

INTERVENTION

Patients underwent LSC with a polypropylene implant.

MEASUREMENTS

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

RESULTS AND LIMITATIONS

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

CONCLUSIONS

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

Overall major histocompatibility complex class I expression is not downregulated in cervix cancer, as detected by immunoelectron microscopy

Downregulation of major histocompatibility complex (MHC) class I molecules in cervix cancer has been proposed as a mechanism for cancer cells to escape immunodetection. By means of light microscopic immunohistochemistry, it has been shown that in 20-70% of cervix cancers MHC class I is downregulated. We have reinvestigated this phenomenon by quantitative immunogold analysis of MHC class I labeling on the plasma membrane of cervix epithelial cells in ten human squamous cancers and ten normal human cervices. We have not found a statistically significant difference in MHC class I expression between normal and cancer cells. The difference with published light microscopic data probably reflects the higher morphologic resolution and quantifiable immunoreactivity of the immunoelectron microscopy.

Does mode of hysterectomy influence micturition and defecation?

OBJECTIVE

Hysterectomy may affect bladder and bowel function. A retrospective study was performed to compare the prevalence of micturition and defecation symptoms between different modes of hysterectomy.

METHODS

All pre-operatively asymptomatic patients, with uteral size < or =10 cm, who underwent hysterectomy between 1988 and 1997 were interviewed about the prevalence of micturition and defecation symptoms and the experienced physical and emotional limitations of these symptoms. Using logistic regression analysis, odds ratios (OR) were calculated for all symptoms of which the prevalence between modes of hysterectomy differed more than 10%. These odds ratios were adjusted for differences in other prognostic factors.

RESULTS

Vaginal hysterectomy was performed on 68 patients, total abdominal hysterectomy on 109 patients and subtotal abdominal hysterectomy on 50 patients. An increased prevalence of urge incontinence (adjusted OR 1.5 (95% CI 0.8-3.1)) and feeling of incomplete evacuation (adjusted OR 1.9 (95% CI 1.0-4.0)) was observed among patients who had undergone vaginal hysterectomy as compared to patients who had undergone total abdominal hysterectomy. The prevalence of urge incontinence (adjusted OR 1.8 (95% CI 0.8-4.2)) and difficulty emptying the rectum (adjusted OR 1.8 (95% CI 0.7-4.4)) was higher among patients who had undergone vaginal hysterectomy than among patients who had undergone subtotal abdominal hysterectomy. Statistically significant odds ratios were not observed. Relevant differences in physical and emotional limitations related to micturition and defecation symptoms were not observed between groups.

CONCLUSION

Our results suggest that technique of hysterectomy may influence the prevalence of micturition and defecation symptoms following hysterectomy.

Is platinum-based chemotherapy with paclitaxel effective in optimally debulked patients with advanced ovarian cancer?

OBJECTIVE

Suboptimally debulked patients with advanced ovarian cancer who are treated with a combination of cisplatin plus paclitaxel (TP therapy) have a better survival as compared to patients treated with a combination of cisplatin plus cyclophosphamide (CP therapy), but this advantage has not been demonstrated in optimally debulked patients. We performed a retrospective study to compare the effectiveness of TP therapy and CP therapy in optimally debulked patients.

STUDY DESIGN

From 1991 to 1996, 87 consecutive patients with advanced ovarian cancer treated in the University Hospital Utrecht and the St. Antonius Hospital were included in the study. Overall survival (OS) of patients treated with TP or CP were compared. Multivariable Cox-regression analysis was used to calculate a hazard rate ratio (HRR) for OS.

RESULTS

In the study period, 51 patients were treated with CP, and 36 patients were treated with TP. In the 18 patients with a tumorrest >2cm, there was a clear, but not statistically significant benefit from TP. In 69 patients with a tumorrest <or=2cm, life expectancy was not increased in patients treated with TP as compared to patients treated with CP (HRR 0.9 (95% CI 0.4-1.9)).

CONCLUSION

We could not show that ovarian cancer patients with residual disease of <or=2cm who were treated with TP had better survival as compared to patients who were treated with CP. Taking into account the high costs of treatment with TP, a randomized trial comparing the effects of TP therapy and CP therapy in optimally debulked patients is warranted.

[The influence of urinary incontinence on quality of life of community-dwelling, 45-70 year old Dutch women]

OBJECTIVE

To establish the prevalence of urinary incontinence in non-institutionalized Dutch women and determine the consequences of urinary incontinence for their quality of life.

DESIGN

Cross sectional questionnaire survey.

METHOD

A random sample of 1905 women aged 45-70 years of the population of Zeist, the Netherlands, were sent a questionnaire. Generic quality of life was measured with the RAND-36 and disease specific quality of life was measured with a Dutch translation of the Urogenital Distress Inventory (UDI) and Incontinence Impact Questionnaire (IIQ). Based on the answers to the questionnaire four groups of women were formed: no incontinence, only stress, only urge or a combination of stress and urge incontinence. These 4 groups were compared as to questionnaire scores.

RESULTS

A total of 1086 questionnaires could be analysed. The prevalence of urinary incontinence was 57.1%: 28.7% stress incontinence, 5.6% urge incontinence and 22.7% both. Of those who reported urinary incontinence 6% were severely inconvenienced by it. Women with urinary incontinence reported a decrease in physical functioning and vitality as compared with women without incontinence (RAND-36). Especially women with urge or a combination of stress and urge incontinence had more severe impairment of their quality of life as compared to women with only stress incontinence.

CONCLUSION

The prevalence of urinary incontinence is higher than it is usually reported. Especially the urge component affects the quality of life in a negative way.