Long-term effects of surgically corrected menstrual outflow obstruction: A case-control study

OBJECTIVE

To enhance evidence-based knowledge on long-term sequalae in patients with surgically corrected obstructing Müllerian anomalies.

METHODS

This long-term case-control study included patients with menstrual outflow obstruction due to congenital anomalies of the uterus or vagina, who were at least 18 years old, and for whom 2 years had elapsed since the first surgery at the start of this study. The control group consisted of women without current gynecological problems. Patients underwent a surgical correction at the Radboud University Medical Center Nijmegen between 1980 and 2013. Of 78 patients approached, 38 (49%) were included in this study. The control group consisted of 54 females. The main outcome measures were pain and health state. The following questionnaires were used: Visual Analogue Scale pain scores, European Quality of Life-5 Dimensions questionnaire (EQ-5D-3L) and the adapted Endometriosis Health Profile questionnaire (EHP-30).

RESULTS

Patients had higher actual and maximum abdominal pain scores compared with controls (11 vs 0 [P = 0.007] and 48 vs 21 [P = 0.035], respectively). Based on the EQ-5D-3L scores, patients had more pain and discomfort (P = 0.005), more mood problems (P = 0.023), and a poorer subjective health state (P = 0.002) and self-rated health state (P = 0.031). Based on the EHP-30, patients had a significant poorer self-rated health state on four out of five subscales.

CONCLUSION

In this study, following surgically corrected menstrual obstruction, patients had statistically significant higher abdominal pain scores and a poorer self-rated health state compared with controls.

Laparoscopic Davydov vs. laparoscopic Vecchietti neovaginoplasty in women with Mayer-Rokitansky-Küster-Hauser syndrome; a systematic review and meta-analysis

OBJECTIVE

To summarize the available evidence on the laparoscopic Davydov and Vecchietti methods to create a neovagina and to compare these techniques with a focus on neovaginal length, sexual function, operative time, and complications.

DESIGN

A systematic electronic search up to August 2022 using PubMed and Embase is performed.

SETTING

Not applicable.

PATIENTS

Women with Mayer-Rokistansky-Küster-Hauser syndrome.

INTERVENTIONS

All published clinical studies concerning the laparoscopic Davydov and laparoscopic Vecchietti procedures as a surgical technique to create a neovagina in women with Mayer-Rokistansky-Küster-Hauser syndrome were obtained. The guidelines for the preferred reporting items for systematic reviews and meta-analysis were followed. The following data were extracted: operative time, hospital stay, major early complications (within 3 months postsurgery), dilation therapy, neovaginal length, vaginal discharge, vaginal stenosis, time to sexual activity, sexual satisfaction, penetrative sexual activity, dyspareunia, score on the Female Sexual Function Index (FSFI), and duration of follow-up. The Newcastle Ottawa Scale was used to assess the quality of articles.

MAIN OUTCOME MEASURES

Neovaginal length, FSFI scores, operative time, and complications.

RESULTS

A total of 1,163 articles were identified, of which 31 studies were included in this systematic review. Of these, 12 studies (380 patients) are related to the Davydov method, 17 studies (804 patients) to the Vecchietti method, and 2 articles concern both. There is clinical heterogeneity and variety in the quality of the studies. Nineteen studies were included in the meta-analyses. The mean neovaginal length 12 months after the Davydov method is 8.3 cm (95% confidence interval [CI] 8.1-8.6), vs. 8.7 cm (95% CI 7.2-10.3) after the Vecchietti method. The mean FSFI score after the Davydov method is 28.9 (95% CI 26.8-31.1), compared with 27.5 (95% CI 25.0-30.1) after the Vecchietti method. The operative time of the Davydov method is 126 minutes (95% CI 109-143), compared with 40 minutes (95% CI 35-45) of the Vecchietti method.

CONCLUSIONS

The operations yield comparable neovaginal length, sexual function, and complication rates. The mean FSFI scores indicate no sexual dysfunction in either group. The operative time of the Davydov method is significantly longer. There is no superiority shown for one of the surgical techniques in functional terms.

Laparoscopic sacrocolpopexy versus vaginal sacrospinous fixation for vaginal vault prolapse: a randomised controlled trial and prospective cohort (SALTO-2 trial)

OBJECTIVE

To determine whether laparoscopic sacrocolpopexy (LSC) or vaginal sacrospinous fixation (VSF) is the most optimal surgical treatment in patients with POP-Q stage ≥2 vaginal vault prolapse (VVP).

DESIGN

Multicentre randomised controlled trial (RCT) and prospective cohort study alongside.

SETTING

Seven non-university teaching hospitals and two university hospitals in the Netherlands.

POPULATION

Patients with symptomatic post-hysterectomy vaginal vault prolapse, requiring surgical treatment.

METHODS

Randomisation in a 1:1 ratio to LSC or VSF. Evaluation of prolapse was done using the pelvic organ prolapse quantification (POP-Q). All participants were asked to fill in various Dutch validated questionnaires 12 months postoperatively.

MAIN OUTCOME MEASURES

Primary outcome was disease-specific quality of life. Secondary outcomes included composite outcome of success and anatomical failure. Furthermore, we examined peri-operative data, complications and sexual function.

RESULTS

A total of 179 women, 64 women randomised and 115 women, participated in a prospective cohort. Disease-specific quality of life did not differ after 12 months between the LSC and VSF group in the RCT and the cohort (RCT: P = 0.887; cohort: P = 0.704). The composite outcomes of success for the apical compartment, in the RCT and cohort, were 89.3% and 90.3% in the LSC group and 86.2% and 87.8% in the VSF group, respectively (RCT: P = 0.810; cohort: P = 0.905). There were no differences in number of reinterventions and complications between both groups (reinterventions RCT: P = 0.934; cohort: P = 0.120; complications RCT: P = 0.395; cohort: P = 0.129).

CONCLUSIONS

LSC and VSF are both effective treatments for vaginal vault prolapse, after a follow-up period of 12 months.

Location and motion of vaginal pessaries in situ in women with successful and unsuccessful pessary treatment for pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

The objective was to compare the location and motion of pessaries between women with pelvic organ prolapse (POP) with a successful (fitting) and unsuccessful (non-fitting) pessary treatment on dynamic magnetic resonance imaging (dMRI).

METHODS

A cross-sectional exploratory study of 15 women who underwent a mid-sagittal dMRI of the pelvic floor at rest, during contraction and during Valsalva with three different types of pessaries. The coordinates of the pessaries cross section, inferior pubic point (IPP) and sacrococcygeal junction (SCJ) were obtained and the location (position, orientation) and the motion (translation and rotation) were calculated. Differences between the groups and between the pessaries within the groups were compared.

RESULTS

Nine women with a fitting pessary and 6 women with a non-fitting pessary were selected. In the non-fitting group, the pessaries were positioned more caudally and rotated more in clockwise direction and descended more, but not significantly, during Valsalva compared with the fitting group. The Falk pessary was positioned more anteriorly in the fitting group and more cranially in the non-fitting group compared with the ring and ring with support pessary.

CONCLUSIONS

A non-fitting pessary was positioned more caudally at rest; on Valsalva, it rotated more clockwise and moved more caudally, suggesting that the dynamic characteristics of the pessary might play an important role in its effectiveness. Findings of this study serve as a basis for the development of new pessary designs.

Manchester Procedure vs Sacrospinous Hysteropexy for Treatment of Uterine Descent: A Randomized Clinical Trial

Importance

In many countries, sacrospinous hysteropexy is the most commonly practiced uterus-preserving technique in women undergoing a first operation for pelvic organ prolapse. However, there are no direct comparisons of outcomes after sacrospinous hysteropexy vs an older technique, the Manchester procedure.

Objective

To compare success of sacrospinous hysteropexy vs the Manchester procedure for the surgical treatment of uterine descent.

Design, Setting, and Participants

Multicenter, noninferiority randomized clinical trial conducted in 26 hospitals in the Netherlands among 434 adult patients undergoing a first surgical treatment for uterine descent that did not protrude beyond the hymen.

Interventions

Participants were randomly assigned to undergo sacrospinous hysteropexy (n = 217) or Manchester procedure (n = 217).

Main Outcomes and Measures

The primary outcome was a composite outcome of success, defined as absence of pelvic organ prolapse beyond the hymen in any compartment evaluated by a standardized vaginal support quantification system, absence of bothersome bulge symptoms, and absence of prolapse retreatment (pessary or surgery) within 2 years after the operation. The predefined noninferiority margin was 9%. Secondary outcomes were anatomical and patient-reported outcomes, perioperative parameters, and surgery-related complications.

Results

Among 393 participants included in the as-randomized analysis (mean age, 61.7 years [SD, 9.1 years]), 151 of 196 (77.0%) in the sacrospinous hysteropexy group and 172 of 197 (87.3%) in the Manchester procedure group achieved the composite outcome of success. Sacrospinous hysteropexy did not meet the noninferiority criterion of -9% for the lower limit of the CI (risk difference, -10.3%; 95% CI, -17.8% to -2.8%; P = .63 for noninferiority). At 2-year follow-up, perioperative outcomes and patient-reported outcomes did not differ between the 2 groups.

Conclusions

Based on the composite outcome of surgical success 2 years after primary uterus-sparing pelvic organ prolapse surgery for uterine descent, these results support a finding that sacrospinous hysteropexy is inferior to the Manchester procedure.

Trial Registration

TrialRegister.nl Identifier: NTR 6978.

Identifying Womens' Needs in Making a Treatment Decision for Stress Urinary Incontinence: A Qualitative Study

Background

Choosing a treatment option for female stress urinary incontinence (SUI) is a preference-sensitive decision. Nowadays, shared decision making (SDM) is the preferred way of decision making. SDM considers the needs patients have regarding the decision-making process. The aim of this study was to identify decisional needs of women who are making a treatment decision for SUI.

Materials and Methods

Semistructured interviews were planned with women who had been seeking treatment for SUI. Patients were recruited in two teaching hospitals in the Netherlands. Interviewers used a topic list based on the Ottawa decision support framework. The interviews were transcribed and coded. Themes and subthemes of factors relating to the treatment decision-making process were identified and described.

Results

We interviewed a total of 16 women. Four major themes of SUI patients' needs were identified: information on disorder and treatment, SDM, personalized health care, and consideration for social context. Within these themes, specific needs varied between individuals. In addition to the provision of objective information, other important identified needs were subjective, such as acknowledgment of symptoms and feeling understood by a physician. It was important for patients that they had a sufficient amount of time to make their decision.

Conclusions

To ensure a good quality treatment decision in female SUI, several topics need to be addressed in an SDM process. The themes of decisional needs identified in this study can help improve the decision-making process.

Subjective outcomes 12 years after transvaginal mesh versus native tissue repair in women with recurrent pelvic organ prolapse; a randomized controlled trial

INTRODUCTION AND HYPOTHESIS

The present study describes an extended follow-up study after 12 years and focusses on subjective outcomes of women who underwent surgery for recurrent pelvic organ prolapse in the randomized index study.

METHODS

One hundred and ninety-four (194) women had been randomized in the original study and in the present study, 45 (47%) in the vaginal mesh repair versus 43 (43%) women with conventional vaginal native tissue repair completed the long-term questionnaires. The mesh used was a first-generation non-absorbable mesh kit. All types of conventional vaginal native tissue repairs were allowed, and additional vaginal native tissue repairs were allowed in the mesh group. The questionnaires as applied at baseline were used. The Patient Global Impression of Improvement questionnaire (PGI-I) was the primary outcome.

RESULTS

At 12 years, 30 (71%) women in the mesh group versus 23 (59%) women in the native tissue repair group reported to be PGI-I (very) much improved (p=0.24). There were no differences found in any of the questionnaire domains. There was, however, a higher number of women who had had additional operations for recurrent pelvic organ prolapse, stress urinary incontinence, and/or exposure in the mesh group: 18 women (40%) in the mesh group versus 8 women (19%) in the native tissue repair group (p=0.03).

CONCLUSIONS

There was no difference in subjective outcome between the groups, but there was a statistically significant higher number of women who had needed further operations. This study confirms that vaginal mesh should not be used in all women with recurrent pelvic organ prolapse.

Molecular Landscape of Pelvic Organ Prolapse Provides Insights into Disease Etiology

Pelvic organ prolapse (POP) represents a major health care burden in women, but its underlying pathophysiological mechanisms have not been elucidated. We first used a case-control design to perform an exome chip study in 526 women with POP and 960 control women to identify single nucleotide variants (SNVs) associated with the disease. We then integrated the functional interactions between the POP candidate proteins derived from the exome chip study and other POP candidate molecules into a molecular landscape. We found significant associations between POP and SNVs in 54 genes. The proteins encoded by 26 of these genes fit into the molecular landscape, together with 43 other POP candidate molecules. The POP landscape is located in and around epithelial cells and fibroblasts of the urogenital tract and harbors four interacting biological processes-epithelial-mesenchymal transition, immune response, modulation of the extracellular matrix, and fibroblast function-that are regulated by sex hormones and TGFB1. Our findings were corroborated by enrichment analyses of differential gene expression data from an independent POP cohort. Lastly, based on the landscape and using vaginal fibroblasts from women with POP, we predicted and showed that metformin alters gene expression in these fibroblasts in a beneficial direction. In conclusion, our integrated molecular landscape of POP provides insights into the biological processes underlying the disease and clues towards novel treatments.

Physicians’ perspectives on using a patient decision aid in female stress urinary incontinence

Introduction and hypothesis

A treatment choice for female stress urinary incontinence (SUI) is preference sensitive for both patients and physicians. Multiple treatment options are available, with none being superior to any other. The decision-making process can be supported by a patient decision aid (PDA). We aimed to assess physicians’ perceptions concerning the use of a PDA.

Methods

In a mixed methods study, urologists, gynecologists and general practitioners in the Netherlands were asked to fill out a web-based questionnaire. Questions were based on the Tailored Implementation for Chronic Diseases checklist using the following domains: guideline factors, individual health professional factors, professional interactions, incentives and resources, and capacity for organizational change. Participants were asked to grade statements using a five-point Likert scale and to answer open questions on facilitators of and barriers to implementation of a PDA. Outcomes of statement rating were quantitatively analyzed and thematic analysis was performed on the outcomes regarding facilitators and barriers.

Results

The response rate was 11%, with a total of 120 participants completing the questionnaire. Ninety-two of the physicians (77%) would use a PDA in female SUI. Evidence-based and unbiased content, the ability to support shared decision making, and patient empowerment are identified as main facilitators. Barriers are the expected prolonged time investment and the possible difficulty using the PDA in less health-literate patient populations.

Conclusions

The majority of physicians would use a PDA for female SUI. We identified facilitators and barriers that can be used when developing and implementing such a PDA.

Patient’s preference for sacrospinous hysteropexy or modified Manchester operation: a discrete choice experiment

OBJECTIVE

To investigate women's preference for modified Manchester (MM) or sacrospinous hysteropexy (SH) as surgery for uterine prolapse.

DESIGN

Labelled discrete choice experiment (DCE).

SETTING

Eight Dutch hospitals.

POPULATION

Women with uterine prolapse, eligible for primary surgery and preference for uterus preservation.

METHODS

DCEs are attribute-based surveys. The two treatment options were labelled as MM and SH. Attributes in this survey were treatment success ( levels SH: 84%, 89%, 94%; levels MM: 89%, 93%, 96%), dyspareunia (levels: 0%, 5%, 10%), cervical stenosis (levels: 1%, 6%, 11%) and severe buttock pain (levels: 0%, 1%). A different combination of attribute levels was used in each choice set. Women completed nine choice sets, making a choice based on attribute levels. Data were analysed in multinomial logit models.

MAIN OUTCOME MEASURES

Women's preference for MM or SH.

RESULTS

137 DCEs were completed (1233 choice sets). SH was chosen in 49% of the choice sets, MM in 51%. Of all women, 39 (28%) always chose the same surgery. After exclusion of this group, 882 choice sets were analysed, in which women preferred MM, likely associated with a labelling effect, i.e. description of the procedure, rather than the tested attributes. In that group, MM was chosen in 53% of the choice sets and SH in 47%. When choosing MM, next to the label, dyspareunia was relevant for decision-making. For SH, all attributes were relevant for decision-making.

CONCLUSIONS

The preference of women for MM or SH seems almost equally divided. The variety in preference supports the importance of individualised healthcare.

Risk factors for primary pelvic organ prolapse and prolapse recurrence: an updated systematic review and meta-analysis

OBJECTIVE

To update a previously published systematic review and perform a meta-analysis on the risk factors for primary pelvic organ prolapse and prolapse recurrence.

DATA SOURCES

PubMed and Embase were systematically searched. We searched from July 1, 2014 until July 5, 2021. The previous search was from inception until August 4, 2014.

STUDY ELIGIBILITY CRITERIA

Randomized controlled trials and cross-sectional and cohort studies conducted in the Western developed countries that reported on multivariable analysis of risk factors for primary prolapse or prolapse recurrence were included. The definition of prolapse was based on anatomic references, and prolapse recurrence was defined as anatomic recurrence after native tissue repair. Studies on prolapse recurrence with a median follow-up of ≥1 year after surgery were included.

METHODS

Quality assessment was performed with the Newcastle-Ottawa Scale. Data from the previous review and this review were combined into forest plots, and meta-analyses were performed where possible. If the data could not be pooled, "confirmed risk factors" were identified if ≥2 studies reported a significant association in multivariable analysis.

RESULTS

After screening, 14 additional studies were selected-8 on the risk factors for primary prolapse and 6 on prolapse recurrence. Combined with the results from the previous review, 27 studies met the inclusion criteria, representing the data of 47,429 women. Not all studies could be pooled because of heterogeneity. Meta-analyses showed that birthweight (n=3, odds ratio, 1.04; 95% confidence interval, 1.02-1.06), age (n=3, odds ratio, 1.34; 95% confidence interval, 1.23-1.47), body mass index (n=2, odds ratio, 1.75; 95% confidence interval, 1.17-2.62), and levator defect (n=2, odds ratio, 3.99; 95% confidence interval, 2.57-6.18) are statistically significant risk factors, and cesarean delivery (n=2, pooled odds ratio, 0.08; 95% confidence interval, 0.03-0.20) and smoking (n=3, odds ratio, 0.59; 95% confidence interval, 0.46-0.75) are protective factors for primary prolapse. Parity, vaginal delivery, and levator hiatal area are identified as "confirmed risk factors." For prolapse recurrence, preoperative prolapse stage (n=5, odds ratio, 2.68; 95% confidence interval, 1.93-3.73) and age (n=2, odds ratio, 3.48; 95% confidence interval, 1.99-6.08) are statistically significant risk factors.

CONCLUSION

Vaginal delivery, parity, birthweight, age, body mass index, levator defect, and levator hiatal area are risk factors, and cesarean delivery and smoking are protective factors for primary prolapse. Preoperative prolapse stage and younger age are risk factors for prolapse recurrence after native tissue surgery.

Risk factors for pelvic organ prolapse recurrence after sacrospinous hysteropexy or vaginal hysterectomy with uterosacral ligament suspension

BACKGROUND

Given that the number of surgeries for pelvic organ prolapse is expected to increase worldwide, knowledge on risk factors for prolapse recurrence is of importance for developing preventive strategies and shared decision-making.

OBJECTIVE

To identify risk factors for subjective and objective failure after either sacrospinous hysteropexy or vaginal hysterectomy with uterosacral ligament suspension over a period of 5 years after surgery.

STUDY DESIGN

This was a secondary analysis of the 5-year follow-up of the SAVE-U trial. The SAVE-U trial was conducted in 4 Dutch hospitals. A total of 208 women with uterine prolapse stage ≥2 were randomized to sacrospinous hysteropexy or vaginal hysterectomy with uterosacral ligament suspension. For the current analysis, available annual 5-year follow-up data of 207 women were analyzed. Without missing values this analysis would have included 1035 measurements in total over the 5-year follow-up. Recurrences were analyzed as "events" using generalized linear mixed models because recurrences of anatomic failure and bothersome vaginal bulge symptoms fluctuated over time. The primary outcome was the composite outcome of failure defined as prolapse beyond the hymen, bothersome bulge symptoms, repeated surgery, or pessary use for recurrent prolapse. Secondary outcome measures were bothersome vaginal bulge symptoms, overall anatomic failure (Pelvic Organ Prolapse Quantification stage ≥2 in any compartment), apical compartment recurrence (Pelvic Organ Prolapse Quantification stage ≥2), anterior compartment recurrence (Pelvic Organ Prolapse Quantification stage ≥2), and posterior compartment recurrence (Pelvic Organ Prolapse Quantification stage ≥2).

RESULTS

For the composite outcome of failure (164 events in 66 different women), statistically significant risk factors were: body mass index (odds ratio, 1.10 [per 1 kg/m²]; 95% confidence interval, 1.02-1.19; P=.02), smoking (odds ratio, 2.88; 95% confidence interval, 1.12-7.40; P=.03), and preoperative Pelvic Organ Prolapse Quantification point Ba (odds ratio, 1.23 [per 1 cm]; 95% confidence interval, 1.01-1.50; P=.04). When analyzing each surgical outcome measure separately, body mass index and Pelvic Organ Prolapse Quantification point Ba were risk factors for overall anatomic failure (462 events in 147 women; odds ratio, 1.15; 95% confidence interval, 1.07-1.25; P<.01 and odds ratio, 1.14; 95% confidence interval, 1.00-1.30; P=.05, respectively) and anterior compartment recurrence (385 events in 128 women; odds ratio, 1.11; 95% confidence interval, 1.02-1.22; P=.02 and odds ratio, 1.17; 95% confidence interval, 1.02-1.34; P=.02, respectively). Vaginal hysterectomy was a risk factor for posterior compartment recurrence when compared with sacrospinous hysteropexy (93 events in 40 women; odds ratio, 5.21; 95% confidence interval, 2.05-13.27; P<.01). Smoking was a risk factor for bothersome vaginal bulge symptoms (70 events in 41 women; odds ratio, 3.80; 95% confidence interval, 1.48-9.75; P=.01), and preoperative Pelvic Organ Prolapse Quantification stage 3 or 4 was significantly protective against bothersome bulge symptoms (odds ratio, 0.32; 95% confidence interval, 0.11-0.89; P=.03).

CONCLUSION

Body mass index, smoking, and Pelvic Organ Prolapse Quantification point Ba were statistically significant risk factors for the composite outcome of failure (prolapse beyond the hymen, bothersome bulge symptoms, repeated surgery, or pessary use for recurrent prolapse) in the period of 5 years after surgery.

The efficacy of botulinum toxin a injections in pelvic floor muscles in chronic pelvic pain patients: a systematic review and meta-analysis

Introduction and hypothesis

Chronic pelvic pain (CPP) is a common multifactorial condition affecting 6 to 27% of women aged 18–50 years worldwide. This study was conducted to review and meta-analyse the current literature on the reduction of chronic pelvic pain after botulinum toxin A (BTA) injection.

Method

In July 2021 we performed a systematic search in PubMed and EMBASE to assess the benefits of BTA injection in pelvic floor muscles in women with chronic pelvic pain. Primary outcome was reduction in visual analogue scale (VAS) after treatment. Secondary outcomes evaluated were: reduction of dyspareunia, pelvic floor resting pressure and quality of life. Identified reports were assessed on quality of reporting and risk of bias. Standardized mean difference (SMD) was used to combine and analyse outcomes of the included studies.

Results

Eight studies with 289 participants were considered eligible to be included in this systematic review and meta-analysis. After recalculating SMD into VAS scores (0–100), long-term follow-up (24–26 weeks) showed a significant 15-point improvement in VAS scores (95% CI: 8.8–21.5) for non-menstrual pelvic pain and a 13-point improvement (95% CI: 2.1–24.0) for dyspareunia. BTA injection had a significant effect on pelvic floor resting pressure and quality of life.

Conclusion

There is limited scientific evidence on the effectiveness of BTA injections in pelvic floor muscles in women with chronic pelvic pain. The available studies show that BTA injections significantly reduce pain levels and improve quality of life at 6 months follow-up.

Prospero ID

CRD42018105204.

Molecular Processes in Stress Urinary Incontinence: A Systematic Review of Human and Animal Studies

Stress urinary incontinence (SUI) is a common and burdensome condition. Because of the large knowledge gap around the molecular processes involved in its pathophysiology, the aim of this review was to provide a systematic overview of genetic variants, gene and protein expression changes related to SUI in human and animal studies. On 5 January 2021, a systematic search was performed in Pubmed, Embase, Web of Science, and the Cochrane library. The screening process and quality assessment were performed in duplicate, using predefined inclusion criteria and different quality assessment tools for human and animal studies respectively. The extracted data were grouped in themes per outcome measure, according to their functions in cellular processes, and synthesized in a narrative review. Finally, 107 studies were included, of which 35 used animal models (rats and mice). Resulting from the most examined processes, the evidence suggests that SUI is associated with altered extracellular matrix metabolism, estrogen receptors, oxidative stress, apoptosis, inflammation, neurodegenerative processes, and muscle cell differentiation and contractility. Due to heterogeneity in the studies (e.g., in examined tissues), the precise contribution of the associated genes and proteins in relation to SUI pathophysiology remained unclear. Future research should focus on possible contributors to these alterations.

Pain after midurethral sling; the underestimated role of mesh removal

Introduction

The primary aim of this study was to evaluate the results of midurethral sling (MUS) removal in women who have pain as their single complication of MUS.

Material and methods

We performed a retrospective chart study supplemented with a cross sectional questionnaire. Women who underwent MUS removal for pain as the solitary reason for removal between 2004 and 2018 were included. Primary outcome was change in pain levels assessed by the visual analogue scale (VAS) pain score (range 0–10). Secondary outcome was the recurrence of stress urinary incontinence (SUI).

Results

Twenty-six of 31 patients returned the questionnaire. Median medical file follow-up was 12 months (range 2–66) and 25 months (range 5–104) regarding questionnaires. VAS pain score dropped from 7.8 (SD 1.9) at baseline to 4.5 (SD 3.2) at follow-up (p <.00). Seven (23%) patients were pain-free. Patients undergoing partial vaginal resection (n = 6) had a VAS pain score decrease of 4.7 (p = .02) versus 2.7 (p = .02) for complete vaginal removal (n = 14). Twenty-three (89%) patients experienced SUI at follow-up, whereof 10 (45%) reported (almost) no incidents of SUI.

Conclusions

MUS removal is a viable and safe option with a significant drop in VAS pain score in patients with chronic pain after MUS placement. A post-operative increase of SUI and a possible renewed wish for SUI treatment have to be considered. This should not be a reason to refrain from information and/or referral for surgical removal.

Gynecologists' perspectives on two types of uterus-preserving surgical repair of uterine descent; sacrospinous hysteropexy versus modified Manchester

INTRODUCTION AND HYPOTHESIS

The modified Manchester (MM) and sacrospinous hysteropexy (SSH) are the most common uterus-preserving surgical procedures for uterine descent. Little is known about gynecologists' preferences regarding the two interventions. The study's aim was to identify which factors influence Dutch (uro)gynecologists when choosing one of these techniques.

METHODS

This qualitative study consists of ten semi-structured interviews with Dutch (uro)gynecologists using predetermined, open explorative questions, based on a structured topic list. An inductive content analysis was performed using Atlas.ti.

RESULTS

For SSH, the majority (6/10 gynecologists) reported the more dorsal change of direction of the vaginal axis as a disadvantage and expected more cystocele recurrences (7/10). The most reported disadvantage of MM was the risk of cervical stenosis (7/10). Four gynecologists found MM not to be appropriate for patients with higher stage uterine prolapse. The quality of the uterosacral ligaments was related to the chance of recurrence according to five gynecologists. Patient counseling was biased toward one of the uterus-preserving operations (7/10). Four gynecologists stated they make the final decision while two let patient-preference lead the final decision.

CONCLUSIONS

Preference for one of the uterus-preserving interventions is mainly based on the gynecologist's own experience and background. The lack of information regarding these two uterus-preserving procedures hampers evidence-based decision making, which explains the practice pattern variation. In conclusion, further research is needed to improve evidence-based counseling and shared decision making regarding the choice of procedure.

Genetic variants and expression changes in urgency urinary incontinence: A systematic review

Aim

To perform a systematic review summarizing the knowledge of genetic variants, gene, and protein expression changes in humans and animals associated with urgency urinary incontinence (UUI) and to provide an overview of the known molecular mechanisms related to UUI.

Methods

A systematic search was performed on March 2, 2020, in PubMed, Embase, Web of Science, and the Cochrane library. Retrieved studies were screened for eligibility. The risk of bias was assessed using the ROBINS‐I (human) and SYRCLE (animal) tool. Data were presented in a structured manner and in the case of greater than five studies on a homogeneous outcome, a meta‐analysis was performed.

Results

Altogether, a total of 10,785 records were screened of which 37 studies met the inclusion criteria. Notably, 24/37 studies scored medium‐high to high on risk of bias, affecting the value of the included studies. The analysis of 70 unique genes and proteins and three genome‐wide association studies showed that specific signal transduction pathways and inflammation are associated with UUI. A meta‐analysis on the predictive value of urinary nerve growth factor (NGF) levels showed that increased urinary NGF levels correlate with UUI.

Conclusion

The collective evidence showed the involvement of two molecular mechanisms (signal transduction and inflammation) and NGF in UUI, enhancing our understanding of the pathophysiology of UUI. Unfortunately, the risk of bias was medium‐high to high for most studies and the value of many observations remains unclear. Future studies should focus on elucidating how deficits in the two identified molecular mechanisms contribute to UUI and should avoid bias.

Sexual functioning, sexual esteem, genital self-image and psychological and relational functioning in women with Mayer-Rokitansky-Küster-Hauser syndrome: a case-control study

STUDY QUESTION

Do sexual functioning, sexual esteem, genital self-image and psychological and relational functioning in women with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome differ from a comparison group of women without the condition?

SUMMARY ANSWER

In comparison to controls, women with MRKH with a non-surgically or surgically created neovagina did not differ in psychological and relational functioning but reported lower sexual esteem and more negative genital self-image, intercourse-related pain, clinically relevant sexual distress and sexual dysfunction, with sexual esteem levels strongly associated with sexual distress and sexual dysfunction.

WHAT IS KNOWN ALREADY

Studies on sexual functioning measured with standardized questionnaires in women with MRKH syndrome compared with women without the condition have yielded contradictory results. Factors associated with sexual functioning in this patient population have rarely been investigated.

STUDY DESIGN, SIZE, DURATION

Between November 2015 and May 2017, 54 women with MRKH syndrome with a neovagina and 79 age-matched healthy women without the condition were enrolled in this case-control study.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All participants had to be at least 18-years old and had to live in a steady heterosexual relationship. Women with MRKH syndrome were asked to participate by their (former) gynecologists at three university hospitals and by MRKH peer support group. Controls were recruited via advertisement in local newspapers and social media. Standardized questionnaires were administered to assess sexual functioning, sexual esteem, genital self-image and psychological and relational functioning.

MAIN RESULTS AND THE ROLE OF CHANCE

Women with MRKH syndrome with a surgically or non-surgically created neovagina reported significantly more pain during intercourse (P < 0.05, d = 0.5), but did not differ in overall sexual functioning from control women. More women with MRKH syndrome reported clinically relevant sexuality-related distress (P < 0.05, odds ratio (OR): 2.756, 95% CI 1.219-6.232) and suffered a sexual dysfunction (P < 0.05, OR: 2.654, 95% CI: 1.088-6.471) in comparison with controls. MRKH women scored significantly lower on the sexual esteem scale (SES) (P < 0.01, d = 0.5) and the female genital self-image scale (FGSIS) (P < 0.01, d = 0.6) than controls. No significant differences were found between the two groups regarding psychological distress, anxiety and depression, global self-esteem and relational dissatisfaction. Sexual esteem was significantly associated with the presence of clinically relevant sexual distress (ß = 0.455, P = 0.001) and suffering a sexual dysfunction (ß = 0.554, P = 0.001) and explained, respectively, 40% and 28% of the variance.

LIMITATIONS, REASONS FOR CAUTION

Given the nature of the study focusing on sexual functioning, a potential selection bias cannot be excluded. It is possible that those women with the most severe sexual and/or psychological disturbances did or did not choose to participate in our study.

WIDER IMPLICATIONS OF THE FINDINGS

The study results add new data to the very limited knowledge about psychosexual functioning of women with MRKH syndrome and are of importance for more adequate counseling and treatment of these women.

STUDY FUNDING/COMPETING INTEREST(S)

The research was financially supported by the Dutch Scientific Society of Sexology (Nederlandse wetenschappelijke Vereniging Voor Seksuologie). The funding was unrestricted, and there was no involvement in the conduct of the research. There are no conflicts of interest to declare.

Extracellular Matrix Stiffness and Composition Regulate the Myofibroblast Differentiation of Vaginal Fibroblasts

Fibroblast to myofibroblast differentiation is a key feature of wound-healing in soft tissues, including the vagina. Vaginal fibroblasts maintain the integrity of the vaginal wall tissues, essential to keep pelvic organs in place and avoid pelvic organ prolapse (POP). The micro-environment of vaginal tissues in POP patients is stiffer and has different extracellular matrix (ECM) composition than healthy vaginal tissues. In this study, we employed a series of matrices with known stiffnesses, as well as vaginal ECMs, in combination with vaginal fibroblasts from POP and healthy tissues to investigate how matrix stiffness and composition regulate myofibroblast differentiation in vaginal fibroblasts. Stiffness was positively correlated to production of α-smooth muscle actin (α-SMA). Vaginal ECMs induced myofibroblast differentiation as both α-SMA and collagen gene expressions were increased. This differentiation was more pronounced in cells seeded on POP-ECMs that were stiffer than those derived from healthy tissues and had higher collagen and elastin protein content. We showed that stiffness and ECM content regulate vaginal myofibroblast differentiation. We provide preliminary evidence that vaginal fibroblasts might recognize POP-ECMs as scar tissues that need to be remodeled. This is fundamentally important for tissue repair, and provides a rational basis for POP disease modelling and therapeutic innovations in vaginal reconstruction.

[Urethral coitus due to congenital abnormality of the genitalia]

BACKGROUND

Urethral coitus is rare and can arise in women who were born without a vagina, for instance in the context of Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome.

CASE DESCRIPTION

A 16-year-old girl presented at the general practitioner's surgery with primary amenorrhoea. After a long diagnostic process she was diagnosed with MRKH syndrome and treatment with a vaginal dilator was started. During follow-up the patient reported pain on coitus and that she sometimes lost a lot of fluid during intercourse. It appeared that the patient had dilated her urethra, not her vagina, and that she had had urethral coitus. The patient underwent Davydovvaginoplasty without complications.

CONCLUSION

In patients with MRKH syndrome who experience urinary incontinence (particularly during and after coitus), recurrent urinary tract infections and dyspareunia urethral coitus should be suspected.

Sacrospinous hysteropexy versus vaginal hysterectomy with uterosacral ligament suspension in women with uterine prolapse stage 2 or higher: observational follow-up of a multicentre randomised trial

OBJECTIVE

To evaluate the effectiveness and success of uterus preserving sacrospinous hysteropexy as an alternative to vaginal hysterectomy with uterosacral ligament suspension in the surgical treatment of uterine prolapse five years after surgery.

DESIGN

Observational follow-up of SAVE U (sacrospinous fixation versus vaginal hysterectomy in treatment of uterine prolapse ≥2) randomised controlled trial.

SETTING

Four non-university teaching hospitals, the Netherlands.

PARTICIPANTS

204 of 208 healthy women in the initial trial (2009-12) with uterine prolapse stage 2 or higher requiring surgery and no history of pelvic floor surgery who had been randomised to sacrospinous hysteropexy or vaginal hysterectomy with uterosacral ligament suspension. The women were followed annually for five years after surgery. This extended trial reports the results at five years.

MAIN OUTCOME MEASURES

Prespecified primary outcome evaluated at five year follow-up was recurrent prolapse of the uterus or vaginal vault (apical compartment) stage 2 or higher evaluated by pelvic organ prolapse quantification system in combination with bothersome bulge symptoms or repeat surgery for recurrent apical prolapse. Secondary outcomes were overall anatomical failure (recurrent prolapse stage 2 or higher in apical, anterior, or posterior compartment), composite outcome of success (defined as no prolapse beyond the hymen, no bothersome bulge symptoms, and no repeat surgery or pessary use for recurrent prolapse), functional outcome, quality of life, repeat surgery, and sexual functioning.

RESULTS

At five years, surgical failure of the apical compartment with bothersome bulge symptoms or repeat surgery occurred in one woman (1%) after sacrospinous hysteropexy compared with eight women (7.8%) after vaginal hysterectomy with uterosacral ligament suspension (difference-6.7%, 95% confidence interval -12.8% to-0.7%). A statistically significant difference was found in composite outcome of success between sacrospinous hysteropexy and vaginal hysterectomy (89/102 (87%) v 77/102 (76%). The other secondary outcomes did not differ. Time-to-event analysis at five years showed no differences between the interventions.

CONCLUSIONS

At five year follow-up significantly less anatomical recurrences of the apical compartment with bothersome bulge symptoms or repeat surgery were found after sacrospinous hysteropexy compared with vaginal hysterectomy with uterosacral ligament suspension. After hysteropexy a higher proportion of women had a composite outcome of success. Time-to-event analysis showed no differences in outcomes between the procedures.

TRIAL REGISTRATION

trialregister.nl NTR1866.

Evaluation of two vaginal, uterus sparing operations for pelvic organ prolapse: modified Manchester operation (MM) and sacrospinous hysteropexy (SSH), a study protocol for a multicentre randomized non-inferiority trial (the SAM study)

BACKGROUND

Pelvic organ prolapse (POP) affects up to 40% of parous women which adversely affects the quality of life. During a life time, 20% of all women will undergo an operation. In general the guidelines advise a vaginal operation in case of uterine descent: hysterectomy with uterosacral ligament plication (VH), sacrospinous hysteropexy (SSH) or a modified Manchester operation (MM). In the last decade, renewed interest in uterus sparing techniques has been observed. Previous studies have shown non-inferiority between SSH and VH. Whether or not SSH and MM are comparable concerning anatomical and functional outcome is still unknown. The practical application of both operations is at least in The Netherlands a known cause of practice pattern variation (PPV). To reveal any difference between both techniques the SAM-study was designed.

METHODS

The SAM-study is a randomized controlled multicentre non-inferiority study which compares SSH and MM. Women with symptomatic POP in any stage, uterine descent and POP-Quantification (POP-Q) point D at ≤ minus 1 cm are eligible. The primary outcome is the composite outcome at two years of absence of prolapse beyond the hymen in any compartment, the absence of bulge symptoms and absence of reoperation for pelvic organ prolapse. Secondary outcomes are hospital parameters, surgery related morbidity/complications, pain perception, further treatments for prolapse or urinary incontinence, POP-Q anatomy in all compartments, quality-of-life, sexual function, and cost-effectiveness. Follow-up takes place at 6 weeks, 12 and 24 months. Additionally at 12 weeks, 6 and 9 months cost-effectiveness will be assessed. Validated questionnaires will be used and gynaecological examination will be performed. Analysis will be performed following the intention-to-treat and per protocol principle. With a non-inferiority margin of 9% and an expected loss to follow-up of 10%, 424 women will be needed to prove non-inferiority with a confidence interval of 95%.

DISCUSSION

This study will evaluate the effectiveness and costs of SSH versus MM in women with primary POP. The evidence will show whether the existing PPV is detrimental and a de-implementation process regarding one of the operations is needed.

TRIAL REGISTRATION

Dutch Trial Register (NTR 6978, http://www.trialregister.nl ). Date of registration: 29 January 2018. Prospectively registered.

Management of Gonads in Adults with Androgen Insensitivity: An International Survey

BACKGROUND

Complete and partial androgen insensitivity syndrome (CAIS, PAIS) are associated with an increased risk of gonadal germ cell cancer (GGCC). Recent guidelines recommend gonadectomy in women with CAIS in late adolescence. Nevertheless, many adult women prefer to retain their gonads.

AIMS

This study aims to explore attitudes towards gonadectomy in AIS in centres around the world, estimate the proportion of adults with retained gonads and/or who developed GGCC, and explore reasons for declining gonadectomy.

METHODS

A survey was performed among health care professionals who use the International DSD Registry (I-DSD).

RESULTS

Data were provided from 22 centres in 16 countries on 166 women (CAIS) and 26 men (PAIS). In CAIS, gonadectomy was recommended in early adulthood in 67% of centres; 19/166 (11.4%) women refused gonadectomy. Among 142 women who had gonadectomy, evidence of germ cell neoplasm in situ (GCNIS), the precursor of GGCC, was reported in 2 (1.4%) out of 8 from whom pathology results were formally provided. Nine out of 26 men with PAIS (34.6%) had retained gonads; 11% of centres recommended routine gonadectomy in PAIS.

CONCLUSION

Although development of GGCC seems rare, gonadectomy after puberty is broadly recommended in CAIS; in PAIS this is more variable. Overall, our data reflect the need for evidence-based guidelines regarding prophylactic gonadectomy in AIS.

De-implementation of urodynamics in The Netherlands after the VALUE/VUSIS-2 results: a nationwide survey

INTRODUCTION AND HYPOTHESIS

We aimed to estimate the level of de-implementation of preoperative routine urodynamics (UDS) before stress urinary incontinence (SUI) surgery in The Netherlands and to analyze facilitators and barriers. Routine UDS was performed by 37% of the medical specialists in 2010. We hypothesized that the recommendations from the recent Value of Urodynamics prior to Stress Incontinence Surgery (VUSIS) and Value of Urodynamic Evaluation (ValUE) studies would have been followed by a reduction of routine UDS.

METHODS

A national survey was performed among all Dutch gynecologists and urologists dealing with SUI in daily practice. The questionnaire contained two parts: (1) respondents' characteristics and their actual care concerning preoperative UDS, and (2) facilitators and barriers.

RESULTS

The response rate was 41% (127/308). Of the respondents, 93% (n = 118) did not perform routine UDS in the preoperative workup for women in this group. Professional characteristics associated with not following the recommendations were profession urologist, academic hospital, and a lower number of midurethral sling (MUS) placed yearly. Facilitators to follow the recommendation not to perform routine UDS were adequate design of the VUSIS-II study and outcome and recommendations from the studies. Barriers not to follow the recommendation were believe in the additional value of UDS, especially the pressure transmission ratio, and the presence of detrusor overactivity.

CONCLUSION

According to respondents to this questionnaire, VUSIS-II and ValUE study results are well implemented in The Netherlands. The vast majority of respondents replied as not performing routine preoperative UDS in women with primary, uncomplicated (predominant) SUI. Therefore, there is no need for a further de-implementation strategy.

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.

[Severe vaginal discharge following rectal surgery]

BACKGROUND

Almost 50% of women who have had rectal surgery subsequently develop vaginal discharge. Due to the recurrent and unexpected nature of this heavy discharge, they often experience it as very distressing. Many of these women undergo extensive diagnostic tests that are mainly focused on identifying fistula formation. If no fistula is found, in most cases no other cause for severe vaginal discharge can be demonstrated.

CASE DESCRIPTION

In our practice, we saw three patients (49-, 54- and 74-years-old, respectively) with similar severe vaginal discharge after rectal surgery and in whom no explanation for the vaginal discharge could be found. For this reason we conducted a literature search into this condition.

CONCLUSION

Anatomical changes appear to be responsible for heavy vaginal discharge following rectal surgery. Changes in pelvic floor muscles and compression of the distal part of the vagina may lead to pooling of fluid in the proximal part of the vagina, resulting in severe discharge. Symptomatic treatment may reduce the symptoms.

Dutch women's attitudes towards hysterectomy and uterus preservation in surgical treatment of pelvic organ prolapse

OBJECTIVE

To investigate Dutch women's attitudes and preferences towards hysterectomy or uterus preservation in surgical treatment of pelvic organ prolapse.

STUDY DESIGN

Women's attitude was assessed by a structured questionnaire in one university hospital and one non-university teaching hospital in the Netherlands. Between December 2013 and November 2014, 102 women referred with prolapse complaints, without previous prolapse surgery, responded to the questionnaire received by mail prior to gynaecological consultation. Main outcome was the preference for uterus preserving surgery versus hysterectomy. Furthermore we studied the impact of uterus preservation and hysterectomy on body image and sexual function and the importance of treatment success, risk of urinary incontinence after surgery, complication risk, recovery time, length of hospital stay, costs and the risk of developing endometrial cancer.

RESULTS

Assuming that functional and anatomical outcomes after hysterectomy and uterus preserving surgery were equal, more women expressed preference for uterus preservation (43%, 44 out of 102 women) compared to hysterectomy (27%, 27 out of 102 women). The majority of women expected a similar improvement in sexuality and body image after the two treatment modalities. Treatment success, risk for urinary incontinence after surgery and complication risk were the most important factors. Taken the future risk of endometrial cancer into account, 18% of the women preferred hysterectomy because of this risk.

CONCLUSIONS

This study demonstrated that women referred with prolapse complaints have a preference for uterus preservation in case outcomes after both interventions are expected to be equal. The majority of women expected that body image and sexual function would equally improve after both interventions.

Choice of mode of delivery in a subsequent pregnancy after OASI: a survey among Dutch gynecologists

Introduction and hypothesis

National and international guidelines do not provide clear recommendations on the mode of delivery in a subsequent pregnancy after obstetric anal sphincter injury (OASI). The aim of this study was to investigate the opinion of gynecologists in The Netherlands on this choice and the extent to which this choice is affected by the gynecologist’s characteristics.

Methods

Of 973 gynecologists sent a questionnaire seeking their opinion on the mode of delivery in 16 different case descriptions, 234 (24%) responded. Factors influencing the opinion of the respondents on the mode of delivery, the presence of anal symptoms, the degree of OASI and the characteristics of the respondents were analyzed by univariate and multivariate logistic regression analysis.

Results

Recommendations on the mode of delivery in a subsequent pregnancy after OASI showed considerable variation. The recommendations depended on (previous) symptoms and the degree of OASI. For gynecologists who based their recommendations on endoanal ultrasonography outcomes (7–20% depending on the case), the degree of OASI and severity of (previous) symptoms were less important. Gynecologists basing their recommendations on endoanal ultrasonography recommended a primary cesarean section less often. Gynecologist’s characteristics (including years of experience, type of hospital and subspecialty) had a small effect on their recommendations on the mode of delivery.

Conclusions

Due to lack of evidence, recommendations of gynecologists in The Netherlands on the mode of delivery in a subsequent pregnancy after OASI vary widely and depend on (previous) symptoms and the degree of OASI. Gynecologists who based their recommendations on endoanal ultrasonography outcomes recommended cesarean section less often.

Rare and low-frequency coding variants alter human adult height

Height is a highly heritable, classic polygenic trait with approximately 700 common associated variants identified through genome-wide association studies so far. Here, we report 83 height-associated coding variants with lower minor-allele frequencies (in the range of 0.1-4.8%) and effects of up to 2 centimetres per allele (such as those in IHH, STC2, AR and CRISPLD2), greater than ten times the average effect of common variants. In functional follow-up studies, rare height-increasing alleles of STC2 (giving an increase of 1-2 centimetres per allele) compromised proteolytic inhibition of PAPP-A and increased cleavage of IGFBP-4 in vitro, resulting in higher bioavailability of insulin-like growth factors. These 83 height-associated variants overlap genes that are mutated in monogenic growth disorders and highlight new biological candidates (such as ADAMTS3, IL11RA and NOX4) and pathways (such as proteoglycan and glycosaminoglycan synthesis) involved in growth. Our results demonstrate that sufficiently large sample sizes can uncover rare and low-frequency variants of moderate-to-large effect associated with polygenic human phenotypes, and that these variants implicate relevant genes and pathways.

Recurrence risk is associated with preoperatively advanced prolapse stage: Is there a difference between women with stage 2 and those with stage 3 or 4 cystocele?

INTRODUCTION AND HYPOTHESIS

Pelvic organ prolapse (POP) recurrence after surgery is a major problem. POP that is more advanced preoperatively is associated with a higher risk of recurrence postoperatively. We hypothesized that women with a stage 2 cystocele differ from those with a stage 3 or 4 cystocele. The aim of this study was to compare the baseline characteristics of women with mild and those with more advanced cystocele.

METHODS

Patients had participated in one of two multicenter prospective cohort studies on women undergoing conventional anterior colporrhaphy without previous POP surgery. This was a secondary analysis of these data. Women with a preoperative cystocele stage 2 were compared with women with a stage 3 or 4 cystocele. Logistic regression models were employed to calculate odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Two hundred and sixty-nine women were assessed, of whom 132 (49.1%) had an advanced cystocele. Only older age was significantly associated with advanced cystocele preoperatively, with an OR of 1.07 (95% CI 1.04-1.10). There were no significant differences between women with advanced or stage 2 cystocele in body mass index, vaginal deliveries, assisted delivery, positive family history of POP, concurrent rectocele, concurrent uterine of vaginal vault prolapse, major levator ani muscle defects, or levator hiatal area.

CONCLUSIONS

Women with advanced cystocele were significantly older than women with stage 2 cystocele. This raises the question whether it would be favorable to perform POP surgery in an earlier stage, i.e., at a younger age, in order to prevent POP recurrence.

Adnexal masses in children, adolescents and women of reproductive age in the Netherlands: A nationwide population-based cohort study

OBJECTIVE

To provide an accurate incidence of adnexal masses in children and young women which can significantly improve the performance of current risk prediction models.

METHODS

We used the PALGA database, a nationwide network and registry of histopathology and cytopathology, as the primary source of our study. Reports on ovarian histology of girls, years 1991-2014, and women aged 21-39, years 2011-2013, were included. Reports were labeled using the WHO-classification and classified as benign, borderline malignant, or malignant. Surgical procedure was scored separately.

RESULTS

Included were 11,595 patients. The incidence of adnexal masses increased exponentially with age, from 0.43 per 100,000womenyears at age 1 to 152 per 100,000womenyears at age 35. A (borderline) malignancy was found in 898 (7.7%) patients, ratios between benign and malignant masses varied with age and were lowest in premenarchal children. Histology varied widely with surface epithelial tumors (35.1%), germ cell tumors (29.8%), and other cysts, tumors and tumorlike lesions (32.8%) being evenly distributed while sex cord stromal tumors were rare and only represented 2.3%. The proportion of malignancies was 6.3% in germ cell tumors while the type of malignant germ cell tumor was dependent on age. Oophorectomy was more often performed in the premenarchal age group and in women approaching the end of their reproductive age.

CONCLUSION

Our results show that adnexal masses in different age groups do not only differ in histological subgroups but also in malignancy rate which is of high value in presurgical risk evaluation.

Comparison of translabial three-dimensional ultrasound with magnetic resonance imaging for measurement of levator hiatal biometry at rest

OBJECTIVES

To compare translabial three-dimensional (3D) ultrasound with magnetic resonance imaging (MRI) for the measurement of levator hiatal biometry at rest in women with pelvic organ prolapse, and to determine the interobserver reliability between two independent observers for ultrasound and MRI measurements.

METHODS

Data were derived from a multicenter prospective cohort study in which women scheduled for conventional anterior colporrhaphy underwent translabial 3D ultrasound and MRI prior to surgery. Intraclass correlation coefficients (ICCs) were calculated to estimate interobserver reliability between two independent observers and determine the agreement between ultrasound and MRI measurements. Bland-Altman plots were created to assess the agreement between ultrasound and MRI measurements.

RESULTS

Data from 139 women from nine hospitals were included in the study. The interobserver reliability of ultrasound assessment at rest, during Valsalva maneuver and during contraction and of MRI assessment at rest were moderate or good. The agreement between ultrasound and MRI for the measurement of levator hiatal biometry at rest was moderate, with ICCs of 0.52 (95%CI, 0.32-0.66) for levator hiatal area, 0.44 (95%CI, 0.21-0.60) for anteroposterior diameter and 0.44 (95%CI, 0.22-0.60) for transverse diameter. Levator hiatal biometry measurements were statistically significantly larger on MRI than on translabial 3D ultrasound.

CONCLUSIONS

The agreement between translabial 3D ultrasound and MRI for measurement of the levator hiatus at rest in women with pelvic organ prolapse was only moderate. The results of translabial 3D ultrasound and MRI should therefore not be used interchangeably in daily practice or in clinical research. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

The value of fine needle aspiration cytology diagnosis in ovarian masses in children and adolescents

STUDY QUESTION

Is ovarian cytology a reliable predictor for a malignant ovarian mass?

SUMMARY ANSWER

Cytology of an ovarian mass in children and adolescents cannot be used to exclude malignancy.

WHAT IS KNOWN ALREADY

It is hard to predict malignancy in case of an ovarian mass in a child or adolescent. The most common reason to perform fine needle aspiration cytology (FNAC) is to exclude malignancy. Ovarian cytology has shown varying results in adults, but test performance in a younger population is unknown.

STUDY DESIGN, SIZE, DURATION

This was a retrospective diagnostic test accuracy study. We used a nationwide registry, the PALGA database, to select girls aged 18 or younger with matching ovarian cytology and histology reports available between 1990 and 2014.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Histology diagnoses were classified according to the WHO classification of ovarian pathology. Cytology diagnoses were classified as benign, borderline malignant or malignant. Cases with inconclusive cytology diagnoses were excluded from the analysis of diagnostic accuracy. Diagnostic accuracy was calculated using a 2 × 2 table.

MAIN RESULTS AND THE ROLE OF CHANCE

Included were 552 girls under the age of 18 who had a cytology and a histology report of the same ovary available in the PALGA database. In 523 (94.7%) patients the mass was benign; 19 (3.4%) patients had a borderline malignancy and 9 (1.7%) patients had a malignant tumour. The histology diagnosis was unknown in one patient due to torsion of the ovary. Cytological diagnosis was inconclusive in 96 patients (17.4%). Cytology had a sensitivity of 32.0% and a specificity of 99.8%. Post-test probability of malignancy with positive cytology was 88.9%; the post-test probability of a malignancy with negative cytology was 3.8%, compared with a pre-test probability of 5.5%.

LIMITATIONS, REASONS FOR CAUTION

This study was retrospective, using data gathered over 24 years. Cytology was retrieved during surgery or at the pathology department in 86.6% of the cases and pathologists were not blinded, which can be a cause for bias.

WIDER IMPLICATIONS OF THE FINDINGS

Since the sensitivity is low, FNAC is not a recommended diagnostic tool in children. The post-test probability of a negative test compared with the incidence in our population resulted in a minimal difference not worth an invasive procedure.

STUDY FUNDING/COMPETING INTERESTS

No study funding was received and no competing interests are present.

TRIAL REGISTRATION NUMBER

NA.

Use of risk of malignancy index to indicate frozen section analysis in the surgical care of women with ovarian tumors

OBJECTIVE

To evaluate the importance of the risk of malignancy index (RMI) in the decision to perform frozen section analysis among women with ovarian tumors.

METHODS

A retrospective study was conducted in 11 centers in the Netherlands. Women who underwent surgical treatment of an ovarian mass with unknown histology between January 2005 and September 2009 were included. The RMI was calculated retrospectively. Frozen section analysis and RMI values were assessed for patients with benign, borderline, and malignant ovarian tumors on final histopathology.

RESULTS

Overall, 670 women were included. Frozen sections were performed in 323 (48.2%) patients, of whom 206 (63.8%) were diagnosed with benign ovarian tumors, 55 (17.0%) with borderline tumors, and 62 (19.2%) with malignant tumors. Overall, 109 (16.3%) women had an RMI below 20, 106 (97.2%) of whom had benign histology results. Among 235 patients with an RMI over 100, 3 (1.3%) postmenopausal women had malignancies that were missed because frozen sections were not performed.

CONCLUSION

Women with an RMI below 20 have a low risk of malignancy and therefore do not require frozen section analysis. Postmenopausal women with an RMI greater than 100 should be referred to centers where frozen sections can be performed, and proper facilities and expertise are available to perform staging procedures if necessary.

Surgical approach to hysterectomy for benign gynaecological disease

BACKGROUND

The four approaches to hysterectomy for benign disease are abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH) and robotic-assisted hysterectomy (RH).

OBJECTIVES

To assess the effectiveness and safety of different surgical approaches to hysterectomy for women with benign gynaecological conditions.

SEARCH METHODS

We searched the following databases (from inception to 14 August 2014) using the Ovid platform: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO. We also searched relevant citation lists. We used both indexed and free-text terms.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in which clinical outcomes were compared between one surgical approach to hysterectomy and another.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials, assessed risk of bias and performed data extraction. Our primary outcomes were return to normal activities, satisfaction, quality of life, intraoperative visceral injury and major long-term complications (i.e. fistula, pelvi-abdominal pain, urinary dysfunction, bowel dysfunction, pelvic floor condition and sexual dysfunction).

MAIN RESULTS

We included 47 studies with 5102 women. The evidence for most comparisons was of low or moderate quality. The main limitations were poor reporting and imprecision. Vaginal hysterectomy (VH) versus abdominal hysterectomy (AH) (nine RCTs, 762 women)Return to normal activities was shorter in the VH group (mean difference (MD) -9.5 days, 95% confidence interval (CI) -12.6 to -6.4, three RCTs, 176 women, I(2) = 75%, moderate quality evidence). There was no evidence of a difference between the groups for the other primary outcomes. Laparoscopic hysterectomy (LH) versus AH (25 RCTs, 2983 women)Return to normal activities was shorter in the LH group (MD -13.6 days, 95% CI -15.4 to -11.8; six RCTs, 520 women, I(2) = 71%, low quality evidence), but there were more urinary tract injuries in the LH group (odds ratio (OR) 2.4, 95% CI 1.2 to 4.8, 13 RCTs, 2140 women, I(2) = 0%, low quality evidence). There was no evidence of a difference between the groups for the other primary outcomes. LH versus VH (16 RCTs, 1440 women)There was no evidence of a difference between the groups for any primary outcomes. Robotic-assisted hysterectomy (RH) versus LH (two RCTs, 152 women)There was no evidence of a difference between the groups for any primary outcomes. Neither of the studies reported satisfaction rates or quality of life.Overall, the number of adverse events was low in the included studies.

AUTHORS' CONCLUSIONS

Among women undergoing hysterectomy for benign disease, VH appears to be superior to LH and AH, as it is associated with faster return to normal activities. When technically feasible, VH should be performed in preference to AH because of more rapid recovery and fewer febrile episodes postoperatively. Where VH is not possible, LH has some advantages over AH (including more rapid recovery and fewer febrile episodes and wound or abdominal wall infections), but these are offset by a longer operating time. No advantages of LH over VH could be found; LH had a longer operation time, and total laparoscopic hysterectomy (TLH) had more urinary tract injuries. Of the three subcategories of LH, there are more RCT data for laparoscopic-assisted vaginal hysterectomy and LH than for TLH. Single-port laparoscopic hysterectomy and RH should either be abandoned or further evaluated since there is a lack of evidence of any benefit over conventional LH. Overall, the evidence in this review has to be interpreted with caution as adverse event rates were low, resulting in low power for these comparisons. The surgical approach to hysterectomy should be discussed and decided in the light of the relative benefits and hazards. These benefits and hazards seem to be dependent on surgical expertise and this may influence the decision. In conclusion, when VH is not feasible, LH may avoid the need for AH, but LH is associated with more urinary tract injuries. There is no evidence that RH is of benefit in this population. Preferably, the surgical approach to hysterectomy should be decided by the woman in discussion with her surgeon.

Sacrospinous hysteropexy versus vaginal hysterectomy with suspension of the uterosacral ligaments in women with uterine prolapse stage 2 or higher: multicentre randomised non-inferiority trial

OBJECTIVE

To investigate whether uterus preserving vaginal sacrospinous hysteropexy is non-inferior to vaginal hysterectomy with suspension of the uterosacral ligaments in the surgical treatment of uterine prolapse.

DESIGN

Multicentre randomised controlled non-blinded non-inferiority trial.

SETTING

4 non-university teaching hospitals, the Netherlands.

PARTICIPANTS

208 healthy women with uterine prolapse stage 2 or higher requiring surgery and no history of pelvic floor surgery.

INTERVENTIONS

Treatment with sacrospinous hysteropexy or vaginal hysterectomy with suspension of the uterosacral ligaments. The predefined non-inferiority margin was an increase in surgical failure rate of 7%.

MAIN OUTCOME MEASURES

Primary outcome was recurrent prolapse stage 2 or higher of the uterus or vaginal vault (apical compartment) evaluated by the pelvic organ prolapse quantification system in combination with bothersome bulge symptoms or repeat surgery for recurrent apical prolapse at 12 months' follow-up. Secondary outcomes were overall anatomical recurrences, including recurrent anterior compartment (bladder) and/or posterior compartment (bowel) prolapse, functional outcome, complications, hospital stay, postoperative recovery, and sexual functioning.

RESULTS

Sacrospinous hysteropexy was non-inferior for anatomical recurrence of the apical compartment with bothersome bulge symptoms or repeat surgery (n=0, 0%) compared with vaginal hysterectomy with suspension of the uterosacral ligaments (n=4, 4.0%, difference -3.9%, 95% confidence interval for difference -8.6% to 0.7%). At 12 months, overall anatomical recurrences, functional outcome, quality of life, complications, hospital stay, measures on postoperative recovery, and sexual functioning did not differ between the two groups. Five serious adverse events were reported during hospital stay. None was considered to be related to the type of surgery.

CONCLUSIONS

Uterus preservation by sacrospinous hysteropexy was non-inferior to vaginal hysterectomy with suspension of the uterosacral ligaments for surgical failure of the apical compartment at 12 months' follow-up.

TRIAL REGISTRATION

trialregister.nl NTR1866.

Does the prevalence of levator ani muscle avulsion differ when assessed using tomographic ultrasound imaging at rest vs on maximum pelvic floor muscle contraction?

OBJECTIVE

It has been suggested that transperineal ultrasound images obtained during maximum pelvic floor muscle contraction improve the diagnosis of levator ani muscle (LAM) avulsion by comparison with those obtained at rest. The objective of this study was to establish, using transperineal tomographic ultrasound imaging (TUI), the correlation between LAM avulsion diagnosed at rest and that on contraction.

METHODS

Primiparous women were examined 3 months postpartum by Pelvic Organ Prolapse Quantification (POP-Q) assessment and for LAM avulsion clinically by digital palpation and by transperineal TUI performed at rest and on pelvic floor muscle contraction. LAM avulsion was diagnosed on TUI when the three central slices were abnormal. A comparison was made between LAM avulsion diagnosed at rest and on maximum contraction. Two independent blinded investigators performed the analyses and a third investigator resolved discrepancies.

RESULTS

One hundred and ninety primiparae were analyzed providing 380 results for comparison, as right and left LAM were analyzed independently. LAM avulsion was found in 36 (9.5%) images obtained at rest and in 35 (9.2%) on contraction, revealing moderate correlation between the two (ICC, 0.58 (95% CI, 0.51-0.64)). Twenty-two cases of LAM avulsion were identified both at rest and on contraction. One woman had LAM avulsion on palpation, which was seen on TUI as LAM avulsion on contraction, but not at rest. More cases of anterior and posterior compartment prolapse were found in women with LAM avulsion diagnosed on contraction only compared to LAM avulsion observed at rest only (POP-Q assessment point Ba, -1.8 vs -2.5 (P = 0.075) and point Bp, -2.5 vs -2.8 (P = 0.072)).

CONCLUSIONS

Findings on transperineal TUI performed in women at rest and on contraction correlate reasonably well. However, given the trend towards an association with signs of pelvic floor dysfunction, diagnosis of LAM avulsion on contraction seems to be more reliable. Consistency in technique and interpretation should be maintained.

Levator hiatal area as a risk factor for cystocele recurrence after surgery: a prospective study

OBJECTIVE

To investigate whether increased levator hiatal area, measured preoperatively, was independently associated with anatom-ical cystocele recurrence 12 months after anterior colporrhaphy.

DESIGN

Multicentre prospective cohort study.

SETTING

Nine teaching hospitals in the Netherlands.

POPULATION

Women planned for conventional anterior colporrhaphy without mesh.

METHODS

Women underwent physical examination, translabial three-dimensional (3D) ultrasound and magnetic resonance imaging (MRI) prior to surgery. At 12 months after surgery the physical examination was repeated.

MAIN OUTCOME MEASURES

Women with and without anatomical cystocele recurrence were compared to assess the association with levator hiatal area on 3D ultrasound, levator hiatal area on MRI, and potential confounding factors. The receiver operating characteristic (ROC) curve was created to quantify the discriminative ability of using levator hiatal area to predict anatomical cystocele recurrence.

RESULTS

Of 139 included women, 76 (54.7%) had anatomical cystocele recurrence. Preoperative stage 3 or 4 and increased levator hiatal area during Valsalva on ultrasound were significantly associated with cystocele recurrence, with odds ratios of 3.47 (95% confidence interval, 95% CI 1.66-7.28) and 1.06 (95% CI 1.01-1.11) respectively. The area under the ROC curve was 0.60 (95% CI 0.51-0.70) for levator hiatal area during Valsalva on ultrasound, and 0.65 (95% CI 0.55-0.71) for preoperative Pelvic Organ Prolapse Quantification (POP-Q) stage.

CONCLUSIONS

Increased levator hiatal area during Valsalva on ultrasound prior to surgery and preoperative stage 3 or 4 are independent risk factors for anatomical cystocele recurrence after anterior colporrhaphy; however, increased levator hiatal area as the sole factor for predicting anatomical cystocele recurrence after surgery shows poor test characteristics.

Long-term results of vaginal construction with the use of Frank dilation and a peritoneal graft (Davydov procedure) in patients with Mayer-Rokitansky-Küster syndrome

OBJECTIVE

To describe long-term outcomes after nonsurgical and surgical treatment of vaginal agenesis in a cohort of girls and women with Mayer-Rokitansky-Küster (MRK) syndrome.

DESIGN

Retrospective cohort study using a standardized case record form.

SETTING

University hospital.

PATIENT(S)

All girls and women with vaginal agenesis due to MRK syndrome, presenting during a 40-year period (1962-2012).

INTERVENTION(S)

Frank dilation and surgical treatment (with the use of a peritoneal graft, i.e., the Davydov method) for vaginal agenesis.

MAIN OUTCOME MEASURE(S)

Functional vaginal depth and complications.

RESULT(S)

Two hundred fifty-four women with MRK visited the department. Urinary tract anomalies were found in 72 patients (31%), and other congenital anomalies in 59 (32%) of the patients with available data. One hundred sixty women were treated for vaginal agenesis. The mean follow-up time was 90 months (range 0-560 months). Sixty-eight patients had surgical treatment for vaginal agenesis with the use of a peritoneal graft (Davydov method) and reached a functional depth of the vagina of 7.8 cm (range 1-13 cm) Surgical therapy preceded by nonsurgical Frank dilation and/or attempted sexual intercourse did not result in more functional depth of the neovagina. The formation of granulation tissue (23%) and the tendency to obliterate (12%) were the major problems when using a peritoneal graft.

CONCLUSION(S)

Long-term results of both Frank dilation and Davydov neovagina procedure in experienced hands were good. The use of a peritoneal graft may be regarded as a good alternative to other widely used neovagina techniques using a graft, such as split-thickness skin graft or sigmoid neovagina.

Inter- and intraobserver reliability for diagnosing levator ani changes on magnetic resonance imaging

OBJECTIVES

To assess the inter- and intraobserver reliability of the diagnosis of pubovisceral muscle avulsions and measurements of the levator hiatus on magnetic resonance imaging (MRI).

METHODS

Women with recurrent pelvic organ prolapse or in whom there was a discrepancy between clinical signs and symptoms of pelvic floor dysfunction underwent MRI and were eligible for inclusion. MRI datasets of the pelvic floor of 262 women were obtained and evaluated by two observers, who scored the presence and extent of pubovisceral muscle avulsions on each side using a scale from 0 to 3 and obtained measurements of the anteroposterior and transverse diameters and area of the levator hiatus. A random sample of 100 patients was reviewed a second time by one of the observers. Intraclass correlation coefficients (ICCs) with their 95% CI were calculated for all measurements. Mean differences with accompanying limits of agreement were calculated to estimate agreement between pairs of measurements and to detect possible systematic bias.

RESULTS

Good interobserver reliability was found for the assessment of pubovisceral muscle avulsions (ICC = 0.76-0.79) and excellent agreement for measurements of the levator hiatus (ICC = 0.85-0.89). The intraobserver reliability for pubovisceral muscle avulsions and other levator hiatus measurements was also excellent (ICC = 0.80-0.97). A significant interobserver systematic bias was observed in the measurement of levator hiatus transverse diameter; however, narrow limits of agreement were observed.

CONCLUSIONS

Pubovisceral muscle avulsions and levator hiatus measurements can be assessed with good to excellent reliability on MRI.