Patient Perspectives toward Undergoing Same-Day Discharge for Apical Pelvic Organ Prolapse Repair Surgery during the COVID-19 Pandemic.

INTRODUCTION: To ensure patient satisfaction during the COVID-19 pandemic, hospitals implemented changes to elective surgeries while upholding safety and quality of care. This includes a growing trend toward same-day discharge (SDD) following apical pelvic organ prolapse (POP) repair surgery, which previously involved overnight hospitalization for some institutions. We assessed patient perspectives following SDD after transvaginal and minimally invasive apical POP repair during the pandemic. METHODS: This was a cross-sectional study of women who underwent apical POP surgery. Preoperatively, we assessed preference for SDD. A postoperative survey evaluated perceived safety, pain control and satisfaction using the "Core questionnaire for the assessment of Patient Satisfaction for general Day-care" and the "Patient Global Impression of Improvement." Postoperative complications were identified. RESULTS: Of 36 recruited patients, 83.3% preferred SDD preoperatively. When rating the influence of COVID-19 on their preference (1-10, 10=high), 13 reported level 10 and 11 reported level 1 (mean 5.9±4.0). A total of 34 postoperative surveys were collected, 29 of which were SDD (85.3%); 89.7% of patients reported feeling safer with SDD, and 40% (2/5) of admitted patients would have preferred SDD. Pain control satisfaction for SDD was assessed on a Likert scale (1-10, 10=very satisfied), with a mean of 9.1 (±1.8); 82.8% of SDD patients rated their overall experience as "very satisfied" and consistently rated individual components highly. CONCLUSIONS: During the pandemic, our patient population preferred SDD after an apical POP repair with a high success and satisfaction rate with minimal complications. In the absence of a pandemic, SDD should be considered to increase patient satisfaction.

How does office assessment of prolapse compare to what is seen in the operating room?

INTRODUCTION AND HYPOTHESIS: It is not known whether the measurements of pelvic organ assessment under anesthesia accurately estimate prolapse severity. We compared Pelvic Organ Prolapse Quantification (POP-Q) measurements in the office to exams under anesthesia. METHODS: We prospectively enrolled patients undergoing prolapse surgery between February 2020 and July 2020. POP-Qs at rest and with Valsalva were performed at pre- and postoperative visits. POP-Q under anesthesia was performed, without traction, at the start of case (pre-surgical), following apical suspension, and at the end of case (post-surgical). Primary outcome was change in POP-Q between the office and operating room. Due to the COVID-19 pandemic, additional patients were recruited to maintain the follow-up time frame. RESULTS: Out of 66 patients, 63 underwent surgery and 33 had postoperative exams within 6 weeks. Mean age was 61.3 ± 11.9 years, and mean BMI was 28.4 ± 6.5 kg/m2. Preoperative Aa, Ba, C, Ap, Bp, and D with Valsalva had greater descent than pre-surgical measurements. However, preoperative Gh with Valsalva (4.1 ± 1.3 cm) was not different from pre-surgical Gh (4.0 ± 1.0 cm) (P = 0.60). Postoperative Aa, Ba, Ap, Bp, and D were not different from post-surgical measurements. In contrast, postoperative Gh at rest (2.3 ± 0.7 cm) and with Valsalva (2.4 ± 0.8 cm) were both narrower than post-surgical Gh (2.8 ± 0.6 cm) (P < 0.05). Gh was also narrowed after apical suspension (3.6 ± 1.0 cm, P = 0.005) prior to posterior repair. CONCLUSIONS: Surgeons should rely on preoperative POP-Q for surgical decisions. Gh should be reassessed after apical suspension, and further correction should consider that Gh may be exaggerated compared to the measurement postoperatively when the patient is awake.

The impact of covid-19 on women's health in nepal

COVID-19 has significantly impacted the world and Nepal is no exception. The pandemic has caused a reduction in health service delivery, especially for women's health conditions, resulting in an increase in challenges for an already vulnerable group. Maternity care, reproductive health services, preventive interventions, nutritional advice and mental health care are not being addressed and with an increase in domestic violence, the health and wellbeing of women in Nepal is precarious and needs to be addressed immediately. Copyright © 2020, Kathmandu University. All rights reserved.

A qualitative study of the impact of the COVID-19 pandemic on women seeking pelvic organ prolapse surgery in Alberta, Canada.

In addition to altering public infrastructure and social patterning, the COVID-19 pandemic has delayed many pelvic organ prolapse (POP) surgeries. POP-related stigma, symptomology and the experience of waiting for POP surgery can negatively impact women's quality of life and mental health. The experience of preoperative POP patients during the pandemic thus entails a new intersection of gendered, stigmatic and medical realities. Qualitative interviews were conducted with 26 preoperative POP patients as part of a larger qualitative study, 20 of whom spontaneously volunteered information about how the pandemic coloured their experience living with and awaiting surgery for POP. Interviews occurred between January and July 2021, which coincided with the second and third waves of the pandemic in Alberta, Canada, and before full immunisation was available for all Albertans. Pandemic-related interview excerpts were thematically analysed, and four main findings emerged. (1) Though surgical delay meant living with unpleasant symptoms for longer than anticipated, some sought this out in order to protect vulnerable loved ones from possible hospital-acquired infection, (2) shifting and unclear hospital policies and logistics resulted in intense preoperative stress, at times causing women to temporarily cease treatment, (3) decreased access to public restroom infrastructure caused women to reduce their outings and (4) the imperative to minimise social gatherings made it easier for women to engage in POP-related, shame-based self-isolation without the notice of friends and family. As they can influence postoperative outcomes and treatment adherence, trends observed should be of interest to clinicians and policymakers alike.

TRENDS IN HYSTERECTOMY FOR PROLAPSE: AN ANALYSIS OF THE EFFECT OF THE COVID-19 PANDEMIC

Introduction: The COVID-19 pandemic has had a considerable and evolving impact on delivery of surgical care to patients. During the early stages of the pandemic, resource scarcity was experienced by many healthcare systems. This led to the implementation of a surgical moratorium on elective surgeries in New York State between the months of March through June 2020. Certain specialties, specifically those performing elective surgeries, experienced significant strain and transformation. Objective: This study aims to describe perioperative and intraoperative characteristics of patients undergoing hysterectomy for pelvic organ prolapse (POP) with and without concomitant urogynecology procedures between 2019-2021 at a multi-hospital healthcare system that experienced significantly strain and a subsequent moratorium on elective surgery during the first peak of the pandemic. Methods: This is a retrospective cohort analysis of all patients in a multi-hospital healthcare system in New York City who underwent hysterectomy for POP from August 19th, 2019 through August 11th, 2021. Cases were identified using procedural and diagnostic codes for hysterectomy and POP, respectively. Patients were separated into three cohorts based on dates corresponding to phases of the COVID-19 pandemic. The 'early peak' was defined from March through June 2020, coinciding with the New York State moratorium. The primary outcome was the stage of POP for patients undergoing surgery. Secondary outcomes included concomitant urogynecologic procedures, route of surgery, time from indication to procedure, length of inpatient stay, and utilization of pre-operative medical assessment/clearance (POMA). Results: A total of 253 cases were included: 106 (41.90%), 15 (5.93%), and 132 (52.17%) patients in the 'pre-pandemic','early peak pandemic', and 'stable pandemic' groups, respectively. Although not statistically significant, vaginal hysterectomy approach was performed less frequently during the 'early peak pandemic' and 'stable pandemic' cohorts (P = 0.0544). The 'early peak pandemic' cohort had significantly more stage IV POP compared to other cohorts (P = 0.0021). Rates of concomitant urogynecology procedures including slings, anterior or posterior repair, or apical repair did not differ between the cohorts. Further, cystoscopy was utilized intraoperatively more frequently in the 'stable pandemic' cohort (P = 0.0272). Time from surgical indication to operation was also significantly different with patients most frequently waiting at least 3 months in the 'early peak pandemic' group (P = 0.0132). Length of inpatient stay did not demonstrate a significant difference (P = 0.3982). The most frequent postoperative complication was transient voiding dysfunction, and this was observed more commonly in the 'stable pandemic' cohort (P = 0.0236), though overall no cases were complicated by persistent voiding dysfunction or urinary retention requiring surgical intervention in any group. Conclusions: In late spring 2020, when the moratorium was lifted, surgical volume returned to pre-peak numbers. However, time from booking to day of surgery remained significantly longer during and after the 'peak'. There was a statistically significant increase in patients with stage IV POP during the 'early peak' and 'stable' pandemic periods. There was a statistically significant increase in use of precautionary measures peri and intra-operatively during the 'peak' and 'stable pandemic' periods with significant increases in use of POMA performed outpatient by anesthesia and an increased utilization of intraoperative cystoscopy.

LIFETIME RISK OF PELVIC ORGAN PROLAPSE AND STRESS URINARY INCONTINENCE SURGERY AND TRENDS IN TYPE OF SURGERY FROM 2010 TO 2020

Introduction: In terms of the lifetime risk of pelvic organ prolapse surgery, based on data obtained from the USA covering the years 2007 - 2011 relating to a large population of adult women (over 10 million), the cumulative risk for POP surgery was 12.6% and for SUI 13.6% [1]. In the Czech Republic all inhabitants have the same mandatory health insurance. All health insurance companies have to report all data about outpatient and inpatient procedures to the National Register of Covered Health Services from the year 2010. Objective: The aim of the study was to estimate the lifetime risk of pelvic organ prolapse surgery and stress urinary incontinence in the whole population of the Czech Republic, and to assess the overall number and type of surgery provided. Methods: The analysis is based on data provided by the Institute of Health Information and Statistics of the Czech Republic (IHIS CR);these data are collected in the context of The National Health Information System (NHIS) and national health registers;the relevant data from 2010 to 2020 are available. The methodology used to establish the lifetime risk of surgery for prolapse (or incontinence) was based on data from the Czech Statistical Office estimating the probability of the woman surviving to a particular age. Results: 60,996 women underwent surgery for pelvic organ prolapse and 44,403 for SUI between 2010-2020 (at 1 January 2020 5,421,943 women were living in the Czech Republic);the average age of women undergoing surgery for POP was 64, and for SUI the mean age was 57. The most common prolapse procedure was hysterectomy (40,082), generally in combination with traditional vaginal wall repair (20,188 procedures). Similarly, the provision of traditional vaginal wall repair remained steady (overall 25,723 procedures). In the period monitored an increase in laparoscopical procedures was evident, rising by 100% from 1180 procedures in 2010 to 2009 surgeries in 2019 (in total 18727 from 2010 to 2020). The most common procedure is laparoscopically assisted vaginal hysterectomy (15268). And increase in laparoscopical sacrocolpopexis is also apparent (total 2298). The risk of reoperation for POP in women undergoing surgery between 2010 and 2015 varied between 3.3 and 4.2%. Mean lifetime risk for POP surgery for women having surgery between the years 2015 and 2020 is 14.12% (min 13.58, max 14.37%). The Covid pandemic significantly decreased the number of procedures for POP (on average on 29%). The most common anti-incontinent procedure is tension-free vaginal tape (total 44389). In terms of risk, the risk of reoperation for SUI for women having surgery between 2010 and 2015 varied between 0.2 and 0.7%. The mean lifetime risk for SUI surgery for women undergoing surgery between the years 2015 and 2020 is 6.44 (min 5.82, max 6.71) with a declining trend of anti-incontinence surgery. Conclusions: We have unique data available which covers the whole female population of the Czech Republic, indicating trends in surgical treatment of POP and SUI and making it possible to estimate lifetime risk of such surgery and also the risk of recurrent surgery.

WEB-BASED YOGA-PILATES REDUCES STRESS URINARY INCONTINENCE

Introduction: Stress urinary incontinence (SUI) occurs in part due to a weakened urethral rhabdosphincter. Yoga and Pilates are low-impact workouts that use bodyweight as resistance, and limited evidence shows these exercises improve pelvic muscle strength and decrease incontinence episodes. Objective: The study objective was to evaluate the effect of an 8-week web-based yoga-Pilates exercise program on SUI severity as measured by the International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form (ICIQ-UI SF) and secondarily to evaluate the potential mechanism of action for yoga-Pilates through ultrasound measurement of the urethral rhabdosphincter cross-sectional area (CSA). We hypothesized that yoga-Pilates would decrease SUI severity and cause hypertrophy of the urethral rhabdosphincter. Methods: This was a prospective interventional cohort study from November 2020 through September 2021. The intervention was an 8-week home yogaPilates web-based video that tracked and prompted participation. Participants with SUI underwent in-person visits pre/post-intervention during which they completed quality of life and severity surveys and underwent pelvic exam, including POP-Q, cough stress test, Brink pelvic floor strength score, and resting 3-dimensional transperineal ultrasound [1]. Ultrasound images were masked and measured post-collection. The rhabdosphincter is located in the middle third of the urethra, so 5 CSA measurements were taken: at the midpoint and then at 2.5 mm and 5 mm cranial and caudal from the midpoint [1]. The urethral CSA was determined by subtracting luminal/submucosal area from total urethral area (Figure 1). Pre/post 24-hour voiding diaries and an automated video viewing log were also collected. The study was powered to detect a mean change of 2.0 ± 4.0 ICIQ UI-SF score units and a mean CSA increase of 0.25 ± 0.6 cm2 with 48 compliant participants. All pre/post- intervention changes were analyzed using paired t-tests with a null change of zero. Results: 78 women, ages 46.6 + 10.4 years, enrolled. 60 women completed the study. The cohort was predominantly premenopausal (67%), vaginally parous (65%), and had done yoga (76%) and/or Pilates (44%) in the past. 73% of the completers performed the exercises at least 3x/week. The ICIQ-UI SF score improved from 9.5 (95% CI 8.7-10.4) to 7.1 (95% CI 6.3-7.9) post-intervention (P < 0.001). The number of incontinence episodes decreased post-intervention from 1 (IQR 1-3) to 1 (IQR 0-1) (P < 0.001). The Brink score also improved from 7.1 (95% CI 6.6-7.7) to 7.7 (95% CI 7.2-8.2) (P = 0.013). Participants were very satisfied with the online exercises. The majority (83%) of completers also reported they were “a little better”, “much better”, or “very much better” on patient global impression of improvement. There were no significant changes in urethral measurements from pre- to post-intervention. Conclusions: Although there were no changes in the urethral rhabdosphincter, this web-based yoga-Pilates exercise program improved symptoms of SUI and decreased number of incontinence episodes in women with SUI over 8 weeks. Web-based yoga-Pilates offers women with SUI a nonsurgical treatment that can be performed at home, which is beneficial in the ongoing COVID-19 pandemic.

LAPAROSCOPIC CERCLAGE SACROHYSTEROPEXY: ANATOMICAL AND SUBJECTIVE POST-OPERATIVE OUTCOMES AT 6 WEEKS

Introduction: Our group first described a novel approach for hysteropexy in 2017. This procedure utilized a combined laparoscopic and vaginal approach to place a polypropylene mesh sling around the cervicouterine junction as a cerclage and attach this mesh to the sacrum. Previous outcomes comparing this technique to laparoscopic hysterectomy and sacrocervicopexy showed equivalent anatomical and subjective outcomes with decreased suturing and intraoperative time compared to traditional sacrocervicopexy at 6 weeks, 6 months and 12 months. The procedure was refined in 2019 when vaginal attachment of the mesh was replaced with a novel laparoscopic mesh attachment technique, now referred to as total laparoscopic cerclage sacrohysteropexy (TLCSH). Objective: To assess postoperative outcomes of the novel, modified TLCSH. Methods: This was a retrospective study of patients who underwent TLCSH from February 2019 to October 2021. Chart review was performed to obtain patient demographics, baseline pelvic organ prolapse quantification (POP-Q) scores and 6- week outcome data. Anatomical success was a composite of anterior, posterior and apical success. We defined anterior and posterior compartment success as Ba and Bp ≤0, respectively. Apical success was defined as C ≤ half the total vaginal length (TVL). As a more conservative measure, we also defined success as C < -4 and C ≤ -2/3 TVL. Subjective outcomes, including patient-reported pelvic organ prolapse distress inventory (POPDI-6), patient global impression of improvement (PGI-I) and satisfaction, were also assessed at 6 weeks. Data are reported as median (interquartile range) and were compared with the Wilcoxon signed rank test. Results: A total of 117 patients underwent TLCSH and 107 (91%) had a 6- week post-operative visit at a median time of 2 months (1-2). Of patients who had a 6-week visit, 9 had a telehealth visit due to COVID-19 and did not have a POP-Q assessment, and 1 patient only had point C documented and therefore was only included in the point C analysis. Pre-operative characteristics are in Table 1. Post-operative changes for points C, Ba, Bp, and GH were significantly improved (P < 0.001 for all;Table 2). Most patients (93%) had surgical success as defined by C ≤ half TVL. Using the more restrictive definitions of apical success there was 94% success with C < -4 and 35% with C ≤ -2/3 TVL. At 6 weeks, 31% of patients were stage 0, 54% stage I, and 15% stage II. There were no mesh exposures. Subjective outcomes were available for 50 (47%) patients. While only available for a portion of patients, median POPDI-6 scores improved significantly from 30 (21-50) to 4 (0-21), P < 0.001. Most patients (85%) reported that they were “very satisfied,” 12% reported “satisfied,” 2% reported “neutral;” none reported “unsatisfied” or “very unsatisfied.” The median PGI-I score was 1 (1-2), with 1 and 2 corresponding to “very much better” and “much better,” respectively. Conclusions: TLCSH results in anatomical success, in addition to decreased POPDI-6 scores and high PGI-I scores at 6 weeks. Given this novel technique, additional follow-up time with further analysis is necessary to assess whether this procedure is a durable repair for long-term prolapse reduction and patient satisfaction. (Table Presented).

Creation and Implementation of Virtual Urogynecology Patient Cases for Medical Student Education.

Introduction: Urogynecologic disorders are highly prevalent, and many physicians across various specialties will encounter and care for patients with pelvic floor disorders. Yet most medical students have had limited to no experience in diagnosing and managing pelvic floor disorders, resulting in a gap in clinical education. Methods: Three virtual and interactive urogynecologic patient cases were developed on an e-learning platform with an overall goal of increasing clinical exposure to various pelvic floor disorders. The cases were integrated into the medical student obstetrics and gynecology clerkship during the 2020-2021 academic year (n = 40). Participants provided feedback regarding usability, acceptability, and educational value of the cases. Results: Twenty-one students (52%) completed the survey. Ninety percent (n = 19) agreed or strongly agreed that they were satisfied with the cases, and 71% (n = 15) agreed or strongly agreed that they would recommend the virtual patient cases to other students. All students (n = 21) felt that the format was easy to use and reported that the cases were appropriate for their level of learning. Most students felt that the cases increased or significantly increased their confidence regarding nonsurgical and surgical management options for pelvic floor disorders. Discussion: Our findings suggest that these interactive virtual patient cases are an acceptable, valuable, and effective tool for learners. Utilizing the cases can help mitigate existing disparities in exposure to pelvic floor disorders both highlighted by and preceding the COVID-19 pandemic.

Prolapse surgery: What are the current trends in England?

Objective: Raising concerns regarding safety of synthetic meshes have led to changes in practice (Zacche et al, 2018). In July 2018, a “pause” for vaginal mesh surgery has been introduced by NHS England. Then, the unprecedented challenge of Covid hit the urogynaecology service. We aim to provide an up-to- date report on surgical trends for women with pelvic organ prolapse (POP). Design: We retrospectively analysed data from the public domain Hospital Episode Statistics (HES) database, which contains information from NHS hospitals in England. Method: Surgical interventions are coded using the Office of Population Censuses and Surveys Surgical Operations and Procedures, Fourth Edition (OPCS-4). A report covering a financial year (from April until March) is released every year. We considered numbers for “all procedures”, which have been published since 2013. Results: Overall, annual POP procedures declined from over 30000 (between 2013 and 2017) to a nadir of 8848 (in 2020-2021). Following the vaginal mesh “pause”, admissions for sacrocolpopexy and sacrohysteropexy more than halved, with respective numbers of 1275 and 585 procedures (in 2016-2017) versus 471 and 245 (in 2019-2020). Sacrospinous fixation of vagina reduced to a lesser extent, from approximately 3000 in the years preceding the “pause” to 2630 in 2019-2020. Concomitantly, suspension of the uterus without mesh increased 2-fold, with a peak of 105 in 2018-2019, while there were small numbers (less than 30 per year) for infracoccygeal hysteropexy throughout the study period. Up to 2019-2020, no significant shifts in practice were noted for Manchester repairs and obliterative procedures, with admissions in the order of 200s and 400s, respectively. Of note, we counted nearly 140 vaginal repairs with mesh-augmentation in 2018-2019 and 2019-2020, while there was a negative trend for native tissue repairs. In fact, numbers for anterior and posterior repairs dropped from 9621 and 6000 (in 2017-2018) to 7414 and 4596 (in 2019-2020), respectively. The report for 2020-2021 highlighted an obvious decrease in admissions for all procedures during the Covid pandemic. Compared to the previous year, reduction rates ranged from 49.2% (colpocleisis) to 69.8% (sacrocolpopexy). Conclusions: Despite a “pause” for vaginal mesh surgery, admissions for alternative options including native tissue repairs have dropped. Procedures involving abdominal mesh have markedly decreased in the last few years. Interestingly, surgeons are still offering vaginal repairs with mesh-augmentation. However, we are unable to further comment on whether this was synthetic or biological. These trends may have an impact on the training of future urogynaecologists.

Gangrenous Small Bowel Due to Reposition of Procidentia in an Elderly Woman.

Gynecologists are familiar with procidentia, a severe form of pelvic organ prolapse (POP) that includes herniation of the anterior, posterior, and apical compartments of the vagina, through the introitus. Usually, women with POP present with concerns of something coming out of the vagina, heaviness, discharge through the vagina, urinary complaints, and, rarely bowel, complaints. Intestinal obstruction secondary to procidentia is a rare complication and is seldom reported in the literature. We report one such case where an elderly woman presented with the primary concerns of constipation, retention of urine, and multiple episodes of vomiting. Clinical history revealed that herniated tissue protruding outside the vaginal introitus was reposited inside the vagina two days ago. Clinical examination and investigations were suggestive of intestinal obstruction, secondary to the reposition of procidentia. Exploratory laparotomy revealed gangrene of the terminal ileum. Right hemicolectomy with ileo-colic anastomosis was done, which saved the woman's life. Reposition of the prolapsed uterus was thought to be the probable reason, leading to obstructed and gangrenous small bowel. As this case illustrates, the chronology of symptoms and signs and progression of disease should be appropriately interpreted to diagnose and manage such potentially life-threatening conditions.

Biologic Graft Augmentation of Anterior Mesh Erosion Complicated by Poor Wound Healing Secondary to Heavy Tobacco Use

(1) Background: Pelvic organ prolapse (POP) is common among post-menopausal women affecting more than 25% in their lifetime—with 11% having a lifetime risk of undergoing an operation for a POP. In April 2019, the Food and Drug Administration (FDA) took surgical mesh for transvaginal use off the market due to safety and effectiveness concerns. This leaves colporrhaphy or colporrhaphy with bio-graft options for a POP surgical repair. (2) Case: In this report, we look at a case with anterior mesh erosion complicated by poor wound healing secondary to heavy tobacco use and how it was successfully removed and augmented with a Coloplast axis allograft dermis biological graft secured with an Anchorsure sacrospinous ligament/arcus tendineus fascia pelvis fixation device and prolene suture. (3) Results: After failing two prior surgeries to rectify the mesh erosion, a final procedure was performed using a biologic dermal graft and a double-layer closure to aid in protecting and increasing the integrity of the tissue. (4) Conclusions: Collectively, the patient and her surgeries highlight the difficult nature of complete mesh removal and how tobacco use can significantly affect the proper healing of surgical sites. The number of surgeries necessary to address the patient’s chief complaint and the resolution of her symptoms with the biologic graft supports the challenges one faces with mesh removal and poor wound healing secondary to tobacco use. This case illustrates that complicated transvaginal mesh erosion should initially be augmented with a biologic dermal graft secured via sacrospinous ligament/arcus tendineus fascia pelvis fixation and double-layer closure and not only if visible mesh removal alone fails.

Translating the Pelvic Organ Prolapse Score into Samoan using a modified back translation methodology.

BACKGROUND: Although Samoan women have a high prevalence of obesity and multiple parity which are risk factors of pelvic organ prolapse, there is no prevalence data on this condition. AIMS: Translate the Pelvic Organ Prolapse-Symptoms Score (POP-SS) from English into Samoan, MATERIALS AND METHODS: Standardised methods for translating questionnaires, individual face to face audio-recorded interviews in which women completed the POP-SS using a Think Aloud method, analysis using a Framework approach. RESULTS: The POP-SS was successfully translated in to Samoan, an additional information leaflet was developed to support women's understanding of what prolapse is, 14 Samoan women were recruited of which 13 were interviewed and completed the POP-SS, results of POP-SS (scores), results of think aloud, results in terms of research experience. CONCLUSIONS: A Samoan version of the POP-SS is now available for further evaluation of its psychometric properties prior to wider use. The team continue to collaborate on their work on establishing the prevalence of prolapse whilst building local research capacity.

British Society of Urogynaecology Abstracts: Annual Research Meeting 2020

The proceedings contain 10 papers. The topics discussed include: are synthetic mesh mid-urethral slings (MUS) for treatment of stress urinary incontinence a risk factor for autoimmune diseases?;patient experience of virtual urogynecology services during Covid-19 pandemic;hysterectomy or hysteropexy? long term follow-up from a randomized controlled trial;episiotomy with operative vaginal delivery and the prevention of obstetric anal sphincter injury (OASI): a systematic review and meta-analysis;sexual function in BPS/IC - a systematic review and meta-analysis of the literature;a systematic review of English language patient-reported outcome measures for use in urogynecology and female pelvic medicine;pregnancy and female sexual function;and comprehensive systematic review of patient reported outcome measures (PROMs) used in women with pelvic organ prolapse (POP).

Pelvic health physiotherapy delivered via telehealth for patients presenting with pelvic organ prolapse and urinary incontinence

Keywords: Pelvic Health Physiotherapy, Telehealth, Service Delivery Purpose: During COVID-19 pelvic health physiotherapy had to change the delivery mode of their appointments to primarily telehealth provision compared to the previous service delivery of all face to face appointments. It was perceived that telehealth would provide equitable results in symptom improvement as measured by the Clinical Global Improvement Scale (CGIS) on discharge via this assessment and treatment method, this is despite not being able to perform an objective assessment of the pelvic floor muscle as would be done in previous service delivery. The aim of the service evaluation was to identify if pelvic health physiotherapy was as affective via telehealth as previous service delivery for patients referred with Urinary Incontinence (UI) and Pelvic Organ Prolapse (POP). Methods: Patients were included if they had only received physiotherapy via telehealth from the 1st April 2020 and were referred with POP or UI. On discharge between September 1st 2020 and March 31st 2021 patients were verbally asked the CGIS which requests people to rate their improvement on a 7 point scale from “very much better” to “very much worse”. The data was collated and compared against results of the CGIS obtained during a previous audit in 2019/2020 for patients presenting with POP and UI. Descriptive statistics were used to analyse the data. Results: There were a total of 118 that fitted the inclusion criteria. The mean number of appointments was 6.9 compared to 3.3 appointments with previous service delivery. There were 29% of patients who reported that they were “very much improved” following treatment via telehealth compared to 42% with previous service delivery. 30% of patients reported that they had “minimal” or “no improvement” from physiotherapy via telehealth compared 19% with previous service delivery. Conclusion(s): Whilst there is a proportion of patients that found telehealth beneficial for the treatment of UI and POP, data shows in comparison to previous service delivery that less patients reported that they were very much better from physiotherapy and more patients reported that they had minimal improvement or no improvement with a telehealth predominant service. Telehealth was also deemed to be less efficient with on average patients required twice the number of appointments compared to previous service delivery. With physiotherapy being the recommended first line management for patients presenting with UI and POP (Nice Guideline 123) it cannot be recommended that this is delivered predominantly via telehealth. Impact: With redevelopment of service delivery in a post COVID environment it must be taken into consideration that for patients presenting with POP and UI that being able to perform a comprehensive objective assessment may influence the outcome of patient treatment. There is a percentage of patients that responded well to treatment via telehealth and the option to provide this method of service delivery is important to maintain and can be part of the shared decision making process. However the results of the service evaluation show that patients perceptions of symptom improvement as measured via the CGIS with pelvic health physiotherapy via telehealth is not as effective as previous service delivery. Funding acknowledgements: No funding was provided to complete this service evaluation

Uterine preservation in pelvic organ prolapse and urinary stress incontinence using robot-assisted laparoscopic surgery. Case report.

INTRODUCTION: To report a case of uterine preservation in pelvic organ prolapse robot-assisted laparoscopic surgery. PRESENTATION OF CASE: The patient is a 42-year old Caucasian woman with pelvic organ prolapse. She previously had undergone a pelvic floor reconstruction with vaginal surgical approach, she had suffered from anorexia nervosa and she had two childbirths with vaginal deliveries. The woman was treated with robotic-assisted laparoscopic sacrohysteropexy and retropubic colposuspension. DISCUSSION: Data suggest that abdominal surgery, typically with an abdominal sacralcolpopexy, provides better objective anatomic outcomes, than vaginal procedures, despite the longer operating times and grater delay in the resumption of activities which can be mitigated by the use of laparoscopic or robotic surgery. Several studies about vaginal approaches suggest that uterus-preserving surgery with vaginal procedures have similar success rates, less blood loss and shorter surgical time compared with hysterectomy. A multicenter study compared laparoscopic sacrohysteropexy with vaginal mesh hysteropexy reported similar one-year cure rates, improvement in pelvic floor symptoms, improvement in sexual function, and satisfaction rates. CONCLUSION: We found robotic-assisted laparoscopic sacrohysteropexy to be a feasible and successful procedure. Combining robotic retropubic colposuspension to sacrohysteropexy is a safe and efficient approach for the treatment of stress urinary incontinence. Further studies are needed to define the standard surgical steps and confirm the efficacy and the advantages of this procedure.

Female Pelvic Floor Dysfunction Continues to Negatively Impact Quality-of-Life during the COVID-19 Lockdown.

The COVID-19 pandemic led to dramatical changes in elective medical care. We analysed its impact on patients with female pelvic floor dysfunction during the 6 weeks of lockdown in Austria. A cross-sectional study was conducted: All 99 women who presented at the urogynaecologic outpatient clinic of the Medical University of Vienna with pelvic organ prolapse (POP) or urinary incontinence (UI) from December 2019 up to the lockdown in March 2020 were included and contacted. 97% of these women (96 participants) agreed to participate in the survey conducted to asses pelvic floor related quality of life (QoL) through telephone- interrogation. The mean age was 59 ± 14.8 years, the POP group consisted of 42 women while the UI group included 54 women. Most participants (83% of POP and 81% of UI cases) stated that their female pelvic floor dysfunction had remained equally relevant or had become even more significant during the lockdown. Associated symptoms and psychological strain also maintained their relevance during the lockdown (UI: p = 0.229; POP: p = 0.234). Furthermore, 97% of all interviewed women indicated to be strongly willing to continue their treatment. A generalised linear model regression revealed no clinical or demographic risk factors for psychological strain during the lockdown (p > 0.05). Our results demonstrate that women's QoL remains significantly impaired by their pelvic-floor disorders even during a worldwide crisis such as COVID-19. Therefore, elective disciplines such as urogynaecology urgently require novel and innovative strategies for continued patient care even in times of a lockdown.

Extensive impact of COVID-19 pandemic on pelvic floor dysfunctions care: A nationwide interdisciplinary survey.

AIMS: To investigate the impact of COVID-19 pandemic on health-care provision to patients suffering from pelvic floor dysfunctions in Italy. METHODS: A retrospective web-based interdisciplinary survey was mailed by the Italian Society of Urodynamics to members involved in pelvic floor dysfunctions management from June 22, 2020 to July 17, 2020. The 84-item questionnaire investigated the period March-June 2020 (first epidemic wave) and showed high content validity. The primary outcome was the mean rate of cancellation for health-care services. Secondary outcomes included estimation of the accumulated surgeries backload until return to baseline activity and of the recovery pattern, using linear regression and scenario-based forecasting. RESULTS: A total of 85 participants provided complete responses. Respondents were mostly urologists (47%), followed by gynecologists (29.5%) and physiatrists (17.6%). On average, 78.4% of outpatient services and 82.7% of functional surgeries were canceled, without significant differences by geographical distribution. An impact on patients' quality of life was anticipated by most of the respondents (87%) and 48.2% also reported potentially serious health risks for patients. Thirty-three percent of the respondents reported the use of telemedicine. If the nation-wide surgical activity increases by 20% postpandemic, it would take 37 months to clear the backlog of functional surgeries. We acknowledge the inherent limitations of the survey methodology and retrospective design. CONCLUSIONS: Access to care for patients suffering from pelvic floor dysfunctions has been dramatically affected by the COVID-19 outbreak. The indirect effects of this unprecedented disruption on pelvic floor dysfunctions care may last for several months.