Uterovesical fistula and its treatment in Sub-Saharan Africa.

AIM: Aim of the study to summarize the current information on diagnostic and treatment options for uterovesical fistula as a consequence of iatrogenic complication. Methods: Literature review of available information on surgical treatment options for uterovesical fistula resulting from previous caesarean section and comparison with our own experience in the developing world. Conclusion: Uterovesical fistula is an abnormal communication between the bladder and uterus. The cause of this pathology in most cases is an iatrogenic complication, most commonly arising after a caesarean section. The incidence of this pathology varies significantly geographically. In developed countries, these fistulas are rather rare. On the other hand, in developing countries, uterovesical fistulas are more common with a significant impact on the subsequent life of the patient due to generally inaccessible health care.

Risk Factors for the Anal and Oral Human Papillomavirus (HPV) Infections among Women with Severe Cervical Lesions: A Prospective Case-Control Study.

The carcinogenicity of HPV infection in the anogenital and oropharyngeal regions is broadly accepted. The aim of the study was to define risk factors for anal and oral HPV infections in high-risk patients with biopsy-proven severe cervical lesions (CIN2+). Altogether immunocompetent 473 females with CIN2+ were categorized into the study group and another 245 women into the control group. The strongest risk factor for anal HPV infection was the presence of cervical HPV infection (p < 0.001). Furthermore, ten or more lifetime sexual partners (p = 0.013), a sexual non-coital contact with the anal area (p < 0.001), and actively practicing anal-penetrative intercourse (p < 0.001) were significantly associated with anal HPV. A history of genital warts in the woman (p = 0.010) and the presence of genital warts in the male partner (p = 0.029) were found statistically significant for the risk of oral HPV infection. Our data suggest that the presence of HPV infection, especially high-risk genotypes, in one anatomical site poses the greatest risk for HPV infection in another anatomical site. The cervix is the main reservoir of infection, but the risk factors for anal and oral HPV infections are dissimilar according to different anatomical distances and more complex routes of transmission.

Implementation of the ERAS protocol in gynecology and oncogynecology - evaluation of a pilot study.

OBJECTIVE: To describe the implementation process and evaluate the success of compliance with the recommended ERAS protocol in the Czech healthcare system. METHODS: The study included 163 patients from March to September 2022, a total of 7 months. Patients were divided into three groups according to the type of surgery. Clinical protocol: Oncogynecology, hysterectomy and laparoscopy. The implementation was realized in three phases (preparation, implementation of the protocol itself and evaluation). RESULTS AND CONCLUSIONS: The cumulative adherence rate was 90% or more in all three groups. Based on the pilot results at our department, we evaluated the ERAS concept as a well-implemented tool for gynaecological departments in the Czech healthcare system.

Experiences in the reconstruction of untreated severe obstetrical injuries including anal sphincter injuries.

OBJECTIVE: Summarize information on reconstruction possibilities of extensive obstetrical injuries including anal sphincter injuries. METHODS: Review of available information on the possibilities of reconstruction of severe obstetrical injuries including anal sphincter and comparison with own results in the developing countries. CONCLUSION: Extensive obstetrical injuries of the perineum are major problem that require adequate and early treatment. In the developing countries, perineum dehiscence and the subsequent development of anal incontinence occur much more often. Even after several years, however, there is hope for an improvement in the condition if an adequate suture is performed.

When to assess residual anal sphincter defect after OASI by ultrasound.

OBJECTIVES: Obstetrical anal sphincter injuries (OASIS) are complications of vaginal delivery. Unrepaired anal sphincter after delivery increases the risk of anal incontinence. The aim of our study is to search for residual defect after OASI repair by 4D introital ultrasound (US). We hypothesised that imaging prior to hospital discharge would show the same number of defects as assessment at 3 months. STUDY DESIGN: This is a retrospective analysis of 138 patients with immediate repair after OASIS. Since 2009, we have been routinely inviting all our patients with OASIS to the perineal clinic for postoperative follow-up. We scheduled the first visit before discharge from hospital and followed up with a second visit after three months. During both visits, patients underwent transperineal 4D ultrasound examination. We provided examination while at rest and during contraction; volumes were saved for further evaluation. RESULTS: Eighty-one patients (58.7%) completed both exams and were included in the analysis. Residual external anal sphincter defect was found in 17.3% at the first visit versus 13.6% at the second (delayed) visit. We were not able to assess the sphincter in 9.9% at early versus none in the delayed examination. In 9.9%, the residual defect was not confirmed by the second examination, and in 4.9% the residual defect was missed by the first examination. CONCLUSIONS: In conclusion, we have found that a 3 month scan yields a smaller number of defects than a scan before discharge.

Fluidothorax as an atypical symptom of late ovarian hyperstimulation syndrome.

OBJECTIVE: To present a case of isolated fluidothorax as a symptom of atypical late ovarian hyperstimulation syndrome. METHODS: Review of available information and presentation of our case observed at the Department of Obstetrics and Gynaecology, 1st Faculty of Medicine, Charles University and University Hospital Bulovka. GnRH antagonist protocol was used to stimulate the patient and fresh embryo transfer was performed. Sixteenth day after the oocyte retrieval the patient was examined due to dyspnoea and lab exam proved ovarian hyperstimulation syndrome. CONCLUSION: Late ovarian hyperstimulation syndrome can lead to isolated fluidothorax in case of additional favourable conditions.

Impact of residual defect of anal sphincter on patients quality of life

AIM: The aim of this retrospective study is to correlate the presence of residual anal sphincter defect with the quality of life of patients after vaginal delivery complicated with obstetrical anal sphincter injury. STUDY GROUP AND METHODS: Patients diagnosed with obstetrical anal sphincter injury are dispensed at our urogynecological unit, with a mean follow-up period of 37 months. Two investigators blinded to the results of clinical symptoms evaluated archived ultrasound volumes taken for the presence of residual anal sphincter defects that were later correlated with the St. Mark's Incontinence Score. RESULTS: The group comprises of 181 patients diagnosed with an obstetrical anal sphincter injury who underwent ultrasound examination of anal sphincter at three post-partum months. The questionnaires were completed by 118 patients (65.2% of all patients). A residual sphincter defect was diagnosed in seven cases (5.9%). In the group with residual defects, fecal urgency (lack of ability to defer defecation) was present in 57.1%. In the group without residual anal sphincter defects, fecal urgency was present in 12.6%. This difference is significant (< 0.001) with the contingency coefficient 0.291. CONCLUSIONS: In conclusion, the presence of residual anal sphincter defect increases the probability of fecal urgency.

Current possibilities in the prevention and therapy of ovarian hyperstimulation syndrome.

OBJECTIVE: To present current possibilities of the prevention and therapy of ovarian hyperstimulation syndrome (OHSS). METHODS: Literature and guidelines were researched. RESULTS: From the view of safety and prevention of OHSS, antagonistic protocol is suitable. Patients with syndrome of polycystic ovaries benefit from the use of metformin or letrozole that can be sufficient to induce ovulation. As a treatment of imminent OHSS, it is recommended to administer 0.5 mg of cabergoline per os daily as well as low molecular weight heparin subcutaneously in prophylactic dose and to maintain sufficient fluid intake. Diuretics are strongly discouraged to use. To maintain intravascular volume, drained ascites can be reintroduced. CONCLUSION: We present a review of current literature and recommendations.

Covid-19 as a possible risk factor of intrauterine fetal death.

OBJECTIVE: To summarize information about possible effects of covid-19 on intrauterine fetal death and present three cases of intrauterine fetal death in women with recent covid-19 infection. METHODS: Review of available information about pregnancy with covid-19 and comparison with own observation of cases during spring 2021. CONCLUSION: Covid-19 influences risk of intrauterine fetal death, preeclampsia/eclampsia or HELLP syndrome. Coagulation changes and drop of platelets is considered as one of the causes of intrauterine fetal death due to fetal vascular malperfusion.

What is the optimal length for single-incision tape?

INTRODUCTION AND HYPOTHESIS: The aim of this study was to assess the length of adjustable single-incision midurethral tape (SIMS; Ajust), which is needed to fix this tape to the obturator membrane. From these data, we can deduce the optimal length of the SIMS. METHODS: For this study, we employed the intra-operative data of patients included in a single-center randomized trial comparing the efficacy of Tension free vaginal tape obturator (TVT-O) and Ajust. The length of the Ajust tape was calculated using the formula: total length of the tape minus the length of the stylet used for the tape lock, minus the length of the lock minus the width of the two anchors. The length of the obturator tape was calculated using the formula: total tape length minus the snipped parts of the tape. The correlation coefficient of the tape length to basic biometric parameters, such as height, weight, and body mass index, was calculated. RESULTS: For this study, data from 50 women from each group, TVT-O and Ajust, were used. The mean length of the Ajust tape inside the body is 11.6 cm (SD 0.9), with a minimum length of 9.6 cm and a maximum length of 14.6 cm. The mean length of TVT-O tape inside the body is 20.3 cm (SD 2.1), with a minimum of 14.8 cm and a maximum length of 24.5 cm. CONCLUSIONS: This study demonstrates that to achieve continence it is necessary to use different lengths of single-incision tape. Inappropriate SIMS length could cause failure related to the tape itself and not to the TVT technique.

Are the same tapes really the same? Ultrasound study of laser-cut and mechanically cut TVT-O post-operative behavior.

INTRODUCTION AND HYPOTHESIS: TVT-O production has been modified to laser cutting from mechanical cutting. We compared the behavior of laser and mechanically cut tension-free vaginal tape-obturator (TVT-O) using ultrasound at various time points after surgery. METHODS: This is a retrospective analysis of clinical and ultrasound data from two previously reported randomized controlled trials with TVT-O. Behavior of mechanically cut TVT-O implanted in January 2007 to November 2009 and laser-cut TVT-O implanted in May 2010 to May 2012 was assessed by ultrasound at day 1, the 2nd week, the 3rd month, and the 1st and 2nd years post-operatively. Bladder neck and tape margins positions were described by coordinates in the orthogonal system calculated from polar coordinates. Tape mobility was measured as a change in the upper and lower tape margin position from rest to maximal Valsalva. Comparison of 2-year subjective and objective surgery outcomes was also performed. RESULTS: In total, 68 mechanically cut and 50 laser-cut TVT-Os were implanted. Follow-up data were available from 49 and 45 women respectively. No differences in any baseline characteristics or bladder neck mobility were observed. Significantly lower tape mobility was observed on day 1 and week 2 after mechanically cut TVT-O, although subsequent mobility was comparable to laser-cut TVT-O. The subjective and objective surgery outcomes were comparable. CONCLUSIONS: Although without clinical significance, early postoperative behavior of the mechanically cut and laser-cut TVT-O tapes differs. The less stiff, mechanically-cut TVT-O loosens within 2 weeks of implantation, whereas the stiffer, laser-cut TVT-O keeps its tension.

Comparison of the efficacy of tension-free vaginal tape obturator (TVT-O) and single-incision tension-free vaginal tape (Ajust™) in the treatment of female stress urinary incontinence: a 1-year follow-up randomized trial.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to compare the efficacy of the tension-free vaginal tape obturator (TVT-O) and single-incision tension-free vaginal tape (Ajust™) in the treatment of stress urinary incontinence in a randomized two-arm study with a 1-year follow-up. METHODS: This single-centre randomized trial compared the objective and subjective cure rates of TVT-O and Ajust using objective criteria (cough test) and subjective criteria (International Consultation on Incontinence Questionnaire short form, ICIQ-UI SF). The objective cure rate was defined as the number of patients with a negative cough stress test. Subjective cure was defined as no stress leakage of urine after surgery based on the ICIQ-UI SF. The primary outcome was to establish differences in objective and subjective cure rates between the TVT-O and Ajust groups. We also compared postoperative pain profiles using a visual analogue scale (VAS), improvement in quality of life using the ICIQ- UI SF and the Incontinence Quality of Life questionnaire, and overall satisfaction with the surgical procedure using a VAS and a five-item Likert scale. Inclusion criteria were age over 18 years, signed informed consent, and urodynamic stress urinary incontinence. Following a power calculation, 50 patients were enrolled into each group (Ajust and TVT-O). RESULTS: The mean follow-up after surgery was 445 days (SD 157.6 days) in the TVT-O group and 451.8 days (SD 127.6 days) in the Ajust group (p = 76.6 %). At 1 year, 47 patients were evaluated in the TVT-O group and 49 in the Ajust group. No differences in subjective cure rates or objective cure rates were observed. In the Ajust and TVT-O groups, the rates for no subjective stress leakage were 89.8 % and 91.5 %, respectively (p = 1.0, OR 1.22, 95 % CI 0.24 - 6.58), and the rates for a negative stress test were 89.8 % and 87.2 %, respectively (p = 0.76, OR 0.77, 95 % CI 0.17 - 3.32). In the Ajust group two patients reported de novo pain during sexual intercourse. CONCLUSIONS: After a 1-year-follow-up, no significant differences were found with regard to subjective and objective outcomes between the single-incision tape Ajust and TVT-O.

TVT ABBREVO: cadaveric study of tape position in foramen obturatum and adductor region.

INTRODUCTION AND HYPOTHESIS: The aim of the study was to describe fixation of the TVT ABBREVO and establish whether the tape penetrates through obturator muscles and membrane (obturator complex) into the adductor region and, if so, how far it penetrates. METHODS: Eight formalin-embalmed female cadavers were used to simulate TVT ABBREVO surgery (totalling 16 insertions). Following tape insertion, dissection was performed and ends of the tape were identified. In cases of penetration, the length of tape penetrating into the adductor region was measured. RESULTS: Of the 16 cases, the tape ended in the obturator membrane in eight, in the internal obturator muscle in one, and penetrated through the obturator membrane into the external obturator muscle in five, where it remained. In two cases, it penetrated through the obturator internus muscle, obturator membrane and obturator externus muscle into the group of thigh adductors; one penetration was by 3 mm and the second by 10 mm. No contact with the obturator nerve or its branches was noted in any case. CONCLUSIONS: No TVT contact with the obturator nerve was noted; tape penetrated into the adductor region in two of the 16 cases.

Fixation of the Ajust minisling based upon cadaveric study.

INTRODUCTION AND HYPOTHESIS: The objective was to describe the fixation site of the anchor of the Ajust mid-urethral minisling. METHODS: This cadaveric study was based on a group of 11 formalin-embalmed bodies with legs positioned in 30° flexion and 30° abduction, and a group of five fresh-frozen bodies with legs positioned as normal during the procedure. The groups were later compared. The fixation site was dissected and described. The distance to the obturator bundle was considered as the primary safety parameter. To compare the groups of fresh-frozen bodies and formalin-embalmed bodies, the Student's t test and Mann-Whitney test were used. RESULTS: In the group of formalin-embalmed bodies the mean distance from the anchoring device to the obturator nerve was 4.23 cm. In 19 cases out of 22 the anchor was within the complex of the obturator membrane and obturator muscles. In the group of fresh frozen bodies the mean distance to the obturator nerve was 3.15 cm. In 9 cases out of 10 the anchor was in the complex of the obturator membrane and obturator muscles. CONCLUSION: The distance from the anchor to the obturator nerve was more than 2 cm in all cases. Correct placement in the obturator membrane was achieved in 65.6 % of cases. In 87.5 % of cases the anchor was placed within the complex of obturator membrane and obturator muscles.

Women's quality of life and sexual function after transvaginal anterior repair with mesh insertion.

OBJECTIVE: Current evidence about the impact of pelvic floor surgery on sexual function is conflicting. Only a few studies have reported with validated questionnaires on sexual function after transvaginal mesh repair, with a discrepancy in reported outcomes. The aim of this study was to prospectively explore the impact of anterior repair (AR) with mesh insertion on sexual function, quality of life and dyspareunia. STUDY DESIGN: 69 women with symptomatic stage II or greater prolapse exclusively of the anterior compartment participated in a prospective study on safety and efficacy of two mesh implantation techniques for anterior vaginal wall prolapse repair between September 2007 and May 2009. They were invited to complete the validated condition-specific short form of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) and quality of life (QoL) questionnaires (Pelvic Organ Prolapse (POP) Distress Inventory (POPDI), Urinary Distress Inventory (UDI), POP Impact Questionnaire (POPIQ), and Urinary Impact Questionnaire (UIQ)) pre-operatively and 6 months post-operatively. All data were processed and analyzed in Statistical Computing Environment R, version 2.9.1. RESULTS: A significant decrease of Qol scores and a significant increase of PISQ-12 scores occurred after surgery. All sexually active women resumed sexual activity postoperatively. The majority of non-sexually active women remained sexually inactive. Postoperatively the frequency of pain during intercourse increased in 31% of cases and decreased or stayed unchanged in 69% of cases. The incidence of de novo dyspareunia after mesh repair was 4% while the incidence of dyspareunia slightly increased from 25% to 29% postoperatively. CONCLUSIONS: The results of this study suggest no deterioration in sexual function, a significant improvement in quality of life and a low incidence of de novo dyspareunia six months after AR with mesh insertion. Despite these findings, the majority of non-sexually active women remain sexually inactive postoperatively. These conclusions should be confirmed in a longer follow-up.

Variation of distances from mid-urethra to the obturator foramen: an MRI study.

INTRODUCTION AND HYPOTHESIS: To estimate distances from the mid-urethra to the obturator foramina and to explore correlations between pelvic dimensions and body height. METHODS: This is a secondary analysis of a parent case-control study on the mechanisms of stress urinary incontinence. We measured pelvic dimensions on magnetic resonance images of women with (cases, n = 50) and without (controls, n = 50) stress urinary incontinence. RESULTS: The mean distance from mid-urethra to the obturator membrane among cases is 31.8 mm (left) and 32.1 mm (right), with a range from 25.9 to 42.0 mm. There were no significant differences in these distances when comparing left with right, or cases with controls. Weak correlation was found between the urethra-to-obturator foramina distances and heights only in the case subjects. CONCLUSION: There is high variability in the distance from mid-urethra to the obturator foramina. Height should not be used as a predictor of dimensions in the lesser pelvis.

Sacrospinous ligaments anterior apical anchoring for needle-guided mesh is a safe option: a cadaveric study.

OBJECTIVE: To evaluate the feasibility and safety of using the sacro-spinous ligament (SSL) as a fixation point for anterior-apical pelvic floor compartment mesh implants. The apical support achieved with the sacro-spinous ligament mesh fixation is considered adequate, as it provides a high and stronger anchoring point. Even though, meshes for anterior pelvic floor reconstruction are traditionally anchored to the arcus tendineous fascia pelvis (ATFP). The authors presumed that fixing the anterior mesh to the sacro-spinous ligament instead of the ATFP is both feasible and safe. The present study evaluated the anatomical aspects and relations of a modified tissue passage with sacro-spinous fixation of the anterior apical mesh arms. METHODS: In 5 embalmed female cadavers and 1 fresh female cadaver, the apical arms of the anterior needle-guided mesh were placed through the SSLs rather than through the ATFP, using a transgluteal approach. The distances between the mesh arms and the ureters and uterine arteries were measured. RESULTS: The minimal final distance between the mesh arms and the ureters or uterine arteries was 1.5 cm in the embalmed cadavers, but only 5 mm in the fresh cadaver. However, when analyzing the procedure carefully, it was noted that during dissection the ureters and arteries were pushed medially by the surgeon's finger, thus the operative procedure did not entail any real risk of injury to these structures. The introduced surgical needle caused no trauma to any adjacent cadaveric organs. CONCLUSIONS: Anterior pelvic floor meshes may be safely anchored to the SSL, thus potentially improving the apical support.

Randomized trial of a comparison of the efficacy of TVT-O and single-incision tape TVT SECUR systems in the treatment of stress urinary incontinent women--2-year follow-up.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to compare the efficacy of the use of tension-free vaginal tape obturator (TVT-O) and single-incision TVT SECUR, hammock and U approach (TVT-S, H and U), in the treatment of urodynamic stress urinary incontinence (SUI). METHODS: This single-center randomized three-arm trial compared the objective and subjective efficacy and early failure rate of the TVT-O and TVT-S H and U approach by objective criteria (cough test) and subjective criteria using the International Consultation on Incontinence Questionnaire--Short Form (ICIQ-UI SF). The objective efficacy rate was defined as the number of patients with a negative cough stress test. Subjective cure was defined by no stress leakage of urine after surgery based on the evaluation of ICIQ-UI SH (when patients ticked "Never"/"Urine does not leak" in answer to question 6: When does urine leak?). Objective and subjective efficacy were evaluated using Last Failure Carried Forward analysis, i.e., final analysis also included patients with early failure. To describe outcome at different time points, the Last Observation Carried Forward method was also implemented. RESULTS: One hundred ninety-seven women with proven SUI were randomized into three groups--TVT-O (n = 68), TVT-S H (n = 64), and TVT-S U (n = 65). Each patient allocated to a treatment group received the planned surgery. There were no differences in each group in preoperative characteristics. Median follow-up after surgery was 2 years (SD, 0.8; range, 0.1 to 3.8 years). Of the subjects, 92.6% in the TVT-O group, 68.8% in the TVT-S H group, and 69.2% in the TVT-S U group had negative stress test (p < 0.001). Of the subjects, 85.3 % in the TVT-O group, 68.8% in the TVT-S H group, and 61.5% in the TVT-S U group were subjectively continent (p = 0.02). CONCLUSIONS: Our study demonstrated a significantly lower subjective and objective cure rate in the single-incision TVT group compared to the TVT-O group.

Pudendal neuralgia following transobturator inside-out tape procedure (TVT-O)--case report and anatomical study.

Persistent pain after TVT-O procedure is a rare complication. Nerve injuries have been suspected as a cause of persistent pain. We present one case of atypical postoperative pain--pudendal neuralgia following TVT-O procedure--which persisted 3 years after the primary procedure. The patient required surgical removal of the tape, which brought only partial relief. Complete relief from pain was afterwards achieved with repeated local applications of anesthetics with corticosteroids. The recurrent stress urinary incontinence was treated with retropubic TVT. Pudendal nerve irritation was also described after retropubic sling procedure, and the cadaveric dissection indicated the theoretic possibility of nerve injury during retropubic sling procedure. To explain the mechanism of nerve injury, we performed cadaveric dissections on a formalin-embalmed female body. We were able to demonstrate the contact of the needle with the pudendal nerve after aberrant passage of the inserter.

Ultrasound appearances after mesh implantation--evidence of mesh contraction or folding?

INTRODUCTION AND HYPOTHESIS: Polypropylene meshes are frequently used in abdominal and vaginal reconstructive surgery. Recently, several authors have claimed that mesh-associated complications may be linked to mesh shrinkage. We have performed a prospective study with postoperative follow-up by ultrasound examination at two time points after Prolift anterior implantation to assess changes in the ultrasound appearance of mesh implants over time. METHODS: We assessed 36 patients who had undergone mesh implantation with Prolift anterior mesh for the correction of symptomatic anterior vaginal wall prolapse. During the surgery, we measured the actual midline length of the mesh (initial length). On the fourth postoperative day, we performed a vaginal ultrasound examination (US) to measure mesh length in the midsagittal plane. A second US was performed 3-5 months after surgery to repeat this measurement. RESULTS: There was a significant difference in mesh length determined before and 4 days after surgery (90.3 vs. 57.1 mm, P = <0.0001) indicating intraoperative folding. On comparing early and late postoperative ultrasound measurements, there was a reduction in length from 57.1 to 48.3 mm (P < 0.0001), indicating possible shrinkage or retraction. CONCLUSIONS: Intraoperative folding seems to be responsible for a large part of the difference between preoperative (in vitro) and postoperative (US) measurements of mesh dimensions, suggesting that surgical techniques may require adjustment.