Long-term outcome after routine surgery for pelvic organ prolapse-A national register-based cohort study.

INTRODUCTION AND HYPOTHESIS: Pelvic organ prolapse (POP) is common, and women have an estimated 12-19% lifetime risk for needing POP surgery. Aims were to measure re-operation rates up to 10 years after POP surgery and patient-reported outcomes (PROMs) 5 years after a first-time operation for POP. METHODS: This is a cohort study using the Swedish National Quality Register for Gynaecological Surgery (GynOp). We retrieved information from 32,086 POP-operated women up to 10 years later. After validation, a web-based PROM questionnaire was sent to 4380 women who 5 years previously had standard POP surgery. Main outcome measures were reoperations due to a relapse of prolapse and PROMs 5 years after the primary operation. RESULTS: Among women operated for all types of POP, 11% had re-operations 5 years later and an additional 4% 10 years later, with similar frequencies for various compartments/types of surgery. PROMs yielded a 75% response rate after 5 years. Cure rate was 68% for anterior, 70% for posterior, and 74% for combined anterior-posterior native repairs. Patient satisfaction exceeded 70%, and symptom reduction was still significant after 5 years (p < 0.0001). CONCLUSIONS: Following primary prolapse surgery, re-operation rates are low, even after 10 years. A web-based survey for follow-up of PROMs after POP surgery is feasible and yields a high response rate after 5 years. The subjective cure rate after primary POP operations is high, with reduced symptoms and satisfied patients regardless of compartment. Standard prolapse surgery with native tissue repair produces satisfactory long-term results.

The tension-free vaginal tape operation: Is the inexperienced surgeon a risk factor? Learning curve and Swedish quality reference.

INTRODUCTION: To reduce the risk of avoidable damage to the patient when training surgeons, one must predefine what standards to achieve, as well as supervise and monitor trainees' performance. The aim of this study is to establish a quality reference, to devise comprehensive tension-free vaginal tape (TVT) learning curves and to compare trainees' results to our quality reference. MATERIAL AND METHODS: Using the Swedish National Quality Register for Gynecologic Surgery, we devised TVT learning curves for all Swedish TVT trainees from 2009 to 2017, covering their first 50 operations. These outcomes were compared with the results of Sweden's most experienced TVT surgeons for 14 quality variables. RESULTS: In all, 163 trainees performed 2804 operations and 40 experienced surgeons performed 3482 operations. For our primary outcomes - perioperative bladder perforations and urinary continence after 1 year - as well as re-admission, re-operation and days to all daily living activities, there was no statistically significant difference between trainees and experienced surgeons at any time. For the first 10 trainee operations only, there were small differences in favor of the experienced surgeons: patient-reported minor complications after discharge (14% vs 18.4%, P = .002), 1-year patient-reported improvement (95.9% vs 91.8%, P < .000), and patient satisfaction (90.9% vs 86.2%, P = .002). For both trainee operations 1-10 and 11-50, compared with experienced surgeons, operation time (33.8 vs 22.2 min, P < .000; 28.3 vs 22.2 min, P < .000) and hospital stay time (0.16 vs 0.06 days, P < .001; 0.1 vs 0.06 days, P < .001) were longer, perioperative blood loss was higher (27.7 vs 24.4 mL, P = .001; 26.5 vs 24.4 mL, P = .004), and patient-reported catheterization within 8 weeks was higher (3.9% vs 1.8%, P < .000; 2.5% vs 1.8%, P = .001). One-year voiding difficulties for trainee patients (operations 1-10:14.2%, P = .260; operations 11-50:14.5%, P = .126) were comparable to the experienced surgeons (12.4%). CONCLUSIONS: There is a learning curve for several secondary outcomes but the small effect size makes it improbable that the difference has clinical significance. Our national Swedish results show that it is possible to train new TVT surgeons without exposing patients to noteworthy extra risk and achieve results which are equivalent to the most experienced Swedish surgeons.

Smoking cessation prior to gynecological surgery-A registry-based randomized trial.

INTRODUCTION: Smoking cessation, both pre- and postoperatively, is important to reduce complications associated with surgery. Identifying feasible and effective means of alerting the patient before surgery to the importance of perioperative smoking cessation is a challenge to healthcare systems. MATERIAL AND METHODS: A randomized registry-based trial using the web-version of the Swedish national quality register for gynecological surgery, GynOp, was performed (ClinicalTrials.gov NCT03942146). Current smokers scheduled for gynecological surgery were randomly assigned before surgery to group 1 (control group, no specific information), group 2 (web-based written information), group 3 (information to doctor that the woman was a smoker and should be recommended smoking cessation or group 4 (a combination of groups 2 and 3). Perioperative smoking habits were evaluated in a postoperative questionnaire 2 months after surgery. The treatment effect was estimated to be a 15% reduction in the number of smokers at the time of surgery. Thus, 94 women in each group were required, in total 376 women, using a one-sided test with an alpha level of 0.001 and a statistical power of 80%. RESULTS: Participants (n = 1427) were recruited between 5 November 2015 and 6 December 2017. A total of 1137 smokers responded to the follow-up questionnaire (80%), with 486 women declining to participate, leaving 651 women eligible for analysis. Women who received both web-based information prior to surgery and information from a doctor, reported smoking cessation more often from 1 to 3 weeks preoperatively (Odds ratio [OR] 1.8, 95% confidence interval [CI] 1.0-3.3) and 1 to 3 weeks after surgery (OR 1.9, 95% CI 1.1-3.3) compared with the control group who received no specific information. CONCLUSIONS: A combination of written information in the health declaration and a recommendation from a doctor regarding smoking cessation may be associated with higher odds of smoking cessation at 1-3 weeks pre- and postoperatively.

Incisional hernias following open gynecological surgery: a population-based study.

INTRODUCTION: Incisional hernia is a common and costly complication following abdominal surgery. The incidence of incisional hernia after gynecological surgery is not as well studied as that after general surgery. MATERIALS AND METHODS: The Swedish National Quality Register for Gynecological Surgery (GynOp) collects preoperative, intraoperative, and postoperative information regarding gynecological surgery. Data were extracted from 2006 to 2014. The National Patient Register (NPR) contains physicians' data from both public and private hospitals. Univariate and multivariate Cox proportional hazard analyzes were performed on risk factors. RESULTS: Between 2006 and 2014, 39,312 women undergoing open surgery were registered in GynOp. The NPR recorded 526 patients who were diagnosed with or had undergone surgery for incisional hernia. The mean follow-up was 2.8 years. Five years after surgery the cumulative incidence of incisional hernias was 2.0% (95% confidence interval 1.8-2.2%). In multivariate Cox proportional hazard analysis obesity (BMI > 30), age > 60 years, midline incision, smoking, kidney, liver, and pulmonary disease were found to predict an increased risk for incisional hernias (all p < 0.05). CONCLUSIONS: There is much to be gained if the patient can cease smoking and lose weight before undergoing abdominal surgery. The Pfannenstiel incision results in fewer incisional hernias and should be considered whenever possible.

Repair of recurrent rectocele with posterior colporrhaphy or non-absorbable polypropylene mesh-patient-reported outcomes at 1-year follow-up.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to compare the results of repair of isolated, recurrent, posterior vaginal wall prolapse using standard posterior colporrhaphy versus non-absorbable polypropylene mesh in a routine health care setting. METHODS: This cohort study was based on prospectively collected data from the Swedish National Register for Gynaecological Surgery. All patients operated for recurrent, posterior vaginal wall prolapse in Sweden between 1 January 2006 and 30 October 2016 were included. A total of 433 women underwent posterior colporrhaphy, and 193 were operated using non-absorbable mesh. Data up to 1 year were collected. RESULTS: The 1-year patient-reported cure rate was higher for the mesh group compared with the colporrhaphy group, with an odds ratio (OR) of 2.06 [95% confidence interval (CI) 1.03-4.35], corresponding to a number needed to treat of 9.7. Patient satisfaction (OR = 2.38; CI 1.2-4.97) and improvement (OR = 2.13; CI 1.02-3.82) were higher in the mesh group. However, minor surgeon-reported complications were more frequent with mesh (OR = 2.74; CI 1.51-5.01). Patient-reported complications and re-operations within 12 months were comparable in the two groups. CONCLUSIONS: For patients with isolated rectocele relapse, mesh reinforcement enhances the likelihood of success compared with colporrhaphy at 1-year follow-up. Also, in our study, mesh repair was associated with greater patient satisfaction and improvement of symptoms, but an increase in minor complications. Our study indicates that the benefits of mesh reinforcement may outweigh the risks of this procedure for women with isolated recurrent posterior prolapse.

Decisions to use surgical mesh in operations for pelvic organ prolapse: a question of geography?

INTRODUCTION AND HYPOTHESIS: Surgical mesh can reinforce damaged biological structures in operations for genital organ prolapse. When a method is new, scientific information is often contradictory. Individual surgeons may accept different observations as useful, resulting in conflicting treatment strategies. Additional scientific information should lead to increasing convergence. METHODS: Based on data from the Swedish National Quality Register of Gynecological Surgery, all patients who underwent their first recurrent anterior compartment prolapse operation between 2006 and 2017 were included (2758 patients). Surgical mesh was used in 56.5%. We analyzed inter-county disparities in and patterns of mesh use over 12 years. To minimize confounding, we selected a group of highly comparable patients where similar decision patterns could be expected. RESULTS: The use of mesh differed between counties by a factor of 11 (8.6-95.3%). Counties with low use of mesh continued with low use and counties with high use continued with high use. CONCLUSIONS: Decisions regarding how to interpret existing scientific information about mesh implants in the early years of mesh use have led to "communities of practice" highly influenced by geographical factors. For 12 years, these groups have made disparate decisions and upheld them without measurable change toward consensus. The scientific learning process has stopped-despite the abundance of new publications and the steady supply of new types of mesh. Ongoing disparity in surgeons' choices in comparable patients has an adverse effect on clinical care. For the patient, this represents 12 years of a geographical lottery concerning whether mesh is used or not.

Correction to: Impact of surgeon experience on routine prolapse operations.

The article "Impact of surgeon experience on routine prolapse operations", written by Emil Nüssler, Jacob Kjær Eskildsen, Emil Karl Nüssler, Marie Bixo, and Mats Löfgren, was originally published without open access.

Impact of surgeon experience on routine prolapse operations.

INTRODUCTION AND HYPOTHESIS: Surgical work encompasses important aspects of personal and manual skills. In major surgery, there is a positive correlation between surgical experience and results. For pelvic organ prolapse (POP), this relationship has to our knowledge never been examined. In any clinical practice, there is always a certain proportion of inexperienced surgeons. In Sweden, most prolapse surgeons have little experience in performing prolapse operations, 74% conducting the procedure once a month or less. Simultaneously, surgery for POP globally has failure rates of 25-30%. In other words, for most surgeons, the operation is a low-frequency procedure, and outcomes are unsatisfactory. The aim of this study was to clarify the acceptability of having a high proportion of low-volume surgeons in the management of POP. METHODS: A group of 14,676 exclusively primary anterior or posterior repair patients was assessed. Data were analyzed by logistic regression and as a group analysis. RESULTS: Experienced surgeons had shorter operation times and hospital stays. Surgical experience did not affect surgical or patient-reported complication rates, organ damage, reoperation, rehospitalization, or patient satisfaction, nor did it improve patient-reported failure rates 1 year after surgery. Assistant experience, similarly, had no effect on the outcome of the operation. CONCLUSIONS: A management model for isolated anterior or posterior POP surgery that includes a high proportion of low-volume surgeons does not have a negative impact on the quality or outcome of anterior or posterior colporrhaphy. Consequently, the high recurrence rate was not due to insufficient experience of the surgeons performing the operation.

Are women adequately informed before gynaecological surgery?

BACKGROUND: Surgery for pelvic organ prolapse, urinary incontinence, and hysterectomy are the most common gynaecological surgeries that can affect the function of the bladder and bowel as well as one's sexual life. There is evidence that adequate patient information given preoperatively regarding expected outcomes of surgery is important because well-informed patients are more satisfied with the results of surgery and recover faster. However, there is little known about the amount and quality of information given to women before surgery. This study investigates whether women received information before gynaecological surgery on the effect of surgery with respect to the functioning of the bladder (micturition, ability to stay continent) and the bowel (empty bowel) as well as the surgery's effect on sexual functioning. METHODS: A prospective, cross-sectional study was conducted. Women undergoing hysterectomy, surgery for vaginal prolapse, or surgery for urinary incontinence (n = 972) and included in the Swedish National Register for Gynaecological Surgery participated in the study. A questionnaire was developed and distributed to the women along with the preoperative questionnaire from the register. RESULTS: About 50% of the women undergoing prolapse surgery were supplied with information regarding the effect of the surgery with respect to remaining continent, to emptying bowels, micturitaion, and sexual life. One out of four women undergoing hysterectomy received information about the effect of the surgery on the sexual life and bladder function. In the incontinence group, the given information about the surgery's effect on bladder function and sexual function was 80 and 30%, respectively. CONCLUSION: Surgery in the vagina and the genital organs may affect function of the organs close to the surgical area (i.e., bladder and bowel) and may affect sexual function. According to this study, women are inadequately informed before surgery. Access to information via oral and written counselling needs to be improved.

Patient-reported lower urinary tract symptoms after hysterectomy or hysteroscopy: a study from the Swedish Quality Register for Gynecological Surgery.

INTRODUCTION AND HYPOTHESIS: Hysterectomy is sometimes considered the cause of lower urinary tract symptoms (LUTS). We hypothesized that hysterectomy for abnormal uterine bleeding and/or symptoms of fibroids is more likely to cause LUTS than a hysteroscopic procedure for the same indications. METHODS: Two groups of women were compared: one group comprised 3,618 women who had had a hysterectomy due to abnormal uterine bleeding or symptoms of fibroids and the other group comprised 238 women who had had hysteroscopic treatment for the same indications. The main outcome measures were occurrence of LUTS before and 1 year after the surgical intervention. The frequencies of LUTS before and after surgery were compared between the groups. Binary logistic regression was used to model the odds of having postoperative urinary leakage and urgency while controlling for uterine size, surgical procedure and preoperative LUTS. RESULTS: There were no statistically significant differences between women after hysterectomy and after hysteroscopy in the frequencies of LUTS before or after surgery, when uterine size was comparable. However, there was a difference in the rates of de novo urinary incontinence between women with hysterectomy and women with hysteroscopy (7.6%, 95% CI 6.3-9.0, and 3.2%, 95% CI 1.6-6.5, respectively). Of the women with a large uterus, 58.6% (95% CI 51.5-65.5) reported relief of urinary incontinence and 85.5% (95% CI 82.3-88.4) reported relief of urinary urgency postoperatively. CONCLUSIONS: Our results suggest that it is important to individualize preoperative information in women prior to hysterectomy since the outcome concerning LUTS depends on preoperative symptoms and uterine size.

A population-based registry study evaluating surgery in newly diagnosed uterine cancer.

INTRODUCTION: The aim was to evaluate surgical treatment of newly diagnosed uterine cancer in a Swedish population. MATERIAL AND METHODS: Data in the GynOp registry from 2008 to 2014 were analyzed. RESULTS: In total, 3443 cases were included: 430 (12%) were robotic-assisted laparoscopic, 272 (8%) laparoscopic, and 2741 (80%) abdominal operations. There was an increasing trend in minimally invasive surgery from 2008 to 2014 (41%). Women with lymph nodes removed in the robotic-assisted laparoscopic group experienced less blood loss (mean 105 vs. 377 mL), shorter length of hospital stay (2.4 vs. 4.1 days), and fewer days to normal activities of daily living (6.5 vs. 12.7 days) (all p < 0.001) compared with the abdominal group, but operating time did not differ. Similar results were found in women with no lymph node removal and in women with body mass index ≥35. Major complications during hospital stay, reoperations, and time to work were less in both minimally invasive groups. More lymph nodes were retrieved in the abdominal (mean 34.4) than in the robotic-assisted laparoscopic (mean 26.0) group, but the number of women with lymph node metastases did not differ, totaling 211/960 (21.9%; 95% CI 19.4-24.7%). Isolated para-aortic lymph node metastases were found in 3.9% (95% CI 2.4-5.6%) of women. CONCLUSIONS: Minimally invasive surgery in uterine cancer patients reduces days to normal activities of daily living, number of days to return to work, length of hospital stay, and blood loss in patients without and with lymph node dissection and in obese patients.

Robot-assisted surgery in cervical cancer patients reduces the time to normal activities of daily living.

OBJECTIVE: To evaluate current surgical cervical cancer treatment in Sweden 2008-12. DESIGN AND SETTING: Analysis of data in the Swedish National Quality Register for Gynecological Surgery (GynOP). SAMPLE: A total of 249 cervical cancer patients undergoing surgery. METHODS: Analysis of prospectively gathered preoperative and postoperative data including patient-reported information. MAIN OUTCOME MEASURES: Mean operating time, blood loss/transfusion, length of hospital stay, return to activities of daily living. RESULTS: The patients undergoing laparoscopic robot-assisted surgery (n = 64) or laparotomy (n = 185) did not differ in age, body mass index, American Society of Anesthesiologists score, International Federation of Gynecology and Obstetrics (FIGO) stage or mean operating time. Blood loss was higher in the laparotomy group (p < 0.001). Thirteen patients in the laparotomy group (7%) received a blood transfusion, but none in the robot group. Intraoperative complications were more common in the laparotomy group (p = 0.03). Re-admission or operations did not differ between the groups. The number of pelvic lymph nodes removed was significantly higher in the laparotomy group (median 31 vs. 24, p < 0.001). There was no difference regarding the number of patients with lymph node metastases in the two groups. The postoperative length of hospital stay was longer in the laparotomy group compared with the robot group (6.1 days vs. 2.1 days, p = 0.01). The patient-reported time to resume normal activities of daily living was longer in the laparotomy than the robot group (13.4 days vs. 9.7 days, p = 0.04). CONCLUSIONS: Laparoscopic robotic-assisted surgery is preferable to laparotomy for cervical cancer patients because it entails a significantly shorter hospital stay, less blood loss, fewer intraoperative complications and shorter time to normal daily activities.

Operation for primary cystocele with anterior colporrhaphy or non-absorbable mesh: patient-reported outcomes.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to compare the results of primary anterior vaginal wall prolapse repair, using standard anterior colporrhaphy or non-absorbable mesh in a routine health care setting. METHODS: The study was based on prospectively collected data from the Swedish National Register for Gynaecological Surgery. All patients were operated on solely for primary, anterior vaginal wall prolapse between January 2006 and October 2013: 6,247 women had an anterior colporrhaphy, and in 356 a non-absorbable mesh was used. Data were collected from doctors and patients up to 1 year after surgery. RESULTS: The 1-year cure rate for the mesh group was superior to that of the colporrhaphy group with an odds ratio (OR) of 1.53 (CI 1.1-2.13), corresponding to a number needed to treat (NNT) of 13.5. Patient satisfaction, OR = 2.45 (CI 1.58-3.80), and patient improvement, OR 2.99 (CI 1.62-5.54), was also higher in the mesh group. However, patient-reported complications, OR = 1.51 (CI 1.15-1.98), and the incidence of persisting pain in the loin, OR = 3.58 (CI 2.32-5.52), were also higher in the mesh group as were surgeon-reported complications, OR = 2.27 (CI 1.77-2.91), bladder injuries, OR = 6.71 (CI 3.14-14.33), and re-operations within 12 months, OR = 6.87 (CI 3.68-12.80). CONCLUSIONS: Mesh reinforcement, in primary anterior vaginal wall prolapse patients, enhanced the likelihood of anatomical success at 1 year after surgery. However, mesh implant was associated with a significantly higher incidence of bladder injury, reoperations, both patient- and surgeon-reported complications, more patient-reported pain and a longer hospital stay.

Operation for recurrent cystocele with anterior colporrhaphy or non-absorbable mesh: patient reported outcomes.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to compare patient reported outcomes and complications after repair of recurrent anterior vaginal wall prolapse in routine health care settings using standard anterior colporrhaphy or non-absorbable mesh. METHODS: The study is based on prospective data from the Swedish National Register for Gynaecological Surgery. 286 women were operated on for recurrent anterior vaginal wall prolapse in 2008-2010; 157 women had an anterior colporrhaphy and 129 were operated on with a non-absorbable mesh. Pre-, and perioperative data were collected from doctors and patients. Patient reported outcomes were evaluated 2 months and 12 months after the operation. RESULTS: After 12 months, the odds ratio (OR) of patient reported cure was 2.90 (1.34-6.31) after mesh implants compared with anterior colporrhaphy. Both patient- and doctor-reported complications were found more often in the mesh group. However, no differences in serious complications were found. Thus, an organ lesion was found in 2.3% after mesh implant compared with 2.5% after anterior colporrhaphy (p = 0.58). Two patients in the mesh group (1.2%) were re-operated compared with 1 patient (0.6%) in the anterior colporrhaphy group (p = 0.58). The infection rate was higher after mesh (8.5%) than after anterior colporrhaphy (2.5%; OR 3.19 ; 1.07-14.25). CONCLUSION: Implantation of synthetic mesh during operation for recurrent cystocele more than doubled the cure rate, whereas no differences in serious complications were found between the groups. However, mesh increased the risk of infection.

Female urinary incontinence: patient-reported outcomes 1 year after midurethral sling operations.

INTRODUCTION AND HYPOTHESIS: Although midurethral slings have become standard surgical methods to treat stress urinary incontinence (SUI), little is known about women who still have urinary incontinence (UI) after surgery. This study assesses and compares the patient-reported outcome 12 months after tension-free vaginal tape (TVT), tension-free vaginal tape-obturator (TVT-O), and transobturator tape (TOT), with a special focus on women who still have urinary leakage postoperatively. METHODS: This study analyzed preoperative and 12-month postoperative data from 3,334 women registered in the Swedish National Quality Register for Gynecological Surgery. RESULTS: Among the women operated with TVT (n = 2,059), TVT-O (n = 797), and TOT (n = 478), 67 %, 62 %, and 61 %, respectively, were very satisfied with the result at the 1-year follow-up. There was a significantly higher chance of becoming continent after TVT compared with TOT. In total, 977 women (29 %) still had some form of urinary leakage postoperatively. Among the postoperatively incontinent women who expressed a negative impact of UI on family, social, work, and sexual life preoperatively, considerably fewer reported a negative impact in all domains after surgery. Of those in the postoperatively incontinent group who had coital incontinence preoperatively, 63 % reported a cure of coital incontinence. CONCLUSIONS: The proportion of women very satisfied with the result of the operation did not differ between the three groups. TVT had a higher SUI cure rate than did TOT. Despite urinary leakage 1-year postoperatively, half of the women were satisfied with the result of the operation.

Vaginal prolapse--perceptions and healthcare-seeking behavior among women prior to gynecological surgery.

OBJECTIVE: To investigate perceptions of vaginal prolapse and healthcare-seeking behavior in women prior to gynecological surgery. DESIGN: Prospective, cross-sectional study using a web-based questionnaire. SETTING: Clinics including patients in the Swedish National Register for Gynecological Surgery (Gynop-register). POPULATION: 214 women with vaginal prolapse and 347 women without prolapse as reference patients. METHODS: A questionnaire was developed for assessment of women's perception of prolapse and their healthcare-seeking behavior. Data were collected through the Gynop-register. For comparisons between the study groups, Student's t-test and the chi-squared test were used. MAIN OUTCOME MEASURES: Perceptions of prolapse, healthcare-seeking behavior, and source of information. RESULTS: The most common definition of prolapse reported by the women was presence of a vaginal bulge. Reasons for seeking healthcare were interference with physical activity and increasing symptoms. One in five women with prolapse could not relate the symptoms to prolapse. Participants in the prolapse group gained less information on their own condition from brochures and public media compared to participants in the reference group (p<0.001). CONCLUSION: There appeared to be a lack of information on pelvic organ prolapse in the public domain. Healthcare professionals have a significant role to play in informing women about symptoms related to the condition and the available treatment options.

Vaginal cleansing and postoperative infectious morbidity in vaginal hysterectomy. A register study from the Swedish National Register for Gynecological Surgery.

OBJECTIVE: To evaluate whether preoperative vaginal preparation routines influence postoperative infectious morbidity in vaginal hysterectomy and to analyze risk factors for postoperative infectious morbidity. DESIGN: Retrospective, longitudinal cohort study. SETTING: Forty -three hospitals in Sweden, participating in the Swedish National Register for Gynecological Surgery. POPULATION: All 6,496 women who were enrolled in the Register and underwent vaginal or laparoscopically assisted vaginal hysterectomy between 1 January 2000 and 1 February 2008. METHODS: Register data were collected prospectively using doctors' forms and patient questionnaires. Information about vaginal preparation routines in the clinics were achieved retrospectively by an e-mail survey. Multiple logistic regression analyses models were used to determine associations and risk factors. MAIN OUTCOME MEASURES: Infectious morbidity within 6-8 weeks postoperatively. RESULTS: No significant differences were seen in postoperative infectious morbidity in long term between vaginal preparation using saline or chlorhexidine solution or no cleansing. At discharge from hospital, those who had had vaginal cleansing using saline solution had a significantly higher risk of postoperative infections. Risk factors for infectious morbidity were young age, obesity, peroperative injury of the urinary bladder, operative time and duration of hospital stay. Protective were prophylactic antibiotics and concomitant prolapse surgery. CONCLUSIONS: Saline solution should not be used for vaginal cleansing due to a higher risk of infectious morbidity in the immediate postoperative period. Infectious morbidity may be reduced further by employing preventive measures such as meticulous surgical technique, preoperative weight reduction in obese women and minimizing time in hospital.

Outcomes of cystocele repair surgery in relation to different anesthesia methods.

OBJECTIVE: To investigate outcomes of cystocele surgery by different anesthesia and evaluation of patient satisfaction. DESIGN: Population-based, retrospective study. SETTING: All clinics that included patients in the Swedish National Register for Gynecological Surgery. POPULATION: A total of 1,364 women who underwent cystocele repair from January 2006 to June 2009. METHODS: The study population was retrieved from the Register among women who had surgery and where there was complete information on concurrently used anesthesia. Clinical variables were compared. Peri- and postoperative complications were investigated. Multivariate logistic regression analysis was applied to identify independent factors for patient satisfaction. MAIN OUTCOME MEASURES: Time to recovery, complications and patient satisfaction. RESULTS: We found a wide variation between hospitals with respect to use of local anesthesia (LA) in cystocele surgery. Length of hospital stay, duration of use of postoperative painkilling drugs, and patient-reported time to return to daily activity were shorter in the LA group compared to the other two anesthesia forms. Postoperative complications did not differ between groups. Age (> or =50 years) and patient-reported complications were independent factors related to patient satisfaction (OR 3.05; 95%CI 1.36-6.82 and OR 0.21; 95%CI 0.12-0.36, respectively). Patient satisfaction did not relate to methods of anesthesia. CONCLUSION: Cystocele surgery can be performed safely using LA thus limiting the use of more invasive anesthesia methods. LA benefits patients and should be increasingly used.

'A hidden disorder until the pieces fall into place'--a qualitative study of vaginal prolapse.

BACKGROUND: Vaginal prolapse affects quality of life negatively and is associated with urinary, bowel, and sexual symptoms. Few qualitative studies have explored women's experiences of vaginal prolapse. The objective of the study was to elucidate the experiences of living with prolapse and its impact on daily life, prior to surgical intervention. METHODS: In-depth interviews were conducted with 14 women with vaginal prolapse, prior to surgical treatment. Recruitment of the informants was according to 'purposive sampling'. An interview guide was developed, including open-ended questions addressing different themes, which was processed and revised during the data collection and constituted part of a study-emergent design. Data were collected until 'saturation' was achieved, that is, when no significant new information was obtained by conducting further interviews. Interviews were audiotaped, transcribed verbatim, and analyzed according to manifest and latent content analysis. RESULTS: The theme defining the process of living with prolapse and women's experiences was labelled 'process of comprehension and action'. The findings constitute two categories: obstacles and facilitators to seeking health care. The category obstacles comprises six subcategories that define the factors restraining women from seeking health care: absence of information, blaming oneself, feeling ignored by the doctor, having a covert condition, adapting to successive impairment, and trivializing the symptoms and de-prioritizing own health. The category facilitators include five subcategories that define the factors promoting the seeking of health care: confirmation and support by others, difficulty in accepting an ageing body, feeling sexually unattractive, having an unnatural body, and reaching the point of action. CONCLUSION: The main theme identified was the 'process of comprehension and action'. This process consisted of factors functioning as either obstacles or facilitators to seeking health care. The main obstacles described by the participants were lack of information and confirmation. The main facilitators constituted feeling sexually unattractive and impaired physical ability due to prolapse. Information on prolapse should be easily accessible, to improve the possibility for women to gain knowledge about the condition and overcome obstacles to seeking health care. Health care professionals have a significant role in facilitating the process by confirming and informing women about available treatment.

Outcomes of vaginal hysterectomy for uterovaginal prolapse: a population-based, retrospective, cross-sectional study of patient perceptions of results including sexual activity, urinary symptoms, and provided care.

BACKGROUND: Vaginal hysterectomy is often used to correct uterovaginal prolapse, however, there is little information regarding outcomes after surgery in routine clinical practice. The objective of this study was to investigate complications, sexual activity, urinary symptoms, and satisfaction with health care after vaginal hysterectomy due to prolapse. METHODS: We analyzed data from the Swedish National Register for Gynecological Surgery (SNRGS) from January 1997 to August 2005. Women participating in the SNRGS were asked to complete surveys at two and six months postoperatively. Of 941 women who underwent vaginal hysterectomy for uterovaginal prolapse, 791 responded to questionnaires at two months and 682 at six months. Complications during surgery and hospital stay were investigated. The two-month questionnaire investigated complications after discharge, and patients' satisfaction with their health care. Sexual activity and urinary symptoms were reported and compared in preoperative and six-month postoperative questionnaires. RESULTS: Almost 60% of women reported normal activity of daily life (ADL) within one week of surgery, irrespective of their age. Severe complications occurred in 3% and were mainly intra-abdominal bleeding and vaginal vault hematomas. Six months postoperative, sexual activity had increased for 20% (p = 0.006) of women and urinary urgency was reduced for 50% (p = 0.001); however, 14% (n = 76) of women developed urinary incontinence, 76% (n = 58) of whom reported urinary stress incontinence. Patients were satisfied with the postoperative result in 93% of cases and 94% recommended the surgery. CONCLUSION: Vaginal hysterectomy is a patient-evaluated efficient treatment for uterovaginal prolapse with swift recovery and a low rate of complication. Sexual activity and symptoms of urinary urgency were improved. However, 14% developed incontinence, mainly urinary stress incontinence (11%). Therefore efforts to disclose latent stress incontinence should be undertaken preoperatively.